Soft Tissue Injuries

Basics & Classification - Intro & Ouchies

• Soft Tissue Injury (STI): Damage to non-bony tissues (muscle, tendon, ligament, bursa, nerve, vessel).
• Classification:
  • By Onset:
    • Acute: Sudden (direct blow, overload, overstretch).
    • Chronic: Overuse (e.g., tendinopathy).
  • By Skin Integrity:
    • Closed: Skin intact.
    • Open: Skin breached.
• Contusion (Bruise): Capillary rupture from blunt trauma; features pain, swelling, ecchymosis.
• Hematoma: Larger vessel damage; forms localized blood collection (mass); features pain, possible fluctuance.
• Healing Phases:
  • Inflammation (0-7 days): Hemostasis, cellular influx.
  • Proliferation (3-21 days): Fibroplasia, angiogenesis.
  • Remodeling (Day 21 - 2 yrs): Collagen maturation, scar strengthening.

⭐ Hematomas often present as a palpable, fluctuant mass due to localized blood collection, distinguishing them from diffuse contusions.

Ligament & Tendon Injuries - Stretch & Snap

• Sprains (Ligament Injury):

  • Grading:

    Gr	Injury	Symptoms	Laxity	Stability
    I	Micro-tears	Mild pain/swell	Minimal	Stable
    II	Partial tear	Mod pain/swell/bruise	↑ (endpt)	Mild instab
    III	Complete tear	Sev pain/swell/bruise	↑↑ (no endpt)	Unstable

  • Common:
    • Ankle: ATFL (most common); Inversion + Plantarflexion. 📌 ATFL: "Always Tears First".
    • Knee: ACL (Lachman, Ant Drawer); PCL (Post Drawer); MCL (Valgus); LCL (Varus). Unhappy Triad: ACL, MCL, Medial Meniscus (AMM).

• Strains (Musculotendinous Injury):

  • Grading:

    Gr	Injury	Symptoms	Functional Loss
    I	Stretch	Mild pain	Minimal
    II	Partial tear	Mod pain/weakness	Moderate
    III	Complete tear	Sev pain/LOF	Severe

  • Common: Hamstrings, Quads, Adductors, Rotator cuff.

• Tendinopathies:

  • Tendinitis (acute inflammation) vs. Tendinosis (chronic degen.).
  • E.g., Achilles, Tennis elbow (Lat. epicondylitis), Golfer's (Med. epicondylitis).

⭐ ATFL: most common ligament in ankle sprains.

Muscle & Fascia Conditions - Aches & Alerts

• Muscle Injuries:
  • Direct: Contusion, laceration.
  • Indirect: Strain (see CG2), rupture.
  • Delayed Onset Muscle Soreness (DOMS): Self-limiting post-exertional pain.
• Myositis Ossificans:
  • Patho: Post-traumatic heterotopic ossification in muscle.
  • Sites: Quadriceps, brachialis. Clinically: Pain, swelling, ↓ROM.
  • X-ray: Fluffy calcification → mature peripheral ossification.
  • Mgmt: Rest, NSAIDs. ⚠️ AVOID early aggressive massage/surgery.
• Compartment Syndrome:
  • Patho: ↑ Intracompartmental pressure (ICP) → ↓ tissue perfusion → ischemia, necrosis.
  • Causes: Tibial fractures, crush injuries, burns, tight casts/dressings.
  • 📌 6 P's: Pain (out of proportion, earliest sign), Paresthesia, Pallor, Pulselessness, Paralysis, Poikilothermia (late signs).
  • Dx: Clinical suspicion crucial. ICP: Normal 0-8 mmHg. Fasciotomy if absolute ICP >30-40 mmHg or $ΔP$ (Diastolic BP - ICP) < 20-30 mmHg.

  ⭐ Pain out of proportion to injury is the earliest and most reliable clinical sign of compartment syndrome.

  • Mgmt: Emergency Fasciotomy.

Nerve Trauma & General Repair - Zaps & Patches

• Peripheral Nerve Injury Classification:

  Seddon	Sunderland	Pathology	Recovery (Prognosis)
  Neuropraxia	I	Myelin damage, axon intact, no Wallerian	Full (days-weeks)
  Axonotmesis	II-IV	Axon damage, Wallerian degen., sheath variable	Variable (1mm/day), may need surgery
  Neurotmesis	V	Complete division, Wallerian degen.	Surgery essential

  • EMG: Denervation (fibrillations, +ve sharp waves) in Axonotmesis/Neurotmesis.

• Common Nerve Palsies: 📌 DR CUMA (Drop wrist - Radial; Claw - Ulnar; Median - Ape/Benediction)

  • Axillary n.: Anterior shoulder dislocation → Deltoid paralysis, regimental badge anaesthesia.
  • Radial n.: Humerus shaft # → Wrist drop.
  • Median n.: Supracondylar #, Carpal Tunnel Syndrome → Ape hand, thenar wasting.
  • Ulnar n.: Medial epicondyle # → Claw hand (4th/5th digits), Froment's sign.
  • Common Peroneal n.: Fibular neck # → Foot drop, steppage gait.

• Soft Tissue Management:

  • Protection, Optimal Loading, Ice, Compression, Elevation (POLICE). Analgesia.
  • Balance immobilization & early mobilization. Physiotherapy crucial.
  • Surgical Indications: Complete tears (active individuals), nerve transection, compartment syndrome, failed conservative management.

⭐ Order of sensory recovery: Pain → Temperature → Touch → Proprioception.

High‑Yield Points - ⚡ Biggest Takeaways

• Sprains are ligament injuries; strains involve muscle/tendon units.
• Ottawa Ankle/Knee Rules are crucial for guiding X-ray decisions.
• Compartment syndrome: surgical emergency; pain out of proportion is the earliest reliable sign.
• Achilles tendon rupture: positive Thompson test (absent plantarflexion on calf squeeze).
• Meniscal injuries: joint line tenderness, locking, or clicking; McMurray test is indicative.
• ACL tears: often non-contact pivoting injuries; Lachman test is most sensitive_._