Bone and Joint Injuries
From R. C. Schafer, DC, PhD, FICC's best-selling book:
“Basic Principles of Chiropractic Neuroscience”
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Bone Injuries Background Probing the History Bone Bruises FracturesTypes of Fractures Symptoms of Fracture The Repair Process in Fractures General Emergency Treatment Emergency Immobilization (Splints) Fatigue Fractures Epiphyseal Disorders Osteochondritis Epiphyseal Displacements Osteochondritis Dissecans Bone Inflammations and Infections Traumatic Arthritis Periostitis Osteomyelitis Post-Traumatic Painful Osteoporosis (Sudeck's Atrophy Related Inflammatory Processes Joint Injuries Inspection Palpation and Percussion Motion Evaluation Measurements and Reflexes Indirect Methods Pertinent Signs and Symptoms Joint Pain Joint Swelling Fluctuation Crepitus Pitting on Pressure Local Temperature and Tenderness Joint Stiffness Joint Restrictions Loose Bodies Joint Dysfunction vs Joint Disease Joint Dysfunction Joint Disease Soft-Tissue Joint Injuries Sprains Fibrocartilage Damage Capsular Tears Intracapsular Pinches Bone Bruises Dislocations Background Emergency Treatment Objectives of Joint Injury Management Reduce and Reabsorb Swelling Minimize Deformity and Wasting Normalize Joint Movements and Function
Chapter 15: Bone and Joint Injuries
In traditional general medical practice, the musculoskeletal system is the most overlooked system in the body, yet it comprises over half the body mass. The relationship between structure and function, and the interrelationship between all body systems, cannot be denied. Muscles, bones, and connective tissues are involved in both local and systemic pathology, and in a wide assortment of functional and referred disturbances. Thus, great care must be taken in eliciting the details of a complaint when any musculoskeletal disorder is suspected. This section reviews the basis of alert management of bone and joint injuries within the health care of athletic and recreational injuries.
Correlation of the history of the present complaint with musculoskeletal dysfunction must be done in detail and with care. Maintain accurate initial and progress records with repeated monitoring. Few patients can appreciate the relationship of dysfunction in one somatic part with a distant somatic part, let alone the relationship between a somatic dysfunction and a visceral dysfunction.In a mild sprain, there is a small amount of internal bleeding in a localized area of the ligament with only a few fibers separated. No actual loss of function or reduced strength is present. Generally, the ligament requires no protection and is not weakened. It is characterized by tenderness over the ligament that is not marked at the bony insertion by swelling and other symptoms of mild local inflammation. Joint instability is negligible.
Musculoskeletal symptoms may be the first clues toward poor structural adaptation or stress adaptation. The most common musculoskeletal symptoms are joint stiffness, joint swelling, and joint pain. Bones, being essentially nonyielding structures, are damaged when excessive force is applied directly or indirectly. The nature of the damage depends on the direction of the applied force on the bones and the manner in which these bones are attached to other structures. The principal acute skeletal injuries are sprains, strains, subluxations, fractures, and dislocations.
Normal bone has an excellent blood supply with some exception in the metaphyseal area; but tendons, ligaments, discs, and cartilage are poorly vascularized. Yet both bone and joints challenge the host's defensive mechanisms. The pressure of pus under hard bone blocks circulation, and emboli and thrombosis can cause additional devascularization. When circulation is deficient, local phagocytic function and nutrition are deficient, and cure is stymied.
The most accurate diagnosis can be made immediately after injury, before swelling clouds the picture. Many fracture and dislocation complications such as nerve and vessel injury occur not from the trauma itself but from poor first aid which does not provide adequate splinting prior to movement. Traumatic bone injury rarely occurs without significant soft-tissue damage. The physical examination must be gentle but thorough because soft-tissue trauma is poorly visible on roentgenograms for several days after injury. For example, a working diagnosis of stress fracture may have to be made in the absence of classic symptoms by bony tenderness alone as the fracture may not be demonstrable on x-ray films for 10-14 days or longer.
Probing the History
Symptoms of a musculoskeletal nature that cannot be linked to trauma are suspect of a chronic organic process. Unfortunately, a history of stress or strain may not be remembered. Even severe trauma is easily put out of the mind uring a game when emotions are high or forgotten once the pain and swelling have left. Whether pain is present or not, the history must be probed to determine if the dysfunction is the result of bone, the joint, or the motor apparatus involved in the joint motion.
When subjected to weight-bearing, traumatic, or occupational stress, bone demineralizes and undergoes degenerative changes resulting in deformity of the articulating surfaces. Concurrently, the attending excoriation of the articular periosteal margins result in proliferative changes in the form of lipping and spur formations or eburnation.
Bones break from either direct blows or indirectly such as a fall on an outstretched hand resulting in a fracture of the forearm, elbow, shoulder, or clavicle. It is thus imperative that the injured person be examined as a whole. For example, even if a fall on the outstretched hand does not result in fracture, a rib or spinal subluxation may result. The inexperienced doctor may overlook a slipped femoral capital epiphysis in a young player whose complaints are restricted to the knee. The list can go on and on.
Certain simple contusions which involve subcutaneous tissues overlying bone and the periosteum are often referred to in sports as "bone bruises". Because the periosteum is richly endowed with nerves and vessels, severe bruises and fractures are quite painful despite no roentgenographic evidence. When the periosteum is affected, tenderness will be present long after true soft-tissue tenderness has eased, sometimes for several months. Wherever the site, the athlete is disabled or considerably hampered as long as tenderness exists.
Initial treatment must be quick to minimize bleeding and swelling through ice, compression, elevation, and rest. Padding, often specially designed, must be worn as long as tenderness persists. During recovery, corrective manipulation, local heat, ultrasound, and massage may be applied to relieve related soreness.
A fracture is a break in the continuity of a bone or a separation of a bone into two or more parts. A great amount of soft-tissue damage may accompany this type of injury.
Types of Fracture
Fractures are classified as open or closed. An open fracture is one in which there is a break in the skin that is contiguous with the fracture. The bone is either protruding from the wound or exposed through a wound channel such as one produced by an arrow, javelin, bullet, or other missile. A closed fracture is not complicated by a break in the skin, but there is usually soft-tissue damage beneath the intact skin.
Intra-articular fractures are not uncommon in sports. They involve the articular surfaces of joints and the associated articular cartilage. Osteoarthrosis results if reduction is not accurate. However, a displaced fragment need not be removed if it does not interfere with function by impingement. Fracture dislocations often involve joint impaction and fragmentation. They usually present great instability and require operative repair.
Symptoms of Fracture
A working diagnosis of fracture may be based on any one of several symptoms. Additional assistance in diagnosis may be obtained from the history and roentgenography. A history of falling, receiving a blow, or of having felt or heard a bone snap may help in the discovery of more evidence such as:
Tenderness over the site of injury. Tenderness or pain upon slight pressure on the injured part may indicate a fracture.
Swelling and discoloration. These signs at the site of injury increase with time and may indicate fracture. The swelling is due to the accumulation of tissue fluid and blood. When blood collects near the surface of the skin, a bluish discoloration may be seen.
Abnormalities with movement. Deep, sharp pain upon an attempt to move the bone is presumptive evidence of fracture. Grating of bone ends against each other indicates fracture. Movement, however, should rarely be attempted to see if crepitation is present as it causes further damage to the surrounding tissues and promotes shock.
Deformity of the part. Protrusion of a bone segment through the skin, unnatural depression, or abnormal flexion may indicate fracture.
Some diagnostic pitfalls in orthopedics, as pointed out by Iversen/Clawson, include:
(1) considering accessory ossicles as fractures;
(2) overlooking an osteochondral, a tibial-spine, or a stress fracture;
(3) forgetting that an upper-tibial fracture might progress into valgus;
(4) failing to realize the instability of an apparently undisplaced lateral condyle fracture of the humerus; and
(5) not appreciating the frequency of distal forearm fractures that slip.
The Repair Process in Fractures
Although bone is noted for its hardness and supportive characteristics, bone is similar to soft tissue in that it is resilient, highly vascular, and constantly changing. It adapts to disease and heals itself when fractured. Both bone growth and repair are most efficient during youth and adolescence, as witnessed in rapid fracture healing. Abnormally slow healing can almost always be contributed to a deficiency in minerals and vitamins, rarely to endocrine or metabolic etiologies. However, if control is poor, too much site motion, joint distraction, infection and other compound-fracture complications can cause delayed union or nonunion.
Fracture represents a rupture of living connective tissue. It repairs, as does all living tissue, by cellular growth, yet there are some unique characteristics due to bone's high mineral content. After fracture, a hematoma develops between the split ends. This space becomes invaded within a few days by granulation tissue which in time becomes converted into fibrocartilage. This fibrocartilage is an osteoid tissue where new bone is laid down for union. After this stage, resorption and remodelling occur to reduce the initial callus formation in an attempt to restore the bone to its original size and shape.
While normal bone is highly vascular, readily repairs itself, and resists infection, avascular bone is defenseless in participating in the reparative process. Thus, after injury, treatment must be directed to prevent further devascularization and to encourage improved vascularity. Intra-articular and metaphyseal fractures enjoy an abundant blood supply, thus early and active movement of the joint should be encouraged. However, proper stabilization of distal and proximal joints must be maintained in diaphyseal fractures because of the relatively poor blood supply. Thus, special concern must be given to increasing circulation and preventing stiffness.
General Emergency Treatment
The first step is to make a brief but thorough examination to determine the extent of injuries. Treatment of any life-endangering condition such as respiratory failure, cardiac arrest, or hemorrhage takes precedence over that for fracture. The care applied directly to the fracture is a part of the prevention or lessening of shock because pain is lessened and the likelihood of further trauma is reduced.
In the treatment for fractures, the rule, "Splint them where they lie", applies. Open fractures are dressed before splints are applied. Care must be taken to avoid moving the fractured part as the razor-sharp ends of fractured bone can easily cut through vessels, nerves, muscles, and skin. Such additional damage would, of course, increase the possibility of hemorrhage, shock, loss of limb or life. If movement of the patient is unavoidable or is essential in treatment, the fractured part must be supported if further damage is to be avoided. Slight traction-adjustment of the fractured part may be necessary to restore circulation, the lack of which is evidenced by absence of the pulse distal to the fracture. This is especially common in elbow fracture.
In the individual suffering multiple injuries, the most commonly overlooked injuries are fractures of the basilar skull, C7 vertebra, femoral neck, orbit, pelvis, radial head, talus, tibial plateau, T12 and L1 vertebrae, and zygomatic arch; and dislocations of the lunate, perilunate, posterior femoral head, posterior shoulder, and scaphoid.
Emergency Immobilization (Splints)
To prevent futher damage, a fractured bone must be immobilized by splinting the joints above and below the fracture, as movement of these joints would move the bone segments. All splints should be well padded to protect the skin from injury, loss of circulation, inflammation, and infection. Bandages used to secure a splint must not be applied so tightly that they impair circulation even for a few minutes. A bluish discoloration of the nailbeds or skin of the affected limb indicates that one or more bandages are too taut. Security bandages should never be tied directly across a wound.
Splints commonly used to immobilize fractures of the extremities are the wire ladder, cage, and Thomas leg splint. If this equipment is not available or training has not been provided for correct application, splints may be improvised by using such items as boards, stiff tree limbs, rolled newspapers, belts, etc.
In limb fracture, the pneumatic inflatable splint is especially useful as it offers both immobilization and compression to minimize hemorrhage. It must be applied only tight enough to support the fragments without inhibiting circulation.
To immobilize a fractured bone in the thigh or hip, an improvised splint must extend from the groin and the armpit to several inches below the foot. Padding should extend over the ends of the splint at the groin and the armpit.
Fatigue (stress) fractures can be the result of any severe repetitive stress (eg, dancing, jumping, marching, running, throwing).
ETIOLOGY AND INCIDENCE IN SPORTS
The causative factor appears to involve tensile forces from severe musculature contractions rather than than the compressive forces of external trauma. Fatigue fractures of the leg and foot are most commonly seen in runners, and fatigue hip fractures are often seen in jumpers. Other patterns of incidence appear to be the pars interarticularis in football linemen and gymnists; the patella, soccer players; ischiopubic area, hurdlers; ulnar, tennis players and pitchers; and the pisiform, volleyball players.
The vast majority (95%) of fatigue fractures occur in the lower extremities, and most are associated with competitive running. The three most common sites of fatigue fractures associated with sports involve the femoral neck, tibia (especially the distal third), metatarsals (especially the 2nd and 3rd metatarsals), and tarsals (os calcis, talus, or cuneiform). Less frequently, a site may be found in the pelvis, especially involving the ischiopubic arch of female athletes.
SYMPTOMATOLOGY AND PHYSICAL FINDINGS
Vague pain may be the only early symptom. The typical case history will reveal the onset of insidious local soreness during a stressful activity. With repeated activity, progressively severe discomfort occurs both during and following the activity, and often during the night while resting.
Physical findings typically include antalgic postures and maneuvers, increased pain on percussion, localized swelling, point tenderness, referred pain, and a restricted range of motion (soft-tissue related). If significant stress is superimposed on a fatigue fracture (eg, fall, blow), a displaced fragment may be produced.
ROENTGENOGRAPHIC AND ULTRASONIC FINDINGS
Roentgenographic evidence rarely appears until 10 days after the precipitating trauma, and it may not appear until 40 days after the incident. The first signs are endosteal or medullary sclerosis and a break or nick in the cortex that is followed by the development of a periosteal callus.
Bone scans have been found to be more sensitive in detecting fatigue fractures than conventional x-ray procedures. This is an important consideration because if a fatigue fracture is found in one area, nonsymptomatic contralateral or remote fatigue fractures may be associated that could lead to serious complications.
The growth plates in the young are highly susceptible to severe stress because of their vascularity.
Traumatic changes as the result of stress (osteochondritis) are featured by displacement, bony fragments, distortion or collapse, and irregular ossification during late stages. Osteochondritris may occur at almost any epiphyseal plate, and is often named after a descriptive author. For example, femoral head, Perthe's disease; heel, Sever's apophysitis; metatarsal heads, Freiberg's disease; tarsal navicular, Kohler's disease; tibial tubercle, Osgood-Schlatter's disease; and the vertebral plates, Scheuermann's disease. Such terminology is confusing as the condition is not a disease, and this should be stressed to the afflicted.
These are seen in the young and are almost always associated with severe trauma. They may occur spontaneously such as in the hip when associated with unexplained knee pain. The growth plate is weakest at the site of cell degeneration and provisional calcification, especially in children who are undergoing a rapid spurt in growth or who are overweight in proportion to their skeletal maturity. A common pitfall in orthopedics is to confuse an epiphyseal slip for a ligament injury; eg, at the knee joint. Epiphyseal slips should be treated as fractures, for fractures are what they are rather than a disease process.
This disorder features inflammation of subchondral bone and articular cartilage which results in split pieces of cartilage within an affected joint. The cause is not completely understood, but the damage is inevitably at a point where compression occurs in a jarring injury. The clinical picture is one of avascular necrosis, where flakes or loose bodies of bone and/or cartilage are extruded into the joint. The knee, ankle, and elbow are most often affected.
Bone Inflammations and Infections
The earliest symptoms and signs of acute bone or joint infection are local pain and tenderness in the periarticular region.
The patient has extreme difficulty or refuses to move the joint. The cardinal signs of infection (heat, redness, swelling) may appear much later than pain and tenderness, and sometimes never appear. Roentgenograms are of little help in arriving at an early diagnosis; when evidence is obvious, the disease is chronic. Sometimes comparative bilateral films exhibit slight soft-tissue-shadow evidence.
Most orthopedists favor immobilizing an infected area, but many disagree over casting or splinting. Casting is usually used when bone damage is significant and to prevent a pathologic fracture. Mild continuous traction is used to allow some joint mobility without further damage to articular cartilage.
When trauma is the chief factor, an acute arthritis may be induced. The extent of the local reaction is relative to the severity of the injury and the resistance of the tissues. Repeated injuries from excessive joint stress may cause pathologic reactions or produce derangements within the joint. Or arthritis resulting from a single severe injury, especially if improperly treated, may be indefinitely prolonged and result in chronic symptoms and permanent disability.
Traumatic arthritis presents signs of pain, possible ecchymosis, and soft-tissue swelling of periarticular tissue that may be limited to effusion within the capsule or obliterate bony prominences. This depends upon the severity of trauma, tenderness on pressure, and loss of function. Motion is usually limited because of pain, and there will be joint instability if the injury is sufficient to tear a tendon or joint capsule. Intra-articular factures and fragments may be associated. The prognosis is excellent in those receiving efficient treatment; however, a subacute arthritis may, at times, persist indefinitely.
Periositis is commonly associated with joint injury, especially that of the knee. It is the result of violent muscle strain which damages the periosteum. If severe enough to detach the periosteum, a degree of hematoma develops. The bruised joint is swollen, extremely tender, and movements are restricted. Physical examination makes one suspicious of fracture, but early roentgenographic findings are negative. Later, ossification of the hematoma is exhibited by induration of the swelling and new bone formation.
If severe hematoma is associated, aspiration may be necessary. In milder cases, firm support and physical therapy are appropriate. The condition is slow to heal and usually requires at least seasonal restriction from further athletic activity.
With the exception of compound fractures, repeated injuries, and piercing wounds, osteomyelitis is rare in sports. When diagnosed, antibiotics are invariably required for control. Staphylococcus aureus is the common agent in all ages, and over 50% of the strains are penicillin resistant. Blacks are prone to develop a subacute form of osteomyelitis, especially if there is any indication of sickle cell anemia.
The time between initial infection and circulatory troubles is often rather short. If effective treatment is delayed and partial circulatory embarrassment is allowed for more than just 72 hr after the infection begins, surgery may be the only alternative and loss of joint function may be the result.
Post-Traumatic Painful Osteoporosis (Sudeck's Atrophy)
Following extremity trauma, bone (being reactive tissue as other tissues) undergoes rapid and extensive physiochemical changes under the influence of the circulatory and trophic disturbances which frequently follow injury.
It is common for immobilized bones to lose considerable mineral salts and show osteoportic areas on x-ray examination. This type of disuse atrophy has little clinical importance as normal bone density and strength return quickly when function is resumed. It is essentially asymptomatic. Osteoporosis can be differentiated from such disuse atrophy in that true osteoporosis is characterized by a patchy decalcification of extremity bone in which there are coexisting signs of pain, vasomotor changes, and trophic disturbances.
A neurogenic type of bone atrophy may show its effects long after the effects of the original trauma have subsided or after fractured bones have united in good position. Not infrequently, it manifests 3-6 weeks after some apparently trivial injury to a polyarticular joint and is confused with malingering when insurance or compensation is involved.
Sudeck first described this disorder in 1900 as an acute reflex atrophy of bone and thought it was due to a low-grade inflammation; but in 1902, he agreed with Kienbock that it was a manifestation of trophoneurosis. Researchers have shown that roentgenographic signs occur much earlier that those of disuse atrophy, and that osseous signs appear even when the extremity was in use. Other researchers disagree. However, the fact that osteoporosis is more frequent after trauma to the polyarticular regions (eg, ankle, wrist) is suggestive evidence that stimulation of the numerous articular and periarticular nerves brings about the reflex vasomotor changes via viscerotrophic fibers which are ultimately responsible for the production of the osteoporosis.
There are two etiologic theories. One is that the disease is the direct result of trauma and that the changes in bone are brought about by reflex action upon the trophicity or the vascularity of the bone. The second theory is that osteoporosis comes on indirectly and that it is due to inactivity or loss of functional stimulation.
In the early stages, it is characterized by constant aching pain, hyperesthesia, local swelling and hypervascularization, local heat, redness, marked joint stiffness, and abnormal sudomotor response of the previously injured part. These indications progress to vasoconstriction and edema, with a moist, cold, cyanotic part. In late stages, the skin becomes atrophic, thin, and shiny, and there is attrition of the nails, excessive hair growth on the part, and diffuse osteoporosis is demonstrated on x-ray films.
Any neural or circulatory interference to the part must be normalized. Vigorous physiotherapeutic measures are necessary to reduce edema, maintain joint motion, and increase deteriorating muscle activity. Minimal immobilization should be followed by active movement, heat, and massage.
Related Inflammatory Processes
Tendinitis, tenosynovitis, peritendinitis, and bursitis directly in a joint region are noninfectious inflammatory processes involving a tendon, a tendon sheath, or a bursa. They may be related to a specific single severe trauma or a series of microtraumas as often seen in weightlifters, tennis players, and even piano players and typists from joint stress and fatigue. Nelson states that they may be the result of reduced microcirculation caused by reflex mechanisms. The symptoms are a gradual onset of pain radiating along the involved tendon upon active contraction or passive stretching. The swelling is localized and soft, and the area may present heat and redness.
Most joints permit movement in the joint itself and/or fix a limb portion while another joint is in motion. They also function in transmitting stress when stabilized by musculature. This stabilization is necessary so that muscles can achieve their maximum leverage for joint motion (eg, angular, gliding, rotational).
The stability of synovial joints is primarily established by action of surrounding musculature. Excessive joint stress results in strained muscles and sprained or ruptured ligaments. When stress is chronic, degenerative changes occur. Joints are usually stressed from a direct blow leading to connectivetissue contusion and possible intra-articular fracture or a slipped growth plate in the young. The blow is often an unexpected one where protective mechanisms have not been put in force, or it may be so excessive that protective mechanisms fail.
The synovial lining is slightly phagocytic, is regenerative if damaged, and secretes synovial fluid which is a nutritive lubricant that has bacteriostatic and anticoagulant characteristics. This anticoagulant effect may result in poor callus formation in a situation of intra-articular fracture where the fracture line is exposed to synovial fluid.
Examination generally includes inspection, bony palpation, soft-tissue palpation, determining the passive and active range of motion, testing muscle integrity and strength, testing superficial and deep reflexes, and investigating associated areas.
First seek gross abnormalities. Observe gait, and note any awkwardness in rhythm, weight shifting, or imbalance. Note any bone distortion, angulation, or limp. When a specific joint is involved, observe any gross deformity or swelling from either
(1) fluid, where a wave can be demonstrated or
(2) thickened synovial tissue, where there is no wave but boggy tissue can be palpated.
Inflammation associated with a red and swollen area suggests an acute synovitis. Inspect muscles for hypertrophy and atrophy, and note areas of old ecchymoses which point to previous trauma. Sinus formation is rarely seen. When present, the sinus leads to necrosed bone, to gouty tophi, or to abscess in or near the joint.
Irregularities of contour may be the result of osteophytes or lipping (attached to the bone); gouty tophi (not attached to the bone); constriction line opposite the articulation; or protrusion of joint pockets in large effusions filling natural depressions. Irregularities of contour are easily recognized provided the normal contour of different body types is familiar. Note distortion or malposition due to muscle contractures near the joint, to necrosis, to exudation, or to subluxation.
Palpation and Percussion
Note any trophic lesions over or near a joint (cold, sweaty, mottled, cyanosed, white, or glossy skin; muscle atrophy). Palpate the joint for masses and points of tenderness which may indicate osteoarthritis, synovitis, a torn ligament or meniscus.
Palpate for muscle tone, fasciculations, and spasms. Fasciculations are small, isolated, involuntary contractions of a portion of muscle fibers, representing spontaneous discharge of a number of fibers innervated by a single motor nerve filament. Spasms are readily palpable, tender, and frequently accentuated during passive joint movement.
Palpate bone for tenderness and masses. Bone tenderness suggests inflammation, tumor, fracture, or complications from trauma. A suggestion of bone inflammation is enhanced when the bone is percussed at a site distant from the point of tenderness and pain is felt at the site of tenderness rather than at the site of percussion.
A hard enlargement is probably of bony origin. If boggy, it is probably infiltration or thickening of the capsule and periarticular structures. If fluctuating, it is probably from fluid in the joint. Enlargement is generally unmistakable; but when there is considerable muscular atrophy between the joints of a mature weekend athelete, the joints may seem enlarged by contrast when in fact they are not.
Fluid or semifluid exudates in joints may fill up and smooth out the natural depressions around the joint, or, if the exudate is large, may bulge the joint pockets. In the knee joint, four eminences may take the place of the natural depressions, two above and two below the patella.
Functional limitation may be the result of
(1) pain associated with movement,
(2) bone or joint instability (eg, muscle weakness, fracture, torn ligament), or
(3) restricted joint movement by effusion, muscular spasm, ankylosis, thickening or adhesions in the capsule and periarticular structures, obstruction by bony overgrowths or gouty tophi.
Determine active and passive ranges of motion bilaterally, and palpate the joint simultaneously to determine the presence of crepitation. Crepitus and creaking are detected simply by resting one hand on the suspected joint, with the other hand putting the joint through its normal range of motion while the patient remains passive. Note bone integrity by its ability to resist a deforming force.
The examination of the musculoskeletal system must be greatly adapted in examining an acutely injured patient from that of a patient presenting nontraumatic complaints. For instance, active and passive range of spinal motion should not be conducted until after roentgenograms have demonstrated the mechanical integrity of the joint.
Excessive motion such as in joint tears is recognized simply by contrast with the limits furnished us by our knowledge of anatomy and physiology of joint motion at different ages. When bone and cartilage appear normal or are not grossly injured, we call the excessive motility of the joint a nonfixated subluxation, but excessive motility may also be due to destruction of bone and other essentials of the joint.
Measurements and Reflexes
Take circumference and limb length measurements at equal points above and below involved joints bilaterally and compare. Swelling enlargement or telescoping of the joint with shortening may be found, evidenced by careful limb measurements.
Test deep tendon reflexes. Upper limb muscles are supplied essentially by C2-T1; lower limb muscles by L1-S2.
Indirectly we may gain information about joint disorders by noting:
(1) General constitutional symptoms, their presence or absence. These include fever, chills, leukocytosis, glandular enlargement, albuminuria, and emaciation.
(2) Blood analyses such as tuberculin and Wassermann reactions, bacterial presence or absence.
(3) Disease of other organs, their presence or absence. And
(4), the course of the disease and the results of treatment.
Pertinent Signs and Symptoms
Typical abnormalities that may be discovered in disorders of the musculoskeletal system include:
(1) color changes such as ecchymoses and redness,
(2) local heat,
(3) soft-tissue swelling from synovial thickening, periarticular swelling, or nodules,
(4) swelling from bony enlargement,
(5) deformity from abnormal bone angulation, subluxation, scoliosis, kyphosis, lordosis,
(6) wasting from atrophy or distrophy,
(7) tenderness on palpation,
(8) pain on motion,
(9) limitation of motion,
(10) joint instability, and
(11) carriage and gait abnormalities.
If the history indicates recent travel abroad, the symptomatic picture may represent problems not usually seen in this country. For example, joint pain may be the result of hydatid disease, amebiasis, fungal infections, or of some tropical diseases that may express themselves in joints during their acute or chronic course.
Probing into the character, origin, timing, onset, and the absence of pain offers important clues. Referred pain is often associated with musculoskeletal disorders, as are somatosomatic, somatovisceral, and other reflexes.
Unusual causes may be found. A history of childhood heart disease, St. Vitus dance, or chorea suggests joint pain resulting from acute rheumatic fever. Allergic conditions (eg, hay fever, asthma, migraine) point to a diagnosis of nonspecific intermittent hydrarthosis. Joint pain associated with a history of joint aspiration or intra-articular medication injections suggests pyarthosis. Or joint pain may be associated with a venereal disease.
Fracture pain is severe, throbbing, and aggravated by movement of the part. A sharp, severe pain (associated with muscle changes and sensory disturbances) radiating along the distribution of a nerve is characteristic of acute nerve compression. Severe throbbing pain is characteristic of gout and septic arthritis. Pain from degenerative arthritis and muscular disorders is an aching type which is relieved by rest, aggravated by certain motions, and often accompanied by splinting and paresthesias. Bone pain resulting from tumor or aneurysm is usually deep, constant, boring, more intense at night, and rarely relieved by rest or a change in position. Severe and persistent pain in one joint that begins to spread to adjacent joints is characteristic of inflammatory arthritis that is chronic and nonspecific in nature.
Although bone proper is insensitive to pain, orthopedic pain originates from the periosteum, joint capsules, surrounding connective tissues, irritated or inflammed bursa. A fractured bone produces pain from the periosteal rupture and soft-tissue hemorrhage pressure. Arthritis is painful because of the joint capsule irritation. A bone tumor yields pain due to the pressure upon and/or stretching of the periosteum. A history of a recent injection of antitoxin or the administration of a new drug may suggest joint symptoms having an allergic basis.
Joint pain worse in the morning after rest that is relieved after mild exercise but worsens in the evening points to joint disease. Deep, aching, throbbing, dull or sharp pain that may be either constant or spasmodic is typical of joint disease. Pain from a herniated disc is relieved by rest and gets progressively worse as the day goes on. A dull ache during rest that's aggravated by motion suggests inflammatory arthritis. Pain lasting for several weeks or longer is common in chronic arthritis. In acute rheumatic fever and often in gonococcal arthritis, pain lasts for several hours, disappears, then reappears in other joints.
Sharp pain occurring only when the joint is moved a certain way and which is usually relieved by rest or immobilization points to joint dysfunction. In degenerative joint disease of the weekend athlete, the pain which occurs on motion and is relieved by rest is the result of joint dysfunction rather than the arthrosis itself.
Both primary joint dysfunction and joint disease may present sudden pain following trauma or an episode of stress; however, joint swelling is uncharacteristic of joint dysfunction but is of joint disease. Joint disease may also have an insidious onset that is unusual in joint dysfunction. An exception to this would be intrinsic trauma causing joint dysfunction occurring during sleep or unconsciousness.
The onset of pain in several joints simultaneously points to joint disease unless several joints have been immobilized such as in multiple fractures or involved in severe trauma with multiple bruises. Gradually developing pain is often associated with chronic nonspecific arthritis. A rapid onset is seen in acute rheumatic conditions and gout.
ABSENCE OF PAIN
Neuropathy is suspect when there is no pain but obvious joint disease. In such cases, diabetes mellitus is the usual fault. When pain fibers are destroyed or deadened in joint disease, injury is not safeguarded against properly and traumatic osteoarthritis advances rapidly. In history of a nonmedicated painless limp, muscle disease is the first suspect, but a metabolic bone disease or an endocrine dysfunction may be involved in children.
Periarticular swellings are classified as
(1) swellings arising in the joint proper,
(2) swellings derived from the bones adjoining the joint, or
(3) swellings originating in the extra-articular tissues around the joint.
Joint swelling is the result of thickening of the synovial membrane or of excess fluid in the joint cavity. Such swelling is often obscured by bones, muscles, and tendons which overlie the joint cavity or its pouches; however, it is noticeable over thinly covered areas of the joint. For instance, swelling in the hip joint is almost impossible to detect. Swelling in the elbow is observed only at the posterior aspect on the sides of the olecranon process because the anterior surface of the elbow joint is thickly covered with muscles and the lateral aspects by strong collateral ligaments which prevent protrusion. For the same reasons, a wrist swelling is least noticeable when viewed from the front and radial side, and a knee swelling is least noticeable when viewed from the medial or posterior aspect.
Joint trauma is profiled by a cool periarticular swelling that's very tender. Trauma or inflammation may result in hemorrhage or effusion. Painless bony lumps and asymptomatic joint swelling can often be traced back to forgotten trauma, especially when associated with sports injuries. For example, surfboard enthusiasts will often present bony lumps slightly inferior to the tibial prominence.
Swelling around a joint can be caused by edema from fluid overload or venous insufficiency. If this is the situation, pain and tenderness will be absent. Swelling around a joint that is warm and painful is characteristic of gout and rheumatic arthritis. Synovial inflammation is characteristic of nonspecific arthritides, rheumatic fever, septic arthritis, gout, and various collagenvascular diseases.
In degenerative joint diseases, the trauma may be only normal activity to elicit effusion. A gonococcal wrist or ankle joint will usually be associated with nearby tenosynovitis. Infiltration, effusion, or inflammation can cause direct joint swelling. Localized infiltration is seen in leukemia, myeloma, and amyloid disorders.
Because of the relative position of various bones and associated relaxation of the muscles around joints, every joint has one position in which the synovial cavity attains the greatest dimensions. When tension increases in the synovial cavity because of effusion, the patient will adopt a position that affords the greatest relief. For instance, the following positions of the larger joints offer the greatest ease:
(1) hip: slight flexion, eversion, abduction,
(2) knee: slight flexion,
(3) elbow: flexion and midposition,
(4) wrist: slight flexion, and
(5) ankle: plantar flexion and eversion.
Shape of the swelling corresponds to that of the synovial membrane distended in toto. For instance, when a subcrureal pouch becomes dilated, the knee joint swelling may extend as much as 7 inches above the joint line. Distention of the tabular process of endothelium about the long head of the biceps in the shoulder may present enlargement over the surgical neck of the humerus.
In general, joint motion becomes restricted from either pain or mechanical disability. Intra-articular swellings impair both active and passive movements, while extra-articular swellings impair one type of movement or none. Foreign bodies or fragments within a joint that result in effusion are associated with intermittent motion restriction.
All swellings should be tested for fluctuation if they are more than an inch in diameter. Testing for fluctuation is made in two planes at right angles to each other. If a mass fluctuates in one plane but not another, it is negative for swelling because a swelling fluctuates in both planes. In testing for fluctuation, fat or muscle also transmit an impulse, but less perfectly than fluid.
Moderate swellings are tested for fluctuation by pressure exerted with the tip of a finger midway between the center and outer border of the swelling while the tip of the other finger is placed at an equal distance on the opposite side but remains stationary. The stationary finger moves passively from the pressure exerted by the action finger on the other side. Then reverse the procedure with the originally passive finger becoming the active finger and vice versa. If displacement takes place in two planes at right angles to each other, there is little doubt that the swelling contains fluid. When examining small swellings, it is often best to use two fingers of each hand.
A swelling of less than an inch is difficult to test for fluctuation. In such a case, use Paget's test which consists of pressing the mass with a fingertip. A solid swelling is hardest in the center, while a cyst is softest in its center.
In the knee, the examiner tests for "floating" of the patella over an effusion by surrounding the joint with both hands, which are pressed slightly toward each other to limit the escape of fluid in either direction, and then suddenly making quick pressure on the patella with one finger. If the examiner feels or hears the patella knock against the bone below and rebound as the pressure is released, fluid in abnormal quantity is present.
There are several types of crepitus which characterize a specific type of lesion: bone crepitus, traumatic pulmonary emphysematous crepitus, joint crepitus, and tendosynovitis crepitations.
Bone fractures elicit an audible grating when the ends of the broken fragments rub against each other during movement. The crepitation from an epiphyseal separation resembles that of a broken bone but is softer in character than bone crepitus from a fracture.
A fractured rib in which a fragment of bone has pierced a lung allows air from the lung to escape into the subcutaneous tissues. Crepitus may be felt when the fingers are placed with mild pressure over the affected area.
Joint crepitus may be tested by placing a hand over the joint while passively moving the joint with the other hand. When coarse crepitations are transmitted to the palm of the palpating hand, osteoarthritis is usually involved. Other acute or chronic lesions present fine crepitations. To amplify the crepitations involved, it is often helpful to apply a stethoscope to the joint during the passive motions.
Crepitus may be felt over an effused joint following inflammation of the tendon sheath. In traumatic tendosynovitis of the extensor tendon sheaths of the forearm, for example, test by grasping the arm above the wrist while instructing the patient to clench his fist and open his hand with rapid motion several times. The presence of effusion will result in a transmittable or audible crepitation.
Pitting on Pressure
Pitting is a sign of liquid infiltration into the underlying tissues. Tenderness associated with pitting is indicative of inflammatory edema. While edema gives rise to a soft pitting, a degree of induration can be felt if pus is present.
A suspicion of edema may be confirmed by applying thumb pressure over the area in cases of massive infiltrations and index-finger pressure in cases of localized swelling. This pressure should be maintained for about 15 sec. A positive sign of edema is indicated by a depression in the area after the action thumb or finger is removed. The depression is often palpable with the fingertips even if it is not visible.
Local Temperature and Tenderness
In cases of inflammation, the presence of local heat is a valuable sign. This may be noted by passing the outstretched hand rapidly over the affected part to an unaffected part and back again. Any difference in warmth from the affected area to the unaffected area signifies an increase in local temperature.
Mild cases of joint involvement invariably present points of maximum tenderness which correspond to those regions of the endothelium most superficial. For example, they are elicited
(1) in the knee on both sides of the patella,
(2) in the wrist over the anatomical snuffbox,
(3) in the elbow over the radiohumeral joint, and
(4) in the ankle at the anterior surface of the joint.
Joint stiffness is often the result of an overly stressed muscle in a young player or a sign of degenerative changes in an older athlete. The history of joint stiffness should be recorded as to distribution, duration, and associated circumstances. The stiffness may be in one joint or several. It may last only a few moments or for several hours or days. Inquire about the related circumstances: what aggravates and what relieves the stiffness?
Joint stiffness is often caused by edema or structural changes. Edema around the joint capsule is found in inflammatory disorders. Edema in the joint capsule secondary to inflammation is characterized by being worse after rest; eg, in the morning or arising after sitting for a long period. Stiffness that lasts for more than a half hour points toward the inflammatory arthritides, wherein it may last for several hours.
Stiffness resulting from structural changes is usually traced to cartilage degeneration or capsule tears. Previous trauma or inflammation of a capsule or associated tendons and sheaths may have resulted in adhesion formation. Stiffness resulting from degenerative disease becomes pronounced when area muscle compensation fails to protect thinning cartilage. Here also the stiffness is more pronounced after rest; however, it is quickly relieved by mild exercise.
To distinguish muscular spasm from bony outgrowth in the weekend athlete as a cause of limited joint motion, notice that bony outgrowths (eg, in the hip) allow perfectly free motion up to a certain point, then motion is arrested suddenly, completely, and without great pain. Muscular spasm, on the contrary, checks motion a little from the onset. The resistance and pain gradually increase until the examiner's efforts are arrested at some point, vaguely determined by the examiner's strength and hard-heartedness and by the patient's ability to bear the pain. Bony outgrowths within the joint are sometimes only recognized by the sudden arrest of an otherwise free joint motion at a certain point. In most cases, roentgenography is necessary. In true ankylosis, there is no mobility whatever.
Motions limited by capsular thickening and adhesions are not, as a rule, so painful after the first limbering-up process is over. There is no sudden arrest after a range of free mobility, but motion is limited from the first and usually in all directions, although the muscles around the joint are not rigid. The possibility of more or less limbering-out after active exercise (or passive motion) distinguishes this type of limitation.
Free bodies in the joint are not palpable externally and are recognized only by their symptoms, by roentgenography, and by operation. These loose bodies in a joint are the result of trauma, degeneration, or an inflammatory process. They may be singular or multiple, be free or attached, and be of bony, cartilaginous, or synovial origin. Loose-body formation is the outstanding symptom of osteochondritis dissecans and osteochondromatosis. They rarely present a problem; but if persistent joint "locking" occurs, surgery is usually advised.
There are certain other conditions in which loose bodies occur as a complication of a pathologic process:
(1) breaking loose of new bone processes and cartilage in certain degenerative joint disorders (eg, osteoarthritis);
(2) the organization of clots of fibrin forming rice bodies and melon-seed bodies; and
(3) intra-articular fractures, especially compression fractures.
Joint Dysfunction vs Joint Disease
Joint dysfunction implies the loss of one or more movements within the normal range of motion and associated pain. Joint dysfunction is only one possible problem that must be differentiated from other causes of joint pain. In a history of joint pain, there may be many clues pointing to the diagnosis of joint disease and many strongly suggesting joint dysfunction. This may represent separate problems overlapping on one another or be one complex problem. Thus, joint and periarticular pain and discomfort must be fully understood to arrive at a correct diagnosis because they appear in such a large variety of dysfunctions and diseases which may underly an apparently acute athletic injury.
Primary joint dysfunction is usually the effect of intrinsic joint stress occurring at an unguarded moment when the joint is active within it's normal range of motion. Another cause is that of extrinsic joint stress following a definite but minor trauma, often classified as a sprain and/or strain.
Secondary joint dysfunction is often overlooked in traditional medicine. Yet joint dysfunction is, according to Mennell, "the commonest cause of residual symptoms after severe bone and joint injury and after almost every joint disease when the primary pathologic condition has been eradicated, has healed, or is quiescent." Immobilization after surgery, immobilization from a fracture cast even if the fracture is far from a joint, and immobilization from a taped sprain all cause residual symptoms of joint dysfunction.
Symptoms also follow joint inflammation or resolution of systemic joint disease with or without internal adhesions. When joint dysfunction causes residual symptoms after so-called joint disease recovery, the symptoms change from that of joint disease to joint dysfunction. That is, during the active process, rest increases joint pain and stiffness; during the residual dysfunction, rest relieves and action aggravates the pain. These points should be brought out during the case history.
To review the key history points of primary joint dysfunction: (1) the pain has a sudden onset and is sharp, (2) it usually follows stress at some unguarded joint motion, (3) pain is limited to one or adjacent joints, (4) pain is aggravated by movement and usually at some particular area of motion, (5) rest relieves the pain and doesn't produce stiffness, and (6) marked swelling or warmth is not associated.
Peculiar features elicited in the history point directly to certain diseases. For instance, hemarthosis has a history of trauma and is characterized by slight but rapid swelling from blood; the joint is hot and acutely painful. Synovitis also has a history of trauma, but the swelling due to excess synovial fluid may not occur for many hours, and the joint may feel warm rather than hot, and aching rather than acutely painful. The athlete, young or old, is not immune to rheumatic or degenerative joint conditions. It is all too easy to think of every joint injury of a sportsman as solely traumatic. Gout, osteoarthrosis, and infection are sometimes underlying factors. Gout may occur in any limb joint and is occasionally found in the spine, and it is not always associated with tophi or limited to the feet and hands.
Infection may be the result of a penetrating wound or be blood borne. A hematoma or hemarthrosis is an invitation to a subclinical blood-borne condition to manifest. Persistent pain following adequate treatment may indicate the presence of a secondary low-grade and unsymptomatic infection or irritation in spite of blood reports to the contrary. In such cases, suspicion should be directed toward a distant focus of infection. But, it need not be infection. It could be irritation from malfunction in a part of the gastrointestinal tract that reflexly produces vasospasm in the joint and hence pain. We must be aware that irritation produced by malfunction of a viscus can produce many difficult to diagnose symptoms.
Painless swelling of the feet or ankles is a common sign in heart failure, in certain kidney conditions, in the use of estrogens, and is the result of several idiopathic origins. However, the musculoskeletal system is often overlooked, and the swelling may be the result of venous and/or lymphatic congestion due to pelvic, thoracolumbar, diaphragm, or rib-cage dysfunction.
Periarthritis is another ill-defined disorder associated with an active process originating elsewhere. The clinical picture is one of infiltration, generalized tenderness, pain on movement, and joint heat. Management consists of seeking the causative factor, normalizing neural or vascular interference, regulation of diet, rest, and moist heat applications.
Soft-Tissue Joint Injuries
Sprains A sprain is a joint injury in which the ligaments, capsule, and surrounding tissues are partially torn or severely stretched without dislocation being present. There may have been a partial dislocation that spontaneously reduced itself. The cause is primarily from forcing a range of motion beyond the power of a ligament to withstand the stress such as from overstretching or overexertion. The extent of damage depends upon the amount and duration of the force.
Sprains are classified by severity as acute, subacute, or chronic, or by the area of involvement such as cervical, thoracic, thoracocervical, brachiocervical, thoracocostal, thoracolumbar, lumbar, lumbosacral, sacroiliac, or iliofemoral. Although the terms subacute and chronic may be diagnostic entities, these terms are confusing and an explanation of the subacute or chronic joint instability is more descriptive and desirable.
In differentiating sprain and strain, keep in mind that sprain involves the ligaments of a joint and strain involves the muscular and tendinous structures. Sprain usually elicits pain on movement of the affected joint even without muscular effort; strain elicits pain on muscular effort even without movement as in resisted contraction. However, any tissue may be strained in injury if the word "strain" is being used as a verb. When used as a noun or state of being, however, sprain refers to ligamentous injury and strain to muscular or tendinous injury.
When a ligamentous tissue is subjected to continuous stress, it will become chronically inflammed and invaded by collagen substance and mineral salts. This results in sclerosing and even varying degrees of calcification. In addition, when ligamentous tissues are subjected to acute traumatic strain, they will experience rupture of some of the comprising fasciculi which is attended by minute hemorrhages. If the involved ligament possessed elastic fibers, there will be a definite shortening.
Sprains, as strains, are divided into three degrees of injury:
Second-Degree Sprain. This is a moderate sprain with a partial ligamentous tear, characterized by increased severity of first-degree symptoms. A tendency toward recurrence is a complication, as is the possibility of traumatic arthritis and permanent instability. A moderate sprain results from severe tearing of the ligaments, although at least half of the fibers remain undamaged. This type of sprain shows some loss of function in the injured area even if the torn ligaments are not widely separated. They will join together again during the natural healing process unless the damage is great. If so, considerable scar tissue may form, and a permanent weakness of this section of the ligament may result. Moderate sprain is characterized by a greater degree of symptoms than presented by a mild sprain, lack of normal ligamentous resistance on digital pressure, and increased joint movement on tension as seen with movement or manipulation.
Third-Degree Sprain. This is a severe sprain with a complete ligamentous tear, characterized by severe swelling, hemorrhage, tenderness, complete loss of function, abnormal motion, and possible deformity. When a sprain is termed severe, it denotes a complete loss of function of the ligament caused by a force sufficient to pull it completely apart or tear it loose from the surrounding tissues. A severe sprain is characterized by a greater degree of symptoms than presented by a moderate sprain plus marked excessive joint motion indicating definite separation on tension or motion. Severe pain may or may not be present. Abnormal motion may be exhibited on bilateral stress roentgenograms. Persistent instability and traumatic arthritis are common complications. If seen soon after injury before swelling occurs, a palpable gap may be felt at the site of tear.
If only a few fibers are stretched or torn, the part should be elevated and treated with cold packs to minimize swelling and relieve pain. Joint stability must be maintained until strength returns; a sprain should be supported (eg, ankle hitch) to prevent further stretching. If there is any doubt as to the severity of the injury, it should be treated as a fracture.
The same regimen is advised if several fibers are torn but the joint remains quite stable. The only change is that movement is delayed and initiated slowly with gentle nonweight-bearing passive movements only. This can be followed by swimming and carefully monitored flexion-extension active movements. Lateral and rotational movements should not be allowed until 2-3 weeks. When such injuries are numbed by an anesthetic so a player may return to competition, the results can be disastrous.
Torn large ligaments may require from 8-16 weeks for the scar to mature enough for protection. In severe sprain, a decision must be made whether motion or stability is the most important consideration. Early mobilization is necessary if motion is the priority; immobilization until solid healing occurs is necessary if stability is the priority. Surgical repair is usually required if the ends of the ligament cannot be approximated, the joint cannot be reduced, or when there is complete lack of stability.
These are usually associated with the spine and knee but are occasionally related to the temporomandibular, sternoclavicular, and distal radioulnar joints. Moderate cases can usually be managed by manipulation, rest, physical therapy, and muscle reeducation, but crippling cases may require surgery.
Cartilaginous and disc substance when traumatized will progressively undergo degenerative change with possible dehydration and fragmentation. Disc damage results from repeated vertebral subluxations and the strain of mechanical and postural incompetence which tend to weaken the annulus, and, in the cervical and lumbar spine areas especially, at the posterolateral aspects with possible bulging into the intervertebral foramen. There may also be a visceral reflex causing a slight vasospasm leading to degeneration.
A capsule tear usually results from an unexpected joint force, often occurring in an abnormal plane of motion. The torn tissues produce hemorrhage and local tenderness. Damage to the synovial membrane is commonly associated, resulting in effusion and possible hemarthrosis. Unless joint stability is severely disrupted, these disorders improve well with conservative care. Early treatment should consider cold, pressure, rest, and a graduated muscle education and exercise regimen. On the third or fourth day, contrast baths, deep heat, and more active movement can begin. Associated contusions are treated the same as the sprain.
A sudden, usually rotational, joint stress may cause some soft tissue to be pinched within articular structures. This is most frequently seen in the knee where infrapatellar fat is nipped, resulting in effusion and possibly hemorrhage. Management is the same as that for sprain, but movement is slightly delayed because injured fat is slow to heal.
An osseous dislocation is the displacement of the normal relationship of the articular surfaces of the bones that make up a movable joint.
Dislocation places considerable strain on ligaments which normally maintain joint position. There may be injury to these ligaments, the capsule they form around some joints, articular cartilage, synovial membrane, and other soft tissues, as well as hemorrhage into or around the joint. A dislocation may result in a complete luxation or a subluxation. In the extremities, a presented subluxation may be the effect of a spontaneously reduced dislocation and be associated with considerable capsule and ligament damage. Pain, swelling, and deformity are centered about the joint. Usually, there is also loss of motion.
A dislocation is immobilized in the same way as a fracture: close to the joint. Cold compresses may be applied to the joint to relieve pain and reduce swelling, but the patient's temperature must not be lowered so as to invite shock. Related ligaments are frequently torn and require surgical repair. Postreduction immobilization usually requires 6 weeks in the lower extremity, 3 weeks in the upper extremity. Inadequate care, especially in ankle and shoulder dislocations, leads to chronic weakness, movement restrictions, instability, and recurrent dislocation wherein subsequent surgery has a poor prognosis in restoring preinjury status. Most all dislocations require x-ray analysis prior to reduction.
Objectives of Joint Injury Management
Prevention is better than cure. A large percentage of traumatic joint injuries can be avoided with proper conditioning, training, and practice. After injury, the following points are the aims of good case management.
Reduce and Reabsorb Swelling. Early cold, compression, elevation, and rest will do much to avoid the hazards of excessive swelling. Heat, massage, and exercise are contraindicated in the early stages, but beneficial in the later stages. Aspiration is contraindicated unless necessary for diagnosis or relief of severe pressure. To prevent capsular stretch from chronic effusion, local compression, elevation, contrast baths, and muscular activity are beneficial after 48 hr. Normal joint movement and tendon function cannot be achieved until periarticular swelling has been absorbed.
Minimize Deformity and Wasting. An attempt must be made to normalize existing deformity, mechanical obstruction, and articular irregularities so that normal joint motion and configuration can be achieved. Joint stability must be achieved by conservative measures (eg, manipulation, physiotherapy, proprioceptive neuromuscular reeducation) or surgical and postoperative rehabilitative methods. Progressively increased exercises are necessary to minimize muscle wasting which rapidly follows joint trauma. A protective reflex muscle spasm may interfere with early rehabilitation. It is best treated with cold and cryokinetics.
Normalize Joint Movements and Function. Progressively increased remedial exercises of a well-supported joint help to restore normal joint motion. Support should not restrict motion in an unaffected plane. Once the joint's full range of normal motion is obtained painlessly, strength-developing and skill exercises can be carefully incorporated with emphasis upon rhythm to avoid tissue breakdown.