Biology of Injury and Healing

Question 1

what are 3 tissue types in terms of growth? what are some examples of each?

Answer 1

liable (bone)

stable (muscle, tendons, ligament, cartilage)

non-division/ permanent

Question 2

what are te 3 phases of healing

Answer 2

1. Inflammation
2. granulation tissue formation
   
   1. cell proliferation and angiogenesis
   2. fibroblast migration
3. remodeling

Question 3

what is the difference in mind set between a question about what you are “most worried about” and what is the “most likely diagnosis”

Answer 3

most worried about means something that is possible, but is the most immediately emergent. this is not necessarily the most likely diagnosis.

Question 4

what are the 3 different kinds of fractures?

Answer 4

• traumatic
  
  • high force exceeds normal bone strength
• pathologic
  
  • normal force exceed damaged bone strength
• stress
  
  • repetitive submaximal forced gradually damages bone

Question 5

What is the process/time line of bony healing?

Answer 5

• Bleeding (seconds to minutes)
• Clot formation (minutes to hours)
• Inflammatory stage (hours to days)
• Repair stage (1-2+ weeks-3+months)
  
  • osteoclasts and osteoblasts invade blood clot
  • soft callus (2-6 weeks)
  • hard callus (4 to 12+ weeks)
  • callus matures (12-26 weeks)
  • bony gaps bridged (6-12 months)
• Remodeling stage (1-2 years)

Question 6

What 2 things should make you think about a bony injury? a;lso what are 3 possible causes?

Answer 6

point tenderness on exam, and pain with indirect loading

acute-known injury

stress-overuse injury

pathologic-normal forces to abnormal bone

Question 7

What is associated with a “locking joint”

Answer 7

something flipping in and out of the joint, either a peice of floatin cartilage, or the tendon

Question 8

what motions lead to pain with a cartilge injury? what is associated with a cartilage injury?

Answer 8

• pain with both active and passive motions (if large enough lesion or involved area stressed)
• poor healing

Question 9

what is a joint mice?

Answer 9

a loose body of cartilage that is sometimes floating around in the joint space after an injury

Question 10

describe the stability of a joint during

dislocation

subluxation

laxity

Answer 10

dislocation-complete displacement

subluxation-transient, partial displacement (goes out and pops back in)

laxity- normal variant in “joint looseness”

Question 11

A positive external rotation test often means_______-

Answer 11

it is NOT a lateral ankle sprain

Question 12

what s a squeeze test? what does a positive squeeze test indicate?

Answer 12

pressing the fibula and tibia together cause the ends to bow out (or stress the lower part of the syndesmosis ligament) and cause pain.

suggestive of a Maisonneuve (proximal fibula) fracture

Question 13

what symptoms are associated with a lateral ankle sprain?

Answer 13

• bleeding
• clot formation
• inflammation
• repair
  
  • fibroblast proliferation
  • neovascularization
• remodeling

Question 14

would you use NSAIDs to treat a chronic illness?

Answer 14

no! You definitely would use it for acute pain, but chornic pain is often degenerative, not inflammatory so an anti-inflammatory probably wouldn’t do anything

Question 15

what is another name for a lateral ankle sprain? what rules this out?

Answer 15

AFT

positive external rotation test!

Question 16

what is necessary for proper ligament healing?

Answer 16

good blood supply

damage section to be approximated or guided to correct area

relative rest

Question 17

Cast vs brace?

Answer 17

• Cast
  
  • greater protection
  • “non-removeable”
• Brace
  
  • limits only certain motions
  • removeable
  • adjustable

Question 18

When does pain with eversion occur?

Answer 18

occurs with peroneal ankle sprain

Question 19

what are the differences between actue and chronic injury

Answer 19

• Acute
  
  • “classic injury” (exact time of injury)
  • gets worse with use
  • inflammation
  • treatments-ice
• Chronic
  
  • overuse injury
    
    • vague time of onset of pain
  • pain gets better after warming up (for a while)
  • degeneration

Question 20

what are the 2 different mechanism of shoulder dislocation?

Answer 20

• acute- from sudden imapct of large force exceeding strength of the joint restraints
• pathologic- from normal forces to weakened or anatomic variant joint/capsular restraints

Question 21

what 5 things are involved in joint stability?

Answer 21

muscles (stabilizers)

capsule (ball and cup)

bony architecture

ligaments

intracapsular (negative) pressure

Question 22

where should the humeral head be siting in the body/ on radiograph? what likely occured if it is not there?

Answer 22

humeral head should be sitting in the glenoid cavity. if the humeral head is below the cavity it is likely due to an anterior shoulder dislocation

Question 23

what nerve is most likely to be damaged in an anterior shoulder dislocation? how do you ensure that you don’t get sued for damageing the nerve while reducing the fracture?

Answer 23

• axillary nerve (transverses through the quadrangular space) can also be the musculocutaneous nerve
• check sensation/ ensure the nerve is in tact and document it, before reducing the fracture

Question 24

what is the typical direction of shoulder dislocation? what are the common etiologies?

Answer 24

anterior (90%)

• forced extension, abduction and external rotation of the arm (open arm tackle or fall onto abducted arm)
• direct blow to posterior shoulder

Question 25

wht alteration alteration of shoulder contour is seen in an anterior dislocation?

Answer 25

promiennt acromion humeral head anterior to acromion and adjacent to coracoid

Question 26

what is a positive apprehension test? feeling of instability with stress (not pain, just the sensation that the should will fall out again)

Question 27

WHat are 2 loading tests? how about shift stress?

Answer 27

* loading-pull out or in * **compression** loading-test joints and structures between surfaces (eg articular cartilage, menisci, labrum) * **distraction** loading-test strucutres surrounding joint (eg capsule and ligament) * shit-pull up or down, to test various strcutures

Question 28

what causes the "popeye" sign?

Answer 28

tear of the biceps long head! usually the long head, not the short

Question 29

what are 3 things to keep in mind when treating musculotendinous ruptures?

Answer 29

impact of absence of muscle presence of alternative muscles functional requirements of patient (olympic athelete or body builder)

Question 30

What is capsulitis? what usually causes it? what would hear on history? what would you see on exam?

Answer 30

* capsular thickening often associated with inflammation and scarring * idiopathic or post -injury * risk factors: injury, diabetes, thyroid disease * history: limited range of motion * exam * decreased ROM * gradually tightening endpoint * exam otherwise c/w underlying etiology

Question 31

what are the 3 phases of capsulitis and what is seen at each phase?

Answer 31

Freeze phase- painful early with decreasing ROM Frozen phase-non-painful, with stable, decreased ROM Thawing-non-painful with improving ROM

Question 32

what is the treatment protocol for capsulitis?

Answer 32

reasurrence educate and set u expectations maintenance of ROM pain control

Question 33

what are 3 differnet type of 5th metatarsal fractions?

Answer 33

* Avulsion-5th metatarsal base at peroneus brevis insertion * Jones-traumatic fracture metaphyseal-diaphysis junction * "pseudo-jones"- stress fracture proximal diaphyses * dancer's spinal fracture mid to distal diaphyses

Question 34

how do you find the dorsalis pedis artery/pulse?

Answer 34

tell patient to raise big toe. this will raise extensor hallucis longus. the artery will be found just lateral to it

Question 35

what are the 4 sections of a bone?

Answer 35

diaphysis-shaft metaphysis-area between shaft and growht plate physis-growth plate epiphyses-end of long bone

Question 36

what is an apophysitis? what is the associated pain pattern? what are the treatments? and what are possible complications?

Answer 36

* pain and inflammation of ossification centers from repetitive tension * pain pattern * after activity * at the beginning of activity * through activity * all the time * treatments are activity as tolerated, ice and sometime NSAIDs * complications would be bony hypertrophy, or fracture (rare)

Question 37

what are 6 common site/conditions associated with apophysitis?

Answer 37

Osgood Schlatter: tibial tubercle Sever's: calcaneal apophysitis sinding-larsen-johansson: distal patellar pole anterior superior iliac spine (ASIS): sartorius Anterior Inferior iliac spine (AIIS)- rectus femoris Little leaguer's elbow (medial epicondyle)

Question 38

word associations! acute=\_\_\_\_\_ chronic= \_\_\_\_\_\_\_\_\_\_

Answer 38

acute=inflammation chronic=degernation

Question 39

growth plates are ___________ what is the significance of this?

Answer 39

**growth plates are inherently weak areas.** so in a person with an open growth plate undergoing repetitive stress (like running) they will damage the growth plate before they damage the tendons or msucles. But the same action in and adult would lead to a tendon injury.

Question 40

describe the repair potential of cartilage. also what motions cause pain with a cartilage injury?

Answer 40

poor repair potential pain with active and passive motions

Question 41

ligaments are associated with \_\_\_\_\_\_\_ muscle and tendon are assocaited with \_\_\_\_\_\_\_\_-

Answer 41

ligaments-stability muscle and tendon- active joint motion