Chapter 43 SKELETAL Flashcards
Differentiate among two type of soft tissue injury
Contusion/Bruise Result of direct trauma Skin remains intact Blood vessel/cell damage Edema, inflammation Ecchymostic (black/blue/brown/yellow)
Hematoma
Localized hemorrhage
Blood accumulation pressures nerves
Pain, increasing with movement/pressure
Identify the most common joint injury
Knee and hip
lower back, elbow, and shoudlers
Discuss causes and consequences of a joint dislocation
CAUSE
-abnormal displacement of articulating surfaces of the joint
Subluxation
Partial dislocation
Some surface contact
Common joints
Shoulder
acromioclavicular
Congenital
Hip or knee usual
Traumatic
MVA: hip
Athletics: shoulder, knee
Fall: wrist, ankle
Pathologic
complication of infection, rheumatoid arthritis, neuromuscular disease
Diagnosis
History, assessment, x-rays
Manifestation
Pain
Deformity
Limited movement
Treatment Spontaneous Manipulation Surgical repair Physiotherapy
Compare muscle strains and ligamentous sprains.
STRAIN
-Involves muscle/tendon
Partial tear, often during muscle contraction
Risk increases with age
Collagen fibres less elastic
Common in back, cervical spine, elbow, shoulder
Sports injuries: hip, hamstring, quadriceps
MANIFESTATION
Often no obvious signs unless inflammation
Pain, increasing with stretching
Stiffness, swelling, tenderness
SPRAINS
-Tearing or rupture of supporting ligament or capsule surrounding joint
d/t abnormal/excess joint movement
Diagnosis
Not visible on X-ray unless bone fragment
MANIFESTATION Pain Rapid swelling limits movement Discoloration Last longer than strain
TREAMENT***
REST ICE COMPRESSION (reduce swelling, provide support) ELEVATION IMMOBILIZATION -strain if severe, sprain x weeks
Describe shoulder injury
Clavicle fracture common d/t childhood falls/blow
- Most resolve without surgery
- Immobilize with sling
Acromioclavicular joint
-Common athletic injury
Glenohumeral joint
- Very common dislocation
- When arm extended
ROTATOR CUFF
Function of cuff is to stabilize the humoral head against the glenoid
Shoulder joints are inherently unstable
Injuries are a result of a combination of:
Direct blow or stretch
Excessive use/repetition (common)
Age-related degeneration
Common conditions
Tendinitis
Subacromial bursitis
Partial/complete tears
Diagnosis Assessment of active & passive ROM History of injury is important MRI Arthroscopic examination
Treatment Anti-inflammatories Corticosteroid (oral, injection) Physiotherapy Surgical repair
Describe Knee joint injury
Ligamentous injuries Meniscus injuries Patellar subluxation and dislocations Patellofemoral pain syndrome Chondromalacia
LIGAMENTOUS INJURY
Most serious of knee injuries is
ACL rupture/tear is most common
The mechanism is one of the forceful stress against the knee, when the extremity is bearing against the weight
Manifestations of ACL rupture/tear "Pop" or tearing sensation Sudden pain Loss of weight-bearing Hemorrhage causes swelling
MENISCUS TEAR (shock absorber)
MANIFESTATION Pain, especially on hyperflexion and hyperextension Edema Instability Locking d/t loose fragment
COMPLICATION
Osteoarthritic changes limiting movement
PATELLA SUBLUXATION AND DISLOCATION
Usually sports related
MANIFESTATION Weakness Swelling Crepitus Stiffness Loss of ROM
CHONDROMALACIA
Inflammation of the underside of the patella
-Sports
-Knee overuse in older adult
PATELLOFEMORAL PAIN SYNDROME
Most common cause of anterior knee pain
CAUSES
Imbalance of forces controlling patella movement
Contact of posterior surface of patella with femur
Running, jumping, sitting
MANIFESTATION
Pain
Weakness
Absence of edema
Describe hip dislocation risk factors and complications
Dislocation
d/t trauma
Emergency
COMPLICATION
Disruption of blood and nerve supply
Avascular necrosis***
Interruption of blood supply resulting in necrosis of bone tissue; collapse
Describe hip fracture risk factor and complication
RISK FACTOR -Age Women Physical inactivity Alcohol excess Phsychotropic medications Institutionalization Visual impairments Polypharmacy Osteoporosis
COMPLICATION
-nonunion and avascular necrosis
Discuss the differences between stress fractures and those caused by sudden injury.
Sudden injury is a force caused by direct, such as fall or blow, or indirect, such as massive muscles contraction.
Stress fractures are incomplete fractures. Either fatigue or pathologic fractures.
Fatigue Fracture occur when excess stress is applied to normal bone.
- any weight-bearing bone
- stress fracture in the tibia may be confused with ‘shin splints’
Pathologic Fracture
-occur when normal stress is applied to bones that have been weakened by disease or tumors.
List the signs and symptoms of a fracture.
Pain/tenderness
Swelling
loss of function/mobility
Deformity
- Angulated fragments damage tissue
- Shortening of extremity
- Rotational
Crepitus (bone rubbing against each other)
Blood loss
Nerve function impairment or loss
-Local shock (numb, flaccid muscles)
Identify the classifications of fractures based on position on bone, degree of communication with the outside environment, degree of break, character of fracture pieces, and direction of break
POSITION ON BONE
Proximal/midshaft/distal
Head/neck
Near prominence (malleolus)
DEGREE OF COMMUNICATION WITH THE OUTSIDE ENVIRONMENT
Open/compound
closed
DEGREE OF BREAK (described as complete or incomplete break)
Greenstick
-Young, soft immature bone
CHARACTER OF FRACTURE PIECES Comminuted -Multiple pieces Compression -Crushing of 2 bones Impacted -Fragments wedged together Butterfly -Triangular bone piece -Typically long bones
DIRECTION OF BREAK Transverse Oblique Spiral Twist, torque
Explain the measures used in treatment of fractures
Reduction of fracture -Closed or open Immobilization: splint, cast, external fixation devices, traction Preservation & restoration of function PT
Describe the fracture healing process
HEMATOMA FORMATION**
- first 1-2 days
- bone/tissue blood vessel rupture
- fibrin network (clot) forms
- -Provides foundation for inflammatory cells**
- degranulated platelets and migrating inflammatory cells release growth factors, which stimulate osteoclast and osteoblast proliferation
FIBROCARTILAGINOUS CALLUS FORMATION
- fibroblast begin repair by producing collagen
- 2-3 weeks but still weak
BONY CALLUS FORMATION: OSSIFICATION
- osteoblast form; calcium salts deposit
- cartilage converts to bony callus
- begins 3-4 weeks, takes months
REMODELLING
- dead cells removed
- compact bone replaces spongy bone
- possible “scar”
Discuss the complications of fractures and the healing process
DELAYED UNION *** CHART
-failure of fracture to heal within predicted time as determined by x-ray
MALUNION
- deformity at fracture site
- demormity or angulation on x-ray
NONUNION
- failure of bone to heal before the process of bone repair stops
- evidence on x-ray
- motion at fracture site
- pain on weight bearing
Explain the implications of bone infections.
Direct contamination
Hematogenous (thru blood)
Via skin lesion
MOST COMMON IS STAPHYLOCOCCUS AUREUS
Discuss the etiology and results of osteonecrosis.
CAUSE
- bone destruction d/t interruption in blood flow
- Idiopathic
- Bone injury
- Thrombosis/embolism
- Vessel injury
- increased intraosseous pressure
- Corticosteriod associated (unclear)
MANIFESTATION
- necrosis of cancellous bone and marrow
- chronic pain
- secondary osteoarthritis
TREATMENT
- immobilization
- NSAIDS
- exercise
- limitation
- joint replacement
Compare the characteristics of hematogenous osteomyelitis and chronic osteomyelitis**.
OSTEOMYELITIS Infection of bone -Direct contamination -Hematogenous (thru blood) -Via skin lesion
Staphylococcus aureus most common
- Adheres to bone, attacks cells
- Evades host defenses and colonizes
HEMATOGENOUS In children -Affects long bones -Purulent exudate inside bone -Damages arteries supplying bone -May penetrate skin or involve joints
In adults
- In vertebrae, sternoclavicular and sacroiliac joints, or pubic symphysis
- Tends to affect joint space
CHRONIC OSTEOMYELITIS**
- usually adults
- secondary to open wound
- Sequestrum (Piece of dead bone that’s become separated)
- -Infected dead bone
- -Separated by sheath
–Difficult to detect when near a joint prosthesis
Discuss the significance of metastatic bone disease
- Skeletal metastasis is the most common bone cancer
- 50% of all cancers metastasize to the bone
- Most often in trunk bones
MANIFESTATION
- pain with impending pathologic fracture
- hypercalcemia
- serum levels of alkaline phosphatase and calcium are elevated
Differentiate between the properties of benign and malignant bone tumors.
BENIGN Confined to bone Well-defined borders Seldom cause fractures Seldom require treatment or surgery
Osteoma Small bony tumor on bone surface Fibrous tumors Common in growing bones Usually asymptomatic Resolve in 2-3 years
Chondroma (tumor made of cartilage) Short bones, solitary lesion Onset @ 20-40 years of age Asymptomatic or painful Can cause fractures
Osteochondroma (cartilage-capped tumor) Bony stalk attaches it to bone Most common Slow-growing, solitary mass Knee is common
Osteoclastoma (giant cell tumor) Behaves like malignant May invade bone and cause bone destruction Knee is common Pathological fractures common
MALIGNANT Osteosarcoma (most common) Tends to be in areas with fastest bone growth UKE, but genetic connection Ill-defined borders Peak-ages: Women Metastasizes early, often to lung
Chondrosarcoma Can arise from pre-existing benign cartilaginous tumor Mild to late adulthood Slow-growing Responds to early excision
Ewing sarcoma
Densely packed small cells
Children & young adults
Men > women
Skeletal metastasis is the most common bone cancer
50% of all cancers metastasize to the bone
Most often in trunk bones
Manifestations
Pain (Most severe @ night)
Pathologic fracture
Hypercalcemia d/t bone destruction
Changes in organ function (organ damage, inflammation, and failure):
Pathologic fracture
Local effects of tumors (e.g., compression of nerves or veins, stretching of periosteum):
Pain and weakness
Nonspecific signs of tissue breakdown (e.g., protein wasting, bone breakdown):
Calcium release, hypercalcemia
Compartment Syndrome (KNOW)
Increased pressure within a limited space due to: Decreased size -Constrictive dressing -Casts -Burns
Increased volume of contents
- Trauma
- Fluid/edema
- Vascular injury/bleeding
- Venous obstruction
Both
Amount of pressure dependent upon Duration Metabolic rate Vascular tone Local blood pressure
Result of increased pressure Compression of vessels = -Ischemia, necrosis Compression of nerves = -Paresthesis, paralysis
Manifestations Severe pain Diminished reflexes, motor function loss Decreased/loss of peripheral pulses Sensation change Burning/tingling/loss
Assessment
Pain
Sensory
Motor function
