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MSK > Growth & Repair > Flashcards

Growth & Repair Flashcards

Tendon injuries Peripheral nerve injuries

1
Q

Describe the parts of a long bone?

A

Diaphysis - Shaft
Metaphysis - Flare at the end of the shaft before epiphysis, contains growth plate
Epiphysis - Joint-end of the bone, after the epiphyseal plate
Medullary Cavity - Inside diaphysis, full of marrow

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2
Q

Whats the structural difference between cortical and cancellous bone?

A

Cortical is made of cylindrical osteons of concentric lamenae. They contain central canals of veins/arteries.

Spongy Bone contains marrow

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3
Q

Compare where cortical bone and trabecular bone are found

A

Cortical bone is found in the diaphysis of long bones

Trabecular is found in the metaphysis & growth plate of long bones

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4
Q

What is the functional difference between cortical and cancellous bone?

A

Compact resists bending & torsion

Cancellous resists compression

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5
Q

What are the stages of fracture repair?

A

1) Inflammation
2) Soft Callus
3) Hard Callus
4) Bone Remodelling

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6
Q

How might we intervene in stage 1 of fracture repair?

A

Inflammation

  • NSAIDS for inflammation
  • Plate Concentrates to improve healing e.g. Platelet derived growth factor (PDGF), IGF & VEGF
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7
Q

What is the soft callus stage of fracture repair?

A

The inflammation/swelling goes down but cartilage and fibrous tissue are yet to unite the bony fragments.
It gives back some stability but angulation ca still occur

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8
Q

What interventions are possible for stage 2 of fracture healing?

A
  • Cartilage replacement with DMB (Demineralised Bone Matrix)
  • Bone Graft
  • Bone substitutes
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9
Q

Describe the types of bone graft?

A

Autogenous Cancellous Bone Graft (Gold standard). IS both osteoconductive and inductive.

Allograft - Osteoconductive but not inductive and risks transmission of disease

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10
Q

What happens during the 3rd stage of fracture repair?

A

Cartilage forms into woven bone

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11
Q

What happens during the 4th stage of fracture repair?

A

Woven bone forms into lamellar bone and the medullary canal is reconstituted

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12
Q

How is strain involved in fracture repair?

A

Mechanical strain induces tissue differentiation so if strain is too low you don’t grow fresh bone
If its too much then the healing process is interrupted

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13
Q

What is a peripheral nerve? [1]
Describe the structure of a peripheral nerve? [3]
Efferent motor unit components [3]
Sensory unit components [2]

A

The part of a spinal nerve distal to the nerve roots

Axon sheathed in endoneurium. Axons grouped into fascicles sheathed in perineurium. Fascicles grouped into a nerve sheathed in epineurium.

Efferent motor unit
○ Anterior horn cell, motor axon, muscle fibres (NMJ)
Sensory unit
○ Cell bodies in posterior root ganglia + single afferent neuron with all its receptor endings

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14
Q

Peripheral nerves compression injuries [3]

A

Median nerve during carpal tunnel syndrome
Spinal root during intervertebral disc prolapse (i.e. sciatica)
Digital nerve in 2/3rd web spaces of foot during morton’s Neuroma

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15
Q

What are the different mechanisms of nerve trauma? [2]

A

Direct (blow or laceration) vs indirect (Avulsion vs traction)

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16
Q

Apraxia [3]

Neurapraxia is the mildest complication of peripheral nerve injury. Describe 2 characteristics

A

Apraxia means loss/impairment of ability to execute complex co-ordinated movements without muscular/sensory impairment.
Neurapraxia:
- Nerve still in continuity
- Temporary loss of motor/sensory function due to blockage of nerve conduction

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17
Q 
Prognosis for neurapraxia [2]
Recovery time [1]
Cause [2]
Pathophysiology [3]
Explain development of swelling adjacent to site of injury [1]
A

Reversible as temporary damage to myelin sheath but leaves nerves intact
6-8wks
Causes: blunt injury, electric shock
Pathophysiology:
- leading to pressure buildup on nerve > (pathogenesis) ischemia > neural lesion > complete/partial AP conduction block over segment of nerve fiber.
Natural response of edema in all directions from source of pressure which explains swelling adjacent to site of injury

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18
Q

What is axonotmesis?
Causes [3]
What does wallerian degeneration mean in this context? [1]
Prognosis [2]

A

Damage to myelin sheath but endo/peri/epineurium intact
Stretch/crush/direct blow
Wallerian degeneration follows meaning everything distal to injury dies but will regrow
Fair prognosis; not complete recovery or normal sensory function but enough to recognise pain, hot/cold, sharp/blunt

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19
Q

Whats is Neurotmesis?
What does wallerian degeneration mean in this context? [1]
What occurs that means there’s a high chance of miswiring during regeneration

A

Completely divided axon and myelin sheath due to laceration or avulsion
Wallerian degeneration occurs but no regrowing occurs
Endoneural tube disruption so high chance of miswiring during regeneration

20
Q

Prognosis for Neurotmesis?

A

Poor. Can only recover with suturing & grafting

21
Q

Clinical features of peripheral nerve injury? [5]

A 
Dysaesthesia
Paresis/paralysis +/- wasting
Dry skin
Diminished/absent reflexes
UMN/LMN signs
22
Q

Describe the process of nerve healing? [3]

What is the first modality that is healed?

A

Distal axon dies via wallerian degeneration
Then proximal axonal budding occurs after roughly 4 days
The nerve regenerates at ~1mm/day

Sensation and pain sensation is first modality to return

23
Q

How do you assess the healing of a nerve? [2]
What grading classification is used to assess the severity of nerve damage?
Prognostic factor for recovery depends on… [2]

A

Nerve conduction studies
Tinel’s Sign - Tap over a nerve, you will feel paraesthesia as far distally as the regeneration has spread

Sunderland’s classification

Prognostic factors: whether nerve is sensory/motor/mixed
How distal the lesion is (proximal is poorer)

24
Q

What methods are there for repairing a nerve injury? And their respective indications [2]

A

Direct repair + GF (to speed regeneration) - indicated in lacerations
Nerve grafting indicated in late repairs - involves harvesting muscle fibers from other sites

25
Q

Describe the surgical rule of 3?

A

for clean/sharp injuries: Immediate surgery within 3 days

for blunt/contusion injuries: Early surgery within 3 wks

for closed injuries if there’s no recovery: Delayed surgery after 3 months

26
Q

What cells make up tendons

A

A longitudinal arrangement of cells, mainly tenocytes.

27
Q

Describe the arrangement of collagen in a tendon? [3]

A

Mostly type 1 collagen bundle surrounded by endotendon.

Bundles arranged into fascicles surrounded by paratendon

Fascicles bundled into a tendon surrounded by epitendon

28
Q

What happens if a tendon is underused? [3]

A

Immobility leads to a low water & glycosaminoglycan concentration
This leads to poor strength

29
Q

List some tendon pathologies? [6]

A 
Degeneration
Inflammation
Enthesiopathy
Traction Apophysitis
Avulsion +/- bone fragment
Tear
Laceration/Incision
30
Q

Example of a degenerative tendon disorder [2] and presentation [3]

A

Intrasubstance Mucoid Degeneration - common in the achilles

Can be asymptomatic but may be swollen, painful on plantar flexion or tender

31
Q

Example and presentation of an inflammatory tendon disorder?
Affected sites [3] and presentation is SOI
Clinical test

A

De Quervain’s Stenosing Tenovaginitis

Tendons of the EPB & APL get swollen, tender, hot and red.

Positive for finklestein’s test

32
Q

What is enthesiopathy? [1]

Give examples [2]

A

Inflammation at the insertion of a tendon to bone or muscle

E.g. Lateral Humeral Epicondylitis aka tennis elbow, plantar fasciitis (ligament involvement no muscle)

33
Q 
Whats is an example of a traction Apophysitis?
Commonly known as...
Affected site [2]
Epidemiology [1]
Presentation - SOI
Mx [1]
A

Osgood Schlatter’s Disease
Affected site: Insertion of patellar tendon into anterior tibial tuberosity
Epidemiology: adolescent active boys
Mx: stop activity

34
Q

How do we treat an avulsion? [2]

Eg and mx

A

Conservative - Retraction
Operative - Reattachment & fixation of the bone fragment
Eg mallet finger - splint holds digit straight allowing ligaments to heal

35
Q

What are the types of tendon tear? [2]

A

Intrasubstance e.g. achilles

Musculotendinous junction

36
Q

How do we treat a tendon tear? [2]

A

Conservative - Mobilise + splint/cast but tendons may pull itself up arm

Operative - If the ends can’t be opposed

37
Q

Whats the function of a ligament? [2]

A

to provide joint stability whilst maintaining ROM

Attached to bone on either side of a joint

38
Q

Compare a ligament to a tendon [4]

A

Ligaments have:

  • Less collagen
  • More proteoglycans/water
  • Less organized collagen
  • Rounder fibroblasts
39
Q

Describe the structure of a ligament? [3]

A

Type 1 collagen
Fibroblasts
Sensory fibres that carry proprioception, stretch & sensory

40
Q

What are the 3 phases of ligament rupture healing?

A

1) Haemorhagic Phase
2) Proliferative Phase
3) Remodelling Phase

41
Q

What happens during the haemorrhagic phase of ligament healing? [2]
What happens during the proliferative phase of ligament healing? [1]
What happens during the remodelling phase of ligament healing?

A

First a blood clot that is then resobed & replaced by Heavy Cellular Infiltrate.
Scar tissue forms (disorganised collagenous CT)
Matrix becomes more ligament-like

42
Q

When would we care for a ligament rupture conservatively? [2]
When would we care for a ligament rupture operatively? [2]

A

A partial rupture with no instability
Or a patient that isn’t fit for surgery

If theres instability, expectation e.g. sportsmen or multiple ruptures

43
Q

How would we operatively treat a ligament rupture? [3]

A

Repair
Augmentation
Replacement

44
Q

Name reasons for a delayed union? (delayed healing of a fracture) [10]

A
  • High energy Injury
  • Instability
  • Infection
  • Steroids/immunosuppressants
  • Smoking
  • Warfarin
  • NSAIDS
  • Ciprofloxacin
  • Age
  • Radiotherapy
45
Q

Name some results of a non-union (complete failure of healing) [5]

A 
Instability
Calcification, bone sclerosis
Abundent calluses
Pain/tenderness
Persistant fracture line

MSK (28 decks)

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