Injury and Healing Flashcards
What occurs when the ACL is injured?
Wobbly knee
What are the three mechanisms of bone fracture?
Trauma- low/high energy
Stress- abnormal stresses on normal bone
Pathological- normal stresses on abnormal bone
How can you describe fracture patterns?
Soft tissue: Open or closed
Bony fragments: Greenstick/ Simple/ Comminuted
Displacement: Displaced/ Undisplaced
What is an example of high energy trauma?
Car crash
Give an example of low energy trauma?
Fall
How can a stress fracture occur?
Overuse Stress exerted on bone is greater than bones capacity to remodel Bone weakening Stress fracture Risk of complete fracture
Who is at risk of developing stress fractures?
Athletes
Military personnel
What is the female athlete triad?
Regular strenuous exercise Insufficient calorie intake Weight loss Amenorrhoea Osteoporosis
Which bones a prone to stress fractures?
Weight baring bones
e.g. tibia, metatarsals, navicular
Give examples of pathological stresses?
Osteoporosis Malignancy Vit D deficiency Osteomyelitis Osteogenesis Imperfecta Paget's disease
What conditions are caused by Vitamin D deficiency?
Osteomalacia
Ricket’s
What occurs when osteoclast activity > osteoblast activity?
Disrupted microarchitecture
More common in females 4:1
What are the different types of osteoporosis?
Postmenopausal Osteoporosis – Women 50-70
Senile Osteoporosis - > 70
Secondary osteoporosis: Any age, 60% Male
Hypogonadism
Glucocorticoid excess
Alcoholism
What are osteopenia and osteoporosis associated with?
Associated with ‘fragility fractures’ – hip, spine, wrist
Low energy trauma fracture
What cancers are blastic?
Prostate
What cancers are lytic?
Kidney
Thyroid
Lung
What does Vit D deficiency cause in paeds?
Before physis closure
Rickets
What does Vit D deficiency cause in adults?
After physis closure
Osteomalacia
What are the main features of osteogenesis imperfecta?
‘Brittle Bone Disease’
Hereditary – autosomal dominant or recessive
↓ Type I Collagen due to:
Decreased secretion
Production of abnormal collagen
Results in insufficient osteoid production
What does OI effect?
Bones Hearing Heart Sight Blue sclera
What are the main features of Paget’s disease?
Aetiology: Genetic & acquired factors
Excessive bone break down and disorganised remodeling deformity, pain, fracture or arthritis
May transform into a malignant disease
What are the 4 stages of Paget’s?
Osteoclastic Activity
Mixed osteoclastic-osteoblastic activity
Osteoblastic activity
Malignant degeneration
What happens during week 1 of fracture healing?
Haematoma formation
Release of Cytokines
Granulation tissue
What happens during week 2- 4 months?
Soft Callus formation
(Type II Collagen - Cartilage)
Converted to hard callus
(Type I Collagen - Bone)
What happens during months 4-12?
Callus responds to activity, external forces, functional demands and growth
Excess bone is removed
What are the signs of fracture?
Oedema
Inflammation
Bleeding
What is primary bone healing?
Intermembranous healing
Absolute stability
What is the secondary bone healing?
Endochondral healing
Involves responses in the periosteum and external soft tissues
Relative stability
What are the different fracture healing times?
3-12 Weeks depending on site
Signs of healing visible on X-ray from 7-10 days
Phalanges: 3 weeks Metacarpals: 4-6 weeks Distal radius: 4-6 weeks Forearm: 8-10 weeks Femur: 12 weeks Tibia: 10 weeks
What does healing time depend on?
Proximity to the heart
Depends on blood supply and soft tissue coverage
What is the secondary bone healing?
Endochondral healing
Involves responses in the periosteum and external soft tissues
Relative stability
greater Callous formation
What are three steps of fracture management?
Reduce
Hold
Rehabilitate
What is reducing?
Bring the two structures together
Closed: Manipulation or Traction
Open: Mini incision or Full exposure
How can you hold?
Without metal: Plaster or Traction
With metal: Fixation
What are the two types of fixation?
Internal: Intramedullary- Pins/Nails Extramedullary- Plates and screws/Pins External Monoplanar Multiplayer
How can you rehabilitate?
Move Physiotherapy Use Strengthen Weigh-bear Retrain Pain relief
What do ligaments do?
Connect bone to bone
What do tendons do?
Connect muscle to bone
What can happen to tendons?
Thickening
Inflammation
Rupture
What do you call abnormal thickening of the tendon?
Tendinosis
What do you call inflammation of the tendons?
Tendinitis
How do you classify ligament injury?
Grade I
Grade II
Grade III
What are the features of grade I?
Grade I – Slight incomplete tear – no notable joint instability
What are the features of grade II?
Grade II – Moderate / Severe Incomplete Tear – Some joint instability. One ligament may be completely torn
What are the features of grade III?
Grade III – complete tearing of 1 or more ligaments – Obvious instability. Surgery usually required
What are the phases of ligament healing?
Inflammatory phase
Proliferation phase
Remodeling
Maturation
What happens in the inflammatory phase?
1-7 days
Fibrin clot formed in ligament tears
What happens in the proliferation phase?
7-21 days
Tendons and ligaments weakest, tensile strength builds
What happens during remodelling phase?
> 14 days
Tendons and ligaments heal with scar tissue thatreduces ultimate strength
causes adhesions
What happens during maturation?
Weeks to years
Max strength reached within a year.
What factors affecting tissue healing?
Mechanical environment
- movement
- forces
Biological environment
- blood supply
- immune function
- infection
- nutrition
What are the effects of immobilisation on injures ligamentous tissue?
GOOD
Less ligament laxity (lengthening)
BAD
Less overall strength of ligament repair scar
Protein degradation exceeds protein synthesis r net d in collagen quantity
Production of inferior tissue by blast cells
Resorption of bone at site of ligament insertion
Build tissue tensile strength (50% in 6 - 9 weeks)
What are the benefits of mobilisation on injured ligamentous tissue?
Ligament scars are wider, stronger, and are more elastic
Better alignment / quality of collagen
What is manipulation?
Movement in to place
What is traction?
Put pin through the bone and pull with a weight/ sticky tape with weight
What does intramedullary mean?
Within the medullary cavity
What does extra-medullary mean?
Alongside the bone
What is multiplanar fixation?
External hardware on all sides (cage-like)
Partly internal
What is monoplanar fixation?
External hardware on one side of the limb
Partly internal
What are the functions of the achilles tendon?
Connects the gastrocnemius and soleus to the calcaneus
Plantar flexes the foot
Tendon pulls the foot down
What complications can result from surgery?
Damage to
Nerves
Vasculature
Surrounding tissues
Shortening of tendon: Stiffness/ restricted movement
Insufficient tightening: Persistent symptoms
Repair might fail: rerupture
Infection
What is the ACL?
Anterior cruciate ligament
What does the ACL do?
Stablises knee joint
Prevents forward movement of the tibia
Connects the femur to the tibia
What should a patient do in the first 6 weeks of healing?
Protect Rest Ice Compression Elevation
What should a patient do from 6-9 months post-injury?
Physio:
movement
strengthen muscles
start walking normally
What should the patient do post 9 months?
Training
Jumping
Improve balance and proprioception
What are the different types of displacement (translation)?
Proximal/distal
Anterior/posterior
Medial /lateral
What are the different types of displacement (angulation)?
Internal/external rotation
Dorsal/volar
Varus/valgus
What are the general complications of fractures?
Fat embolus (hours - from bone marrow release)
DVT (days-weeks)
PE
Infection/sepsis
Prolonged immobility (UTI, chest infections, sores)
What are urgent local complications of fractures?
Local visceral Vascular injury Nerve injury Compartment syndrome Haemarthrosis Infection Gangrene
What are less urgent local complications of fractures?
Fracture blisters Plaster sores Pressure sores Nerve entrapment Myositis ossificans ligament injury Tendon lesions Joint stiffness Algodystrophy
What are the late local complications of fractures?
Delayed union Mal-union Non-union Avascular necrosis Muscle contracture Joint instability Osteoarthritis
What are the different NoF fractures?
Subcapital Transcervical Intertrochanteric Subtrochanteric 3 part intertrochanteric
What are the features of extra-capsular NoF fracture?
minimal risk to blood supply and AVN: fix with plate and screws (Dynamic hip screw)
What are the features of intra-capsular NoF fracture?
if undisplaced: less risk to blood supply: fix with screws
If displaced: 25-30% risk AVN: replace in older patients; fix if young
How are synovial joint stabilised
Muscles/tendons
Ligament
Bone surface congruity
What are the components of a synovial joint?
Synovium
Synovial fluid
Articular cartilage
What is cartilage composed of?
1) specialized cells (chondrocytes)
2) extracellular matrix: water, collagen and proteoglycans
mainly aggrecan
What is aggrecan?
- a proteoglycan that possesses many chondroitin sulfate and keratin sulfate chains
- characterized by its ability to interact with hyaluronan (HA) to form large proteoglycan aggregates
What is osteoarthritis?
Degenerative arthritis
What is inflammatory arthritis?
Main type is rheumatoid
What is the same in osteoarthritis and rheumatoid arthritis?
Joint space narrowing
Indicates articular cartilage loss
This can occur in osteoarthritis (primary abnormality) and in Rheumatoid Arthritis (secondary damage due to synovitis)
What are features in osteoarthritis not present in rheumatoid arthritis?
Subchondral sclerosis
Osteophytes
What are features of rheumatoid arthritis not present in osteoarthritis?
Osteopenia
Bony erosions
What is the WHO definition of OA?
is a long-term chronic disease characterized by the deterioration of cartilage in joints which results in bones rubbing together and creating stiffness, pain, and impaired movement.
What are the main OA risk factors?
Age Weight Metabolic syndrome Mechanical constraints (high levels of activity) Hereditary Female Post-menopause
What are the radiographic changes of OA?
Joint space narrowing
Osteophytes
Subchondral cysts
Sclerosis
What are the symptoms of OA?
Pain (exertional/rest/night)
Disability: walking distance/stairs/giving way
Deformity
What comprises a limb assessment?
Look
Feel
Move
Special tests
What is the conservative management of OA?
Analgesics Physiotherapy Walking aids Avoidance of exacerbating activity Injections (steroid/viscosupplementation)
What are the interventions for OA?
Replace (knee/hip) Realign (knee/big toe) Excise (toe) Fuse (big toe) Synovectomy (Rheumatoid) Denervate (wrist)
What are the main features of osteomyelitis?
Acute or chronic Primary or secondary Pain/swelling/discharge Systemic signs: Fevers, sweats wt loss
What are the main features of septic arthritis?
Pain
Joint swelling/stiffness
Fevers, sweats, wt loss
What causes septic arthritis?
Bacterial infection of a joint (usually caused by spread from the blood)
What are the risk factors of septic arthritis?
Immunosuppressed, pre-existing joint damage, intravenous drug use (IVDU)
Why is septic arthritis a medical emergency?
Untreated, septic arthritis can rapidly destroy a joint
In who should you consider septic arthritis?
Consider septic arthritis in any patient with an acute painful, red, hot, swelling of a joint, especially if there is fever
How is septic arthritis diagnosed?
Diagnosis is by joint aspiration. Send sample for urgent Gram stain and culture
What commonly is responsible for septic arthritis?
Staphylococcus aureus, Streptococci, Gonococcus
What is the treatment for septic arthritis?
Treatment is with surgical wash-out (‘lavage’) and intravenous antibiotics
Immobilise joint in acute phase
Physiotherapy once over acute phase
What investigations are done with bone infection?
Plain films MRI scans: bony architecture/collections CT if MRI not available Bone scans: multifocal disease Labelled White cell scans
CRP: acute marker
ESR slower response
WCC
TB culture/PCR
What are the treatments for osteomyelitis?
Immobilise joint in acute phase
Physiotherapy once over acute phase
