Injury and Healing Flashcards
Mechanisms of bone fracture
Trauma (low/high energy)
Stress(repetitive)- abnormal stresses on bone
Pathological - normal stresses on bone but indicated underlying problem with bone structure
How does a stress fracture occur
Overuse Stress exerted on bone > bone's capacity to remodel Bone weakening Stress fracture Risk of complete fracture
Weight bearing bones
Femur
Tibia
Metatarsals
Navicular
Activity related stress fracture
Atheletes Occupational Military Female Stress fracture Risk of complete fracture
Female athlete triad
Disordered eating
amenorrhea
osteoporosis
Pathological causes
Osteoporosis- soft bone Malignancy - primary/bone mets Vitamin D deficiency ( calcitriol) - osteomalacia/rickets Osteomylitis Osteogenesis Imperfecta Pagets
What infection can particularly predispose people to fractures
TB
Osteoporosis
Loss of bone density
Osteoporosis cause
Osteoclast activity is greater than osteoblast activity and so there is disrupted microarchitecture.
associated with ‘fragility fractures’- hip, spine , wrist
Low energy trauma- leads to fracture
Primary vs secondary osteoporosis
Primary osteoporosis is due to the normal ageing process while secondary osteoporosis is due to specific clinical disorders
Primary osteoporosis
senile osteoporosis->70
Post menopausal osteoporosis - 50-70
Secondary osteoporosis
Hypogonadism
Glucocorticoid excess
alcoholism
Vitamin d deficiency
inadequate calcium or phosphate - defect in osteoid matrix mineralisaton
OI
Brittle bone disease
Heriditary - autosomal dom or rec
OI pathogenesis
Decreased Type 1 collagen due to decreased secretion or production of abnormal collage
This leads to insufficient osteoid production ( due to lack of normal collagen`)
Effects of OI
Bones
Hearing
Heart
Sight
Patients can present with blue sclera, lens dislocation and short stature
Pagets Disease
Metabolic disturbance of bone turnover so you have increased/decreased osteoblast and osteoclast activity
Genetic/acquired
excessive bone breakdown and disorgansed remodelling leads to deformity, pain , fracture and arthritis
Pathogenesis of pagets disease
osteoclastic activity
Mixed osteoclastic-osteoblastic activity
Osteoblastic activity
Malignant degeneration- develop into osteosarcoma of bone or osteomalacia
Primary bone cancer
Osteosarcoma (osteoblastic tissues)
Chondrosarcoma (chondral tissue)
Ewing sarcoma
Lymphoma
Secondary bone cancer
Blastic- prostate
Lytic- kidney, thyroid, lung
Both - breast
Fracture patterns stages
1) Soft tissue integrity (pierced skin or not)- open /closed
2) Bony fragments:
- greenstick( bent only really happens in children)
- Simple (one break)
- Multifragmentary ( comminuted)
3) Movement: displaced/undisplaced
Tissue healing general stages
Bleeding - blood
Inflammation - neutrophils, macrophages
New tissue formation- BLASTS ( chondro for bones, osteo for bones, fibro for collagen tissue such as tendons or ligaments)
Remodelling - ma
Fracture healing
1) Bleeding - haematoma formation
2) inflammation : release of cytokines. granulation of tissue and blood vessel formation
3) Repair - soft callus formation ( type 2 collagen - cartilage)
Converted to hard callus - Type 1 collagen : bone
4) remodelling : callus responds to activity, external forces, functional demands and growth. Excess bone is removed ( wolffs law)
Primary bone healing
Intramembranous healing
Absolute stability
Direct to woven bone
secondary bone healing
Endochondral healing
Involves responses in the periosteum and external soft tissues
Relative stability
Endochondral ossification : more callus (in comparison to primary bone healing)
Bone healing times
Upper limbs generally heal quicker than lower limbs
hands heal quicker than feet
Babies are very good
But healing times vary according to age, biology and comorbidity of patient
Principles of fracture management
Reduce : closed/open
Hold: no metal/metal
Rehabilitate: move, physiotherapy , use
Reduction of closed fracture manipulation example
Collis fracture where the radium is dorsally tilted/angulated - like a dinner fork
Reduction traction
Skin ( bandage and the hand to weight)
Skeletal ( pins in bones) - put a bin and then out a weight to the metal as you can apply more force to pin and the actual bone then you can to skin
Look at fixation flow chart
Look at fixation flow chart
Rehabilitation
Use- pain relief/ retrain
Move
Strengthen
Weight bear
Why do tendons tear
Tendinopathy
- tendinosis ( abnormal thickening )
- tendinitis - inflammation
- rupture
Sportsmen may already have thickening/inflammation of the tendons
treatment of tendon or ligament tears
1) immobolise - rely on the haematoma formation process and place in a plaster or boot or brace
2) Surgical repair - suture
immobilisation vs surgical repair on ligament inury
Immobilisation means there is less lengthening/laxity. But there s less overall strength of the ligament repair scar and there is protein degradation.
Surgical repair means that the ligament scars are wider, stronger and more elastic and that there is better alignment and quality of collagen
Factors afecting tissue healing
Mechanical environment: movement /force
biological environment: blood supply, immune function , infection, nutrition ( diabetes increases healing time)
What might you see when examining a patient for a fracture
Inability to weight bear severe pain Swelling and point tenderness deformity scrapes/abrasions wound if open fracture loss of movement Loss of sensation of nerve injury
STAR
Site
Which side and where is it (position by thirds)
TAR (all about displacement)
Translation
Movement of fracture bony ends away from eachother
Angulation
Displacement from the normal axis
Rotation
Rotation of the distal fragment in relation to the proximal portion - may be more obvious clinically than on XR
Role of ACL
Connect bone to bone
Stabilise joint
Made of type I/III collagen
ACL prevents anterior shift of tibia on femur
Also stops tibia moving forward and sliding in from of fibula
presentation of ACL tear
pain, knee giving way, can’t push or twist knee
test for ACL tear
lachmanns
anterior drawer
pivot shift
Short term management for ACL injury
PRICE and then maybe splinting/bracing
long term management for ACL injury
Operative vs Non operative
Operative : repair and replace ( graft from hamstring)
Non operative : brace
ACL does not heal well once torn and you will have an unstable knee and cant stick back onto ligament. Knee may stick onto PCL.
but some muscles can compensate - go onto quads
Things to think about when operating on ACL injury
age symptoms- pain or giving way activity level has physio been tried other structures involved indications for ACL reconstruction patellar tendon/ hamstring
which muscles insert into the achilles tendon
soleus and gastrocnemius
function of achiles
plantar flexion - point foot away from you
signs of achilles tendon injury
difficulty walking/limp - says that it feels like a shot to the back of the leg
unable to perform heel raises - standing on tip toes (even after a couple of months)
thickening, tenderness and swelling on affected side
when prone with feet off the end of couch, the affected side is held in dorsiflexion
achilles tendon/ any surgery operation complications
General :
DVT, infection, prolonged immobility leading to chest, UTI, infections and sores
Specific: Neurovascular injury tendon rupture local infection ankle stiffness pressure sores from plaster or boot
