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14. Year 2: Musculoskeletal > Musculoskeletal Growth, Injury and Repair - Bones and Tendons > Flashcards

Musculoskeletal Growth, Injury and Repair - Bones and Tendons Flashcards

1
Q

What are ligaments?

A
  • Dense band of collagenous tissue
  • Connects bone to bone (or cartilage)
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2
Q

What are ligaments anchored by?

A
  • Span a joint
  • Anchored to bone at either end
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3
Q

What is the function of ligaments?

A
  • Anchored to bone at either end
  • Gives joint stability through range of positions
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4
Q

What type of collagen makes up ligaments?

A
  • Made of type 1 collagen fibres
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5
Q

Describe the structure of ligaments?

A
  • Made of type 1 collagen fibres
  • Fibroblasts in them
  • Sensory fibres
    • Proprioception (allows brain to know where the joint is in space)
    • Stretch
    • Sensory
  • Vessels on the surface
    • Vessels are crimped to allow stretching
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6
Q

What is the difference in the composition between ligaments and tendons?

A
  • Composition, compared to tendons ligaments have
    • Lower percentage of collagen
    • Higher percentage of proteoglycans and water
    • Less organised collagen fibres
    • Rounder fibroblasts
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7
Q

Which of ligaments and tendons have greater percentage of collagen?

A

Tendons

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8
Q

Which of ligaments and tendons have higher percentage of proteoglycans and water?

A

Tendons

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9
Q

Which of ligaments and tendons have more organised collagen fibres?

A

Tendons

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10
Q

When does ligament rupture occur?

A

Ligament rupture occurs when forces exceed strength of ligament:

  • Can be complete or incomplete
  • Maybe lead to stability loss or proprioception loss
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11
Q

Describe the process of ligaments healing?

A
  • Haemorrhage
    • Blood clot is made that is then resorbed and replaced with heavier cellular infiltrate
  • Proliferative phase
    • Production of scar tissue
    • Disorganised collagenous connective tissue
  • Remodelling
    • Matrix becomes more ligament like
    • Major differences in composition, architecture and function persist
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12
Q

What is the treatment for ligament rupture?

A
  • Non-operative
    • Indicated in partial tears, complete tears where no loss of stability or patient poor candidate for surgery
    • Cast and immobilisation
  • Operative
    • Indicated in instability
    • Can be repair, augmentation or replacement
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13
Q

When is non-operative treatment indicated in ligament ruptures?

A

In partial tears or no loss of stability

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14
Q

When is operative treatment indicated for ligament tears?

A

Indicated in instability

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15
Q

Can tendons be seperated from muscles?

A

Tendons cannot be separated from muscle so thought of as muscle/tendon composite unit

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16
Q

Describe the structure of tendons?

A
  • Muscle origin (usually bone)
  • Muscle belly
  • Musculotendinous junction
  • Tendon
    • With or without sesamoid bone such as patella
    • With or without tendon sheath
  • Tendinous insertion (into bone), Sharpey’s fibres
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17
Q

Describe the layers of a tendon?

A
  • Layers
    • Collagen bundles covered by endotenon
    • Making fascicles covered by paratenon
    • Making tendon covered by epitenon
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18
Q

How does blood supply tendons?

A
  • Blood supply comes through vinculum and forms fine network of vessels in paratenon
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19
Q

What are tendons formed from?

A
  • Longitudinal arrangement of cells (mostly tenocytes) and fibres (collagen type 1)
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20
Q

Tendons are connected to tendon sheath by what?

A
  • Tendons connected to sheath by vincula
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21
Q

What are the functions of tendons?

A
  • Tendons are flexible and strong in tension
  • Immobility reduces water content and glycosaminoglycan concentration falls reducing strength
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22
Q

How does immobility affect tendons?

A
  • Tendons are flexible and strong in tension
  • Immobility reduces water content and glycosaminoglycan concentration falls reducing strength
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23
Q

What are the different types of tendon injuries?

A
  • Degeneration
    • Example of Achilles tendon
      • Intrasubstance mucoid degeneration
      • May be swollen, painful, tender
  • Inflammation
    • Example de Quervain’s stenosing tenovaginitis
      • Tendons of EPB and APL passing through common tendon sheath at radial aspect of wrist
      • Swollen, tender, hot, rest
      • Positive Finklestein’s test
  • Enthesiopathy
    • Inflammation at insertion to bone of muscle or tendon
      • Usually muscle origin and not tendon insertion
    • Due to repetitive injury
    • Can also get it in ligaments, example is plantar fasciitis
  • Traction apophysitis
    • Example is Osgood schlatter’s disease
      • Insertion of patellar tendon into anterior tibial tuberosity with pain and swelling
      • Usually in adolescent active boys
      • Due to recurrent load with inflammatory component
      • Treatment is rest
  • Avulsion with or without bone fragments
    • Failure at insertion
    • Load exceeds failure strength while muscle contracting
    • Classically called Mallet finger
      • Insertion of extensor tendon into dorsum of base of distal phalanx of finger
    • Treatment
      • Conservative
        • Limited application
        • Retraction tendon
      • Operative
        • Reattachment tendon
        • Fixation bone fragment
  • Tear in the intrasubstance (rupture)
    • Happens when load exceeds failure strength
    • Example of Achilles tendon
      • Positive Simmond’s (squeeze) test
      • Palpable tender gap
  • Tear in musculotendinous junction
  • Laceration/incision
    • Affects males more than females
    • Normally young adults
    • Repair surgically and early
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24
Q

What is the presentation of a degenerative tendon injury?

A
  • Intrasubstance mucoid degeneration
  • May be swollen, painful, tender
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25
Q

What is an example of an inflammatory tendon injury?

A

de Quervain’s stenosing tenovaginitis

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26
Q

What is the presentation of an inflammatory tendon injury?

A
  • Swollen, tender, hot, rest
  • Positive Finklestein’s test
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27
Q

What is enthesiopathy?

A
  • Inflammation at insertion to bone of muscle or tendon
    • Usually muscle origin and not tendon insertion
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28
Q

What is the cause of enthesiopathy?

A
  • Due to repetitive injury
29
Q

What is an example of traction apophysitis?

A
  • Example is Osgood schlatter’s disease
    • Insertion of patellar tendon into anterior tibial tuberosity with pain and swelling
    • Usually in adolescent active boys
    • Due to recurrent load with inflammatory component
    • Treatment is rest
30
Q

What is traction apophysitis?

A

When excessive pull on a large tendon causes damage to apophysis

31
Q

What is avulsion with or without bone fragments?

A
  • Failure at insertion of tendon
  • Load exceeds failure strength while muscle contracting
32
Q

What causes avulsion with or without bony fragments of tendon?

A
  • Load exceeds failure strength while muscle contracting
33
Q

What is an example of avulsion with or without bony fragments?

A
  • Classically called Mallet finger
    • Insertion of extensor tendon into dorsum of base of distal phalanx of finger
34
Q

What is the treatment of avulsion with or without bone fragments?

A
  • Conservative
    • Limited application
    • Retraction tendon
  • Operative
    • Reattachment tendon
    • Fixation bone fragment
35
Q

What is a tear in the intrasubstance of a tendon also called?

A

Ruptured tendon

36
Q

What causes a tendon to rupture?

A
  • Happens when load exceeds failure strength
37
Q

What is the presentation of a tendon rupturing?

A
  • Positive Simmond’s (squeeze) test
  • Palpable tender gap
38
Q

What is the treatment for laceration/incision of a tendon?

A
  • Repair surgically and early
39
Q

What is the treatment of tendon ruptures?

A
  • Conservative
    • Done where ends can be opposed
    • Mobilise if partial rupture, use splint/cast
  • Operative
    • Done when high risk of re-rupture of ends cannot be opposed
40
Q

What are the 5 phases of bone growth?

A
  1. Hyaline cartilage model
  2. Primary ossification centre allowing growth
  3. Secondary ossification centre at each end
  4. Medullary cavity formed as bone continues to grow
  5. Epiphyseal plate forms at end of long bone, which closes on maturity
41
Q

Describe the anatomy of a long bone?

A
  • Diaphysis (shaft)
  • Metaphysis
    • Flare at end of shaft
  • Epiphysis
    • On joint side of physis
  • Epiphysis growth plate
  • Medullary canal
42
Q

Compare and contrast cortical and cancellous bone?

A
43
Q

What does cortical bone resist and what does cancellous bone resist?

A

Cortial - bending, torsion

Cancellous - compression

44
Q

Which of cortical and cancellous bone is more biologically active?

A

Cancellous bone

45
Q

What is a fracture?

A

Fracture = break in structural continuity of bone

46
Q

In clinical practice, what symbol indicates a fracture?

A

”#”

47
Q

What are causes of bones fracturing?

A
  • High energy transfer in normal bones (takes a lot of energy)
  • Repetitive stress in normal bones (stress fracture)
  • Low energy transfer in abnormal bones (maybe older people)
    • Osteoporosis
    • Osteomalacia, metastatic tumour
    • Other bone disorders
48
Q

What is delayed union of a fracture?

A

Delayed union is when fracture fails to heal in expected time:

49
Q

What are some causes of delayed union of a fracture?

A
  • Can occur due to anything that can interfere with repair
    • High energy injury
    • Distraction (fracture ends are not close together)
    • Instability
    • Infection
    • Steroids
    • Immune suppressants
    • Smoking
    • Warfarin
    • NSAID
    • Ciprofloxacin
  • When this happens consider alternative management
    • Different fixation dynaminisation bone grafting
50
Q

What is non-union of a fracture?

A

Non-union is failure to heal, which can occur due to:

  • Failure calcification fibrocartilage
  • Instability
  • Abundant callus formation
51
Q

What are some causes of non-union of a fracture?

A
  • Failure calcification fibrocartilage
  • Instability
  • Abundant callus formation
52
Q

What are the clinical features of non-union of a fracture?

A
  • Pain and tenderness
  • Persistent fracture line
  • Sclerosis
53
Q

What does fracture biology occur due to?

A
  • Due to mechanical and structural failure of the bone and disruption of blood supply
54
Q

What is very unique about the fracture regeneration process?

A

Leaves no scar

55
Q

What are the 4 stages of fracture regeneration?

A

1) Inflammation
2) Soft callus
3) Hard callus
4) Bone remodelling

56
Q

Descibe the steps of phase 1 (inflammation) of fracture regeneration?

A
  • Begins immediately after fracture when haematoma and fibrin clot released into area
  • Platelets, PMNs, neutrophils, monocytes and macrophages released
  • Local areas of cell death released lysosomal enzymes, creating biological mix designed to get new cells in for repair (following migrate in)
    • Fibroblasts
    • Mesenchymal and osteoprogenitor cells
      • These are transformed endothelial cells from medullary canal and/or periosteum
      • Also get osteogenic induction of cells from muscle and soft tissues
    • Angiogenesis
      • Oxygen gradient required (low oxygen in fracture)
      • Macrophages produce angiogenic factors under hypoxic conditions
57
Q

What can doctors do to assist phase 1 (inflammation) of fracture regeneration?

A
  • What doctors can do, give the patient platelet concentrates
    • Platelet derived growth factor (PDGF)
    • Transforming growth factor beta (TGF-B)
    • Insulin like growth factor (IGF)
    • Vascular endothelial growth factor (VEGF)
58
Q

What does PDGF stand for?

A

Platelet derived growth factor

59
Q

What does TGF-B stand for?

A

Tranforming growth factor beta

60
Q

What does IGF stand for?

A

Insulin like growth factor

61
Q

What does VEGF stand for?

A

Vascular endothelial growth factor

62
Q

Describe stage 2 (soft callus) of fracture regeneration?

A
  • Begins when pain and swelling subside, lasting until bony fragments are united by cartilage or fibrous tissue
  • Continued increase in vascularity
63
Q

What can doctors do to assist phase 2 (soft callus) of fracture regeneration?

A
  • Replace cartilage – DMB (demineralised bone matrix)
  • Bone graft or bone substitutes
    • Autogenous cancellous bone graft is the gold standard
      • Is osteoconductive and osteoinductive (allows cells to grow in)
    • Can use allograft bone from other patients
      • Risk of disease transmission
      • Not osteoinductive but is osteoconductive
64
Q

What does osteoconductive and osteoinductive mean?

A

Osteoinduction - process where osteogenesis is induced

Osteoconductive - bone graft material acts as scaffolding for new bone growth

65
Q

Describe stage 3 (hard callus) of fracture regeneration?

A
  • Conversion of cartilage to woven bone
    • Endochondral and membranous bone formation
66
Q

Describe stage 4 (bone remodelling) of fracture regeneration?

A
  • Conversion of woven bone to lamellar bone
  • Medullary canal is reconstituted
  • Bone responds to loading characteristics Wolff’s Law (becomes stronger in direction of load)
    • If strain is too high or too low healing will not be correct
      • If too low mechanical induction of tissue differentiation fails
      • If too high healing progress does not progress to bone formation
67
Q

What is Wolff’s law?

A
  • Bone responds to loading characteristics Wolff’s Law (becomes stronger in direction of load)
    • If strain is too high or too low healing will not be correct
      • If too low mechanical induction of tissue differentiation fails
      • If too high healing progress does not progress to bone formation
68
Q

What happens if strain on newly growing bone is too high?

A
  • Bone responds to loading characteristics Wolff’s Law (becomes stronger in direction of load)
    • If strain is too high or too low healing will not be correct
      • If too low mechanical induction of tissue differentiation fails
      • If too high healing progress does not progress to bone formation
69
Q

What happens if strain on newly growing bone is too low?

A
  • Bone responds to loading characteristics Wolff’s Law (becomes stronger in direction of load)
    • If strain is too high or too low healing will not be correct
      • If too low mechanical induction of tissue differentiation fails
      • If too high healing progress does not progress to bone formation

14. Year 2: Musculoskeletal (40 decks)

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