Orthopedic/Musculoskeletal Disorders Flashcards
Parts of the musculoskeletal system
Bones
Muscles
Joints
Cartilage
Ligaments
Tendons
Nerves
Skin/scars
Joints
space between 2 articular surfaces
Types:
- Synarthrosis
- Amphiarthrosis
- Diarthrosis
* ball and socket (greatest degree of freedom)
* condyloid
* gliding
* hinge
* pivot
* saddle
Cartilage
Lines articular bones
Protects against impact and friction
Gets blood through osmosis, so it doesn’t easily heal, if at all
No nerves, so it doesn’t hurt when you tear it
Thickening of cartilage in the knee - meniscus or disc
Types:
- Hyaline cartilage: most common; found in nose and ribs
- Fibrocartilage: found in intervertebral disks, joint capsules, and ligaments
Ligaments
Connect articulating bones
Prevent movement
Have very little vascular supply
Take a long time to heal
Ulnar collateral ligament of MP joint of thumb
- Gamekeeper’s thumb or skier’s thumb
- AKA medial collateral ligament
Grades of ligament sprains
Grade I: stretch the ligament causing mild swelling and pain with stress testing, but no laxity
Grade II: partial tear resulting in more moderate swelling and pain along with some laxity on stress testing; have definitive endpoint with stress testing
Grade III: complete tear with a lot of pain, swelling, and gross laxity on stress testing without any definitive endpoint
Grade IV: not really a sprain; avulsion fracture
Types of muscle movement
Isotonic
- eccentric: lengthening of muscle
- concentric: shortening of muscle
Isometric
- muscle contraction, not shortening or lengthening
- happens with co-contraction of flexors and extensors
Energy metabolism of muscles
METS (metabolic equivalent task score)
Primary engine that burns calories
What to muscles do?
Move the body
Energy metabolism
Generate body heat
Atrophy and hypertrophy
What is muscle atrophy?
muscle wasting, often with age
Muscle fibers
All or none
- motor unit: motor neuron and its end plate
- recruitment
Muscle spasm or cramp
Painful condition of muscle contraction (temporary)
Reason is varied and unknown
Muscle spasticity
Involuntary, intense, and sometimes painful contraction due to inappropriate CNS neural signs
Not strength
Ashworth’s scale
Muscle contracture
Muscle shortening from being stationary
Muscle fatigue
Decreased blood supply
Exhaustion of ACT
Accumulation of lactic acid (most common)
Myalgia
Muscle strain
RICE
Bleed and bruise
Chronic fatigue syndrome
Extreme fatigue lasting for at least 6 months and can’t be explained by any other medical cause
Symptoms:
- Post-exertional malaise
- Unrefreshing sleep
- Brain fog
- Muscle and joint pain
- Headache and light sensitivity
- Chills
- Stomach pain, bloating, nausea
- Sinus problems, swollen glands, tender lymph nodes, sore throat
No known cause or cure
Fibromyalgia
Often triggered by physical or emotional stress
If you have lupus or rheumatoid arthritis (RA), you are more likely to develop fibromyalgia.
Symptoms:
- Fatigue, cognitive and memory problems, headaches, diziness, trouble sleeping
- Vision problems
- Tender points
- Nausea
- Urinary problems, dysmenorrhea in women
- Restless leg syndrome
- Joint pain and stiffness
- Skin problems
- Muscle pain
- Jaw pain
Medication and stress reduction can help symtoms.
Bones
Provide structure
Reservoir of calcium and phosphate
Site of hematopoiesis
- RBC creation
Haversian canals (blood vessels in bones)
- avascular necrosis
- Kienbock’s disease: lunate (high risk for avascular necrosis)
Epiphyseal plates
- harden at 18 for women and 22 for men
- bone mass decreases at 40-60
Constant rate of uptake and production
- osteoblasts and osteocytes produce
- osteoclasts absorb
Wolfe’s law
What is Wolfe’s law?
Soft tissue (musculoskeletal tissue and bone) responds to the forces placed on it.
- Weight bearing can decrease the affect of the disease
- Osteoporosis can begin 6 weeks after spine injury
Rickets (Osteomalacia)
- bad bones
- due to vitamin D and E deficiency
- common in children outside the US
- bowing is caused by bodyweight
- can be corrected
Nerves
Get impinged or compressed by soft tissue or neuromuscular structures
- can get compressed against humerus when sleeping funny
Radial nerve
Innervates extensor wad
Responsible for wrist, thumb, and MP extension
Clinical presentation:
- Weakness of wrist dorsiflexion and finger extension, causing wrist drop and MP drop
What happens if there is damage to the axilla?
All radial-innervated muscles are involved
- anconeus and triceps
Decreased sensation
Arm drop
Limp and uncoordinated self-feeding
Very jerky
What happens if there is damage to the spiral groove?
All radial-innervated muscles distal to the triceps are weak
- extensor wad in forearm
What happens if there is damage to isolated posterior interosseous lesions (PIN)?
Sensation is spared and motor involvement occurs in radial muscles distal to the supinator
Lose a little bit of thumb and sensation
Innervation of the radial nerve
The radial n. innervates motor outside the hand in the extrinsic muscles of the forearm. Once it crosses over into the hand, it only functions in sensory.
Posterior interosseous nerve coarse
Ulnar nerve
Ulnar n. in ulnar groove - funny bone
- innervates adductor pollicis long head
- flexes intrinsic and ulnar half of lumbricals
- Guyon’s tunnel
- when power comes from
Ulnar nerve palsy
Occurs due to compression at the elbow (cubital tunnel) or at the wrist (Guyon’s tunnel)
Muscle weakness and atrophy predominate the clinical presentation
If it gets trapped at the cubital tunnel, there will be numbness and tingling
Can cause ulnar claw hand
- caused by an imbalance between strong extrinsic muscles and weakened intrinsic muscles
- MCP hyperextension
- PIP and DIP flexion
Ulnar innervated muscles
Forearm:
- flexor carpi ulnaris (C7, C8, T1)
- flexor digitorum profundus III and IV (C7, C8)
Thenar:
- hypothenar muscles (C8, T1)
- adductor pollicis (C8, T1)
- flexor pollicis brevis (C8, T1)
Fingers:
- palmer interosseous (C8, T1)
- dorsal interosseous (C8, T1)
- III and IV lumbricles (C8, T1)
Digiti minimi:
- abductor digiti minimi (Quinti) (C8, T1)
- opponens digiti minimi (C8, T1)
- flexor digiti minimi (C8, T1)
Median nerve
Injury at elbow or wrist
Commonly compressed at the wrist causing carpal tunnel syndrome
Deformity or ape-like hand
- flat thenar eminence and adducted thumb
Opposition and abduction aren’t possible leading to loss of pincer-like action of hand
- difficulty with fine motor tasks like buttoning
Cause:
- paralysis and wasting of the muscles of the thenar eminence
- adductor pollicis is unopposed since it is supplied by ulnar n.
- opponens pollicis, abductor pollicis brevis, and flexor pollicis brevis
Big driver of thumb flexion and adduction, except for deep adductor pollicis
If anterior interosseous n. injury is present, the patient will be unable to bring together the distal phalanx or thumb and index finger to make the OK sign.
Carpal tunnel
Carpal tunnel syndrome (CTS) occurs when the median nerve, which runs from the forearm into the palm of the hand, becomes pressed or squeezed at the wrist.
Causes numbness and tingling
Tendons
Connect muscle to bone
Covered in a sheath which provides nutrients
Tendonitis
Micro tear from lifting off the bone
Types:
- Epicondylitis
- Lateral: tennis
- Medial: golfers
DeQuervain’s Tenosynovitis
Affects abductor pollicis longus and extensor pollicis brevis
Use the Finklestien’s test
Intersections Syndrome
Abductor pollicis longus and extensor pollicis brevis cross over the extensor carpi radialis longus and the extensor carpi radialis brevis
Trigger finger
Affects the pulleys of the finger
- Annular (A 1-5)
- Cruciate (C 1-3)
If caught at or before 30 days, can be treated with injection and splinting.
Dupuytrens’ disease
Non cancerous tumor that grows around tendons and causes contractures
30º contracture at MP joint
Any contracture at PIP joint
Flat hand test
Z plasty to prevent straight line scar the pulls into flexion
Bursitis
Potential space filled with fluid
Found in areas where bone approaches another surface
May be removed or drained
Ganglion cysts
A fluid filled sac that grows out of the tissues surrounding a joint or tendon.
Ganglion cysts are common in the soft tissue along the back of the wrist, as 60% to 70% develop along the front or back of the wrist.
Can be associated with rheumatoid arthritis or osteoarthritis
Usually right on the carpal bones
If you pop it, theres a 50% chance it won’t grow back.
Joint disorders
Osteoporosis
Osteopenia
Heterotropic Ossification
Arthrogryposis multiplex congenita
Ankylosing spondylitis
Osteoporosis
Decreased bone density
Silent disease until there is a fracture
Loss of balance between production and uptake
Kyphosis
Dowager’s hump
- not fixable by a therapist
Frequently a comorbidity or RSD/CRPS, spinal cord injuries, or astronauts
Causes:
- age (over 50)
- hereditary
- poor diet
- alcohol
- prolonged steroid use
- cigarettes
- vitamin D (rickets)
- non weight bearing
Symptoms: none, fractures, shrinking
Dual energy x-ray obsorptiometry (DEXA)
Treatment:
- weight bearing
- medication
- diet
Osteopenia
Reversible weakening of the bone
- fracture without trauma (standing while washing dishes and hip suddenly just breaks)
“Pre” osteoporosis
- pathological fracture
Heterotopic ossification
Growing bone where you shouldn’t be growing bone
- more likely to happen where there’s already bone on bone (elbow)
- burns
- head injury
- spinal cord
Fracture vs. break
SAME THING
Break is the lay term for fracture
Fractures
Can be open (bone sticking out) or closed
Complete or partial
Compression
Pathological
- osteoporosis, rickets
What is a “bad” fracture?
Position: if it doesn’t stay by the other piece of bone; if it moves and causes tissue damage
Age
Fragments
Soft tissue
Fat emboli: fat escapes from marrow and can result in a stroke
Other diseases: like osteoporosis
Volkman’s ischemia
Volkmann contracture occurs when there is a lack of blood flow (ischemia) to the forearm. This occurs when there is increased pressure due to swelling, called compartment syndrome.
Types of union after a fracture
Delayed union: couldn’t put the bone back together quickly, possibly because of an infection
Malunion: poorly healed
Non Union: ends of the bones heal, but not together
Types of fractures
Greenstick: almost always in children; most don’t need surgery, just a cast; pressure on one side, break on the other
Spiral: only way it can occur is by twisting really hard, so if this happens in a child, CPS will be called
Comminuted: crush, shattered; non-stable
Transverse (oblique): complete or partial
Compound: total
Compression: bone is stable; will heal on its own
Delayed union: complete; a midshaft humeral fracture is inherently unstable and will result in surgery
Common fractures
Distal radius
- also called Bennett or Colles
- fall on outstretched hand
- CRPS?
Hip
- pelvis or femur
- usually results in hip replacement
Humeral
- elbow or shoulder
- risk to radial n.
Scaphoid
Treatment for fractures
Casts
External fixator
ORIF: Pins, screws, plates
When to start AROM vs PROM
AROM first so you don’t sheer soft callus. Pt will know when to stop on their own. If PROM the OT may cause more damage.
Dislocation vs subluxation
Shoulder
- sulcus sign, you can see the separation
Nursemaid’s elbow
- reduction: apply pressure at radial head, grasp wrist and apply slight traction, supinate wrist while flexing elbow to 90º
Apprehension test
- abduction and external rotation
Compartmental syndrome
Excessive inflammatory response
Volkman’s ischemia or ischemic contracture
- any place there is a compartment
* shin splings
- treated with fasciotomy if excessive
Osteoarthritis vs. rheumatoid arthritis
Osteoarthritis
Degenerative joint disorder (DJD)
Crepitus
Herberden’s nodes (DIP)
Bouchard’s nodes (PIP)
Often develops in hip, knee, or CMC
Interventions for osteoarthritis
Joint protection
Replacement
Symptom mangagement
- edema control
- heat/ice
- modalities
- meicine
Rheumatoid arthritis
System, RH factor
- severe joint inflammation, changes in the synovial lining
* pannus: corrosive agent that breaks down cartilage in bone
- more than just joints
- autoimmune
- leading cause of disability worldwide
- any age (JRA), adults 40-70
- all races and ethnic groups
- hereditary component
Symptoms and issues of rheumatoid arthritis
Moves from acute to chronic
- active vs inactive (flares)
Ulnar deviation
- wind swept or ulnar drift
- swan neck: hyperextension of PIP and flexion of DIP
- boutonnière: flexion of PIP and hyperextension of DIP
Swan neck deformity
Hyperextension of PIP and flexion of DIP
Points palmar
LB - dorsal
Injury outside of RH:
- injury to terminal ligament (mallet or jersey finger)
Boutonnière deformity
Flexion of PIP, hyperextension of DIP
Points dorsal
LB - anterior
Injury outside of RH:
- injury to central slip (buttonhole deformity)
Classification criteria for rheumatoid arthritis
Criterai:
1. morning stiffness (at least 1 hour)
2. arthritis in 3+ joint areas
3. arthritis of hand joints (1+ swollen)
4. symmetric arthritis
5. rheumatoid nodules
6. serum RF
7. radiographic changes (erosions) on x-rays of hands
Applicable for: all arthritis patients
Results in: classification of RA (yes/no)
Positive in case: 4/7 criteria must be present; criteria 1-4 must have been present for at least 6 weeks
Test characteristics: sensitivity of 79-80% and specificity of 90-93% for established RA; 77-80% and specificity of 22-77% for early RA
Intervention for osteoarthritis and rheumatoid arthritis
Meds to slow/control the disease:
- Disease modifying anti-rheumatic drugs (DMARDs)
* Methotrexate (can cause nausea, low blood count, increase risk of infection)
- Biological agents
* suppress the immune system to decrease inflammation
* Humira, Enbral
Treat symptoms:
- Steroids and corticosteroids
* Prednisone (increases risk of infection, weight gain, swelling)
* short term use only
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- less irritating than aspirin, but patients who can’t take aspirin may not be able to take these either
- primarily an anti-inflammatory but also analgesic (pain reliever)
- Ibuprofen (Advil, Motrin)
- Naproxen (Aleve, Naprosyn)
- Meloxicam (Mobic)
- Diclofenac (Voltaren), oral and as a topical skin gel (first one for OA)
- Side effects: GI Bleeding (black poo), Hepitatis, Tinnitus, photosensitivity, rashes
Intervention for RH
Joint replacements
- hip
- knee
- shoulder
- digits
- CMC
RH related arthritis
Juvenile rheumtoid or idiopathic arthritis (JRA or JIA)
Psoriatic arthritis
Gout
Juvenile rheumtoid or idiopathic arthritis (JRA or JIA)
Before 16 years old with a minimum 6 week duration
Types:
- oligoarticular
- polyarticular
- systemic
Differences:
- F:M :: 2:1
- Oliogarthritis is more common
- systemic (fever, rash) more usual
- large joints
- no rheumatic nodules and rheumatic factor
- pathogenesis: similar to RA
- outcome: 70-90% fully recover
Gout
Due to hyperuricemia (uric acid) in blood and tissues
Presents as a painful form of arthritis
Frequently affects the large joint of the big tow, although any joint can be affected
Acute gouty arthritis is sudden onset of joint pain caused by an inflammatory reaction to precipitated uric acid deposits in a joint
Occurs predominantly in men
Tends to run in families
Red, swollen joint
Treatment:
NSAIDs, lifestyle change
Medications associated with osteoarthritis
Acetaminophen (Tylenol): preferred first line treatment
- Mild to moderate pain-it does NOT decrease inflammation
- Doesn’t upset stomach, few side effects, non addictive
- If taken with alcohol can cause renal failure, rash
Salicylate drugs: oldest drugs known to man
- Aspirin (Bayer, Ecotrin) (acetylsalicylic acid or ASA)-analgesic and anti-inflammatory
- Irritate the stomach
* Long term use can cause gastric ulcers
- Tinnitus (ringing in ears)
- GI Bleeds, thinning of blood
- Some companies coat the aspirin (enteric-coated) to help with this
NSAIDs
Arthroplasty
Fancy word for joint replacement
Joints commonly replaced:
- knee
- hip
- shoulder
- CMC
- MP
- IP
Reasons:
- fractures into joint space
- arthritis
Complex regional pain syndrome
Used to be called reflexive sympathetic dystrophy (RSD)
Cardinal signs: pain outside the norm associated with that injury, swelling outside the norm associated for that injury, temperature change, stiffness or motor changes
Complete overreaction of the system to an injury
Can occur anywhere in the body, but most commonly in the arm after a distal radial fracture
Many different symptoms associated with it
Narcotics don’t affect the pain
Extremely hypersensitive to ice
6-12 weeks in, an x-ray will show osteoporotic changes in the affected limb
Duchene’s muscular dystrophy
Weakness in pelvic and shoulder girdle
Difficulty in rising
Hypertrophy of calves
Mental retardation
Early onset
Wheelchair confinement
Death by 20 years
Gower’s sign
Becker’s muscular dystrophy
Facioscapulo-humeral muscular dystrophy
Limb-girdle muscular dystrophy
Myotonic dystrophy
Developmental hip discplacia (ADD)
Also congenital
Seen in children
Galeazzi sign
Trendelenburg sign
Ortolani test
Osgood Schlatter’s Disease
Legg-Calve Perthes Disease
Spinal issues
Lordosis
Kyphosis
Scoliosis
- any lateral deviation, even 1º
- anything 15º+ needs intervention like bracing or surgery
- can be postural or birth
- 30º-40º can impact respiratory status, child bearing ability, liver and digestive function
Ankylosing Spondylitis
Spondylolisthesis: occurs when there’s bilateral defects in the vertebral pars intrarticulariss which permit the vertebral body to slip anteriorly; usually occurs at level L5, S1
Spondylolysis: the most common cause for spondylolisthesis; it’s a unilateral or bilateral defect in the vertebral pars interarticularis result from stress fracture
Myasthenia gravis
Weakness and exhaustion of skeletal muscles (droopy eye)
Autoimmune, motor nerves and muscles are OK
Less aggressive than MD, ALS
More common in women than men
Amyotrophic lateral sclerosis (ALS)
Degeneration of the nerve, spinal cord, and muscle
Muscular dystrophy
break down in myelin
Chronic, progressive neuromuscular diseases
Myasthenia gravis
ALS
MD
Weight bearing status on the operated leg
NWB
TDWB
PWB
WBAT
FWB
Total hip precaustions
No bending hip past 90º
No rotation of surgical leg
No adduction of surgical leg (crossing)
No lying on uninvolved side because the surgical leg will adduct
Hip vs. knee replacement
Touch down weight bearing after hip surgery
Knee is full weight bearing or weight bearing as tolerated after surgery
Bone cancer and cysts
Children and adults
Osteosarcoma - malignant
“sarcoma”
Criteria for complex regional pain syndrom
Budapest Criteria is the definitive way to diagnose CRPS
Criteria:
- The pt. has continuing pain that is disproportionate to any inciting event
- The pt. has a least 1 sign in 2 or more categories
- The pt. reports at least 1 symptom in 3 or more categories below
- No other diagnosis can better explain the signs and symptoms
- A sign is an objective measure (ROM, swelling, temperature)
- Symptom is something the patient says, can’t take a picture of it
Categories
1. Sensory: allodynia (pain to light touch, temperature, deep pressure, and/or joint movement; hyperalgesia (pinprick)
2. Vasomotor: temperature asymmetry, skin color changes, and/or skin color asymmetry
3. Sudomotor/edema: edema, sweating changes, and/or sweating asymmetry
4. Motor/trophic: decreased ROM, motor dysfunction (weakness, tremor, dystonia), and/or trophic changes (hair, skin, nails)
- Sensory category is going to be a symptom
- Vasomotor, sudomotor, and motor/trophic are signs
Complex regional pain syndrome STAMP
Sensory
- allodynia
- hypo/hyperalgesia
- hypo/hyperesthesia
Trophic
- skin, hair, nail changes
Autonomic
- swelling
- edema
- sweating
Motor
- weakness
- contractures
- atrophy
Pain
Low back pain
One of the most common musculoskeletal complaints with 80% of people experience it.
People that are inactive are at higher risk for back injury.
Typically have tight hamstrings, causing posterior tilt
Limited ROM when 4+ vertebrae are fused
Causes:
- muscle pain/strain
* often linked to tight hamstrings
* pelvic position
* posture
* it hurts “here,” true back pain
* ergonomic intervention
- lumbar radiculopathy (pinched nerve)
* bone, cartilage, degenerative disease of spine, bone spur, disc
- herniated or ruptured disc
- degenerative disc
Herniated vs ruptured intervertebral disc
Herniated (bulging)
- symptoms will occur down the distribution
- by correcting pelvic positions and strengthening muscles you can reverse the effects
- therapy can fix it
Ruptured
- the nucleus pulpous begins to exit the disc and may compress a nerve
- same symptoms as herniated disc
- surgery is the only way to fix the disc
- controversial that therapy can help
Either of these can be asymptomatic if the spinal nerve isn’t being compressed.
Can’t tell the difference in X-rays, need to get MRI.
Spondylolisthesis
Vertebra slide or displace over each
condition of spine in which forward displacement of one of the lower lumbar vertebrae over the vertebrae below it
Spondylosis
also known as spinal arthritis
an age-related condition that affects the joints and discs in your neck and back
Spondylitis
Facet joint syndrome
an inflammation of any of the joints between the vertebral spine
may occur in osteoarthritis, RA, or ankylosing spondylitis
Spinal stenosis
Narrowing of one or more spinal openings or foramina due to
- osteoarthritis and bone spur growth
- degenerative disc disease
- ossification of spinal ligaments
Usually caused by general wear and tear related to aging
Can also be caused by things like tumors, herniated discs, spinal injuries, and bone diseases
Sometimes there are no noticable symptoms.
Can include pain, weakness, numbness, bladder and bowel problems, craping or pain in legs
Symptoms generally worsen over time
ADD TREATMENT
Intervention for low back pain
Medication
Therapy
Surgery (fusion)
- Spondylolisthesis
Amputation
Birth or trauma
Developmental aspect
- Appropriate age for prosthetic use for upper limb is 6 months and for lower limb for 6-9 months.
New and old terminology for amputations
The terms long and short refer to the residual limb
Scapula and shoulder amputation is forequarter
The terms in ( ) are new
Aging and musculoskeletal system
Joint aging
Bones
Role of exercise/activity
OT’s in musculoskeletal intervention
Exercise goal is function
ADL
Splinting
Adaptations
Prosthetics
Re-training
Rehab
Pain control
Who do we work with?
PT
Doctors
- orthopedics
- general
- neurologist
- rheumatologist
ATC, coaches, parents, nurses, case workers, personnel managers
What is the purpose of skin?
Protective covering
Retards loss of water and fluid
Regulates body temperature
Houses sensory receptors
Synthesis of chemical (vitamin D)
Excretes waste
Cosmetic
Epidermis
Most superficial layer of skin
Made up of stratified squamous epithelium
Houses melanin (color)
Keratin “seals the skin” and prevents dehydration. IT also makes us waterproof.
Has no blood supply
Sloughs off every 15-30 days
Has a basement membrane (zone or basal)
- located between the dermis and epidermis
- collagen fibers connect the two
- poor at birth and degenerates with age which can cause shearing injuries
Dermis
Second layer of skin
Thick
Made up of
- fibrous connective tissue
- epithelial tissue
- smooth muscle tissue
- nerve tissue
- blood
- support system for hair follicles
Has sebaceous glands that continuously produce sebum to keep the skin moisturized.
- Age decreases sebum production.
Sudoriferous glands act on demand to produce sweat.
Subcutaneous
Deepest layer of skin
Fibrous connective tissue
Adipose tissue
Anchors to the muscle
Primary skin lesions
Arise from normal skin
Types:
- macule (freckle or hyperpigmentation
- tumor greater than 2 cm
* nodule - smaller tumor
* fibroma (fibrous sac), lipoma (fat sac), melanoma, hemangioma (blood vessels)
- cysts
- scale
- vesicle (blister)
- pustule (zit)
* sterile or infected
Secondary skin lesions
Results from injury
Irritation
Invasion
Healing of a primary lesion
How does a shallow injury heal?
Epithelial cells along the margin are stimulated and fill in the wound from margins to center and from the bottom up.
How do injuries to the dermis or subcutaneous layer heal?
- Blood escapes and cleans the wound. It brings in clotting factor to form a scab.
- Scab forms.
- Fibroblasts migrate and begin to form collagenous fiber from the bottom up and sides to middle.
- Blood vessels send out new branches below the scab.
- Phagocytic cells remove dead cells.
- Scab sloughs off.
- If depth is greater than width, you will need to pack the wound
What are the 4 phases of wound healing?
Hemostasis: day 1-3, stop bleeding and fluid loss
Inflammation: day 3-20, new framework for blood vessel growth; swelling, redness, heat
Proliferation or granulation: Week 1-6, pulls the wound closed, looks like sand, tissue regenerates and wound begins to close
Remodeling or maturation: week 6-2 years, final proper tissue
Scarring
Scar occurs if excessive connective tissue is needed
Types of scars
Hypotrophic: doesn’t affect function, flat and smooth
Hypertrophic: stays in the perimeter of the wound, can occur from picking a scab
- keloid: doesn’t stay in the perimeter, skin thickness and race can cause keloid development
- not a lot can be done about keloids: acid injection, surgery
- raised, hard, adhesions
Granulations
Small rounded masses consisting of new blood vessels and a cluster of connective tissue to nourish the blood vessel
Red, sandy appearance
Causes of burns
Thermal: sun, curling iron, hot sidewalk
Chemical: clorox
Electrical: always has an entry and exit
- follows the nerve and vessel system
- fasciotomy or amputation are often required
- can cause a microstoma
For every percent of the body covered in burn, you lose 1% chance of survival
Classification of burns
First degree:
- superficial
- red with mild edema
- don’t scar
- self resolving
Second degree:
- partial thickness
- epidermis and dermis
- blistering
- red to a waxy white
- heals spontaneously
- non scaring if it heals well
- no grafting
- doesn’t matter if you pop it
- MUST pop if it covers a joint, it has become cloudy or bloody, or it impacts function
Third degree:
- full thickness
- destroys the dermis, epidermis, and accessory organs
- dry/leathery - read to black to white
- non blanching (when you poke it, it turns white then red)
- not painful, but the area around it hurts because it is probably a 2nd degree burn
- healing
* margins in only
* grafting if bigger than 50¢
* severe scaring
Fourth degree:
- muscle and bone
Eschar
Crust or drainage and sloughed cells
Non productive scab
Black in color
No sensation
HAs to be debreided
Other areas a burn can affect
Respiratory
Inhalation injury
Temperature regulation (can’t shiver or sweat)
Hypermetabolism
- increase by up to 40%
- need for more calories
Dehydration
- burn shock: due to fluid loss
Infection
- difficult to diagnos
Burn treatment
Sterile for 48-72 hours
Topical treatments
Debridement
- Mechanical
* hydrotherapy
* whirlpool
* tanking
* manual
- Surgical
*usually first 48 hours
* bad apple principle: cut until you get to good skin
* infection
* scar release: not good because it creates more scar tissue, but okay in children because they grow
* enzymatic (chemically)
Burn grafts
Homograft: human skin the comes from someone else, often a cadaver
Autograft: comes from the individual, often their inner thighs
Zenograft: not human skin, often pig skin; currently they are working on creating skin in the lab
What are the 2 methods to classify burns?
Rule of 9s
Lund-Brower
Possible burn disabilities
Loss of muscle strength
Nerve involvement
Wasting
Loss of sensation
Loss of a body part
Loss of motion due to scaring
- contractures
Disfigurement
Blindness
Lung/respiratory
Fractures
Abuse and burns
When to suspect abuse:
- story doesn’t fit
- shape
* cigarette
* iron
- area doesn’t fit
* stocking burn
* genitals
- amount of time before reported
- more than one story
How to prevent burns?
Education
Safety
Fire retardant material
Who is on the burn team?
Nurses
Doctors
- ortho
- plastics
- neuro
- podiatrists
- internist
Psychiatrist
Social worker
Nutritionist
OT/PT
Respiratory
Vocational rehab
Burn prognosis
Less than 20% burn, excellent survival rate
Sent to burn unit:
- any full thickness burn
- burns on hands, face, or genitals
- joints are involved
- electrical burns
- severe chemical burns
- inhalation injury
- high risk or other mobidities
Burn precautions
Shearing
Removal of graft
Infection
Contractures
Psychosocial problems
OT and burns
Burn unit
Inpatient/Outpatient rehab
Wound care
Exercise in water
Pressure garments
Prevent deformities
Increase function
Adaptive equipment
Developmental issues
Psychological issues
