What is a soft tissue injury?
Contusion/Bruise - Result of direct trauma - Skin remains intact - Blood vessel/cell damage - Edema, inflammation - Ecchymotic (black, blue, brown, yellow) Hematoma - Localized hemorrhage - Blood accumulation pressures nerves - Pain, increasing with movement/pressure
Describe a strain and list its manifestations.
Involves muscle/tendon
Partial tear, often during muscle contraction
Risk increases with age
- Collagen fibers less elastic
Common in back, cervical spine, elbow, shoulder
Sports injuries: hip, hamstring, quadriceps
> Manifestations
Often no visible signs unless inflammation
Pain, increasing with stretching
Stiffness, swelling, tenderness
Describe a sprain and its manifestations
Tearing or rupture of supporting ligament or capsule surrounding joint d/t abnormal/excess joint movement Diagnosis Not visible on X-ray unless bone fragment > Manifestations Pain Rapid swelling limits movement Discoloration Last longer than strain
Strain/sprain treatment
Rest Ice Compression Reduces swelling Provides support Elevation Immobilization - Strains if severe - Sprains x weeks Immobilization
Strain/sprain healing and complications
Able to heal to original tensile strength
Capillaries bring oxygen/nutrients
Fibroblasts produce collagen
Collagen bundles strengthen over time
> Complications
Contraction can pull healing apart and result is lengthened position upon final healing
adhesions
Describe a dislocation and where do dislocations often occur?
Abnormal displacement of articulating surfaces of joint Subluxation Partial dislocation Some surface contact Common joints Shoulder Acromioclavicular
Dislocations Classifications
1. Congenital Hip or knee usual 2. Traumatic MVA: hip Athletics: shoulder, knee Fall: wrist, ankle 3. Pathologic - Complication of infection, rheumatoid arthritis, neuromuscular disease, etc.
Dislocation diagnosis, manifestations, and treatment
> Diagnosis History, assessment, x-rays > Manifestation Pain Deformity Limited movement > Treatment Spontaneous (can pop joint back into place) Manipulation Surgical repair Immobilization Physiotherapy
Shoulder injury
Clavicle fracture common d/t childhood falls/blow Most resolve without surgery Immobilize with sling > Acromioclavicular joint - Common athletic injury > Glenohumeral joint Very common dislocation E.g. when arm extended
What is a rotator cuff injury and common resulting conditions.
Function of cuff is to stabilize the humoral head against the glenoid
Injuries are a result of a combination of: Direct blow or stretch Excessive use/repetition (common) Altered blood supply to tendons Age-related degeneration
Common resulting conditions
Tendinitis
Sub-acromial bursitis
Partial/ complete tears
Rotator cuff manifestations
Pain
Tenderness
Difficult abducting/rotating arm
Muscle atrophy
Shoulder/Rotator cuff diagnosis and treatment
> Diagnosis Assessment of active & passive ROM History of injury is important MRI Arthroscopic examination > Treatment Anti-inflammatories Corticosteroid (oral, injection) Physiotherapy Surgical repair
Knee ligamentous injuries and manifestations
Most serious of knee injuries
- ACL rupture/tear is most common
Manifestations of ACL rupture/tear “pop” or tearing sensation Sudden pain Loss of weight-bearing Hemorrhage causes swelling
What are the manifestations and complications of meniscus tears?
> Manifestations
pain, especially on hyperflexion & hyperextension
Edema
Instability
Locking d/t loose fragment
Complications
- Osteoarthritic changes limiting movement.
Patellar Subluxation & Dislocation manifestations
Usually sports related Manifestations Weakness Swelling Crepitus Sound you hear when tissue is rubbing against each other and they shouldn’t be Stiffness Loss of ROM
What is chondromalacia patellae and what causes this?
Inflammation of the underside of the patella
Sports
Knee overuse in older adult
What are the causes and manifesations of patellofemoral Pain Syndrome?
Most common cause of anterior knee pain > Causes Imbalance of forces controlling patella movement Contact of posterior surface of patella with femur Running, jumping, sitting > Manifestations Pain weakness Absence of edema
Cause of hip injuries
Dislocation d/t trauma Emergency Disruption of blood and nerve supply Avascular necrosis: interruption of blood supply resulting in necrosis of bone tissue = collapse of bone
What are risk factors for hip fractures?
Risk Factors Age Women d/t osteoarthritis Physical inactivity Alcohol excess Psychotropic medications Institutionalization Visual impairments Polypharmacy Osteoporosis.
What are surgical options for hip fractures?
Total hip replacement (THA)
Hemi-arthroplasty (ball and socket replacement)
ORIF (open reduction internal fixation- hold bones together with pins)
Revision
Fractures in general
Sudden Injury /or/ Stress Fractures Incomplete fractures Fatigue fracture Any weight-bearing bone E.g. tibia SF can be mistaken for “shin splint” Pathologic fracture Bone weakened by previous disease/tumor
Fractures: classifications
> Position on bone Proximal/mid-shaft/distal Head/neck Near prominence (malleolus) > Degree of communication with outside environment Open/compound Closed > Degree of break Greenstick - Young, soft immature bone
Fractures: classifications cont’d
> Character of fracture pieces
- Comminuted: multiple pieces
- Compression: crushing of 2 bones
- Impacted: fragments wedged together
- Butterfly: triangular bone piece, typically long bones
- Avulsion: when the tendon or ligament tears off a piece of the bone
> Direction of break Transverse (all the way across bone) Oblique Spiral (result of opposite movement) Twist, torque
What are the manifestations of fractures?
Pain/tenderness Swelling loss of function/mobility Deformity Angulated fragments damage tissue Shortening of extremity Rotational Crepitus Blood loss (bones are very vascular-can lose up to a liter of blood from hip fracture-internally) Nerve function impairment or loss - Local shock (numbness, flaccid muscles)
Fractures diagnosis and treatment
> Diagnosis
Assessment
X-ray
> Treatment
Reduction of fracture
Closed or open
Immobilization: splint, cast, external fixation devices, traction
Preservation & restoration of function
Physiotherapy
Describe the process of bone healing
1. Hematoma formation First 1-2 days Bone/tissue blood vessel rupture Fibrin network (clot) forms - Provides foundation for inflammatory cells
- Fibrocartilaginous callus formation
Fibroblasts begin repair
Takes 2-3 weeks, but still weak
Bone healing cont’d
3. Bony callus formation: ossification Osteoblasts form; calcium salts deposit Cartilage converts to bony callus Begins 3-4 weeks after injury, takes months 4. Remodelling Dead cells removed Compact bone replaces spongy bone; callus shrinks Possible “scar”.
What are some complications of healing?
1. Delayed union Failure to heal in usual time, but eventually does 2. Malunion Deformity 3. Nonunion Failure to heal
Complications of fractures: Fracture Blisters
- Epidermal necrosis d/t fluid separating it from dermis
- Often where minimal s/c tissue between epidermis and bone
- Chance of infection if broken
Complications of fractures: compartment syndrome
> Increased intra-osseus pressure within a limited space due to: Decreased size Constrictive dressings Casts Burns Increased volume of contents Trauma Fluid/edema Vascular injury/bleeding Venous obstruction Both
Compartment syndrome pressure is dependent on…
> Amount of pressure dependent upon: Duration Metabolic rate Vascular tone Local blood pressure
> Result of increased pressure
Compression of vessels = ischemia, necrosis
Compression of nerves = paresthesis, paralysis
What are the manifestations of compartment syndrome and what assessments should be performed?
> Manifestations Severe pain Sensation change: burning/tingling/loss Diminished reflexes, motor function loss Decreases/loss peripheral pulses > Assessment Pain Sensory Motor function
What are the 6 p’s of a neurovascular assessment?
- Pain
- Pulselessness
- Paralysis
- Paresthesia
- Polar (temp)
- Pallor (colour)
Complications of Fractures: Fat Embolism Syndrome (FES)
Common but few people have symptoms or complications
Fat droplets from bone & adipose tissue circulate though venous system to body
Not the same as a “fat emboli”
FES manifestations
Respiratory failure Dyspnea, pallor, cyanosis Angina, tachycardia, diaphoresis Cerebral dysfunction Early or late sign Mentation/behaviour changes Focal deficits, encephalopathy, seizures Skin/mucosa petechiae Rash 2-3 days post event
Complications of Soft-Tissue Injury
> Skin injury - Fracture blisters > Muscle injury - Compartment syndrome > Nerve injury - Paresthesia, paralysis > Adipose/bone injury - Fat emboli, FES
What is osteomyelitis and what bacteria most commonly causes this?
> Infection of bone
Direct contamination
Hematogenous (thru blood)
Via skin lesion
> Staphylococcus aureus most common
Adheres to bone, attacks cells
Evades host defenses and colonizes
Decribe hematogenous osteomyelitis in children and in adults.
> In children Affects long bones Purulent exudate inside bone Damages arteries supplying bone May penetrate skin or involve joints > In adults In vertebrae, sternoclavicular and sacroiliac joints, or pubic symphysis Tends to affect joint space
What are hematogenous osteomyelitis manifestations?
Manifestations Signs of bacteremia Fever, chills, malaise Pain on movement of area Tenderness Erythema Edema
Chronic osteomyelitis
Usually adults Usually secondary to open wound Sequestrum Infected dead bone Separated by sheath Difficult to detect when near a joint prosthesis.
Osteonecrosis
> Bone destruction d/t interruption in blood flow Idiopathic Bone injury Thrombosis/embolism Vessel injury Increased intraosseous pressure Corticosteroid associated (unclear)
Osteonecrosis manifestations and treatment
> Manifestations
Chronic pain, unrelated to movement
> Treatment
Dependent on cause
Immobilization, anti-inflammatories, exercise
Surgery often needed for hip involvement
Benign bone tumors
Confined to bone Well-defined borders Seldom cause fractures Seldom require treatment or surgery 1. Osteoma Small bony tumor (new bone tissue) on bone surface 2. Fibrous tumors Common in growing bones Usually asymptomatic Resolve in 2-3 years
Benign bone tumors cont’d
- Chondroma (tumor made of cartilage)
Short bones; solitary lesion
Onset @ 20-40 years of age
Asymptomatic or painful
4. Osteochondroma (cartilage-capped tumor) Bony stalk attaches it to bone Most common Slow-growing, solitary mass Knee is common
5. Osteoclastoma (giant cell tumor) Behaves like malignant Metastasizes via bloodstream Recurs after removal May invade bone and cause bone destruction Knee is common Pathological fractures common
Malignant Bone Tumors
1. Osteosarcoma (most common) Tends to be in areas with fastest bone growth Unknown etiology, but genetic connection Peak ages: women Metastasizes early, often to lung 2. Chondrosarcoma Can arise from pre-existing benign cartilaginous tumor Mid to late adulthood Slow-growing Responds to early excision 3. Ewing sarcoma Densely packed small cells Children & young adults Men > women
Metastatic Bone disease and manifestations
Skeletal metastasis is the most common bone cancer
50% of all cancers metastasize to the bone
Most often in trunk bones
Manifestations
Pain
Pathologic fracture
Hypercalcemia d/t bone destruction
Manifestations of bone cancer
- Changes in organ function (organ damage, inflammation, and failure):
- Local effects of tumors (e.g., compression of nerves or veins, stretching of periosteum):
- Nonspecific signs of tissue breakdown (e.g., protein wasting, bone breakdown):
