Injury and Healing

Question 1

Mechanisms of bone fracture

Answer 1

Trauma (low/high energy)
Stress(repetitive)- abnormal stresses on bone
Pathological - normal stresses on bone but indicated underlying problem with bone structure

Question 2

How does a stress fracture occur

Answer 2

Overuse
Stress exerted on bone > bone's capacity to remodel
Bone weakening
Stress fracture
Risk of complete fracture

Question 3

Weight bearing bones

Answer 3

Femur
Tibia
Metatarsals
Navicular

Question 4

Activity related stress fracture

Answer 4

Atheletes
Occupational 
Military
Female 
Stress fracture
Risk of complete fracture

Question 5

Female athlete triad

Answer 5

Disordered eating
amenorrhea
osteoporosis

Question 6

Pathological causes

Answer 6

Osteoporosis- soft bone
Malignancy - primary/bone mets
Vitamin D deficiency ( calcitriol) - osteomalacia/rickets
Osteomylitis
Osteogenesis Imperfecta
Pagets

Question 7

What infection can particularly predispose people to fractures

Answer 7

TB

Question 8

Osteoporosis

Answer 8

Loss of bone density

Question 9

Osteoporosis cause

Answer 9

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

Question 10

Primary vs secondary osteoporosis

Answer 10

Primary osteoporosis is due to the normal ageing process while secondary osteoporosis is due to specific clinical disorders

Question 11

Primary osteoporosis

Answer 11

senile osteoporosis->70

Post menopausal osteoporosis - 50-70

Question 12

Secondary osteoporosis

Answer 12

Hypogonadism
Glucocorticoid excess
alcoholism

Question 13

Vitamin d deficiency

Answer 13

inadequate calcium or phosphate - defect in osteoid matrix mineralisaton

Question 14

OI

Answer 14

Brittle bone disease

Heriditary - autosomal dom or rec

Question 15

OI pathogenesis

Answer 15

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`)

Question 16

Effects of OI

Answer 16

Bones
Hearing
Heart
Sight

Patients can present with blue sclera, lens dislocation and short stature

Question 17

Pagets Disease

Answer 17

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

Question 18

Pathogenesis of pagets disease

Answer 18

osteoclastic activity
Mixed osteoclastic-osteoblastic activity
Osteoblastic activity
Malignant degeneration- develop into osteosarcoma of bone or osteomalacia

Question 19

Primary bone cancer

Answer 19

Osteosarcoma (osteoblastic tissues)
Chondrosarcoma (chondral tissue)
Ewing sarcoma
Lymphoma

Question 20

Secondary bone cancer

Answer 20

Blastic- prostate
Lytic- kidney, thyroid, lung
Both - breast

Question 21

Fracture patterns stages

Answer 21

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

Question 22

Tissue healing general stages

Answer 22

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

Question 23

Fracture healing

Answer 23

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)

Question 24

Primary bone healing

Answer 24

Intramembranous healing
Absolute stability
Direct to woven bone

Question 25

secondary bone healing

Answer 25

Endochondral healing Involves responses in the periosteum and external soft tissues Relative stability Endochondral ossification : more callus (in comparison to primary bone healing)

Question 26

Bone healing times

Answer 26

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

Question 27

Principles of fracture management

Answer 27

Reduce : closed/open Hold: no metal/metal Rehabilitate: move, physiotherapy , use

Question 28

Reduction of closed fracture manipulation example

Answer 28

Collis fracture where the radium is dorsally tilted/angulated - like a dinner fork

Question 29

Reduction traction

Answer 29

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

Question 30

Look at fixation flow chart

Answer 30

Look at fixation flow chart

Question 31

Rehabilitation

Answer 31

Use- pain relief/ retrain Move Strengthen Weight bear

Question 32

Why do tendons tear

Answer 32

Tendinopathy - tendinosis ( abnormal thickening ) - tendinitis - inflammation - rupture Sportsmen may already have thickening/inflammation of the tendons

Question 33

treatment of tendon or ligament tears

Answer 33

1) immobolise - rely on the haematoma formation process and place in a plaster or boot or brace 2) Surgical repair - suture

Question 34

immobilisation vs surgical repair on ligament inury

Answer 34

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

Question 35

Factors afecting tissue healing

Answer 35

Mechanical environment: movement /force | biological environment: blood supply, immune function , infection, nutrition ( diabetes increases healing time)

Question 36

What might you see when examining a patient for a fracture

Answer 36

``` 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 ```

Question 37

STAR

Answer 37

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

Question 38

Role of ACL

Answer 38

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

Question 39

presentation of ACL tear

Answer 39

pain, knee giving way, can't push or twist knee

Question 40

test for ACL tear

Answer 40

lachmanns anterior drawer pivot shift

Question 41

Short term management for ACL injury

Answer 41

PRICE and then maybe splinting/bracing

Question 42

long term management for ACL injury

Answer 42

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

Question 43

Things to think about when operating on ACL injury

Answer 43

``` age symptoms- pain or giving way activity level has physio been tried other structures involved indications for ACL reconstruction patellar tendon/ hamstring ```

Question 44

which muscles insert into the achilles tendon

Answer 44

soleus and gastrocnemius

Question 45

function of achiles

Answer 45

plantar flexion - point foot away from you

Question 46

signs of achilles tendon injury

Answer 46

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

Question 47

achilles tendon/ any surgery operation complications

Answer 47

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 ```