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MBBS II MSS > L20 - Introduction to soft tissue injury and fractures > Flashcards

L20 - Introduction to soft tissue injury and fractures Flashcards

■Common injuries ■Why fractures happen ■Steps of tissue healing ■List basic treatment of fractures ■Relate biological tissue healing to function

1
Q

List examples of soft tissue injuries?

SALAD PIC

A 
Sprain injury (stretch joint/ soft tissue) 
Abrasions (grazes) 
Lacerations 
Avulsions 
Deglove injury

Puncture wound (i.e. dog bite)
Internal (closed) deglove injury
Contusion

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2
Q

What are the predominant causes of death due to injury?

A

~1/4: suicide (16%, top 20), homicide (10%)

~1/4: road traffic injuries

Other main causes: falls (14%, rising to 17th), drowning (7%), fire-related burns (5%), poisoning (4%)

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3
Q

What is the epidemiology of higher injury death rates?

A

higher injury death rates in:
 Poorer countries (growing problem in some countries)

 Men

 Youth

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4
Q

What type of injuries do most young people have?

A

High energy, high mortality, Poly-trauma with multiple system involvement

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5
Q

What is the golden period of treatment for heart stop, respiration stop, Massive haemorrhage?

A

 Heart stop: 50% death rate after 3 minutes

 Respiration stop: 50% death rate after 10 minutes

 Massive bleeding (haemorrhage): 50% death rate after 30 minutes

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6
Q

What type of injuries do most old people have?

A

Low energy, mostly slip and fall injuries

75% with head injury / fractures

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7
Q

What are the measures to prevent road traffic deaths?

A

speeding enforcements, drinking, helmets, seatbelts, child restraints, infrastructure upgrades, vehicle and equipment standards, graduated driver’s license

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8
Q

What causes contusion?

A

direct blow to tissue with blunt object, often resulting in ruptured capillaries and bruising

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9
Q

What causes abrasions?

A

caused by the skin rubbing against a rough surface

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10
Q

What causes lacerations?

A

tearing of the skin that results in an irregular wound (unlike a cut which preserves skin)

caused by injury with a sharp object or by impact injury from a blunt object or force

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11
Q

What causes avulsion?

A

forceful detachment of body part

a body structure is torn off by either trauma or surgery

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12
Q

What causes deglove injuries?

A

an extensive section of skin is completely torn off the underlying tissue, severing its blood supply

Incomplete avulsion with laceration on top

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13
Q

What causes internal deglove injury?

A

shearing force separates subcutaneous fat from deep fascia

> > simple / complex fluid collection (blood, serous, lymphatic, liquefied fat, and/or pus) in potential space

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14
Q

complication of puncture wounds?

A

bacteria in saliva > infection

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15
Q

List some types of fracture?

A

transverse, oblique, spiral (twisting), comminuated, avulsion (e.g. connected to ligament), impacted, fissure, greenstick

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16
Q

What are the 3 classification of fractures?

A
  • Complete or incomplete
  • Closed (overlying tissue is intact) or Compound (fracture extends into the overlying skin)
  • Comminuted (bone is splintered) or Displaced (fractured bone is not aligned)
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17
Q

What is a pathologic fracture?

A

break occurs at the site of previous disease (e.g.,

a bone cyst, a malignant tumor…etc)

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18
Q

What is stress fracture?

A

develops slowly over time as a collection of microfractures associated with increased physical activity, especially with new repetitive mechanical loads on bone

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19
Q

What is the consequence and treatment of displaced intracapsular neck fracture?

A
  • Avascular necrosis of femur head&raquo_space; need to remove (cannot heal)
  • Treatment: prosthesis replacement (hip-arthroplasty)
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20
Q

What types of injuries are common at fingers and wrists?

A

 Lacerations, puncture, amputations (>50%)

 Fractures (17%, less common)

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21
Q

What types of injuries are common at elbow to shoulder?

A

 Fractures dislocations (~60%, more common)

 Sprains, contusions (~30%)

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22
Q

What are the phases in skin wound healing?

A

1) Exudative phase
2) Resorptive phase
3) Proliferative phase
4) Repair phase

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23
Q

List what occurs in the exudative phase of wound healing?

A

 Bleeding (haemorrhagic)

 Clot: wound is filled with fibrin, coagulated blood (form clot)

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24
Q

List what occurs in the resorptive phase of wound healing?

A

Clearance + Granulation

 Inflammation: scavenger cells (first polymorphonuclear neutrophils, then macrophages) remove dead cells, germs

 Granulation: form fibrous tissue

25
Q

List what occurs in the proliferative phase of wound healing?

A

 Wound Contraction

 Re-epithelization: new cells formed fill in the wound

 Form fibrous scar

26
Q

List what occurs in the repair phase of wound healing?

A

Epithelial remodeling

Skin creation and wound closure, scar formation

27
Q

What are the 4 phases of tendon healing?

A

1) Bleeding
2) Inflammatory
3) Proliferative
4) Remodeling

28
Q

List what occurs in the bleeding phase of tendon healing?

A

Open wound haemorrhage restricted by blood clot

Vasoconstriction to restrict local blood loss

29
Q

List what occurs in the inflammatory phase of tendon healing?

A

(onset after hours,
maximum in 3 days)

Exudation + Clearance + Vasodilation

Leaky vessels for exudates, cause swelling, cells and growth factors for wound repair move in:

damaged cells, pathogens, and bacteria are removed from the wound area

Chemically amplified cytokine cascade for vasodilation

30
Q

List what occurs in the proliferative phase of tendon healing?

A

2-3 weeks

**Scar + Re-epithelization + Wound contraction **

1) Fibrous scar formation: Recruit fibrocytes to deposit collagen
2) Re-epithelization: wound is rebuilt with disorganized collagen and extracellular matrix
3) Wound contraction: by myofibroblasts, agiogenesis to supply granulation tissue

31
Q

List what occurs in the remodeling phase of tendon healing?

A

Months

Wound close + Resurface

epithelial cells resurface the injury

collagen is remodeled from type III to type I and the wound fully closes, collagen cross-linking and alignment, water re absorption

Cells for repair die

32
Q

What are some pathological consequences of poorly regulated tissue healing?

A

Fibrosis, metaplasia and/or tumor growth

Infection, ischemia, poor perfusion

33
Q

List some important growth factors for tendon and ligament healing?

A

Insulin-like growth factor (IGF-I)

Platelet-derived growth factor (PDGF)

Basic fibroblast growth factor (bFGF)

Transforming growth factor (TGFβ)

34
Q

How does mechanical forces affect wound healing?

A

Mechanica loading stimulates protein synthesis:

Integrin proteins activate pathways for matrix remodeling

35
Q

What are the 4 phases of bone healing?

A

1) Hematoma formation
2) Fibrocartilaginous callus formation
3) Bony callus formation
4) Bone remodeling

36
Q

What occurs in the Hematoma formation phase of bone healing?

A
  • Torn blood vessels hemorrhage, clot/ hematoma forms
  • Inflammatory cells and fibroblasts infiltrate the bone
  • Site becomes swollen, painful and inflamed
37
Q

What occurs in the Fibrocartilaginous callus formation phase of bone healing?

A
  • Phagocytic cells remove cellular debris, granulation tissue formation, vascular tissue ingrowth, mesenchymal cell migration
  • Osteoblasts begin forming spongy bone within 1 week
  • Fibroblasts secrete collagen fibers to connect fractured ends&raquo_space; woven bone formation and endochondral ossification
  • Mass of repair tissue = fibrocartilaginous callus (hold the ends of the fractured bone in apposition but is noncalcified )
38
Q

What occurs in the Bony callus formation phase of bone healing?

A

Bone progenitors in the periosteum and medullary cavity deposit new foci of woven bone

Newly formed cartilage acts as nidues for endocondral ossification

Connects cortices and trabeculae in cortical bone and spongy bone

Final Ossification = bridge fractured ends with bony callus

39
Q

What occurs in the Bone remodeling phase of bone healing?

A

In response to mechanical stress

Balance between bone formation (osteoblasts) and resorption (osteoclasts) to adjust the bone architecture

restores the original size, shape, and integrity of the bone.

40
Q

What is the difference between primary and secondary bone healing?

A

Primary bone healing = involves a direct attempt by the cortex to re-establish itself after interruption without the formation of a fracture callus

Secondary bone healing = involves the classical stages of injury, hemorrhage inflammation, primary soft callus formation, callus mineralization, and callus remodeling.

41
Q

What are the requirements for bone healing?

A

Stability
Blood supply
Bone contact and scaffold
Growth factors

42
Q

Explain the cause of pseudoarthrosis in poor bone healing?

A

Inadequate immobilization and persistent movement

> > nonunion casuses central portion of callus to undergo cystic degeneration and create a FALSE JOINT

43
Q

What are some hurdles to bone healing?

A
  • Displaced and comminuted fractures result in deformity (loose bone fragments causes very long remodeling period)
  • Inadequate immobilization cause pseudoarthrosis
  • Infection
  • Poor nutrition: Inadequate calcium or phosphorus, vitamin deficiencies
  • Systemic diseases: systemic infection, diabetes, or vascular insufficiency
  • Wound: Large gap, scar contracture
44
Q

Why does secondary bone healing create longer healed bones?

A

Widening of healing zone = more mechanical stability

Conversion of fibrous soft callus to calcified hard callus = widening of bone

45
Q

List some causes of iatrogenic necrosis of skin?

A

wounds too tight, excessive retraction, undermined skin flaps

Thermal necrosis from electrocautery, high-speed drilling

46
Q

Which type of tissue can never heal properly in MSS?

A

Cartilage&raquo_space; forms Fibrocartilage

Tendon, Muscle and bone heal better than cartilage

47
Q

List the 2 classifications of nerve injury?

A

Seddon and Sunderland

Seddon = Neurapraxia, Axontmesis, Neurotmesis

Sunderland = Type 1 to 5

48
Q

What are the pathophysiologic features of Neurapraxia?

A

Type 1 / Neurapraxia:

  • Local myelin damage usually secondary to compression or pressure ischemia = conduction block
  • Functional disruption with no anatomical discontinuity
  • Nerve sheath intact
  • No Wallerian degeneration
49
Q

What are the pathophysiologic features of Axonotomesis?

A

Sunderland classification type 2-4 = Axontmesis

  • Microscopic discontinuation of nerve axon and myelin sheath without discontinuity of nerve sheath
  • With Wallerian regenration** loss of nerve conduction in distal segment, NO absence of distal sensory-motor response
  • Partial or complete recovery → remaining uninjured mesenchymal latticework provides a path for subsequent sprouting axons for reinnervation
50
Q

What are the pathophysiologic features of Neurotmesis?

A

Complete physiologic disruption of entire nerve trunk (axon and sheath disconnected)

Wallarian degeneration and no nerve conduction distal to site of injury

51
Q

Describe the phases of Wallerian Degeneration?

A

axonal degeneration (axonal skeleton disintegration and breaking of axonal membrane)
→ degradation of myelin sheath and macrophage infiltration
→ clearance of debris from the degeneration

Schwann cells line up, axonal sprouts form

Schwann cells myelinate axon > recovery

52
Q

What are the stages of Axonotomesis?

A

Type 2:
 Loss of continuity of axons  Sheath (endoneurium, perineurium, epineurium) intact

Type 3
 Loss of continuity of axons, endoneurium
 Perineurium, epineurium intact

Type 4
 Loss of continuity of axons, endoneurium, perineurium
 Epineurium intact

53
Q

Compare the outcome between successful nerve regeneration and unsuccessful?

A

Successful = Muscle initially atrophy, then regenerate. Axonal sprouts finds its path to penetrate bands of Bungner

Unsuccessful = muscle atrophy, Disorganized axonal sprouts causing Neuroma (also caused by amputation)

54
Q

How to treat neuroma?

A 
 Surgical treatment  
 Desensitization  
 Antiepileptics  
 GABA receptor inhibitor 
 Painkillers (opioids less effective)
55
Q

List some chronic problems with non-healing tissue?

A

Ulcer with infection
Tissue gangrene
Explosed implant

56
Q

The basics of treating a fracture?

A

Realign if deformed enough

Stabilize if unstable

Always rehab function

57
Q

List some ways to help fractures heal?

A

1) External traction
2) Cast
3) External fixation
4) Internal fixation (Intramedullary nail)
5) Internal fixation (plating)

58
Q

■Most likely to be high energy injury?
A. Oblique fracture of the neck of femur
B. Transverse fracture of tibia shaft
C. Oblique fracture of distal radius
D. Compression fracture of cervical spine
E. Spiral fracture of femur shaft

A

B. Transverse fracture of tibia shaft

MBBS II MSS (31 decks)

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