Chapter 10: Tissue Healing and Wound Care - PowerPoint Presentation

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Chapter 10:

Tissue Healing and Wound Care

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Two potential effects of forceAccelerationDeformationFactors that determine injuryMagnitude of forceMaterial properties of tissues involved

Force and Its Effects

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Small load—elastic response Load is removed, material returns to its original shapeLoad reaching yield point—plastic responseLoad is removed, some amount of deformation remainsYield loadMaximum load a material can handle without permanent deformation Failure Force such as loss of continuity, rupturing soft-tissue or fracturing bone

Response to Force

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Many tissues are anisotropic.Different strengths in response to loads from different directionsAnatomic make-up of jointSusceptibility from a given direction

Direction of Force

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Axial Force that acts on the long axis of a structureCompressionAxial load that produces a crushing or squeezing type forceTensionAxial force in opposite direction; pulling or stretching the tissuesShear Force parallel to a plane passing through the objectTends to cause sliding or displacement

Categorize Force Relative to Direction

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Categorize Force Relative to Direction (cont.)

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StressForce divided by the area over which the force actsA given force over a large area versus a small concentrated area can have very different results

Magnitude of Stress

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Strain The amount of deformation relative to the original size of the structureResultCompression—shortening and wideningTension—lengthening and narrowingShear—internal deformationProblem: high strain rather than high forceThe ability to resist strain relative to strength of tissues

Strain versus Force

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Acute injury Results from a single force Causative factor: macrotraumaCharacterized by a definitive moment of onsetChronic or stress injuryResults from repeated loadingCausative factor: microtraumaCharacterized by becoming more problematic over time

Element of Time

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Gradual mechanical stress Size & strength

Positive Stress versus Adverse Stress

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Moment armPerpendicular distance from force line of action to the axis of rotationTorque Force × moment armProduces rotation of a body

Torque

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Torque (cont.)

Injury potentialBendingTension on one side of object and compression on the other sideTorsion Twisting an object’s longitudinal axis

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CollagenPrimary constituent of skin, tendon, ligamentsProtein substance strong in resisting tensile forcesWavy configuration that allows for an elastic type deformation or stretch but, otherwise, is inelasticElastinProtein substanceAdds elasticity

Soft Tissue: Anatomic Properties

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Skin

EpidermisDermisMultidirectional arrangement of collagen

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Muscle to bone Dense connective tissue with unidirectional bundles of collagen and some elastinCollagen: parallel arrangementHelps in resisting high, unidirectional tension loads from the attached muscleTwo times as strong as muscle it servesYield point 8% to 10% in length

Tendons

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Aponeuroses

Attach muscle to other muscles or bone

Dense connective tissue

Strong, flat, sheetlike

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ViscoelasticExtensibility—ability to be stretchedElasticity—ability to return to normal lengthViscoelasticity allows muscle to stretch to greater lengths over time in response to a sustained tensile force.

Muscle

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Irritability—ability to respond to a stimulusElectrochemical: nerve impulseMechanical: external blowContractility—ability to develop tensionIsometricConcentricEccentric

Muscle (cont.)

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Joint Capsule

Membrane that encloses a joint; composed primarily of collagen

Function: hold bones in place

Inner lining: synovial membrane

Exit for waste; entrance for nutrients

Secretes synovial fluid (lubricates and nourishes)

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Bone to boneCollagen is parallel and interwoven.Resists large tensile loads along the long axis of the ligament and smaller loads from other directions Collagen and elastin intermixed (more elastic than tendons)

Ligaments

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Bursa

Fluid-filled sacs

Reduce friction

Common sites—areas of friction

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Classification of Joints

Fibrous (

synarthrosis

)

Held together by fibrous tissue

Can absorb shock but permits little or no movement of the articulating bones

Example: sutures in the skull

Syndesmoses

Joined by dense fibrous tissue

Permit extremely limited motion

Example: interosseous membrane

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Classification of Joints (cont.)

Cartilaginous (amphiarthroses)

Primary

Held together by hyaline cartilage

Example: sternocostal joints; epiphyseal plates

Can absorb shock but permits little or no movement

Secondary

Held together by fibrocartilage

Movement of the articulating bones

Designed for strength and shock absorption

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Classification of Joints (cont.)

Synovial (diarthroses)

Freely movable joints

Classified according to their shape—dictates type and range of motion permitted

Plane

Hinge

Pivot

Condyloid

Saddle

Ball-and-socket

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Classification of Joints (cont.)

Synovial jointArticular cartilageCovers ends of long bones, cushion and protection, no nerve or blood supplyJoint cavityFilled with synovial fluid

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Classification of Joints (cont.)

Articular capsule

Joint capsule

Synovial fluid

Reduces friction

Ligaments

Capsular, extracapsular

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Skin Injury Classifications

Abrasions

Scraping away of layers of skin

Blisters

Accumulation of fluid between epidermis and dermis

Skin bruises

Accumulation of blood within skin

Incisions

Clean cut

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Skin Injury Classifications (cont.)

Lacerations

Irregular tear

Avulsions

Complete separation of skin

Punctures

Penetration of skin and underlying tissue

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Mechanism: compressionSigns and symptoms Onset: acutePain: localizedEcchymosis: if superficialRestrictions in ROM SwellingAssociated nerve compression

Classification of Muscle/Tendon Injuries

Contusion

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Contusion (cont.)

Basis for rating

severity—ROM

1st—little or no restriction

2nd—noticeable

reduction

3rd—severe restriction

Concern: can lead to muscle strain

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Stretch or tear of a muscleMechanism: tension forceMost common site for tears: near the musculotendinous junctionKey factor: magnitude of force and structure’s cross-sectional area

Strain

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Classification of Strains

First Degree

Second Degree

Third Degree

Damage to fibers

Few fibers torn

Nearly half torn

All fibers torn

Weakness

Mild

Moderate (reflex inhibition)

Severe

Muscle spasm

Mild

Moderate

Severe

Loss of function

Mild

Moderate

Severe (reflex inhibition)

Swelling

Mild

Moderate

Severe

Palpable defect

No

No

Yes (if early)

Pain-contraction

Mild

Moderate/severe

None/mild

Pain-stretching

Yes

Yes

No

ROM

Decreased

Decreased

Depends on swelling

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Involuntary muscle contractionCramp Biochemical imbalance, fatigue TypesClonic—alternating contraction/relaxationTonic—constantSpasm Reflex action caused byBiochemical or Mechanical blow to nerve or muscle

Cramps and Sprains

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MyositisInflammation of the connective tissueFasciitisInflammation of the fascia surrounding portions of a muscle

Myositis and Fasciitis

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TendinitisInflammation of tendonPain and swelling with tendon movementProblems: repeated microtraumaDegenerative changesTenosynovitisInflammation of synovial sheathSigns and symptomsAcute: rapid onset, crepitus, local swellingChronic: thickened tendon, nodule formation in sheath

Tendinitis and Tenosynovitis

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Ectopic calcification—located in place other than normalBone (calcium) is deposited within a muscle.Usually macrotrauma, but can be microtrauma

Myositis Ossificans

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Result of repeated irritation of tissuesClassificationStage 1: pain after activity onlyStage 2: pain during activity, does not restrict performanceStage 3: pain during activity, restricts performanceStage 4: chronic, unremitting pain even at restProblem: low-grade inflammatory condition that results in collagen resorption and scarring

Chronic Conditions

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Stretch or tear of ligamentMechanism of injury (MOI)—tension forceCompromises the ability of the ligament to stabilize the joint

Joint Injury

Classifications

Sprain

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Classification of Sprains

First Degree

Second Degree

Third Degree

Damage to ligament

Few fibers torn

Nearly half torn

All fibers torn

Distraction stress

<5 mm

5–10 mm

>10 mm

Weakness

Mild

Moderate/severe

Moderate/severe

Muscle spasm

None

None/minor

None/minor

Loss of function

Mild

Moderate/severe

Severe

Swelling

Mild

Moderate

Moderate/severe

Pain

—

contraction

None

None

None

Pain-stretching

Yes

Yes

No

ROM

Decreased

Decreased

Increase or decrease

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Dislocation/Subluxation

Joint force beyond normal limits

MOI: tension

Signs and symptoms

Loss of limb function

Deformity

Swelling

Point tenderness

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Dislocation/Subluxation (cont.)

Problem of reoccurrence

Caused by overstretching of capsule to the extent that it will not return to normal; unstable joint

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Bursitis

Inflammation of bursa

Acute or chronic

MOI: compression

Signs and

symptoms: swelling, pain, loss of function, eventual degeneration

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Osteoarthritis

Degeneration of articular cartilage

Signs and

symptoms: pain and limited movement

No definitive cause; rather, several contributing factors

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Soft-Tissue Healing

Inflammatory phase (0 to 6 days)

Acute or chronic inflammation possible

Exudate

forms

Mechanisms for stopping blood flow

Local vasoconstriction

Platelet reaction

Coagulation cascade

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Soft-Tissue Healing (cont.)

Vasodilation brings neutrophils and macrophages to clean the area via phagocytosis.

Mast cells release

Heparin: thins the blood and prolongs clotting

Histamine: promotes further vasodilation

Bradykinin: opens the blood vessel walls; causes pain

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Soft-Tissue Healing (cont.)

Inflammatory phase (cont.)

Zone of primary injury

Hematoma forms

Edema occurs

Increased permeability and pressure within the vessels forces a plasma exudate into the interstitial tissue

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Soft-Tissue Healing (cont.)

Zone of secondary injury

Interstitial tissues affected by inflammation, edema, and hypoxia

Prostaglandins promote further healing and clearing of debris

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Soft-Tissue Healing (cont.)

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Soft-Tissue Healing (cont.)

Proliferative phase (3 to 42 days)

Repair and regeneration of tissue

Processes

Angiogenesis

Fibroplasia

Reepithelialization

Wound contraction

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Soft-Tissue Healing (cont.)

Hematoma reduces for new healing to take place

Scar formation with soft tissue

Accumulated exudate contains fibroblasts that generate new collagen

Newly formed blood supply and support of matrix will determine overall healing of new tissue

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Soft-Tissue Healing (cont.)

Maturation phase (3 weeks to 1 year)

Associated processes

Remodeling of fibrous matrix to form mature scar tissue

Decreased fibroblastic activity

Increased organization of new tissue

Decreased water content

Decreased blood flow

Resumption of normal cell activity in the area

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Soft-Tissue Healing (cont.)

Scar tissue is fibrous, inelastic, and nonvascular

Less functional and flexible than original tissues

Tensile strength

3 to 4 weeks: 25% of normal

4 to 5 months: 30% below preinjury strength

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Soft-Tissue Healing (cont.)

Maturation phase (cont.)

Muscle fibers form adhesions

Tendons and ligaments slower to heal

Potential for atrophy with immobilization

Loss of strength and decreased rates of healing are directly related to length of immobilization.

Begin strengthening as soon as it’s safe after injury to ensure hypertrophy of healing tissues and decreased reoccurrence of injury

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Soft -Tissue Wound Care

Open wound

Follow universal precautions and infection control standards

General

Apply pressure

Cleanse the wound

Dress and bandage the wound

Use of creams or ointments

Re-dress and inspect

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Soft-Tissue Wound Care (cont.)

Closed wound

Goal: reduce inflammation, pain, and secondary hypoxia

Treatment: ice, compression, and elevation

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Long Bones: Anatomic Properties

Primary constituents: minerals, collagen, waterComponentsDiaphysisShaft: hollow, cylindricalMedullary cavity: shock potential improves

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Long Bones: Anatomic Properties (cont.)

Epiphysis

Ends of long bones

Epiphyseal

plate—cartilaginous

disk found near ends of long bones

Periosteum

Sheath covers bone

Life support system

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Long Bones: Anatomic Properties (cont.)

Bone growth Longitudinal Continues until epiphysis closesDiameterCan continue to grow through the lifespan

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Long Bones: Anatomic Properties (cont.)

New bone formed via the periosteum; bone is resorbed around the medullary cavity

Osteoblasts: form new bone

Osteoclasts: resorb bone

Bone experiences constant remodeling

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Internal Composition Long Bones: Anatomic Properties (cont.)

CorticalCompact bone tissue of high density (low porosity)OutsideCan withstand greater stress but less strain

Cancellous

Bone tissue of low density (high porosity)

Inside

Can tolerate more strain

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Long Bones: Anatomic Properties (cont.)

Size will increase in response to increased stress (conditioning)

Hollow

cylinder—strongest

structure in resisting tension and compression

Anatomic

weakness—site

where bone changes shape and direction (especially sudden change)

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Mechanical Forces Affecting Bones

Tension, compression, shear, bending, torsion

Stronger in resisting compression than both tension and shear

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Disruption in the continuity of boneClosed or openType of fracture determined byForce applied The health and maturity of bone at the time of injury

Classification of Bone

Injuries Fractures

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Types of Fractures

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Stress Fracture

Stress fracture

Fracture results from repeated loading with lower magnitude forces

Can become worse over time

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Osteopenia

Osteopenia

Reduced bone mineral density that predisposes individual to fracture

Possible causes: amenorrhea, hormonal factors, dietary insufficiencies

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Epiphyseal Injuries

Injury to growth plate could result in alteration in normal growthAcute injuryTypes I to VOsteochondrosis

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Epiphyseal Injuries (cont.)

Osteochondrosis

Disruption of blood supply to epiphysis

Idiopathic

Example: Legg-Calvé-Perthes disease

Apophysitis

Osteochondrosis of apophysis

Example

Sever disease

Osgood-Schlatter disease

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Bony Tissue Healing

Acute inflammatory phase

Formation of hematoma

Inflammatory response

Proliferative phase

Osteoclasts—resorb

damaged tissue;

osteoblasts—deposit

new bone

Callus formation

Maturation phase

Continued activity of osteoclasts and osteoblasts

Remodeling of bone

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Bony Tissue Healing (cont.)

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Bony Tissue Healing (cont.)

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Bony Tissue Healing (cont.)

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Bone Injury Management

Fracture detection

Palpation, percussion, tuning fork, compression, distraction

Management: splinting (Refer to Application Strategy 10.3)

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Nerve: Anatomic Properties

Spinal nerve

Roots

Posterior: afferent

Anterior: efferent

Heavily vascularized

Myelin sheath

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Spinal Nerves

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Classification of Nerve Injuries

Tensile force injuries

Neurapraxia (grade 1)

Localized conduction block: temporary loss of sensation and/or motor

Resolves within days to a few weeks

Axonotmesis (grade 2)

Significant motor and mild sensory deficits

Lasts at least 2 weeks

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Classification of Nerve Injuries (cont.)

Neurotmesis (grade 3)

Motor and sensory deficit

Lasts up to 1 year

Compressive injuries

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Classification of Nerve Injuries (cont.)

Nerve injuries result in a variety of afferent symptoms

Hyperesthesia

Hypoesthesia

Paresthesia

Neuralgia

Chronic pain along nerve’s course

Healing: if completely severed, healing does not occur

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Management of Nerve Injuries

Mild: follow acute care protocol

Moderate-to-severe: physician referral

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Pain

Sources

Somatic, visceral, and psychogenic

Nociceptors

Mechanosensitive

Chemosensitive

Fibers transmitting pain

A fibers

C fibers

T cells

Gate control theory of pain

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Pain (cont.)

Factors than mediate pain

Brain production of opioid peptides and endorphins

Cognitive and affective filters

Referred pain

Pain perceived at a location remote from the site actually causing the pain

Radiating pain

Pain felt both at its source and along a nerve