Unit #4 Pathology of Injuries

1. Unit #4Pathology of Injuries ILLNOIS WESLEYAN UNIV

2. Mechanisms and Characteristics of Sports Trauma Chapter 9

3. General Injury Mechanisms • Primary Injury: results directly from the stress of the sport • Extrinsic • Intrinsic • Secondary Injury: injury caused by a previous injury

4. Mechanisms of Injury • Tension: a force that pulls (muscle) • Strain • Cramp • Stretching: the elongation of tissues • Strain • Sprain • Compression: a forceful blow to tissues • Contusion • Fracture

5. Mechanism of Injury • Shearing: a force that moves parallel to the tissues • Blisters • Abrasions • Vertebral disc injuries • Bending: a horizontal force causing the tissue to bend or strain • Spiral fracture or Greenstick fracture

6. Injury Forces To The Skin • Friction • Scraping • Compression • Tearing • Cutting • Penetrating

7. Skin Wound Classification • Friction Blister: continuous rubbing on the skin • Abrasion: skin is scraped against a rough surface • Bruise: compression causes bleeding under the skin • Laceration: an irregular tear of the skin • Avulsion: skin is ripped off • Incision: a sharp cut • Puncture: penetration of the skin by a sharp object

8. Treatments For Skin Wounds • Powders: drying agents • Water: drying agent • Creams: usually contain medications • Tinactin • Hydrocortizone cream • Analgesic cream • Ointments: moistening agents • bacitracin

9. Treatments For Skin Wounds • Lotions and Salves: moistening agents • Antipruritic agents: control temperature • Antihistamine drugs: allergies • Hydrogen Peroxide: anticoagulant • Isoprophyl alcohol: drying and sterilizing agent • Iodine: antiseptic and germicide agent • Dressings: protection of the skin • Gauze, bandaid, telfa pad • Roller bandage, tape

10. Skeletal Muscle Injuries • Contusion: an acute compression causing hemorrhage of the muscle tissue • Strain: is an acute stretch, tear, or rip in the muscle or tendon caused by an abnormal muscle contraction, tension, or stretch • Grade 1: minimal tearing with tenderness and a decrease in strength • Grade 2: moderate tearing with pain and impaired muscle function • Grade 3: severe tearing with pain and loss of muscle function and a palpable deformity

11. Skeletal Muscle Injuries • Muscle Cramps: an acute painful involuntary muscle contraction caused by dehydration or an electrolyte imbalance. • Muscle Spasm: a reflex reaction caused by acute trauma • Clonic: alternating involuntary contractions • Tonic: a rigid muscle contraction that lasts a period of time

12. Skeletal Muscle Injuries • Acute onset muscle soreness • Delayed onset muscle soreness • Muscle stiffness (swelling) • Muscle cramps • Myositis / Fasciitis • Tendinitis • Tenosynovitis • Myositis ossificans • Atrophy

13. Synovial Joint Injury Classifications • Acute Sprain: stretching or tearing of the stabilizing connective tissues • Grade 1: minimal pain and loss of function, mild point tenderness, little or no swelling, and no abnormal motion when tested. • Grade 2: moderate pain and loss of function, swelling, moderate instability • Grade 3: extremely painful with a major loss of function, severe instability tenderness and swelling

14. Synovial Joint Injury Classifications • Acute Synovitis: inflammation of the synovial membrane. • Dislocation: a complete separation between two articulating bones. • Subluxation: an incomplete separation between two articulating bones. • Separation / diastasis: an increase in joint space between articulating surfaces.

15. Synovial Joint Injury Classifications • Osteochondrosis: degenerative changes in the epiphysis or apophysis of bones. • Osteochondritis dissecans: occurs in the knee • Apophysitis: occurs to tendon-bone junctions • Traumatic arthritis: thickness of synovium of a joint causing creptitis and grating • Bursitis • Capsulitis

16. Skeletal Injury Classification Acute Bone Fractures • Depressed fractures (indent) • Greenstick fractures • Impacted fracture (compression) • Longitudinal fracture (bone splits) • Oblique fracture (diagonal) • Serrated fracture (sawtooth sharp edged) • Spiral fracture • Transverse fracture (straight line) • Comminuted fracture (fragments)

17. Skeletal Injury Classification • Acute Fractures • Contrecoup fracture (skull) • Blowout fracture (eye orbit) • Avulsion fracture (bone chip) • Stress fracture (from overload) • Shin • Metatarsal • Calcaneus • Pars interarticularis • ribs

18. Nerve Trauma Classifications • Burner (stretched nerve cells) • Neuritis (inflammation of nerve cells) • Sciatica (stretch of sciatic nerve) • Carpal Tunnel (compression of nerve cells) • Mortons Neuroma (tumor of nerve cells)

19. Common Injuries • Sprained toe • Sprained ankle • Sprained knee • Sprained finger (jammed finger) • Sprained shoulder • Sprained wrist • Sprained elbow

20. Common Injuries • Strained achilles • Strained quadriceps • Strained hamstrings • Strained rotator cuff • Strained back • Strained hip flexor

21. Common Injuries • Ruptured ACL • Ruptured achilles • Ruptured flexor tendon (jersey finger) • Ruptured bicep tendon • Bulging disc • Herniated disc • Torn meniscus (knee) • Torn labrum (shoulder) • Concussion

22. Common Injuries • Achilles tendinitis • Patellar tendinitis • Common flexor tendinitis (pitchers elbow) • Common extensor tendinitis (tennis elbow) • Rotator cuff tendinitis • Medial tibial stress syndrome (shin splints) • OTHERS………

23. Outline of Injury Presentation • Choose an injury that occurs in your sport • Name of the injury • Mechanism of the injury • Description of the injury • Symptoms of the injury • Treatment of the injury • Presentation should include a picture of the injury • Provide handouts for your peers

24. CHAPTER 10 TISSUE RESPONSE TO INJURY THE INFLAMMATORY RESPONSE AND THE HEALING PROCESS

25. DEFINITION & PURPOSE OF INFLAMMATION • Definition: The reaction of the body tissues to anirritant or injury; which may be either acute or chronic. It is a protective mechanism, designed to? • Thepurpose of inflammation is to: rid the body of the irritant and to promote repair and healing of the damaged tissues.

26. PURPOSE OF INFLAMMATION • Is a protective mechanism designed to localize the irritant and rid body of the injurious agent in preparation for healing • The major causes of inflammation are: • Trauma ( sprain, strain, contusion, etc.. ) • Chemical agents ( poisons, stings, etc. ) • Thermal extremes of heat or cold (burns) • Pathogenic organisms ( infections )

27. SIGNS AND SYMPTOMS OF INFLAMMATION • The inflammatory response can be either acute or chronic, but the local reactions are described as the cardinal signs and symptoms of inflammation: • Typical signs and symptoms include: • Redness • Heat (local) • Swelling • Pain • Malfunction (loss of motion or use)

28. INFLAMMATION • In sports every injury is accompanied by some tissue damage. The seriousness of the injury will be determined by the type of tissue involved and the extent of the tissue damage.

29. INFLAMMATION PHASES • Acute Reactive Phase ( 24-48 hrs.) • Body’s fundamental reaction designed to protect, localize, and fight the injurious agent, as well as prepare the area for healing and repair (Nature’s Way). • Repair-Regeneration Phase(48hrs>) • Tissue repairs by resolution (granulation tissue) and regeneration . • Repair depends on type of tissue & amountof tissue damage.

30. PHASES cont. • Remodeling Phase (3wks. - 1 yr.) • Remodeling depends on the type of tissue which is injured and the degree of damage to that tissue. • Overlaps repair and regeneration phase • Scar tissue forms in first 3-6 weeks • Strength of the scar increases from 3 months to 2 yrs after injury. • Early mobilization promotes healing, but to early and the healing process is delayed.

31. RESPONSE: FIRST HOUR • Vasoconstriction, followed by vaso-dilation. • Capillary hemorrhage • Coagulation of broken vessels • Release of chemical mediators • Vasodilation

32. ACUTE PHASE VASCULAR RESPONSE • Vasoconstriction • Coagulation begins to seal broken blood vessels • Chemical mediators released • Histamine: the first chemical to appear and increases vasodilation and permeability • Serotonin: powerful vasoconstrictor • Bradykinin: increases permeability and causes pain • Heparin: temporarily prevents blood coagulation • Vasodilation • Permeability Changes • Margination (pavementing): plasma exudate coagulates into a network of fibrin and localizes the injured area. • Phagocytosis: the process of ingesting material such as bacteria, dead cells, and other debris.

33. SWELLING The amount of swelling present with any injury is highly dependent upon the extent of the tissue damage and the subsequent inflammatory response. Swelling basically comes from two sources: (1) capillary bleeding, and (2) leakage of edema, and is sometimes referred to as EXUDATE.

34. Capillary Bleeding • Capillary bleeding occurs when the small blood vessels (capillaries, arterioles, & venules) are injured, and results in the initial, primary swelling. • Primary swelling is the result of immediate hemorrhage which may cause some tissue cell death and swelling until coagulation occurs.

35. Leakage of Edema • Edema come from the leakage of blood plasma thru the intact vessels in the area of the injury. • Secondary swelling is delayed swelling, caused by the release of chemical mediators as a result of the inflammatory response following injury: • Permeability changes caused by brakykinin

36. PERMEABILITY CHANGES Permeability changes are going to be very limited in minor injuries where there has been little tissue damage. However, in more severe injuries, there may be a delayed response with delayed swelling which may not appear for many hours.

37. CHEMICAL MEDIATORS Histamine causes vasodilation and permeability changes. Serotonin is a powerful vasoconstrictor. Bradykinin increases permeability and causes pain. Heparin: anticoagulant Prostaglandins both encourage and inhibit inflammation, depending on the need.

38. PHASE II: REPAIR ANDREGENERATION • Repair is synonymous with healing • Regeneration refers to the restoration of destroyed or lost tissue • Granulation or scar tissue is that tissue which has been repaired or regenerated, and is the scab which forms on wounded tissues as they heal. With time this scar tissue will become more like the original tissue.

39. SCAR TISSUE • Immature scar is less viable, not as strong and less elastic than the original tissue, and is highly vascular. • Mature scar eventually forms ( can take as long as 3wks. to 6 months to occur ) • Healing occurs in two ways ( types ): • Primary healing • Secondary healing

40. REGENERATION • Regeneration in man (unlike the salamander or earthworm) is limited to certain tissues. • Type of tissue, amount of tissue damage, age, nutrition, etc., can all be factors which limit regeneration of tissues . • Generallyconnective tissue can regenerate and repair itself.

41. REGENERATION, REPAIR, & HEALING STAGES: • Elimination of the tissue debris at site of the wound must occur before repair and regeneration can occur (elim. Swelling) • Regeneration of endothelial cells occurs • Production of fibroblasts (which compose connective tissue throughout the body) takes place, and is the basis for scar tissue formation • New blood vessels form around wound

42. PHASE III REMODELING Remodeling overlaps the repair and regeneration phase. Generally the first 3-6 weeks are characterized by the production of scar tissue and strengthening of its fibers. Strengthening of the scar tissuecontinues for 3 - 6 months followinginjury, and may take as long as a year to be completely healed (if infact it ever does).

43. Critical Thinking Exercise An athlete has sustained a grade 2 lateral ankle sprain 3 weeks ago. It was given proper immediate and follow-up care. What repair has taken place in the ankle during this time? What kind of sports performance would you expect from this athlete?

44. SUBACUTE OR CHRONIC INFLAMMATION • Book defines subacute as an acute inflammation failing to resolve in 1 month. Chronic is defined as lasting for months or years. Proliferation and degeneration of tissue is characteristic of chronic inflammation.

45. SIGNS & SYMPTOMS OFCHRONIC INFLAMMATION • Develops gradually over period of time, (versus immediate onset - acute), and may last for months or even years. • Caused by repeated acute injury, repeated microtrauma, or tissue disease or degeneration (ex.,aging, ). • Usually little or no swelling. Swelling may come and go with ^ activity level, as does pain and ROM.

46. Critical Thinking Exercise A basketball player complains of a swollen ankle that never became completely resolved since a sprain was sustained 9 months ago. What is thereason for this chronic swelling? What background information would you need to know (what questions would you ask)?

47. TREATMENT & CARE: POINTS TO REMEMBER • HEALING IS UNIQUE TO EACH ATHLETE • TISSUES HEAL DIFFERENTLY • AGE AND MOTIVATION PLAY A ROLE • ORGANIC DISORDERS (ie., diabetes) CAN DELAY HEALING • HEREDITY CAN BE A FACTOR • PSYCHOLOGICAL CONSIDERATIONS?

48. Potential for Healing of VariousTypes of Soft Tissues • Cartilage-limited, primarily because of its little if any blood supply. • Ligaments- as good as other tissues with a vascular supply; gradually a scar is formed (may take as long as 1 year) • Skeletal Muscle- regeneration of myofibers is minimal, otherwise heal the same as other vascular tissues. • Nerve- CNS nerves are poor healers; peripheral nerves are fair.

49. MANAGEMENT CONCEPTS • DRUGS • SUPERFICIAL HEAT AND COLD Tx • PHYSICAL MODALITIES • MASSAGE • EXERCISE REHABILITATION • OTHERS

50. Confuscius say………. “…..if all you have is a hammer, then everything looks like a nail “.