Pathology of Trauma

1. Pathology of Trauma <ul><li>if we ignore the &quot;carrot&quot; of our Dreams, then we invite the &quot;stick&quot; of struggle. </li></ul><ul><li>Gill Edwards From &quot;Stepping Into the Magic - A New Approach to Everyday Life&quot; </li></ul>

2. CPC4.3.4- 19y Karen & Mike, <ul><li>Karen and Mike were returning home from a party in the early hours of Sunday morning. They left the party at about midnight . They were riding Mike’s 500cc motorbike with Mike driving and Karen as passenger. Both had helmets on. </li></ul><ul><li>A passing motorist calls ‘000 ’ at 02h15 asking for an ambulance. He says: ‘…they are both lying on the ground. He is very still . She appears to be in terrible pain and can’t move .’ The location is approximately 20 km from Charters Towers on the Hughenden road. </li></ul><ul><li>The first ambulance arrives about 15 minutes after the 000 call, followed by a police car about 5 minutes later. </li></ul> CPC4.3.4- 19y Karen & Mike, <ul><li>Karen and Mike were returning home from a party in the early hours of Sunday morning. They left the party at about midnight . They were riding Mike’s 500cc motorbike with Mike driving and Karen as passenger. Both had helmets on. </li></ul><ul><li>A passing motorist calls ‘000 ’ at 02h15 asking for an ambulance. He says: ‘…they are both lying on the ground. He is very still . She appears to be in terrible pain and can’t move .’ The location is approximately 20 km from Charters Towers on the Hughenden road. </li></ul><ul><li>The first ambulance arrives about 15 minutes after the 000 call, followed by a police car about 5 minutes later. </li></ul>

3. CPC4.3.4- At the Scene… <ul><li>ABC assessment </li></ul><ul><ul><li>Mike: airway intact, breathing spontaneously 22 breaths/min, radial Pulse 110 bpm </li></ul></ul><ul><ul><li>Karen-Ann: airway intact, breathing spontaneously respiratory rate 34 breaths/min, radial pulse 140 beats/min </li></ul></ul><ul><li>Detailed examination </li></ul><ul><ul><li>Karen-Ann: bilateral compound femur fractures; ?fractured lower jaw (Left), no chest injury apparent, no abdominal injury apparent </li></ul></ul><ul><ul><li>Mike: L hypochondrial pain, L upper arm pain and loss movement ?fractured L humerus, no chest injury apparent. </li></ul></ul><ul><li>Tutors please introduce/remind students re concept of ‘AMPLE’ history (Allergies, Medications, Past history, Last ate/Tetanus/Events) </li></ul> CPC4.3.4- At the Scene… <ul><li>ABC assessment </li></ul><ul><ul><li>Mike: airway intact, breathing spontaneously 22 breaths/min, radial Pulse 110 bpm </li></ul></ul><ul><ul><li>Karen-Ann: airway intact, breathing spontaneously respiratory rate 34 breaths/min, radial pulse 140 beats/min </li></ul></ul><ul><li>Detailed examination </li></ul><ul><ul><li>Karen-Ann: bilateral compound femur fractures; ?fractured lower jaw (Left), no chest injury apparent, no abdominal injury apparent </li></ul></ul><ul><ul><li>Mike: L hypochondrial pain, L upper arm pain and loss movement ?fractured L humerus, no chest injury apparent. </li></ul></ul><ul><li>Tutors please introduce/remind students re concept of ‘AMPLE’ history (Allergies, Medications, Past history, Last ate/Tetanus/Events) </li></ul>

4. CPC4.3.4- At the Scene… <ul><li>Triage decision who needs to be taken to hospital first? </li></ul><ul><li>Tutors please facilitate this discussion based on ‘ABCD’ findings. The finding of a fractured jaw should immediately raise suspicion of cervical spine fracture; L hypochondrial pain should raise possibility of ruptured spleen </li></ul><ul><li>Which hospital Charters Towers : on call GP; TTH : Trauma unit. What are the pros and cons of each? Tutors: remind students re ‘stay and play’/’scoop and run’ debate; concept of ‘The Golden Hour’. </li></ul><ul><li>The ambulance paramedic calls TTH ED and speaks to the on call consultant; the helicopter is dispatched to collect Karen-Ann to take her to TTH; the ambulance will transport Mike by road to TTH. </li></ul> CPC4.3.4- At the Scene… <ul><li>Triage decision who needs to be taken to hospital first? </li></ul><ul><li>Tutors please facilitate this discussion based on ‘ABCD’ findings. The finding of a fractured jaw should immediately raise suspicion of cervical spine fracture; L hypochondrial pain should raise possibility of ruptured spleen </li></ul><ul><li>Which hospital Charters Towers : on call GP; TTH : Trauma unit. What are the pros and cons of each? Tutors: remind students re ‘stay and play’/’scoop and run’ debate; concept of ‘The Golden Hour’. </li></ul><ul><li>The ambulance paramedic calls TTH ED and speaks to the on call consultant; the helicopter is dispatched to collect Karen-Ann to take her to TTH; the ambulance will transport Mike by road to TTH. </li></ul>

5. CPC4.3.4- Core learning Issues… <ul><li>Basic science - Core Learning Issues: </li></ul><ul><ul><li>Over view of tissue injury & Healing . </li></ul></ul><ul><ul><li>Metabolic response to trauma </li></ul></ul><ul><ul><li>Shock - types and Pathophysiology. </li></ul></ul><ul><ul><li>Hypovolaemic shock </li></ul></ul><ul><ul><li>Limb anatomy : upper, lower, femur, humerus and associations (nerves, vessels, muscle attachments etc) </li></ul></ul><ul><li>Clinical Core Learning Issues: </li></ul><ul><ul><li>Assessment of trauma patients </li></ul></ul><ul><ul><li>Assessing patients in shock. </li></ul></ul><ul><ul><li>Assessment of patients with chest injury </li></ul></ul><ul><ul><li>Glasgow coma score </li></ul></ul> CPC4.3.4- Core learning Issues… <ul><li>Basic science - Core Learning Issues: </li></ul><ul><ul><li>Over view of tissue injury & Healing . </li></ul></ul><ul><ul><li>Metabolic response to trauma </li></ul></ul><ul><ul><li>Shock - types and Pathophysiology. </li></ul></ul><ul><ul><li>Hypovolaemic shock </li></ul></ul><ul><ul><li>Limb anatomy : upper, lower, femur, humerus and associations (nerves, vessels, muscle attachments etc) </li></ul></ul><ul><li>Clinical Core Learning Issues: </li></ul><ul><ul><li>Assessment of trauma patients </li></ul></ul><ul><ul><li>Assessing patients in shock. </li></ul></ul><ul><ul><li>Assessment of patients with chest injury </li></ul></ul><ul><ul><li>Glasgow coma score </li></ul></ul>

6. CPC4.3.4- Core learning Issues… <ul><li>Pathology - Core Learning Issues: </li></ul><ul><ul><li>Pathology of fractures, fracture healing * </li></ul></ul><ul><ul><li>Pathology review of trauma, Tissue injury & Wound healing in skin & special tissues. </li></ul></ul><ul><ul><li>Chest injury – lung collapse, surgical emphysema, </li></ul></ul><ul><ul><li>Abdominal Trauma - Splenic rupture. </li></ul></ul><ul><ul><li>Pathology of Head Injury * </li></ul></ul> CPC4.3.4- Core learning Issues… <ul><li>Pathology - Core Learning Issues: </li></ul><ul><ul><li>Pathology of fractures, fracture healing * </li></ul></ul><ul><ul><li>Pathology review of trauma, Tissue injury & Wound healing in skin & special tissues. </li></ul></ul><ul><ul><li>Chest injury – lung collapse, surgical emphysema, </li></ul></ul><ul><ul><li>Abdominal Trauma - Splenic rupture. </li></ul></ul><ul><ul><li>Pathology of Head Injury * </li></ul></ul>

7. &quot;People blame their circumstances for what they are. I don't believe in circumstances. The people who get on in the world are the people who get up and look for the circumstances they want, and if they can't find them, make them ….!&quot; - George Bernard Shaw &quot;People blame their circumstances for what they are. I don't believe in circumstances. The people who get on in the world are the people who get up and look for the circumstances they want, and if they can't find them, make them ….!&quot; - George Bernard Shaw

8. Pathology of Bone Fracture & Healing Dr. Venkatesh M. Shashidhar Senior Lecturer & Head of Pathology Pathology of Bone Fracture & Healing Dr. Venkatesh M. Shashidhar Senior Lecturer & Head of Pathology

9. Introduction: <ul><li>Bone is a dynamic tissue - </li></ul><ul><li>Osteoblasts - osteoid (type 1 collagen) </li></ul><ul><li>Calcium and phosphate (calcium hydroxyapatite) </li></ul><ul><li>Osteoclasts are multi-nucleated cells which resorb bone (PTH). </li></ul> Introduction: <ul><li>Bone is a dynamic tissue - </li></ul><ul><li>Osteoblasts - osteoid (type 1 collagen) </li></ul><ul><li>Calcium and phosphate (calcium hydroxyapatite) </li></ul><ul><li>Osteoclasts are multi-nucleated cells which resorb bone (PTH). </li></ul>

10. . Bone Anatomy <ul><li>Diaphysis </li></ul><ul><li>Metaphysis </li></ul><ul><li>Epiphysis – Prox/Dist </li></ul><ul><li>Epiphyseal line </li></ul><ul><li>Periosteum </li></ul><ul><li>Compact cortical bone </li></ul><ul><li>Spongy bone </li></ul><ul><li>Articular Cartilage </li></ul><ul><li>Medullary cavity </li></ul><ul><li>Marrow </li></ul><ul><li>Nutrient artery </li></ul>

11. . Blood Supply to Bone:

12. . Bone tissue: <ul><li>Woven bone – Irregular, immature, fetus / growth plate / fracture. </li></ul><ul><li>Lamellar bone – regular – mature. </li></ul><ul><ul><li>Compact Bone. </li></ul></ul><ul><ul><ul><li>Circumferential </li></ul></ul></ul><ul><ul><ul><li>Concentric </li></ul></ul></ul><ul><ul><ul><li>Interstitial </li></ul></ul></ul><ul><ul><li>Spongy Bone </li></ul></ul><ul><ul><ul><li>Trabecular </li></ul></ul></ul><ul><li>Ossification: Formation of bone. </li></ul><ul><ul><li>Enchondral (long) / Intramembranous (flat) </li></ul></ul><ul><li>Osteoid: – protein mould of future bone. </li></ul>

13. . Lamellar Bone:

14. . Cancellous bone: (Polarization.M) Osteocyte Lamellae

15. . Bone histology: lines of stress: (Black arrows)

16. . Compact Bone: <ul><li>Osteons or Haversian systems. </li></ul><ul><ul><li>blood vessels, lymphatics & nerves. </li></ul></ul><ul><ul><li>osteocytes & in rings of calcified matrix. </li></ul></ul><ul><li>Osteons are aligned to lines of stress. </li></ul><ul><li>In spongy bone: (Trabecular) Lamellae are present but no osteons (& blood vessels). </li></ul>

17. . The matrix of bone : <ul><li>Calcium Hydroxyapatite in collagen framework – RCC* </li></ul><ul><li>Minerals  hardness </li></ul><ul><li>Collagen fibres  Tensile strength. </li></ul><ul><li>Osteoblasts - Calcification - Mineralization </li></ul><ul><li>Collagen & matrix (osteoid) is necessary for Calcification. </li></ul>

18. . Bone is dynamic  cont. remodeling <ul><li>5-10% / year </li></ul><ul><li>Vitamin D </li></ul><ul><li>Nutrition </li></ul><ul><li>Physical activity </li></ul><ul><li>Age, hormones </li></ul><ul><li>PTH, PHRP </li></ul><ul><li>IL1, TNF,TGF- β </li></ul>

19. . Osteoblasts & Osteocytes in Osteoid: Osteocyte Osteoblasts Osteoid

20. . Osteoclast in lacuna; Osteoclast Lacuna

21. . Growth plate: Mature bone Immature bone

22. . Osteoblasts & Osteoid: Osteocyte Osteoblasts Osteoid

23. . Bone Review: <ul><li>Bone Function: </li></ul><ul><ul><li>Anatomy </li></ul></ul><ul><ul><li>Mineral homeostasis. </li></ul></ul><ul><ul><li>Hemopoiesis. </li></ul></ul><ul><li>Ossification/Calcification </li></ul><ul><ul><li>Intramembranous </li></ul></ul><ul><ul><li>Endochondral </li></ul></ul>Key Words: Mineralization Calcification Ossification Osteoid Tensile strength Volkmann’s canal Haversian canal Lacunae Osteon Compact bone Trabecular bone

24. . Obstacles cannot crush me. Every obstacle yields to stern resolve. -Leonardo da Vinci

25. . Pathology of Bone Fracture & Healing Dr. Venkatesh M. Shashidhar Senior Lecturer & Head of Pathology

26. . Fractures: <ul><li>Discontinuity in the bone. </li></ul><ul><li>Simple / Compound. </li></ul><ul><li>Horizontal, oblique, spiral, </li></ul><ul><li>Comminuted – multiple. </li></ul><ul><li>Greenstick – partial, usually in children. </li></ul><ul><li>Torus – compression of cortex – children. </li></ul><ul><li>Colle's fracture ? </li></ul>

27. . An individual at prolonged bed rest quickly begins to lose bone mineral density (BMD). Conversely, physical activity increases BMD . Use it or Loose it….!

28. . Fracture Types: Transverse Spiral Oblique Linear

29. . Fracture Types: Pott’s Incomplete Impacted Green stick

30. . Fracture Types: Comminuted Colle’s Compound

31. . Simple / Compound Fracture

32. . Fracture Healing: 1 day 1-3 Week (Soft) 6 Weeks (Hard) >8 Weeks

33. . Stages of fracture healing: <ul><li>1Day - Hematoma </li></ul><ul><ul><li>Blood clot, fibrin mesh – provide frame support. </li></ul></ul><ul><li>3Day-1wk - Inflammation </li></ul><ul><ul><li>Inflammatory cells infiltrate the wound. PDGF, IL, TGF etc.. Factors promote proliferation of stroma. </li></ul></ul><ul><li>1-3 Week - Soft callus. </li></ul><ul><ul><li>granulation tissue- Fibroblasts & endothelial cell proliferation with osteoid deposition. </li></ul></ul><ul><li>3-6 Week – Hard Callus </li></ul><ul><ul><li>– Mineralization of osteoid, ca+, woven bone forms. </li></ul></ul><ul><li>8Week+ - Re-modeling </li></ul><ul><ul><li>resorption/deposition along lines of stress. Lamellation & osteon formation. </li></ul></ul>

34. . Bone healing - Callus Fracture Fibula 6 weeks later Callus Fracture

35. . Bone healing - Callus

36. . <ul><li>Irregular osteoid trabeculae </li></ul><ul><li>Lack of lamellae. </li></ul><ul><li>Prominent lining by osteoblasts. </li></ul><ul><li>Irregularly arranged osteocytes. </li></ul>Callus – Woven bone

37. . Fracture with Callus <ul><li>Fractured bone ends. </li></ul><ul><li>Osteoid (note surrounding plump osteoblasts) </li></ul><ul><li>Granulation tissue </li></ul>

38. . Fracture with Callus <ul><li>Fractured bone ends. </li></ul><ul><li>Granulation tissue </li></ul><ul><li>Woven bone (callus) </li></ul>

39. . Factors affecting Bone Healing: <ul><li>Local factors </li></ul><ul><li>Immobilization * </li></ul><ul><li>Improper reduction – abnormal position </li></ul><ul><li>Infection. Debris, dead tissue in wound </li></ul><ul><li>Joint involvement </li></ul><ul><li>Damage to nerves / blood vessels. </li></ul><ul><li>Bone pathology – tumors, osteoporosis, etc. </li></ul><ul><li>Systemic Factors </li></ul><ul><li>Age* </li></ul><ul><li>Nutrition – vitamin /mineral deficiency. </li></ul><ul><li>Immune status. </li></ul><ul><li>Systemic Diseases </li></ul><ul><ul><li>Chronic disease </li></ul></ul><ul><ul><li>Diabetes* </li></ul></ul><ul><li>Drugs – steroids. </li></ul><ul><li>Genetic disorders </li></ul><ul><ul><li>Haemophilia etc.. </li></ul></ul>

40. . Immobilization

41. . Complications: <ul><li>Short Term: </li></ul><ul><li>Haemorrhage, Vascular injury* </li></ul><ul><li>Nerve / Visceral Injury* </li></ul><ul><li>Crush Syndrome* </li></ul><ul><li>Fat embolism </li></ul><ul><li>Renal failure </li></ul><ul><li>Shock, DIC. </li></ul><ul><li>Thromboembolism </li></ul><ul><li>Infection – Septicemia </li></ul><ul><li>Tetanus, Gas Gangrene </li></ul><ul><li>Long Term: </li></ul><ul><li>Delayed union </li></ul><ul><li>Non-union </li></ul><ul><li>Mal-union – deformity. </li></ul><ul><li>Growth disturbances </li></ul><ul><li>Contractures </li></ul><ul><li>Avascular Necrosis. </li></ul><ul><li>Osteomyelitis </li></ul><ul><li>Pseudoarthrosis </li></ul><ul><li>Osteoarthritis. </li></ul>

42. . Crush Syndrome: <ul><li>Increase in osteofascial compartments pressure leading to Muscle ischemia / necrosis – may lead to limb amputation </li></ul><ul><li>Signs: </li></ul><ul><ul><li>Pain, Swelling, Inflammation, mottling (necrosis) and blisters. </li></ul></ul><ul><li>Complications: </li></ul><ul><ul><li>Acute Renal failure (Low-output uraemia with acidosis) </li></ul></ul><ul><ul><li>DIC </li></ul></ul><ul><ul><li>Rhabdomyolysis </li></ul></ul>

43. . Osteomyelitis – excess Callus

44. . Complications of # <ul><li>This is a photograph of the left calf showing 30° equinus deformity and severe scarring to the back of the lower leg. This was due to a severe soft tissue injury with ischaemia of the calf muscles and infection. Note the split skin grafting of the lesion. </li></ul>

45. . Pseudoarthrosis <ul><li>Established non union of the mid shaft of the humerus of several years duration. </li></ul><ul><li>It was forming a mobile painless pseudarthrosis which he was using as an effective elbow joint. His actual elbow joint was completely stiff. No treatment was indicated. </li></ul>

46. . Cubitus valgus deformity: <ul><li>Cubitus valgus deformity due to a fracture of the lower humerus 3 years previously. </li></ul><ul><li>Gradually increasing due to damaged lateral & continued growth of medial epiphysis. </li></ul><ul><li>Also note late or tardy ulnar nerve palsy. </li></ul>

47. . Bone necrosis, Sequestrum - involucrum Sequestrum - Involucrum Sequestrum

48. . Large sequestrum:

49. . Disorders of Bone Paget’s Disease

50. . Paget’s Disease