Traumatic and mechanical disorders of musculoskeletal system
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Transcript of Traumatic and mechanical disorders of musculoskeletal system
Traumatic and mechanical disorders of musculoskeletal
system
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Ligament sprains
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• ประกอบุไปดู"วิย extracellular matrix, Proteoglycan, collagen, Fibroblast ฯล้ฯ
Classification
Ligamentous injuries of the knee
Intra-articular structures
• ACL• PCL• Medial meniscus• Lateral meniscus
Extra-articular structures
• MCL• LCL• Posterolateral corner complex : Biceps
femoris tendon, Arcuate ligament, Fabellofibular ligament, Popliteus tendon, Popliteofibular ligament, Posterior oblique collateral ligament, Plantaris longus muscle, Lateral gastrocnemius muscle(tendon part) etc.
Common injuries
• ACL injury• PCL injury• MCL injury• LCL injury• Meniscus injury
Cause of injury
• Sport injury• Motor vehicle injury
Natural history
• Ligament injury : Knee instability• Meniscus injury : pain, range of motion• Cartilage injury• Osteoarthritis
Physical examination
• Swelling• Point of tenderness• Limitation of range of motion• Special tests ***
Special tests
Stability test• Anterior drawer test • Posterior drawer test• Varus stress test• Valgus stress test• Prone external rotation test• Lachman test• Lateral pivot shift test
Lachman test
Special tests (cont.)
Meniscus test• McMurray test• Apley grind test• Squat test
McMurray test
Apley grind test
Investigation or Imaging
• Plain film X-ray • MRI (Magnetic Resonance Imaging)
Treatment
• Depend on which ligament was injuried• Non-operative treatment• Operative treatment : Repair, Reconstruction
Ligamentous injuries of the ankle
Key structures
• ATFL : Anterior Tibiofibular ligament• Deltoid ligament• Syndesmotic ligament
Mechanisms of injury
Physical examinations
• Swelling• Point of tenderness• Inability to bear weight• Special test ***
Anterior Drawer Test
Talar Tilt Test
Squeeze test External rotation test
Investigation or Imaging
• Plain film radiograph : AP ,lateral, mortise view
• For exclude bone fracture • Able to exclude ligament sprain grade by
measuring parameter
Radiographs
Treatment
• Ankle sprain grade 1 + 2 : Immobilize in slab or cast
• Ankle sprain grade 3 : Surgery Repair
Ligament healing
1. Inflammatory phase2. Reparative phase3. Remodeling phase
Strain
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• Muscle and Tendon
Anatomy
Tendon
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• ม ควิามแข�งแรงอย 'ระห้วิ'างกระดู กแล้ะกล้"ามเน$%อ• ม สุ'วินประกอบุของ Extracellular matrix,
Collagen, Proteoglycan, Tenocyte, Tenoblast
Causes
• Improper use• Heavy lifting• Over-stretched• Occurs in Lower back, Neck, shoulder, Thigh
Treatment
• Rest • Immobilization• NSAIDs : Non Steroidal Anti Inflammatory
Drugs• Physiotherapy : Short wave, U/S
Fractures
BONE AND JOINT INJURIES
• Fracture = Disruptions of bone tissue• Osteochondral or intraarticular fractures =
Visible disruptions of articular cartilage or fractures involved both the articular cartilage and subchondral bone
• Chondral fractures = involved only the cartilage
Gross anatomy
• Spine • Upper extremity• Lower extremity• Pelvis
Bone Tissue• Its tensile strength nearly equals that of
cast iron• 3 times lighter• 10 times more flexible• Consists of mesenchymal cells embeded
within abundant extracellular matrix • Constantly changing in response to
mechanical and hormonal signals
Bone TissueThe matrix contains :1. Mineral great strength and stiffness in
compression and bending2. Collagen type 1 strength and plasticity3. Cytokine , Growth factors
Periosteum• Outer layer more fibrous layer• Inner layer more cellular and vascular
cambium layer• Participates in healing of many types of
fractures• In children , Thicker periosteum than
Adults
Types of BoneWoven bone (immature bone)
• Embryonic skeleton• More rapid rate of
deposition and resorption• Initial fracture repair• Irregular pattern of matrix
fibrils• relatively high cell content
and water concentration• 4 times the number of
osteocytes per unit volume• Less stiffness• More easily deformed
Lamellar bone (mature bone)
• Replaces woven bone during growth and development
• Replaces woven bone in remodeling phase under mechanical load
• More stiffness• Difficultly deformed
Bone formation
1. Cutting cone 2. Intramembranous formation3. Endochondral bone formation
Cutting cone
• Primarily a mechanism to remodel bone• Osteoclasts at the front• Trailing osteoblasts lay down new bone
Intramembranous formation• Long bone grows in width• Osteoblasts differentiate directly from
preosteoblasts and lay down seams of osteoid• Do not involve cartilage anlage
Endochondral bone formation
• Long bone grows in length• The chondrocytes hypertrophy, degenerate
and calcify• Vascular invasion of cartilage occurs followed
by ossification
Stages of Fracture healing• Inflammation• Repair• Remodeling
Inflammatory phase• Require high energy until remodeling• Inflammatory mediators released from
platelets, dead cells• Vasodilatation and exudate plasma
edema in the region• Macrophages and Lymphocyte migration• The inflammatory response subsides,
necrotic tissue and exudate are resorbed
Repair phase
• Fibroblasts and chondrocytes start producing a new matrix, the fracture callus
• Follows inflammatory phase rapidly• Unstable Vs Stable fracture ???
Repair and Remodeling of Unstable Fractures (Secondary bone healing
• Organization of hematoma first step in fracture repair
• Initiate fracture healing• The intact fracture hematoma provides a
fibrin scaffold that facilitates migration of repair cells
• Platelets and cells in hematoma release GFs and other proteins cell migration, proliferation, matrix synthesis
• Blood supply, medullary system and periosteum are important for fracture healing
• The mesenchymal cells proliferate, differentiate, and produce the fracture callus consisting of fibrous tissue, cartilage, and woven bone
Osteoclast
• Derived from circulating monocytes in the blood and monocytic precursor cells from the bone marrow
• Do not appear to form repair tissue
Osteoblast• Develop from the
undifferentiated mesenchymal cells that migrate into the fracture site
• Participate in bone formation
• Hard (bony) callus “The bone formed initially at the periphery of the callus by intramembranous bone formation”• Soft (fibrous and cartilaginous) callus“forms in the central regions with low oxygen tension and consists primarily of cartilage and fibrous tissue”• Endochondral ossificationenlarging the hard callus and increasing the stability of the fracture fragments
Callus
• At these stages, the healing is not complete
• The immature fracture callus is weaker than normal bone
• Gaining full strength during remodeling phase
• During final stage of Repair, Remodeling of the repair tissue begins with replacement of woven bone by lamellar bone and resorption of unneeded callus
• By radioisotope studies, the remodeling process continues for year after clinical and radiographic union
• Decrease bone density and remains changes for years
Repair and Remodeling of Stabilized Fractures (Primary Bone Healing)
The fracture surfaces are rigidly held in contact
Fracture healing can occur without grossly visible callus in either cancellous or cortical bone
Called “ Primary bone healing”Small bone gaps Vs bone contact??
• Lamellar bone can form directly across the fracture line by extension of osteons
• A cluster of osteoclasts cuts across the fracture line, osteoblasts following the osteoclasts deposit new bone, and blood vessels follow the osteoblasts
• The new bone matrix, enclosed osteocytes, and blood vessels form new haversian systems.
Joint tissue (synovial joint)
• Congruent articulating cartilaginous surfaces• Subchondral bone• Metaphyseal bone• Joint capsule• Ligaments• Synovial membrane• **fibrous tissue meniscus** (labrum)
Articular cartilage
• Sparsely distributed chondrocytes• Surrounded by an elaborate, highly organized
macromolecular framework filled with water• Collagens, Proteoglycans and Non-
collagenous proteins form the macromolecular framework
Physical examination
• Pain• Swelling• Tenderness• Limitation of Range of motion• Neurological status• Vascular status
Imaging
• Plain film X-ray• Computerized Tomography
Treatment
• Non-operative• OperativeDecision making depend on • Site of injury, • Severity of injury• Fracture configuration• Surrounding structures injury• Other organ system injury• Patient’s underlying disease
Non-operative treatments
• Splint• Slab• Casting• Bracing• Traction
Operative treatments
Internal fixation• Dynamic compression plate and screw • Locking plate and screw • Intramedullary nailing system• WiringExternal fixation• External fixator• Ilizarov system
Principles of treatment
• Displacement• Intra-articular involvement• Soft tissue injury• Nerve and Vascular injury• Diaphysis of Lower extremity : Nailing
Bone Healing
• Dynamic compression plate : Primary• Locking plate : Secondary• Nailing : Secondary• Wiring : Primary• External fixator : Secondary• Ilizarov : Distraction osteogenesis
“Clinical union”• Stability of the fracture fragments
progressively increases because of the internal and external callus formation
• The fracture site becomes stable and pain-free
“Radiographic union”
• Plain radiographs show bone trabeculae or cortical bone crossing the fracture site
• Often occurs later than clinical union
Failure of Fracture Healing
Delay union
• Fracture line remains clearly visible radiographically• There is no undue separation of the
fragments, no cavitation of the surfaces, no calcification, and no sclerosis• Related to the severity of the injury, poor
blood supply, the age and nutritional status of the patient, or other factors
Nonunion
• An arrest of the healing process• With a large volume of callus called “Hypertrophic
nonunion”• With some callus but less than normal
“Oligotrophic nonunion”• Without callus or less called “Atrophic nonunion”• With cartilagenous tissue and clear fluid filled in
cavity called “Pseudarthrosis”• “A Fibrous Union”
HypertrophicNon-union
Oligotrophic non-union
AtrophicNonunion
Synovial pseudarthrosis
Dislocation
• Joint dislocation• Low velocity Shoulder, Elbow, wrist, finger• High velocity Hip, Knee, Ankle
Common direction
• Shoulder : anterior• Elbow : posterior• Wrist : Lunate volar dislocation• Finger : Posterior• Hip : posterior• Knee : all direction• Ankle : all direction
Physical examination
• Mark swelling• Mark deformity• Limitation of motion• Neurological status• Vascular status
Imaging
• Plain film X-ray
Treatment
• Emergency closed reduction• Under sedation• Under General anesthesia• Open reduction
Acute compartment syndrome
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