kin 188 tissue healing

KIN 188KIN 188Prevention and Care of Prevention and Care of

Athletic InjuriesAthletic InjuriesTissue HealingTissue Healing

Tissue HealingTissue Healing

Soft tissue healingSoft tissue healing

Bone/fracture healingBone/fracture healing

Nerve healingNerve healing

Phases of Soft Tissue HealingPhases of Soft Tissue Healing

Phase I – Inflammatory ResponsePhase I – Inflammatory Response

Phase II – Repair/RegenerationPhase II – Repair/Regeneration

Phase III – Remodeling/MaturationPhase III – Remodeling/Maturation


OnsetOnset Immediate and typically progresses x 3-5 daysImmediate and typically progresses x 3-5 days

Signs and symptoms Signs and symptoms Redness (rubor)Redness (rubor) Pain/point tenderness (dolor)Pain/point tenderness (dolor) Warmth (calor)Warmth (calor) Swelling (tumor)Swelling (tumor) Limited ROM (functio laesa)Limited ROM (functio laesa)


Tissue damage – initiates inflammationTissue damage – initiates inflammation

VasocontrictionVasocontriction Initial attempt to limit bleeding at siteInitial attempt to limit bleeding at sitePlatelet reactionPlatelet reaction Provokes clotting at site to “plug” ruptured Provokes clotting at site to “plug” ruptured

vascular structuresvascular structuresCoagulationCoagulation Clot/hematoma is formedClot/hematoma is formed


White blood cell infiltrationWhite blood cell infiltration Neutrophils and macrophages attracted to area via Neutrophils and macrophages attracted to area via

chemical processes to rid waste, debris and infectious chemical processes to rid waste, debris and infectious agents (phagocytosis)agents (phagocytosis)

VasodilationVasodilation Additional blood flow to area via chemical processesAdditional blood flow to area via chemical processes Increases cell permeability causing swelling/edema Increases cell permeability causing swelling/edema

from tissue exudate – allows for further arrival of from tissue exudate – allows for further arrival of “good stuff” and removal of “bad stuff”“good stuff” and removal of “bad stuff”

Inflammatory ResponseInflammatory Response


OnsetOnset 48 hours – 8 weeks48 hours – 8 weeks Somewhat dependent upon tissue type – Somewhat dependent upon tissue type –

quicker proliferation with greater blood supplyquicker proliferation with greater blood supply

Signs and symptomsSigns and symptoms Decreased sx of inflammationDecreased sx of inflammation


Proliferative phaseProliferative phase New blood supply allows for waste removal and arrival of New blood supply allows for waste removal and arrival of

fibroblastsfibroblasts

FibroplasiaFibroplasia Process of generating collagen tissue via fibroblast activityProcess of generating collagen tissue via fibroblast activity

Progression of phase – changes in cellular Progression of phase – changes in cellular activityactivity

Proliferation of new blood supply and fibroblast activity reinforce Proliferation of new blood supply and fibroblast activity reinforce new connective tissue matrix - each fuels the othernew connective tissue matrix - each fuels the other

Phase III – Remodeling/MaturationPhase III – Remodeling/Maturation

OnsetOnset 6-8 weeks6-8 weeks May last months/years - unknownMay last months/years - unknown

Signs and symptomsSigns and symptoms Minimal sxMinimal sx Resolution of sx of inflammation unless Resolution of sx of inflammation unless

complications have arisencomplications have arisen

Properties of Scar TissueProperties of Scar Tissue

Structurally weakStructurally weak

Decreased elasticityDecreased elasticity

Contractures/adhesionsContractures/adhesions

Sensory impairmentSensory impairment

Factors Affecting Rate of HealingFactors Affecting Rate of Healing

Blood supplyBlood supply

Degree of immobilizationDegree of immobilization

Foreign substancesForeign substances

Vitamin/mineral deficiencyVitamin/mineral deficiency

Steroid useSteroid use

Phases of Fracture HealingPhases of Fracture Healing

Phase I – Inflammation and Hematoma Phase I – Inflammation and Hematoma Formation Formation

Phase II – Cellular ProliferationPhase II – Cellular Proliferation

Phase III – Callous FormationPhase III – Callous Formation

Phase IV – Bony Union/OssificationPhase IV – Bony Union/Ossification

Phase V – RemodelingPhase V – Remodeling

Phase I – Inflammation and Phase I – Inflammation and Hematoma FormationHematoma Formation

Bleeding from periosteum, endosteum, Bleeding from periosteum, endosteum, bone marrow and surrounding soft tissuebone marrow and surrounding soft tissue

Typically lasts approximately 4 daysTypically lasts approximately 4 days

Phase I – Inflammation and Phase I – Inflammation and Hematoma FormationHematoma Formation

Hematoma accumulates in area to form matrix Hematoma accumulates in area to form matrix for healing – blood clotting initially occludes for healing – blood clotting initially occludes normal blood flow and local cells dienormal blood flow and local cells die

Secondary to cellular death, inflammatory Secondary to cellular death, inflammatory response occurs similar to soft tissue injuriesresponse occurs similar to soft tissue injuries Vasodilation, inflammatory cell arrival, swellingVasodilation, inflammatory cell arrival, swelling


Vascular proliferationVascular proliferation Capillary buds in callous and surrounding soft tissueCapillary buds in callous and surrounding soft tissue Bring endosteal cells to areaBring endosteal cells to area

Osteogenic (endosteal) cells proliferate intoOsteogenic (endosteal) cells proliferate into Osteoblasts - formation of callous (bone)Osteoblasts - formation of callous (bone)

Osteoblasts more numerous in highly vascular areasOsteoblasts more numerous in highly vascular areas Chondroblasts - formation of callous (cartilage)Chondroblasts - formation of callous (cartilage) Osteoclasts - reabsorption of boneOsteoclasts - reabsorption of bone


Fibrous junction between ends of bones at Fibrous junction between ends of bones at fracture site is built fracture site is built First it’s callous then progresses to cartilage First it’s callous then progresses to cartilage

and finally boneand finally bone


External callous from periosteal cellsExternal callous from periosteal cells

Internal callous from endosteal cellsInternal callous from endosteal cells

Soft callous forms externally and internally Soft callous forms externally and internally to bridge the fracture site (internal callous to bridge the fracture site (internal callous grows faster to create natural grows faster to create natural immobilization)immobilization)


Hard callous starts forming at 3-4 weeks Hard callous starts forming at 3-4 weeks and continues for 3-4 monthsand continues for 3-4 months

Unsatisfactory immobilization leads to Unsatisfactory immobilization leads to cartilagenous union vs. bony union due to cartilagenous union vs. bony union due to incomplete formation of hard callousincomplete formation of hard callous

Phase IV – Bony Union/OssificationPhase IV – Bony Union/Ossification

Callous replaced by boneCallous replaced by bone InternalInternal ExternalExternal Influx of new Haversian system/blood supplyInflux of new Haversian system/blood supply

Callous “comes together” in bony unionCallous “comes together” in bony union Fracture site is bridged by boneFracture site is bridged by bone

Phase V - RemodelingPhase V - Remodeling

Callous reabsorbed by osteoclasts and bone Callous reabsorbed by osteoclasts and bone assumes normal formation/appearanceassumes normal formation/appearance

Complete remodeling may take yearsComplete remodeling may take years

Remodeling complete when fractured bone is Remodeling complete when fractured bone is restored to normal shape or has developed a restored to normal shape or has developed a shape that can withstand imposed stressesshape that can withstand imposed stresses

Fracture HealingFracture Healing

Factors Affecting Bone HealingFactors Affecting Bone Healing

InfectionInfection Especially with open fractures but also may Especially with open fractures but also may

arise with systemic infections of closed fracturesarise with systemic infections of closed fractures

Metabolic disorders/diseasesMetabolic disorders/diseases Vitamin and mineral deficienciesVitamin and mineral deficiencies

Steroid useSteroid use Interferes with collagen synthesisInterferes with collagen synthesis

Factors Affecting Bone HealingFactors Affecting Bone Healing

Unbridgeable gapsUnbridgeable gaps Loss of bone tissue, interposition of soft tissueLoss of bone tissue, interposition of soft tissue

Vascular destruction/poor vascular supplyVascular destruction/poor vascular supply Avascular necrosis (carpal navicular/schaphoid, head of Avascular necrosis (carpal navicular/schaphoid, head of

femur)femur)

Inadequate reduction/poor immobilizationInadequate reduction/poor immobilization Not only may impact healing but may contribute to Not only may impact healing but may contribute to

development of permanent deformitydevelopment of permanent deformity

Nerve HealingNerve Healing

When nerve severed, healing does not When nerve severed, healing does not occur and loss of function typically occur and loss of function typically permanentpermanent

If nerve fibers ruptured but surrounding If nerve fibers ruptured but surrounding myelin sheath intact, it’s possible for myelin sheath intact, it’s possible for regeneration to occurregeneration to occur Very slow process (<1mm/day, Very slow process (<1mm/day,

~2.5cm/month)~2.5cm/month)

kin 188 tissue healing

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