refrat soft tissue injury musculoskeletal

8/11/2019 Refrat Soft Tissue Injury Musculoskeletal

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SOFT TISSUE INJURIESLINA, PANDU, MARTHIN, BOBBY, MARSELLA


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INTRODUCTION

acute

connective

tissue

injury

that

may

involve

muscle,

ligament,

tendon,

capsular

structures

and/

or

cartilaginous

structures

single episode of injury result of repeated overuse

damage and pain


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SOFT-TISSUE INJURIES ARE OFTEN

CLASSIFIED AS:

sprains

strains contusions

tendinitis

bursitisAssociated fractures


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STRAINS

Injury to a muscle or tendon.

A serious tear may require surgery.

simplestretch

partialcomplete tear


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CONTUSION

A bruise caused by a blow to the muscle,

tendon, or ligament caused by blood poolingaround the injury and discoloring the skin.

respond well to Rest, Ice, Compression, andElevation (R.I.C.E).


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BURSITIS

bursitis

RestAnti-inflammatory

medication.

Repeated Small Stress


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DEGREES OF SEVERITY OF

SOFT TISSUE INJURY

First degree (mild)

mild stretch of ligament or capsular

structures

over-stretch or direct blow to muscle.

minimal swelling and bruising

mild pain is felt at the end of range ofmovement

No joint instability, minimal muscle spasm andno loss of function.


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SECOND DEGREE

MODERATE)

Moderate stretch of ligament or capsularstructures

Excessive stretch or direct blow to muscle,causing tearing of some fibers.

Interferes with the ability of the muscle to

contract or lengthen. Some joint instability with ligament / capsular

injuries.


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Due to the tearing of some fibres

- a decrease in the tensile strength of

ligament / capsule or

- a decrease in the contractile strength of

muscle

interference with function


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THIRD DEGREE

SEVERE)

severe over-stretch of ligament

excessive stretch or direct blow to muscle,

causing a complete tear of the injured structure. significant swelling and bruising

severe pain even at rest interferes withfunction with muscle injuries

Function is severely impaired.severe muscle spasm and 'splinting


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TISSUE RESPONSE TO INJURY

3 PHASES

Phase One (Vascular response,inflammation) - lasts several days

Bleeding from vascular disruption andcollagen rupture

Coagulation - Platelet activation factorsinitiate the clotting system and a fibrin

clot forms Edema - Vasoactive mediators increase

vascular permeability and local bloodflow, causing edema


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Phase One of healing demonstrating

extravasation together with polymorphs andmacrophages

Inflammation Leukocytes and other

phagocytic cells are delivered to the

injured tissue

Inflammation is necessary for repair but

true tissuerepair and regeneration willnot occur until the inflammatory process

subsides

Control of inflammation important


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May last anything up to six days(Houglum, 1992).

The cardinal signs of inflammation :

Calor(heat),

Rubor(redness),

Dolor (pain) andTumor (swelling).


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CALOR AND RUBOR

Caused by the opening up of thousands of tiny local bloodvessels in response to the interaction between cellular andchemical components.

Inside the dilated capillaries, the rate of blood flow slows.

four hours after injury, WBC are beginning to pass throughthe vessel walls.

The heat and redness take a few hours to develop.

The increase in local tissue temperature increases themetabolic demands of the area that also results invasodilation.


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DOLOR

pain is caused by chemicals released at the

site of injury by the dead and dying cells

acting on the bare nerve endings of pain

fibres.

As swelling begins to develop, pain will also

result from increased tissue pressure.


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TUMOR

swelling occurs : increased permeability of the

blood vessel walls, caused by the release of

chemicals by the damaged cells. The swelling of inflammation is mostly fluid,

called the inflammatory exudate, which

contains a large number of inflammatory cells

and a high concentration of protein.


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PHASE TWO

TISSUE RECONSTRUCTION, REPAIR PHASE)

6-8 WEEKS

Cell proliferation - Growth factorssimulate fibroblasts which

produces collagenFormation of granulation tissueby angiogenesis

Delicate tissue

Composed of fibroblasts,collagen and capillaries


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PHASE THREE

REMODELING AND FUNCTIONAL RESTORATION )

LASTS FOR MONTHS

Matrix synthesis - Type III collagenfibrils followed by TypeI

Scar tissue(mixed form of

collagen) develops


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Degenerative and hypoxic region thatresults in tissuehyperplasia andangiogenesis

Microvascular thrombosis and collagenfiber repair and degeneration lead tomicrotears and chronic inflammatorygranulation tissueor scar tissue

Reinjury is common

Ineffective range of motion results ininadequate healing


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MANAGEMENT OF

ACUTE SOFT TISSUE INJURIES

The use of the RICE(Rest, Ice, Compression

and Elevation) regime, together with the morerecent addition of a Protection element is

widely accepted in the approach to the

management of acute soft tissue injuries

(Quillen and Rouillier, 1982; Pincivero et al,1993).


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PROTECTION

Required to protect the injured tissues from unduestress which may disrupt the healing process anddelay rather than promote healing. Protection may be

applied by: plaster cast

bandaging

splints

slings

crutches (protection from weight-bearing)


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REST

How ?

rest from activity.

Moving the injured part:

will increase the blood flow and

bleeding to the injury site

may cause the blood clot to dislodge,and begin bleeding again

may cause more tissue damage.


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ICE

Apply ice:

directly over the injury and surrounding tissue

for 10 to 20 minutes every 2 hours.

How

ice in a wet towel or plastic bag

frozen cup of water continuously moved over the area

a commercial ice pack

iced water in a bucket.

Why

ice decreases swelling

ice decreases pain.

Do not apply ice directly to the skin, always wrap ina wet towel or wet cloth to avoid ice burns.


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COMPRESSION

How

apply a firm, elastic, non-adhesive bandage

if using an ice pack, the compression bandage is

applied over the ice pack and above and below theinjury site to hold it in place and provide compression

even when you are not icing, the compressionbandage should remain directly over the injury site,above and below

release the compression prior to sleep. Why

reduces swelling and bleeding at the injury site.


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ELEVATION

How

raise the injured area above the level of theheart whenever possible.

Why

elevation decreases bleeding, swellingand pain.


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REFERRAL

How

refer to an appropriate health care

professional for definitive diagnosis and

continuing management

The R.I.C.E.R. Regime should be repeated

for the first 48 to 72 hours


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PERIPHERAL NERVE INJURIES

Types of Peripheral Nerve Injuries :

Neuropraxia

Pathophysiology :

Reversible conduction block characterized by

local ischemia and selective demyelination of

the axon sheath

Prognosis : Good


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AXONOTMESIS

Pathophysiology :

More severe injury with disruption of the axonand myelin sheath but with an intact

epinerium

Prognosis :Fair


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NEUROTMESIS

Pathophysiology :Complete nerve division with disruption of the

endonerium

Prognosis : Poor


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SKELETAL MUSCLE INJURIES

Typically heal with dense scarring.

Surgical repair of clean laceration of sceletal

muscle usually results in minimal regeneration

of muscle fibers distally, scar formation at the

laceration, and approximately 50% of musclestrength


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TENDON

Tendon are composed of fibroblasts arranged inparalel rows in fascicles.

2 type of tendons : Paratenon : covered (vascular) tendons , many

vessels supply a rich capillary system

Sheated tendons : a mesotenon (vincula) carries

a vessel that supplies only one segment of thetendon ; avascular areas receives nutrition fromvascularized segment


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TENDON HEALING

Because of the differences in vascular supply,paratenon covered tendons heal better thansheated tendons.

Tendinous healing in response to injury is initiatedby fibroblasts that originate in the epitenon andmacrophages that initiate healing andremodeling.

Tendon repairs are weakest at 7 to 10 days ;regain most of their original strength at 21 to 28days ; achieve maximal strength at 6 months.


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LIGAMENT

The ultrastructure of ligament is similar to thatof tendons, but the fibers are more variable

and have a higher elastin content. The most common mechanism of ligamentous

failure is rupture of sequential series ofcollagen fiber bundles distributed throughout

the body of the ligament and not localized toone specific area.


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MANAGEMENT ASSOCIATED WITH #

Assesment of the zone of soft tissue injuries

Generally much larger than the area of the # itself

Assesment for associated vascular injuries

Assesment for nerve injuries

Irrigation : in the operating room , copious

isotonic solution, removing necrotic and foreign

material


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