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Title: Unit


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
    an irritant or injury which may be either acute
    or chronic. It is a protective mechanism,
    designed to?
  • The purpose 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.)
  • Bodys fundamental reaction designed to protect,
    localize, and fight the injurious agent, as well
    as prepare the area for healing and repair
    (Natures Way).
  • Repair-Regeneration Phase(48hrs)
  • Tissue repairs by resolution (granulation tissue)
    and regeneration .
  • Repair depends on type of tissue amount of
    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 AND REGENERATION
  • 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 .
  • Generally connective 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 tissue continues for 3 - 6 months
    following injury, and may take as long as a year
    to be completely healed (if in fact 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 OF CHRONIC 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 the
    reason 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 Various Types 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 .

51
Inflammation Implications for Immediate Care ?
  • R.I.C.E. ?
  • Rest - what effect does rest have upon the
    physiological changes resulting from the injury
    and subsequent inflammatory response?
  • Ice - ?
  • Compression - ?
  • Elevation - ?
  • Other ? immobilize, NSAIDS

52
Inflammation Implications for Follow-up Care?
  • Regardless of which method of follow-up therapy
    you choose, what would your knowledge of the
    inflammatory process tell you about the purpose
    of your treatment?
  • What treatment methods might be contraindicated?
  • Acute vs. Chronic inflammation?

53
Inflammation Implications for Follow-up Care?
  • Moist heat packs
  • Whirlpool (110 deg)
  • Analgesics
  • Ultrasound
  • Massage
  • Paraffin bath
  • Fluidotherapy
  • Diathermy (electromagnetic)
  • Low Power Laser
  • Ice bag
  • Ice massage
  • Cold whirlpool (55 deg)
  • Vapocoolant sprays
  • Phonophoresis
  • Iontophoresis
  • EMS
  • Alternative therapy

54
Inflammation Implications for Therapeutic
Exercise
  • Deciding when to begin therapeutic exercise,
    reconditioning, and/or a return to activity, is
    always a difficult decision. Based upon what you
    have learned about the inflammatory process and
    the bodys response to injury
  • When should therapeutic exercise begin?
  • How much exercise should be allowed?
  • Does the type of exercise make a difference.

55
FRACTURE HEALING
  • TIME is a major concern as bone healing goes thru
    the various phases of healing, but generally 4-6
    weeks.
  • Acute Phase first 3-4 days
  • Repair Phase hematoma formation, organization
    of scar, and fibrous junction between bone ends
    (soft callus - hard callus)
  • Remodeling Phase May take years.

56
FRACTURE CARE
  • Immobilization until hard callus has formed,
    usually 4-6 weeks, but can last several months
    depending on the nature, extent, site of the
    fracture.
  • Conditions which can delay healing
  • poor blood supply to fracture area
  • poor immobilization
  • infection or disease
  • age and/or osteoporosis

57
Healing of Stress Fractures
  • if the osteoclastic activity is greater than
    the osteoblastic activity, the bone becomes
    increasingly susceptible to stress fracture.
  • decrease in activity and elimination of other
    factors in training that cause stress will allow
    bone remolding

58
PAIN
  • CAUSES OF PAIN
  • released CHEMICAL SUBSTANCES
  • PRESSURE ON NERVE ENDINGS
  • ISCHEMIA IN THE AREA
  • PAIN, SPASM,SWELLING, PAIN CYCLE
  • TYPES OF PAIN
  • SHARP (EXCRUCIATING), DULL, ACHE, CONSTANT,
    OFF\ON, THROBBING,NIGHT

59
Acute vs Chronic Pain
  • Acute Pain
  • Less than 6 days in duration
  • Specific cause or mechanism of injury
  • Generally of short duration
  • Usually a specific area of origin
  • Chronic Pain
  • Gradual onset and/or long duration
  • that which continues beyond the usual normal
    healing time

60
Referred Pain
  • Pain is common in sports
  • Types of pain by location
  • Away from the actual site of irritation
  • May be motor, sensory or both
  • May produce paresthesia
  • Three types common to athletics
  • Myofacial pain at trigger points
  • sclerotomic is deep pain
  • dermatomic pain is sharp and well organized

61
PAIN SENSITIVITY
  • Pain tolerance can be a learned response, and is
    both physiological and psychological in nature
  • Pain is a feeling
  • Pain is subjectivebut we try to get objective
    data to make our decisions. Unfortunately the
    so-called objective tests that we often use are
    often unreliable.

62
Pain Assessment
  • Methods for Pain Assessment
  • Numeric value scale
  • 1 to 10 with 1 representing the least
  • Verbal descriptors as assessment, such as none,
    slight, mild, moderate, and severe
  • Palpation
  • Response to activity,weight bearing, etc.

63
Pain Treatment
  • Management methods can be used separately or in
    combination
  • Break the pain-spasm-pain cycle thru a variety of
    methods, such as
  • heat or cold
  • electrical stim and ultra sound
  • phonophoresis iontophoresis
  • pharmacological agents(analgesics)
  • topical counterirritants
  • others?

64
Psychological Aspects of Pain
  • Pain can cause serious emotional changes in an
    athlete, including depression and irritability
  • Pain is a physiological and psychological
    phenomenon, unique to each athletic
  • Through conditioning, athletes can learn pain
    tolerance
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