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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Tissue Healing and Wound Care Chapter 6.

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Presentation on theme: "Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Tissue Healing and Wound Care Chapter 6."— Presentation transcript:

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2 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Tissue Healing and Wound Care Chapter 6

3 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Two potential effects of force: –Acceleration –Deformation Factors that determine injury –Magnitude of force –Material properties of tissues involved Force and Its Effects

4 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Small load - elastic response –Load is removed, material returns to its original shape Load reaching yield point - plastic response –Load is removed, some amount of deformation remains Yield load –Maximum load a material can handle without permanent deformation Failure –Force such as loss of continuity, rupturing soft tissue or fracturing bone Response to Force

5 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Many tissues are anisotropic –Different strengths in response to loads from different directions Anatomic make-up of joint –Susceptibility from a given direction Direction of Force

6 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Axial – Force that acts on the long axis of a structure Compression –Axial load that produces a crushing or squeezing type force Tension –Axial force in opposite direction; pulling or stretching the tissues Shear –Force parallel to a plane passing through the object –Tends to cause sliding or displacement Categorize Force Relative to Direction

7 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Categorize Force Relative to Direction (cont.)

8 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Stress –Force divided by the area over which the force acts A given force over a large area vs. a small concentrated area can have very different results Magnitude of Stress

9 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strain –The amount of deformation relative to the original size of the structure –Result Compression - shortening and widening Tension - lengthening and narrowing Shear - internal deformation Problem: high strain rather than high force The ability to resist strain relative to strength of tissues Strain vs. Force

10 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Acute injury –Results from a single force –Causative factor - macrotrauma –Characterized by a definitive moment of onset Chronic or stress injury –Results from repeated loading –Causative factor - microtrauma –Characterized by becoming more problematic over time Element of Time

11 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins gradual mechanical stress size & strength Positive Stress vs. Adverse Stress

12 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Moment arm –Perpendicular distance from force line of action to the axis of rotation Torque –Force × moment arm –Produces rotation of a body Torque

13 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Torque (cont.) Injury potential –Bending Tension on one side of object and compression on the other side –Torsion Twisting an object's longitudinal axis

14 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Collagen –Primary constituent of skin, tendon, ligaments –Protein substance strong in resisting tensile forces –Wavy configuration that allows for an elastic type deformation or stretch but, otherwise, is inelastic Elastin –Protein substance –Adds elasticity Soft Tissue – Anatomic Properties

15 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Skin Epidermis Dermis –Multidirectional arrangement of collagen

16 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Muscle to bone Dense connective tissue with unidirectional bundles of collagen and some elastin Collagen - parallel arrangement –Helps in resisting high, unidirectional tension loads from the attached muscle Two times as strong as muscle it serves –Yield point 5-8% in length Tendons

17 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Aponeuroses Attach muscle to other muscles or bone Dense connective tissue Strong, flat, sheet-like

18 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Viscoelastic –Extensibility - ability to be stretched –Elasticity - ability to return to normal length Viscoelasticity allows muscle to stretch to greater lengths over time in response to a sustained tensile force Muscle

19 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Irritability - ability to respond to a stimulus –Electrochemical - nerve impulse –Mechanical - external blow Contractility - ability to develop tension –Isometric –Concentric –Eccentric Muscle (cont.)

20 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Joint Capsule Membrane that encloses a joint; composed primarily of collagen Function: hold bones in place Inner lining: synovial membrane –Exit for waste; entrance for nutrients –Secretes synovial fluid (lubricates and nourishes)

21 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bone to bone Collagen is parallel and interwoven –Resists large tensile loads along the long axis of the ligament and smaller loads from other directions Collagen and elastin intermixed (more elastic than tendons) Ligaments

22 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursa Fluid-filled sacs Reduce friction Common sites – areas of friction

23 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Classification of Joints Fibrous (synarthrosis) –Held together by fibrous tissue –Can absorb shock but permits little or no movement of the articulating bones –Example: sutures in the skull –Syndesmoses Joined by dense fibrous tissue Permit extremely limited motion Example: interosseous membrane

24 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Classification of Joints (cont.) Cartilaginous (amphiarthroses) –Primary Held together by hyaline cartilage Example: sternocostal joints; epiphyseal plates Can absorb shock, but permits little or no movement –Secondary Held together by fibrocartilage Movement of the articulating bones Designed for strength and shock absorption

25 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Classification of Joints (cont.) Synovial (diarthroses) –Freely movable joints –Classified according to their shape – dictates type and range of motion permitted Plane Hinge Pivot Condyloid Saddle Ball and socket

26 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Classification of Joints (cont.) Synovial joint –Articular cartilage Covers ends of long bones, cushion and protection, no nerve or blood supply –Joint cavity Filled with synovial fluid

27 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Classification of Joints (cont.) –Articular capsule Joint capsule –Synovial fluid Reduces friction –Ligaments Capsular, extracapsular

28 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Skin Injury Classifications Abrasions –Scraping away of layers of skin Blisters –Accumulation of fluid between epidermis and dermis Skin bruises –Accumulation of blood within skin Incisions –Clean cut

29 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Skin Injury Classifications (cont.) Lacerations –Irregular tear Avulsions –Complete separation of skin Punctures –Penetration of skin and underlying tissue

30 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Mechanism: compression Signs and symptoms (S&S) –Onset - acute –Pain - localized –Ecchymosis: if superficial –Restrictions in ROM –Swelling –Associated nerve compression Classification of Muscle/ Tendon Injuries Contusion

31 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusion (cont.) Basis for rating severity – ROM –1 st – little or no restriction –2 nd – noticeable reduction –3 rd – severe restriction Concern: can lead to muscle strain

32 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Stretch or tear of a muscle Mechanism: tension force Most common site for tears: near the musculotendinous junction Key factor: magnitude of force and structure's cross-sectional area Strain

33 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Classification of Strains 1 st 2 nd 3 rd damage to fibersfew fibers tornnearly half tornall fibers torn weaknessmildmoderate (reflex inhibition) severe muscle spasmmildmoderatesevere loss of functionmildmoderatesevere (reflex inhibition) swellingmildmoderatesevere palpable defectno yes (if early) pain-contractionmildmoderate /severenone/mild pain-stretchingyes no ROMdecreased depends on swelling

34 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Involuntary muscle contraction Cramp –Biochemical imbalance, fatigue –Types Clonic - alternating contraction/relaxation Tonic - constant Spasm –Reflex action due to: Biochemical or Mechanical blow to nerve or muscle Cramps and Sprains

35 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Myositis –Inflammation of connective tissue Fasciitis –Inflammation of the fascia surrounding portions of a muscle Myositis and Fasciitis

36 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Tendinitis –Inflammation of tendon –Pain and swelling with tendon movement –Problems - repeated microtrauma Degenerative changes Tenosynovitis –Inflammation of synovial sheath –S&S Acute: rapid onset, crepitus, local swelling Chronic: thickened tendon, nodule formation in sheath Tendinitis and Tenosynovitis

37 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Ectopic calcification - located in place other than normal Bone (calcium) is deposited within a muscle Usually macrotrauma, but can be microtrauma Myositis Ossificans

38 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Result of repeated irritation of tissues Classification –Stage 1: pain after activity only –Stage 2: pain during activity, does not restrict performance –Stage 3: pain during activity, restricts performance –Stage 4: chronic unremitting pain, even at rest Problem – low-grade inflammatory condition that results in collagen resorption and scarring Chronic Conditions

39 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprain Stretch or tear of ligament Mechanism of injury (MOI) – tension force Compromises the ability of the ligament to stabilize the joint Joint Injury Classifications

40 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Classification of Sprains 1 st 2 nd 3 rd damage to ligamentfew fibers tornnearly half tornall fibers torn distraction stress<5 mm5-10 mm>10 mm weaknessmildmoderate/severe muscle spasmnonenone/minor loss of functionmildmoderate/severesevere swellingmildmoderatemoderate/severe pain-contractionnone pain-stretchingyes no ROMdecreased increase or decrease

41 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Dislocation/Subluxation Joint force beyond normal limits MOI: tension S&S –Loss of limb function –Deformity –Swelling –Point tenderness

42 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Dislocation/Subluxation Problem of reoccurrence –Due to overstretching of capsule to the extent that it will not return to normal; unstable joint

43 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis Inflammation of bursa Acute or chronic MOI: compression S&S: swelling, pain, loss of function, eventual degeneration

44 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Osteoarthritis Degeneration of articular cartilage S&S: pain and limited movement No definitive cause; rather, several contributing factors

45 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Soft Tissue Healing Inflammatory phase (0-6 days) –Acute or chronic inflammation possible –Exudate forms –Mechanisms for stopping blood flow Local vasoconstriction Platelet reaction Coagulation cascade

46 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Soft Tissue Healing (cont.) –Vasodilation brings neutrophils and macrophages to clean the area via phagocytosis –Mast cells release Heparin: thins the blood and prolongs clotting Histamine: promotes further vasodilation Bradykinin: opens the blood vessel walls; causes pain

47 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Soft Tissue Healing (cont.) Inflammatory phase (cont.) –Zone of primary injury Hematoma forms –Edema occurs Increased permeability and pressure within the vessels forces a plasma exudate into the interstitial tissue

48 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Soft Tissue Healing (cont.) –Zone of secondary injury Interstitial tissues affected by inflammation, edema, and hypoxia Prostaglandins promote further healing and clearing of debris

49 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Soft Tissue Healing (cont.)

50 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Soft Tissue Healing (cont.) Proliferative phase (3-42 days) –Repair and regeneration of tissue –Processes Angiogenesis Fibroplasia Re-epithelialization Wound contraction

51 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Soft Tissue Healing (cont.) –Hematoma reduces for new healing to take place –Scar formation with soft tissue –Accumulated exudate contains fibroblasts that generate new collagen –Newly formed blood supply and support of matrix will determine overall healing of new tissue

52 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Soft Tissue Healing (cont.) Maturation phase (3 weeks – 1 year) –Associated processes –Remodeling of fibrous matrix to form mature scar tissue Decreased fibroblastic activity Increased organization of new tissue Decreased water content Decreased blood flow Resumption of normal cell activity in the area

53 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Soft Tissue Healing (cont.) –Scar tissue is fibrous, inelastic, and nonvascular Less functional and flexible than original tissues Tensile strength  3-4 weeks – 25% of normal  4-5 months – 30% below preinjury strength

54 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Soft Tissue Healing (cont.) Maturation phase (cont.) –Muscle fibers form adhesions –Tendons and ligaments slower to heal –Potential for atrophy with immobilization –Loss of strength and decreased rates of healing are directly related to length of immobilization –Begin strengthening as soon as it’s safe after injury to ensure hypertrophy of healing tissues and decreased reoccurrence of injury

55 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Soft Tissue Wound Care Open wound –Follow universal precautions and infection control standards –General Apply pressure Cleanse the wound Dress and bandage the wound Use of creams or ointments Re-dress and inspect

56 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Soft Tissue Wound Care (cont.) Closed wound –Goal: reduce inflammation, pain, and secondary hypoxia –Treatment: ice, compression, and elevation

57 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Long Bones – Anatomic Properties Primary constituents: minerals, collagen, water Components –Diaphysis Shaft - hollow, cylindrical Medullary cavity - shock potential improves

58 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Long Bones – Anatomic Properties (cont.) –Epiphysis Ends of long bones Epiphyseal plate - cartilaginous disc found near ends of long bones –Periosteum Sheath covers bone Life support system

59 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Long Bones – Anatomic Properties (cont.) Bone growth –Longitudinal Continues until epiphysis closes –Diameter Can continue to grow through the lifespan

60 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Long Bones – Anatomic Properties (cont.) New bone formed via the periosteum; bone is resorbed around the medullary cavity –Osteoblasts – form new bone –Osteoclasts – resorb bone Bone experiences constant remodeling

61 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Internal Composition: Long Bones – Anatomic Properties (cont.) Cortical –Compact bone tissue of high density (low porosity) –Outside –Can withstand greater stress but less strain Cancellous –Bone tissue of low density (high porosity) –Inside –Can tolerate more strain

62 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Long Bones – Anatomic Properties (cont.) Size will increase in response to increased stress (conditioning) Hollow cylinder - strongest structure in resisting tension and compression Anatomic weakness - site where bone changes shape and direction (especially sudden change)

63 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Mechanical Forces Affecting Bones Tension, compression, shear, bending, torsion Stronger in resisting compression than both tension and shear

64 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures Disruption in the continuity of bone –Closed or open Type of fracture determined by: –Force applied –The health and maturity of bone at the time of injury Classification of Bone Injuries

65 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Fractures

66 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Stress Fracture Stress fracture –Fracture results from repeated loading with lower magnitude forces –Can become worse over time

67 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Osteopenia –Reduced bone mineral density that predisposes individual to fracture –Possible causes: amenorrhea, hormonal factors, dietary insufficiencies

68 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Epiphyseal Injuries Injury to growth plate could result in alteration in normal growth Acute injury –Types I-V Osteochondrosis

69 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Epiphyseal Injuries (cont.) Osteochondrosis –Disruption of blood supply to epiphysis –Idiopathic –Example: Legg-Calvé-Perthes disease Apophysitis –Osteochondrosis of apophysis –Example: Sever’s disease Osgood-Schlatter disease

70 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bony Tissue Healing Acute inflammatory phase –Formation of hematoma –Inflammatory response Proliferative phase –Osteoclasts – resorb damaged tissue; osteoblasts – deposit new bone –Callus formation Maturation phase –Continued activity of osteoclasts and osteoblasts –Remodeling of bone

71 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bony Tissue Healing (cont.)

72 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bony Tissue Healing (cont.)

73 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bony Tissue Healing (cont.)

74 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bone Injury Management Fracture detection –Palpation, percussion, tuning fork, compression, distraction Management – splinting (refer to Application Strategy 6.3)

75 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerve – Anatomic Properties Spinal nerve –Roots Posterior – afferent Anterior – efferent –Heavily vascularized –Myelin sheath

76 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Spinal Nerves

77 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Classification of Nerve Injuries Tensile force injuries –Neurapraxia (grade 1) Localized conduction block: temporary loss of sensation and/or motor Resolves within days to a few weeks –Axonotmesis (grade 2) Significant motor and mild sensory deficits Lasts at least 2 weeks

78 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Classification of Nerve Injuries (cont.) –Neurotmesis (grade 3) Motor and sensory deficit Lasts up to 1 year Compressive injuries

79 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Classification of Nerve Injuries (cont.) Nerve injuries result in a variety of afferent symptoms –Hyperesthesia –Hypoesthesia –Paresthesia Neuralgia –Chronic pain along nerve’s course Healing: if completely severed, healing does not occur

80 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Management of Nerve Injuries Mild – follow acute care protocol Moderate to severe – physician referral

81 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pain Sources –Somatic, visceral, and psychogenic Nociceptors –Mechanosensitive –Chemosensitive Fibers transmitting pain –A fibers –C fibers –T cells Gate control theory of pain

82 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pain (cont.) Factors than mediate pain –Brain production of opioid peptides and endorphins –Cognitive and affective filters Referred pain –Pain perceived at a location remote from the site actually causing the pain Radiating pain –Pain felt both at its source and along a nerve


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