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Chapter 14 Injuries to the Tissues. OA 10.21 Differentiate between a primary injury and secondary injury 2.

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Presentation on theme: "Chapter 14 Injuries to the Tissues. OA 10.21 Differentiate between a primary injury and secondary injury 2."— Presentation transcript:

1 Chapter 14 Injuries to the Tissues

2 OA Differentiate between a primary injury and secondary injury 2

3 Objectives Introduce the terminology associated with injury classification Introduce biomechanical forces that cause injuries Explain biomechanical concepts for various tissues

4 Injury classification Intrinsic –Infection (viral, bacterial) Extrinsic –Tissue stressed to the point of mechanical failure due to excessive force

5 Extrinsic injury classification Primary Injury –Direct immediate consequence of excessive force (trauma) Secondary Injury –Delayed injury some time after initial trauma –An accommodation to the primary injury

6 Extrinsic injury classification Acute Injury –Mechanical failure of soft tissue due to excessive force occurring in a single bout –Sudden onset of short duration

7 Extrinsic injury classification Chronic Injury –Mechanical failure of soft tissue due to repeated micro-trauma occurring over an extended period of time –Gradual onset and are of prolonged duration

8 Injury classification Microtrauma –Occurs with repeated submaximal forces over time, and the tissues are unable to adapt Macrotrauma –Occurs when a single force exceeds the tissue’s failure point

9 Open vs. closed Open –Exposed –Breaks the surface of the skin Closed –Unexposed –Any injury that does not involve disruption of the skin surface

10 Mechanical stresses Load/Stress –External/internal force acting on the tissue –Force = Mass x Acceleration (F=ma) Deformation/Strain –Extent of deformation under loading

11 load/deformation Mechanical force causes deformation Degree of deformation depends on: –Tissue composition –Speed of applied load –Frequency of loading –Direction of loading Deformation Load

12 Yield point Load is greater than mechanical capabilities of the tissue Elastic limit of the tissue has been reached Mechanical failure occurs Deformation Load Yield Point Ultimate Failure Point Elastic Region Plastic Region

13 Tissue stresses Five primary mechanical forces that cause injury –Tension –Compression –Bending –Shear –Torsion

14 Tissue stresses Can occur alone or in combination Type of force = Mechanism of Injury (MOI)

15 tension Creates a pulling action trying to elongate the structure –Longitudinal “tearing” stress –Overstretched tissue (i.e. valgus force)

16 Valgus force

17 compression Creates a pushing action tending to shorten the structure –Stress is applied at each end (i.e. FOOSH)


19 bending Loading about an axis – Combination of tension and compression

20 Shear force Force that acts perpendicular to the surface of a structure

21 Shear force

22 torsion Load applied causing structure to twist about an axis

23 23

24 Combined loading Tissue is seldom loaded in one mode only Subjected to multiple indeterminate loads Geometric structure is irregular

25 forces

26 OA Give an example of each of the 5 mechanical forces that cause injury. 26


28 Integumentary System Skin and structures derived from it –Hair, nails, sweat and oil glands

29 Functions –Regulate body temperature –Protects body –Receives stimuli Temp, pressure, pain –Eliminates waste Sweat

30 Three Layers Epidermis: –Most Superficial

31 Three Layers Dermis: –Tough, Leathery Fibrous Connective Tissue –Partly Vascularized

32 Three Layers Subcutaneous (Hypodermis): –Superficial Fascia –Mostly Fat (Insulate & Absorb Shock) –Anchors Skin to Underlying Structures

33 Three Layers

34 Injurious Mechanical Forces Friction Scraping Compression Tearing Cutting Penetrating

35 Open Vs. Closed Open –Exposed –Breaks the surface of the skin Closed –Unexposed –Any injury that does not involve disruption of the skin surface

36 Abrasions Scraping away of the superficial tissue –Sliding or skidding across a surface Superficial in depth, large in area Bleeding is minimal, risk of infection is great


38 Laceration Irregular cut caused by tearing forces –Jagged wound edges –Can be minor or very deep


40 Puncture Penetration of the skin by an object –Most susceptible to infection– why? –Impaling = object is embedded & partially sticks out


42 Incision A clean, straight, knife-like cut –Commonly caused by a surgeon


44 Avulsion Tearing away of tissue, commonly paired with a laceration. –Flap avulsion – tissue is still connected


46 Calluses Skin thickening due to increased friction or intermittent pressure


48 Blister Excessive friction combined with shear forces causing fluid build-up under the skin

49 General Principles Of Wound Care

50 Chain of infection RESERVOIR HOST Infected individual PORTAL OF EXIT Nose, mouth, eyes, urinary/reproductive system, open wounds ROUTE OF TRANSMISSION Direct or indirect contact PORTAL OF ENTRY Nose, mouth, eyes, urinary/reproductive system, open wounds SUSCEPTIBLE HOST Very young and elderly are most susceptible

51 Universal Precautions Those in direct contact must use protective equipment –Non-latex gloves, gowns, aprons, masks & face shield, eye protection, CPR barriers –Emergency kits should include gloves, CPR barrier, alcohol prep pads at minimum

52 Universal Precautions Doubling gloves is suggested with severe bleeding

53 Universal precautions Use Personal Precautions –Extreme care must be used with glove removal –Glove RemovalGlove Removal

54 Universal precautions Use Personal Precautions –Wash hand & skin surfaces Proper Hand Washing

55 Supplies to have on hand Non-latex gloves Sterile 4”x4” gauze pads/sponges Sterile saline solution Non-adherent pads Antiseptic/antibiotic ointment Non-adherent cohesive tape Optional: soap, water, hand sanitizer, hydrogen peroxide, cinder suds, nitrotan

56 bleeding 3 types of external bleeding –Venous – dark red blood, slowly flowing –Capillary – bright red, seeping/oozing –Arterial – bright red, spurts or streams

57 Controlling bleeding For all types of bleeding direct pressure must be applied to the area –Blood takes 4-6 minutes to clot

58 Controlling bleeding Use a sterile gauze pad/compress to collect the blood –If saturated, add additional gauze as needed Never remove and replace, always add!

59 Controlling bleeding Arterial bleeding is a medical emergency –Direct pressure must be applied until EMS arrives Elevation can help slow blood loss –Body part placed above level of the heart –Exceptions: fractures & spinal injuries

60 Controlling bleeding Indirect pressure can slow blood loss –Pressure points proximal to the injury must be compressed

61 Controlling bleeding An ice pack causes vasoconstriction (narrowing of blood vessels), slowing bleeding

62 Wound cleansing Debridement - removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.

63 Wound cleansing Cleansing and debriding a wound prevents infections and increases healing time.

64 OA List in order the four methods for controlling bleeding. 64

65 Wound cleansing 1.Remove any dirty bandages, clothing, etc. from the wound 2.Apply a solution to irrigate the wound 1.Saline, sterile water, etc. 3.Clean the wound with circular motion starting at the center and working outwards 4.Irrigate the wound once more to remove all dirt & debris 5.Dry the area with sterile gauze 6.Cover the wound with a sterile dressing

66 Wound cleansing Wound Cleansing

67 Applying bandages & dressings Dressing = contact with the wound Bandage = holds dressing in place

68 Applying bandages & dressings Bandages and dressings decrease the risk of infection if properly applied and maintained –Must cover the wound entirely and stay in place –Allow for normal movement and activity –Absorb blood and drainage –Protect the wound from further injury

69 Bandage & dressing types Dressings: –Non-adherent pads –Vasiline gauze –Telfa pads –Adaptic pads –Xeroform gauze

70 Bandage & dressing types Bandages –Sterile gauze –ABD dressings –Rolled gauze –Oval eye pads –Adhesive bandages

71 Applying dressings 1.Select the proper dressing 2.Ensure the wound is cleansed 3.Apply antibiotic ointment to the dressing 4.Place dressing directly over the wound

72 Applying bandages 1.Select appropriate bandage 1.Allows movement 2.Remains sturdy 2.Remove jewelry, clothing, etc. near bandage site 1.Circulation can be impaired with swelling 3.Leave fingers & toes exposed 1.To check circulation

73 Applying bandages 4.Cover the dressing entirely 5.Apply bandage snugly, but not too tightly 1.Apply in the position they will remain in 6.Secure loose ends with tape, or tuck them in


75 Wound care management Patient instructions –Keep wound clean and dry –Change dressings daily –Remove and replace if wet –Watch circulation of the limb; seek medical help if circulation is impaired –Watch for signs of infection

76 Signs of infection Redness Swelling Increased pain Red streak up the arm or leg Foul-smelling odor Elevation in temperature over the wound or surrounding tissue

77 OA List the 6 signs of infection 77

78 Tissue stresses Five primary mechanical forces that cause injury –Tension –Compression –Bending –Shear –Torsion

79 Tissue stresses Can occur alone or in combination Type of force = Mechanism of Injury (MOI)


81 Five Major Functions Of The Skeleton Protection of vital soft tissues Support human posture Movement by serving as points of attachment for muscles Storage for minerals Hemopoiesis – the process of blood formation that occurs in the red bone marrow

82 Mechanical properties of bone Wolff’s Law: bone will adapt to the loads under which it is placed.

83 Mechanical properties of bone Direction of Loading –Strongest in compression –Weak in tension –Weakest in shear Compression > Tension > Shear

84 Mechanical properties of bone Bone size –↑ size of bone (mass) = ↑ bone strength –Greater area to distribute mechanical stresses

85 Mechanical properties of bone Bone shape –Sudden shape changes are areas where mechanical stresses are most concentrated Weak points/Stress risers

86 Bone growth Epiphyseal growth plate –Cartilaginous disk near the end of each long bone –Dependent on plate –Injury can prematurely close the plate causing loss of length

87 Mechanisms of bone injuries Pure tensile forces Compression forces Bending

88 Three-point bending ↑ distance from center = ↑ bending moment Tensile Force Compressive Force



91 Bone injuries Periostitis –Inflammation of the periosteum, usually from contusion Bone contusion –Bruising of the bone tissue –Very painful –Slow to heal – typically 6-8 weeks

92 Live Injuries Proper Field Set-Up Femur ACL Knee Broken Leg

93 OA Describe the properties of bone that make it strongest, weakest, and most prone to injury. 93

94 Bone injuries Fracture –Any disruption in the continuity of the bone or periosteum

95 Bone injuries Description of Fracture –Site –Extent – partial, complete, hairline –Configuration - type –Relationship of fragments – displaced, non-displaced –Relationship to external environment – closed, compound

96 Incomplete Fracture

97 Undisplaced Fracture

98 Displaced Fracture

99 Open (Compound) Fracture

100 Bone trauma classification TypeEtiology TransverseDirect Blow SpiralRotation on planted foot ObliqueOne end fixed, other sudden torsion ComminutedBlow or fall in awkward position DepressedFlat bones, direct blow

101 Bone trauma classification TypeEtiology GreenstickIncomplete Fx, skeletally immature (convex) LongitudinalSplits along length, jumping from height SerratedDirect blow, jagged edges ContrecoupSide opposite to point of impact ImpactedCompressive force on long axis of bone

102 Transverse Fracture

103 Spiral Fracture

104 Oblique Fracture

105 Comminuted Fracture

106 Depression Fracture

107 Greenstick Fracture

108 Longitudinal fracture

109 Serrated fracture

110 Impacted Fracture

111 Other fractures Some fractures have names based on founder, mechanism, common type –Bennett’s fracture –Maisonneuve fracture –Boxer’s fracture –Bankart fracture –Pott’s fracture –Many, many more

112 Bennett’s fracture

113 Maisonneuve fracture

114 Boxer’s fracture

115 Bankart fracture

116 Pott’s fracture

117 Stress Fractures Also called march, fatigue, & spontaneous fractures Weight bearing bones become weaker before they become stronger

118 Stress Fractures Typical causes in sports: –Coming back too soon after injury or illness –Changing events without proper training –Starting initial training too quickly –Changing habits or the environment

119 Stress Fracture

120 Avulsion Fracture


122 Joints (Articulations) All joints are comprised of capsular tissue surrounding the joint itself –Strong, fibrous tissue Synovial joints –Capsular tissue –Articular cartilage at ends of bones –Synovial membrane & fluid –Muscles affecting the joint

123 Synovial Joints Synovial Membrane & Fluid –Membrane made of connective tissue for articular capsule –Fluid is secreted & absorbed in membrane; acts as lubricant

124 Synovial Joints Articular Cartilage –Connective tissue providing support –Hyaline (nasal septum), fibrous (vertebral disks & menisci), & elastic (ear) –Aids in motion control, stability, and load transmission for joints


126 Functional Synovial Joint Characteristics Synovial Joint Stabilization –Provided by skeleton, ligaments, joint capsules and muscles –Reflex contraction of muscles to prevent overstretch

127 Functional Synovial Joint Characteristics Articular Capsule & Ligaments –Elastic fibers as opposed to contractile –Fast protective response time –Ligaments are strongest in center of ligament

128 Synovial Joint Trauma Constant compression or tension can lead to ligament or capsular deterioration Intermittent compression or stress can increase strength

129 Synovial Joint Trauma Tension, torsion, or twisting forces that exceed yield point will lead to injury Articular cartilage failing to properly transmit load may lead to failure

130 Synovial Joint Injury Classification Acute Joint Injuries –Joint Sprains Stretch or tear of stabilizing connective tissue Severity Grading

131 Synovial Joint Injury Classification Acute Joint Injuries –Acute synovitis Injury to synovial membrane of joint Result of contusion or sprain

132 Synovial Joint Injury Classification Acute Joint Injuries –Subluxations & dislocations Disruption of the joint capsule & membrane or joint surfaces

133 Synovial Joint Injury Classification Chronic Joint Injuries –Osteochondrosis Degenerative changes in ossification centers of epiphyses of bones Joint (OCD) or tuberosity (apophysitis)

134 Synovial Joint Injury Classification Chronic Joint Injuries –Osteoarthritis Wearing down of cartilage Most often in weight-bearing joints

135 OA

136 Synovial Joint Injury Classification Chronic Joint Injuries –Bursitis Caused by overuse or external compression/trauma

137 Synovial Joint Injury Classification Chronic Joint Injuries –Capsulitis & synovitis Degenerative tissue changes

138 Bursitis Fluid filled sac in places where friction occurs –Between bony prominences and tendons

139 Tendons and Ligaments Functions –Tendons Execute joint motion by transmitting mechanical forces from muscles to bones –Ligaments Join bones and provide stability to joints Inert Structures –Non-contractile structures (passive tissues) –Unable to actively generate forces

140 Mechanical Properties of Tendon Composed of mostly collagen fibers –High resistance to tensile forces Location –Strongest in mid-point –Weakest at myo-tendinous and osteo- tendinous junctions Due to changes in tissue composition

141 Tendon Injuries Tendinitis – inflammation of the tendon –Chronic injury due to repetitive motion or overuse –Appears as dull, aching pain before/during/after exercise –Occurs with crepitus

142 Tendon Injuries Tenosynovitis – inflammation of the synovial sheath –More severe form of “-itis” injury

143 Tendon Injuries Strain / Rupture – overload of the tendinous junction Contusion

144 Tendon Injury Attaches muscle to bone Usually double the strength of the muscle it serves Acute strain Tendonitis

145 Mechanisms of Tendon Injuries High magnitude, single load, tensile forces –Acute strain or rupture Low magnitude, repetitive load, tensile forces –Tendinitis or tenosynovitis Dynamite vs. Axe

146 Mechanical Properties of Ligaments Greater proportion of elastic collagen fibers than in tendon –Less resistant to tensile forces –Greater deformation occurs prior to mechanical failure

147 Mechanical Properties of Ligaments Frequency of Loading –Repeated loading  Mechanical Weakening  instability Direction of Loading –Resists tensile forces

148 Mechanisms of Ligament Injuries High magnitude, single load, tensile forces –Acute sprain or rupture Low magnitude, repetitive load, tensile forces –Constant tensile forces lead to ligamentous deterioration –Chronic instability

149 Mechanisms of Ligament Injuries

150 Grades of Ligamentous Injury DegreeEtiologyEnd FeelInstability First Mild overstretching, no tissue disruption FirmNone Second Partial disruption or macrotearing of the ligament Definite (soft)Slight to Moderate Third Complete disruptionNoneSevere

151 Skeletal Muscle Composed of contractile cells Function –Generates force to drive motion –Dynamic stability of joints

152 Skeletal Muscle Tensile Forces –Produces active and passive tensile forces –Active tension  contraction –Passive tension  stretched past resting length

153 Skeletal Muscle Injuries Strains Contusions Muscle lacerations Myositis Atrophy Contracture DOMS Spasm

154 Muscle Injury Acute –Contusions Sudden traumatic blow with compressive force Superficial or deep tissue affected Rated by the ability of muscle to produce ROM

155 Muscle Injury Acute –Strains Stretch or tear in muscle Abnormal muscle contraction –Mineral imbalance or dehydration –Fatigue –Strength imbalance

156 Muscle Injury Acute –Muscle spams (cramps) Clonic - intermittent Tonic – constant Contracture May lead to strains DOMS

157 Muscle Injury Chronic –Myositis Inflammation of muscle –Fasciitis Inflammation of fascia within the muscle –Myositis ossificans Repeat trauma Calcium deposits within the muscle Can resorb in 9-12 months

158 Mechanisms of Muscle Injuries High magnitude, single load, tensile forces –Acute strains or ruptures Low magnitude, repetitive load, tensile forces –Degenerative effect Dynamite vs. Axe

159 Grades of Muscle Injuries DegreeEtiologySigns/Symptoms First Overstretching or microtearing of muscle or tendon Mild loss of strength, swelling, ecchymosis, point tenderness Second Further stretching and partial tearing of muscle or tendon fibers Symptoms are more severe, greater function loss Third Complete rupture Severe symptoms, loss of muscle function, possible palpable defect

160 Nerve Injuries Compression or tensioning of neural structure –Secondary to direct blow –Acute swelling in enclosed space –Pathology which compromises space for nerve

161 Nerve Injuries Anesthesia – absent sensation Paresthesia – diminished sensation Hyperesthesia – over-sensation

162 Neuropraxia “Burners” or “stingers” Transient and reversible loss in nerve function Secondary to trauma or irritation Mechanical deformation of the nerve Disruption of nerve fibers & signals Short-lived sensory and motor deficits (seconds-two weeks)

163 A shortstop is hit in the shin by a batted ball that took a bad hop What kind of force is involved? What type of injury is likely to have occurred?

164 A football player sustains repeated blows to his left quadriceps muscle What type of injury could be sustained from repeated compressive forces to the muscle?

165 A basketball player steps on another player’s foot and sustains a lateral ankle injury What forces are applied? What type of injury has occurred?

166 An alpine skier catches his right ski tip and severely twists the lower leg What type of serious injury could be created by this mechanism?

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