4. Musculoskeletal Injuries
• Contusion
▫ Damage to soft tissue , sub-q structures, and muscle
• Strains
▫ Tear to the musculotendinous unit
• Sprains
▫ Trauma to joint, ligament may be completely torn
or stretched
• Dislocation
▫ Displacement of the normal position
5. Fractures
• A bone fracture is a medical condition in which
there is a break in the continuity of the bone
• While many fractures are the result of high
force impact or stress, bone fracture can also occur
as a result of certain medical conditions that weaken
the bones, such as osteoporosis, certain types
of cancer, or osteogenesis imperfecta, where the
fracture is then termed pathological fracture
6. • The proper healing of a fracture depends on whether
or not, the blood supply and cellular components of
the periosteum and endosteum survive.
9. Symptoms
• A visibly out-of-place or misshapen limb or joint
• Swelling, bruising, or bleeding
• Intense pain
• Numbness and tingling
• Broken skin with bone protruding
• Limited mobility or inability to move a limb
10. Fracture Types
FRX or FX
• Fractures are often classified according to the position of the bone ends after the
break:
Open (compound): Bone ends penetrate the skin.
Closed (simple): Bone ends don’t penetrate the skin.
Comminuted: Bone fragments into 3 or more pieces. Common in the elderly
(brittle bones).
Greenstick: Bone breaks incompletely. One side bent, one side broken.
Common in children whose bone contains more collagen
and are less mineralized.
Spiral: Ragged break caused by excessive twisting forces. Sports injury/Injury
of abuse.
Impacted: One bone fragment is driven into the medullary space or spongy
bone of another bone
14. avulsion fracture separation of a small fragment of
bone cortex at the site of attachment of a ligament or
tendon.
15. • Closed fractures are those in which the skin is intact,
while Open fractures involve wounds that
communicate with the fracture and may expose bone
contamination (need antibiotics).
• They require urgent surgical treatment.
• This involves removal of all dirt, contamination and
dead tissue.
16. Open (compound) fractures
• High risk of infection
• Can be associated with gross soft tissue damage, severe
haemorrhage or vascular injury
17. Fracture Healing
• The natural process of healing a fracture starts when
the injured bone and surrounding tissues bleed.
• The blood coagulates to form a blood clot situated
between the broken fragments.
• Within a few days blood vessels grow into the jelly-
like matrix of the blood clot.
• The new blood vessels bring white blood cells to the
area, which gradually remove the non-viable
material.
18. Fracture Healing
• The blood vessels also bring fibroblasts in the walls
of the vessels and these multiply and produce
collagen fibres.
• In this way the blood clot is replaced by a matrix of
collagen.
• Collagen's rubbery consistency allows bone
fragments to move only a small amount unless severe
or persistent force is applied.
19. Fracture Healing
• At this stage, some of the fibroblasts begin to lay
down bone matrix (calcium) in the form of insoluble
crystals.
• This mineralization of the collagen matrix stiffens it
and transforms it into bone.
• Healing bone callus is on average sufficiently
mineralized to show up on X-ray within 6 weeks in
adults and less in children.
20. Fracture Healing
• This initial "woven" bone does not have the strong
mechanical properties of mature bone.
• By a process of remodeling, the woven bone is
replaced by mature "lamellar" bone.
• The whole process can take up to 18 months, but in
adults the strength of the healing bone is usually 80%
of normal by 3 months after the injury.
21. Healing times
• Neonatal period
▫ 2-4 weeks
• Early childhood
▫ 4 weeks
• Later childhood
▫ 6-8 weeks
• Adolescence
▫ 8-12 weeks
22. Healing in Bone:
1D - Hematoma formation (fibrin mesh)
3D - Inflammation – PDGF, IL, TGF
1W - Soft callus – granulation, matrix.
3-6W - Callus – ossification, woven bone
8+W - Re-modeling – absorb/deposit,
strength, lamellate.
23. Stages of wound healing
Time after injury
Hemostasis
Inflammation
Proliferation
Resolution/ Remodeling
PMNs, Macrophages, Lymphocytes
Reepithelialization, Angiogenesis, Fibrogenesis,
Vessel regression, Collagen remodeling
Fibrin clot, platelet
deposition
1D 3D 1wk 6wk 8wk
41. Complications:
• Delayed healing.
• Non healing.
• Joint involvement – ankylosis (stiffness of a joint due to
abnormal adhesion and rigidity of the bones of the joint)
• Abnormal position – arthritis.
• Bone necrosis – nutrient artery
42. • Involucrum formation. (a layer of new bone growth
outside existing bone usually in OM )
• Fat embolism
• DVT/PE
• Bed sores
• Depression/PTSD
• Tetanus
• Infections
43. • Malunion
▫ Healing of fragments of a fracture in a faulty position.
• Delayed union
▫ Any fracture that takes longer to heal than the average fracture
at that anatomic location.
• Non-union
▫ The fracture healing process has completely stopped and the
fragments will remain un-united even with prolonged
immobilization.
44. Treatment of fracture
• 1) Reduce
• 2) Maintain reduction (+ hold until union)
• 3) Rehabilitate – restore function
• 4) Prevent or treat complications
45. Reduction
• Does the fracture
require reduction?
▫ Is it displaced?
▫ Does it need to be
reduced?
46. Reduction
• If necessary, what reduction technique?
• 1) Closed reduction
▫ Need anaesthesia/sedation, analgesia, x-ray facilities, equipment,
knowledge
▫ Used for minimally displaced fractures and most fractures of
children
1) Distal part of limb pulled in line of bone
2) As fragments disengage, they are repositioned (reverse original
direction of deforming force)
Alignment adjusted in each plane
• 2) Open reduction
▫ Above + theatre staff + additional equipment
▫ Risks
47. Maintain reduction
• Necessary?
1) Relieve pain
2) Prevent mal-union – nature heals the fracture, we
keep it in a good position
3) Minimise non-union – maintenance of reduction
should be continuous
48. Nutritional Effects on Bone
• Normal bone growth/maintenance cannot occur
without sufficient dietary intake of calcium and
phosphate salts.
• Calcium and phosphate are not absorbed in the
intestine unless the hormone calcitriol is present.
Calcitriol synthesis is dependent on the availability of
the (Vitamin D) which synthesized in the skin or
obtained from the diet.
• Vitamins C, A, K, and B12 are all necessary for bone
growth as well.
50. Hormonal Effects on Bone
• Growth hormone, produced by the pituitary gland,
and thyroxine, produced by the thyroid gland,
stimulate bone growth.
▫ GH stimulates protein synthesis and cell growth
throughout the body.
▫ Thyroxine stimulates cell metabolism and increases the
rate of osteoblast activity.
51. • Clinical Conditions
• Osteomalacia
▫ Literally “soft bones.”
▫ Includes many disorders in which osteoid is produced but inadequately
mineralized.
Causes can include insufficient dietary calcium
Insufficient vitamin D fortification or insufficient exposure to sun light.
• Rickets
▫ Children's form of osteomalacia
▫ More detrimental due to the fact that their bones are still growing.
▫ Signs include bowed legs, and deformities of the pelvis, ribs, and skull.
53. Osteoporosis
▫ Group of diseases in which bone resorption occurs at a faster
rate than bone deposition.
▫ Bone mass drops and bones become increasingly porous.
▫ Compression fractures of the vertebrae and fractures of the
femur are common.
▫ Often seen in postmenopausal women because they experience
a rapid decline in estrogen secretion; estrogen stimulates
osteoblast and inhibits osteoclast activity.
57. Acromegaly
• Acromegaly
▫ Adult-hood hyper-secretion of GH causes overgrowth
of bony areas still responsive to GH such as the bones
of the face, feet, and hands.
• Pituitary dwarfism
▫ GH deficiency in children resulting in extremely short
long bones and maximum stature of 4 feet.
58. • When you were born, you had more than 300 bones.
By the time you stop growing, you’ll have 206.
59. Definitions
• 1. osteohypertrophy: overgrowth of bone.
• 2. osteosarcoma: tumor of the bone.
• 3. osteosclerosis: abnormal hardening or
eburnation of bone.
• 4. osteoporosis: progressive reduction in
quantity of bone.
• 5. osteopenia: decreased calcification or density of
bone.
