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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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