Kin 188 Tissue Healing


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Kin 188 Tissue Healing

  1. 1. KIN 188 Prevention and Care of Athletic Injuries Tissue Healing
  2. 2. Tissue Healing <ul><li>Soft tissue healing </li></ul><ul><li>Bone/fracture healing </li></ul><ul><li>Nerve healing </li></ul>
  3. 3. Phases of Soft Tissue Healing <ul><li>Phase I – Inflammatory Response </li></ul><ul><li>Phase II – Repair/Regeneration </li></ul><ul><li>Phase III – Remodeling/Maturation </li></ul>
  4. 4. Phase I – Inflammatory Response <ul><li>Onset </li></ul><ul><ul><li>Immediate and typically progresses x 3-5 days </li></ul></ul><ul><li>Signs and symptoms </li></ul><ul><ul><li>Redness (rubor) </li></ul></ul><ul><ul><li>Pain/point tenderness (dolor) </li></ul></ul><ul><ul><li>Warmth (calor) </li></ul></ul><ul><ul><li>Swelling (tumor) </li></ul></ul><ul><ul><li>Limited ROM (functio laesa) </li></ul></ul>
  5. 5. Phase I – Inflammatory Response <ul><li>Tissue damage – initiates inflammation </li></ul><ul><li>Vasocontriction </li></ul><ul><ul><li>Initial attempt to limit bleeding at site </li></ul></ul><ul><li>Platelet reaction </li></ul><ul><ul><li>Provokes clotting at site to “plug” ruptured vascular structures </li></ul></ul><ul><li>Coagulation </li></ul><ul><ul><li>Clot/hematoma is formed </li></ul></ul>
  6. 6. Phase I – Inflammatory Response <ul><li>White blood cell infiltration </li></ul><ul><ul><li>Neutrophils and macrophages attracted to area via chemical processes to rid waste, debris and infectious agents (phagocytosis) </li></ul></ul><ul><li>Vasodilation </li></ul><ul><ul><li>Additional blood flow to area via chemical processes </li></ul></ul><ul><ul><li>Increases cell permeability causing swelling/edema from tissue exudate – allows for further arrival of “good stuff” and removal of “bad stuff” </li></ul></ul>
  7. 7. Inflammatory Response
  8. 8. Phase II – Repair/Regeneration <ul><li>Onset </li></ul><ul><ul><li>48 hours – 8 weeks </li></ul></ul><ul><ul><li>Somewhat dependent upon tissue type – quicker proliferation with greater blood supply </li></ul></ul><ul><li>Signs and symptoms </li></ul><ul><ul><li>Decreased sx of inflammation </li></ul></ul>
  9. 9. Phase II – Repair/Regeneration <ul><li>Proliferative phase </li></ul><ul><ul><li>New blood supply allows for waste removal and arrival of fibroblasts </li></ul></ul><ul><li>Fibroplasia </li></ul><ul><ul><li>Process of generating collagen tissue via fibroblast activity </li></ul></ul><ul><li>Progression of phase – changes in cellular activity </li></ul><ul><ul><li>Proliferation of new blood supply and fibroblast activity reinforce new connective tissue matrix - each fuels the other </li></ul></ul>
  10. 10. Phase III – Remodeling/Maturation <ul><li>Onset </li></ul><ul><ul><li>6-8 weeks </li></ul></ul><ul><ul><li>May last months/years - unknown </li></ul></ul><ul><li>Signs and symptoms </li></ul><ul><ul><li>Minimal sx </li></ul></ul><ul><ul><li>Resolution of sx of inflammation unless complications have arisen </li></ul></ul>
  11. 11. Properties of Scar Tissue <ul><li>Structurally weak </li></ul><ul><li>Decreased elasticity </li></ul><ul><li>Contractures/adhesions </li></ul><ul><li>Sensory impairment </li></ul>
  12. 12. Factors Affecting Rate of Healing <ul><li>Blood supply </li></ul><ul><li>Degree of immobilization </li></ul><ul><li>Foreign substances </li></ul><ul><li>Vitamin/mineral deficiency </li></ul><ul><li>Steroid use </li></ul>
  13. 13. Phases of Fracture Healing <ul><li>Phase I – Inflammation and Hematoma Formation </li></ul><ul><li>Phase II – Cellular Proliferation </li></ul><ul><li>Phase III – Callous Formation </li></ul><ul><li>Phase IV – Bony Union/Ossification </li></ul><ul><li>Phase V – Remodeling </li></ul>
  14. 14. Phase I – Inflammation and Hematoma Formation <ul><li>Bleeding from periosteum, endosteum, bone marrow and surrounding soft tissue </li></ul><ul><li>Typically lasts approximately 4 days </li></ul>
  15. 15. Phase I – Inflammation and Hematoma Formation <ul><li>Hematoma accumulates in area to form matrix for healing – blood clotting initially occludes normal blood flow and local cells die </li></ul><ul><li>Secondary to cellular death, inflammatory response occurs similar to soft tissue injuries </li></ul><ul><ul><li>Vasodilation, inflammatory cell arrival, swelling </li></ul></ul>
  16. 16. Phase II – Cellular Proliferation <ul><li>Vascular proliferation </li></ul><ul><ul><li>Capillary buds in callous and surrounding soft tissue </li></ul></ul><ul><ul><li>Bring endosteal cells to area </li></ul></ul><ul><li>Osteogenic (endosteal) cells proliferate into </li></ul><ul><ul><li>Osteoblasts - formation of callous (bone) </li></ul></ul><ul><ul><ul><li>Osteoblasts more numerous in highly vascular areas </li></ul></ul></ul><ul><ul><li>Chondroblasts - formation of callous (cartilage) </li></ul></ul><ul><ul><li>Osteoclasts - reabsorption of bone </li></ul></ul>
  17. 17. Phase II – Cellular Proliferation <ul><li>Fibrous junction between ends of bones at fracture site is built </li></ul><ul><ul><li>First it’s callous then progresses to cartilage and finally bone </li></ul></ul>
  18. 18. Phase III – Callous Formation <ul><li>External callous from periosteal cells </li></ul><ul><li>Internal callous from endosteal cells </li></ul><ul><li>Soft callous forms externally and internally to bridge the fracture site (internal callous grows faster to create natural immobilization) </li></ul>
  19. 19. Phase III – Callous Formation <ul><li>Hard callous starts forming at 3-4 weeks and continues for 3-4 months </li></ul><ul><li>Unsatisfactory immobilization leads to cartilagenous union vs. bony union due to incomplete formation of hard callous </li></ul>
  20. 20. Phase IV – Bony Union/Ossification <ul><li>Callous replaced by bone </li></ul><ul><ul><li>Internal </li></ul></ul><ul><ul><li>External </li></ul></ul><ul><ul><li>Influx of new Haversian system/blood supply </li></ul></ul><ul><li>Callous “comes together” in bony union </li></ul><ul><ul><li>Fracture site is bridged by bone </li></ul></ul>
  21. 21. Phase V - Remodeling <ul><li>Callous reabsorbed by osteoclasts and bone assumes normal formation/appearance </li></ul><ul><li>Complete remodeling may take years </li></ul><ul><li>Remodeling complete when fractured bone is restored to normal shape or has developed a shape that can withstand imposed stresses </li></ul>
  22. 22. Fracture Healing
  23. 23. Factors Affecting Bone Healing <ul><li>Infection </li></ul><ul><ul><li>Especially with open fractures but also may arise with systemic infections of closed fractures </li></ul></ul><ul><li>Metabolic disorders/diseases </li></ul><ul><ul><li>Vitamin and mineral deficiencies </li></ul></ul><ul><li>Steroid use </li></ul><ul><ul><li>Interferes with collagen synthesis </li></ul></ul>
  24. 24. Factors Affecting Bone Healing <ul><li>Unbridgeable gaps </li></ul><ul><ul><li>Loss of bone tissue, interposition of soft tissue </li></ul></ul><ul><li>Vascular destruction/poor vascular supply </li></ul><ul><ul><li>Avascular necrosis (carpal navicular/schaphoid, head of femur) </li></ul></ul><ul><li>Inadequate reduction/poor immobilization </li></ul><ul><ul><li>Not only may impact healing but may contribute to development of permanent deformity </li></ul></ul>
  25. 25. Nerve Healing <ul><li>When nerve severed, healing does not occur and loss of function typically permanent </li></ul><ul><li>If nerve fibers ruptured but surrounding myelin sheath intact, it’s possible for regeneration to occur </li></ul><ul><ul><li>Very slow process (<1mm/day, ~2.5cm/month) </li></ul></ul>