Traumatic and mechanical disorders of musculoskeletal system
•Download as PPTX, PDF•
2 likes•2,065 views
for preclinic medical student
More Related Content
Viewers also liked
Viewers also liked (8)
Similar to Traumatic and mechanical disorders of musculoskeletal system
Similar to Traumatic and mechanical disorders of musculoskeletal system (7)
Traumatic and mechanical disorders of musculoskeletal system
- 1. Traumatic and mechanical disorders of musculoskeletal system อ.นพ.สุวิทยา เธียรประธาน สานักวิชาแพทยศาสตร์
- 2. Objectives • ระบุกายวิภาควิทยาของเอ็นกระดูก เอ็นกล้ามเนื้อ กระดูก และข้อกระดูกใน ส่วนต่างๆของร่างกายได้ถูกต้อง • อธิบายกลไกพยาธิสรีรวิทยาที่ทาให้เกิดแต่ละอาการบอกเล่า(chief complaint) และอาการแสดง(physical examination) ได้ อย่างถูกต้อง • อธิบายอาการแสดงของกลุ่มการบาดเจ็บของเอ็นกระดูก เอ็นกล้ามเนื้อ กระดูก และข้อกระดูกที่พบบ่อยในเวชปฏิบัติได้อย่างถูกต้อง • ให้การวินิจฉัยการบาดเจ็บของเอ็นกระดูก เอ็นกล้ามเนื้อ กระดูก และข้อ กระดูกได้อย่างถูกต้อง • อธิบายผลกระทบของการบาดเจ็บของเอ็นกระดูก เอ็นกล้ามเนื้อ กระดูก และ ข้อกระดูกต่อจิตใจและสังคม • ให้การวินิจฉัย compartment syndrome ได้อย่างถูกต้อง
- 4. Ligament sprains • เอ็นกระดูก คือโครงสร้างเนื้อเยื่อหนาแน่นที่แข็งแรง เป็นส่วนประกอบ ของข้อกระดูก เป็นส่วนเชื่อมกระดูกแต่ละชิ้นเข้าด้วยกัน • มีความยืดหยุ่นได้บางส่วนแต่แข็งแรงกว่าเอ็นกล้ามเนื้อ • ประกอบไปด้วย extracellular matrix, Proteoglycan, collagen, Fibroblast ฯลฯ
- 7. Ligamentous injuries of the knee
- 11. Intra-articular structures • ACL • PCL • Medial meniscus • Lateral meniscus
- 12. Extra-articular structures • MCL • LCL • Posterolateral corner complex : Biceps femoris tendon, Arcuate ligament, Fabellofibular ligament, Popliteus tendon, Popliteofibular ligament, Posterior oblique collateral ligament, Plantaris longus muscle, Lateral gastrocnemius muscle(tendon part) etc.
- 14. Common injuries • ACL injury • PCL injury • MCL injury • LCL injury • Meniscus injury
- 17. Cause of injury • Sport injury • Motor vehicle injury
- 18. Natural history • Ligament injury : Knee instability • Meniscus injury : pain, range of motion • Cartilage injury • Osteoarthritis
- 19. Physical examination • Swelling • Point of tenderness • Limitation of range of motion • Special tests ***
- 20. Special tests Stability test • Anterior drawer test • Posterior drawer test • Varus stress test • Valgus stress test • Prone external rotation test • Lachman test • Lateral pivot shift test
- 26. Lachman test
- 27. Special tests (cont.) Meniscus test • McMurray test • Apley grind test • Squat test
- 28. McMurray test
- 29. Apley grind test
- 30. Investigation or Imaging • Plain film X-ray • MRI (Magnetic Resonance Imaging)
- 31. Treatment • Depend on which ligament was injuried • Non-operative treatment • Operative treatment : Repair, Reconstruction
- 32. Ligamentous injuries of the ankle
- 35. Key structures • ATFL : Anterior Tibiofibular ligament • Deltoid ligament • Syndesmotic ligament
- 38. Physical examinations • Swelling • Point of tenderness • Inability to bear weight • Special test ***
- 40. Talar Tilt Test
- 41. Squeeze test External rotation test
- 42. Investigation or Imaging • Plain film radiograph : AP ,lateral, mortise view • For exclude bone fracture • Able to exclude ligament sprain grade by measuring parameter
- 43. Radiographs
- 47. Treatment • Ankle sprain grade 1 + 2 : Immobilize in slab or cast • Ankle sprain grade 3 : Surgery Repair
- 48. Ligament healing 1. Inflammatory phase 2. Reparative phase 3. Remodeling phase
- 52. Strain • ตัวคาศัพท์เดิมหมายถึง ความตึง ความเค้น • ตามหลักกลศาสตร์ คานี้ หมายถึง ความยาวที่เปลี่ยนแปลงไปเมื่อถูก กระทาด้วยแรงค่าๆหนึ่งต่อหนึ่งหน่วยพื้นที่ • แต่ในทางการแพทย์น่าจะหมายถึงกลุ่มอาการที่กล้ามเนื้อหรือเอ็น กล้ามเนื้ออักเสบจากการถูกแรงรูปแบบใดๆมากระทา • Muscle and Tendon
- 53. Anatomy
- 54. Tendon • เอ็นกล้ามเนื้อ คือ อวัยวะส่วนทเี่ชื่อมต่อกล้ามเนื้อกับปุ่มกระดูก มีหน้าที่ ช่วยรวบรวมแรงกระทาจากกล้ามเนื้อ ทาให้การทางานของกล้ามเนื้อมี ประสิทธิภาพมากขึ้น • มีความแข็งแรงอยู่ระหว่างกระดูกและกล้ามเนื้อ • มีส่วนประกอบของ Extracellular matrix, Collagen, Proteoglycan, Tenocyte, Tenoblast
- 56. Causes • Improper use • Heavy lifting • Over-stretched • Occurs in Lower back, Neck, shoulder, Thigh
- 58. Treatment • Rest • Immobilization • NSAIDs : Non Steroidal Anti Inflammatory Drugs • Physiotherapy : Short wave, U/S
- 60. Fractures
- 61. BONE AND JOINT INJURIES • Fracture = Disruptions of bone tissue • Osteochondral or intraarticular fractures = Visible disruptions of articular cartilage or fractures involved both the articular cartilage and subchondral bone • Chondral fractures = involved only the cartilage
- 62. Gross anatomy • Spine • Upper extremity • Lower extremity • Pelvis
- 63. Bone Tissue • Its tensile strength nearly equals that of cast iron • 3 times lighter • 10 times more flexible • Consists of mesenchymal cells embeded within abundant extracellular matrix • Constantly changing in response to mechanical and hormonal signals
- 65. Bone Tissue The matrix contains : 1. Mineral great strength and stiffness in compression and bending 2. Collagen type 1 strength and plasticity 3. Cytokine , Growth factors
- 66. Periosteum • Outer layer more fibrous layer • Inner layer more cellular and vascular cambium layer • Participates in healing of many types of fractures • In children , Thicker periosteum than Adults
- 67. Types of Bone Woven bone (immature bone) • Embryonic skeleton • More rapid rate of deposition and resorption • Initial fracture repair • Irregular pattern of matrix fibrils • relatively high cell content and water concentration • 4 times the number of osteocytes per unit volume • Less stiffness • More easily deformed Lamellar bone (mature bone) • Replaces woven bone during growth and development • Replaces woven bone in remodeling phase under mechanical load • More stiffness • Difficultly deformed
- 69. Bone formation 1. Cutting cone 2. Intramembranous formation 3. Endochondral bone formation
- 70. Cutting cone • Primarily a mechanism to remodel bone • Osteoclasts at the front • Trailing osteoblasts lay down new bone
- 71. Intramembranous formation • Long bone grows in width • Osteoblasts differentiate directly from preosteoblasts and lay down seams of osteoid • Do not involve cartilage anlage
- 72. Endochondral bone formation • Long bone grows in length • The chondrocytes hypertrophy, degenerate and calcify • Vascular invasion of cartilage occurs followed by ossification
- 73. Stages of Fracture healing • Inflammation • Repair • Remodeling
- 74. Inflammatory phase • Require high energy until remodeling • Inflammatory mediators released from platelets, dead cells • Vasodilatation and exudate plasma edema in the region • Macrophages and Lymphocyte migration • The inflammatory response subsides, necrotic tissue and exudate are resorbed
- 76. Repair phase • Fibroblasts and chondrocytes start producing a new matrix, the fracture callus • Follows inflammatory phase rapidly • Unstable Vs Stable fracture ???
- 78. Repair and Remodeling of Unstable Fractures (Secondary bone healing • Organization of hematoma first step in fracture repair • Initiate fracture healing • The intact fracture hematoma provides a fibrin scaffold that facilitates migration of repair cells
- 79. • Platelets and cells in hematoma release GFs and other proteins cell migration, proliferation, matrix synthesis • Blood supply, medullary system and periosteum are important for fracture healing • The mesenchymal cells proliferate, differentiate, and produce the fracture callus consisting of fibrous tissue, cartilage, and woven bone
- 80. Osteoclast • Derived from circulating monocytes in the blood and monocytic precursor cells from the bone marrow • Do not appear to form repair tissue
- 81. Osteoblast • Develop from the undifferentiated mesenchymal cells that migrate into the fracture site • Participate in bone formation
- 82. • Hard (bony) callus “The bone formed initially at the periphery of the callus by intramembranous bone formation” • Soft (fibrous and cartilaginous) callus “forms in the central regions with low oxygen tension and consists primarily of cartilage and fibrous tissue” • Endochondral ossification enlarging the hard callus and increasing the stability of the fracture fragments
- 83. Callus
- 87. • At these stages, the healing is not complete • The immature fracture callus is weaker than normal bone • Gaining full strength during remodeling phase • During final stage of Repair, Remodeling of the repair tissue begins with replacement of woven bone by lamellar bone and resorption of unneeded callus
- 88. • By radioisotope studies, the remodeling process continues for year after clinical and radiographic union • Decrease bone density and remains changes for years
- 90. Repair and Remodeling of Stabilized Fractures (Primary Bone Healing) The fracture surfaces are rigidly held in contact Fracture healing can occur without grossly visible callus in either cancellous or cortical bone Called “ Primary bone healing” Small bone gaps Vs bone contact??
- 91. • Lamellar bone can form directly across the fracture line by extension of osteons • A cluster of osteoclasts cuts across the fracture line, osteoblasts following the osteoclasts deposit new bone, and blood vessels follow the osteoblasts • The new bone matrix, enclosed osteocytes, and blood vessels form new haversian systems.
- 102. Joint tissue (synovial joint) • Congruent articulating cartilaginous surfaces • Subchondral bone • Metaphyseal bone • Joint capsule • Ligaments • Synovial membrane • **fibrous tissue meniscus** (labrum)
- 104. Articular cartilage • Sparsely distributed chondrocytes • Surrounded by an elaborate, highly organized macromolecular framework filled with water • Collagens, Proteoglycans and Non-collagenous proteins form the macromolecular framework
- 107. Physical examination • Pain • Swelling • Tenderness • Limitation of Range of motion • Neurological status • Vascular status
- 108. Imaging • Plain film X-ray • Computerized Tomography
- 111. Treatment • Non-operative • Operative Decision making depend on • Site of injury, • Severity of injury • Fracture configuration • Surrounding structures injury • Other organ system injury • Patient’s underlying disease
- 112. Non-operative treatments • Splint • Slab • Casting • Bracing • Traction
- 116. Operative treatments Internal fixation • Dynamic compression plate and screw • Locking plate and screw • Intramedullary nailing system • Wiring External fixation • External fixator • Ilizarov system
- 120. Principles of treatment • Displacement • Intra-articular involvement • Soft tissue injury • Nerve and Vascular injury • Diaphysis of Lower extremity : Nailing
- 121. Bone Healing • Dynamic compression plate : Primary • Locking plate : Secondary • Nailing : Secondary • Wiring : Primary • External fixator : Secondary • Ilizarov : Distraction osteogenesis
- 122. “Clinical union” • Stability of the fracture fragments progressively increases because of the internal and external callus formation • The fracture site becomes stable and pain-free
- 123. “Radiographic union” • Plain radiographs show bone trabeculae or cortical bone crossing the fracture site • Often occurs later than clinical union
- 125. Failure of Fracture Healing
- 126. Delay union • Fracture line remains clearly visible radiographically • There is no undue separation of the fragments, no cavitation of the surfaces, no calcification, and no sclerosis • Related to the severity of the injury, poor blood supply, the age and nutritional status of the patient, or other factors
- 127. Nonunion • An arrest of the healing process • With a large volume of callus called “Hypertrophic nonunion” • With some callus but less than normal “Oligotrophic nonunion” • Without callus or less called “Atrophic nonunion” • With cartilagenous tissue and clear fluid filled in cavity called “Pseudarthrosis” • “A Fibrous Union”
- 130. Atrophic Nonunion
- 133. Dislocation • Joint dislocation • Low velocity Shoulder, Elbow, wrist, finger • High velocity Hip, Knee, Ankle
- 134. Common direction • Shoulder : anterior • Elbow : posterior • Wrist : Lunate volar dislocation • Finger : Posterior • Hip : posterior • Knee : all direction • Ankle : all direction
- 142. Physical examination • Mark swelling • Mark deformity • Limitation of motion • Neurological status • Vascular status
- 143. Imaging • Plain film X-ray
- 144. Treatment • Emergency closed reduction • Under sedation • Under General anesthesia • Open reduction
- 146. Acute compartment syndrome • ให้หาอ่านและศึกษาเองเนื่องจากมีอยู่ในโจทย์ POL • แนะนาให้อ่าน paper ที่จะให้ใน FB