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Ch. 2

Ch. 2 . Tissue Healing. Introduction. Tissue healing occurs and is influenced by several factors There are three phases: Inflammatory response Repair/regeneration remodeling. Inflammatory Response. Cells remove debris Cells create groundwork for repair and regeneration phase.

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Ch. 2

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  1. Ch. 2 Tissue Healing

  2. Introduction • Tissue healing occurs and is influenced by several factors • There are three phases: • Inflammatory response • Repair/regeneration • remodeling

  3. Inflammatory Response • Cells remove debris • Cells create groundwork for repair and regeneration phase

  4. Repair/Regeneration Phase • Cells restore the vascular and structural integrity of injured structures

  5. Remodeling Phase • Healed tissue adapts to functional loading • Gets stronger based on the stress that is applied to it • The three phases overlap one another • Disruption of any one phase can cause an unsatisfactory outcome

  6. Types of Tissue • Epithelial tissue • Connective • Muscle • nervous

  7. Epithelial Tissue • Composed of layers of cells • Protect organs • Secretions (glands) • Absorption ( lining of the stomach )

  8. Connective Tissue • Most abundant and variable tissue in the body • Attaching organs • Support/structure • Movement • Physical protection • Immune response, energy & mineral storage • Heat generation and transportation (blood, etc.)

  9. Connective Tissue • Subtypes: • Fluid connective tissue=blood and lymph • Fibroconnective tissue=fat, tendons and ligaments • Supportive connective tissue=cartilage and bone

  10. Nervous Tissue • Located in brain and spinal cord and nerves • Electrically exciteable • Used to transmit and respond to various impulses and forms of information

  11. Muscle Tissue • Skeletal- striated or voluntary • Cardiac – heart muscle • Smooth- linings of organs and blood vessels

  12. Common Injuries

  13. Puncture and Laceration

  14. Incision

  15. Acute vs. Chronic • Acute – single forcefull event (ACL tear) • Chronic – occur over a period of time (Tennis elbow)

  16. Acute Injuries • Contusions – bruises • Strains – muscle or tendon injuries • Sprains – ligamentous injuries

  17. Contusions • Caused by compressive forces • or direct impacts and are graded by degrees of trauma • 1st degree-minimal swelling, no limits • 2nd – pain, bleeding, moderate functional limits • 3rd-hematoma formation,sever limitations

  18. Sprains and Strains

  19. Fracture Classifications • Greenstick • Transverse • Oblique • Spiral • Comminuted • Avulsion • Impacted • Depressed • Epiphyseal (Salter-Harris classification)

  20. Peripheral Nerve Injuries • Neuropraxia-least severe, transient and reversible loss of nerve function • Axontomesis- partial disruption, may cause atrophy or weakness for 2 – 52 weeks • Neurotomesis – complete severance of a nerve resulting in permanent loss of function

  21. Chronic Injuries • Blisters – continuous friction • Repetitive overload – tendinosis, tenosynovitis • Chronic irritation –could cause neuralgia or neuroma

  22. Soft Tissue Healing • Phase 1: Inflammatory Response • Phase 2: Repair/Regeneration • Phase 3: Remodeling/Maturation

  23. Phase 1 • Signs and symptoms: • Redness • Heat • Pain • Swelling • Loss of function

  24. Phase 1 con’t • Lasts 7-10 days • Initial damage is called “the primary injury” • Caused by a release of proteins at the injury site • Mast cells produce chemicals (histamines) which promote vasodilation • This causes the redness and heat • Vessels become more permeable which contributes to the swelling

  25. Phase 1 • Mast cells also release chemicals that attract neutrophils (immune cells) to come to the injury • Neutrophils clear debris and regulate the early inflammatory process • Injured area becomes ischemic and acidic which may cause secondary damage to otherwise healthy areas around the injury

  26. Phase 1 • Neutrophils die and are ingested by macrophages at the injury site • When this happens the macrophages begin to produce proteins that promote tissue repair • Early scar tissue forms • Early rehab should focus on pain management, decreasing swelling, promote tissue healing

  27. Phase 1 • Immobilization or protection should be done • RICE • NSAIDS for decreased inflammatory symptoms • Short term analgesic

  28. Phase 2: Repair/Regeneration • Repair- articular cartilage, meniscus, spinal cord (new tissue is not identical) • Regeneration- bone, muscle, peripheral nerve, blood vessels (heal with identical tissue) • Patients are still swollen and pain with motion • Blends with the inflammatory phase and remodeling phase • Day 7 to 21

  29. Phase 2 • Fibrin clots form • Fibroblasts proliferate near the injury • Capillary proliferation occurs (more oxygen needed) • Fibroblasts produce fibronectin, collagens, glycoproteins • Fibronectin begins dormant followed by type III collagen then to stronger type I

  30. Phase 2 • Initially patient has structural deficiency • Treatment – early controlled mobilization • This aligns collagen with areas of physical stress making it stronger • Prevents atrophy

  31. Phase 3: Remodeling/Maturation • Lasts up to 24 months • May have persistent swelling and pain with motion • Fibroblast activity decreases throughout this phase • Capillary density decreases • Cellular matrix becomes more refined

  32. Phase 3 • More type I and type III collagen fibers are produced • Tensile strength improves • Rehab can increase the physical demands until patients return to their activities of daily living

  33. Fracture Healing • Four phases: • Inflammation • Soft callus formation • Hard callus formation • Bone remodeling

  34. Phase 1: Acute • Lasts up to a week • Hematoma formation, inflammation, angiogenesis (new blood vessel formation), soft callus formation • Dominated by immune cells • Phagocytic cells remove debris • Platelets form clots

  35. Phase 2: Repair/Regeneration • Lasts 8 to 12 weeks • Remodeling of scar tissue through cartilage formation, calcification and bone formation • Mesenchymal cells become cartilage cells • Proliferate the soft callus • Replace the scar tissue with cartilage • Chondrycytes hypertrophy and release chemicals to promote bone formation

  36. Phase 2 • Osteoblasts produce new bone • Revascularization of the region occurs • Soft tissue is replaced by bone • Casting is used to allow time for a proper callus to develop

  37. Phase 3: Remodeling • Starts during Phase 2 and continues for several years • Starts 21 days post fracture • Woven bone replaced by cortical or trabecular bone • New bone is remodeled by osteoclasts and osteoblasts based on mechanical loading

  38. Fracture Management • Treatment varies by : • type of fixation • No reduction • Closed reduction • Open reduction • Open reduction internal fixation (ORIF) • Location of fx • Involved bone • Mechanical loads • Surrounding soft tissue

  39. Fracture Management • ORIF • Surgical fixation • Uses metal implants to stabilize fx’s • May allow rehab to begin within first week after surgery ( edema control, wound management, early motion) • More aggressive rehab can begin in 6-8 weeks

  40. Fracture Management • Non-surgical fixation • ROM delayed for 3 weeks • Until callus has enough tensile strength to tolerate movement • At 6-8 weeks patient may begin strengthening exercises and increase mechanical loads • Upper extremity fx’s may begin ROM exercises sooner because of smaller loads and fear of atrophy

  41. Delayed/Non Union Fx’s • Causes • Nutritional deficiencies • Diabetes, anemia • Smoking • Pharmacological drug use • Pre-injury vascular status • Muscle around fracture • Inadequate immobilization • Infection • High energy fractures • Gap distance • Nerve injury

  42. Delayed / Non Union Fx’s • Susceptible areas • Tibia • Ulna • Femoral neck • Scaphoid (most common)

  43. Peripheral Nervous Healing • More proximal injuries result in greater losses • Within 3 -5 days, axons distal to the injury undergo a degenerative process called Wallerian degeneration • This is promote by immune cells, Schwann cells(the cell that normally myelinate axons) and the distal axon

  44. Nerve Healing • Produce proteins that produce and inflammatory response and pain • Schwann cells divide to create an optimal environment for regeneration • Surgical repairs can be helpful but are not guaranteed • Only one proximal branch will form a new axon the others will degenerate

  45. Muscle Healing • Tissue trauma • Hematoma formation • Inflammatory cell reaction • Phagocytosis • Capillary regrowth • Scar formation • remodeling

  46. Muscle Healing • Must balance regeneration with scar formation • Scar tissue is weak and only serves as a “scaffold” for the healing process • Site is still weak • No active motion immediately after injury • Could result in re-rupture • However, prolonged immobilization could result in atrophy

  47. Muscle Healing • What do you do?

  48. Muscle Healing • Early mobilization and motion may be started within the first 24 hours • It must be pain free to avoid overloading • Pain is your guide

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