Orthopedics: Disabilities and Treatment

Orthopedics: Disabilities and Treatment

• Orthopedic surgery and research are constantly evolving.
• Athletes of all ages and sizes compete at various levels.
• Workman's compensation is relevant to workplace injuries.
• Geriatric considerations relate to older adults' health.
• Traumatic injuries are a significant concern.
• The anatomy of the body's various components is crucial to orthopedic practices.

Synovial Joint Classification

• Stability Joints:
  • Articulating surfaces are congruent.
  • Have a dense, thick capsule.
  • Supported with numerous ligaments.
• Mobility Joints:
  • Articulating surfaces are incongruent.
  • Have a loose capsule.
  • Supported with very few ligaments.
• Synovial Joint Characteristics:
  • The most common joint type.
  • No direct connection between bones,
  • Surrounded by a strong fibrous capsule.
  • Allows for free motion of the joint.
  • A synovial membrane secretes synovial fluid.
  • Hyaline cartilage covers articular surfaces, decreasing friction.

Synovial Joint Components

• Includes stratum fibrosum (outer layer)
  • Dense fibrous tissue
  • Poorly vascularized
  • Richly innervated by joint receptors that detect:
    • Compression or tension
    • Pain
    • Movement (rate and direction)
    • Vibration
• Includes stratum synovium (inner layer)
  • Highly vascularized
  • Poorly innervated
  • Purpose is to produce synovial fluid.

Purpose of Synovial Fluid

• Lubricates the joint.
• Acts as a shock absorber.
• Nourishes articular cartilage.

Effects of Immobilization (on Synovial Fluid)

• No synovial fluid is produced when a joint is immobilized.
• This leads to lack of nourishment for the hyaline cartilage.
• This will result in osteoarthritis.

Hyaline Cartilage

• Crucial for joint movement and health.
• Is avascular, causing slow or limited repair capabilities.

Joint Capsule and Supporting Tissue

• Adaptive shortening occurs due to disuse atrophy.
• Disuse atrophy causes muscle and ligament weakness.
• Diseases or injuries can cause joint/muscle contractures.

Ligaments / Tendons / Stratum Fibrosum

• Makeup of connective tissue.
  • Collagen
  • Elastin
  • Collagen/Elastin Mix

Collagen

• A main component of fibrous connective tissue.
• The most abundant protein.
• High tensile strength.

Elastin

• Provides elastic properties.
• Allows fibers to deform and return to their original shape.

Collagen/Elastin Mix

• Synovial joints primarily consist of both collagen and elastin.
• Proportion of elastin to collagen varies depending on the joint.
• Elastin is a smaller portion of the fibrous component.

Function of Connective Tissue

• Maintains the joint's stability.

Susceptibility to Injury (of Joints)

• Susceptibility depends on the elastin amount and arrangement of collagen fibers.
• Ligaments have more elastin than tendons.

Tendons

• Higher collagen content.
• Collagen has a parallel arrangement suitable for high unidirectional tensile forces to be withstood.

Joint Capsule

• Varies greatly in composition.
• The composition changes depending on stresses imposed.
• Joints designed for stability have more collagen than joints designed for mobility.

Cartilage (Overview)

• Solid type of connective tissue.
• Avascular (no blood supply) limits its repair capability.

Cartilage Types

• Fibrocartilage:
  • Forms joints that permit little motion.
  • Forms intervertebral discs.
  • White fibrocartilage.
  • Yellow fibrocartilage.
• Hyaline Cartilage (Articular):
  • Most abundant cartilage type.
  • Forms a thin covering on many bones.
  • Resilient, smooth, and low friction.
  • Crucial for articulation between bones.
  • Consists of three distinct layers or zones.

Bone Tissue Characteristics

• Hardest form of connective tissue.
• Composed of fibrous connective tissue and inorganic substances.
• Somewhat elastic despite its rigidity.

Wolff's Law

• Bone deposition occurs in areas of stress.
• Bone resorption occurs in areas of reduced stress.
• Bone models and remodels throughout life in response to stress.

Bone Nourishment

• Bone receives nourishment from capillaries within the bone, not from hyaline cartilage.

Bone Function

• Provides a rigid framework.
• Serves as levers.
• Protects vulnerable internal organs
• Contains sites for blood cell development.
• Acts as a mineral reservoir for the body.

Bone Terms

• Epiphysis: The distal end of a bone.
• Diaphysis: The shaft of a bone; a hollow tube of compact bone surrounding the medullary cavity.
• Metaphysis: The region where the diaphysis and epiphysis meet in mature bones.

Bone Cells

• Osteoblasts: Produce bone tissue.
• Osteoclasts: Resorb bone tissue.
• Osteocytes: Mature osteoblasts embedded within the bone matrix.

Tissue Response to Injury

• Injury to soft tissue initiates a series of responses collectively known as inflammation and repair.

Timeline for Tissue Healing

• The timetable is variable for each patient.
• Factors like injury extent, disease, and medications impact the healing process.

Healing Process (Soft Tissue)

• Injured soft tissue does not regenerate; repair occurs instead.
• Healing is nonspecific, with scar tissue replacing the damaged tissues.
• Scar tissue is mainly collagen, which is rigid and limits motion.

Components of Inflammation and Repair

• Inflammation Phase: Area swells and becomes warm.
  • Rid the area of microorganisms, foreign matter, and debris.
  • Preparing the area for repair.
  • Characterized by four symptoms: pain, redness, warmth, and swelling.
• Fibroplasia Phase: Formation of new fibrous connective tissue.
• Scar Maturation Phase: Remodeling of connective tissue.

Inflammation Phase (Stages)

• 1st stage: immediate vasoconstriction followed by vasodilation, platelet aggregation and clot formation.
• 2nd stage: infiltration of leukocytes, like neutrophils, monocytes, and macrophages, to phagocytose debris.
• 3rd stage: Release of growth factors by macrophages to stimulate epithelial cell growth, angiogenesis, and fibroblast attraction.

Treatment for Acute Stage (of Injury)

• PRICE: Protection, Rest, Ice, Compression, Elevation.

Subacute Phase (Treatment Stages)

• Continuing with ROM (range of motion) exercises, stretching.
• Beginning strengthening exercises (like isometrics, using therabands, and stabilization exercises).
• Exercise programs progress gradually.

Scar Maturation (Remodeling) Phase

• New collagen and connective tissue gradually reorganize along the lines of physical stress.
• Active stress or muscular contractions, with progressive joint motion (PROM > AAROM > AROM), promote organized, stronger, more functional collagen arrangements.

Remodeling Phase (Return to Activity)

• Aggressive ROM and strengthening exercises.
• Regaining activity-specific skills.

Physical Therapy Role

• Physical therapy is crucial for scar tissue remodeling and improving tensile strength.
• The more organized collagen fibers, the stronger the tensile strength.

Additional Notes

• The final scar strength and extensibility depend greatly on the patient's diligence in home exercises.
• Despite remodeling, scar tissue is never as strong as the original tissue.

Specialized Tissue Repair

• Striated muscle. -Limited ability to regenerate myofibrils. -Edges must be closely approximated for repair. -Scar formation will occur to heal wound tissue.
• Nerves.
  • If the cell body and axon ends are close together, the nerve may heal.
  • Healing is very slow (3-4 mm per day).
• Some cartilages have some regeneration abilities. -Mature cartilage cannot regenerate.
  • Will often lose anatomical characteristics.
  • Will lose cushion abilities.

Sprains

• Grade I, II, and III sprains

Strains

• Grade I, II, and III strains

Ligaments

• Treatment of ruptures and avulsions (rupture has same repair process as tendons)
• Fixation with screws for avulsions

Tendons

• Repair treatment.
• Union of severed ends required.
• Prevent tendon sheath adhesions.

Terms (related to tendons)

• Tendinitis
• Tendinosis
• Tenosynovitis

Orthopaedic Considerations in Various Populations (general concepts)

• Athletes: Injury prevention and rehabilitation programs required.
• Workers: Workman's compensation and injury prevention.
• Geriatric patients: Special considerations in treatment and care.