Injuries of bones and joints
Last updated date: 30-Mar-2023
Originally Written in English
Injuries of Bones and Joints
Musculoskeletal complaints may be the first sign of structural or stress adaptation problems. Joint stiffness, edema, and pain are the most frequent musculoskeletal symptoms. Excessive force, which is exerted directly or indirectly, damages bones, which are non-yielding structures. The type of damage is determined by the direction of the exerted force on the bones and how these bones are connected to other structures. Sprains, strains, subluxations, fractures, and dislocations are the most common acute bone and joint injuries.
Normal bone, excluding the metaphyseal area, has a good blood supply; however, tendons, ligaments, discs, and cartilage are weakly vascularized. Both bone and joints, however, put the host's defense mechanisms to the challenge. The pressure of pus under a hard bone prevents blood flow, and emboli and thrombosis can further devascularize the area. When circulation is compromised, local phagocytic function and nutrition suffer as a result, and healing is slowed.
Before swelling obscures the picture, the best accurate assessment can be established right after the accident. Many fracture and dislocation consequences, such as nerve and vascular injury, are caused by insufficient splinting before movement, rather than by the trauma directly. Traumatic bone injury is uncommon in the absence of severe soft-tissue damage. Because soft-tissue trauma is not visible on x-ray for several days after injury, the physical assessment must be careful but thorough. For example, in the absence of typical symptoms, a clinical diagnosis of stress fracture may have to be made solely on the basis of bone soreness, as the fracture may not be seen on x-ray films for 10-14 days or more.
In sports, "bone bruises" refer to some simple contusions involving subcutaneous tissues overlaying bone and the periosteum. Despite the lack of radiographic evidence, severe bruising and fractures are highly painful due to the periosteum's abundance of nerves and arteries. When the periosteum is damaged, the discomfort persists for several months after actual soft-tissue tenderness has subsided. As long as tenderness continues, the athlete is incapacitated or significantly restricted, regardless of the site.
Ice, compression, elevation, and rest must be used as soon as possible to reduce bleeding and swelling. Padding, which is sometimes custom-made, must be used as long as the tenderness remains. Corrective manipulation, local warming, ultrasound, and massage may be used to relieve related pain after recovery.
Bones and Joints Fractures
A fracture is a break in a bone's continuity or the separation of two or more pieces of a bone. This type of injury can result in a lot of soft-tissue damage.
Open and closed fractures are the two types of fractures. An open fracture is defined as a breach in the skin that runs parallel to the fracture. The bone protrudes from the wound or is revealed through a wound channel created by an arrow, bullet, or other weapons. A closed fracture is not complicated by a skin breach, but the soft-tissue injury is common beneath the intact skin.
In sports, intra-articular fractures are prevalent. They affect the articular surfaces of joints as well as the articular cartilage that surrounds them. If the reduction is not precise, osteoarthrosis develops. A misplaced piece, on the other hand, does not need to be removed if it does not impact the function. Joint impaction and fragmentation are common in fracture dislocations. They normally have a lot of instability and need to be repaired surgically.
Any one of various signs can be used to make a working fracture diagnosis. The history and radiography may provide further diagnostic information. A history of falling, taking a hit, or feeling or hearing a bone shatter may aid in the discovery of more evidence, such as:
- Tenderness at the injured location. Slight pressure on the affected portion can cause tenderness or pain, which could indicate a fracture.
- Swelling and discoloration. These findings at the injury site become more prominent over time and may indicate a fracture. The collection of tissue fluid and blood causes edema. A bluish coloration can appear when blood gathers near the skin's surface.
- Movement abnormalities. The presence of deep, acute pain when attempting to move the bone is suggestive of a fracture. Fracture is indicated by the grating of bone ends against one other. Movement, on the other hand, should be avoided when checking for crepitation since it causes more damage to the surrounding tissues and increases shock.
- Part deformity. Fractures can be identified by the protrusion of a bone fragment through the skin, unnatural depression, or atypical flexion.
Stress (Fatigue) Fractures
Any extreme repeated stress can cause fatigue (stress) fractures (e.g., dancing, marching, running).
Stress Fractures Causes
Rather that the compressive forces of external injury, the causal component appears to be tensile forces from intense muscular contractions. Runners are more likely to suffer from fatigue leg and foot fractures, while jumpers are more likely to suffer from fatigue hip fractures. The pars interarticularis in football lineman and gymnasts, the ischiopubic area in hurdlers, the ulnar in tennis players, and the pisiform in volleyball players appear to represent further patterns of frequency.
The large bulk of fatigue fractures (95 percent) occur in the lower limbs, and the bulk of them are linked to competitive running. The femoral neck, tibia, metatarsals, and tarsals are the three most prevalent locations for fatigue fractures in sports. A location in the pelvis, notably including the ischiopubic arch in female athletes, is identified less commonly.
Stress Fractures Symptoms
The sole early indication could be a vague ache. During strenuous activity, the normal case history will demonstrate the start of subtle local discomfort. With repeated action, acute discomfort develops during and after the activity, as well as frequently during the night while sleeping.
Antalgic postures and movements, increased pain on pressure, regional edema, point tenderness, referred pain, and a limited range of motion are all common physical findings. When a fatigue fracture is subjected to significant stress (e.g., a fall or a blow), a displaced fragment may develop.
Stress Fractures Diagnosis
radiographic evidence does not usually present until 10 days after the triggering trauma, and it can take up to 40 days. Endosteal or medullary sclerosis and a crack or nick in the cortex are the earliest indications, followed by the formation of a periosteal callus.
Bone scans have been proven to be more sensitive than traditional x-ray treatments in detecting fatigue fractures. This is crucial because if a fatigue fracture is discovered in one site, non-symptomatic contralateral or distant fatigue fractures may be present, representing a severe risk of serious sequelae.
Emergency Fractures Treatment
To evaluate the degree of injuries, the first step is to conduct a quick but thorough examination. Any life-threatening emergency, such as respiratory failure, cardiac arrest, or bleeding, takes priority over fracture treatment. Because pain is reduced and the probability of future trauma is minimized, direct fracture care contributes to the prevention or lowering of shock.
The rule "Splint them where they lie" pertains to the treatment of fractures. Splints are used after open fractures have been treated. The razor-sharp edges of the broken bone can readily cut through veins, nerves, muscles, and skin, so it's important to avoid moving the fractured area. Of course, additional injury would raise the risk of hemorrhage, shock, and limb or life loss. If the patient's mobility is unavoidable or necessary for treatment, the broken component must be stabilized to prevent further injury. To restore circulation, a slight traction correction of the fractured section may be required, as demonstrated by the absence of a pulse distal to the fracture. This is especially true in the case of an elbow fracture.
Fractures of the basilar skull, C7 vertebra, femoral neck, pelvis, radial head, tibial plateau, and T12 and L1 vertebrae; and dislocations of the lunate, posterior femoral head, posterior shoulder, and scaphoid are the most frequently ignored injuries in people who have multiple injuries.
Emergency Fractures Immobilization (Splinting)
A broken bone must be stabilized by splinting the joints above and below the fracture, as the movement of these joints would displace the bone segments, resulting in further injury. To protect the skin from damage, loss of circulation, inflammation, and infections, all splints should be properly padded. Bandages used to secure a splint should not be applied so firmly that circulation is obstructed for more than a few minutes. One or more bandages are too tight, resulting in a bluish discoloration of the nail beds or skin of the injured area. It is never a good idea to tie a security bandage exactly across a wound.
The wire ladder, cage, and Thomas leg splint are all typical splints used to stabilize fractures of the limbs. Splints can be constructed with objects like boards, stiff tree branches, rolled newspapers, belts, and other items if this equipment is not available or training for proper application is not provided.
The pneumatic inflatable splint is especially beneficial in limb fractures because it provides both immobilization and compression to reduce bleeding. It should only be applied tight enough to hold the fragments in place without obstructing circulation.
An improvised splint must reach from the groin and armpit to several inches below the foot to stabilize a fractured bone in the thigh or hip. Padding should reach over the splints' ends at the groin and the axilla.
Acute arthritis can be developed when trauma is the main culprit. The intensity of the damage and the tissues' resistance determine the amount of the local reaction. Excessive joint stress might induce pathologic responses or derangement within the joint if it is recurrent. Alternatively, arthritis caused by a single severe injury, especially if not treated effectively, can last continuously, leading to chronic symptoms and irreversible disability.
Pain, bruises, and soft-tissue swelling of periarticular tissue may be confined to effusion within the capsule or obliterate bony prominences are all hallmarks of traumatic arthritis. The intensity of the trauma, tenderness to touch, and loss of function all play a role. Because of the discomfort, movement is generally limited, and if the injury is severe enough to rupture a tendon or joint capsule, there will be joint instability. Fractures and fragments within the articular cartilage may be related. In individuals who receive effective treatment, the prognosis is excellent; nonetheless, subacute arthritis can often last permanently.
Most joints allow for movement inside the joint and/or the fixation of a limb segment while another joint is in motion. When stabilized by musculature, they also serve to transmit stress. This stability is required so that muscles can attain maximum joint motion leverage.
The surrounding musculature is principally responsible for the stability of synovial joints. Excessive joint stress causes strained muscles and ligament sprains or ruptures. Chronic stress causes degenerative changes in the joint. In the young, a direct hit to the joint might cause connective tissue contusion and possibly an intra-articular fracture or a slipped growth plate. The blow is frequently unexpected, and defensive reflexes have not been activated, or it may be so severe that defensive mechanisms are ineffective.
The synovial lining is mildly phagocytic, regenerating if injured, and secretes synovial fluid, a nutritive lubricant with anticoagulant and bacteriostatic properties. In the case of an intra-articular fracture when the fracture line is exposed to synovial fluid, this anticoagulant activity may lead to poor callus formation.
Inspection, bone palpation, soft-tissue palpation, evaluating the passive and active range of motion, assessing muscle integrity and power, evaluating superficial and deep reflexes, and examining related areas are all part of the examination.
Joints Injury Symptoms
The following are examples of common complaints experienced in joints injuries:
- Variations in color, such as bruises and redness
- Warmth in the close surroundings
- Swelling of the soft
- Swelling due to bony expansion
- Joint Deformity
- Atrophic or dystrophic wasting
- Profound tenderness
- Discomfort when moving
- Movement Restriction
- Instability of the joints
- Impairments in carriage and gait
Sprains are joint injuries in which the ligaments, capsule, and surrounding tissues are partially damaged or severely stretched, but there is no dislocation. It's possible that there was a partial dislocation that spontaneously reduced. The main reason is overstretching or overexertion, which puts a range of motion beyond the ligaments' ability to withstand the stress. The magnitude and length of the force determine the extent of the injury.
Sprains are categorized as acute, subacute, or chronic depending on their severity and the area of involvement (cervical, thoracic, thoracocervical, brachiocervical, thoracolumbar, lumbar, lumbosacral, sacroiliac, or iliofemoral). Although the terms subacute and chronic are diagnostic, they are confusing, and a definition of subacute or chronic joint instability would be more descriptive and preferable.
When deciding between a sprain and a strain, keep in mind that a sprain affects the ligaments of a joint, whereas a strain affects the muscular and tendinous components. The sprain causes pain when the injured joint moves even when there is no muscular effort; strain causes pain when there is a muscular effort but no movement, as in opposed contraction. If the word "strain" is used as a verb, any tissue can be strained in an injury. Sprain, on the other hand, refers to ligamentous injury whereas a strain refers to muscular or tendinous injury when used as a noun or state of being.
When ligamentous tissue is repeatedly stressed, it becomes chronically inflamed and infiltrated by collagen and mineral salts. Sclerosing and different degrees of calcification develop as a result of this. Furthermore, when ligamentous tissues are exposed to acute traumatic stress, some of the fasciculi that make up the ligament are broken, resulting in minute hemorrhages. There will be a noticeable shortening if the affected ligament has elastic fibers.
- First-degree sprain. There is a minimal amount of internal bleeding in a confined location of the ligament with only a few fibers torn in a mild sprain. There is no real loss of function or reduced strength. In most cases, the ligament does not require protection and is not compromised. It is characterized by pain across the ligament that is not accompanied by edema and other signs of minor local inflammation at the bone insertion. The risk of joint instability is quite low.
- Second-degree sprain. This is a mild sprain with a partial ligamentous tear that causes first-degree symptoms to be more severe. A complication is the likelihood of recurrence, as well as traumatic arthritis and persistent instability. A moderate sprain is caused by severe ligament rupture, with at least half of the fibers remaining uninjured. Even if the injured ligaments are not widely separated, this type of sprain results in some loss of function in the damaged area. Unless the injury is severe, they will reunite through the normal healing process. If this is the case, significant scar tissue may grow, resulting in a lifelong weakening of this part of the ligament. A moderate sprain has more complaints than a mild sprain, as well as a lack of typical ligamentous resistance on the applied pressure and increased joint mobility on tension as evidenced with motion or manipulation.
- Third-degree sprain. Severe swelling, bleeding, discomfort, complete loss of function, aberrant motion, and potential deformity define this severe sprain with a complete ligamentous tear. When a sprain is classified as severe, it means the ligament has entirely lost its function as a result of a force strong enough to pull it apart or tear it apart from the surrounding structures. A severe sprain is characterized by more complaints than a mild sprain, as well as marked excessive joint mobility indicating evident separation on tension or movement. There might or might not be severe pain. Bilateral stress radiograph may reveal abnormal motion. Complications such as persistent instability and traumatic arthritis are prevalent. A palpable gap may be detected at the location of the tear if noticed soon after the injury before swelling starts.
If only a few fibers are strained or ripped, elevate the affected area and apply cold compresses to reduce swelling and pain. A sprain should be supported (e.g., ankle hitch) until strength recovers to avoid more stretching. If the seriousness of the injury is in doubt, it should be managed as a fracture.
If numerous fibers are torn but the joint is still stable, the same treatment is recommended. The only difference is that movement is delayed and started slowly, with only modest non-weight-bearing passive movements. Swimming and strictly monitored flexion-extension active motions can be done after that. Lateral and rotational motions should be avoided for at least the first two weeks. When anesthetics are used to numb such injuries so that a player can participate in sport, the outcomes might be catastrophic.
Large ligament tears can take anywhere from 9 to 15 weeks for the scar to evolve enough to provide protection. When dealing with a serious sprain, you must decide if motion or stability is more essential. If the motion is a top priority, early mobilization is required; if stability is a top goal, immobilization is required until solid healing occurs. If the ligament ends cannot be approximated, the joint cannot be reduced, or there is a total lack of stability, surgical correction is typically needed.
An osseous dislocation occurs when the articular surfaces of the bones that make up a moveable joint are displaced from their usual connection.
Ligaments that ordinarily keep the joint in place are put under a lot of stress when it dislocates. These ligaments, as well as the capsules they form surrounding some joints, articular cartilage, synovial membrane, and other soft tissues, may be injured, and there may be hemorrhage into or around the joint. A full luxation or a subluxation can occur as a result of a dislocation. A reported subluxation in the extremities could be the result of a spontaneously decreased dislocation and be linked with significant capsule and ligament injury. The joint is the source of pain, swelling, and deformity. There is usually a loss of mobility as well.
In the same manner a fracture is immobilized, a dislocation is immobilized close to the joint. To ease pain and reduce swelling, apply cold compresses to the joint, but do not lower the patient's temperature. Ligaments in the area are commonly damaged and require surgery to heal. In most cases, post-reduction immobilization lasts 5 weeks for the lower extremity and 3 weeks for the upper extremity. Inadequate management, particularly in the case of ankle and shoulder dislocations, results in persistent weakness, movement limitations, instability, and recurrent dislocation, with a poor prognosis for recovering pre-injury state. Before reduction, almost all dislocations must be x-rayed.
The joints and bones injuries are common entities. These include various bone fractures, dislocations, subluxations, sprains, strains, and bruises. The management of them depends on the findings during thorough physical examination and imaging studies.