PTA 222 Clinical orthopedics

Length Tension Relationship
Active insufficiency

the muscle is incapable of shortening to necessary extent to allow full range of motion at all joints crossed.

Length Tension Relationship
Passive insufficiency

the muscle cannot stretch to the necessary extent for full range of motion in the opposite direction of all joints crosse

What are the types of muscle contractions

Isometric
Isotonic
-Eccentric
-Concentric

Kinematic Chain
Closed Chain (CKC)

distal segment of kinematic chain meets considerable resistance

Kinematic Chain
Open Chain (OKC)

activities that involve the distal segment moving freely through space to isolate movement of a joint

Joint Position
Open Pack Position
Position of least joint congruity

“Loose-packed” or “resting” position
Slack of major ligaments
Minimal surface congruity
Minimal joint surface contact
Maximal joint volume
Minimal joint stability

Joint Position
Closed Pack Position
Position of maximum joint congruity

Maximal tautness of ligaments
Maximal surface congruity
Minimal joint volume
Maximal stability of the joint

Arthrokinematic motion
Occurs where

at bone ends, without regard to body movement

Arthrokinematic motion
what movement

accessory movements

Arthrokinematic motion
motions to specific to what
not what
What kinds are there
also known as what

motions specific to articulating joint surfaces
not volitional
Glide (slide), spin, and roll
Joint play

Arthrokinematic motion
Glide/Slide

One portion of the articular surface comes into contact with a series of locations on the corresponding surface

Arthrokinematic motion
Spin

Portion of one joint spins (clockwise or counterclock wise) around the stationary longitudinal axis

Arthrokinematic motion
Roll

Multiple points of contact on one joint surface come into contact with multiple points on the corresponding joint surface

What are the classifications of fractures

Open, closed, complete, incomplete, displaced, non displaced

Types of fracture

Spiral, comminuted, Avulsion

What does precaution mean

its like a yellow light
You proceed with caution

What does contraindication mean

Red light
Stop immediately

Special Tests
Precautions/Contraindications

Previous or chronic injury to the area
Fracture of the area
Surgery of the area
Acute injury to the area

Imaging
Conventional Radiography
Descending density
Light to darkest

Metal
Bone
Soft tissue
Water/body fluid
Fat
Air

Imaging
Arthrography

Study of structures within encapsulated joint

Imaging
Myelography

Spinal cord, nerve roots, dura mater, spinal canal

Imaging
Angiography

Vascular system

Imaging
Computed Tomography (CT)

Axial Plane Image
Greater Contrast to detail soft tissue than x-ray

Imaging
Mahnetic Resonance Imaging (MRI)

Thin Slices without radiation
Also details soft tissue greater than x-ray

Which type of imaging shows vascular structures

Angiography

What is the Load Deformation Curve

a graph that plots applied force (load) against a change in shape (deformation), biomechanics to show how body tissues like tendons and ligaments react to stress

Tissues and Tissue Repair
Strain

overstretching/overuse of musculotendinous unit, slight trauma or repetitive trauma

Tissues and Tissue Repair
Sprain

Severe stress/stretch/tear of ligament

Tissues and Tissue Repair
Dislocation

displacement of boney partners in result, loss of anatomical relationship associated with secondary trauma to surrounding soft tissue

Tissues and Tissue Repair
Subluxation

incomplete/partial dislocation of bony partners in joint associated with secondary trauma to surrounding soft tissue

Tissues and Tissue Repair
Hemarthrosis

bleeding in joint, usually due to trauma

Tissues and Tissue Repair
Contusion

bruising from direct blow, capillary rupture, bleeding, edema and inflammatory response

Tissues and Tissue Repair
Contracture

adaptive shortening of skin, fascia, muscle or joint capsule that prevents normal mobility and flexibility

Tissues and Tissue Repair
Adhesion

abnormal adherence of collagen fibers to surrounding structures during immobilization/trauma/surgery

Tissues and Tissue Repair
Bursitis

Inflammation of bursa

Tissues and Tissue Repair
Synovitis

inflammation of synovial membrane resulting in excess synovial fluid in joint or tendon sheath

Tissues and Tissue Repair
Dysfunction

Loss of normal function of tissue

Tissues and Tissue Repair
Reflex Muscle Guarding

prolonged contraction of a muscule in response to painful stimulus

Tissues and Tissue Repair
Intrinsic Spam

prolonged contraction of a muscle in response to local circulatory and metabolic changes

What is the difference between muscle, tendon and ligament?

Muscle has a lot of blood vessels and connect to bone, tendons have a limited blood supply and connect muscle to bone, ligaments have a small amount of blood supply and connect bone to bone

Stages of Soft Tissue Healing
Acute

Coagulation and inflammation
Begins at initial onset of injury

Stages of Soft Tissue Healing
Subacute

Migratory and proliferative
Beings within days and include major processes of healing

Stages of Soft Tissue Healing
Chronic

Maturation and remodeling
May last for up to a year
Responsible for scar tissue formation and development of new tissue

Acute
Day 1-6
Defensive events

Vasoconstriction 5-10 minutes

Acute
Day 1-6
Inflammatory response

Vasodilation
-stimulates pain receptors, clot formation, plasma synthesis, healing proteins

Acute
Day 1-6
what happens typically day 4-6

Complete removal of debris marks end of inflammatory process

Is swelling and inflammation good or bad?

They are neither good or bad, it just depends on factors like how long it has been going on, if its short term then it could be good because it means the body is healing and it’ll go away on its own. If it happens for a long time, then that means something is wrong and requires more attention

Acute
signs and symptoms

Swelling, Redness, Loss of function, Increased Warmth, Pain at rest/with active motion, empty end feel, muscle inhibition and guarding

Acute
Physical Therapy Goals

Protection to allow healing
Control pain and inflammation
Control and then eliminate edema
Restore pain free ROM
Prevent muscle atrophy
Minimize effects of immobilization / participation restriction
Scar Management
Maintain general fitness
Patient Education & independence with home exercise

Acute
Physical Therapy Interventions

Grade I mobilization
Compression/Elevation
Modalities
PROM, then AROM in pain free ranges
Gentle massage
Isometrics
Exercise with muscle in shortened position or in joint resting position

Acute
Physical therapy interventions
-Effects of manual treatment

pain reduction (endorphin release and large fiber joint afferents), decreased intra articular pressure, increase joint mobility, remodel connective tissue, increased tendon glide, increase joint lubrication

Subacute
Criteria to advance

adequate pain control and tissue healing, near normal ROM, tolerance for strengthening

Subacute
Overlaps what

the inflammation phase

Subacute
what happens with blood vessels and tissues

Capillary growth, granulation tissue formation, fibroblast proliferation with collagen synthesis, increased macrophage and mast cell activity

Subacute
Develops what

Wound’s Tensile Strength (Low)

Subacute
Develops Wound’s Tensile Strength (Low)
What tissue type
and how

Connective tissue (collagen type I & III)
Fibrinogen -> Fibrin -> honeycomb matrix
-Glue that provides protection and prevents infection

Subacute
Signs and Symptoms
Decreased what

Decreased pain and swelling
-Residual effusion may still be present

Subacute
Signs and Symptoms
Increase of what

Increase in pain free AROM and PROM
-Pain occurs with tissue resistance as opposed to at rest

Subacute
Signs and Symptoms
What is the criteria to progress interventions

decreased swelling, pain that isn’t constant or exacerbated by ROM

Subacute
Physical Therapy Goals
What movement will help what

Gentle movement will help guide collage fiber replacement

Subacute
Physical Therapy Goals
Gentle movement will help guide collage fiber replacement
still protecting what

Still protecting the collagen formation and direct formation to II lines

Subacute
Physical Therapy Goals

Full pain free ROM
Restore normal joint osteo and arthro kinematics
Improve muscle strength
Improve neuromuscular control
Restore muscle force couple relationships

Subacute
Physical Therapy Goals
overly aggressive can cause what

delay/disruption, but patient should return to normal activities that don’t acerbate symptoms or cause risk in re injury

Subacute
Physical Therapy Interventions
Submax Isometrics

Early range/resting joint position then progressed to multi-angle
Contraction is below perception of pain

Subacute
Physical Therapy Interventions
Submax Isometrics
what is it and how can it be progressed and modified

Light resistance, concentric exercise
-Control motion, proper joint mechanics in single plane
-Can progress to combined motion / diagonal planes

Subactue
Physical Therapy Interventions
what do you constant check and what is this used for

Monitor symptoms
Exercise for muscular endurance (high reps, light weight)
-Slow twitch are first to atrophy

Subactue
Physical Therapy Interventions
what does it help fix

Address muscle length and strength imbalances including postural stability issue

Chronic
Criteria to advance

no complaints of pain, full pain free ROM, good flexibility and balance, strength of 75-80% compared to uninvolved side

Chronic
what transfers into what in this part

Conversion of initial healing to scar tissue

Chronic
how long can this last and what becomes stronger

Can last up to 1 year with goals of tissue remodeling and increasing tensile strength

Chronic
day 21-60

predominance of fibroblasts that are easily remodeled
-This is 1-2 MONTHS

Chronic
1 month to 1 year
What tissue is formed into what and where is it located

Contracted tissue = scar formation
Inferior to original tissue, if left immobilized the scar will be less than 20% of its original size
-Can impact function

Chronic
Physical therapy goals

improve muscle strength to normal levels, return neuromuscular control, complete full return to functional activities

Chronic
what happens with pain at this stage

Pain may be present at end ranges when tissue is stressed or due to soreness from resistive exercises

Chronic
what happens with exercise at this stage

Exercise is progressed from isolated, unidirectional simple movements to complex patterns and multidirectional movement with muscular coordination

Chronic
what happens with collagen

Collagen strength will develop in the direction that forces occur
-Inappropriate stresses will affect strength and lead to adhesion, contracture, tissue dysfunction, laxity, fibrosis, structural failure

Chronic Inflammation
Reasons why it may occur

overuse/repetitive strain
new trauma
reinjury
length-strength imbalances
tissue weakness or too much tension on wound site
return to activity to soon
hypertrophic scarring, poor blood supply

Musculotendonious Injury
Direct

Result of contact

Musculotendonious Injury
Indirect

Result of physical impact without contact

Musculotendonious Injury
Overuse

Continuous impact on bone/tendon

Musculotendonious Injury
Grade 1 (First degree strain (mild) )

tear of few muscle fibers with minor swelling and tenderness, minimal loss of strength and motion, monitor for exacerbation

Musculotendonious Injury
Grade ll Second degree strain (moderate)

• greater damage to muscle, loss of strength, pain on activity that prevents participation, 3-28 days of rehab

Musculotendonious Injury
Grade lll Third degree strain (severe)

•tear across entire muscle belly, severe pain and loss of function, can be no pain if there is a full tear, surgery may be necessary, healing up to 3 months nonoperatively

Musculotendonious Injury
Tendonitis

inflammation of tendon, overuse; painful with loss of motion, calcium may be deposited along tendon

Musculotendonious Injury
Tendinosis

chronic alternation of the tendon with tissue degeneration, cell atrophy, tendon thickening and pain

Musculotendonious Injury
Paratendonitis/tenosynovitis

repetitive friction over sheath

Ligamentous injury
Grade l sprain

stretching of ligament but no fiber damage, minimal loss of structural integrity, no abnormal motion, little swelling, local tenderness, minimal bruising

Ligamentous injury
Grade ll sprain

stretching of ligament, tearing of some fibers, significant structural weakness, some abnormal motion, solid end feel, bruising/swelling, hemarthrosis/effusion

Ligamentous injury
Grade lll sprain

complete or almost complete ligament disruption, full tear; loss of structural integrity, marked abnormal motion, significant bruising and hemarthorsis

Articular Cartilage Injury
Type l

superficial, microscopic damage to chondrocytes and extracellular membrane (ECM)

Articular Cartilage Injury
Type ll

partial thickness, disruption of articular cartilage surface

Articular Cartilage Injury
Type lll

full thickness, disruption of articular cartilage with penetration to subchondral bone

Fibrocartilage Healing
what is it composed of

Type l collagen

Fibrocartilage Healing
Type l collagen

hyaline cartilage/articular cartilage is Type II Collagen

Fibrocartilage Healing
Nourishment is what and what is it typically, what is usually preformed

Nourishment is diffused through synovial fluid
Typically avascular - low potential for regeneration
Often surgery is performed  

Bony Healing
Hematoma Formation (Inflammatory) Phase

Tissue volume is filled with matrix including blood clot/ hematoma
Release of product, increase in blood flow, invasion of nuetorphils & monocytes, local fibrin clot degradation

Bony Healing
Soft Callus Formation (Repair) Phase
Formation of what, what is new

Formation of connective tissues, including cartilage, new capillaries

Bony Healing
Soft Callus Formation (Repair) Phase
what happens 7-10 and week 2

Day 7-10 periosteum undergoes intramembranous bone formation response
Week 2 cartilage overlies fracture site
Prepares for ossification

Bony Healing
Hard Callus Formation (Modeling) Phase

Osteoclastic and Chondroclastic Resorption
Replaces with lamellar bone via osteoblasts 
-called CLINICAL UNION

Bony Healing
Hard Callus Formation (Modeling) Phase
random what, what can be reduced

Random alignment / weak
Splinting can be reduced though still needs protection