Bone and Joint Injuries
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This is Chapter 15 from RC’s best-selling book:
Second Edition ~ Wiliams & Wilkins
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Chapter 15: Bone and Joint Injuries
In traditional general medical practice, the musculoskeletal system is the most overlooked system in the body, yet it comprises over half the body mass. The relationship between structure and function, and the interrelationship between all body systems, cannot be denied. Muscles, bones, and connective tissues are involved in both local and systemic pathology, and in a wide assortment of functional and referred disturbances. Thus, great care must be taken in eliciting the details of a complaint when any musculoskeletal disorder is suspected. This section reviews the basis of alert management of bone and joint injuries within the health care of athletic and recreational injuries.
Correlation of the history of the present complaint with musculoskeletal dysfunction must be done in detail and with care. Maintain accurate initial and progress records with repeated monitoring. Few patients can appreciate the relationship of dysfunction in one somatic part with a distant somatic part, let alone the relationship between a somatic dysfunction and a visceral dysfunction.
Musculoskeletal symptoms may be the first clues toward poor structural adaptation or stress adaptation. The most common musculoskeletal symptoms are joint stiffness, joint swelling, and joint pain. Bones, being essentially nonyielding structures, are damaged when excessive force is applied directly or indirectly. The nature of the damage depends on the direction of the applied force on the bones and the manner in which these bones are attached to other structures. The principal acute skeletal injuries are sprains, strains, subluxations, fractures, and dislocations.
Normal bone has an excellent blood supply with some exception in the metaphyseal area; but tendons, ligaments, discs, and cartilage are poorly vascularized. Yet both bone and joints challenge the host’s defensive mechanisms. The pressure of pus under hard bone blocks circulation, and emboli and thrombosis can cause additional devascularization. When circulation is deficient, local phagocytic function and nutrition are deficient, and cure is stymied.
The most accurate diagnosis can be made immediately after injury, before swelling clouds the picture. Many fracture and dislocation complications such as nerve and vessel injury occur not from the trauma itself but from poor first aid which does not provide adequate splinting prior to movement. Traumatic bone injury rarely occurs without significant soft-tissue damage. The physical examination must be gentle but thorough because soft-tissue trauma is poorly visible on roentgenograms for several days after injury. For example, a working diagnosis of stress fracture may have to be made in the absence of classic symptoms by bony tenderness alone as the fracture may not be demonstrable on x-ray films for 10-14 days or longer.
Probing the History
Symptoms of a musculoskeletal nature that cannot be linked to trauma are suspect of a chronic organic process. Unfortunately, a history of stress or strain may not be remembered. Even severe trauma is easily put out of the mind uring a game when emotions are high or forgotten once the pain and swelling have left. Whether pain is present or not, the history must be probed to determine if the dysfunction is the result of bone, the joint, or the motor apparatus involved in the joint motion.
When subjected to weight-bearing, traumatic, or occupational stress, bone demineralizes and undergoes degenerative changes resulting in deformity of the articulating surfaces. Concurrently, the attending excoriation of the articular periosteal margins result in proliferative changes in the form of lipping and spur formations or eburnation.
Bones break from either direct blows or indirectly such as a fall on an outstretched hand resulting in a fracture of the forearm, elbow, shoulder, or clavicle. It is thus imperative that the injured person be examined as a whole. For example, even if a fall on the outstretched hand does not result in fracture, a rib or spinal subluxation may result. The inexperienced doctor may overlook a slipped femoral capital epiphysis in a young player whose complaints are restricted to the knee. The list can go on and on.
Certain simple contusions which involve subcutaneous tissues overlying bone and the periosteum are often referred to in sports as “bone bruises”. Because the periosteum is richly endowed with nerves and vessels, severe bruises and fractures are quite painful despite no roentgenographic evidence. When the periosteum is affected, tenderness will be present long after true soft-tissue tenderness has eased, sometimes for several months. Wherever the site, the athlete is disabled or considerably hampered as long as tenderness exists.
Initial treatment must be quick to minimize bleeding and swelling through ice, compression, elevation, and rest. Padding, often specially designed, must be worn as long as tenderness persists. During recovery, corrective manipulation, local heat, ultrasound, and massage may be applied to relieve related soreness.
A fracture is a break in the continuity of a bone or a separation of a bone into two or more parts. A great amount of soft-tissue damage may accompany this type of injury.
Types of Fracture
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