MICROTRAUMA (grech, mikros small + an injury) — the damage caused by any influence, usually insignificant on the force but exceeding limits of physiological resistance of fabrics and leading to dysfunction and structures of fabrics after single or its repeated same influence. At long impact of the damaging agent on fabrics there are patol, states caused by an overstrain and an overload of these fabrics. M.'s emergence is promoted by exhaustion, an overtraining, the previous diseases, the bad organization and the wrong equipment of work and exercises and sport.
A clinical picture
Distinguish the acute M. arising at single action of the injuring agent and chronic M. — a consequence of its repeated influence. On M.'s localization divide into microtraumas of skin and hypodermic cellulose, fatty tissue, sinews, sheaves, muscles, a cartilaginous and bone tissue. M share also on opened (with disturbance of an integrity of skin) and closed (without it).
Microtrauma of skin and hypodermic cellulose. Carry grazes to acute M. and bruises (see). Grazes — various extent of disturbance of an integrity of a derma and epidermis. At extensive grazes there are pain, burning, bystry infiltration and hypostasis of surrounding fabrics in connection with pollution and infection. Skin carry to acute M. also scratches (linear injuries of epidermis), cuts (linear injuries of epidermis and a derma) and the small sizes (dot) wounds, most often from foreign bodys (see) — splinters, sewing needles, etc. (see. Wounds, wounds ).
Investigation hron. The m of skin is fibrosis of skin and a fibrosclerosis of hypodermic cellulose — a skin polyp, callosity (see). Together with development of a hyperkeratosis and a hypertrophy of hypodermic cellulose there are painful cracks (see). At longer action of a disturbing factor disturbance of an integrity of skin — development is possible attritions (see). The m of fingers can become the reason felon (see).
Microtrauma of fatty tissue. Acute M. are possible at bruises. Hron. M of a fatty tissue can be etiol, a factor of such states as lipomatous regeneration of an adipose body of a knee joint (see. Goffy disease ) and ossifying process in cellulose (see. Ossificates ).
Microtrauma of sinews. The tendinous fabric possessing a large supply of mechanical strength, a rezistentn to acute M. Hron leads microdamage to development of a tendoperiostopatiya (a traumatic tendinitis, a tendinoz). The disease develops most often in the place of an attachment of a sinew to a periosteum i.e. where conditions of food are less favorable, and application of muscle strength most intensively. In tendinous fibers sites of fatty regeneration are formed, there are microtears with hemorrhage in places of a vpleteniye of tendinous fibers in a periosteum. At the same time durability of a sinew decreases and danger of its anguishes and a gap is created. Tendoperiostopatiya develops usually at persons of physical work, athletes, ballet dancers and circus. Its most frequent localization — on the lower extremities in the place of an attachment of a sinew of a direct muscle of a hip to an upper pole of a patella, in the field of a proximal attachment of own ligament of patella, in points of an attachment of sinews of adductors of a hip to pelvic bones. On upper extremities of a tendoperiostopatiya are more often observed in a shoulder joint in the place of an attachment of sinews to a big hillock of a humeral bone (e.g., at weightlifters), in an elbow joint in the place of an attachment of sinews beam and elbow a sgibately brush — a so-called tennis elbow (see. Epicondylitis ). Clinically the tendoperiostopatiya is shown by local morbidity, in far come cases puffiness of soft tissues and consolidation of a periosteum in the place of an attachment of a sinew comes to light.
Also primary traumatic epicondylitis of a shoulder concerns to group of tendoperiostopatiya, to-ry develops as a result of M. of places of attachments of sinews of muscles of a brush and fingers to epicondyles of a humeral bone. This process is considered as local unlike the secondary epicondylitis which is a symptom of cervical osteochondrosis. More often persons of physical work (mechanics, painters, carpenters, grinders), and also athletes (tennis players, throwers) and musicians — violinists, pianists suffer. Clinically an epicondylitis is shown by local morbidity in the field of lateral and medial epicondyles of a humeral bone, consolidation of soft tissues. Pain amplifies at the nek-ry movements of a brush and fingers, force of muscles decreases. On roentgenograms of an elbow joint and backbone of pathology is not defined.
Is M.'s consequence of okolosukhozhilny fabrics tendovaginitis (see) — the disease arising at M. of vaginas of sinews. The long overload leads to traumatization synovial membrane (see) tendinous vaginas, to microhemorrhages, hypostasis and aseptic inflammation. It is long the proceeding tendovaginitis gain the stenosing character that worsens conditions of food and complicates movement of a sinew on his vagina. The painful ring-shaped thickening is determined by the course of a sinew at a palpation.
A paratenonitis — a disease of okolosukhozhilny cellulose. It is most often observed in a calcaneal (akhillov) sinew (at skiers, runners), it is caused by micro hemorrhage with the subsequent fibrous deposits and scarring of cellulose. It is shown by pains in a sinew. Survey and a palpation reveal pastosity, morbidity, and in a stage of exudation — crepitation of okolosukhozhilny fabric.
Close adjoins group of a tendovaginitis hron, bursitis (see) — the disease of synovial bags arising at their long traumatization. Clinically a bursitis is shown by symptoms of an aseptic inflammation (local pain, hypostasis, an exudate, restriction of movements, sometimes crepitation in the field of a synovial bag). At the same time it is necessary to differentiate the bursitis caused by M. from infectious and infectious and allergic inflammations of bags. At hron. M most often arise inflammations of a subdeltoid bag, an elbow hypodermic bag, hypodermic prepatellar and deep subpatellar bags, a bag of an Achilles tendon and a hypodermic calcaneal bag.
Microtrauma of sheaves. Their stretching belongs to acute M. of sheaves (see. Distortion ).
Hron. M of the copular device (a ligamentopatiya, ligamentoz, a tendovaginitis) on etiopatogenetichesky and a wedge, a picture it is similar to tendoperiostopatiya. Characteristic localization of anguishes of fibers of sheaves — in places of their attachment to a bone tissue. Most often hron, traumatizations are subject a tibial collateral linking of a knee joint, a ligament of an ankle joint and a small linking of foot; on upper extremities — ligaments of joints of a brush.
Microtrauma of muscular tissue. To acute M, muscles carry the anguishes and break-up of separate groups of muscle fibers arising at the sharp movements or at bruises, Are shown by local morbidity and at superficial localization — formation of bruise.
The chronic microtrauma of muscles develops at persons whose work is connected with a big exercise stress, and at occupations power and high-speed sports. Damages of muscle fibers arise at the repeated forced movements exceeding limits of elasticity of fabrics and also at repeated bruises of a muscle. The m is observed more often in the four-head, two-headed, adductors and in a gastrocnemius muscle of a shin. Damages can be observed in all departments of a muscle, but their localization in the place of transition of a muscular part to tendinous is most characteristic. In sites of damage to result of an injury and a spasm of capillaries there comes disorder of local blood circulation. The deviation from normal indicators of content of albumine and phosphorylases reflects depth of damage or extent of recovery of a muscle in blood. Definition of acid-base equilibrium in the area M. reveals the subcompensated or compensated metabolic acidosis, degree to-rogo is in direct dependence on weight of an injury. The research at the submicroscopic level of punctate of the muscular tissue taken in the place of the greatest morbidity reveals change of myofibrils in the form of disturbance of their continuity with filling of defect with cytogranules.
In an initial stage of M. are not diagnosed, at constant repeatability of injuries and development hron, process in the place of damage there is a morbidity which is coming to light at a palpation of the damaged area and at a tension of a muscle.
Microtrauma of cartilaginous tissue. Acute M. arise as a component of an injury of a joint — local bruises of a cartilage, hemorrhage. Against the background of the general injury they clinically, as a rule, remain unnoticed.
Hron. The m of cartilaginous tissue (a chondropathy, a chondromalacia, a perichondritis) is observed both in hyaline, and in a fibrous cartilage. Injuries of a cover cartilage to one cases result from repeatedly repeating tolchkoobrazny compression of joint surfaces, napr, at athletes jumpers. Certain sites of a cartilage are rumpled, have signs of a razvolokneniye, lose the gloss, at repeated injuries they exfoliate and drop out in a cavity of a joint in the form of free bodies. In other cases permanent excess loading leads to education in a cartilage of cracks, to-rye can go deep to a bone plate over time (see. Osteochondrosis ). The joint cartilage of a femur, a joint cartilage of a patella, meniscuses of a knee joint is most often injured (see. Knee joint , Meniscuses joint , Patella ).
At a research of the cartilaginous tissue taken at a biopsy the submicroscopy reveals transformation of cartilaginous cells in fibroblastopodobny, proliferation of chondrocytes, change of properties of cells in the form of a hypertrophy of a lamellar complex (Golgi's complex), education in cytoplasm of lysosomes and lysosomic sequesters.
M.'s clinic of cartilaginous tissue is very poor and uncharacteristic. The most constant symptoms consider synovitis (see) and the pains arising in the injured joint after an exercise stress. At injury of a cartilage of a patella of its movement are followed by an easy crunch. In far come cases when injuries of a cartilage become visible, the diagnosis can be made by method of an arthroscopy (fig. 1).
At hron. M of a fibrous cartilage the first a wedge, symptoms of a disease are at first insignificant, and then, at the proceeding loading, megalgias in the field of connection of bones. At injury of a cartilage pubic symphysis (see) perhaps development of a symphysitis; at damage in sternocostal (the II—III — IV edges) joints — a syndrome to Tittsa (see. to Tittsa syndrome ). In the latter case in the place of defeat the dense, painful swelling is defined. Uncured M. of cartilaginous tissue lead to development of the deforming osteoarthrosis (cm. Arthroses ). See also Joints , Cartilaginous tissue .
Microtrauma of a bone tissue. From acute M. bruises are possible periosteums (see), followed by subperiostal hemorrhage and local (sometimes strong) morbidity. Treatment: rest, thermal procedures.
Under influence hron. M of a bone tissue arise local processes of reorganization of a bone. Further the integrity of all frame system is broken that causes eventually at first a hypertrophy of cortical substance, and then formation of the considerable center patol, reorganizations in the form of cross sites of an enlightenment — Loozer's zones (see. Loozera of a zone ). In a spongy bone the sites of an aseptic necrosis which are coming to light radiological in a look uzur or cystic educations form. Process of reorganization is most often observed in a tibial bone, plusnevy bones and bones of a tarsus. Patol. changes in a bone tissue are clinically shown by the swelling and local morbidity which is defined at a palpation and loading.
For M.'s diagnosis bone weaved during the early period of a disease use a method of scanning by isotonic solution of osteotropny isotope of strontium-85 (see. Scanning ). During the late period of a disease on roentgenograms the thickening of cortical substance comes to light, and then — the sites of an enlightenment which are formed as a result of substitution of bone plates fibrous or cartilaginous tissue.
At overloads of bones of foot (athletes, the military personnel, etc.) have them funkts, an insufficiency. It can lead to formation of loozerovsky fractures of plusnevy bones (see. Mid-flight foot ), and also to development of bottom neuritis (metatarsalgias, plantalgiya) which are shown the sharp localized pain in the area 3 — 4 metatarsophalangeal joints, the caused neuropathy of the 4th manual nerve (see. Mortonovsky metatarsal neuralgia ). In the started cases the fixed flat-footedness develops.
At acute M. skin make its processing by solutions of antiseptic agents (Rivanolum, iodine, etc.), apply aseptic dressing; at extensive grazes also process them solutions of antiseptic agents, apply aseptic dressing, enter antitetanic anatoxin (see. Immunization ); scratches, cuts, small on the area of a graze process antiseptic kleyushchy substances (e.g., Novikov's liquid), foreign bodys surely delete. At acute M. of other localizations rest, thermal, physiotherapeutic procedures are shown.
Main method of treatment hron. M — conservative: rest, an electrophoresis of novocaine, gumizolya, a lity with iodine, fonoforez corticosteroid drugs (a hydrocortisone, Prednisolonum), radonic, hydrosulphuric, solyanokhvoyny bathtubs, mud applications. Futlyarny blockade of 0,5% solution of novocaine in number of 100 — 150 ml with addition of B12 vitamin and analginum with the subsequent imposing of a bandage are effective. Injections to the painful area of microcrystallic suspension of a hydrocortisone on 1 — 2 ml 3 — 4 times with a break 3 — 4 days are recommended. The good therapeutic effect gives administration of oxygen in patol, the center for the purpose of improvement of food and blood circulation of local fabrics. The oxygenotherapy was widely adopted at effects hron, M. and development of degenerative and dystrophic processes in joints. In joints enter oxygen according to their capacity (into talocrural 15 — 20 ml, into knee — 60 — 100 ml etc.). The oxygenotherapy can be combined with simultaneous introduction to a joint of 1 — 2 ml of a hydrocortisone or 1 ml of a vitreous (drug of mucopolysaccharides). On a course — 5 injections with an interval of 3 — 4 days. At M. use of thyrocalcitonin (TKT) is shown to a bone tissue. Drug positively influences metabolic processes in a bone. It is entered in solution intramusculary or accepted in the form of tablets 2 times a day on 15 conventional units during 4 weeks with one day of a break a week. Treatment by drug TKT shall be combined surely using a gluconate of calcium.
At unsuccessfulness of conservative treatment in nek-ry cases the operational treatment undertaken for the purpose of improvement of local blood circulation, denervation patol, the center, removal of hyperplastic fabrics is shown.
At hron, a paratenonitis of an Achilles tendon operation — a tenolysis of a sinew is recommended, at Krom on lateral edge of a sinew in the place of morbidity and consolidation cut skin and a fibrous vagina, the last stupidly on a circle is separated from a sinew on all its extent. According to indications tenolysis (see) combine with removal of the fibrous changed pretendinous cellulose. Stitches are put only on skin. The movements in an ankle joint begin from the 2nd day after operation. At hron, a bursitis of an Achilles tendon excision of a mucous bag is shown.
At a tendoperiostopatiya of own ligament of patella the tendoperiostotomiya (fig. 2) is shown; operation consists in drawing 4 — 6 slits of a sheaf up to 1 cm long. At deformation of the lower pole of a patella its resection is recommended. At a subpatellar bursitis removal of a deep bag is shown.
At processes of reorganization of a bone tissue of a tibial bone in a stage of periosteal reaction the fasciotomy — separation of a fascia from a periosteum throughout all painful area is shown. At education in a bone tissue of zones of Loozer apply a tunnelization of a bone by Beck's method for the purpose of stimulation of germination of osteocytes in a dense bezosteotsitny bone via the created channels.
In cases of a chondropathy and a chondromalacia of a joint surface of a patella or condyles of a femur the good result is yielded by removal of a plate of an otsloyenny or razvoloknenny cartilage.
The forecast and Prevention
the Forecast at early and purposeful treatment of M. favorable.
Prevention. Necessary conditions of prevention of M. is the correct organization of work, mechanization of laborious works, use of defensors and medical means, timely treatment of small injuries in the acute period; medical examination of patients, the rational organization of sports occupations, constant medical control in sport.
See also Damages .
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3. S. Mironova, I. A. Badnin, E. V. Bogutskaya, R. I. Merkulova.