chapter 4 injury mechanism and classification of injury
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Chapter 4 Injury Mechanism and Classification of Injury. Anatomic Foundations. Anatomic position Joint movement Sagittal plane Frontal plane Transverse plane Directional terms Movement Terms. Anatomic position. Mechanism of Injury. Mechanism of Injury (MOI): How an injury occurs - PowerPoint PPT PresentationTRANSCRIPT
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Chapter 4
Injury Mechanism and Classification of Injury
Chapter 4
Injury Mechanism and Classification of Injury
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Anatomic FoundationsAnatomic Foundations
• Anatomic position
• Joint movement
– Sagittal plane
– Frontal plane
– Transverse plane
• Directional terms
• Movement Terms
Anatomic position
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Mechanism of InjuryMechanism of Injury
• Mechanism of Injury (MOI): How an injury occurs
• Components used to analyze MOI:
– Application of force
– Tissue type
• Severity of force
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ForceForce
• Force: a push or pull acting on a body (e.g., gravity, friction)
• Force acting on a body causes:
– Acceleration
– Deformation
• Factors that determine injury:
– Magnitude of force
– Material properties of tissues involved
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Force (cont’d)Force (cont’d)
• Small load = elastic response
• Large load = plastic response
• Yield point = load exceeds the ultimate failure point of the tissue resulting in mechanical failure
• Anisotropic = material is stronger in resisting force from certain directions than others
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Mechanical Forces - InjuryMechanical Forces - Injury
• Compression
– Force that crushes tissues
• Tension
– Force that pulls and stretches tissues
• Shearing
– Force that moves across the parallel design of the fibers
Mechanisms of injury
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StressStress
• Stress = Force x Surface area affected
• Same force over a large area vs. a small area can have very different results
Stress
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Injury TypesInjury Types
• Acute Injury
– Single force
– Characterized by a definitive moment of onset
– Force = macrotrauma
• Chronic Injury
– Repeated forces
– Characterized by becoming more problematic over time (Gradual onset over time)
– Forces = microtrauma
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Check for Understanding!Check for Understanding!
Movements in the sagittal plane include flexion, extension, abduction, and adduction.
A.True
B.False
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Check for Understanding!Check for Understanding!
Which of the following is a correctly matched pair of terms? (Select all that apply)
A.Adduction – movement away from the midline of the body
B.Flexion – decreasing an angle
C.Extension – increasing an angle
D.Plantar flexion – movement of the forefoot toward the shin
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Check for Understanding!Check for Understanding!
When tissues sustain a force, what are the primary factors that determine the occurrence of an injury? (Select all that apply)
A.The magnitude of the force
B.The direction of the force
C.The material properties of the involved tissues
D.The length of time the force is applied
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Check for Understanding!Check for Understanding!
What are the three primary mechanical forces that produce injury?
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Anatomical Properties of Soft TissueAnatomical Properties of Soft Tissue
• Collagen
– Primary component of skin, tendon, ligaments
– Protein substance strong in resisting tensile forces
– Wavy configuration that allows for an elastic type deformation or stretch but, otherwise, is inelastic
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Anatomical Properties of Soft Tissue (cont’d)
Anatomical Properties of Soft Tissue (cont’d)
• Elastin
– Protein substance in connective tissue
– Adds elasticity
Collagen fibers
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SkinSkin
• Epidermis
– Multiple layers
• Dermis
– Loose, multidirectional arrangement of collagen fibers
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Skin Injury ClassificationSkin Injury Classification
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Skin WoundsSkin Wounds
• Blisters
– Accumulation of fluid between epidermis and dermis
– Caused by repeated application of shear in one or more directions
• Skin bruises
– Accumulation of blood within skin
– Results from compression sustained during a blow
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MusclesMuscles
• Produce skeletal movement and maintain postural alignment
• Viscoelastic
– Extensibility
– Elasticity
Muscle tissue
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Muscle (cont’d)Muscle (cont’d)
• Irritability: ability to respond to a stimulus
– Electrochemical – nerve impulse
– Mechanical – external blow
• Contractility: ability to develop tension
– Isometric
– Concentric
– Eccentric
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TendonsTendons
• Muscle to bone
• Dense connective tissue with unidirectional bundles of collagen & some elastin
• Collagen – parallel arrangement
– Helps in resisting high, unidirectional tension loads from the attached muscle
• 2X as strong as muscle it serves
• Yield point 5-8% in length
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Tendons (cont’d)Tendons (cont’d)Collagen arrangements in tendon and ligament tissue
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Contusions Contusions
• MOI: compression
• Can be both deep and superficial
• Must be cautious and aware of more severe injuries associated with repeated blows
• S&S:
– Onset - acute
– Ecchymosis: if superficial
– Hematoma
– Restrictions in ROM
– Pain – localized
– Swelling
– Associated nerve compression
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Classification for ContusionsClassification for Contusions
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StrainsStrains
• Damage to muscle or tendon
– Key factor: magnitude of force and structure's cross-sectional area
• MOI:
– Abnormally high tensile force
• Most common site for tears: near the musculotendinous junction
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Classification of StrainsClassification of Strains
<table 4.4, classifications of strains>
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Muscle Cramps and SpasmsMuscle Cramps and Spasms
• Involuntary muscle contraction
• Cramp:
– Biochemical imbalance (dehydration) associated with muscle fatigue
– Painful
– Types
• Clonic – alternating contraction/relaxation
• Tonic – constant
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Muscle Cramps and Spasms (cont’d)Muscle Cramps and Spasms (cont’d)
• Spasm:
– Reflex action caused by:
• Biochemical imbalance or
• Mechanical blow to nerve or muscle
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Myositis and FasciitisMyositis and Fasciitis
• MOI: repeated movements irritate the tissues
• Myositis:
– Inflammation of muscle tissue (e.g., shin splints)
• Fasciitis:
– Inflammation of the fascia (e.g., plantar fasciitis)
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Tendinitis and TenosynovitisTendinitis and Tenosynovitis
• Tendinitis: inflammation of a tendon
– Related to aging and degenerative changes
– S&S: pain and swelling with tendon movement
• Tenosynovitis: inflammation of the tendon sheath
– Acute: rapid onset, crepitus, local swelling
– Chronic: same as acute, thickened tendon, nodule formation in sheath
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Myositis OssificansMyositis Ossificans
• Mineral deposits in muscle associated with prolonged chronic inflammation
– Ectopic calcification
– Common site: quadriceps
• Calcific tendinitis: mineral deposits in the tendon
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Overuse InjuriesOveruse Injuries
• Results from repetitive use
• Factors:
– Intrinsic
– Extrinsic
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Overuse Injuries (cont’d)Overuse Injuries (cont’d)
• Classification
– Stage 1: pain after activity only
– Stage 2: pain during activity, does not restrict performance
– Stage 3: pain during activity, restricts performance
– Stage 4: chronic unremitting pain, even at rest
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Anatomical Considerations of JointsAnatomical Considerations of Joints
• Articulation of two bones
• Classified by structure and function
• Structure
– Cartilaginous
– Fibrous
– Synovial
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Anatomical Considerations of Joints (cont’d)
Anatomical Considerations of Joints (cont’d)
• Function: based on the amount of movement allowed
– Synarthoses
– Amphiarthroses
– Diarthroses
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Diarthrodial JointsDiarthrodial Joints
• Components
– Articular cartilage
– Joint (synovial) cavity
– Articular capsule
– Synovial fluid
– Reinforcing ligaments
• Intrinsic or Extrinsic
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Diarthrodial Joints (cont’d)Diarthrodial Joints (cont’d)
Joint components
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Articular CartilageArticular Cartilage
• Ends of bones covered by hyaline cartilage…solid type of connective tissue
• More resistant to deformation than fibrous connective tissue and more resilient than bone
• No blood supply; nourished by synovial fluid
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Joint CavityJoint Cavity
• Filled with synovial fluid
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Articular CapsuleArticular Capsule
• Cuff of fibrous tissue
– Primarily bundles of collagen
• Primary function: hold bones together
• Inner layer: synovial membrane
– Produces synovial fluid that lubricates the joint.
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Synovial FluidSynovial Fluid
• Functions
– Lubricate joint
– Reduce friction
– Nourish joint
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Ligaments Ligaments
• Bone to bone
– Intrinsic
– Extrinsic
• Maintain anatomical integrity and structural alignment
• Collagen and elastin intermixed (contain elastin – more elastic than tendons)
– Viscoelastic
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Ligaments (cont’d)Ligaments (cont’d)
• Resists large tensile loads along the long axis of the ligament and smaller loads from other directions – static stabilizers
• Fail in fast loading situations
• Strongest in their middle and weakest at their ends
• Healing process – slow due to a limited blood supply
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Classification of Diarthrodial JointsClassification of Diarthrodial Joints
• Plane
• Hinge
• Pivot
• Condyloid
• Saddle
• Ball-and-socket
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Injury to the LigamentInjury to the Ligament
• Compromises the ability of the ligament to stabilize the joint
• MOI:
– High tensile force
• S&S:
– Pain; point tenderness; swelling; loss of function; instability
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Classification of SprainsClassification of Sprains
<table 4.5, classification of sprains>
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Dislocations and SubluxationsDislocations and Subluxations
• Joint forced beyond normal limits
• MOI: tension
• Increased susceptibility for chronic or recurrent dislocations
• S&S:
– Pain
– Swelling
– Point tenderness
– Deformity
– Loss of limb function
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Osteoarthritis Osteoarthritis
• Degeneration of articular cartilage
• S&S:
– Pain
– Limited movement
• No definitive cause; rather, several contributing factors
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Bursitis Bursitis
• Inflammation of bursa
• Acute or chronic
• MOI:
– Compression
• S&S:
– Localized swelling
– Point tenderness
– Warm to touch
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Soft Tissue InjuryCheck for Understanding!
Soft Tissue InjuryCheck for Understanding!
The discoloration or swelling outside a joint in the surrounding soft tissue is termed:
A.Bruising
B.Ecchymosis
C.Edema
D.Effusion
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Soft Tissue Injury Check for Understanding!
Soft Tissue Injury Check for Understanding!
The ability of a muscle to be stretched or increased in length is termed:
A.Contractility
B.Elasticity
C.Plasticity
D.Extensibility
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Soft Tissue InjuryCheck for Understanding!
Soft Tissue InjuryCheck for Understanding!
Joint capsules are fluid-filled sacs that serve to reduce friction in the tissues surrounding the joints.
A.True
B.False
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Soft Tissue InjuryCheck for Understanding!
Soft Tissue InjuryCheck for Understanding!
Which of the following statements is true? (Select all that apply)
A.A tear of a ligament is referred to as a sprain.
B.A muscle spasm is brought on by a biochemical imbalance, sometimes associated with muscle fatigue.
C.Overuse injuries are more often attributed to intrinsic rather than extrinsic factors.
D.The onset of bursitis can be acute or chronic.
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Soft Tissue InjuryCheck for Understanding!
Soft Tissue InjuryCheck for Understanding!
Strains and sprains that produce moderate discomfort, tenderness, swelling, ecchymosis, detectable joint instability, and/or muscle weakness are categorized as:
A.1st degree
B.2nd degree
C.3rd degree
D.Severe
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Anatomical Properties of BoneAnatomical Properties of Bone
• Primary constituents:
– Calcium carbonate
– Calcium phosphate
– Collagen
– Water
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Anatomical Properties of Bone (cont’d)Anatomical Properties of Bone (cont’d)
• Structure:
– Diaphysis
– Epiphysis
– Membranes
• Periosteum
– Medullary cavity
– Apophysis
Bone macrostructure
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Anatomical Properties of Bone (cont’d)Anatomical Properties of Bone (cont’d)
• Bone growth:
– Longitudinal
• Continues until epiphysis closes
– Diameter
• Continues to grow throughout life
– New bone formed via the periosteum; bone is resorbed around the medullary cavity
• Osteoblasts: form new bone
• Osteoclasts: resorb bone
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Anatomical Properties of Bone (cont’d)Anatomical Properties of Bone (cont’d)
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Anatomical properties of Bone (cont’d)Anatomical properties of Bone (cont’d)
• Composition
– Cortical
• Compact bone tissue of high density (low porosity)
• Outside
• Can withstand greater stress but less strain
– Cancellous
• Bone tissue of low density (high porosity)
• Inside
• Can tolerate more strain
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Bone Injury ClassificationsBone Injury Classifications
Bone injury mechanisms
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Bone Injury Classifications (cont’d)Bone Injury Classifications (cont’d)
• Fracture: Disruption in the continuity of bone
• S&S:
– Rapid swelling
– Ecchymosis
– Deformity or shortening of the limb
– Precise point tenderness
– Grating or crepitus
– Guarding or disability
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Bone Injury Classifications (cont’d)Bone Injury Classifications (cont’d)
• Type of fracture dependent upon:
– Force applied
– The health and maturity of the bone at the time of injury
• Bone susceptible to:
– Compression, tension, shear, bending, and torsion
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Types of FracturesTypes of Fractures
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Stress FractureStress Fracture
• MOI: repeated lower magnitude forces
• Can become worse over time
• Begins as a small disruption in the outer layers of cortical bone and ending as complete cortical fracture with possible displacement
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OsteopeniaOsteopenia
• Reduced bone mineral density
• Predisposes individual to fracture
– Particularly stress fractures
• Possible causes:
– Amenorrhea, hormonal factors, dietary insufficiencies
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Classification of Epiphyseal InjuriesClassification of Epiphyseal Injuries• Classifications
– Injury to growth plate could result in alteration in normal growth
– Acute injury
• Types I-V
Epiphyseal injuries
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Classification of Epiphyseal Injuries (cont’d)
Classification of Epiphyseal Injuries (cont’d)
• Osteochondrosis
– Disruption of blood supply to epiphysis
– Idiopathic
– Causing necrosis and possible deformity
– Example: Legg-Calvé-Perthes disease
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Classification of Epiphyseal Injuries (cont’d)
Classification of Epiphyseal Injuries (cont’d)
• Apophysitis
– Osteochondrosis of apophysis
– Idiopathic or traumatic avulsion fracture
– Example:
• Sever’s disease
• Osgood-Schlatter disease
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Bone Tissue Injury Check for Understanding!
Bone Tissue Injury Check for Understanding!
In a comminuted fracture, the bone fragments into several pieces.
A.True
B.False
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Bone Tissue InjuryCheck for Understanding!
Bone Tissue InjuryCheck for Understanding!
Osteopenia is a condition:
A.That is exclusive to an older adult population
B.That predisposes an individual to stress fractures
C.That only involves females
D.That inhibits longitudinal bone growth
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Bone Tissue InjuryCheck for Understanding!
Bone Tissue InjuryCheck for Understanding!
Epiphyseal injuries can include damage to the: (select all that apply)
A.Epiphyseal plate
B.Ligaments
C.Articular cartilage
D.The apophysis
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Anatomical Properties of NervesAnatomical Properties of Nerves
• Nervous System
– CNS:
• Brain
• Spinal cord
– PNS:
• 12 pairs of cranial nerves
• 31 pairs of spinal nerves, along with their branches
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Anatomical Properties of Nerves (cont’d)Anatomical Properties of Nerves (cont’d)
• Spinal nerves
– Roots
• Posterior – afferent
• Anterior – efferent
Spinal nerves
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Nerve Injury ClassificationsNerve Injury Classifications
• MOI: Tensile or compression force
• Neurapraxia (grade 1)
– Localized conduction block: temporary loss of sensation and/or motor
– Resolves within days to a few weeks
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Nerve Injury Classifications (cont’d)Nerve Injury Classifications (cont’d)
• Axonotmesis (grade 2)
– Significant motor and mild sensory deficits
– Lasts at least 2 weeks
• Neurotmesis (grade 3)
– Motor and sensory deficit
– Lasts up to 1 year
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Nerve Injury Classifications (cont’d)Nerve Injury Classifications (cont’d)
• Compression:
– More complex; dependent upon:
• Force magnitude and duration
• Direct or indirect
• Nerve injuries result in a variety of afferent symptoms
– Hyperesthesia
– Hypoesthesia
– Paresthesia
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Nerve Injury Classifications (cont’d)Nerve Injury Classifications (cont’d)
• Neuralgia
– Chronic pain along nerve course
• Healing: if completely severed, healing does not occur
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The Neurological Basis of PainThe Neurological Basis of Pain
• Sources
– Somatic, visceral, and psychogenic
• Nociceptors: produce pain sensation
– Mechanosensitive: initiate pain by acute trauma
– Chemosensitive: causes persistent pain in chronic injuries and the early stages of healing
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The Neurological Basis of Pain (cont’d)The Neurological Basis of Pain (cont’d)
• Fibers transmitting pain
– A fibers
– C fibers
– T cells
• Gate control theory of pain
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The Neurological Basis of Pain (cont’d)The Neurological Basis of Pain (cont’d)
• Factors than mediate pain
– Brain production of opioid peptides and endorphins
– Cognitive and affective filters
• Referred pain
– Pain perceived at a location remote from the site actually causing the pain
• Radiating pain
– Pain felt both at its source and along a nerve
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Bone Tissue InjuryCheck for Understanding!
Bone Tissue InjuryCheck for Understanding!
The posterior branches are the afferent (sensory) nerves that transmit information from sensory receptors in the skin, tendons, ligaments, and muscles to the central nervous system.
A.True
B.False
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Bone Tissue InjuryCheck for Understanding!
Bone Tissue InjuryCheck for Understanding!
___________ is perceived at a location remote from the site of the tissues actually causing the pain.
A.Radiating pain
B.Cognitive pain
C.Acute pain
D.Referred pain
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Bone Tissue InjuryCheck for Understanding!
Bone Tissue InjuryCheck for Understanding!
Grade II nerve injuries that produce significant motor and mild sensory deficits that last at least two weeks are termed:
A.Neurapraxia
B.Axonotmesis
C.Neurotmesis