PainNot a disease or curse

Protective mechanism

Dr. Shrikant GoreM.S. Orthopaedics

• Professor and Head• Department of Orthopaedics• Government Medical College • Latur – 413512• E-mail – laturmedical@gmail,com

Definition

• Unpleasant sensation felt, by a person, to any injury to the body• Mechanical - pinch, prick, cut, stretch, crush etc.• Chemical - external & internal (Bradykinines,

Serotonins, prostaglandins, Bacterial toxins)• Thermal, electrical• Psychological

Protective

• It initiates body’s protective response to injury• Minimizing the damage and helps in repairs by

initiating healing process• Pain is essential to maintain health and repair

damage • Pain needs to be treated as an emergency to

protect body from damage by removing the cause of pain

Physiology

• Stimulus• Sensory receptors at nerve endings• Receptors are type specific and their

concentration is area specific, depending on the the need of the area, e.g. maximum concentration of touch receptors at finger tips minimum touch receptors on visceral organs

Pathway

• On stimulation of receptor biochemical reaction sets in generating electrical impulse with injury specific modality, Carried through nerves, spinal cord.

• Spinal reflex is set in and the part of body subjected to injury is withdrawn away from the injury source to avoid damage

Perception

• The impulse is carried further to Sensory cortex representing the area of stimulus

• The sensory cortex analyses this modality to recognize the specific injury type resulting in perfect location of the area of injury and the type of injury

• It sends suppressive signals to spinal cord to reduce the severity of further similar impulse

Pathological Sites

• Nerve ending• Peripheral Nerves• Nerves• Nerve root • Spinal cord • Basal Ganglion

• Neuropathies• Stretching• Compression,• Girdle pain• Involuntary movements

Pathological Sites

• Cerebellum• Cerebrum• Psyche• Autonomous n.

• Ataxia, Balance• Altered, lost,• Pain without stimulus• Causalgia

Peripheral Nerves

• Carry electrical current generated at sensory receptor

• If the nerve is affected by inflammation or pressure the modality(frequency) of electrical current changes on its way to brain changing the perception of sensation (Altered sensation)

• Touch is perceived as Tingling, Burning, Numbness, pricking etc. due to alteration of the electrical impulse

Peripheral neuropathies

• Nutritional - B-complex Vitamins• Metabolic - Diabetes mellitus• Toxicity - Lead • Infections - Leprosy, viral• Drugs - Alcohol,

Abnormal Types

• Throbbing• Radiating • Referred• Shifting• Phantom• Causalgia

Throbbing pain

• Pulsatile pain • Spike of pain coming at regular intervals• Aneurisms Aortic - stretching of outer layer of vascular

wallBerry’s – increased intra cranial pressure with

each pulsation

Migraine dilated intracranial vessels increased blood with each pulsation increases intracranial pressure

• Abscess Inflamed abscess wall and surrounding tissue with hyperactive nerve endings getting stretched and stimulated with every pulsation

Radiating Pain

• Nerves, Nerve roots - Compression, Stretching• In addition to altered sensation• Affected nerve becomes painful • The pain radiating along the course of the nerve

Referred Pain

• Pathology at one site, pain felt at other site• Cerebral cortex unable to locate the site of pain. • Commonly seen in pathologies affecting deeper

structures Heart, appendicitis, Hip joint• Deeper structures less likely to get injured by

physical trauma have very low number of pain receptors.

Referred Pain

• One single nerve supplies multiple organs• The pain is felt at the organ having better number

of sensory receptors , supplied by same nerve root

• It gets distributed to larger area of brain making it difficult for pin point location

Shifting pain

• Pain initially felt at one site disappears and is felt at other site

• Referred pain with progression of damage is better located by the brain and felt at the site of pathology. The confusion of site getting cleared with increase in the injury at the site

Phantom

• Phantom sensation is felt in amputated part The person feels presence of limb with every type of sensation in it.

• The cut nerve at the end of amputation stump heals by fibrosis forming sensitive neuro-fibromatous mass which on stimulation sends impulses to brain which are analyzed by brain as coming from the limb more the fibrosis more the chance of phantom sensation

CausalgiaComplex regional pain syndrome

• Condition where partial peripheral nerve injury in associated with reflex sympathetic dystrophy

• Injured peripheral nerve with sympathetic dysfunction

• Commonly seen in Brachial plexus injury

Clinical features

• Peripheral vasodilatation – Burning, swelling, edema, increased sweating, hair & nail growth initially but loss of hair, dry cracked nails with progression

• Three times more Common in female patients• Average age being 42 years

Clinical features

• Pain initiated with any stimulus hypersensitivity• gradually worsens• Red, hot, shiny skin with excessive or less

sweating• Wasting of muscles• Stiffness of joints• Regional Osteo porosis

AttitudePosition taken by the part at the time of examination

Attitude / Deformity

• Attitude of joint to be described in every direction in which normal physiological movements are possible

• Any position not possible physiologically will be called as deformity

• Any loss of physiological position will be called as deformity

DeformityLoss of form

Any deviation from normal anatomy

The Size

• Change in size or shape &loss of range of movement

• Size -The length

-The width

-The Depth

-The circumference

with its exact location, extent & site of maximum deviation

The shape

• The extremity Change in

-The angle -The shift or step

-The rotation

-The curvature –concavity or convexity – reduced obliterated or reversed

- The outline -any local bump or depression

Local changes

• Change at a site

Lump or swelling• Presence of

Scar, Sinus, ulcer,

abrasion, wound, blebs

abnormal skin patch,

The look

• The Skin

-Appearance – Normal, stretched, wrinkled

-Color - pale, red, blue, black

-Dilated veins

-Hydration – Normal, dry, wet, oily, glossy

-Texture – normal, smooth, roughened, puckered

-The hair distribution & appearance

-The skin thickness- thinned, thickened, edematous

Loss of range of movements

• Loss of range of movement will be called as fixed deformity

• In fixed flection deformity of 10 degrees neutral position will not be possible as will be extension

• From fixed flection deformity of 10 degrees further flection up to certain degrees will be possible

• To confirm fixed deformity in a joint the joint above and below must be in normal anatomical position as the deformity can be masked by change in the position of joint above or below