Bone Injuries Flashcards
What are the different types of fractures?
Transverse Oblique Spiral Comminuted (major trauma - several pieces of bone) Segmental Torus Greenstick (if goes through growth plate then can affect growth) Avulsed Impacted
Describe the Salter Harris classification (I-V)
Type 1: # through the growth plate
TYPE 2: # through physis and metaphysis (MOST COMMON)
Type 3: # through physis and epiphysis
Type 4: # through epiphysis, physis, metaphysis
Type 4: impaction # (WORST PROGNOSIS)
What are the OARs?
XR indicated if there’s pain @ malleoli/5th MT/navicular + any of these findings:
Pain at lateral/medial malleolus OR navicular/5th MT
Inability to WB 4 steps immediately after injury or in ED
OAR sensitivity/specificity
OAR is good to rule OUT a # 99% SENS
but if there IS pain - it could be fracture but could also be lot of other things - LOW SPECIFICITY 35%
Ottawa Knee Rules
XR indicated if:
- Age > 55
- Tenderness head of fibula
- Tenderness of patella
- Cant bend knee >90º
- Cant WB in ED or right after injury > 4 steps
Again - high sensitivity + lower spec (45%)
XRs - pros and cons?
Pros:
- cheap
- good resolution/accessible
- standard investigation
Cons:
- poor sensitivity to detect subtle pathology
- radiation
- not good for soft tissues
What is the rule of twos in XRs?
Views - take 2 views 90º to each other
Joints - visualize 2 joints
Sides - if damage to growth plate?
Times - if monitoring change
Fracture Healing process: Inflammation
Step 1: INFLAMMATION
- right after # - haematoma forms (good for stability)
- inflammatory exudate
- fibrin and collagen fibrils present in haematoma - haematoma replaced by granulation tissue
- osteoclasts remove the bony necrosis from fracture
Fracture healing process: Soft Callus
- osteoblasts are stimulated
- bone growth starts away from # gap
- capillaries grow into callus
- fragments no longer moving freely
Fracture healing process: Hard Callus
- intramembranous bone formation
- ossification of soft tissues in gap
- bone callus grows PERIPHERAL to central
- endochondral ossification (soft tissue replaced by woven bone)
- fragments now firmly united
Fracture healing process: Remodelling
- lamellar bone replaces woven bone
What are radiographic and clinical signs of good fracture healing/union?
XR:
- bony continuiity
- callus formation
Clinical signs:
- no pain on palpation
- no pain on angulation
- no mobility between fragments
What factors affect healing?
Age
Fracture type (ie severity of #)
Blood supply
Infection
How long (roughly) does it take for a fracture to heal?
(Perkin’s timetable):
UL spiral # - 3 weeks
LL - 6 wks
LL transverse - 6 wks
What are the general principles to be addressed when managing a #
Reduce (align the fragments)
Immobilize (immob/stabilize)
Mobilize (treat assoc impairments to prevent joint stiffness elsewhere?)
Name 5 complications (at least) from #
Stiffness
- d/t immobs - immob causes loss of sarcomeres and shortened mm on contracted side
Deformity
- causes abnormal biomechanics, OA, poor function of limb
Non/Mal-union
- Risk factors = high energy injuries, smoking, blood supply, little soft tissue (eg. tibia has little tissue around it)
Vascular Damage:
- Direct -arterial injury
- Secondary - compartment syndrome
Nerve Injury, Growth disturbance, Infection, OA
Fat embolism - reduce risk by EARLY STABILIZATION of bone #; can go to lungs/brain - hypoxaemia/cerebral ischemia
Colles Fracture
MOI - FOOSH
Presentation: hx of trauma/swelling/pain/deformity/osteoporosis in women?
Management: open or closed, immobs (6/52), rx joint stiffness, mm strength etc
Stress fracture - hip and groin
MOI: sudden change in training regimen
Presentation: worse with activity, better with rest, assoc with eating disorders/amenorrhea; common in PUBIC RAMUS/FEMORAL NECK
Management: rest+graded RTS
Femoral shaft fractures
MOI - high energy; transverse, oblique, comminuted, spiral; may also have other fractures
Management: ORIF, plates/screws/intramedullary screw
Patella fractures
MOI - fall/direct blow to knee
Types of patella fractures - transverse (MOST COMMON), lower pole, stellate, vertical, minimally displaced
Management: ORIF - scews, pins, wires
Supracondylar fractures of the knee
just above the knee
MOI - high energy trauma
Management - ORIF
Tibial plateau fracture
MOI - direct blow, fall, rotational force
Management: ORIF if displaced; 6 weeks NWB (so immob will cause stiffness); healing can be 10-12 weeks)
Implications: Valgus deformity/OA/knee stiffness
Tibial shaft fractures
MOI - low or high energy
- transverse/oblique/comminuted/spiral
- poor soft tissue coverage - so may develop ulcers from cast?
- poorer healing potential than femoral shaft
- if there’s a rotational force - then tibia/fibula # at different levels; if direct blow - then tibia/fibula # at same level
Management:
Closed or ORIF + immobs
What is the Danis-Weber Classification for ankle fractures?
Type A - infrasyndesmotic
Type B - transsyndesmotic
Type C - suprasyndesmotic (WORST+most complex - NWB for 10 weeks; screw through tib/fib for 10wks)
Management for ankle fractures
6 weeks cast
PT intervention - advice is as good as rehab - Moseley et al (2015)
Calcaneal Stress fracture
MOI - usually assoc with running
Presentation - tender post calc; ++ squeeze test
Management: reduce load; heel pads if needed
Navicular Stress Fracture
MOI - common in jumping, sprinting, hurdling; d/t traction from tib post? impingement of tarsal bones?
Presentation - point tenderness
Management: Reduce load, cast/brace 6/52 + rehab post immob
Jones fracture
Avulsion of 5th MT
MOI - inversion injury
Management - closed reduction, boot, WBAT
Stress fracture, 2/3 MT
MOI - walking/marching
Management - boot
Lisfranc injury
Tarsometarsal dislocation
MOI - low energy - twist/fall or high energy - fall from a height
Management - ORIF (lot of screws put in which can cause significant pain over time) or conservative - 6-8wks
- can result in OA/ankle fusino/chronic pain
