Fractures Flashcards
Define fracture
- defect in continuity of bone
Define traumatic fractures
- sudden, forceful impact
- MVA, fall, assault, or abuse
Define pathologic/insufficiency fractures
- osteoporosis
- nutrient deficiency, age, sex, smoking, proton pump inhibitors, or corticosteroids
Define stress fractures
- change in training frequency, intensity, or volume
- overtraining, inadequate recovery
- LE mechanics
Describe an avulsion fracture
- occurs from tensile load usually from a tendon
- when under high tension the bone is what is broken and pulled away
Salter Harris classification of epiphyseal fractures
- Type I: straight through the growth plate
- Type II: begins in the growth plate then goes through the diaphysis
- Type III: begins in the epiphysis and goes through the growth plate
- Type IV: goes through all layers
- Type V: compression of the growth plate (impaction fracture)
- Type VI: compression of one side of growth plate
- Type VII: only goes through the epiphysis
- Type VIII: only goes through the diaphysis & metaphysis
- Type IX: tendon coming off of the side
Describe a closed reduction of fractures
- placing the bone back into place with the used of soft tissue hinge without surgery
Describe an open reduction of fractures
- placing the bone back into place through surgery
Describe a Galeazzi fracture
- distal radius
- dislocation of distal radioulnar joint
Describe a Jones fracture
- base of 5th metatarsal
Describe a Maisonneuve fracture
- fibula
- a few inches above mortise
Describe a Monteggia fracture
- proximal ulna
- dislocation of radial head
Describe a Nightstick fracture
- midshaft ulna
Describe a Piedmont fracture
- radial shaft
Describe a Pott’s fracture
- oblique lateral malleolus
- transverse medial malleolus
Describe a Torus/Buckle fracture
- cortical bone compression type defect without displacement
Describe primary/direct cortical bone healing
- continuity is restored by direct contact & healing of the original cortical tissue
- requires near perfect reduction, very stable immobilization
Describe secondary/indirect cortical bone healing
- follows more classic healing response (inflammation, repair, remodeling)
- facilitated by some motion & some weight bearing
Describe cancellous bone healing
- direct, membranous bone formation
- occurs quickly but can only cover a few millimeters
- probably mediated by local stem cells
Factors that affect bone healing
- age
- degree of local trauma
- degree of bone loss
- type of bone involved
- degree of immobilization
- infection
- local malignancy
- radiation necrosis
- avascular necrosis
- hormones
- exercise/modified tension along the line of stress
Complications related to bone healing
- delayed union (pathological)
- slow union (non-pathological)
- nonunion (fragments do not form into one bone)
- malunion (fragments heal improperly)
- pseudoarthrosis (false joint, fibrous union)
- osteomyelitis (infection)
- avascular necrosis
Complications in adjacent tissues to bone healing
- soft tissue injury
- arterial injury
- nerve injury
- compartment syndrome
What are the 5 P’s of compartment syndrome
- Pain
- Paresthesia (numbness/tingling)
- Paralysis
- Pallor (unhealthy pale appearance)
- Pulselessness
Commonly missed fractures on X-ray
- C1-2
- C6-7
- vertebral body fractures (osteoporosis)
- scaphoid
- radial head
- femoral neck
- tibial plateau
- patella
- calcaneus
Late effect complications related to bone healing
- complex regional pain syndrome (CRPS)
Describe complex regional pain syndrome (CRPS)
- grouping of complex painful disorders that develop as a consequence of trauma affecting the extremities with or without an obvious peripheral nerve lesion
- MOI unclear
- often associated with surgery
- very difficult to manage
Difference between type I and type II CRPS
- Type I: no nerve injury evident
- Type II: peripheral nerve injury present
Clinical features of CRPS
- pain
- hyperesthesia
- tenderness
- swelling
Signs and symptoms of CRPS
- severe pain with hypersensitivity
- trophic changes : nail, hair, skin, & bone/osteopenia
- autonomic disturbances
- functional impairment
Describe stage I/acute reversible stage of CRPS
- lasts 3-6 months
- vasodilation
- pain & edema are dominant clinical features
- erythema, hyperhydrosis, rapid nail growth, & warmth
- early intervention may prevent progression
Describe stage II/dystrophic ischemic stage of CRPS
- may lasts 3-9 months
- vasoconstriction
- pain (burning) & edema increases
- brittle nails
- cold/cyanotic/dry/mottled skin
- hypersensitivity to cold
- osteoporosis
Describe stage III/atrophic stage of CRPS
- may last years
- spontaneous recovery often occurs within 18-24 months
- pain increases or decreases
- atrophy
- severe osteoporosis
Management of CRPS
- control pain & edema (compression garments, e-stim, elevation, gentle massage, moist heat, or splints)
- desensitization techniques
- active movement within pain free range (all pain provoking activities must be eliminated)
- weight bearing
- joint mobilization is contraindicated
Describe a Colles fracture
- radial fracture with dorsal displacement of the distal fragment & radial shift of the carpal bones
What causes greater injury to a Colles fracture
- greater wrist extension at impact generally results in greater injury, possibly including a comminuted fracture
Management for a Colles fracture
- ranges from closed reduction (cast or external fixation) to surgical reduction & internal fixation
- fracture healing takes 5-8 weeks with expected full functional recovery in 4 months
Describe a Smiths fracture
- distal portion of radial fracture dislocates palmarly
Management of a Smiths fracture
- surgery usually required
- fracture healing in 5-9 weeks with expected full functional recovery in 6 months to a year
Treatment for a Smiths fracture
- While casted: ORM at digits, elbow, & shoulder with the goal to reduce edema & prevent capsular & tendon tightness
- Cast removed: gentle ROM at thumb & wrist in pain free range & edema control
- If continued limited ROM: joint mobilizations may need to be incorporated
- Once full ROM: strengthening exercises can be added
What is the most common carpal bone fracture
- scaphoid (60-70%)
- typically with a history of FOOSH (fall on outstretched hand)
Complications related to scaphoid fractures
- non-union or necrosis due to blood flow interruption
Scaphoid fracture rehab during immobilization
- primary focus is edema reduction & ROM of the uninvolved distal joints
Scaphoid fracture rehab following cast removal/use of thumb spica splint
- wrist exercises that focus on differential gliding of the wrist & finger
- strengthening with exercise putty, sustained grip activities, & gradual closed chain activities progress to tolerance
- return to full activity within 12 weeks after cast removal
Describe a SLAC (scaphoid lunate advanced collapse)
- disruption of the scapholunate ligament
- rotary subluxation of the scaphoid, it flexes in a palmar direction
- abnormal forces from the scaphoid to radius & from capitate to lunate
Describe stage I SLAC
- degeneration at radial styloid & distal radial aspect of scaphoid
Describe stage II SLAC
- Stage IIA: entire radioscaphoid articulation involved
- Stage IIB: radioscaphoid & STT joint arthritis
Describe stage III SLAC
- radioscaphoid, scaphocapitate, & lunocapitate articulations involved
Describe the different surgeries for a SLAC
- Proximal row carpectomy: 60% of normal ROM as compared to opposite wrist & over 90% of normal grip strength
- Four corner fusion: less than 50% ROM & about 75% grip strength
What does a tibial plateau fracture history look like
- high energy trauma
- ensure no symptoms of compartment syndrome
- beware that 50% of closed tibial plateau fractures have menisci & collateral ligament tears
Symptoms of a tibial plateau fracture
- pain especially with weight bearing
- swelling
- decreased flexion ROM
Diagnosis of a tibial plateau fracture
- AP (anterior posterior) & oblique X-ray
- CT may be used after diagnosis to determine surgical approach
