Fractures Flashcards
What is the Difference Between Primary & Secondary Healing?
Primary Healing (Outside-In): Rigid Bone connects with internal fixation to heal
- No Callus
- Open Reduction (internal/external fixation)
- Direct
- AROM usually immediately
Secondary Healing (Inside-Out): bone is regenerated through secondary intention (endochonral ossification)
- Callus Formation
- Close Reduction
- Indirect
- AROM s/P 3-6 wks
What are all the phases of Secondary Healing?
Inflammatory
Endochondral Ossification
Remodeling
What occurs in each phase of Secondary Healing?
Inflammatory: begin to form hematoma for protection
▪ Osteogenic Osteogenic periosteum & endosteum cells
▪ Osteoclasts and macrophages: remove necrotic tissue
▪ Precursor osteoblasts and chondrocytes: form soft callus
Endochondral Ossification- Repair (occurs ~2 wks)
▪ Fibrins & granulation tissues create scaffold for cell migration
▪ Callus formation outside of periosteum (no bone yet)
▪Blood Supply Forms →Capillary Buds grow into callus
HARD CALLUS: give mechanical integrative (@4-16wks)
Remodeling:
▪ internal&external callus join – more strength
▪ bone is smooth and breakthrough callus
What factor might impede healing fractures?
age, comorbidities, medications, social factors (ie. smoking), nutrition, fracture type, trauma, local factors
What impact does smoking having on healing fractures?
Smoking can slow down the process of bone healing
What is the difference between Closed & Open Reduction?
Closed Reduction: Cast, Splint (Secondary Healing)
▪takes longer than open reduction (7-10wks longer)
Open Reduction: surgical interventions thru internal/external fixations (primary healing)
What is the difference between External Fixation and Internal Fixation?
External Fixation: longitudinal traction prevent shortening or angulation, holding 2 bone ends to maintain length-tension (prevent fragment from collapsing onto each other)
▪Allow movement and is not rigid
Internal Fixation: rigid fixation, there is no flexibility
Why might external fixtures be used?
▪ allow muscle tendon unit function across
▪ variable compression/distraction
▪ significant tissue loss/injury – gunshot wounds
Why might internal fixtures be used?
▪ displaced & articular fractures
▪ fractures required mobilization
▪ fractures prone to mal/non-union (scaphoid, ulna, radius)
o Malunion = fracture heals but not really well
o Nonunion = fracture has no bone growth/union at all, continues to look like a fracture
What is the wrist compromised of?
8 Carpal Bones
Distal Radius
Ulna
Associated joint capsule
Several ligaments
What are the 2 axes of motion on the radiocarpal joint?
wrist/extension
radial/ulnar deviation
What is the Distal Radius Ulna Joint (DRUJ)?
forearm rotation (supination and pronation)
hand &carpus move in conjunction with
What does the distal radius articulate with?
scaphoid & lunate→ palmar tilt
What is the normal palmar tilt?
10-15°
What is Triangular fibrocartilage complex (TFCC)?
- cartilage and ligament structure that stabilizes the DRUJ
- distributes force between distal ulna and proximal carpal row (ulnar head and triquetrium)
*distal ulna doesn’t articulate with proximal carpal row
What is ulnar variance?
how distal/proximal ulna is in comparison to radius
*impacts pronations & supination
Norm: 1-2 mm → norm function
What is the difference between positive, neutral & negative ulnar variance?
● Positive ulnar deviance = ulna placed too distally towards the carpus
● Neutral ulnar deviance = ulna and radius at equal level, line up
● Negative ulnar variance = ulna placed too proximally
When is the pain experienced with positive and negative ulnar variance?
(Positive)Pain experienced when:
pronating
gripping/weightbearing at ulnar aspect
(Negative) Pain experienced when:
radial aspect - supination
gripping/weightbearing
*RCP is absorbing too much force ⇨ osteoarthritis
What is the difference between the displacements associated with Colles vs/ Smiths Fx?
Colles (FOOSH): fracture of distal radius with dorsal displacement
- required ORIF/External Fixation
- Most common
Smiths: fracture of distal radius with palmar displacement
- ORIF
What is ligamentotaxis?
two ends of two bones of a fracture are pulled and held in place with an external fixator
What are the rehabilitation guidelines for distal radius fx - Nonoperative protocols?
cast immobilization for non-displaced, stable fractures
- <=20° wrist flexion & ulnar deviation
- well-padded cast with MPs free
- Address issues with cast - avoid complications
- Blocking
-External Fixation
-Internal Fixation
What are strategies for regaining ROM?
o Tenodesis (demonstrate on unaffected side)
▪ so that they don’t use digital extensors for wrist extension (as a substitution pattern)
▪ use pure wrist extensors to perform wrist extension and grasp with digits
o Common substitution pattern = wrist extension with the aid of digital extensors
o PROM (when appropriate)
o Joint mobilizations (prn and only with physician involvement)
o Modalities prn (ie. heat, cold)
o Gradual addition of PREs when appropriate
o Continual upgrade and revision of home program
What are the scaphoid fractures?
Scaphoid Tubercle
Scaphoid Waist: most common area (70% of scaphoid fx)
Proximal Pole: Poor Blood Supply (PPP); due to mal/non-union lack of blood supply
* leads to necrosis
*worst type of scaphoid
How common are scaphoid fractures?
Most common!
60-70
What is the scaphoid supplied by?
Radial artery, recurrent arterial blood supply
What is the association between Kienbocks disease & lunate bone?
During Lunate Fractures
avascular necrosis of lunate – blood supply is compromised and an issue
What is SALTER HARRIS?
pediatric fracture of the epiphyseal growth plate
What are the types of metacarpal fracture?
Boxer’s fracture = an extraarticular MCP neck fracture
caused: compression force/direct blow w
MCP shaft fractures = immobilization for 3-5 weeks
*same posture as Boxer’s fracture (safe
position)
MCP head fractures – usually require ORIF
MCP base fractures =
uncommon; 2nd and 3rd digits usually stable; 4th or 5th digits
*not correctable but functional
▪ Bennett fracture = 1st MCP base fracture (thumb)
▪ Rolando fracture = 1st MCP base fracture (thumb), involving 3 fragments
What are the phalangeal fractures?
P1: Proximal Fx - most are nondisplaced/ stable fixtures
P2: Middle Fx - deforming forces at FDS & Central Slip on Extensor Side
* monitored for swan neck, DIP extensor
P3: Distal Fx - injury or avulsion to terminal tendon
most common
Monitor: DIP extensor lag
