Fractures Flashcards
Metaphysis
Flare; the transitional zone at which the diaphysis and epiphysis of a bone come together. Stops growing at 18-25 yo and ossifies.
Physis
Growth Plate
Epiphysis
Rounded end of a long bone, at its joint with adjacent bone(s). Between the epiphysis and diaphysis.
Salter Harris Fractures
Salter fractures are fractures of the epiphyseal plate in a growing child. They are classified into five types, based on the pattern of the fracture line. Generally correlates with the potential for future growth disturbance.
What Salter Harris Fracture has the lest impact on growth disturbances, which is the worst?
The potential for growth disturbance is least for type I and increases with the classification number, the worst prognosis being associated with type V injuries.
Salter Harris Type I
The entire epiphysis
Salter Harris Type II
The entire epiphysis with a portion of the metaphysis
Salter Harris Type III
A portion of the epiphysis
Salter Harris Type IV
A portion of the epiphysis with a portion of the metaphysis
Salter Harris Type V
Nothing “broken off”; compression injury of the epiphyseal plate
Diagnosing Type I S-H Fractures
Type I and type V Salter fractures may be radiologically undetectable. Type I injuries usually involve little or no separation of epiphysis from rest of bone, and lucent fracture line is not visible along equally lucent epiphyseal plate. Diagnosis of acute Salter type I fractures is usually clinical, based on presence of swelling and tenderness in region of physis.
Diagnosing Type V S-H Fractures
Type V injuries may be evident only retrospectively, when growth disturbance first begins to appear. At the time of initial presentation, however, a history of a significant axial loading force, coupled with significant tenderness in the area of the epiphyseal plate, should suggest the possibility of a type V injury. Such injuries should be immobilized and referred for orthopedic follow-up.
Avulsed Fracture
fx where a fragment of bone is separated from the main mass
Angulated Fracture
degree and direction: need to estimate amt of unbending to make fragments parallel, specify direction of deviation of distal fragment
Night Stick Fracture
isolated fx of ulna (from lifting arm to protect against night stick strike, usu midshaft)
Green stick fracture
Extends into the midpoint of the bone and becomes oriented along the longitudinal axis of the bone with out disrupting the opposite cortex. Bone failure on tension side and bend deformity on compression side
Pathologic Fracture
fx that occur from relatively minor trauma to diseased or otherwise abnormal bone; preexisting process have weakened the bone and rendered it susceptible to fx
Examples of Pathologic Fractures
Metastatic lesions, fx thru bone cysts, compression fx with osteoporosis
Shortened Fractures
amount by which a bone’s length has been reduced. May be from impaction (telescoping) or overlap of fragments
Stress Fracture
Overuse injury. Bone is constantly attempting to remodel and repair itself, esp when extraordinary stress is applied. When enough stress is placed on bone, causes an imbalance b/t osteoclastic and osteoblastic activity and a stress fracture may appear.
Areas most prone to stress fractures
Most common in weight-bearing bones of lower extremity, esp in lower leg and foot.
Transverse Fracture
fx that is at right angle to bone’s long axis
Comminuted Fracture
fx in which bone has broken into several pieces
Oblique Fracture
fx that is diagonal to a bone’s long axis
Spiral Fracture
fx where at least one part of the bone has been twisted
Segmented Fracture
fx in multiple pieces
Rank these in strength: Physis, Metaphysis, Ligament
Just know that physis is weakest and that it is most resistant to traction and least resistant to torsional fxs
Open Fractures
The implications of open fracture are of such significance that this factor alone may determine the patient’s immediate care or ultimate disposition. An open fracture has bone aspects that are visible through broken skin.
Intraarticular Fractures
When a fracture extends into the adjacent joint, it is termed intraarticular. Intraarticular fractures have special significance because disruption of the joint surface may warrant surgery to restore the joint’s contour and prevent subsequent traumatic arthritis. This feature of a fracture line, if present, constitutes important information.
Supracondylar Fracture
A fracture just above the condyles. Usually in the femur or the humerus.
Intertrochanteric Fracture
A fracture running from the greater to the lesser trochanter of the proximal femur is an intertrochanteric hip fracture
Subtrochanteric Fracture
A fracture just below the trochanters is subtrochanteric
T/F: Torus and greenstick fractures are seen almost exclusively in young children.
True
What does a comminuted fracture imply in regards to bone damage?
Comminuted implies splintering or shattering of the bone
Segmented Fracture
A single, large, free-floating segment of bone between two well-defined fracture lines.
T/F: The proximity to the physis determines the remodeling potential
True; the younger the child and the proximity to the physis = greater amount of remodeling
Displacement
Refers to the fracture fragments being nonconcentric or offset from each other. It is expressed in terms of direct measurement (4-mm displacement) or in terms of the percentage of the width of the bone (e.g., 50 percent displacement or complete displacement).
What determines displacement?
The direction of displacement is based on the position of the distal fragment in relation to the proximal fragment.
Separation
The distance two fragments have separated
Shortening
The amount by which the bone’s length has been reduced by the fracture. Shortening may occur by impaction (telescoping of the fragments into one another).
What is a common cause of shortening?
Overriding- The overlap of two completely displaced fragments
Why is it important to get multiple views on an X-ray of a fracture?
Because an x-ray affords no depth perception, a fracture that appears impacted on one view must be visualized at an angle 90 degrees from the first to differentiate it from a fracture whose ends are completely displaced and overriding.
Angulation
Expressed in terms of two parameters: direction and amount. One need only estimate the amount of “unbending” (expressed in degrees) that would be required to make the fragments parallel.
Malunion
Healing of fx in a non-anatomic position. Malalignment due to angulation, rotation, translation, shortening. Compare with other side!
Effects of Malunion
Loss of ROM, pain, weakness; chronic can lead to arthritis and changes in weight distribution of joint surface. Can fix with shoe lifts or with surgery.
Nonunion
Fracture that has not and is not going to heal. Usually no healing for > 6 mo.
Causes of Nonunion
Lack of adequate blood supply at fx site, inadequate stabilization of fx, interposition at fx site, stabilized in unacceptable way, metabolic abnormalities, infection.
Delayed Union
Fracture that requires more time than is usual and ordinary to heal. Usually > 3 mo.
What bones are more prone to Nonunion
Distal tibial diaphysis, scaphoid, proximal diaphysis in 5th MT have higher incidence. Segmental fx of long bones, fx with large “butterfly” fragments b/c of devascularization.
Complications of Fractures
DVT, Fat Emboli, Compartment Syndrome, Neurologic deficits and Vasuclar injury.
DVT
Virchow’s Triad: stasis, injury to blood vessel (trauma), and hypercoaguability.
Treatment of DVT
Medical prophylaxis is currently indicated in pts with significant risk factors, multiple long bone fx, and pts with an isolate long bone fracture above the knee
Mechanical prophylaxis of all pts unless a contraindication exists.
Fat Emboli
1-3% incidence in long bone fracture. Present 12-72 hours after injury. Triad of respiratory changes (dyspnea, tachypnea, hypoxemia), CNS manifestation (mild confusion, drowsiness, seizure), and petechiae.
Treatment for Fat Emboli
Treat with supportive care, consider corticosteroids.
Compartment Syndrome
A Surgical Emergency!!!! Significant swelling that leads to decreased perfusion of extremity.
Symptoms of Compartment Syndrome
5 P’s: pain out of proportion to injury, pain with passive ROM, pulselessness, pallor, paresthesias (also poikilothermia and paralysis)
Diagnosing Compartment Syndrome
Clinical Diagnosis: Check compartment pressures: DBP- Compartment pressure = < 30 needs fasciotomy. Palpate compartments: hard, painful.
Diagnosing Neurologic Deficits as a result of fractures
Test peripheral nerves below fracture site. Look for anatomic association with injury. Can be from traction/pressure on peripheral nerve or plexus.
UE: extend index finger- PIN (radial); A-OK sign- AIN (median); biceps (musculocutaneous), digit abduction (ulnar), shoulder abduction (axillary).
LE: EHL/tibialis Anterior (peroneal); RHL/gastroc (Tibial); Quadriceps (femoral).
Preventing Neurologic Deficits
Prompt reduction of deformity may prevent/eliminate/mitigate effects of neuro.
Diagnosing a Vascular Injury as a result of a fracture
Check pulses distally; if unable to palpate consider ABI or angiogram. Compressed or disrupted when joint becomes dislocated.
When do we use an arm sling?
Arm sling for clavicle fractures, shoulder dislocations, proximal humerus fractures, support arm with a cast
Casting Materials
Plaster, fiberglass, premade splints, cast padding, jones cotton, kerlex, ace bandages
When do we use a knee imobilizer?
Prevents flexion of knee; ligament or meniscal injury, tibial plateau fractures, patella fractures
Immobilization technique (Table 264-3)
xx
Splinting Techniques
Immobilize joint above and joint below. Splints allow the soft tissue to swell: can change to cast after swelling reduced. Must respect soft tissue condition; pad all bony prominences well, do not wrap tightly.
Long Arm Splint
Prevents elbow movement. Elbow injuries, distal humerus fractures, forearm fractures
Ulnar Gutter Splint
Immobilizes wrist and ulnar metacarpals. Metacarpal fx, proximal phalanx fx (good for Boxer fx)
Thumb Spica Splint
Immobilizes wrist and thumb. Scaphoid fx, 1st MCP fx, thumb fx
Short leg posterior splint
Can add stirrup or extend above knee; immobilizes ankle and foot. Ankle fx/dislocations, distal tibia fractures
Sugartong Splint
Prevent pronation/supination and allows some elbow flexion. Both bone forearm fx, distal radius fx
Hard-sole shoe
Provides hard surface to protect metatarsals. Toe fracture, some metatarsal fractures
Walking boot
Protects foot and ankle while allowing weight bearing. Ankle sprains, foot fracture, some metatarsal fractures
Goals of Casting:
Semi-rigid immobilization. Avoid pressure/skin complications.
When is casting a bad treatment choice?
Poor choice in the acute tx of acute fx. Swelling or Soft tissue complications
Complications of Casting
Loss of reduction. Pressure necrosis- as fast as 2 hrs. Tight cast/compartment syndrome- cutting cast padding further reduces pressure. (Univalving = 30% pressure drop, Bilvalving = 60% pressure drop). Thermal injury (Avoid plaster > 10 ply, water > 24 C; Unusual with fiberglass).Cuts and burns during removal. Joint stiffness (Leave joints free when possible (ie. Thumb MCP for below elbow cast, Place in position of function when possible)
Casting Techniques
Stockinette: may require 2 different diameters to avoid overtight or loose material. Caution not to lift leg by stockinette- stretching too tight around heel = high skin pressure. Avoid wrinkles in stockinette, cut along concave surface and overlap to produce a smooth contour.
Cast padding: roll distal to proximal, 50% overlap, 2 layers minimum, extra padding at fibular head, malleoli, patella, olecrenon. Cast molding: avoid molding w/ anything but the heels of palm in order to avoid pressure points, mold applied to produce 3 point fixation.
Principles of closed reduction
All displaced fx or dislocated joints should be reduced to minimize soft tissue complications. Adequate analgesia is critical for success. Axial traction and reversal of mechanism of injury. Attempt to correct/restore length, rotation, and angulation. Reduction maneuvers- often specific for particular location.
Forearm Casts/Spints
MCP joints should be free: do not go past proximal palmar crease. Thumb should be free to base of MC: opposition to 5th digit should be unobstructed, “coke can” sign.
Example of Closed Reduction for a Distal Radius Fracture
Local or regional block, exaggerate deformity, longitudinal traction, restore length and alignment, apply splint or cast.
Indications for cast and splints ( ie management for fx and dislocations)
To treat simple acute nondisplaced fxs, Immobilize dislocation after it has been reduced and for treatment of severe soft tissue injuries like lig sprains and muscle strains.
Cast dermatitis
combo of insufficient air circulation and perspiration that causes pruritis. This itching is scratched by a number of items that cause abrasions or lacerations and eventually infection.
Cast pressure sores
Caused by inadequate cast padding over bony prominences. These may progress to pressure ulcers and require surgical debridement
Nerve injuries
It can cause temporary palsy or permanent paralysis of nerve. Pressure over superficial nerves most commonly occurs over ulnar nerve in elbow or peroneal nerve over fibular head.
Work up for a Fractured Clavicle
- Swelling around fracture, but skin is not compromised.
- Lungs clear with good air entry
- Neck has full ROM with no tenderness
- Neurovascular exam of Upper Limb normal
- X-rays show midshaft Fracture with minimal or no angulation or displacement
Treatment: Clavicular splint for 6 weeks in children, and 8 to 10 weeks in adults
Work up for a Fractured of neck the Humerus
- Swelling around fracture, but no skin compromise and no deformity
- Neurovascular exam of Upper Limb is normal
- X-rays show not more than 30 degrees of angulation
Treatment: Arm sling or shoulder immobilizer for 6 weeks in children, and 8 to 10 weeks in adults
Fractures of lower radius and ulna - Swelling around fracture, but no skin compromise and no deformity
- Neurovascular exam normal
- X-rays show fractures with angulation of not more than 15 degrees
Treatment: Casting or Wrist Fracture Brace for 4 to 6 weeks in children, and 6 to 8 weeks in adults
Work up for a Fracture of a Metacarpal
- Swelling around fracture, but no deformity
- Neurovascular exam normal
- X-rays show angulation of not more than 15 degrees
Treatment: Wrist-Hand-Finger Orthosis (WHFO) immobilizing the MP and IP joints for 4 to 6 weeks
Work up for a Fractured Phalanx (finger)
- Swelling expected, but no deformity. Check especially for rotational deformities
- Neurvascular exam normal
- X-rays show angulation of not more than 15 degrees
Treatment: Wrist-Hand-Finger Orthosis (WHFO) for proximal phalanx; Finger aluminum splint for middle and distal phalanx, immobilizing the joint proximal and distal to the fracture for about 3 weeks.
Work up for a Fractured Metatarsal
- Swelling around fracture, but no deformity
- Neurovascular exam normal
- X-rays show angulation of no more than 15 degrees
Treatment: Regular walking cast, or a removeable walking cast (Pediwalker) for 6 to 8 weeks
Work up for a Fractured Toe
- Swelling around fracture, but no deformity
- Neurovascular exam normal
- X-rays show angulation of no more than 15 degrees
Treatment: Buddy taping for 3 weeks, using sticky tape or Coflex bandage.
Work up for a Contusion or Type I Epiphyseal plate injury in children
If there is exquisite tenderness at the epiphyseal plate, the diagnosis is assumed.
- Swelling expected, but skin is not compromised
- Neurovascular exam is normal
- X-rays may be normal or may show slight widening of the epiphyseal plate
Most common cause of Compartment Syndrome
Frequently occurs after fracture (tibia most common). Can occur after soft tissue injury w/o fracture.
Etiology of Compartment Syndrome
Fx or direct blow to extremity, extravasation of blood, swelling of muscle tissues, impairment of venous flow w/in one or more fascial compartments. Increase in pressure w/in limb may lead to circulatory compromise, neuro damage, muscle necrosis.
Treatment for Contusion or Type I Epiphyseal plate injuries in children
Treatment: Immobilization of the joint involved:
Type I Epiphyseal plate injury of lower fibula - short leg walking cast or Pediwalker for 3 weeks
Type I Epiphyseal plate injury of lower radius/ulna - short arm cast or Wrist fracture brace for 3 weeks
Type I Epiphyseal plate injury of base of 1st Metacarpal - thumb spica cast or thumb spica fracture brace
Fractures Suspicious of Child Abuse:
Posterior Rib Fracture, Sternal Fracture, Multiple fractures at different stages of healing, Spiral fractures in non-ambulatory patients.
