Fractures Flashcards
Classification of Spinal Fractures & Stability
Stability = refers to the risk of spinal cord & spinal nerve root injury
- Type I = stable
- involving 1 column; ligaments intact & no sign. displacement
- i.e. compression, traumatic disc herniations, unilateral facet dislocations - Type II = unstable
- slight displacement & ligamentous damage - Type III = very unstable
- involving all 3 columns (if 2 involved, determine if stable or unstable by middle column)
- significant displacement (or potential of)
- i.e. fracture-dislocations, bilateral facet dislocations
Most Vulnerable Sites for Injury of Vertebral Column
-cervical, thoracic & lumbar
Cervical = lower portion, & c-t junction
- -> can be occipital-cervical OR subaxial (C3-C7)
- -> usually traumatic
Thoracic = c-t junction & T1-T4, t-l junction & T9-12 are highly susceptible, but most common is T12 & L1
- -> usually flexion force
- -> compression, burst, flexion-distraction, or dislocations
Lumbar = T11-L2 region highly susceptible, but T12 &L1 most common
–> usually hyperflexion & associated w/ hindfoot or burst fractures
Acute Interventions for Spine Patient
Post surgical = immobilization
Goal is to get patient upright and functional ASAP to prevent secondary conditions such as pneumonia, UTI…
Bed mobility: log rolling
Education & ADL’s: avoid flexion & rotation
Assistive Device: use if needed to promote early ambulation
Prognosis may change based on extent of injury & if spinal cord injury is involved
Bone Healing & Functional Limitations
Inflammatory Phase (1-2 weeks): increased vascularity & formation of hematoma - NWB & immobilization
Proliferative Phase (months): cell differentiation
- early: PWB, PROM/limited AROM
- late: WBAT, increased AROM
Remodeling Phase (months to years): reformation of medullary cavity - FWB, full AROM/RROM
Factors that affect Fracture Healing (4)
- Age:
the younger you are the quicker you heal - Location & Configuration:
faster if: surrounded by muscle, cancellous > cortical, & long oblique & spiral > transverse - Extent of initial displacement:
non-displaced w/ intact periosteal sleeve 2x faster (greater initial displacement = prolonged healing time) - Blood supply: excellent prognosis if all fragments have adequate supply
Compartment Syndrome
Emergency Complication - EARLY in fractures healing process
increased pressure w/n fascial compartment due to edema or hematome –> compresses blood vessels –> ischemia
Symptoms: painful, edematous & tight, shiny, hair loss, absent or diminished pulse
*Acute is emergency, chronic is not (aka shin splints)
Heterotropic Ossification
Late complication of a fracture –> specifically dealing w/ myositis ossificans
DEFN: bone formation at an abnormal anatomical site; usually in soft tissues (^^muscle)
Risk factors: SC injury, open wounds/burns, sepsis, prolonged critical illness, & aggressive ROM
Transverse Fracture
fracture line perpendicular to the axis of the joint
MOI - trauma
Oblique Fracture
fracture line that runs obliquely to the axis
MOI - sharp, angled blow
Spiral (torsion) Fracture
fracture line that spirals around axis of bone
MOI - sports, child abuse
Longitudinal Fracture
through the long axis of the bone
Comminuted Fracture
multiple fragments, often open
MOI - trauma or aging
Impacted Fracture
Pressure fracture; common in hip & shoulder
Depressed Fracture
common in the skull
MOI - blunt force trauma head injury
Avulsion Fracture
small fragment of bone is pulled away from the larger (main) bone
-usually seen in children before complete development of the bone; cannot withstand the strain from tendons
MOI - kids at growth plates
Susceptibility of cortical & cancellous bone
Cortical bone is the outer, tougher part of bone; more susceptible to tension force (bending, twisting, pulling)
Cancellous (spongy) bone is the inner portion of the bone; more susceptible to compression forces
Greenstick Fractures
Seen in children b/c the cortical bone is more flexible; doesn’t fracture completely & periosteal sleeve remains intact
MOI - bending force (fall or direct blow)
Growth Plate Injuries (Type I-VI)
-defn & prognosis
Based on Salter-Harris Classification
Type I - fracture along the plate, but unaffected & intact to epiphysis; Excellent
Type II - MOST COMMON - fracture along the plate & across metaphysis, including triangular part of meta; Good
Type III - fracture along part of plate & continues perpendicular through GP and epiphysis; Good if adequate blood supply
Type IV - fracture completely through meta, GP and epiphysis; Fair, may cause premature focal fusion & deformity
Type V - compression fracture of GP –> can lead to type VI which is when GP tethers to bone; Poor b/c often not recognized at time of injury
Intracapsular vs. Extracapsular Hip Fractures
Intracapsular - involve femoral head or neck; higher rate of non-union and AVN
–> usually treated w/ hemiarthroplasty or THA
Extracapsular - involve trochanteric region
–> usually treated w/ ORIF
Surgical Approaches for Hip Fractures
- ORIF
- bone conserving; good for younger, highly active patients OR older and less stable
- lower mortality rate BUT higher failure rate - Hemiarthroplasty
- hip replacement w/o acetabular component
- lower failure rate BUT can have deterioration of function after 3-5 years - Total Hip Arthroplasty
- hip replacement containing acetabular component
- better outcomes than HA beyond 3 years BUT increased risk of dislocation
- often used to revise ORIF or HA
Post-Surgical Hip Precautions
Posterior - more functionally limitation!!
–> NO flexion >90, adduction, or IR
Anterior
–> NO extension, abduction or ER
Delirium
Single best predictor of post-operative mortality
DEFN: state of mental confusion & excitement, disorientation, illusions & hallicunations
- delirium is transient
- occurs 30-50% of time
- should be resolved by POD7 at the latest
- very poor prognosis
PT Interventions for Hip Fractures
Early mobilization is crucial!!
-delayed leads to delirium, pneumonia, inc. length of stay, greater 6month mortality rate, poorer 2month functional performance
Acute stage - general ROM, UPRIGHT in chair, by day 7 should be ambulatory (w/ precautions & ass. device if necessary)
Subacute/Chronic stage - more aggressive strength training, ROM & mobility
EDUCATION is key b/c 90% of hip fractures are due to falls
Mallet Finger
DEFN - extensor tendon disrupted & often associated w/ an avulsion fracture
MOI - forced flexion of extended DIP
Scaphoid Fracture
MOI - FOOSH + radial deviation
often associated w/ non-union and AVN
Perilunate Fracture/Dislocation
DEFN - axial loading into hyperextension & UD that causes the carpals to be dislocated to the lunate w/ the lunate stays in line w/ the radius
MOI - high energy impact, typically young adults
Often missed!
Boxer’s Fracture
DEFN - fracture of the distal portion of 4th or 5th metacarpal
MOI - blow w/ a clinched fist
Bennett’s Fracture
DEFN - fracture/dislocation of the base of the 1st metacarpal
- radial notch appearance at base b/c pulled by APL
MOI - axial loading of the partially flexed thumb
Colles’ Fracture
DEFN - fracture of the distal radius w/ a dorsal displacement
-dinner fork deformity
MOI - FOOSH
- more common in women
Smith’s Fracture
DEFN - fracture of the distal radius w/ a palmar displacement
MOI - fall onto flexed wrist
-more common in men
Monteggia Fracture
DEFN - fracture of proximal or mid 1/3 of ulna w/ radial head dislocation
MOI - FOOSH or direct blow (MVA)
Galeazzi Fracture
DEFN - fracture of the distal 1/3 of radius w/ distal radiaoulnar disruption
MOI - FOOSH or direct blow (MVA)
Radial Head Fracture
DEFN - valgus force impaction of capitellum onto radial head causing a fracture
MOI - axial loading on a pronated & partially flexed or outstretched arm
Humeral Fractures
Usually diaphyseal (distal) in children & proximal in adults
MOI - FOOSH, fall onto elbow, or direct blow
Clavicle Fracture
DEFN - typically middle 1/3 of clavicle
MOI - fall onto or direct blow to shoulder
Femoral Shaft Fracture
DEFN - usually related to OP, metatsttic disease or TKA
MOI - ^^ and high energy trauma (MVA)
Tibial Plateau Fracture
DEFN - fracture along the joint line; critical load bearing area
- often associated w/ meniscal and/or ligamentous damage
MOI - valgus force w/ axial loading
Tibial Shaft Fracture
MOST COMMON fractured long bone
MOI - high energy trauma
Talus & Calcaneal Fracture
Talus - intra-articular; prone to AVN
MOI - fall from height or trauma (>3feet is associated w/ lumbar spine burst or compression fractures)
Garden Staging System for Hip Fracture
Stage 1 - incomplete, may be impacted
Stage 2 - complete, non-displaced
Stage 3 - complete, slight displacement
Stage 4 - complete, fully displaced
Occipital-Cervical Fracture
fracture of occipital condyle on base of skull
RARE
Treatment -
type I = arthosis
type II = halo
type III = orthosis or halo +/- PSF
Atlanto-Occipital Dislocation (AOD)
Internal decapitation
–>severe spinal cord involvement
Treatment - immobilization, reduction w/ PSF & halo
Atlas Fracture
Jefferson or “burst” fracture
1/2 associated w/ dens fracture
Rare neurological compromise b/c burst away from spinal cord
MOI = axial loading/compression on top of head
Treatment -
2 w/ other fracture = traction & halo
Unstable = AA fusion
C2 Odontoid Fracture
fracture of the dens (can be 3 different places)
Young risk takers or elderly are at risk
High non-union rates
Treatment -
Type I = orthosis
Type II & III = halo (5mm)
C2 Axis Fracture
Handman’s Fracture
MOI = traumatic hyperextension causing bilateral pars interarticularis fractures
–>distraction (not fracture) causes neurological compromise
Treatment -
Type I = orthosis
Type II = halo
Type III = ORIF or PSF
Distraction-Flexion Cervical Injury
Whiplash injury w/ “bowtie” sign - C5/6 & C6/7 most susceptible
MOI = distraction load on a flexed neck
PSF needed only if disc is herneated
Vertical Compression Cervical Injury
Compress & shortens anterior & middle columns - C5/6/7 most susceptible
MOI = MVA, diving
Treatment =
If stable & no kyphosis = orthosis
Unstable w/ kyphosis ACDF or PSF w/ rigid orthosis or halo
Compression-Flexion Cervical Injury
“teardrop” fracture
Facet dislocation, compromised stability, ligament rupture & disc tearing
Treatment -
ACDF +/- PSF & cervical orthosis
Lateral Flexion Injury
MOI = MVA or blow to head
Rarely involves ligamentous injury & rarely needs surgery
Thoracic Spine Fractures (4 common types)
T12-L1 most susceptible; usually FLEXION force
- Compression - failure of anterior column
- Flexion distraction - “seatbelt” fracture; transverse fracture line
- Burst - axial loading (neurological compromise)
- Dislocation - unstable; involving all 3 columns; can be conservative or PSF or ACDF
Lumbar Spine Fracture
-common MOI & types of fractures (2)
T12 & L1 most susceptible
MOI = hyperflexion w/ or w/o shear force, rotation, or axial compression
Can be due to jumping from height >3feet
Types of fractures it is associated w/:
- Hindfoot
- Burst
Treatment - based on amount of kyphosis of lumbar spine
When is surgery indicated for a patient w/ scoliosis vs. conservative treatment?
If the curve is >40-50 degrees then surgery is indicated
Can be idiopathic or neuropathic
