L2 Fractures Flashcards
Signs and Symptoms of Fracture
- swelling/edema or bruising/ecchymosis over fracture site and distal to site
- deformity, especially seen in long bones
- pain at fracture site which increases up movement, direct pressure, torsion
- Loss of function: NWB, decreased or absent AROM
- Open fracture = bone protruding through the dermis
Bending Force
angulatory force, causes fracture on convex side
type of fracture = transverse, oblique, greenstick
Twisting force
torsional force
causes spiral tension failure
will produce a spiral fracture
Straight pull
traction force
causes tension failure from pull of ligament or muscle
will produce an avulsion fracture
Crushing force
compression force, will compact or burst the bone
causes a compression, burst fracture or torus fracture in children
Repetitive Microtrauma
small crack in bone unaccustomed to stress
will produce a fatigue or stress fracture
Normal force on abnormal bone
will cause a pathological fracture due to osteoporosis, tumor, or other disease
Etiology of Fractures
Traumatic
Stress
Pathologic
Stress etiology is also characterized as
a mismatch of bone strength and chronic load
Insufficiency fracture
normal load on abnormal bone, term typically used with osteoporosis
Traumatic Fractures
major, high energy trauma
common examples: FOOSH, crush, MVA, fall from height, abuse
Factors that influence rate of healing bones
- older age >60
- Comorbidities
- Medications like steroids, chemo, NSAIDs
- degree of trauma
- Type of immobilization
- Infection, malignancy, irradiation
- Avascular necrosis
ABCs of Radiography
A = adequacy, alignment
B = bone margins, density
C = cartilage
S = soft tissue
Adequacy
one view is one view too few, check quality, views, number of images
Alignment
what is the normal alignment
“Bone” (ABCs)
trace along outline/contours = look for callus, exostosis, changes, fracture
radio-opaque = thicker, than surrounding bones
radio-lucent = thinner bone
Cartilage
joint space –uniform, loose bodies
How to describe a fracture
- alignment/relationship of bony fragments
- pattern/configuration of fracture line
- anatomic site
- relationship to the environment –open/closed
- Complete/incomplete
- Special features
- associated abnormalities
Alignment of bony fragments
NAMED FOR HOW THE DISTAL FRAGMENT DISPLACES IN RELATIONSHIP TO PROXIMAL FRAGMENT
nondisplaced
medial displacement
lateral displacement
distracted
overriding with posterior and superior dispalcement
distracted and rotated laterally
Direction of fracture line
- Transverse
- Longitudinal
- Oblique
- Spiral
Transverse
perpendicular to longitudinal axis
Longitudinal
parallel to the longitudinal axis
Oblieque
not at a right angle across the bone
Spiral
curves and winds around shaft of bone
Salter-Harris Classification of growth plate injuries
5 different types
used with immature bone
applies to any bone with a growth plate
Type 1 SH Growth Plate
through the growth plate, transverse
Type 2 SH Growth Plate
transverse fx through growth plate and metaphysis, travels proximally
Type 3 SH Growth Plate
through growth plate and epiphysis, travels distally and exits into the adjacent joint
Type 4 SH Growth Plate
through all three elements, travels proximally and distally
most damaging problem
can cause incongruency and fracture into the joint space
Type 5 SH Growth Plate
crush injury of growth plate
FOOSH/Colles Fracture
common extra-articular fx of distal radius at distal radial metaphyseal region with dorsal angulation and impaction, without involvement of articular surface
Tx for Colles Fx
closed reduction and cast immobilization
cast should go from the elbow to the metacarpal heads. Wrist is in slight flexion and ulnar deviation
patients should perform active finger motion exercises
Non-displaced FOOSh
a removable splint can be worn
Distal radius fx treated without surgery
should have repeated xrays for three weeks and the use of a splint or cast is discontinued
Greenstick will crack on ____ and stay intact on ____
convex
concave
Common visual appearance of colles fracture
dinner fork deformity
Neck of Femur Fracture
relatively common in older patients, those with unsteady gait, reduced bone density, females
this fx has significant complications w/out surgery, including avascular necrosis and non union
can weight bear as tolerated
What is the weakest point of the femur?
the neck
Tibial Plateau Fractures
MOI: axial loading like falling from a signficant height
fractures on the lateral plateau are more common than medial
soft tissue injuries are in 10% of fxs
Younger vs Older tibial plateau fxs
younger = splitting pattern
older = depression pattern, most common with osteoporosis
Tibial Plateau Fx Tx
- early mobilization – >3 weeks of immob increasing the potential for losing ROM permanently
- left uncorrected, the depression of plateau can cause a varus/valgus deformity, with increased OA
- PT can detect ligament injuries, which can lead to OA and malalignment
Vertebral Fracture
also known as a wedge deformity
caused by an isolated failure of anterior column, usually due to forward flexion and compression
Treatment for vertebral fracture
normally a stable fracture
early ambulation is encouraged
should use a hyperextension orthoses
avoidance of compression overloads for a period of 12 weeks
Other types of vertebral fractures
compression
burst
flexion-distraction
Boxer fracture
most common type of MC fx, usually in young adult males
transverse fx of the 5th metacarpal. Occurs in the transverse plane through metacarpal neck, Dorsal angulation of distal fragment
Treatment of boxer fracture
relatively unstable, so wire fixation is often required
palmar angulation is fine, but rotational deformity is NOT. can cause significant deformity with the little finger covering the other digits
can also use a short arm splint, with flexion of MCP joint, for 2-3 weeks
Avulsion Fracture
small bone fragments at the end of long bones, adjacent to joints
usually occur in locations with tendon or ligament attachments
MOI: tension force
Avulsion Fracture treatment
typically stable
surgery is required for pain or to regain anatomic fixation
treated on an outpatient basis with crutches pain meds, modified pain
recovery is in 4 to 6 weeks
Humeral Shaft Fractures
-3-5% of all fractures
-common in younger males and older females
-usually the middle third of the humerus is fx
most commonly associated with a radial nerve injury
MOI for Humeral Shaft
direct blow to the upper arm = transverse
indirect trauma from fall or twisting = spiral/oblique/open
Humeral Shaft Treatment
-supportive cast and then splint
-does not require ORIF
-shortening with some angulation is fine
Internal Fixation for a humeral shaft fracture is required
- adequate alignment cannot be maintained
- open fx
- presence of vascular injury
- segmental fracture
- poly-trauma, brachial plexus injury
- non-union
- pathological etiology
Radial Nerve Injury
associated with middle 1/3 humeral shaft fx
-can either be a laceration, entrapment, crush, demylenation (neuropraxia)
a closed fx will see the nerve heal within 3-4 months
Immediate open exploration required for these with radial nerve injury:
open fx, irreducible fx, vascular injuries, radial nerve palsy after manupulation, intractable neuro pain
16-18 weeks of management after surgery
Jones Fracture
transverse fracture at the base of the fifth metatarsal
MOI: significant adduction force to the forefoot with ankle in PF
common athletic injury, often mistreated
Jones Fracture Treatment
prone to non-union; need to use internal fixation or grafting
immobilization is important; NWB cast for 6-8 wks
Diastasis/Subluxation
abnormal separation of two anatomical structures that are normally located together
MOI: shear and tension (falling from a horse)
Stress Fracture
occurring due to a mismatch of bone strength and chronic mechanical stress
can either be fatigue or insufficiency
Fatigue fracture
abnormal stresses on normal bone
Insufficiency Fracture
normal stresses on abnormal bone
an example of a pathological fracture
Most common sites for fatigue stress fractures
tibia
tarsals
metatarsals
femur
pelvic ring
Most common populations for fatigue stress fractures
athletes
military
dancers
female
RF for fatigue stress fractures
repetitive overuse
sudden change in training regimen
alterations in training surface
female
leg length discrepancy
diminished muscle strength
CP of Fatigue Stress Fractures
pattern of decreased WB tolerance over time
localized pain
tenderness with palpation
antalgic gait
minimal joint ROM loss for extra-articular lesions
Plain films for fatigue stress fractures?
NO
low sensitivities
plain films can be negative for 14 to 21 days
MRI and bone scan are the gold standard
Osteophony
percuss distal to suspected lesion, while auscultate proximal to suspected lesion
confounding factors are joint effusion, bilateral injury, non-traumatic lesions
positive test lets us know that there is a bone pathology
Tx for stress fracture
dependent on location
options include conservative, plaster cast, internal fixation
you must reduce the activity which has led to the fracture
How can a fracture be stable?
incomplete fracture
intact periosteum
lack of significant angulation
avulsion and compression are usually stable
Instability characteristics
shear injuries tend to be unstable
periosteal tissue disruption leads to increased fx instability
unstable fx will display gross motion between shaft and head fragments
Femoral neck fxs stability
A = tension side of neck
B = compression side of neck, less likely to be displaced, more stable
Night stick fracture
isolated fracture of the ulnar shaft
Stable night stick
displaced < 50%
periosteum and interosseus membrane intact and act as restraint to rotation
Unstable night stick
displaced >50% or at a 10-15° of angulation
displacement/angulation towards the IM is poorly tolerated
associated with radial head fx or dislocation
Stress Sharing device
permits some transmission of load across fracture site
ex: cast, rods, pins, wires
Stress shielding device
protects the fracture completely from mechanical stress, transfers stress to the fixation device
ex: surgical plates, external fixators
Traumatic fracture complications
- Hemorrhage
- Fat embolism
- Brachial artery injury
- Axillary nerve injuries
- Avascular necrosis
Hemorrhage
pelvic fractures
closed femoral fx
Fat embolism
multiple or crushing type injuries, develops within 3 days of injury
Brachial artery injury
supracondylar fx
Axillary nerve injury
proximal humeral fx
Avascular necrosis
scaphoid fx
Minor traumas are…
sneeze, misstep, lifting a gallon milk, raising a window, basic ADLs, etc
Most common sites for suspicious fx
vertebral bodies
femur
distal radius
Rf for decreased bone density
family hx
caucasian/asian
female
age 50+
low body weight
immobilization
inactivity
long term exposure to alcohol, tobacco
medications
co-morbidities
dietary deficiencies
northern european ancestry
Medications that can caused decreased boney density
aluminum
anticonvulsants
corticosteroids
cytotoxic drugs
excessive thryoxine
heparin
lithium
tamoxifen
Examples of diseases that cause decreased bone density
diabetes
enodmetriosis
MS
COPD
hyperthyroidism
Secondary bone tumors
metastatic tumors
most common >50
shoes up as localized pain, palpable tenderness, edema, mass, fever, weight loss, malaise
Malignant tumors
osteosarcoma
Benign tumor
osteochondroma
Osteosarcoma
most common in bone tumor in children
occurs in the knee usually, proximal humerus, proximal femur, pelvis
S/S: painless bony mass, limited ROM
Osteochondroma
an abnormal extension of metaplastic cartilage that responds to the factors that stimulates the growth plate resulting in exotosis growth
most common at knee, in males, younger than 20
