Lecture 3: Fractures

Question 1

What is this type of epiphyseal fracture?

Answer 1

Salter Harris type 1:

Represents isolated fracture through the growth plate. Usually the radiograph appears normal, with the diagnosis being made clinically because of tenderness over the epiphyseal plate and soft tissue swelling.

Question 2

What is this kind of fracture?

Answer 2

Pathologic #: A pathologic fracture is a f# through a bone that us weakened by localised or systemic disease process. Pathologic fractures are usually transverse and often appear quite smooth.

Question 3

Describe this type of fracture

Answer 3

Impaction: Impaction # occurs when a portion off bone is driven to its adjacent segment. Because of compressive forces, the radiolucent fracture line is seldom visible; instead a subtle radio opaque white line is seen in the region of impaction.

Question 4

What is this type of epiphyseal fracture?

Answer 4

Salter Harris type 2:

This is a fracture through the displaced growth plate, which carries with it a corner of the metaphysis. The metaphyseal fragment has been called the Thurston Holland sign. Most common epiphyseal injury, comprising approximately 75% of cases. The most common sites are the distal radius (50%), as well as the tibia, fibula, femur and ulna. The epiphyseal separation is usually easily reduced and a good prognosis is the outcome.

Question 5

What are some immediate complications of fractures?

Answer 5

Vascular injury:

• Especially likely with open or comminuted #.
• Most common arterial rupture is popliteal then superficial femoral.

Compartment syndromes:

• Unrelenting pressure increase due to oedema and hemorrhage in closed compartments.
• May cause permanent necrosis of compromised muscles.
• Eg. Anterior tibial compartment; anterior forearm (Volkmann’s)

Fat embolism:

• Pulmonary fat embolism up to five days after #.
• Emboli mobilized by vaso-activity and fat hydrolysis.
• Femur facture most frequently involved.

Thromboembolism:

• Deep vein thrombosis facilitated by immobilization and bed rest after fracture.
• Potential for pulmonary emboli esp. with hip, pelvis and lower extremity #’s.

Question 6

What is this kind of fracture?

Answer 6

Incomplete: incomplete fractures are broken on only one side of the bone, leaving a buckling or bending of the bone as the only sign of #. Most common is greenstick fracture in children.

Question 7

What type of fracture is usually seen in unhealthy/pathological bones?

Answer 7

Transverse

Question 8

What is this type of epiphyseal fracture?

Answer 8

Salter Harris type 3:

The fracture line is directed along the growth plate and then turns towards the epiphysis. It results in intra-articular fracture that may require open reduction treatment. Most frequent site is the distal tibia.

Question 9

What is a subluxation?

Answer 9

Occurs when there is a partial loss of contact between the usually articular surface components of the joint. The joint surfaces are incongruous, but a significant portion remains opposed.

Question 10

Delayed (long term) complications of fractures

Answer 10

Osteonecrosis:

• Avascular necrosis. Loss of blood to bone
• Common sites femoral head, humeral head, scaphoid and talus.

DJD:

• Intra-articular fracture damages articular cartilage.
• Most frequent at hip, knee, and ankle.

Osteoporosis:

• If functional weight bearing is delayed, bone is lost.
• Factors: pain, nerve palsy, altered function, failure to mobilise.

Malunion:

• Union occurs but not correct anatomic position.
• Altered joint mechanics and loss of function result.
• Limb may be shortened; alters gait, causes unleveled pelvis, scoliosis.

Nonunion:

• Failure of full osseous fusion at fracture site.
• Factors include; inadequate immobilization, impaired circulation, infection.
• Most commonly seen at midclavicle, ulna and tibia.
• X-ray signs become apparent months after trauma; fracture margin rounding, sclerotic fracture margins, pseudarthrosis, lack of callus formation.

Question 11

Describe these 2 images. What is the difference between them?

Answer 11

A = normal epiphyseal growth plate

B = ischial avulsion fracture

**Avulsion: Avulsion # exhibits the tearing away of a portion of the bone by a forceful muscular or ligamentous pull. Frequent sites are tuberosities of tubular bones.

Question 12

What is a spondylosis?

Answer 12

Spondylolysis is a defect of a vertebra.

More specifically it is defined as a defect in the pars interarticularis of the vertebral arch. The great majority of cases occur in the lowest of the lumbar vertebrae (L5), but spondylolysis may also occur in the other lumbar vertebrae, as well as in the thoracic vertebrae.

Question 13

What is this kind of fracture?

What else could it be?

Answer 13

Chip (corner) #: This represents a form of avulsion fracture that is usually limited, demonstrating the separation of a small chip of bone from the corner of a phalanx or other short or long tubular bone.

Could also be:

• limbic bone
• intercalorie bone

Question 14

What is a diestasis?

Answer 14

Diastasis: Diastasis represents displacement or frank separation of a slightly moveable joint (syndesmosis). Most common location is at the pubic symphysis., sutures of skull, or distal tib/fib syndesmosis.

Question 15

What do we see in this image?

Answer 15

Impaction fracture

Avulsion of psoas/lesser trochanter

Question 16

What kind of fracture is this? In what conditions do we usually see this?

Answer 16

Pseudo fracture

• seen in
• osteomalacia
• pagets

Question 17

What is the difference between these 3 images?

Answer 17

Left = normal ischial epiphysis

Middle = avulsion of hamstrigs

Right = Malunion of ischial tuberosity

Question 18

What could this be?

Answer 18

Avulsion fracture of the medial humeral epicondyle

Normal variant

Question 19

Describe these types of fractures using correct terminology

Answer 19

A+B = Comminuted #: Two or more bony fragments have separated.

C+D = Non comminuted: One that penetrates completely through the bone, separating the bone into two fragments only.

Question 20

Describe these images

Answer 20

Could be:

Avulsion

Oshgood schlatters

Question 21

What are the stages of fracture repair timing?

Answer 21

Stage 1: Haematoma and localized swelling. May see soft tissue swelling on films. No apparent change to surrounding bone tissue (unless blatant).

Stage 2: 24-48 hrs: Localized osteopoenia. First 5 days see osteoclastic activity visibly increasing width of fracture line.

Stage 3: About 2 weeks (10-30 days): Callus formation appears as a veil of new bone adjacent to the fracture site.

Stage 4: Next 4-12 weeks: Gradual remodeling and repair of cortical integrity. Generally 4-6 weeks in pediatric cases and 6-12 weeks in geriatric.

Question 22

Describe this fracture

Answer 22

Diestasis

Question 23

What is this type of epiphyseal fracture?

Answer 23

Slater Harris type 4:

Obliquely orientated, vertical fracture that passes through the epiphysis, growth plate and metaphysis. The fracture fragment consists of a portion each of the metaphysis, growth plate and epiphysis. The most common sites are the lateral condyles of the distal humerus in patients under 10 yrs., and the distal tibia in those over 10.

Question 24

What are the 3 main kinds of vertebral fracture?

Answer 24

Pancake

Wedge

Bi-concave

Question 25

Describe these types of fractures using correct terminology

Answer 25

A = Closed #: Does not break the skin or communicate with external environment. (simple #)

B = Open #: One which penetrates the skin over fracture site. (Compound)

Question 26

What are these images all showing?

Answer 26

Spondylosis

Question 28

Intermediate Complications of fractures

Answer 28

Osteomyelitis:

• Staph aureus causes 60-70% of these infections.
• Rarely seen with closed #, yet common with open or surgical reduction.
• Most commonly seen with femoral and tibial #’s.
• Usually manifests within one month of trauma or reparative surgery.
• Plain films show moth eaten lytic lesions, sequestra formation, periosteal response at painful area.

Hardware failure:

• Screws and plates used to stabilize the healing bone may fail.
• Loosening, breaking, bending.

Re-fracture:

• Usually secondary to bone pathology, noncompliance by the patient, inadequate immobilization, or bone weakened at pin site.

Synostosis:

• Between closely apposed bones.
• Most commonly radio-ulna, tib/fib or small bones of hand or feet.
• Loss of functional motion.

Question 29

What is a dislocation?

Answer 29

Dislocation refers to a complete loss of contact between the usual articular components of a joint. When found associated with a fracture, it is referred to as a fracture dislocation. In the extremities a dislocated bone is always described in relation to the proximal bone. In the spine the dislocated segments is described relative to the segment below.

Question 30

What is this type of epiphyseal fracture?

Answer 30

Salter Harris type 5:

Least common and results from a compressive deformity of the growth plate. Initially, the radiographs are normal, until cessation of growth plate creates bone shortening or partial arrest, which leads to progressive angular deformity. Most common sites are distal tibial and distal femoral epiphyseal centres.

Question 31

Describe this fracture

Answer 31

Dislocation of talocrural joint in an 8-12 year old

Avulsion # of distal tibia

Type 1 fracture of fib head

Type 3 fracture of distal tibia