Case 6: Ronnie Olchuk

Long Bones: Epiphysis

Proximal + distal ends

Compact bone around trabecular (spongy) bone

Epiphyseal plate (physis)

Epiphysis: Physis

Hyaline cartilage between epiphysis + metaphysis

Longitudinal growth location

• Closure after puberty = Stop growth

5 layers: Epiphysis → Diaphysis

1. Resting cartilage zone

2. Proliferation zone

3. Hypertrophy zone

4. Calcification zone

5. Ossification zone

Physis Layer: Resting Cartilage Zone

Undifferentiated precursor chondrocytes

Physis Layer: Proliferation Zone

Chondrocyte mitosis = Cells stack + enlarge = ECM layers

Physis Layer: Hypertrophy Zone

Chondrocyte hypertrophy = Collagen production + longitudinal septa calcification

Physis Layer: Calcification Zone

Chondrocyte secrete VEGF + metalloproteinases = Blood vessels + macrophages migrate = Transverse septa erode

Physis Layer: Ossification Zone

Osteoblasts colonize longitudinal septa = Osteoid formation = Mineralization

Long Bones: Metaphysis

Between epiphysis + diaphysis

Long Bones: Diaphysis

Shaft

Compact bone around medullary cavity (bone marrow)

Long Bones: Apophysis

Bony projections

Attach ligaments + tendons

Fractures Classification: Anatomy

Location

Position (dia, meta, epiphysis)

Fractures Classification: Extent

Complete: Fracture line through entire bone

Incomplete: Fracture line not through entire bone

Fractures Classification: Orientation

Transverse: Perpendicular (horizontal) fracture line

Oblique: Diagonal fracture line

Spiral: Twisted fracture line (corkscrew shape)

Fractures Classification: Displacement

Angulation: Angled axis

Translation: Lateral bone fragment displacement

Rotation: Around longitudinal axis

Longitudinal bone fragment displacement

• Distraction: Elongated

• Impaction: Shortened

Fracture Classification: Fragmentation

Comminuted: 2+ fracture lines = Multiple bone fragments

• Butterfly Fragment: Triangle-shaped fragment

Segmental: 2 fracture lines + bone fragment between proximal + distal bone portions

Fracture Classification: Soft Tissue Involvement

Closed/Simple: No contact with outside environment

Compound/Open: Bone/soft tissue contact with outside environment

Fracture Classification: Stability

Stable: Bone fragments in alignment (no significant displacement)

• Low dislocation + open fracture risk

Unstable: Bone fragments not in alignment (displaced, misaligned, shifted)

• High displacement + healing complication risk

Fracture Acceptable Alignment

Location

• Low Tolerance:

  • Intraarticular

  • Close to joint

  • Forearm

• High Tolerance:

  • Diaphyseal

  • Humerus

  • Femur

Age: Younger = Increased remodelling capacity

• Tolerate higher degree angulation, malrotation, displacement

Fracture Management: Stable Fractures

Closed reduction

• Realign displaced fracture/dislocation

Immobilization (cast-splint)

• Lower limbs: VTE prophylaxis

Elevation above heart

Ice

Analgesics

Fracture Management: Analgesics

Non-opioid

• Acetaminiophen

• NSAIDs

• Gabapentin (Inhibit Ca2+ channels = Reduce neuropathic pain)

Opioids: Severe pain

• Tramadol

• Hydrocodone

Fracture Management: Unstable Fractures

Open/closed reduction

Immobilization

• External Fixation: Pins/screws outside skin

• Internal: Implants (plates, screws, wires)

Fracture Management: Compound Fractures

STAND

S: Stabilize + immobilize

T: Tetanus shot

A: Antibiotic prophylaxis (Ancef)

N: Neurovascular exam

D: Dressing

• Acute wound management

  • Remove foreign bodies + debris

  • Irrigate wound

  • Cover with dressing

• Operative irrigation + debridement (remove dead tissue)

  • ≤ 24h

Pediatric Fractures: Description

Fractures in children

Pediatric vs Adult Fractures

Pediatric: Softer bones = Different fracture patterns

• Physeal: Involving growth plate (Salter-Harris fractures)

• Non-Physeal: Not involving growth plate

  • Bowing

  • Buckle/torus

  • Greenstick

Adults:

• Intraarticular fractures (crossing joints)

• Comminuted fractures

Pediatric Fractures: Epidemiology

Physeal: Beginning of puberty

Pediatric Fractures: Etiology

Non-Physeal: Indirect axial force (FOOSH)

Pediatric Physeal Fractures: Pathophysiology

Salter-harris fractures: SALTER

Type 1: Straight across joint

• Transverse fracture through physis

• Separate epiphysis from metaphysis

Type 2: Above joint

• Transverse fracture through physis + metaphysis

• Most common

Type 3: Lower

• Transverse fracture through physis + epiphysis

Type 4: Through everything

• Fracture through physis + epiphysis + metaphysis

• Intraarticular fracture

Type 5: Ruined/rammed

• Crush injury from compression

Pediatric Non-Physeal Fracture: Pathophysiology

Bowing: Bone bending + no break

Buckle/Torus: Bone compressing + no break

• Compressed side = Buckling deformity

• Tension side = Intact

Greenstick: Bone bend (1 side) + bone break (1 side)

• Compressed side = Intact

• Tension side = Break

Pediatric Fractures: Clinical Presentation

Localized pain, edema, erythema

Limb/bone deviation from normal axis

Gap on bone surface

Crepitus

Pediatric Fractures: Investigations

XR

MRI: Salter-Harris fractures

• Confirm XR findings

Pediatric Fractures: Treatment

Thicker periosteum (outer bone connective tissue layer) = Metabolically active = Faster healing

Non-Physeal:

• Buckle: Splint

• Greenstick + Bowing

  • Acceptable angulation: Splint/cast

  • Unacceptable angulation: Reduction

Physeal/Salter-Harris:

• Type 1 + 2: Closed reduction + splint/cast

• Type 3 + 4 + 5: Surgery = Open reduction + internal fixation + cast

Analgesics

Ice

Elevation

Pediatric Fractures: Complications

Growth arrest: Bone bridge across physis = Connect metaphysis + epiphysis = Cover growth plate…

• Completely: Limb-length discrepancies

• Partially: Angular deformity

  • Abnormal bone angulation

Acute Compartment Syndrome (ACS): Description

Tissue ischemia from increased pressure in fascial compartment

ACS: Epidemiology

Common in limbs (Usually lower leg)

ACS: Etiology

Trauma

• Burn (scar tissue, edema)

• Fractures

• Reperfusion injury (returning blood supply after ischemia = Increase vessel permeability = Tissue swelling)

Non-Traume

• Poor limb position (immobile)

• Shock (increase capillary permeability)

ACS: Pathophysiology

Pressure from fascial compartment > Pressure from arteries = Block blood flow = Ischemia → Necrosis

ACS: Clinical Presentation

Rapid progression

Early:

• Extreme pain

  • Worse with muscle movement

  • Tenderness

• Tight muscles

Later: Impaired perfusion (6 Ps)

• Pain

• Pallor/cyanosis

• Pulselessness

• Paresthesia

• Paralysis/muscle weakness

• Pokilothermia

  • Inability to regulate body temp

  • Cold extremities

ACS: Investigations

Clinical diagnosis

• Etiology/risk factors + ≥ 1/6 Ps

Peripheral nerve exam

Invasive compartment pressure measurement

Blood test

Imaging

ACS Investigations: Peripheral Nerve Exam

Sensory: Decreased sensation

Motor: Decreased movement

Gait

Balance: Impaired proprioception

ACS Investigations: Invasive Compartment Pressure Measurement

If unclear clinical findings

Method:

1. Insert device into compartment + inject saline

2. Measure pressure + determine ΔP = DBP - intracompartmental pressure

• Normal: ΔP ≤ 30 mmHg

Increased compartment pressure

ACS Investigations: Blood Tes

Rhabdomyolysis + Crush Syndrome: Increased creatine kinase + myoglobin

Skeletal muscle breakdown = Release cell components → Blood = Cause AKI

ACS Investigations: Imaging

XR: Fractures

US: DVT + evaluate arterial bloodflow

ACS: Treatment

Surgery: Fasciotomy

• Incision in skin + fascia = Relieve compartment pressure + restore perfusion

• Leave wound open

Supportive care

• Analgesia

• O2

ACS: Complications

Necrosis

Rhabdomyolysis + Crush syndrome

Volkmann ischemic contracture

ACS Complications: Volkmann Ischemic Contracture

Description: Permanent forearm muscle shortening = Claw-like fingers, hand, wrist

Pathophysiology: Supracondylar humeral fracture → Compartment syndrome = Flexor muscle atrophy

Treatment:

• Physical therapy

• Elbow splint

• Surgery: Tendon transfer, nerve decompression