fractures

define dislocation

external force is applied to the joint but no fracture occurs. the joint becomes misaligned

how do we describe dislocations

described according to the position of the distal fragment relative to the main/proximal bone

T or F: there is usually some nerve or ligament damage associated with a dislocation

true

describe the two types of dislocation

can have a complete loss of articular contact, or the joint space widens

when there is a dislocation where there is a complete loss of articular contact, how do we describe it

describe the apposition/distance between the structures

one type of dislocation is where the joint space has widened. give 2 names for this

partial dislocation, subluxation

partial dislocations (aka subluxations) are common where

spine, AC joints, ankles

T or F: sometimes there is a fracture associated with a dislocation

true

sometimes there is a fracture associated with a dislocation. what do we call these pathologies

fracture dislocations

what 5 things can we look for on an image when trying to locate a fracture

symmetry, joint alignment, continuity of cortical edges, bone density, swelling

define joint effusion

fluid collecting in and around the joint capsule

what 5 factors do we use to describe fractures

type, orientation, spatial relationships, ST involvement, stability

when describing the type of fracture, what factors do we consider

is the skin penetrated, how many fracture fragments are there, is the fracture line complete or incomplete

what is a compound fracture

when the fracture is open to the air (skin is penetrated)

when we discuss the orientation to describe a fracture, what do we talk about

it’s alignment, apposition, and rotation (if any)

when we discuss spatial relationships to describe a fracture, what 2 characteristics do we discuss

alignment, apposition

describe alignment when it comes to fractures. how do we talk about it when discussing fractures

refers to the specific direction of the distal bone fragment relative to the proximal portion of bone, expressed in degrees + which specific direction its in

T or F: when discussing a fracture, the direction of the distal bone or bone fragment is always discussed in reference to its normal anatomical position

true

when imaging for fractures, why do we take two views at 90 degrees

to determine whether the fragmented bone is angled in more than one plane

what is apposition

the distance between fractured fragments

list the 3 types of apposition

good, partial, distraction

what is good apposition

there is almost complete contact between the fragments

what is partial apposition

there is a gap between fractured fragments

what is distraction apposition

fragments have a considerable amount of space between them

what do fractures do to ST

cause ST swelling around the injury site

what is another term for ST swelling due to a fracture

edema

T or F: sometimes ST injuries are the only indicator that there is a fracture

true

T or F: injuries to ST/vasculature are not always visible on radiographic images

true

what is a stable fracture

has fragments that will not dislocate

what is an unstable fracture

have fragments which can dislocate and contribute to ST injury

T or F: unstable fractures have poor quality of healing and alignment

true

list the 5 stages of fracture healing

hematoma formation, inflammatory process, callus formation, consolidation, remodeling

describe hematoma formation in fracture repair

fracture occurs and the periosteum/endosteum is ruptures. bleeding into the marrow and ST occurs, injury site swells, hematoma forms

when does the inflammatory process in fracture repair occur

starts 48 hours after injury

another term for the inflammatory process of fracture repair

granulation process

describe the inflammatory process in fracture repair

fibroblasts and capillaries increase in the area and begin to repair the damage. periosteal and endosteal repair occurs. the marrow and cancellous bone are repaired. fibroblasts break down the hematoma and remove it

when does callus formation occur

5-10 days after the injury

describe callus formation in fracture repair

periosteal repair occurs, bony collar (callus) is formed around the fracture

when does consolidation of a fracture occur

4 weeks after the injury

describe consolidation in fracture repair

osteoblasts change the primary callus into mature bone, the periosteum and endosteum are strengthened

when does remodeling during fracture repair occur

8-12 weeks after the injury

describe remodeling in fracture repair

secondary bone formation is almost normal, periosteum and endosteum appear normal, there is a residual scar in the tissue

list 5 immediate complications of fracture healing

arterial injuries, compartment syndrome, gangrene, fat embolism, thromboembolism

immediate fracture complications: describe arterial injuries

displaced bone affects arterial flow, can be life threatening. blood loss depends on location type and number of fractures

immediate fracture complications: describe compartment syndrome

refers to the rise of interstitial pressure within a closed space. a fracture causes uncontrolled edema/hemorrhage so the pressure rises and vessels are compressed. if left untreated, there is cell necrosis due to loss of blood supply

immediate fracture complications: describe gas gangrene

results in the loss of blood supply due to an infection by Clostridium bacteria. seen within 1-3 days post injury/surgery, spreads throughout the body if left untreated

which bacteria causes gangrene

Clostridium

immediate fracture complications: describe fat embolism

due to a fracture, fatty particles escape from the bone marrow into the injured venous system and then to the pulmonary system

how does pulmonary/fat embolism present (+ when)

sudden chest pain, respiratory distress 24-72 hours post trauma/surgery

at least 50% of pulmonary/fat embolisms are a result of which bone fracture

femur

immediate fracture complications: describe thromboembolism

after surgery, pt is inactive for prolonged periods = causes blood clots to grow that impede blood flow. clots migrate to lungs and impede blood flow here

another name for thromboembolism

deep vein thrombosis

list 8 intermediate complications of fracture repair

osteomyelitis, hardware failure, complex regional pain syndrome, post traumatic osteolysis, refracture, synostosis, delayed union, infection

intermediate fracture complications: describe osteomyelitis

bone infection caused by staphylococcus aureus, which gets in via open wounds

when does osteomyelitis occur

1 month post trauma

signs and symptoms of osteomyelitis

localized pain, bone destruction

which organism caused osteomyelitis

staphylococcus aureus

intermediate fracture complications: describe hardware failure

hardware we use to treat fractures can loosen, bend, break, or migrate. occurs when patients don’t follow their immobilization regime and start mobilizing too soon

intermediate fracture complications: describe complex regional pain syndrome (CRPS)

there is abnormal localized pain a the site of trauma which is disproportionate to the injury

signs of complex regional pain syndrome

swelling, redness, warm/dry/pale/cool/glossy skin, burning/stabbing/searing pain, decreased ROM, evidence of osteopenia (decrease in bone mass)

most common sites for complex regional pain syndrome

hands, feet, knee, hip

what is the first clinical sign of complex regional pain syndrome

edema; reddened/thickened skin, increased nail growth

chronic complex regional pain syndrome can result in which condition

osteoporosis

intermediate fracture complications: describe post traumatic osteolysis

bone begins to break down at the trauma site = impaired healing. caused due to an inflammatory response to polyethylene debris from hardware component insertion

T or F: post traumatic osteolysis can be asymptomatic

true

intermediate fracture complications: describe refracture

indicates a disruption of healing at the fracture site. caused by inadequate immobilization, non-compliant patient, underlying tumor or infection, weakened bone

intermediate fracture complications: describe synostosis

abnormal fusion between adjacent bones after a trauma = loss of motion/function

where in the body is synostosis common

between MCs, between radius and ulna

intermediate fracture complications: describe delayed union

a fracture site fails to reunite within the normal time span; healing occurs but at a slower rate

list some common causes of delayed union after a fracture (6)

poor reduction or immobilization, severe trauma, poor circulation, infection at the trauma site, distraction or apposition of fragments, poor nutrition

intermediate fracture complications: describe infection (ie what are the effects)

causes continuous tissue destruction, delays/prevents healing

T or F: chronic infection may require surgical intervention

true

list 5 delayed complications of fracture repair

osteonecrosis, degenerative joint disease, osteoporosis, non union, mal-union

delayed fracture complications: describe osteonecrosis

interrupted/lack of blood supply to a tissue site causes bone death

common sites of osteonecrosis (4)

femoral head, humeral head, scaphoid, talus

what 3 things does the severity of osteonecrosis depend on

fracture location on the bone, treatment timing, complexity of normal blood supply

delayed fracture complications: describe degenerative joint disease

an intra-articular fracture results in articular damage, which contributes to premature wear and tear of the cartilage surface of the joint

where in the body is degenerative joint disease most commonly seen

in weight bearing bones

another term for degenerative joint disease

post-traumatic arthritis

delayed fracture complications: describe osteoporosis

loss of bone mass occurs due to inactivity post-trauma = more prone to fractures

delayed fracture complications: describe non-union

bone repair stops so the fracture cannot heal; no callus bone production, the ends of the medullary cavity become sealed over with new bone

how to fix non union of a fracture

bone graft

where in the body is non union common

scaphoid

in which population is non union common

elderly

delayed fracture complications: describe mal-union

a fracture heals but there is rotational or angulation deformities = loss in function, limb shortening, compensating spine scoliosis, altered walking, and changes in pelvic orientation

list 3 causes of mal-union

poor reduction, poor immobilization, interrupted healing (ie re-injury)

clinical signs of a fracture

swelling, skin discoloration, patient is in pain that is localized, bleeding, change in pulse or temp, external distortion of the injured part

drawback of radiography for fracture diagnosis

false negatives for undisplaced fractures

describe what stress views are

forces are placed on joints to check the stability and determine the extent of an injury

how does nuclear medicine work

uses radioactive isotopes

how does ultrasound work

uses sound waves

list 4 fracture treatment options

reduction, fixation, closed reduction with external fixation, surgical intervention

fracture treatment: describe reduction

used to restore alignment of fragments in a fracture

list the 3 main methods of reduction

manual, mechanical, closed joint

describe manual reduction

various maneuvers are used to manually apply traction to reposition the fragments so they’re aligned

describe mechanical reduction

gravity with or without weighs is used

describe closed joint reduction

fracture is reduced externally with the skin still intact

fracture treatment: describe fixation

surgical devices are used to hold fracture fragments in place to prevent further displacement and disruption of healing (can be internal or external)

fracture treatment: describe closed reduction with external fixation

pins inserted through the skin and into bone, attached externally to a bar. the bar holds the pins in place until the fracture is healed

disadvantage of closed reduction external fixation

greater chance of infection of the pin sites and pin tracts