second lecture skeletal trauma (axial and peripheral (upper and lower extremities)

Second Lecture

Skeletal trauma (Axial

and peripheral (Upper and Lower

extremities)

Definitons

1. Fracture: complete disruption in the continuity of bone2. Dislocation: complete disruption of a joint, articular surfaces

are no longer in contact3. Subluxation: minor disruption of a joint where some articular

content remainsDescription of fractures1. Bone involved2. Size and extent3. Type4. Direction of fracture line5. Alignment of fragments6. Any impression, depression or compression

General principles of trauma evaluation by plain x-rays

• Principle of “twos”( 2 views, 2 joints

2 times )

Anteroposterior view and lateral view

• Principle of “twos”• Each view including 2

adjacent joints

Description of fractures•Bone(s) involved•Size and extent

Description of fractures

• Type of fracturecomplete / incomplete

• Complete1. simple2. comminuted

Description of fractures

incomplete1. bowing 2. torus 3. greenstick

Description of fractures

• AlignmentDisplacement Medial

lateral

Description of fractures

• AlignmentAngulations

Medial lateral

Description of fractures

• AlignmentRotation

• internal rotation • external rotation

Description of fractures

• Alignment

• shortening• lengthening

-shortening lengthening

Description of fracturesDirection of fracture line

obliquetransverse

Description of fracturesDirection cont’d

spiral

longitudinal

Fracture:A Fracture is a structural break in the normal

continuity of bone.1-Fracture types:A - Simple and Compound fractures:1} Simple Fracture: The Skin remains intact2) Compound Fracture:Fracture is communicating with the exterior

through a laceration in the skin or mucous membrane

.Laceration may be caused by fracture fragments or by the object causing the fracture.

2- Fracture lines1) Green stick: Incomplete fracture which occurs in

children. It is the simplest type of fractures which heals rapidly with potentially complete reconstruction of the preexisting architecture“

2) 2) Transverse or linear fracture * Complete fracture of the bone• Heals with adequate fixation of the bone3) Spiral fractureA more severe type of fractures may need internal

fixation4) Comminuted fracture: Multiple bone fragments are present at the fracture

site

Complications of fractures

І- Union problemsA - Mal-union and cross union

B -Delayed unionC- Non union

ІІ - Sudeck's atrophy

ІІІ - subperiosteal hematomas

І V- A vascular necrosis

І- Union problems

Improper union, the description of the fracture refers to the position of the distal fragment relevant to the proximal fragment,

Possible types includes; 1-Angulation(anterior, posterior, medial and lateral)2- Shortening(over lap .overriding)

A-Mal union

3-Cross-unionIt occurs when 2 adjacent bones are fractured e.g.

tibia, fibula or ulna and radius when healing occurs, the proximal end of one bone heals with distal end of the other bone

This may cause severe problems interfering with the function e.g. when cross union occurs between the tibia and fibula (fibula is a weak bone that can't maintain the body weight)

Investigations X.ray should be performed in 2 views, antroposterior and lateral

Management (ttt) In case of mal-union-the bone may need to be

re-fractured then accurate reduction is applied to restore the normal anatomy to be followed by stabilization and immobilization.

Causes of union problems

1-lnadequate fixation e-g cast was not tight enough2- Interposition of soft tissueA muscular tendon is interposed between the fracture edges

preventing healing3- Infection*The liability for infection increases In compound fractures

more than in simple fractures* The presence of bacteria and pus delay the union process* In compound fractures, Tetanus toxoid and broad spectrum

antibiotics should be given4- Bad general condition of the patientOld patients or patients with systemic diseases e.g diabetes

usually show delayed union or even non union

B - Delayed union

Normally healing occur within 6-8 weeks in adults. Visualization of fracture line in the follow up x rays long time after the expected lime of healing with poor callus formation=delayed union

TreatmentThe Cause of delayed union is treated if possible

(nutrition, antibiotics and re fixation if needed)

C) Non-union

The reaction of healing comes to an end without union of the fracture

The fracture lines are seen with poor callus formation and sclerosis of the fracture edges

TreatmentExposure and excision of sclerosed edges &

coaptation of the raw edges by Internal fixation e.g. intramedulllary nail and Bone grafting if needed

ІІ- Sudeck's Atrophy:

Etiology: Bone dystrophy due to unknown cause but thought to be due to

1-Reflex vascular stenosis2-Disuse atrophy after removal of splints

Pathology: Marked osteoporosis distal to the fracture site, most commonly in the hand following fracture of radius

Radiological diagnosis of spine fracture

l-Plain X ray

Antero posterior, lateral views (most important). 1) Vertebral fracture

a) Burst/comminuted: The vertebra shows decrease height and fragmented body

b) ANTERIOR wedging: Anterior aspect of vertebral body is shorter than posterior border

C) Tear drop: common in cervical region

2- Ligamentous iniury leads to Subluxation and

Dislocation

movement of vertebral body at the fracture

level usually indicate ligamentous injury. the

lower vertebra moves either posteriorly

(posterior subluxation) or anteriorly(anterior

subluxation)

•

N.B Fractures Of Neural Elements:

This may occur with fracture of vertebral body at the level of injury or above as well as below the level

Ligaments:Ligamentous injury usually leads to

Unstable fracture which leads to Subluxation or dislocations of vertebral body

Complications of spinal trauma:

Spinal cord lesions (edema , contusion , hemorrhage , laceration and transaction). Cord atrophy & syrinx later on.

Intraspinal and paravertebral hematomas

Disc bulge and herniation.

Skeletal TraumaSpinal Trauma

Trauma of the spine affects one or more of the following:

{1} Bones (vertebrae-neural elements.)

{2} Spinal cord{3} Ligament{4} paravertebral soft tissue (muscles)

Bones:Fracture of vertebral body or neural elements

(laminae, pedicles, spinous process) Fractures of vertebral bodies

A) Burst Fracture It occurs with axial trauma e.g. falling from a height.

The most common level is D12-L1 vertebraeB ) Anterior Wedging:it is the most common type spinal fractures, very

common in lumbar vertebrae.The vertebra collapse anteriorly and is usually

subluxated posteriorlyC) Tear-drop fracture:Common in cervical region

3)subperiosteal hematomaCollection of blood under the periostium is normally,

small hematoma is formed in the soft tissues around the fracture site. Then invaded by granulation tissue. This process stimulates healing of the fracture.

If the nutrient artery of the bone becomes injured due to fracture, large hematoma may be formed

This large hematomas heal by calcification, a condition which causes disfigurement especially in apparent areas e.g. clavicle or hand

Treatment Surgical excision of the calcified hematoma

4- Avascular necrosis It occurs when the nutrient arteries of the bone

become injured, so that, the part of the bone which is supplied by the artery becomes deprived from its blood supply leading to its death

Example:The most common example is avascular necrosis of

the head of femur following fracture of the neck of femur

•It occurs in about 15-35% of cases• It appears in X ray as increase in bone density of

the femoral head with loss of volume and irregular contour

• Some other local complication of fracture: Skin injury, necrosis & gangrene Vascular injury (arteries or veins) Neurological injuries (peripheral nerves) Muscular and tendon injury Joint complications: Stiffness, Secondary osteo-

arthritis, infectionGeneral complication of fractures:1- hemorrhage and stroke2- Crush syndrome3- Pulmonary embolism4- fat embolism5- Tetanus6- Complications of prolonged recumbancy e.g. bed

soars...

Imaging Technology

1. X-RAYS: These show (1) disc narrowing, (2) bone spurs (osteophytes), and (3) vertebrae slipping off another (spondylo-listhesis)

2. CAT SCAN: This is a computerized X ray that shows how much the diameter of the canal is reduced and how far out the discs are.

3. M.R.I. (Magnetic Resonance Imaging): It produces picture like the CAT scan but they are generated using a magnetic field (instead of radiation) – not needed if the CAT scan shows the problems. 34

Fracture lateral malleolus

Oblique fracture

Burst # of C7

C2

C7

Burst # of the spine

Burst # of the spine

MRI

Burst # of the spine CT & Plain

Burst # of the spine

Burst # of the spine CT

CT & Plain x ray of burst fx

A vascular necrosis

A vascular necrosis

A vascular necrosis

DDX for both hips

A vascular necrosis Head of the femur

Comminuted Fractures

Fracture lower end of humerus plain X-Ray lateral view

Comminuted Fractures

Comminuted Fractures

Comminuted Fractures

Comminuted Fractures

Comminuted Fractures

Comminuted Fractures

Tear drop # of the spine

Dislocation

C2-C3 Fracture/Dislocation

C6-C7 Vertebral Dislocation

Dislocation

Dislocation & fx Dislocation

Elbow dislocation

Subluxation

Atlanto axial subluxation

Internal fixation of upper tibia

Simple #

Comminuted fx

Simple fx

Simple fx

Transverse #

Transverse #

Wedge fractures

Wedge fractures

Wedge fractures

Anterior wedge fracture