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Fractures and Dislocations

If a fracture is away from the joint, it’s not going to lead to arthritis in the future fractures, broken bones, dislocated, dislocated. Obviously if it’s through the joint, it has a high propensity to lead to arthritis in the future. If it’s around the growth plate, children can have growth arrest or deformity. That’s not going to be true, depending on the various anatomic locations.

The next thing we need to talk about in addition to anatomy when you are trying to describe a fracture, is displacement. There all sorts of eponyms, everyone has little words they use, but these are four basics we can all agree on, angulation, translation, rotation and shortening. There is an example of all four, I am going to go through them one at time. Angulation: This is where the fracture ends up bowing away from it’s normal position, and the way we describe that is the direction of the apex of the bone, I hope that got left on your hand-out this year, it’s the apex of the bow.

Translation, where bones aren’t so much angled but they are just moved with respect to one another, they actually line up pretty well. The wrist is lining up at the elbow, it’s just shifted to one side. Here is a both bone forearm fracture that’s translated and these, like dislocations, you describe by where the distal fragment goes.

So this is a radially translated both bone forearm fracture. This humerus fracture would be medially translated. Humerus is moved over toward the inside of the arm and is medially translated.

Rotation. By nature, rotation only happens with sort of oblique fractures or spiral fractures, and it has to do with the mechanism but also how you can reduce these. You can see this rotated fracture of the tibia and the way to reduce that is to straighten the foot up. Same with the distal femur, where there is rotation, but it almost always has to be an oblique type fracture for there to be pure rotation.

Shortening. This is a femur fracture that’s shortened and why do they shorten? What you don’t see on the x-ray are all the muscles pulling. Here, it’s the hamstring. The hamstrings are pulling, they are unrestrained at this point, and this bone is not gonna come back here and be stable, in all likelihood, unless you can exert such a force on the leg that it will stay in place, so this is shortening another example of shortening in the arm where the deltoid and proximal humerus is going to be stable. This has no place to go, the capsule is solid, but the distal arm can migrate up.

This is an example of a simple fracture, it’s two pieces, it’s not comminuted. This is an example of a fracture that’s comminuted, multiple pieces, when you open these up you want a bowl of milk.

Special considerations, growing bone. Real common that we see distal radius fractures in children, there are the Salter classifications I will show you in a minute. Physeal injuries, all of which carry some risk of growth arrest. Parents need to know that up front. The more severe the injury, the higher risk to the person.

So this is a Salter classification, Dr. Salter at the hospital, sick children in Toronto, the most common classification, it goes 1 through 4 or there is a type 5 that I left out. This is from general musculoskeletal medicine as will be all the figures here. A type 1, you won’t see this usually, It actually looks pretty normal.

As an example, and as bad as it looks, this is a Salter I fracture of the distal femur. Here is the diathesis and metaphysis of the distal femur and the whole epiphysis has slipped up and out. That’s a Salter I fracture. This is the equivalent of a knee dislocation, the artery is stuck back her, this is a big problem, often times it will have a hole in their popliteal artery.

This is a Salter II fracture of the distal tibia. The energy goes through the metaphysis, exits out the physis, the joint is going to be fine, you have to reduce this to prevent deformity, but once it heals the child will do quite well.

Elbow fractures like the lateral condyle fracture, because essentially the entire distal humerus in a child is cartilage, these are all growth plate fractures and all have some potential for growth arrest or deformity.

This is an example of a green stick fracture where the bone fails under tension, it’s as if you take something that is sort of soft, like a stem and started to bend it, if it fails under tension, that’s a green stick fracture,

Stress fractures, very common. Unfortunately, it takes several weeks to make the diagnosis most of the time. The foot in marchers new recruits, people who are not used to doing a certain thing that all of a sudden they take up, an activity, they develop metatarsal pain. The x-ray initially is negative.

Bone scan is going to be positive within a week usually. The x-ray is going to be six to eight weeks. The bone scan will be hot right away. This is an example, a woman had unexplained hip pain, and in retrospect, if you look closely at her x-ray she has this radiodense line across her femoral neck, but really, this is a normal looking hip x-ray, a bone scan shows the dark scintigraphic image of the femoral neck and she has a stress fracture of the femoral neck.

Dislocations. Very common. Those of you that work in emergency rooms, anterior shoulder dislocations are extremely common, often the patient has a history of shoulder dislocation, it’s most common in the front and every body knows the look. They come in bent over, trying not to move that shoulder at all, it is usually not locked.

Digital dislocation is very common, it’s very common to pop out a digit as I mentioned in the hand-out. I think if you are in the field and you see it out.

Evaluation and treatment. History, our history is basically when was the x-ray done, history is important. We want the trauma to match the crime, in other words, the fracture should sort of go with the type of trauma there was. A person shouldn’t be walking down the street and break their tibia, if that’s true, there is something wrong with their tibia.

In addition, we talk about medical conditions, diabetes, the common things that we see that can affect bone density, can affect activity status, strokes, and then the sort of game we get into whether they fainted, whether they had syncope, all these things are important considerations and then medications, especially things like Dilantin that can affect bone density.

Examination. I can’t stress enough to examine the joint above and below the level of the fracture, we are talking about fractures here. Also beware in paired bones like in the forearm or in the leg where there are two bones, it’s hard to break one without doing something to the other, either breaking it or dislocating the joint.

If you draw a line through the radius, that ought to be pointing right at the capitellum. This is a Monteggia fracture, it’s an ulnar fracture, and what they’ve done is dislocate the radial head. It has to be reduced and the radial head has to be held in place otherwise you are going to end up with severe elbow limitations.

So the initial care, the usual ABCs, physical examination, neurovascular and skin are probably the most important, circulation. Biplanar radiographs. I want to show you an example of why that’s important. It’s ok to get the lateral C-spine but always complete the C-spine, don’t walk way with just the lateral, except for a pelvis, virtually all our bones, we can see them in 3-dimensions by having biplane radiographs, and wound care, if there are open wounds, go ahead and put a Betadine sponge on there or some sort of dressing and antibiotics. I would caution you against injecting a lot of things with Lidocaine and doing this for nerve blocks right away. You really want to know what the neurologic status is first. This is an example of why to get a biplanar radiograph, here is a child hurt in a car accident, has seat belt on, and that AP radiograph looks pretty good. Things line up well, before you let them go get the lateral, cause obviously there is a fracture dislocation of the spine here. That’s completely off, so you really need to get two views on virtually every bone.