Académique Documents
Professionnel Documents
Culture Documents
•Reparative
–Vascular dilation
–New vessel proliferation
–Mesenchymal cell proliferation
–Change from acid to alkaline pH
–Collagen production in wound
–Cartilage and bone fomration begins
Three stages of healing:
•Inflammatory
•Reparative
•Remodeling
•Remodeling
–osteoblastic resorptioin
–new bone formation
– prominent endosteal and periosteal callus formation
MECHANISMS OF BONE HEALING
•TWO BASIC TYPES OF CALLUS
–INTERNAL
–EXTERNAL
EXTERNAL / PERIOSTEAL CALLUS
•The most reliable radiographic sign of beginning osseous union.
•The fastest type of callus to form
•Very dependent upon blood supply of surrounding soft tissues.
•more perioteal callus beneath areas of thick soft tissue
•Very tolerant to limited motion at fracture site
•Structurally oriented perpendicular to long axis of cortices
–Longitudinal orientation of bone will be re-established upon
remodeling of periosteal callus
Periosteal callus
•Radial fracture stablized with a pin shows periosteal callus
•Intramedullary callus seen as band of increased density across
metaphysis of ulna
EXTERNAL / PERIOSTEAL CALLUS
•Periosteal callus, because of it's peripheral location, is strongest
•The rigidity-
rigidity-efficiency of the tissue increases with the fourth power of
the distance from the center of rotation or bending.
•Periosteal callus does not form in intracapsular areas; no periosteum
-Periosteal callus does not form in flat skull bones
ENDOSTEAL/INTERNAL OR
LATE MEDULLARY CALLUS
•Predominates when external/periosteal callus has
failed
•Assisted by rigid immobilization
•Slow, steady bridging
•Medullary callus forms the earliest osseous bridging
of fracture line
PRIMARY BONE UNION
•Depends upon normal mechanism of bone turnover which
occurs continuously
•Must have absolute rigid immobilization; eg. occurs when
compression plate internal fixation is used properly.
•Primary angiogenic ossification occurs; secondary
osteotones form directly without an intervening cartilage
step in development.
–Longitudinally oriented osteotones formed around blood vessels
running across the fracture line.
•Depends on good endosteal circulation.
•Very slow process
•Periosteal callus may be minimal if primary bone union is
being achieved in conjunction with internal fixation device
SECONDARY BONE UNION
•Occurs when there is a gap between bone ends
(poor apposition and/or alignment) that must be
filled with new bone.
•Results mostly as result of excessive periosteal
callus that undergoes all the intermediate steps of
bone formation
–Granulation tissue – fibrous tissue – fibrocartilage –
woven bone- compact bone
WHEN IS A FRACTURE "HEALED"?
• Clinically: a fracture is healed when there is no
local tenderness or motion of bone across fracture
site when manually stressed by examining physician.
–Clinical union precedes osseous union, and may occur in
6-8 weeks, average.
–Removal of cast and limited use of the part may be
instituted by orthopedist at this time
–Clearly visible fracture line may be present on x-ray
•Radiographically: Strict radiographic criterion for
osseous union is complete obliteration of the fracture
line and evidence of remodeling.
Spondylolysis
•Myerding grading
–Divide sacral base into 1/4ths from back P to A
–Into which 1/4th does a line along posterior aspect L5 vert body fall?
–Grades I-IV; Grade V if spondyloptosis occurs.
•% assessment
–Estimate displacement of L5 relative to the total (100%) P-A
measurement of sacral base.
Spondylolysis
•L4 spondylolysis
Spondylolysis
•May be unstable- flexion/extension may be useful
Spondylolysis
•Spondyloptosis may occur
•“inverted Napolean hat” sign on AP view due to overlap of
L5 on sacral base
Spondylolysis
•Cervical spondyolysis most common at C6
•Spina bifida is typically associated
•Instability may be present
Fractures involving the growth plate
•Salter-Harris classification
–Type I = A “slip” of the epiphysis due to separation thru
the physis- injury to cartilage plate
–Type II – “Slip and a chip”; fracture thru physeal plate
and obliquely thru corner of adjacent metaphysis
–Type III – “A Slip and a crack”; fracture thru epiphysis
(crack), across physis (slip)
–Type IV – Fracture thru epiphysis, physis and metaphysis;
no significant slippage of physis/metaphysis
–Type V – Compression/impaction injury of physis
Salter-Harris # Type I
•Approx. 6% of epiphyseal fractures
•Common locations are distal extremities
•Easily overlooked without complete series
•Slipped Femoral Capital Epiphysis (SFCE) is a chronically
acquired S-H type I fracture
Salter-Harris # Type I
•Note the tibial physis is closed
•Offset seen on oblique and wide physis on lateral
Salter-Harris # Type II
•Most common (75%) of the Salter-Harris #s
•Easily overlooked without complete series
•Approx. 50% in distal radius
Salter-Harris # Type II
•What kind of Salter-Harris injury is present?
•What other injury is also present?
Salter-Harris # Type III
•Fracture thru epiphysis (crack) and across physis (slip)
•Approx. 8% of all epiphyseal fractures
Salter-Harris # Type III
•Most common location is distal tibia
•Optimal reduction especially important due to involvement
of articular surface
Salter-Harris # Type IV
•Fracture extends thru metaphysis, physis and epiphysis
•Most common sites are lateral condyle of humerus and
distal tibia
•Approx. 10% of epiphyseal plate fractures
•Open reduction typically performed
Salter-Harris # Type V
•Easily overlooked! Initial films may be negative
–MR much more sensitive!
•Least common of S-H types
•Compressive mechanism of injury
•Early growth plate closure may result in limb-length
problems
•Distal tibia and femur most common
Complications of fracture
•Immediate
–Arterial injury
–Compartment syndrome
–Gasgangrene
–Fat embolism
–Thromboembolism
•Later
–Osteonecrosis
–DJD
–Osteoporosis
–Aneurysmal bone cyst
–Non union
–malunion
•Intemediate
–Osteomyelitis
– hardware failure
–Reflex sympathetic dystrophy
–Post-traumatic osteolysis
–Refracture
–Myositis ossificans
–Synostosis
–Delayed union
Complications of fracture
Delayed vs Non-union
•Delayed union = fracture has not united at the average
time for the location and type of fracture.
–Expected healing time quite variable based on site and any
favorable/unfavorable factors;
–“delayed” is relative term.
Complications: Delayed vs Non-union
•Non-
Non-union = the repair process has completely stopped and union will
not occur without surgical intervention.
Non-union
•Smoothly corticated margins and closed medullary canal on left
characterize atrophic non-union of fibula
•Residual fracture line despite bone proliferation and sclerosis in
middle frame shows hypertrophic non-union
•Far right frame shows malunited fibula and non-union of the tibia
Non-union- what type?
•Hypertrophic “elephant foot” appearance
Malunion
•This case from Greenspan’s text shows residual angular
deformity from a united both-bones fracture of the lower leg
(reading left) and subsequent surgical intervention (right) to
restore alignment.
Early growth plate closure
•Length disparity and deformity secondary to central
ossification across physeal plate of distal left femur
•Distal tibia shows ossification across posterior part of
physeal plate, while anterior part not joined. Also note
deformity of fibula and disparity of length relative to tibia.
•(Cases from Greenspan text)
Avascular necrosis
•41 yr. old man with hx of traumatic hip dislocation
•Note the irregular, mixed sclerosis and cystic lucency of the
femoral head
•Frog-leg projection shows classic “cresent sign”
Avascular necrosis
•56 yr. old female with hx of intracapsular fx of femoral neck which
healed after internal fixation device applied.
• Irregular sclerosis of femoral head (best seen in tomo on rt)
consistent with avascular necrosis
Disuse osteoporosis
•These examples from Greenspan’s text show disuse osteoporosis that
may accompany united (left) or ununited (right) fractures. The
appearance may be alarming, although not necessarily of clinical
importance.
Chronic Regional Pain Syndrome-
Reflex Sympathetic Dystrophy (RSD)
•Also previously reported as Sudeck’s atrophy or causalgia
•Believed to be associated with antidromal sympathetic input to the
CNS secondary to trauma to peripheral trauma; overt fracture, neural
or vascular injury may or may not be present.
•Characterized by excessive pain (causalgia), not relieved by
immobilization.
•Initial soft tissue swelling followed by atrophy of skin/muscles
•Predominant X-ray findings are rapidly developing, patchy
osteoporosis distal to site of injury and changes (early, swelling; later,
atrophy)
Reflex Sympathetic Dystrophy (RSD)
•AKA: Sudeck’s atrophy
•Believed to be associated with antidromal sympathetic input to the CNS secondary
to trauma to peripheral trauma; overt fracture, neural or vascular injury may or may
not be present.
•Characterized by excessive pain (causalgia), not relieved by immobilization.
•Initial soft tissue swelling followed by atrophy of skin/muscles
•Predominant X-ray findings are rapidly developing, patchy osteoporosis distal to site
of injury and changes (early, swelling; later, atrophy)
Infection
•Both bones # with attempted internal fixation (left)
Shoulder- dislocation
•Most common presenting dislocation
•95% are anterior
– Subcoracoid (most common)
–Subglenoid
–Subclavicular
–Intrathoracic (rarely)
•Commonly associated injuries
–Hills-Sachs lesion
–Bankhart lesion
Clavicle fracture
Clavicle fracture
•12 yr old boy with history of trauma to shoulder 2-3 weeks
ago
Elbow fractures
•Radial head fx is most common adult elbow fracture
–Take oblique view in addition to AP/lat!
•Remember- the posterior fat pad is NOT normally visible on
the lateral x-ray
–In child with hx of trauma this is a reliable sign of fracture
•No obvious fx, but visible posterior fat pad (positive fat pad
sign) and displaced anterior fat pad (“sail sign”)
Trauma-
•Ulnar fracture with radial head dislocation
Trauma- supracondylar #
•Initial exam (left) somewhat light; fracture more easily seen
on darker repeat lateral
Trauma- supracondylar #
•Abnormal anterior humeral line
Radial head fx
Radial head fx
Elbow fractures
•Supracondylar fracture is most common pediatric elbow
fracture
•Injury to the brachial artery or median nv. may occur with
significant displacement
Nursemaid’s elbow
•Eponyms: Goyrand's injury / Malgaigne's luxation
•Mechanism: subluxation of radial head distally to annular ligament
such that the lig. becomes interposed between the capitellum and
radial head.
•Typically occurs when small child is lifted forcibly by axial distraction
on forearm.
•Occurs before the radial head is fully developed (prior to age 6 )
•Most common at age 2; not common after age 8.
•Clinical presentation
–.Rubbery resistance to passive supination and extension of elbow.
–Arm held in flexion approx. 20 degrees and slight pronation.
• Treatment: reduction without anaesthesia by anteriorward pressure
on radial head with thumb as elbow is slowly extended and
supinated; occasionally, flexion and pronation of elbow may also be
needed.
•X-rays are negative
Forearm fractures
•Monteggia fx
–Fx of ulna with dislocation of radial head
–This example is a non-united Monteggia fx in a patient with a who
gave a history of “recent trauma”
Forearm fractures
•Monteggia fx
–Pediatric patient (right)
–Adult patient (below)
Forearm fractures
•Galeazzi Fracture
–Fx of radius with diastasis of the distal radio-ulnar joint (two
different cases)
Wrist injuries
•Distal radius or ulna fx 10X more common than carpal bone
fx.
•Colle’s fx
–Fx. distal radial metaphysis with dorsalangulation
–+/- intra-articular involvement
–Assoc. ulnar styloid fx often due to attachment of triangular
cartilage
–Usually cause is fall on outstretched hand
Colle’s fx
•Note- even with the impacted fx, the distal radial articular
surface has lost normal volar slant (see below diag)
•Force applied thru TFCC to ulnar styloid may cause avulsion injury in
Colles fx.
Wrist injuries
•Colle’s fx
–Fx. distal radial metaphysis with dorsalangulation
–+/- intra-articular involvement
–Assoc. ulnar styloid fx often due to attachment of triangular
cartilage
–Usually cause is fall on outstretched hand
Wrist injuries
•Smith’s fx
–Fx distal radius with palmar displacement
–Articular surface not involved (case below most likely does have
articular involvement)
Wrist injuries
•Barton’s fx
–Fx of the dorsal rim of the radius due to impaction of carpus
•Barton originally described either dorsal or palmar rim fx
–By definition, an intra-articular fracture
–Carpus is dislocated or subluxed in addition to fracture
Wrist injuries
•Barton’s fx
–Equivocal plain film (right)
–T1 MR demonstrates definite loss of signal due to edema and linear
Wrist injuries
•Both bones fracture distal forearm
–Distal radial meta-diaphysis # with posterior displacement
–Salter-Harris # distal ulna with posterior displacement (?Type I or II?)
Wrist injuries
•Hutchinson fx
–Fx radial styloid process
–Involves the articular surface
–AKA “Chauffeur’s fx”
–Brachioradialis m. inserts on the radial styloid, therefore usually
above elbow cast
Carpal injuries
•Scapholunate dissociation
–Scapho-lunate space >2mm is suspicious and >4mm is diagnostic
of rupture of scapho-lunate ligament
–“Terry Thomas” sign
–Clenched fist view may be useful to emphasize this finding
Carpal injuries
•More recently, the “Terry Thomas sign” has been referred to
as the “David Letterman sign”.
Carpal injuries
•Scapholunate dissociation
–Scapho-lunate space >2mm is suspicious and >4mm is diagnostic
of rupture of scapho-lunate ligament
–“Terry Thomas” sign
–Clenched fist view may be useful to emphasize this finding
Boxer Fracture
Hand injuries – Metacarpal fx
•Midshaft MC fracture with pin to avoid flexion deformity
Injuries of the pelvis
•Pelvis is stable unless the pelvic ring is
broken/separated in two places
•Stable injuries include
–Avulsion fractures (see next slide)
–Isolated iliac wing fracture (not into pelvic opening)
–Single ramus fracture of obturator foramen
–Horizontal fracture of sacrum
–Dislocation and/or fracture of coccyx
•Monitor sacral and coccygeal fracture for
neurological injury
Pelvic fracture
•Anterior fractures acetabulum and pubic ramus
•Posterior fracutre is ……..
Pelvic fx diagragm
Avulsion injuries of the pelvis
•Common sites
–ASIS – sartorius muscle
–AIIS – rectus femoris muscle
–Ischial tuberosity – hamstring muscle
•Stable injuries, typically managed conservatively
Avulsion injuries of the pelvis
•Avulsions of AIIS (left) and ASIS (right)
Avulsion injuries of the pelvis
•Old avulsions of ASIS
Avulsion injuries of the pelvis
•Avulsion of ischial tuberosity
Pubic Symphysis
•Diastasis may occur due to multiple childbirth
•Case below is 39 yr. old female with 10 children- note the
wide symphysis pubis
Stress fracture of pelvis
•In osteoporotic patients who begin walking program, stress
fracture may develop in pelvis
Slipped Femoral Capital Epiphysis
•Separation thru the proximal femoral physis
•Easily overlooked!
–May present with “knee” (lower thigh) pain
•Age: peak in late childhood/early adolescence
•Sex: Males > Females approx. 2:1
•Left hip > right hip, but bilateral in 20-30%
–Females more commonly bilateral
•Avascular necrosis may occur as complication
S F C E – x-ray
•Blurring, irregularity of metaphyseal border of physeal plate
•Widening of physis
•Klein’s line does not intersect FCE
–Klein’s line along lateral femoral neck should intersect small
portion of FCE on both AP and frogleg views
S F C E – x-ray
•Apparent dec. height of FCE
–Due to posterior, medial and inferior displacement of FCE
•Loss of Capener’s triangle
–overlap of medial metaphyseal margin over acetabulum
•Decreased height of FCE
SFCE
Proximal femoral fractures
•Types
–intracapsular
–extracapsular
•Intracapsular
–subcapital- most common type
–mid-cervical
–Basicervical
•Extracapsular
–intertrochanteric
–subtrochanteric
–trochanteric
–May be difficult to see
When to x-ray? Ottowa Rules
•Investigators in Ottawa conducted a retrospective
chart review of all patients with acute knee injuries
who presented to an emergency department over a
10-month
•The knees of 74 percent of these patients were
evaluated radiographically, but only 5.2 percent were
found to have fractures..
When to x-ray? Ottowa Rules
•Age
•gender
• mechanism of injury
–(blunt trauma or fall versus twisting)
•Effusion
•ligamentous instability, and pain on palpation.
•history of swelling
•history of deformity
•ability to ambulate (i.e., to walk four steps)
•Swelling
•decreased range of motion
Ottawa Rules- X-ray if….
•Age 55 years or older with hx blunt trauma
•Tenderness at head of fibula
•Isolated tenderness of patella
•Inability to flex knee to 90 degrees
•Inability to walk four weight-bearing steps
immediately after the injury and in the emergency
department
Subsequent studies have shown these rules to be
nearly 100% sensitive, but may show significant
false positives.
•Blunt trauma or a fall as mechanism of injury plus either of
the following:
•LATERAL FLEXION
–Uncinate process fracture
•VERTICAL COMPRESSION
–Jefferson bursting fracture
–Burst fracture
•C1 - 6%
•C2 - 27%
•C3 - 10%
•C4 - 10%
•C5 - 18% C7 - 18%
• C6 - 27%
JEFFERSON FRACTURE
–Bilateral fractures thru the anterior and posterior neural
ring of atlas
–May be associated with lateral displacement of the
lateral masses and transverse ligament disruption.
–Results from compression force
–Low incidence of neurological injury
–Usually treated with conservative immobilization.
–Look for combined overlap >/= 7mm; indicates t'verse
lig. rupture.
–Associated spine #’s in 24-48%- check other areas
carefully!