Trauma



Trauma






OPEN FRACTURE

An open fracture, also called a compound fracture, is a fracture resulting in the bone penetrating through the skin. Open fractures are usually the result of high-energy trauma. These injuries are considered contaminated, but if they are left without treatment for 6 to 8 hours, they are considered infected. Open fractures are considered a medical or surgical emergency, and patients should be admitted for antibiotics, closed reduction/open reduction internal fixation (ORIF), and/or debridement.


Classification (Gustilo and Anderson)


Type I

Fracture with an open wound less than 1 cm in length

Clean, with minimal soft tissue damage/necrosis

Fracture is usually simple (transverse or short oblique) with minimal or no comminution.

Adequate skin coverage maintained

If a bone graft is required for repair, may be done immediately

No neurovascular compromise


Type II

Fracture with open wound greater than 1 cm in length

Clean, with mild to moderate soft tissue necrosis

Fracture is usually simple (transverse or short oblique) with minimal or no comminution.

Adequate skin coverage

No major neurovascular compromise

If a bone graft is required for repair, best done at the time of delayed primary closure when there is no evidence of infection1


Type III

Fracture with extensive open wound greater than 10 cm in length

Moderate to severe contamination and/or necrosis of skin, muscle, N/V structures, and soft tissue

Often comminution

If a bone graft is required for repair, best done at 3 months after the reactive bone callus has diminished1


IIIA

Type III with adequate soft tissue coverage of bone with minimal to no periosteal stripping


IIIB

Type III with extensive soft tissue loss with periosteal stripping and bone exposure


IIIC

Type III with arterial injury requiring microvascular repair



STRESS FRACTURE

A stress fracture is a fracture that develops due to cyclical loading on a bone. These forces are seen in people with overuse and repetitive activities, such as runners and athletes. Ninety-five percent of stress fractures occur in the lower extremity, most notably the neck of the 2nd metatarsal. They may take 14 to 21 days to present radiographically after a bony callus has developed. If x-rays are inconclusive, a three-phase technetium bone scan may be positive as early as 2 to 8 days after onset of symptoms. MRI may show early signs within 1 to 2 weeks, and exposes patient to less radiation.


GREENSTICK FRACTURE

A greenstick fracture is an incomplete fracture in which the cortex on only one side of the bone is cracked. They are more commonly seen in children due to their soft bones.


TURF TOE

Turf toe is a traumatic soft tissue injury of the 1st MPJ caused by forced hyperextension of the joint. Turf toe is more common in sports played on synthetic surfaces, hence the name “turf toe.” Turf toe results in plantar capsular and ligamentous injury, causing dislocation of the joint.










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JAHSS Classification


Type I

Dorsal dislocation of the proximal phalanx, in which the metatarsal head punctures through the plantar capsule

The intersesamoidal ligament remains intact, and there are no fractures.


The deformity is tight and difficult to close reduce, and may require ORIF.










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Type IIA

Dorsal dislocation of the proximal phalanx, in which the metatarsal head punctures through the plantar capsule

The intersesamoidal ligament is ruptured, and the sesamoids no longer remain apposed to one another.

The deformity is loose and easier to close reduce.










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Type IIB

Dorsal dislocation of the proximal phalanx, in which the metatarsal head punctures through the plantar capsule

The intersesamoidal ligament remains intact, and there is a transverse avulsion fracture of one of the sesamoids.

The deformity is close reducible.










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MPJ SEQUENTIAL RELEASE FOR A HAMMERTOE

1. Release of extensor expansion

2. Tenotomy/lengthening of extensor digitorum longus/extensor digitorum brevis

3. Transverse MPJ capsulotomy

4. Release of collateral ligaments

5. Plantar plate release—metatarsal (McGlamry) scoop


SEQUENTIAL RELEASE FOR AN OVERLAPPING 5TH TOE

1. Z-Plasty or V-Y skin plasty

2. Z-Tendon lengthening (for severe cases, transfer tendon to metatarsal head)

3. Release of extensor hood

4. Capsulotomy (dorsally and medially)


5. Plantar plate release (McGlamry elevator)

6. Plantar skin wedge excision


SESAMOID FRACTURE

A fractured sesamoid must be distinguished from a bipartite sesamoid, which has an incidence of 20%. The easiest way to make the distinction is to compare current radiographs with previous films, if available. When earlier films are not available, comparing the contralateral foot can be useful. Fractured sesamoids may show irregular jagged edges of separation with interrupted peripheral cortices, longitudinal or oblique division lines, or a bone callus formation.



ANKLE SPRAINS

Ankle sprains occur when the ligaments of the ankle are stretched or torn. There are three main types of ankle sprains: inversion sprains, eversion sprains, and high ankle sprains. Eversion sprains are rare for two reasons: The fibula prevents the foot from everting and the deltoid ligament on the medial ankle is very strong. High ankle sprains are syndesmotic injuries.

Most ankle sprains are inversion sprains, in which the foot inverts and the lateral ligaments are damaged. The position of the foot at the time of an inversion sprain determines which ligaments are damaged. When the foot is plantarflexed at the time of injury, the anterior talofibular (ATF) ligament is damaged. This accounts for 95% of ankle sprains. When the foot is dorsiflexed at the time of injury, the calcaneofibular ligament is most likely damaged. Due to its proximity, rupture of the calcaneofibular ligament may also result in tearing of the peroneal tendon sheath.





DISTAL TIBIOFIBULAR SYNDESMOTIC INJURY

A distal tibiofibular syndesmotic injury is also called a high ankle sprain and accounts for 10% of all ankle sprains. The mechanism of injury is eversion, dorsiflexion, and pronation, which forces the talus against the fibula widening the mortise. This results in damage to the ligaments holding the tibia and fibula together. The distal tibiofibular syndesmosis is a fibrous joint connecting the bones just above the ankle joint. The distal tibiofibular syndesmosis is composed of the following four ligaments, listed from anterior to posterior:

Anterior inferior tibiofibular ligament

Tibiofibular interosseous ligament

Inferior transverse tibiofibular ligament

Posterior inferior tibiofibular ligament (PITFL; strongest)










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The talar dome is wider anteriorly than posteriorly, and the syndesmosis shows elasticity of 1 to 2 mm when the foot moves from plantarflexion to dorsiflexion. Extreme dorsiflexion can cause separation of the distal tibiofibular articulation and injure the ligamentous structures.




ANKLE FRACTURES

1. Bosworth fracture: Lateral malleolar fracture with posterior displacement of proximal fibula

2. Cotton fracture: Trimalleolar fracture

3. Dupuytren fracture: Pott fracture (bimalleolar fracture)

4. Maisonneuve fracture: Proximal 1/3 fibular fracture (fibular neck), associated with syndesmotic injury. Often involves medial malleolar fracture or rupture of the deltoid ligaments.

5. Tillaux-Chaput fracture: Avulsion fracture of anterior inferior lateral tibia

6. Wagstaffe fracture: Avulsion fracture of anterior inferior medial fibula

7. Volkmann fracture: Posterior malleolar fracture


Classification (Lauge-Hansen)


SAD (Supination-Adduction)

Stage 1: Rupture of lateral collateral ligament or transverse lateral malleolus fracture

Stage 2: Vertical medial malleolar fracture


SER (Supination External Rotation)—Most Common

Stage 1: Rupture of anterior inferior tibiofibular ligament or a Tillaux-Chaput fracture or Wagstaffe fracture

Stage 2: Short oblique fibular fracture beginning at the level of the syndesmosis (posterior spike); SER stage 2 is the most common fracture

Stage 3 (Volkmann fracture): Posterior malleolus fracture (small fragment) or PITFL rupture

Stage 4: Transverse fracture of medial malleolus or rupture of the deltoid ligament


PAB (Pronation-Abduction)

Stage 1: Transverse fracture of medial malleolus (below syndesmosis) or rupture of the deltoid ligament

Stage 2: Rupture of the anterior inferior and PITFLs or a
Tillaux-Chaput or Wagstaffe fragment

Stage 3: Transverse or comminuted fracture of the fibula at the level of syndesmosis (lateral spike)


PER (Pronation-External Rotation)—Worst Kind

Stage 1: Transverse fracture of medial malleolus or rupture of the deltoid ligament

Stage 2: Rupture of the anterior syndesmosis and rupture of the interosseous membrane or Tillaux-Chaput fragment or Wagstaffe fragment

Stage 3: Spiral fracture of the fibula above the level of the syndesmosis; can be as high as the fibular neck (Maisonneuve fracture)

Stage 4: Posterior talofibular ligament rupture or fracture of the post malleolus (large fragment)


Classification (Danis-Weber)

This is based on the location of the fibular fracture with respect to the syndesmosis.


Type A

Fracture below the level of the syndesmosis (infrasyndesmotic)


Type B

Fracture at the level of the syndesmosis (transsyndesmotic)


Type C

Fracture above the level of the syndesmosis (suprasyndesmotic)


EPIPHYSEAL PLATE FRACTURES


Classification (Salter-Harris)

Associated with 35% of all skeletal injuries in children


Type 1 (6%)

Transverse minor fracture through growth plate

No shortening


Type 2 (75%)

Through growth plate and traveling above into the metaphysis

Extra-articular

Minimal shortening, with no functional limitations after healing


Type 3 (8%)

Through the growth plate and traveling below into the epiphysis

Intra-articular

Tilleaux-Chaput type fracture that can cause shortening


Type 4 (10%)

Oblique fracture through the epiphysis and metaphysis/diaphysis

Intra-articular


Type 5 (1%)

Crush injury of the growth plate

Growth plate disturbance that can cause shortening and is associated with poor prognosis











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CALCANEAL FRACTURES

Calcaneal fractures account for 1% to 2% of all fractures and typically occur as a result of axial loading such as a fall from a height or an MVA. The mechanism of injury is by way of the lateral process of the talus being driven down into the neutral triangle. Twenty percent of calcaneal fractures are associated with a spinal fracture between T12 and L2, L1 being the most common. Lumbar radiographs are, therefore, recommended in all fall/calcaneal injury patients presenting with back pain. Surgical repair should be performed within 5 hours of injury before acute swelling begins. If this window is missed, surgery should be delayed until swelling subsides, usually around 7 to 10 days, but before the 3-week mark when consolidation of the fracture begins. The goal of ORIF is to reestablish height and length to the calcaneus and realign the articular cartilage. These patients should be monitored for compartment syndrome.

Mondor sign is a clinical indicator for a calcaneal fracture. Patients present with ecchymosis extending from the malleoli to the sole of the foot.

Böhler angle is useful in evaluating calcaneal fractures. Normal values range between 20° and 40°; average is around 30° to 35°. Measurements less than 20° are seen in calcaneal fractures. Surgeons should strive to correct Böhler angle following ORIF for optimal outcome.

Gissane angle (critical angle) is useful in evaluating calcaneal fractures. Normal is 120° to 145°; a
fractured calcaneus will cause this angle to increase. Surgeons should strive to correct Gissane angle following ORIF for optimal outcome.


Fracture Lines










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The primary fracture line extends obliquely through the calcaneus from the posteromedial to the anterolateral. The anteromedial fragment consists of the anterior process, the sustentaculum tali, and a portion of the posterior facet. The posterolateral segment contains the tuberosity, the lateral wall, and variable portion of the posterior facet. The primary fracture line is a vertical fracture oriented from superior to inferior at the Gissane angle and is the result of the lateral process of the talus being driven down into the calcaneus. Secondary fracture lines are more varied and are determined by the direction of force.

Secondary fracture lines are determined by the direction of force. It can extend into the calcaneocuboid joint separating the anterior process into anteromedial and anterolateral fragments, or it can extend medially separating the sustentacular fragment from the anteromedial fragment.


Fragments



  • Constant fragment (a.k.a. superomedial fragment, sustentacular fragment). Because of its strong ligamentous and tendon support, this fragment remains constant as far as its location relative to the talus. This is the fragment to which all other fragments are fixated.


  • Anteromedial fragment


  • Anterolateral fragment


  • Lateral articular fragment is found with a joint depression type of injury where a fragment consisting of the lateral portion of the posterior facet develops. It is termed semilunar fragment, and with the tongue type, it is termed thalamic or comet fragment.


  • Lateral wall fragment develops as a result of a hydraulic tangential burst that occurs when the posterior facet is driven down into the body of the calcaneus.


  • Tuberosity (tuber) fragment is typically displaced varus and laterally.


Classification (Rowe)


Type IA

Medial calcaneal tuberosity fracture










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Type IB

Sustentaculum tali fracture










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Type IC

Anterior process fracture










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Type IIA

Post beak avulsion fracture (Achilles not involved)










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Nov 20, 2018 | Posted by in ORTHOPEDIC | Comments Off on Trauma
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