Fracture & Bone Disorders PDF

MDPT FRACTURE & BONE DISORDERS I. Bone G. Salter-Harris Classification - highly specialized connective tissue composed Grade 1: epiphyseal plate, incomplete fx of cells calcified in a...

MDPT FRACTURE & BONE DISORDERS I. Bone G. Salter-Harris Classification - highly specialized connective tissue composed Grade 1: epiphyseal plate, incomplete fx of cells calcified in an organic osteoid matrix Grade 2: epiphyseal plate + triangular segment of metaphysis A. Embryology Grade 3: epiphyseal plate + epiphysis 1. Membranous Grade 4: epiphyseal plate + epiphysis + - gradual replacement of tissue into an osteoid metaphysis (all) matrix (structural framework) ○ (+) Growth arrest - connective tissue → calcification → bone Grade 5: crushed epiphyseal plate - facial bones & cranial vault 2. Endochondral *“SALTR” - mesenchymal cells will form into cartilage 1: Simple - mesenchymal cells → cartilage → bone 2: Above (the epiphyseal plate = meta) - long bones, spine, scapula, sternum, ribs 3: Lower (the epiphyseal plate = dia) 4: Through/Tatlo B. Bone cells 5: Rammed = crushed 1. Osteoblasts - bone formation 2. Osteoclasts - bone resorption *Normally, osteoblasts & osteoclasts activities II. Fracture should be equal - break / discontinuity of a bone 3. Osteocytes - “living element of bone”; carries nutrients for bone development A. Types Incomplete = (+) break / avulsion (such as C. Composition hairline fx) 1. Organic (30%) = collagen type 1 Complete = total discontinuity 2. Inorganic (70%) = hydroxyapatite a. Phosphate Open / Compound = (+) communication c b. Carbonate surrounding tissues; (+) wound 3. H2O (10%) Closed / Simple = total discontinuity D. Bone Cross-Section According to appearance: 1. Haversian System / Osteon - long patent Transverse Fx = creates a right angle along columns that are irregularly parallel along the the shaft axis of the shaft of bones Oblique Fx = creates a diagonal angle along a. Haversian canal - central spaces the shaft located in bet haversian systems Spiral Fx = 2° to torsional F; heals fastest b. Lamellae - concentric layers of Segmental Fx = broken to several segments intercellular substances that surrounds Comminuted Fx = separated into several canal fragments c. Lacunae - spaces in bet lamellae; storage of osteocytes Other types: d. Canaliculi - links the lamellae; where Avulsion Fx = 2° to strong pull of muscle processes of osteocytes happen Compression Fx = 2° to axial loading e. Volkmann’s canal - transverse / oblique Stress Fx = 2° to repetitive trauma channels that transmit blood supply Pathological Fx = 2° to underlying condition Impacted Fx = fx ends are jammed to each other; most stable fx *for open (wound coverage): Gustilo-Anderson Classification Grade 1: 1 cm but 10 cm ○ 3A: periosteal stripping, soft tissue injury E. Types of Bones ○ 3B: soft tissue injury, bony coverage; 1. Long bones - bones which length > width require flaps 2. Short bones - bones which length is almost ○ 3C: involves blood vessels (*circulatory) equal to width (cuboidal shape; capitate) 3. Sesamoid bones - sesame-shaped (patella) *for close:Tscherne Classification 4. Flat bones - flat, thin or curve (skull) 5. Complex bones - irregular shape (pelvis, *for femoral neck fx: Garden Classification vertebra) F. Bone architecture internally → externally: 1. medullary canal - hollow space 2. → endosteum 3. → diaphysis - shaft 4. → periosteum - covering of diaphysis ends of long bones: 1. Metaphysis 2. Epiphyseal plates / cartilaginous plate / growth plate 3. Epiphysis - most end MDPT FRACTURE & BONE DISORDERS B. Upper Extremity Fx D. Vertebral Fx 1. Supracondylar Fx = prox to elbow jt 1. Jefferson’s Fx = burst fx @ ring of atlas; (-) SCI - mc complication: Volkmann’s 2. Hangman’s Fx = axis, neural arch ischemic contracture (dt marked 3. Teardrop Fx = Dens / Odontoid process swelling; results to interrupted blood Types supply) a. Type 1 - fx of the tip of Odontoid; blood - mc deformity: Gunstock deformity = supply maintained cubitus varus / valgus b. Type 2 (mc) - fx of base of Odontoid; high non-union rate 2. Fx of distal radius c. Type 3 - axis is affected; HALO traction 4. Clayshoveler’s fx = fx of tip of C7 (& T1) Colle’s Fx / Poteau’s Smith’s Fx / Reverse spinous process Fx Colle’s Fx 5. Chance fx = spinal fx 2° tight seatbelts dorsal displacement volar displacement of E. Le Fort Classification for Facial Fx of distal radius distal radius 1. Le Fort 1 = low maxillary fx a. maxillary sinuses MOI: FOOSH MOI: FOBOTH / fall b. lower nasal septum on flexed hand c. pterygoid plates 2. Le Fort 2 = pyramidal / oblique fx present.: Dinner / present.: Garden a. zygomaticomaxillary sutures Silver Fork Deformity Spade Deformity b. inferior orbital rim c. nasal bridge 3. Monteggia’s Fx = fx of ulna c d/l of radial head 3. Le Fort 3 = craniofacial dysfunction Types: a. above zygomatic arch Type 1 ( mc): fx of ulnar diaphysis c ant b. med & lat orbital wall d/l of radial head Type 2: fx of ulnar diaphysis c post d/l of F. Bone Healing radial head 1. Inflammatory Phase Type 3: fx of ulnar metaphysis c ant / - hematoma formation ant+lat d/l of radial head - prostaglandin mediation (to control pain) Type 4: fx of ulna & radius c d/l of radial - neutrophils / macrophages activated to head release cytokines (for tissue repair) - days to wks 4. Galleazi’s Fx / Reverse Monteggia’s / 2. Reparative Phase Piedmont / Dupuytren’s Fx / Fx of Necessity - fibroblastic activity, for: = fx of radius c d/l of ulnar head - callus formation (soft → hard callus) - wks to mos 5. Barton’s Fx = fx &/ d/l of wrist 3. Remodeling Phase - hard callus is formed 6. Chauffeur’s Fx = fx of radial styloid process - WB status - common in automobile operators - stages (ARRFQ): - starting kickback Activation = of osteoclasts Resorption = (+) osteoclasts 7. Fx of Capitulum activity (destroy bone) a. Hahn-Steinthal Fx = complete Reversal = osteoblasts will be b. Kocher-Lorenz Fx = articular cartilage recruited Formation = (+) osteoblasts 8. Bennet’s Fx = avulsion fx of 1st MCP / thumb activity (form new bone) - APL & AdP Quiescence = bone will a. Rolando’s Fx = comminuted Bennet’s undergo dormancy until the next cycle begins 9. Boxer’s / Fist Fighters / Street Fighters Fx = 5th MCP (neck) G. Principles of Fx Healing - Treatment: 1. Reduction - replacement / realignment of fxed a. Gutter splint = 40° angulation a. Traction skin = use of adhesive rubber tips; max: *clavicular fx; displacement of the outer and middle 5-6 lbs only thirds of the bone dt pull of SCM ○ ex: Buck & Russel (for children) *DRUJ fx; focus on supination-pronation movement skeletal = drilled using screws & nails (intramedullary nail); mc: proximal tibia; C. Lower Extremity Fx max: 20-30 lbs: only very minimal 1. Femoral neck fx = interruption in blood supply / movement is allowed; additional tool to AVN prevent atrophy: Pearson attachment 2. Intertrochanteric fx = no interruption in bs (attached to the splint) 3. Walther’s fx = ischioacetabular fx ○ ex: Balance Skeletal Traction 4. Duverney’s fx = avulsion fx of iliac wing / ala b. Internal Fixation 5. Shepherd’s fx = lat tubercle of talus c. External Fixation (mc) = cast 6. Cotton fx = transmalleolar fx of the foot 3. Preservation of Reduction 7. Nutcracker fx = calcaneus & cuboid 8. March fx = stress fx of the 2nd MTT H. Anomalies in Bone Healing 9. Trimalleolar fx = dt abd, ER; add / IR 1. Delayed union - failure of fx to heal within: 10. Calcaneal fx (primary movement concern; a. UE: 3-12 wks inversion-eversion) b. LE: 12-18 wks MDPT FRACTURE & BONE DISORDERS 2. Malunion - union in an a unsatisfactory - risk factors: alignment - M (dt hormonal imbalance in 3. Non-union - failure of fx ends to unite (common F postmenopausal) in long bones) - >60 y/o: F=M - caucasians Causes: - inc caffeine intake (can inc osteoclast ○ Impaired circulation activity) ○ Interrupted stability - critical during - corticosteroids healing phase - Pharma Mx: ○ (+) infection - osteomyelitis - Bisphosphonates sequestrum = “dead bone” - Calcium: N daily dietary intake = 1,500 involucrum = thickened layer mg/day or 1,000-1,500 mg/day of bone; “living portion of bone” - Clinical features: ○ inaccurate reduction - Kyphotic ○ loss of bone substance - Dowager’s hump - Radiographic findings: - Codfish vertebra = 2° to expansion of III. Bone Disorders IVD creating a biconcavity appearance A. Achondroplasia of vertebra - mc form of short limb dwarfism - endochondral ossification retardation D. Osteogenesis Imperfecta / Brittle bones / - disproportion of trunk & limbs Fragilitas ossium - congenital disorders; autosomal dominant - a genetic connective tissue d/o caused by - features: mutation of COL1A1 & COL1A2 genes that - height seldom reaches 4 ft encode collagen type 1 - face smaller in relation to head - triad: - brachycephalic head: ant-post 1. Brittle bones diameter of head is shorter than N 2. Wedge-wood blue sclera - high & broad forehead 3. Deafness - flattened nose & depressed nose bridge - prominent lower jaw E. Progressive Myositis Ossificans - Main En Trident Deformity - gap in bet - transformation of fascia, ligaments, tendons & 3rd & 4th fingers, wrist radially shifted muscles into an immobile structures - lordotic - initially: fascia, ligaments - variants: - secondary: muscles Pseudoachondroplasia ○ features not present @ birth F. Mucopolysaccharidosis ○ head & face looks N - inherited disease Hypochondroplasia - accumulation of Mucopolysaccharides (long ○ milder form chain of sugar) ○ reaches 5 ft - lysosomal enzyme storage d/o (impaired Metaphyseal Chondrodysplasia destruction of toxic / foreign substances) ○ similarities c Rickets disease bc (HHSM(5)MS) (Vit D deficiency in children; no MPS 1: Hurler’s Syndrome (mc) calcium bone absorption) ○ (+) hurler’s / gorgoyle cells Chondroectodermal dysplasia / ○ shortened neck & trunk / spine Ellis-Van Creveld disease ○ enlarged skull & prominent forehead ○ polydactyly ○ shortening of FA ○ dysplastic fingernails ○ impaired jt mobility ○ distal shortening of FA & legs ○ hepatosplenomegaly Chondrodysplasia punctata MPS 2: Hunter’s Syndrome ○ stippled calcification in bone ○ only x-linked d/o Diastrophic Dwarfism MPS 3: San Filippo ○ multiple jt contracture ○ fatal in teens ○ external ear deformity MPS 4: Morquio’s Syndrome ○ kyphoscoliosis ○ leads to short spine dwarfism ○ clubfoot deformity ○ enlarged femoral head = hip ER ○ proximally set hitchhikers thumb ○ Waddling gait MPS 5 B. Osteosclerosis MPS 6: Maroteaux-Lamy - skeletal disease characterized by regions of inc ○ N intelligence bone density ○ corneal opacities Osteopetrosis / Marble Bones MPS 7: Sly disease ○ failure in osteoclastic activity ○ almost similar manifestation c classic ○ “bone in a bone” appearance MPS Osteopoikilosis / Spotted Bones ○ (+) ovoid spots of inc sclerosis seen in radiographs (formed by osteoblast dt IV. Amputation inactive osteoclast) - removal of a body part, a portion or the entire Osteopathia striata limb that has been severely injured, infected or ○ coarse longitudinal lines has lost its function A. Terminologies C. Osteoporosis Congenital - bone mass density falls @ -2.5 SD from N Acquired - through surgery - if 1.00-2.00 = osteopenia (less severe form) - silent disease; manifests until presence of fx Open - wound is left unclosed - DEXA / Dual Energy X-ray Absorptiometry = Close - final / definitive amputation gold standard for assessing osteoporosis MDPT FRACTURE & BONE DISORDERS Major = amputation is proximal to MCP & MTP Minor = amputation is distal to MCP & MTP Disarticulation = amputation through a jt B. Indications vascular disease / accident infection (s. aureus) trauma malignant tumor congenital anomaly (excessive growth) electrical / chemical burns C. Types of Amputation in UE Cineplastic - designed for UE for prosthetic use Krukenberg - separation of radius & ulna to create a crude pinching mechanism D. Levels of Amputation AEA / Above Elbow Amputation / Transhumeral Amputation ○ 0% = sh disarticulation / through jt ○ 0-30% = humeral neck dissection ○ 30-50% = short AEA ○ 50-90% = long AEA; standard AEA ○ 90-100% = elbow disarticulation BEA / Below Elbow Amputation / Transradial Amputation ○ 0-35% = very short BEA ○ 35-55% = short BEA (standard) ○ 55-90% = long BEA ○ 90-100% = wrist disarticulation AKA / Above Knee Amputation / Transfemoral Amputation ○ 66% = long AKA BKA / Below Knee Amputation / Transtibial Amputation ○ 50% = long BKA E. Stump Shape “BCyACo” BK = cylindrical AK = conical F. Complications Improper wound healing infection phantom sensation = can still feel the amputated segment / limb ○ telescoping: sensation of movement of amputated segment (distal) proximally phantom pain = noxious sensation on the amputated segment / limb dermatologic problems jt contractures G. Amputation in LE Lisfranc = tarsometatarsal Chopart = midtarsal Boyd = talectomy H. Others mc birth fx = clavicular fx mc limb deficiency fx = left terminal transverse radial limb / left intercalary radial limb mc fx in children = greenstick fx *Wolff’s Law = every change in forms & function is followed by a definitive change in its internal architecture; allows bone to adapt to certain stresses that is being applied to it