Category Archive Fracture of Bone A-Z

Odontoid Fracture/The odontoid process, or dens, is a superior projecting bony element from the second cervical vertebrae (C2, or the axis). The first cervical vertebrae (atlas) rotates around the odontoid process to provide the largest single component of lateral rotation of the cervical spine. Fracture of the odontoid process is classified into one of three types, which are type I, type II, or type III fractures, depending on the location and morphology of the fracture.[rx]

The odontoid fracture can also occur with hyperflexion of the cervical spine. The transverse ligament runs dorsal to (behind) the odontoid process and attaches to the lateral mass of C1 on either side. If the cervical spine is excessively flexed, then the transverse ligament can transmit the excessive anterior forces to the odontoid process and cause an odontoid fracture.[rx]

A hangman’s fracture is better described as bilateral fracture traversing the pars inter articularis of C2 with an associated traumatic subluxation of C2 on C3. It is the second most common fracture of the C2 vertebrae following a fracture of the odontoid process and is almost always stable without the need for surgical intervention. Steele’s rule of thirds states that the cross-sectional area at the level of the atlas may be divided into three equally represented parts: the dens, space, and the spinal cord. This increased area for the spinal cord at this level is what allows for the relative lack of neurologic injury associated with a hangman’s fracture. [rx]

Mechanisms of Odontoid Fracture

Apart from hangings, the mechanism of injury—a sudden forceful hyperextension centered just under the chin—occurs mainly with deceleration injuries in which the victim’s face or chin strike an unyielding object with the neck in extension. The most common scenario is a frontal motor vehicle accident with an unrestrained passenger or driver, with the person striking the dashboard or windshield with their face or chin. Other scenarios include falls, diving injuries, and collisions between players in contact sports.

Although a hangman’s fracture is unstable, survival from this fracture is relatively common, as the fracture itself tends to expand the spinal canal at the C2 level. It is not unusual for patients to walk in for treatment and have such a fracture discovered on X-rays. Only if the force of the injury is severe enough that the vertebral body of C2 is severely subluxated from C3 does the spinal cord become crushed, usually between the vertebral body of C3 and the posterior elements of C1 and C2.

Types of Odontoid Fracture

Type I Odontoid Fracture 

A type I odontoid fracture occurs when the rostral tip of the odontoid process is avulsed (broken or torn off). This injury commonly occurs due to pulling forces from the apical ligament attachment to the odontoid process. The apical ligament attaches the tip of the odontoid process to the foramen magnum (skull base).

Type II Odontoid Fracture

A type II odontoid fracture is a fracture through the base of the odontoid process. This injury occurs most typically when there is an excessive extension of the cervical spine, and the anterior arch of C1 pushes dorsally (backward) with sufficient force on the odontoid process (dens) to fracture the odontoid process at its base. Type II odontoid fractures can also occur with hyperflexion of the neck and the transverse ligament, pushing the odontoid process forward to the point of fracture.

Type III Odontoid Fracture

A type III odontoid fracture is a fracture through the body of the C2 vertebrae and may involve a variable portion of the C1 and C2 facets.  Type III odontoid fractures occur secondary to hyperextension or hyperflexion of the cervical spine in a similar manner to type II odontoid fractures. The difference is where the fracture line occurs.

C2 fractures can be divided into 2 kinds: Odontoid and Hangmen

Odontoid Fractures

Location

• Fracture through the dens, flexion or extension injury

Nomenclature

Anderson and D’Alonzo classification is the most ubiquitous.

• Type-1 fractures: Upper portion of the odontoid peg, above the transverse portion of the cruciform ligament, these are generally stable
• Type-2 fractures: These are the most common, the fracture through the based of the odontoid below the transverse portion of the cruciform ligament, they have a high risk of non-union
• Type-3 fractures: These fracture through the odontoid peg and into the body of C2, generally well tolerated

The Roy-Camille classification of odontoid fractures is another but less frequently used nomenclature format focusing on the direction of the fracture line.

Hangman’s Fractures

Location

• Fracture through the bilateral pars, generally from hyperextension and axial loading generally
• Stable 90% heal with immobilization alone

Nomenclature

Levine and Edwards Classification

• Type 1: Less than 3 mm subluxation of C2 on C3, due to axial loading, stable, rigid cervical collar treatment
• Type 2: disruption of the C2 to C3 disc, posterior longitudinal ligament, greater than 4 mm subluxation, greater than 11 degrees angulation, less than 5 mm requires a reduction in axial traction and halo fixation for 6 to 12 weeks while those greater than 5 mms can require surgery
• Type 2a: Less displacement more angular deformity, flexion injury, unstable, not suitable for axial traction, treatment in halo
• Type 3: C2 to C3 facet capsule disrupted, anterior longitudinal ligament disruption, unstable, may have deficit, surgical candidates.

Levine and Edwards Classification[rx]

Specifics

• Angulation in this system is measured as the angle between the inferior endplate of C2 and C3. Anterior subluxation of C2 on C3 greater than 3 mm serves as a marker for C2 to C3 intervertebral disc disruption. It is important to recognize that this grading system is not applicaple in the pediatric population.

Grading

• Type 1: Less than 3 mm subluxation of C2 on C3, due to axial loading, stable, rigid cervical collar treatment
• Type 2: Disruption of the C2 to C3 disc, posterior longitudinal ligament, greater than 4 mm subluxation, greater than 11 degrees angulation, less than 5 mm requires a reduction in axial traction and halo fixation for 6 to 12 weeks while those greater than 5 mm can require surgery
• Type 2a: Less displacement more angular deformity, flexion injury, unstable, not suitable for axial traction, treatment in halo
• Type 3: C2 to C3 facet capsule disrupted, anterior longitudinal ligament disruption, unstable, may have deficit, surgical candidates

Francis Grading System[rx]

Specifics

• Two factors are taken into consideration for the Francis Grading system: angulation and displacement. Angulation is measured by the degree of anterior angulation off of the posterior vertebral line drawn straight up from the C3 vertebral body. Displacement is measured by the amount of anterolisthesis, either greater than or less than 3.5 mm.

Grading

• Type 1: Less than 11 degrees of angulation and less than 3.5 mm of displacement
• Type 2: Greater than 11 degrees of angulation and less than 3.5 mm of displacement
• Type 3: Less than 11 degrees of angulation and greater than 3.5 mm displacement
• Type 4: Greater than 11 degrees of angulation and greater than 3.5 mm of displacement
• Type 5: Complete disc disruption

Typical versus Atypical Fractures

• It is important to recognize that not all C2, hangman’s type fractures can be described using these classification systems. A typical hangman’s fracture allows for separation of the anterior elements from the posterior elements of the C2 vertebrae, therefore increase the available space for the spinal cord.
• However, in the case of an atypical hangman’s fracture the posterior aspect of the C2 vertebral body, not the bilateral pars, is involved. This leads to a higher risk of neurologic injury as the space remaining for the spinal cord does not increase secondary to the fracture.

Causes of Odontoid Fracture

• Odontoid fractures occur as a result of trauma to the cervical spine.
• high-energy trauma, which occurs as a result of a motor vehicle or diving accidents.
• trauma can occur after lower energy impacts such as falls from a standing position.
• hyperextension of the cervical spine, pushing the head and C1 vertebrae backward.
• forceful thrust are high enough (or the patient’s bone density is compromised secondary to osteopenia/osteoporosis),
• The odontoid fracture can also occur with hyperflexion of the cervical spine.
• The transverse ligament runs dorsal to (behind) the odontoid process and attaches to the lateral mass of C1 on either side.
• If the cervical spine is excessively flexed, then the transverse ligament can transmit the excessive anterior forces to the odontoid process and cause an odontoid fracture.[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of the broken cervical spine.
• Sports injuries – Many cervical spine fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause cervical spine to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
• Previous pelvic fractures record.
• Wave an inadequate intake of calcium or vitamin D.
• Football or soccer, especially on artificial turf
• Athletic injury with a sports injury.
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• Clumsiness in hands
• Gait imbalance
• Degenerative cervical spondylosis (CSM) 
  
• Compression usually caused by anterior degenerative changes (osteophytes, disc osteophyte complex)
• Degenerative spondylolisthesis and hypertrophy of ligamentum flavum may contribute
• The most common cause of cervical myelopathy.

Symptoms of Odontoid Fracture

Symptoms of cervical spondylosis include:

• Neck stiffness and pain
• Numbness and weakness in the upper limbs
• Difficulty in walking, losing balance, or weakness in limbs
• Difficulty in turning the head fully or bending the neck, which may hinder drive
• Muscle spasms in neck and shoulders
• Headaches
• Grinding and popping feeling in the neck when rotating the head
• Loss of bladder and bowel control.
• neck pain and stiffness
• axial neck pain (oftentimes absent)
• occipital headache common
• extremity paresthesias
• diffuse nondermatomal numbness and tingling
• weakness and clumsiness
• weakness and decreased manual dexterity (dropping object, difficulty manipulating fine objects)
• Gait instability patient feels “unstable” on feet
• weakness walking up and downstairs
• gait changes are the most important clinical predictor
• urinary retention rare and only appear late in disease progression, not very useful in diagnosis due to the high prevalence of urinary conditions in this patient population
• Cervical pain aggravated by movement
• Referred pain (occiput, between the shoulder blades, upper limbs)
• Retro-orbital or temporal pain (from C1 to C2)
• Cervical stiffness—reversible or irreversible
• Vague numbness, tingling, or weakness in upper limbs
• Dizziness or vertigo
• Poor balance
• Rarely, syncope triggers a migraine, “pseudo-angina”

Diagnosis of Odontoid Fracture

Laboratory tests should be ordered as an adjunct in overall medical status.

• Normalized hemoglobin,
• hematocrit,
• coagulation profile with prothrombin time (PT),
• partial thromboplastin time (PTT), and
• platelet counts will be needed for operative intervention.

In hospitals and countries without readily available advanced imaging capabilities, radiographs are critical to evaluate and assist in ruling out potential odontoid fractures.  Recommended views include:[rx]

• AP C-spine
• Lateral C-spine
• Open-mouth odontoid view

Although radiographs yield lower sensitivity and specificity rates when compared to computed tomogram (CT) scans, experienced clinicians and practitioners can still appreciate suspected injury without CT utilization.  In addition, in the setting of suspected occipito cervical instability (useful in type I odontoid fractures or the setting of os odontoideum), flexion-extension radiographs should be obtained.

X-ray

Evaluation of x-rays will provide limited but important information. Care must be taken to ensure proper radiographic imaging creates a picture from the occiput to the C7 through T1 disc space. This is essential in reviewing cervical spine trauma. Lateral, anteroposterior (AP) and open mouth odontoid views are necessary. Approximately, 93% of cervical spine injuries are apparent with combined, lateral, AP, and odontoid view radiographs. X-rays are an excellent modality for determining alignment during the immediate injury, post-operative period, as well as long-term, follow up.

Computed tomogram (CT) scan

CT scan is the most important modality for determining fracture etiology and ruling out an injury with regards to a C2 fracture. Even if plain films are negative and clinical suspicion is high a CT scan is warranted. CT scan does not directly evaluate the spinal cord, soft tissue, or ligamentous construct. It is important to recognize the importance that complete imaging will require dedicated thin-cut CT reconstructions. Non-contrast CT scan is adequate for evaluation of the bony anatomy for fracture. This can be coupled with a CT angiogram for evaluation of the vascular anatomy.

Magnetic resonance imaging (MRI) scan

Evaluation with MRI is important for the analysis of the ligamentous construct, disc space, spinal cord, nerve roots, and other soft tissue injuries. MRI is also useful for determining the acute nature of the fracture when this is otherwise unknown. This is done via non-contrasted imaging. T2 signal hyperintensities and STIR changes within the dens, ligaments, or soft tissue can illustrate an acute component.

Vascular Imaging

Vascular imaging may be indicated. The vertebral artery’s second segment (V2) runs through the transverse foramen of C2 to C6 while V3 runs extramurally exiting the C2 foramen across the sulcus arteriosus.  This can place it at risk for injury. Indeed, in one series 15% of patients with C1 to C2 fractures had a vertebral artery injury. Of which, type-III odontoid fractures posed the greatest risk. It is important to note that an untreated vertebral artery injury has a 24% stroke rate.

Advanced Imaging modalities

The imaging modality of choice is a CT of the cervical spine. The CT provides the best resolution of the bony elements allowing for identification and characterization of an odontoid fracture. If there is neurologic injury (paresthesia, weakness), then magnetic resonance imaging (MRI) without the contrast of the cervical spine should be obtained to assess the cervical cord for injuries.

Nuclear bone scan – a diagnostic procedure in which a radioactive substance is injected into the body to measure activity in the bones.  (The amount of radiation is small–less than the radiation in half of one CT scan.) This scan helps identify damaged bones.

Treatment of Odontoid Fracture

The treatment of an odontoid fracture depends on the type of fracture and age of the patient.[rx][rx][rx][rx]

Non-Surgical Treatment

Treatment available can be broadly

• Skeletal traction – Available evidence suggests that treatment depends on the part of the pelvic fracture that is fractured. Traction may be useful for odontoid fracture because it counteracts the force of the muscle pulling the two separated parts together, and thus may decrease bleeding and pain.^[rx] Traction should not be used in the femoral neck and odontoid fracture or when there is any other trauma to the leg or pelvis.^[rx][rx] It is typically only a temporary measure used before surgery. It only considered the definitive treatment for patients with significant comorbidities that contraindicate surgical management.^[rx]
• Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your hip area, then get medical care immediately. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up. Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness, and tingling in the leg.
• Apply ice – After you get home from the hospital odontoid fracture (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your odontoid fracture  for 15 minutes three to five times daily until the soreness and inflammation eventually fades away
• Lightly exercise after the pain fades – After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your hip joints in all different directions. Don’t aggravate the odontoid fracture so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light, and then progress to holding light weights (five-pound weights to start).
• Practice stretching and strengthening exercises – of the fingers, leg if your doctor recommends them.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
• Get a supportive arm sling – Due to their anatomical position, necks of odontoid fracture can’t be cast like a broken spine. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture.
• Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your neck and lower chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and necks movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
• Rigid fixation – osteosynthesis with locking plate, hook plate fixation, fixation with a locking plate, coracoclavicular screws, Knowles pin fixation.
• Flexible fixation – simple k wire fixation, tension band wiring, suture anchors, vinyl tape, dacron arterial graft for ligament reconstruction.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)

Rest Your Leg – Once you’re discharged from the hospital in an arm sling, your top priority is to rest your and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.

Type I Odontoid Fracture

• Most consider a type I odontoid fracture a stable fracture and treatment for six to 12 weeks in a rigid cervical orthosis (hard cervical collar). Some have suggested that rarely a type I odontoid fracture may be unstable secondary to more extensive and unrecognized ligamentous injury, and flexion/extension x-rays should be obtained at the time of removal of the cervical collar after six to 12 weeks to ensure cervical stability.

Type II Odontoid Fracture[rx]

• Type II odontoid fractures are inherently unstable and have a lower union rate than type III odontoid fractures due to the lower surface area of a fractured bone in type II versus type III odontoid fractures.
• The configuration of type II odontoid fracture and age of patient also play important roles in treatment decisions. The current treatment options for a type II odontoid fracture include rigid cervical orthosis, halo vest immobilization, odontoid screw, transoral adenoidectomy, and posterior instrumentation.

Rigid Cervical Orthosis 

• A type II odontoid fracture is inherently unstable, and a rigid cervical orthosis is not the ideal treatment for such an injury. In the elderly population, many are not surgical candidates (due to comorbidities or poor bone quality), and the elderly typically poorly tolerate a halo vest immobilization. In such situations, a practitioner may attempt a rigid cervical orthosis, although union rates are low.

Halo Vest Immobilization

• If a patient is relatively young and healthy, and there is low risk for nonunion, then halo vest immobilization may be the best treatment for a type II odontoid fracture. Risk factors for nonunion include a fractured space greater than a few millimeters between the odontoid process and vertebral body, poor alignment of the odontoid process with respect to the vertebral body, and poor bone quality and/or health status of the patient.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement-to remove general weakness & improved health.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).

Odontoid Screw

• An anterior odontoid osteosynthesis (odontoid screw) is a screw placed from the inferior anterior aspect of the C2 vertebral body, in a superior trajectory, and capturing the odontoid process and affixing it in place to allow bony fusion to occur.  The odontoid screw has an advantage of relative preservation of motion of the upper cervical spine while treating a type II odontoid fracture.
• A surgeon can only place the odontoid screw if there are acceptable alignment and minimal displacement of the odontoid process, the fracture line is oblique or perpendicular to the screw trajectory, the injury is relatively recent, and the patient has acceptable body habitus to place the odontoid screw.

Transoral Odontoidectomy

• In some situations, the odontoid process (dens) may be severely posteriorly displaced and compressing the spinal cord causing neurologic deficits. It is difficult and dangerous to reduce the odontoid process in a closed manner, so surgical removal of the odontoid process is required to relieve the compression of the spinal cord.
• This relief is commonly achieved through a transoral adenoidectomy, as the odontoid process commonly is located posterior to the oropharynx. If the odontoid process is removed, the cervical spine remains unstable, and the patient requires instrumented fusion, commonly from a posterior or combined anterior-posterior approach.

Posterior Instrumentation

If the patient has certain risk factors for nonunion, then posterior instrumentation may provide the best treatment option for a type II odontoid fracture. The risk factors include:

• More than a few millimeters gap between the odontoid process and the vertebral body
• Poor odontoid process alignment
• Poor bone quality, older fractures
• Older patients
• Failure of other treatment modalities
• Smoking

Posterior instrumented fusion techniques vary widely and include fusion limited to C1 and C2 as well as more extensive fusions. The fusion of only C1 and C2 will lead to approximately 50% reduction of the lateral rotation of the cervical spine.

Surgical Treatment

Treatment options include conservative management, cervical orthosis, halo-vest orthosis, and surgical procedures.[rx][rx][rx][rx]

External Fixation

• Rigid cervical collar represents the immediate first treatment. For type-I and type-III odontoid fractures this is generally adequate. This is also true for 90% of Hangman’s fractures. Halo-vest orthosis can be used as well for external fixation in certain cases of type-II odontoid fractures or angulated/displaced Hangman’s fractures but is not very well tolerated in the elderly population.

Internal Fixation

• Internal fixation can be achieved via anterior fixation or by a variety of posterior constructs.

Anterior

• An odontoid screw can be placed for type-II odontoid fractures in good alignment with an intact transverse ligament in the acute setting.  There is concern about the placement of the odontoid screw in the elderly population and instances of delayed non-union.

Posterior

• C1 to C2 transarticular screws
• C1 lateral mass and C2 pedicle screws
• C1 lateral mass and C2 pars interarticularis screws
• C1 to C2 wiring (also as an adjunct technique)

Posterior fixation technique selection requires significant review by neurosurgeon or orthopedic spine surgeon. It takes into consideration a variety of factors including surgeon experience, fracture location, vertebral artery location, biomechanical suitability, and anatomical variations. Vascular imaging is mandatory to illustrate the location of the vertebral artery in the V2 and V3 segments.

Collars and Halo Fixators

• The use of collars and halo fixators remains controversial. Soft collars have no stabilizing function, thus we do not recommend them in the early phase. However, they may be used for nonoperative treatment in stable fractures after an initial phase with a hard collar.
• Hard collars (Philadelphia, for example) may be used in the first phase for unstable fractures until a decision for further treatment is made. It may be used for 6 to 8 weeks in cases where nonoperative treatment is indicated. ^[rx–rx]

Anterior Odontoid Screw Fixation

• Initially described by Böhler,^rx] osteosyntheses with 1 or 2 screws by an anterior approach is a standard operative treatment in younger patients with good bone quality if adverse modifiers are absent.
• Patients are operated on in the supine position. With a minimal open incision, the preparation follows the anatomical structures for the standard anterior approach to the cervical spine.

Pelvic Ring Fracture/A pelvic fracture involves damage to the hip bones, sacrum, or coccyx – the bony structures forming the pelvic ring. Due to the inherent structural and mechanical integrity of this ring, the pelvis is a highly stable structure. Therefore, fractures of the pelvis occur most commonly in the setting of a high-impact trauma and are often associated with additional fractures or injuries elsewhere in the body. [rx][rx][rx]

A pelvic fracture is a break of the bony structure of the pelvis.^[1] This includes any break of the sacrum, hip bones (ischium, pubis, ilium), or tailbone. Symptoms include pain, particularly with movement. Complications may include internal bleeding, injury to the bladder, or vaginal trauma.^[rx][rx]

Types of Pelvic Ring Fracture

There are two main classification systems used to describe pelvic fractures – Tile (based on the integrity of the posterior sacroiliac complex) and Young (based on the mechanism of injury).

The Tile classification system: developed by Pennal and Tile, divides injuries into lateral compression (LC), anteroposterior compression (APC) or vertical shear (VS) injuries.  This classification system also takes into consideration radiographic signs of pelvic stability or instability.

• Type A – The sacroiliac complex remains intact, and the pelvic ring contains a stable fracture (often managed operatively).A1 – avulsion fracturesA2 – stable iliac wing fracture or minimally displaced pelvic ring fractureA3 – transverse sacral or coccyx fracture
• Type B – Partial disruption of the posterior sacroiliac complex – caused by external or internal rotational forces (rotationally unstable and vertically stable).B1 – open-book injuryB2 – LC injuryB3 – bilateral type-B injury
• Type C – Complete disruption of the posterior sacroiliac complex (both rotationally and vertically unstable) often as a result of intense force (e.g. motor vehicle accident, fall from a height or severe compression injury). C1 – unilateral injuryC2 – bilateral injury (one side is a type B, and the other is a type C)C3 – bilateral injury (both sides type C)

The Young classification system

• Developed by Young and Burgess, expanded on Tile’s classification by including combined fractures (as many pelvic fractures occur as a combination of forces in multiple directions).
• The most common combination fracture is LC/VS.   LC fractures involve transverse fractures of the pubic rami (either ipsilaterally or contralaterally to the posterior injury).  VS fractures involve symphyseal diastasis or vertical displacement (either anteriorly or posteriorly – usually through the SI joint, or less commonly through the iliac wing or sacrum).

Grade I

• A slight widening of the pubic symphysis or anterior sacroiliac (SI) joint and sacral compression on the side of the impact
• Sacrotuberous, sacrospinous and posterior SI ligaments remain intact

Grade II

• Widening of the anterior SI joint (e.g. due to disruption of the anterior SI, sacrotuberous and sacrospinous ligaments) and posterior iliac (“crescent”) fractures on the side of the impact
• Posterior SI ligaments remain intact.

Grade III (open book) 

• Complete SI joint disruption and lateral displacement (e.g. disruption of the anterior SI, sacrotuberous, sacrospinous, and posterior SI ligaments
• Contralateral sacroiliac joint injury.

Causes of Pelvic Ring Fracture

• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of the broken pelvic.
• Sports injuries – Many pelvic fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause necks of femur fracture to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
• Previous pelvic fractures record.
• Wave an inadequate intake of calcium or vitamin D.
• Football or soccer, especially on artificial turf
• Athletic injury with a sports injury.
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms Of Pelvic Ring Fracture

Common symptoms of fractures include:

• Severe pain that might worsen when gripping or squeezing or moving your hip.
• Inability to move immediately after a fall
• Severe pain in your pelvic or groin.
• Inability to put weight on your leg on the side of your injured pelvic.
• Stiffness, bruising and swelling in and around your hip area
• Shorter leg on the side of your injured hip and pelvic
• Turning outward of your leg on the side of your injured
• Swelling
• Tenderness
• Bruising
• Obvious deformity, such as a bent pelvic.
• Pain
• Pain, especially when flexing the hip
• Deformity of the pelvic, causing it to look crooked and bent.
• Your hip is in great pain.

Diagnosis of Pelvic Ring Fracture

Lateral Compression (LC)

Treatment of Pelvic Fracture/A pelvic fracture involves damage to the hip bones, sacrum, or coccyx – the bony structures forming the pelvic ring. Due to the inherent structural and mechanical integrity of this ring, the pelvis is a highly stable structure. Therefore, fractures of the pelvis occur most commonly in the setting of a high-impact trauma and are often associated with additional fractures or injuries elsewhere in the body. [rx][rx][rx]

A pelvic fracture is a break of the bony structure of the pelvis.^[1] This includes any break of the sacrum, hip bones (ischium, pubis, ilium), or tailbone. Symptoms include pain, particularly with movement. Complications may include internal bleeding, injury to the bladder, or vaginal trauma.^[rx][rx]

Types of Pelvic Fracture

There are two main classification systems used to describe pelvic fractures – Tile (based on the integrity of the posterior sacroiliac complex) and Young (based on the mechanism of injury).

The Tile classification system: developed by Pennal and Tile, divides injuries into lateral compression (LC), anteroposterior compression (APC) or vertical shear (VS) injuries.  This classification system also takes into consideration radiographic signs of pelvic stability or instability.

• Type A – The sacroiliac complex remains intact, and the pelvic ring contains a stable fracture (often managed operatively).A1 – avulsion fracturesA2 – stable iliac wing fracture or minimally displaced pelvic ring fractureA3 – transverse sacral or coccyx fracture
• Type B – Partial disruption of the posterior sacroiliac complex – caused by external or internal rotational forces (rotationally unstable and vertically stable).B1 – open-book injuryB2 – LC injuryB3 – bilateral type-B injury
• Type C – Complete disruption of the posterior sacroiliac complex (both rotationally and vertically unstable) often as a result of intense force (e.g. motor vehicle accident, fall from a height or severe compression injury). C1 – unilateral injuryC2 – bilateral injury (one side is a type B, and the other is a type C)C3 – bilateral injury (both sides type C)

The Young classification system

• Developed by Young and Burgess, expanded on Tile’s classification by including combined fractures (as many pelvic fractures occur as a combination of forces in multiple directions).
• The most common combination fracture is LC/VS.   LC fractures involve transverse fractures of the pubic rami (either ipsilaterally or contralaterally to the posterior injury).  VS fractures involve symphyseal diastasis or vertical displacement (either anteriorly or posteriorly – usually through the SI joint, or less commonly through the iliac wing or sacrum).

Grade I

• A slight widening of the pubic symphysis or anterior sacroiliac (SI) joint and sacral compression on the side of the impact
• Sacrotuberous, sacrospinous and posterior SI ligaments remain intact

Grade II

• Widening of the anterior SI joint (e.g. due to disruption of the anterior SI, sacrotuberous and sacrospinous ligaments) and posterior iliac (“crescent”) fractures on the side of the impact
• Posterior SI ligaments remain intact.

Grade III (open book) 

• Complete SI joint disruption and lateral displacement (e.g. disruption of the anterior SI, sacrotuberous, sacrospinous, and posterior SI ligaments
• Contralateral sacroiliac joint injury.

Causes of Pelvic Fracture

• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of the broken pelvic.
• Sports injuries – Many pelvic fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause necks of femur fracture to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
• Previous pelvic fractures record.
• Wave an inadequate intake of calcium or vitamin D.
• Football or soccer, especially on artificial turf
• Athletic injury with a sports injury.
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms Of Pelvic Fracture

Common symptoms of fractures include:

• Severe pain that might worsen when gripping or squeezing or moving your hip.
• Inability to move immediately after a fall
• Severe pain in your pelvic or groin.
• Inability to put weight on your leg on the side of your injured pelvic.
• Stiffness, bruising and swelling in and around your hip area
• Shorter leg on the side of your injured hip and pelvic
• Turning outward of your leg on the side of your injured
• Swelling
• Tenderness
• Bruising
• Obvious deformity, such as a bent pelvic.
• Pain
• Pain, especially when flexing the hip
• Deformity of the pelvic, causing it to look crooked and bent.
• Your hip is in great pain.

Diagnosis of Pelvic Fracture

Lateral Compression (LC)

Test Diagnosis of Pelvic Fracture /A pelvic fracture involves damage to the hip bones, sacrum, or coccyx – the bony structures forming the pelvic ring. Due to the inherent structural and mechanical integrity of this ring, the pelvis is a highly stable structure. Therefore, fractures of the pelvis occur most commonly in the setting of a high-impact trauma and are often associated with additional fractures or injuries elsewhere in the body. [rx][rx][rx]

A pelvic fracture is a break of the bony structure of the pelvis.^[1] This includes any break of the sacrum, hip bones (ischium, pubis, ilium), or tailbone. Symptoms include pain, particularly with movement. Complications may include internal bleeding, injury to the bladder, or vaginal trauma.^[rx][rx]

Types of Pelvic Fracture

There are two main classification systems used to describe pelvic fractures – Tile (based on the integrity of the posterior sacroiliac complex) and Young (based on the mechanism of injury).

The Tile classification system: developed by Pennal and Tile, divides injuries into lateral compression (LC), anteroposterior compression (APC) or vertical shear (VS) injuries.  This classification system also takes into consideration radiographic signs of pelvic stability or instability.

• Type A – The sacroiliac complex remains intact, and the pelvic ring contains a stable fracture (often managed operatively).A1 – avulsion fracturesA2 – stable iliac wing fracture or minimally displaced pelvic ring fractureA3 – transverse sacral or coccyx fracture
• Type B – Partial disruption of the posterior sacroiliac complex – caused by external or internal rotational forces (rotationally unstable and vertically stable).B1 – open-book injuryB2 – LC injuryB3 – bilateral type-B injury
• Type C – Complete disruption of the posterior sacroiliac complex (both rotationally and vertically unstable) often as a result of intense force (e.g. motor vehicle accident, fall from a height or severe compression injury). C1 – unilateral injuryC2 – bilateral injury (one side is a type B, and the other is a type C)C3 – bilateral injury (both sides type C)

The Young classification system

• Developed by Young and Burgess, expanded on Tile’s classification by including combined fractures (as many pelvic fractures occur as a combination of forces in multiple directions).
• The most common combination fracture is LC/VS.   LC fractures involve transverse fractures of the pubic rami (either ipsilaterally or contralaterally to the posterior injury).  VS fractures involve symphyseal diastasis or vertical displacement (either anteriorly or posteriorly – usually through the SI joint, or less commonly through the iliac wing or sacrum).

Grade I

• A slight widening of the pubic symphysis or anterior sacroiliac (SI) joint and sacral compression on the side of the impact
• Sacrotuberous, sacrospinous and posterior SI ligaments remain intact

Grade II

• Widening of the anterior SI joint (e.g. due to disruption of the anterior SI, sacrotuberous and sacrospinous ligaments) and posterior iliac (“crescent”) fractures on the side of the impact
• Posterior SI ligaments remain intact.

Grade III (open book) 

• Complete SI joint disruption and lateral displacement (e.g. disruption of the anterior SI, sacrotuberous, sacrospinous, and posterior SI ligaments
• Contralateral sacroiliac joint injury.

Causes of Pelvic Fracture

• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of the broken pelvic.
• Sports injuries – Many pelvic fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause necks of femur fracture to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
• Previous pelvic fractures record.
• Wave an inadequate intake of calcium or vitamin D.
• Football or soccer, especially on artificial turf
• Athletic injury with a sports injury.
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms Of Pelvic Fracture

Common symptoms of fractures include:

• Severe pain that might worsen when gripping or squeezing or moving your hip.
• Inability to move immediately after a fall
• Severe pain in your pelvic or groin.
• Inability to put weight on your leg on the side of your injured pelvic.
• Stiffness, bruising and swelling in and around your hip area
• Shorter leg on the side of your injured hip and pelvic
• Turning outward of your leg on the side of your injured
• Swelling
• Tenderness
• Bruising
• Obvious deformity, such as a bent pelvic.
• Pain
• Pain, especially when flexing the hip
• Deformity of the pelvic, causing it to look crooked and bent.
• Your hip is in great pain.

Diagnosis of Pelvic Fracture

Lateral Compression (LC)

What Is Pelvic Fracture?/A pelvic fracture involves damage to the hip bones, sacrum, or coccyx – the bony structures forming the pelvic ring. Due to the inherent structural and mechanical integrity of this ring, the pelvis is a highly stable structure. Therefore, fractures of the pelvis occur most commonly in the setting of a high-impact trauma and are often associated with additional fractures or injuries elsewhere in the body. [rx][rx][rx]

A pelvic fracture is a break of the bony structure of the pelvis.^[1] This includes any break of the sacrum, hip bones (ischium, pubis, ilium), or tailbone. Symptoms include pain, particularly with movement. Complications may include internal bleeding, injury to the bladder, or vaginal trauma.^[rx][rx]

Types of Pelvic Fracture

There are two main classification systems used to describe pelvic fractures – Tile (based on the integrity of the posterior sacroiliac complex) and Young (based on the mechanism of injury).

The Tile classification system: developed by Pennal and Tile, divides injuries into lateral compression (LC), anteroposterior compression (APC) or vertical shear (VS) injuries.  This classification system also takes into consideration radiographic signs of pelvic stability or instability.

• Type A – The sacroiliac complex remains intact, and the pelvic ring contains a stable fracture (often managed operatively).A1 – avulsion fracturesA2 – stable iliac wing fracture or minimally displaced pelvic ring fractureA3 – transverse sacral or coccyx fracture
• Type B – Partial disruption of the posterior sacroiliac complex – caused by external or internal rotational forces (rotationally unstable and vertically stable).B1 – open-book injuryB2 – LC injuryB3 – bilateral type-B injury
• Type C – Complete disruption of the posterior sacroiliac complex (both rotationally and vertically unstable) often as a result of intense force (e.g. motor vehicle accident, fall from a height or severe compression injury). C1 – unilateral injuryC2 – bilateral injury (one side is a type B, and the other is a type C)C3 – bilateral injury (both sides type C)

The Young classification system

• Developed by Young and Burgess, expanded on Tile’s classification by including combined fractures (as many pelvic fractures occur as a combination of forces in multiple directions).
• The most common combination fracture is LC/VS.   LC fractures involve transverse fractures of the pubic rami (either ipsilaterally or contralaterally to the posterior injury).  VS fractures involve symphyseal diastasis or vertical displacement (either anteriorly or posteriorly – usually through the SI joint, or less commonly through the iliac wing or sacrum).

Grade I

• A slight widening of the pubic symphysis or anterior sacroiliac (SI) joint and sacral compression on the side of the impact
• Sacrotuberous, sacrospinous and posterior SI ligaments remain intact

Grade II

• Widening of the anterior SI joint (e.g. due to disruption of the anterior SI, sacrotuberous and sacrospinous ligaments) and posterior iliac (“crescent”) fractures on the side of the impact
• Posterior SI ligaments remain intact.

Grade III (open book) 

• Complete SI joint disruption and lateral displacement (e.g. disruption of the anterior SI, sacrotuberous, sacrospinous, and posterior SI ligaments
• Contralateral sacroiliac joint injury.

Causes of Pelvic Fracture

• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of the broken pelvic.
• Sports injuries – Many pelvic fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause necks of femur fracture to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
• Previous pelvic fractures record.
• Wave an inadequate intake of calcium or vitamin D.
• Football or soccer, especially on artificial turf
• Athletic injury with a sports injury.
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms Of Pelvic Fracture

Common symptoms of fractures include:

• Severe pain that might worsen when gripping or squeezing or moving your hip.
• Inability to move immediately after a fall
• Severe pain in your pelvic or groin.
• Inability to put weight on your leg on the side of your injured pelvic.
• Stiffness, bruising and swelling in and around your hip area
• Shorter leg on the side of your injured hip and pelvic
• Turning outward of your leg on the side of your injured
• Swelling
• Tenderness
• Bruising
• Obvious deformity, such as a bent pelvic.
• Pain
• Pain, especially when flexing the hip
• Deformity of the pelvic, causing it to look crooked and bent.
• Your hip is in great pain.

Diagnosis of Pelvic Fracture

Lateral Compression (LC)

Pelvic Fracture/A pelvic fracture involves damage to the hip bones, sacrum, or coccyx – the bony structures forming the pelvic ring. Due to the inherent structural and mechanical integrity of this ring, the pelvis is a highly stable structure. Therefore, fractures of the pelvis occur most commonly in the setting of a high-impact trauma and are often associated with additional fractures or injuries elsewhere in the body. [rx][rx][rx]

A pelvic fracture is a break of the bony structure of the pelvis.^[1] This includes any break of the sacrum, hip bones (ischium, pubis, ilium), or tailbone. Symptoms include pain, particularly with movement. Complications may include internal bleeding, injury to the bladder, or vaginal trauma.^[rx][rx]

Types of Pelvic Fracture

There are two main classification systems used to describe pelvic fractures – Tile (based on the integrity of the posterior sacroiliac complex) and Young (based on the mechanism of injury).

The Tile classification system: developed by Pennal and Tile, divides injuries into lateral compression (LC), anteroposterior compression (APC) or vertical shear (VS) injuries.  This classification system also takes into consideration radiographic signs of pelvic stability or instability.

• Type A – The sacroiliac complex remains intact, and the pelvic ring contains a stable fracture (often managed operatively).A1 – avulsion fracturesA2 – stable iliac wing fracture or minimally displaced pelvic ring fractureA3 – transverse sacral or coccyx fracture
• Type B – Partial disruption of the posterior sacroiliac complex – caused by external or internal rotational forces (rotationally unstable and vertically stable).B1 – open-book injuryB2 – LC injuryB3 – bilateral type-B injury
• Type C – Complete disruption of the posterior sacroiliac complex (both rotationally and vertically unstable) often as a result of intense force (e.g. motor vehicle accident, fall from a height or severe compression injury). C1 – unilateral injuryC2 – bilateral injury (one side is a type B, and the other is a type C)C3 – bilateral injury (both sides type C)

The Young classification system

• Developed by Young and Burgess, expanded on Tile’s classification by including combined fractures (as many pelvic fractures occur as a combination of forces in multiple directions).
• The most common combination fracture is LC/VS.   LC fractures involve transverse fractures of the pubic rami (either ipsilaterally or contralaterally to the posterior injury).  VS fractures involve symphyseal diastasis or vertical displacement (either anteriorly or posteriorly – usually through the SI joint, or less commonly through the iliac wing or sacrum).

Grade I

• A slight widening of the pubic symphysis or anterior sacroiliac (SI) joint and sacral compression on the side of the impact
• Sacrotuberous, sacrospinous and posterior SI ligaments remain intact

Grade II

• Widening of the anterior SI joint (e.g. due to disruption of the anterior SI, sacrotuberous and sacrospinous ligaments) and posterior iliac (“crescent”) fractures on the side of the impact
• Posterior SI ligaments remain intact.

Grade III (open book) 

• Complete SI joint disruption and lateral displacement (e.g. disruption of the anterior SI, sacrotuberous, sacrospinous, and posterior SI ligaments
• Contralateral sacroiliac joint injury.

Causes of Pelvic Fracture

• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of the broken pelvic.
• Sports injuries – Many pelvic fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause necks of femur fracture to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
• Previous pelvic fractures record.
• Wave an inadequate intake of calcium or vitamin D.
• Football or soccer, especially on artificial turf
• Athletic injury with a sports injury.
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms Of Pelvic Fracture

Common symptoms of fractures include:

• Severe pain that might worsen when gripping or squeezing or moving your hip.
• Inability to move immediately after a fall
• Severe pain in your pelvic or groin.
• Inability to put weight on your leg on the side of your injured pelvic.
• Stiffness, bruising and swelling in and around your hip area
• Shorter leg on the side of your injured hip and pelvic
• Turning outward of your leg on the side of your injured
• Swelling
• Tenderness
• Bruising
• Obvious deformity, such as a bent pelvic.
• Pain
• Pain, especially when flexing the hip
• Deformity of the pelvic, causing it to look crooked and bent.
• Your hip is in great pain.

Diagnosis of Pelvic Fracture

Lateral Compression (LC)

Tibia fractures are common injuries. The subcutaneous nature of the tibia makes it more prone to open injury. The musculature about the lower leg divides into four compartments separated by fascial tissue. Radiographs are essential in the initial evaluation of the fractures.  In the case of injury or fracture of the lower extremity, the fascial tissue may have to be released by fasciotomies to prevent the sequelae of compartment syndrome.  Treatment methods can be non-operative for minimally displaced fractures although operative fixation for displaced and open fractures is preferred.

Types of Tibia Fracture

Classifications

Some classifications help with treatment decisions.

Western and Tscherne

This is a classification of closed fracture soft tissue injury and is as follows:

• Grade 0: Injuries from indirect forces with minimal soft tissue damage
• Grade 1: Superficial contusion/ abrasion, simple fractures
• Grade II: Deep abrasions, muscle/skin contusion, direct trauma, impending compartment syndrome
• Grade III: Excessive skin contusion, crushed skin or muscle destruction, subcutaneous degloving, acute compartment syndrome, and rupture of a major blood vessel or nerve

The Gustilo-Anderson

This classification is used to assess open tibia fractures.

• Type I is limited periosteal stripping, clean wound less than 1 cm
• Type II mild to moderate periosteal stripping; wound greater than 1 cm in length
• Type IIIA significant soft tissue injury, significant periosteal stripping with a wound that is usually greater than 1 cm in length with no flap required
• Type IIIB is significant periosteal stripping and soft tissue injury with a flap required due to inadequate soft tissue coverage
• Type IIIC these are significant soft tissue injury with a vascular injury requiring repair

Treatment of Tibia Fracture

Non-Operative Treatment

Closed-reduction and nonoperative treatment in a long leg cast is acceptable for fractures in less than 5 degrees of varus-valgus angulation, less than 10 degrees in anterior-posterior angulation, greater than 50% cortical apposition, less than 1-cm shortening and less than 10 to 20 degrees of flexion and less than 10 degrees of rotational malalignment after reduction.

Operative Treatment[2][9][10]

External Fixation

Treatment of choice when significant soft tissue compromise is present or in polytrauma cases where damage-control orthopedics is needed.

Intramedullary Nailing (IMN)

This is the treatment of choice for operative fixation.

When comparing outcomes of IMN with external fixation, IMN is associated with decreased malalignment and compared to closed treatment, IMN is associated with decreased union time and time to weight bearing.

Percutaneous Plating-Shaft

This method is often used in the distal tibia or proximal-third fractures that are too proximal or distal for intramedullary nailing.

Amputation

This is another treatment method but can be difficult to get the patient to buy into this treatment. The mangled extremity severity score (MESS) can help predict when an amputation is necessary. A score of 7 or greater is highly predictive of amputation. MESS has a high specificity but low sensitivity in predicting amputations. Relative indications include significant soft tissue trauma, warm ischemia greater than 6 hours, and severe ipsilateral foot trauma. It is important to note that loss of plantar sensation is not an absolute indication for amputation.

Management of Tibial Fractures

Tibial plateau fracture: These fractures present with knee pain and effusion. They classically occur after a car hits a pedestrian’s fixed knee, which is known as a “bumper fracture.” They are classified using the Schatzker classification and managed by using nonsurgical or surgical methods to achieve stable alignment. Operative strategies include external fixation and open reduction internal fixation.[10]

• Schatzker Classification

  • Type 1: lateral split fracture
  • Type 2: lateral split-depressed fracture
  • Type 3: lateral pure depression fracture
  • Type 4: medial fracture
  • Type 5: bicondylar fracture
  • Type 6: metaphyseal-diaphyseal disassociation

Tibial shaft fracture: Compared to most long bone fractures, tibial shaft fractures are more likely to be open because the medial surface is adjacent to the subcutaneous tissue. The fracture can have a low or high energy pattern. The low energy patterns are a result of torsional injury resulting in a spiral fracture. The high energy pattern is from a direct force that causes a wedge or oblique fracture. Nonoperative treatment is chosen for low-energy fractures that are minimally displaced while operative treatment is indicated for high-energy fractures including external fixation, intramedullary nailing, and percutaneous locking plate. These fractures can lead to extensive soft tissue injury, compartment syndrome, malunion, and bone loss. [rx]

Ankle fractures involving the distal tibia: These injuries generally present with ankle pain and swelling and an inability to bear weight. They are usually the result of severe inversion or eversion of the ankle joint. The Lauge-Hansen and Danis-Weber classifications are commonly used to determine the type of fracture. There are also several specific distal tibial fractures that have their own name. The Pilon fracture involves the distal tibia and its articular surface with the ankle joint, and the Tillaux fracture involves the anterolateral distal tibial epiphysis. Distal tibial fractures are most commonly treated with open reduction and internal fixation.[rx],[rx]

• Lauge-Hansen Classification

  • Supination-adduction
  • Supination-external rotation
  • Pronation-abduction
  • Pronation-external rotation

• Danis-Weber classification

  • Type A: fracture of lateral malleolus distal to the syndesmosis
  • Type B: fracture of the fibula at the level of syndesmosis
  • Type C: fracture of the fibula proximal to syndesmosis

Nonunion is a permanent failure of healing following a broken bone unless intervention (such as surgery) is performed. A fracture with nonunion generally forms a structural resemblance to a fibrous joint and is therefore often called a “false joint” or pseudoarthrosis (the Greek stem “pseudo-” means false and “arthrosis” means joint). The diagnosis is generally made when there is no healing between two sets of medical imaging such as an X-ray or CT scan. This is generally after 6–8 months.

Types of Nonunion

Types of Nonunion

Judet and Judet, Muller, Weber and Cech, and others classified nonunions into two types according to the viability of the ends of the fragments: Hypervascular nonunions and avascular nonunions.

Hypervascular nonunions are subdivided as:

• “Elephant foot” nonunions: These are hypertrophic, rich in callus, and are a result of inadequate immobilization, insecure fixation, or premature weight-bearing.
• “Horse hoof” nonunions: Mildly hypertrophic, poor in callus and is due to unstable fixation.
• Oligotrophic nonunions: They are not hypertrophic but vascular, no callus seen, and is due to severely displaced fracture or fixation without accurate apposition of fragments.

Avascular nonunions are subdivided as

• Torsion wedge nonunions have an intermediate fragment with decreased or absent blood supply. This fragment has healed to one main fragment but not to the other.
• Comminuted nonunions have one or more intermediate fragments that are necrotic.
• Defect nonunions have a gap in the diaphysis of bone due to a loss of a fragment.
• Atrophic nonunions usually are the final result when the intermediate fragments are missing and scar tissue that lacks osteogenic potential is left in their place.

Depending on its cause, nonunion classifications are as follows:

• Septic (infected) or aseptic 
• Pseudarthrosis
• Hypertrophic – characterized by inadequate immobilization, but adequate blood supply persists
• Atrophic – characterized by inadequate immobilization and inadequate blood supply in the early stages of fracture healing
• Oligotrophic – characterized by inadequate reduction with the persistence of fracture diastasis; no callus can form
• Hypertrophic non-union – Callus is formed, but the bone fractures have not joined. This can be due to inadequate fixation of the fracture and treated with rigid immobilization.
• Atrophic non-union – No callus is formed. This is often due to impaired bony healing, for example, due to vascular causes (e.g. impaired blood supply to the bone fragments) or metabolic causes (e.g. diabetes or smoking). Failure of the initial union, for example, when bone fragments are separated by soft tissue may also lead to atrophic non-union. Atrophic non-union can be treated by improving fixation, removing the end layer of bone to provide raw ends for healing, and the use of bone grafts.

As mentioned, an adequate interplay between host biology and reduction technique are key to achieve fracture healing. The development of a nonunion is multifactorial. Factors that contribute to the development of a nonunion include the following, listed here with known risk factors[8][10][11]

Causes of Nonunion

The reasons for non-union are

• avascular necrosis (the blood supply was interrupted by the fracture)
• the two ends are not opposed (that is, they are not next to each other)
• infection (particularly osteomyelitis)
• the fracture is not fixed (that is, the two ends are still mobile)
• soft-tissue imposition (there is muscle or ligament covering the broken ends and preventing them from touching each other)

Fracture and Injury-Related Factors

• High-energy fractures with significant comminution
• Type of fracture (closed/open)
• Location and pattern (highly comminuted or butterfly fragments)
• Extent of soft tissue injury
• Bone loss and fracture gaps (greater than 3 mm)
• Lack of cortical continuity
• Infection

Biology and Patient-Related Factors (Local and Systemic)

• Nutritional status
• Diabetes
• Smoking
• Inadequate blood supply
• Vitamin D deficiency
• Renal insufficiency
• Medications (steroids, NSAIDs, opiates, etc.)

Surgical-Related Factors

• Inadequate stabilization

Related to the person

• Age: Common in old age
• Nutritional status: poor
• Habits : Nicotine and alcohol consumption
• Metabolic disturbance: Hyperparathyroidism
• can be found in those with NF1
• Genetic predisposition

Causes related to fracture

• Related to the fracture site
• Soft tissue interposition
• Bone loss at the fracture
• Infection
• Loss of blood supply
• Damage of surrounding muscles

Related to treatment

• Inadequate reduction
• Insufficient immobilization
• Improperly applied fixation devices.

Symptoms of Nonunion

• A history of a broken bone is usually apparent. The patient complains of persistent pain at the fracture site and may also notice abnormal movement or clicking at the level of the fracture. An x-ray plate of the fractured bone shows a persistent radiolucent line at the fracture. Callus formation may be evident but callus does not bridge across the fracture. If there is doubt about the interpretation of the x-ray, stress x-rays, tomograms or CT scan may be used for confirmation.

Treatment of Nonunion

Treatment of nonunions should aim to achieve healing of the fracture while preserving functionality. The following are available options for the treatment of non-unions[rx]:

Nonoperative Treatment

• Removal of all scar tissue  – from between the fracture fragment immobilization of the fracture with internal or external fixation. Metal plates, pins, screws, and rods, that are screwed or driven into a bone, are used to stabilize the broken bone fragments.
• Conservative treatment/weight-bearing – In some circumstances and special patient characteristics (e.g., elderly patients not eligible for operative treatments), nonunions can be treated with weight-bearing and watchful waiting. Weight-bearing can be coupled with operative methods such as dynamization or bone excision.
• Electrical stimulator/electromagnetic fields – Growth factors are stimulated in response to the electric and electromagnetic fields.[rx][rx]
• Ultrasound (low-intensity pulsed ultrasound [LIPUS]) – Low sine waves will promote bone healing by increasing the osteoblastic response.[rx]

Operative Treatments

When an operative treatment has been considered, intraoperative culture should always be performed to diagnose a subclinical infection. Radiologic findings and patient characteristics should guide the clinician in the decision of what operative treatment should be done. The following are treatment options:

• Bone grafting – Donor bone or autologous bone (harvested from the same person undergoing the surgery) is used as a stimulus to bone healing. The presence of the bone is thought to cause stem cells in the circulation and marrow to form cartilage, which then turns to bone, instead of a fibrous scar that forms to heal all other tissues of the body. Bone is the only tissue that can heal without a fibrous scar. The autologous bone graft is the “gold standard” treatment of the nonunion the bone is obtained from the iliac crest.
• Nail dynamization and nail exchange – Nail Dynamization and exchange have two similar indications; comminuted fractures and absence of cortical contact after IM Nail.[rx]
• Nail dynamization – A relatively low-cost treatment done when axial stability has been achieved and maintained. The dynamization is achieved by removing interlocking bolts distant to the fracture site facilitating compression and loading across the fracture site.[rx][rx][rx]
• Nail exchange – Removal of the prior intramedullary nail, reaming, and use of a nail with a larger diameter. With this, the reaming process will biologically activate the fracture site, and better axial and mechanical stability can be achieved.[rx][rx][rx]
• Partial fistulectomy – This procedure can be done on its own or combined with other procedures. Two important requisites have to be fulfilled, a stable nonunion and the fistulectomy has to be done in another site different.[rx]
• External fixation – Considered in complex nonunions (e.g., when internal fixation is not possible or not recommended due to infection, substantial deformity, and/or bone loss).[rx]
• Bone grafting – Traditionally, iliac crest bone graft has been used when poor vascular supply is present. This treatment option aims to provide an adequate environment for bone formation (biological factors of the diamond concept).
• Cell therapy – The use of mesenchymal cells within the fracture gap creates a healing environment.  [rx][rx]
• Amputation – Considered when adequate functional outcomes cannot be achieved.

References

Salter-Harris Type Fractures/ A Salter-Harris fracture is a pediatric fracture that involves the epiphyseal plate. These fractures can occur in any bone that has a growth plate but frequently occur in the distal radius. The Salter-Harris scheme was first developed by Doctors William Harris and Robert Salter in 1963 and remains the most common classification system for epiphyseal fractures. Salter-Harris fractures are graded I through IX, with I through V being the most frequently used in clinical practice. Type I is a fracture that runs transversely through the growth plate. Type II runs through the growth plate and the metaphysis. Type III involves the growth plate and epiphysis. Type IV is a fracture of metaphysis, epiphysis, and growth plate. Type V is a complete direct compression fracture of the growth plate. Each of these has a different prognosis and management. [rx][rx][rx]

A Salter-Harris fracture is a fracture that involves the epiphyseal plate or growth plate of a bone, specifically the zone of provisional calcification.^[rx] It is thus a form of child bone fracture. It is a common injury found in children, occurring in 15% of childhood long bone fractures.^[rx] This type of fracture and its classification system is named for Robert B. Salter and William H. Harris, who created and published this classification system in the Journal of Bone and Joint Surgery in 1963.^[rx]

Types of Salter-Harris Type Fractures

There are nine types of Salter-Harris fractures; types I to V as described by Robert B Salter and W Robert Harris in 1963, and the rarer types VI to IX which have been added subsequently:^[rx]

• Type I – transverse fracture through the growth plate (also referred to as the “physis”):^[rx] 6% incidence
• Type II – A fracture through the growth plate and the metaphysis, sparing the epiphysis:^[rx] 75% incidence, takes approximately 12-90 weeks or more in the spine to heal.^[rx]
• Type III-A fracture through the growth plate and epiphysis, sparing the metaphysis:^[rx] 8% incidence
• Type IV – A fracture through all three elements of the bone, the growth plate, metaphysis, and epiphysis:^[rx] 10% incidence
• Type V – A compression fracture of the growth plate (resulting in a decrease in the perceived space between the epiphysis and metaphysis on x-ray):^[rx] 1% incidence
• Type VI – Injury to the peripheral portion of the physis and a resultant bony bridge formation which may produce an angular deformity (added in 1969 by Mercer Rang)^[rx]
• Type VII – Isolated injury of the epiphyseal plate (VII-IX added in 1982 by JA Ogden)^[rx]
• Type VIII – Isolated injury of the metaphysis with possible impairment of endochondral ossification
• Type IX – Injury of the periosteum which may impair intramembranous ossification

SALTER mnemonic for classification

The mnemonic “SALTER” can be used to help remember the first five types.

N.B.: This mnemonic requires the reader to imagine the bones as long bones, with the epiphyses at the base.

• I – S = Slip (separated or straight across). Fracture of the cartilage of the physis (growth plate)
• II – A = Above. The fracture lies above the physis, or Away from the joint.
• III – L = Lower. The fracture is below the physis in the epiphysis.
• IV – TE = Through Everything. The fracture is through the metaphysis, physis, and epiphysis.
• V – R = Rammed (crushed). The physis has been crushed.

Alternatively, SALTER can be used for the first 6 types, as above but adding Type V — ‘E’ for ‘Everything’ or ‘Epiphysis’ and Type VI — ‘R’ for ‘Ring’.

Causes of Salter-Harris Type Fractures

Most of these injuries occur during the time of a child’s growth spurt when physis is the weakest. Active children are the most likely to encounter injuries involving the growth plate as the ligaments and joint capsules surrounding the growth plate tend to be much stronger and more stable. The ligaments and capsules are thereby able to sustain greater external loads to the joint, relative to the growth plate itself.[rx][rx]

Symptoms of Salter-Harris Type Fractures

• Pain and swelling
• Tenderness
• A change in the shape of the injured area that is different than usual
• Not being able to move or put weight on the injured arm or leg

Diagnosis of Salter-Harris Type Fractures

Clinical Findings

• Point tenderness
• Pain
• Swelling
• Limitation of motion

Imaging Findings

• Soft tissue swelling
• Depending on the type of fracture, some displacement of the epiphysis or corner sign (Thurston-Holland fragment)
• Conventional radiography remains study of first choice
• CT with multiplanar reconstruction has been used in problem cases
• Ultrasound can be helpful in infants whose cartilage has not yet ossified
• MRI in problem cases

Treatment of Salter-Harris Type Fractures

Salter-Harris I and II fractures can be treated with closed reduction and casting or splinting. The reduction should be performed carefully to avoid damage to or grating of the physis on any metaphyseal bone fragments.[rx][rx][rx]

Salter-Harris III and IV fractures usually require open reduction and internal fixation (avoiding crossing the physis).

Salter V fracture diagnosis may be delayed unless there is a high degree of clinical suspicion and often the diagnosis is not made at the initial presentation. An emergent orthopedic consultation should be obtained if the fracture is recognized. As these fractures involve the germinal matrix, they have a potential for growth arrest.

In all cases, a reexamination in seven to ten days is necessary to monitor proper reduction and healing. This is also important to determine whether any complications, such as growth arrest, have occurred. If clinically indicated, an additional follow-up radiograph at six and 12 months may be obtained to reassess for any growth arrest.

• A cast or splint – may be used to help prevent movement in the injured area until more treatment is done. Some Salter-Harris fractures take up to 14 days before they can be seen on an x-ray. Your child’s injury may need to be put in a cast or splint if a Salter-Harris fracture is known or suspected. This will help prevent more injury to the growth plate and surrounding bone. If the bone is not displaced (moved out of place), your child may get a cast to secure the bone as it heals. Casts are also used after reduction (when the bone is put back into place) or surgery.
• Surgery – may be needed to repair certain types of Salter-Harris fractures. Pins or screws will be placed inside the broken bone. These hold the bone pieces together in the correct places.

Complications of Salter-Harris Type Fractures

• The complications include growth arrest with potential for deformity and limb length discrepancy. An entrapment of periosteum within the fracture is a rare complication which requires an MRI scan.  Beware that entrapped periosteum can prevent a complete reduction of the fracture.
• In general, the higher the number, the more likely the complication so that Salter-Harris types Iv and V have the highest associated complications.
• Greater risk for complication comes with fracture of distal tibia followed by the distal femur
• The primary complication is growth plate disturbance, Early closure, Limb length discrepancy, Closure of only a portion of the plate resulting in angular deformity.

References

Torus Fractures Both Torus and greenstick fractures are incomplete fractures. Pediatric bones are poorly mineralized relative to adults and can bend without frankly breaking. These fractures can occur in any long bone but frequently occur in the metaphysis of the distal radius. Torus fractures occur with axial loading whereas Greenstick fractures result from bending forces. Torus fractures are characterized by buckling of the bony cortex and periosteum without any true fracture lines. There is generally minimal deformity with Torus fractures, and the periosteum and cortex are intact. Greenstick fractures will show bony bending. There will be a fracture of the convex surface with an intact concave surface. These fractures are extremely common in children, and unfortunately frequently missed.

A greenstick fracture is a fracture in a young, soft bone in which the bone bends and breaks. Greenstick fractures occur most often during infancy and childhood when bones are soft. The name is by analogy with green (i.e., fresh) wood which similarly breaks on the outside when bent.

Causes Of Greenstick and Buckle/Torus Fractures

• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of broken Greenstick and Buckle/Torus Fractures.
• Sports injuries – Many Greenstick and Buckle/Torus Fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate intake of calcium or vitamin D
• Football or soccer, especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms Of Greenstick and Buckle/Torus Fractures

Common symptoms of radial styloid fractures include:

• Severe pain that might worsen when gripping or squeezing or moving your hand or wrist
• Swelling
• Tenderness
• Bruising
• Obvious deformity, such as a bent wrist
• Pain
• The wrist hanging in a deformed way
• Pain, especially when flexing the wrist
• Deformity of the wrist, causing it to look crooked and bent.
• Your wrist is in great pain.
• Your wrist, arm, or hand is numb.
• Your fingers are pale.

Diagnosis of Greenstick and Buckle/Torus Fractures

Plain Radiographs

• Radiographic imaging is important in diagnosis, classification, treatment, and follow-up assessment of these fractures. The routine minimal evaluation for Greenstick and Buckle/Torus Fractures must include two views-a posteroanterior (PA) view and a lateral view.[rx]
• The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[rx] The palm is maintained flat against the cassette

Computed Tomography

• CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, radial and ulnar shaft articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[rx] assessments of fracture healing as well as post-surgical evaluation.[rx]
• CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

• Although this modality is not the first choice in evaluating acute Greenstick and Buckle/Torus Fractures, it is a powerful diagnostic tool to assess bony, ligamentous, and soft tissue abnormalities associated with these fractures.
• MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[rx] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Treatment Of Greenstick and Buckle/Torus Fractures

Non-Surgical

Treatment available can be broadly

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
•  Antidepressants – A Drug that blocks pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bone health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement -to remove general weakness & improved health.

Complications Of Greenstick and Buckle/Torus Fractures

There were no major complications such as neurovascular injury, infection, or impaired wound healing. Surgery-related complication at 2-year follow-up included nonunion in 3 patients (11%),

• DRUJ subluxation in 3 patients (11%),
• Implant migration in 4 patients (14%),
• Radiographic resorption of the ulnar styloid in 4 patients (14%).
• Radiographic nonunion was noted in 1 patient in group A (8%) and 2 in group B (13%). Residual DRUJ subluxation was noted in 3 patients; all were in group B (20%).
• Partial or complete radiographic resorption of the ulna was found in 1 patient in group A (8%) and 3 in group B (20%).
• Implant migration was noted in 1 patient in group A (8%), and 2 in group B (13%).
• Subsequent removal surgery due to implant irritation occurred in 13 patients (46%), with 4 in group A (31%) and 8 in group B (53%).
• A total of 11 patients (39%) with surgery-related complications included 5 (38%) in group A and 12 (80%) in group B, with a significant difference

There are risks associated with any type of surgery. These include

• Nonunion (1-5%)
• Infection (~4.8%)
• 4% in the surgical group develop adhesive capsulitis requiring surgical intervention
• Bleeding
• Problems with wound healing
• Blood clots
• Damage to blood vessels or nerves
• Reaction to anesthesia
• Hardware prominence
• Malunion with cosmetic deformity
• Restriction of ROM
• The difficulty with bone healing
• Hardware irritation
• Fracture comminution (Z deformity)
• Fracture displacement
• Increased fatigue with overhead activities
• Dissatisfaction with appearance
• The difficulty with shoulder straps, backpacks and the like
• ~30% of patient request plate removal
• Superior plates associated with increased irritation
• Superior plates associated with increased risk of subclavian artery or vein penetration

References

Buckle Fractures/Buckle or Torus Fractures Both Torus and greenstick fractures are incomplete fractures. Pediatric bones are poorly mineralized relative to adults and can bend without frankly breaking. These fractures can occur in any long bone but frequently occur in the metaphysis of the distal radius. Torus fractures occur with axial loading whereas Greenstick fractures result from bending forces. Torus fractures are characterized by buckling of the bony cortex and periosteum without any true fracture lines. There is generally minimal deformity with Torus fractures, and the periosteum and cortex are intact. Greenstick fractures will show bony bending. There will be a fracture of the convex surface with an intact concave surface. These fractures are extremely common in children, and unfortunately frequently missed.

A greenstick fracture is a fracture in a young, soft bone in which the bone bends and breaks. Greenstick fractures occur most often during infancy and childhood when bones are soft. The name is by analogy with green (i.e., fresh) wood which similarly breaks on the outside when bent.

Causes Of Greenstick and Buckle/Torus Fractures

• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of broken Greenstick and Buckle/Torus Fractures.
• Sports injuries – Many Greenstick and Buckle/Torus Fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate intake of calcium or vitamin D
• Football or soccer, especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms Of Greenstick and Buckle/Torus Fractures

Common symptoms of radial styloid fractures include:

• Severe pain that might worsen when gripping or squeezing or moving your hand or wrist
• Swelling
• Tenderness
• Bruising
• Obvious deformity, such as a bent wrist
• Pain
• The wrist hanging in a deformed way
• Pain, especially when flexing the wrist
• Deformity of the wrist, causing it to look crooked and bent.
• Your wrist is in great pain.
• Your wrist, arm, or hand is numb.
• Your fingers are pale.

Diagnosis of Greenstick and Buckle/Torus Fractures

Plain Radiographs

• Radiographic imaging is important in diagnosis, classification, treatment, and follow-up assessment of these fractures. The routine minimal evaluation for Greenstick and Buckle/Torus Fractures must include two views-a posteroanterior (PA) view and a lateral view.[rx]
• The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[rx] The palm is maintained flat against the cassette

Computed Tomography

• CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, radial and ulnar shaft articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[rx] assessments of fracture healing as well as post-surgical evaluation.[rx]
• CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

• Although this modality is not the first choice in evaluating acute Greenstick and Buckle/Torus Fractures, it is a powerful diagnostic tool to assess bony, ligamentous, and soft tissue abnormalities associated with these fractures.
• MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[rx] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Treatment Of Greenstick and Buckle/Torus Fractures

Non-Surgical

Treatment available can be broadly

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
•  Antidepressants – A Drug that blocks pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bone health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement -to remove general weakness & improved health.

Complications Of Greenstick and Buckle/Torus Fractures

There were no major complications such as neurovascular injury, infection, or impaired wound healing. Surgery-related complication at 2-year follow-up included nonunion in 3 patients (11%),

• DRUJ subluxation in 3 patients (11%),
• Implant migration in 4 patients (14%),
• Radiographic resorption of the ulnar styloid in 4 patients (14%).
• Radiographic nonunion was noted in 1 patient in group A (8%) and 2 in group B (13%). Residual DRUJ subluxation was noted in 3 patients; all were in group B (20%).
• Partial or complete radiographic resorption of the ulna was found in 1 patient in group A (8%) and 3 in group B (20%).
• Implant migration was noted in 1 patient in group A (8%), and 2 in group B (13%).
• Subsequent removal surgery due to implant irritation occurred in 13 patients (46%), with 4 in group A (31%) and 8 in group B (53%).
• A total of 11 patients (39%) with surgery-related complications included 5 (38%) in group A and 12 (80%) in group B, with a significant difference

There are risks associated with any type of surgery. These include

• Nonunion (1-5%)
• Infection (~4.8%)
• 4% in the surgical group develop adhesive capsulitis requiring surgical intervention
• Bleeding
• Problems with wound healing
• Blood clots
• Damage to blood vessels or nerves
• Reaction to anesthesia
• Hardware prominence
• Malunion with cosmetic deformity
• Restriction of ROM
• The difficulty with bone healing
• Hardware irritation
• Fracture comminution (Z deformity)
• Fracture displacement
• Increased fatigue with overhead activities
• Dissatisfaction with appearance
• The difficulty with shoulder straps, backpacks and the like
• ~30% of patient request plate removal
• Superior plates associated with increased irritation
• Superior plates associated with increased risk of subclavian artery or vein penetration

References

Greenstick Fractures/Greenstick and Buckle or Torus Fractures Both Torus and greenstick fractures are incomplete fractures. Pediatric bones are poorly mineralized relative to adults and can bend without frankly breaking. These fractures can occur in any long bone but frequently occur in the metaphysis of the distal radius. Torus fractures occur with axial loading whereas Greenstick fractures result from bending forces. Torus fractures are characterized by buckling of the bony cortex and periosteum without any true fracture lines. There is generally minimal deformity with Torus fractures, and the periosteum and cortex are intact. Greenstick fractures will show bony bending. There will be a fracture of the convex surface with an intact concave surface. These fractures are extremely common in children, and unfortunately frequently missed.

A greenstick fracture is a fracture in a young, soft bone in which the bone bends and breaks. Greenstick fractures occur most often during infancy and childhood when bones are soft. The name is by analogy with green (i.e., fresh) wood which similarly breaks on the outside when bent.

Causes Of Greenstick and Buckle/Torus Fractures

• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of broken Greenstick and Buckle/Torus Fractures.
• Sports injuries – Many Greenstick and Buckle/Torus Fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate intake of calcium or vitamin D
• Football or soccer, especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms Of Greenstick and Buckle/Torus Fractures

Common symptoms of radial styloid fractures include:

• Severe pain that might worsen when gripping or squeezing or moving your hand or wrist
• Swelling
• Tenderness
• Bruising
• Obvious deformity, such as a bent wrist
• Pain
• The wrist hanging in a deformed way
• Pain, especially when flexing the wrist
• Deformity of the wrist, causing it to look crooked and bent.
• Your wrist is in great pain.
• Your wrist, arm, or hand is numb.
• Your fingers are pale.

Diagnosis of Greenstick and Buckle/Torus Fractures

Plain Radiographs

• Radiographic imaging is important in diagnosis, classification, treatment, and follow-up assessment of these fractures. The routine minimal evaluation for Greenstick and Buckle/Torus Fractures must include two views-a posteroanterior (PA) view and a lateral view.[rx]
• The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[rx] The palm is maintained flat against the cassette

Computed Tomography

• CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, radial and ulnar shaft articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[rx] assessments of fracture healing as well as post-surgical evaluation.[rx]
• CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

• Although this modality is not the first choice in evaluating acute Greenstick and Buckle/Torus Fractures, it is a powerful diagnostic tool to assess bony, ligamentous, and soft tissue abnormalities associated with these fractures.
• MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[rx] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Treatment Of Greenstick and Buckle/Torus Fractures

Non-Surgical

Treatment available can be broadly

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
•  Antidepressants – A Drug that blocks pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bone health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement -to remove general weakness & improved health.

Complications Of Greenstick and Buckle/Torus Fractures

There were no major complications such as neurovascular injury, infection, or impaired wound healing. Surgery-related complication at 2-year follow-up included nonunion in 3 patients (11%),

• DRUJ subluxation in 3 patients (11%),
• Implant migration in 4 patients (14%),
• Radiographic resorption of the ulnar styloid in 4 patients (14%).
• Radiographic nonunion was noted in 1 patient in group A (8%) and 2 in group B (13%). Residual DRUJ subluxation was noted in 3 patients; all were in group B (20%).
• Partial or complete radiographic resorption of the ulna was found in 1 patient in group A (8%) and 3 in group B (20%).
• Implant migration was noted in 1 patient in group A (8%), and 2 in group B (13%).
• Subsequent removal surgery due to implant irritation occurred in 13 patients (46%), with 4 in group A (31%) and 8 in group B (53%).
• A total of 11 patients (39%) with surgery-related complications included 5 (38%) in group A and 12 (80%) in group B, with a significant difference

There are risks associated with any type of surgery. These include

• Nonunion (1-5%)
• Infection (~4.8%)
• 4% in the surgical group develop adhesive capsulitis requiring surgical intervention
• Bleeding
• Problems with wound healing
• Blood clots
• Damage to blood vessels or nerves
• Reaction to anesthesia
• Hardware prominence
• Malunion with cosmetic deformity
• Restriction of ROM
• The difficulty with bone healing
• Hardware irritation
• Fracture comminution (Z deformity)
• Fracture displacement
• Increased fatigue with overhead activities
• Dissatisfaction with appearance
• The difficulty with shoulder straps, backpacks and the like
• ~30% of patient request plate removal
• Superior plates associated with increased irritation
• Superior plates associated with increased risk of subclavian artery or vein penetration

References