PCL 8 - Fracture

Fracture???

- broken bone

How???

- Trauma

e.g. a fall, a motor vehicle accident, a tackle during a football game

- Osteoporosis

bone disease that results in the "thinning" of the bone. The bones become fragile and easily broken

- Overuse

sometimes results in hairline fractures, especially in athletes

Categories

1) Displaced vs Non-displaced

- displaced: bone snaps into 2 or more parts

- non-displaced: bone cracks either part or all the way throug

h, does not move, maintains proper alignment

2) Closed vs Open

- closed: NO puncture or open wound in skin

- open / compound:

bone breaks through skin

it may then recede bak into wound and not be visible

risk of deep bone infection

3) Complete vs Incomplete

Incomplete Fracture???

- bone is only cracked or partially broken

1) Hairline Fracture?

- incomplete fracture, like a crack that does not break all the way through the bone

- usually result of a relatively minor injury

2) Greenstick Fracture?

- incomplete fracture

- similar to the break of a young tree branch

- only one side of the bone breaks causing the bone to bend

Both hairline and greenstick fractures are usually treated by immobilization with a cast to allow it to mend.

Complete Fracture???

When the bone is broken into pieces

1) Simple Fracture?

- complete fracture

- bone is broken into two fragments

a) transverse (which means straight across the bone)

b) oblique (which means at an angle - diagonal break)

c) spiral (the break spirals around the bone; common in a twisting injury)

2) Comminuted Fracture?

- complete fracture

- bone is broken into several fragments (multifragmentary fracture)

- usually a result of a severe injury.

Both simple and comminuted fractures are usually treated with immobilization with a cast or sometimes with pins, screws, and plates.

Other types

Compression fracture

• - the bone is crushed, causing the broken bone to be wider or flatter in appearance.

PCL 7- Signs and Symptoms of Osteoarthritis.

Osteoarthritis symptoms often develop slowly and worsen over time. Signs and symptoms of osteoarthritis include:

Pain- Your joint may hurt during or after movement.

Tenderness- Your joint may feel tender when you apply light pressure to it.

Stiffness- Joint stiffness may be most noticeable when you wake up in the morning or after a period of inactivity.

Loss of flexibility- You may not be able to move your joint through its full range of motion.

Grating sensation- You may hear or feel a grating sensation when you use the joint.

Bone spurs- These extra bits of bone, which feel like hard lumps, may form around the affected joint.

Joint effusion (swelling)

Local inflammation

PCL 7- INVESTIGATION OF HIP PAIN

Plain Radiography

~Plain radiographs of the hip and pelvis should be ordered as the first diagnostic test for patients with hip pain.

~Plain radiographs can delineate the alignment, bone mineralization, articular cartilage, and soft tissue.

~Alignment abnormality may indicate a fracture, a dislocation, or secondary causes of osteoarthritis such as congenital dislocation of the hip or slipped capital femoral epiphysis.

~Bone mineralization indicates osteoporosis or osteopenia as the underlying cause of pain.

~ An anteroposterior pelvic radiograph and a "frog-leg" lateral hip radiograph may reveal fractures, provide a better view of the anterolateral femoral head, and help evaluate for osteonecrosis.

~For patients in the later stages of osteonecrosis, radiographs show a break in the cortex and a rim sign (a subcortical black lucent line) characteristic of femoral head collapse.

~ A 40-degree cephalad anteroposterior view is useful for elucidating subtle femoral neck and pubic fractures.

~ On plain radiographs, joint-space narrowing is indicative of articular cartilage loss, spurs or osteophytes are indicative of arthritic change, segmental radiolucency or sclerotic changes of the femoral head are indicative of avascular necrosis, calcifications are indicative of synovial chondromatosis, and soft-tissue calcification is indicative of calcific tendinitis.



Arthrography

~Arthrography, which involves obtaining images after a contrast agent has been injected into the hip, is a useful tool for showing labral abnormalities, especially when it is performed in conjunction with magnetic resonance imaging (MRI).

~Magnetic resonance arthrography is the most sensitive and specific test for labral tear of the hip. Injection with local anesthetic agents during the arthrogram can be a powerful tool for the diagnosis of hip abnormalities: if the injection does not
reduce the pain (however transiently), other diagnoses should be ruled out.

~Arthrography continues to have a role in the diagnosis of infection and loosening of the prosthesis in the patient with a painful total joint arthroplasty.



Computed Tomography

~Computed tomography (CT) of the hip and pelvis is most useful in the assessment of fractures, particularly complex fractures. Pelvic and acetabular fractures, osseous sequelae of hip dislocation, and intra-articular osseous fragments are better visualized by CT than by plain radiographs.

~CT also is useful in characterizing calcifications secondary to tumor matrix within bone or soft tissue or to ossification, and CT is the best modality for imaging cortical bone.



Magnetic Resonance Imaging

~MRI provides excellent visualization of medullary bone and soft tissues.

~The diagnosis of osteonecrosis of the femoral head is made earlier by MRI than by any other technique, including bone scintigraphy, CT, and plain radiographs.

~MRI also is the method of choice for the diagnosis of occult hip fracture in the elderly, and despite its expense, can be cost-effective for this purpose.

~MRI is the most accurate method for the diagnosis of stress fractures around the hip and pelvis, and it is the best test for the diagnosis of transient osteonecrosis of the hip.

~It is also the most valuable test for the staging of bony and soft tissue tumors around the hip.

~MRI is frequently helpful in documenting synovitis of the hip joint by revealing effusion (eg, in pigmented villonodular synovitis).

~Magnetic resonance arthrography is useful in defining labral abnormalities.



Electromyography and Nerve Conduction Velocity Studies

Electromyography and nerve conduction velocity studies are used in the differential diagnosis of hip pain to evaluate referred lumbosacral plexopathies and to assess local nerve entrapment or nerve damage from trauma, surgery, or other disease states.



Injections

~Differential block of the hip joint can be a valuable adjunct in differentiating the source of intra-articular hip joint pain.

~This procedure is best undertaken in the fluoroscopy suite, with arthrography used to confirm the location of the injection.

~The technique may be particularly useful in distinguishing intra-articular hip abnormalities from referred lumbosacral radiculopathy and possible soft-tissue conditions.

~Dye injection along the iliopsoas tendon sheath under fluoroscopy sometimes reveals the snapping of the iliopsoas tendon over the pelvic brim, and when accompanied by lidocaine or corticosteroid injection, may help prove that the tendon condition is the pain generator.



SOURCE: Ilksen Gurkan, MD, & Simon Mears, MD, PhD, Current Rheumatology Diagnosis and Treatment,Chapter 11: The Patient with Hip Pain

PCL 7 - Treatment & Management

Non-pharmacological

1. Weight Loss

- Research shown → 5% to 10% reduction of body weight can dramatically reduce joint pain and improve exercise tolerance.

Tips to Lose Weight for Arthritis

#1: Keep Your Goal Reasonable


#2: Low-Impact Is the Way to Go

- walking long distances is difficult.
- therefore → swimming or water aerobics as a way to exercise without joint pain

#3: Diet Is Just as Important

- healthy diet
- trying to lose weight by a sudden, dramatic change in exercise habits or diet is unlikely to succeed.

#4: Get Help

- help and a support network
- talking with your doctor
- making goals with friends
- using online tools

2. Activity Modification

Exercise for Joint Pain:

• Keep your weight down and your muscles strong → delay joint replacement and improve your surgical result from joint-replacement surgery

• Learn different ways to exercise so that you are pain-free, despite your arthritis:

Pilates:

• terrific way to strengthen the most important muscles in the body (the core) in a low-impact, safe manner

• popular tool for injury treatment and management even with professional athletes

• safe for the joints and can help improve body mechanics.

Water Workouts:

• a way to perform normal activities without the impact of working out on land

• can involve aerobics, walking, jogging or just about anything else

• even sports can be played in the water (e.g. water polo, basketball, etc.), preventing joint pain.

Swimming:

• your joints are supported by the water, easing arthritis pain

• for people with the most severe arthritis in their hip or knee, swimming can be done with a pull buoy to give you a good cardiovascular workout without placing any burden on your hip or knees.

Cycling:

• low-impact way to exercise, but the cyclic motion of cycling is stimulating for the cartilage within a joint

• gives a good muscular and cardiovascular workout and loosens up stiff joints common in people with arthritis

• start off with stationary cycling, and move outdoors as you get stronger.

Weight Machines:

• can help strengthen muscles and is also an excellent way to stimulate bone health.

• must be done safely, but with proper instruction, just about anyone can learn a few good strength-training exercise

• even with a few dumbbells and some basic knowledge, a weight workout can be perfect for arthritis

Walking:

• favorite activity of many arthritis patients

• may not be the best workout for those with arthritis, walking for exercise is certainly better than no exercise at all

• some ways to modify your walking for a better workout: trying interval walks and incorporating your arms.

  

3. Walking Aids

Single Point Cane

• helpful for many conditions where a little extra support can alleviate pain and discomfort

• cane is the simplest way to lend some support to the leg, though it is not an appropriate option when weight must be completely removed from the extremity.

Quad Cane

• good option for people who need more stability than given by single point cane

• but who do not need the full support of a walker.

Crutches

• allow you to completely remove weight from the extremity

• require good stability and upper body strength

• often less useful to elderly patients

Walker

• most supportive walking aid, though it's also the most cumbersome

• excellent option for patients with poor balance or less upper body strength

4. Physical Therapy

Stretching Tight Muscles and Joints:

• After an injury or surgery, scar tissue forms and soft tissue contracts

• It is important to regularly stretch in these situations to ensure that scar formation does not get in the way of your rehabilitation.

Ice and Heat application

• useful in warming up and cooling off muscles

• stimulate blood flow and decrease swelling

Ultrasound

• high frequency sound waves to stimulate deep tissues within the body

• warming and increased blood flow to these tissues

Electrical Stimulation

• passes electric current to an affected area

• blood flow increased

• patient experiences diminished pain after treatment

5. Surgical Treatment

Hip Replacement Surgery


• cartilage is removed and a metal & plastic implant is placed in the hip

• total hip replacement (THR) surgery replaces the upper end of the thighbone (femur) with a metal ball and resurfaces the hip socket in the pelvic bone with a metal shell and plastic liner

  
  

Hip Resurfacing Surgery


• an alternative to hip replacement

• metal-on-metal hip device

• THR requires that the upper portion of the femur bone be cut off to accept the stem portion of a THR hip device

• The femur cap of the hip resurfacing surgery does not require the femur bone be cut off; it is shaped to accept the cap.

• Both techniques require that a cup is placed in the acetabulum of the hip socket.

• The potential advantages:
  - less bone removal (bone preservation)
  - a potentially lower number of hip dislocations due to a relatively larger femoral head size
  - possibly easier revision surgery for a subsequent total hip replacement device because a surgeon will have more bone stock available to work with.

• The potential disadvantages of hip resurfacing are femoral neck fractures (rate of 0-4%), aseptic loosening, and metal wear.[2] .

Complementary Medicine

Acupuncture - works on the theory that inserting needles along energy lines of the body can stimulate energy flow and reduce pain

Alexander technique - a way of teaching improved posture to help people stand and move more efficiently

Aromatherapy - the use of essential oils from flowers, plants and trees, sometimes combined with massage

Chiropractic - manipulation to improve mobility and relieve pain by adjusting the joints of the spine and limbs where there are signs of restricted movement (not usually recommended for those with osteoporosis or inflamed joints)

Herbalism - use of plants and herbal remedies to treat illness

Homeopathy - a system of remedies based on giving people very dilute amounts of a substance that in larger amounts might produce symptoms similar to the condition being treated

Osteopathy - manipulation to restore normal action to the body and reduce pain (not usually recommended for those with osteoporosis or inflamed joints)

Reflexology - massage using pressure to the feet to improve the health of various parts of the body

Yoga - a combination of relaxation, breathing techniques and exercise to combat stress and help circulation and movement of the joints

What is Osteoarthritis

AKA degenerative arthritis

Group of mechanical abnormalities involving degradation of joints and their cartilages

Commonly affects the hands, feet, spine and large weight bearing joints (knees and hips)

Unknown cause of OA (Primary osteoarthritis)

Known cause of OA (Secondary osteoarthritis)

Causes/Risk factors

Primary OA mainly related to aging

Water content of cartilage increases in older people and the protein makeup of cartilage degenerates

Hence cartilage begins to degenerate

Has a hereditary basis as multiple members of one family may develop OA

Wear and tear of cartilages, especially in athletes and laborers

Previous injuries or overuse

Basketball and football players are more likely to develop OA later

Inactivity

Weakens the muscles that support the joints and decreases joint flexibility – Become stiff, dysfunctional and prone to injuries - OA

Obesity

Joints are more strained due to excess weight

Especially evident in knees and hips

Signs and symptoms

Pain in joint mobility

Due to stiffness, bone ends rubbing together,

Tenderness

Joints feel tender when light pressure is applied

Stiffness

Most noticeable when you wake up in the morning/after a period of inactivity

Loss of flexibility

May not be able to move your joint through its full range of motion.

Cracking

Joints make crunching, creaking sounds

See a doctor when swelling or stiffness lasts more than 2 weeks

Treatment

Weight control

Proper exercise

Pain medication

Surgery

Diagnosis

In most cases osteoarthritis of the hip can be diagnosed based on the medical history, physical examination and an x-ray of the affected hip.

Medical history

W-where is the pain ( location ), and radiation of symptom

W- when it began, fluctuation over time, duration

Q- quantity of pain(pain scale),extent, degree of disability

Q- quality of pain(shooting pain),

A- aggravating factors (walking, sitting, dancing), alleviating factors

A- associating symptoms

B- Patient’s beliefs about the symptoms

Coping strategy.

Examples of questions that focus on the patient’s

coping strategy:

How have you been able to cope with the complaint so far?

What have you personally done to reduce your complaints?

To which extent are you able to predict the onset of your complaints?

How often have you been able to prevent the development of your complaints?

Which form of treatment do you think will help most and why?

Which hindrances and difficulties do you experience in performing your daily activities and which would you like to overcome?

Risk factors

-Occupation and sport

-family history

-infections

-medications

Physical examination

1. Observing gait

-Watch the patient walk,one leg at a time

-Start with the ankle and then move up the knee,hip and pelvis

2. Look and feel for sweats

s- swelling

w- wasting of muscle

e- erythaemia

a -asymmetry

t- Traumatic bruises, temperature

s-skin changes/surgical scars, rashes

3. Movements (for hip joint)

-flexion

-extension

-rotation (internal and external)

-abduction

-adduction

-measure true and apparent leg length

Laboratory tests — Laboratory tests may be recommended to help diagnose osteoarthritis by ruling out conditions with similar symptoms.

Imaging tests — X-rays are often helpful for tracking the status of osteoarthritis over time, but x-rays may appear normal during the early stages.

Other types of imaging tests, such as ultrasound and magnetic resonance imaging (MRI), may be used to detect damage to cartilage, ligaments, and tendons, which cannot be seen on x-ray.