INTRA-ARTICULAR FRACTURE

QUESTIONS AND ANSWERS

Intra-articular Fractures Commonly Occur in the Following Areas:

Shoulder

Might affect the glenoid and articular cartilage, and also the humerus, scapula, acromion, and coracoid processes. Understanding these anatomical components is crucial when addressing various shoulder conditions.

Common Conditions Treated:

• Acromio-Clavicular Strain: This condition involves the ligaments connecting the collarbone to the shoulder blade, often caused by direct impact or overuse.
• Ehlers-Danlos Syndrome: A connective tissue disorder that can lead to joint hypermobility and frequent dislocations.
• Frozen Shoulder: Characterized by stiffness and pain in the shoulder joint, often developing slowly over time.
• Intraarticular Fractures: These fractures occur within the joint space, affecting the movement and function of the shoulder.
• Shoulder Pain Management: Encompasses various treatments aimed at alleviating pain and restoring function, tailored to the specific condition.

By recognizing these conditions, healthcare providers can effectively target treatment strategies, ensuring each component of the shoulder is addressed for optimal recovery. This holistic view is essential for comprehensive shoulder care.

Hip

It could also affect the articular cartilage of the hip and a piece of the pelvis, as well as the head, upper neck, or head of the femur. While there are no specific hip conditions listed for treatment under this category, it’s essential for doctors to understand the areas impacted. It could also affect the articular cartilage of the hip and a piece of the pelvis, as well as the head, upper neck, or head of the femur.

This information is crucial for understanding the broader scope of potential issues, even in the absence of explicitly listed conditions. Being aware of these areas helps in recognizing symptoms and seeking appropriate medical advice.

Elbow

It can affect the lower end of the humerus, the upper end of the radial and ulnar collateral ligaments, and the cartilage between the bones. The elbow is a complex joint that can be affected by various conditions. It can affect the lower end of the humerus, the upper end of the radial and ulnar collateral ligaments, and the cartilage between the bones.

Here are some common elbow conditions managed at the facility:

• Bursitis: Inflammation of the bursa, often resulting in pain and swelling.
• Intraarticular Fractures: Fractures that occur within the joint space, impacting movement and stability.
• Tennis Elbow: A condition characterized by pain and tenderness on the outside of the elbow, typically caused by overuse.

By understanding these conditions, patients can better navigate their treatment options and work towards effective recovery.

Wrist

It can affect the lower ends of the radius and ulna, the carpal bones, and the cartilage between the smaller carpal bones. The wrist is a complex joint that can affect the lower ends of the radius and ulna, the carpal bones, and the cartilage between the smaller carpal bones. This intricate structure is susceptible to various conditions that require specialized treatment.

Common Conditions Treated:

• Carpal Tunnel Syndrome: A condition caused by pressure on the median nerve, leading to pain and numbness.
• Dupuytren’s Contracture: A hand deformity that gradually develops over years, affecting the connective tissue under the skin of the palm.
• Fracture of Middle Phalanx of Finger: Breaks in the bones of the fingers can severely impact hand function and require precise treatment.
• Ganglion Cysts: Noncancerous lumps that most commonly develop along the tendons or joints of wrists and hands.
• Tendonitis of the Wrist: Inflammation of the tendons around the wrist joint, often due to repetitive motion.
• Trigger Finger: A condition where a finger gets stuck in a bent position and may snap straight.

Understanding these conditions is crucial for effective diagnosis and treatment, ensuring that the complex interplay of bones and tissues in the wrist remains functional and pain-free.

Knee

It can affect the lower edge of the femur, the patella, the upper edge of the tibia and/or fibula, and the articular cartilage and collateral ligaments. It can affect the lower edge of the femur, the patella, the upper edge of the tibia and/or fibula, and the articular cartilage and collateral ligaments.

When discussing knee-related treatments, several specific conditions are typically addressed:

• ACL Repair: A common procedure to fix a torn anterior cruciate ligament, crucial for stabilizing the knee joint.
• Cruciate Ligament Injury: Injuries that affect any of the ligaments inside the knee, impacting its function and stability.
• Fractured Tibia: A break in the shinbone that can significantly impair mobility and require surgical intervention.
• Knock Knees: A condition where the knees angle in and touch each other when the legs are straightened, often necessitating correction for improved alignment.

These conditions highlight the range of knee issues that may need treatment, emphasizing the importance of understanding both the anatomical areas affected and the specific treatments available.

Ankle

It may involve the lower edge of the tibia or fibula, the subtalar joint and articular cartilage, the anterior tibiofibular ligament, and the lateral collateral ligament.

Symptoms of Intra-Articular Fractures

Severe joint pain:

• Pain is often immediate and localized to the injured joint, worsened by movement or weight-bearing.

Swelling and bruising:

• The joint may become significantly swollen and bruised due to internal bleeding and inflammation.

Joint stiffness and loss of motion

• The fracture can disrupt normal joint mechanics, limiting range of motion.

Visible deformity or joint misalignment:

• In some cases, the joint may appear misshapen or out of position.

Instability or inability to bear weight:

• If the fracture affects load-bearing joints like the knee or ankle, the patient may find standing or walking impossible.

Crepitus or grinding sensation:

• Broken bone fragments may grind against each other during movement.

Diagnosis

Doctors normally diagnose intraarticular fractures through a combination of clinical examination and imaging studies. These imaging tools include visual observation, X-rays, CT scans, and MRI scans. Each of these tests plays a crucial role in the diagnostic process.

• Visual Observation: Initial assessments often involve a thorough physical examination to identify visible signs of injury, such as swelling or deformity.
• X-rays: These are typically the first imaging tests performed, providing a basic view of the bone structure and helping to identify fractures.
• CT Scans: When more detail is needed, CT scans offer a clearer, more detailed image of the bone, allowing doctors to better understand the fracture’s complexity and alignment.
• MRI Scans: These are particularly useful for assessing soft tissue around the joint and any potential impact on ligaments and cartilage.

These tests help assess the location and severity of the fracture, as well as its impact on the joint. By combining these methods, healthcare providers can formulate a comprehensive understanding of the injury, ensuring that the treatment plan is both accurate and effective.

Diarthrodial joints enable the appendicular skeleton’s bones to articulate smoothly and securely, enabling them to perform certain functions. Accordingly, the two end segments of a bone are joined by a fibrous capsule to form a synovial joint. Hyaline cartilage, which is supple, elastic, but avascular, covers the bone’s articulating end portion. Overall, cartilage aids in distributing forces to the subchondral bone underneath. At various joint motion locations, various surfaces of the joint come into touch. Therefore, the joint’s capsule, surrounding muscles and tendons, ligaments, and form all work together to support the joint. Overall, the surfaces of the articular cartilage are lubricated and fed by synovial fluid. Finally, joint health depends on joint movement and repeated physiological loads.

Mechanism of Intra-articular Injury

Articular fractures often result from one of two damage mechanisms:

Indirect Forces

Ligaments provide resistance to the force that causes a bending moment, which changes the eccentric load into a direct axial overload and fractures the joint surface. Henceforth, the most frequent cause of intra-articular fractures is this mechanism. Usually, a partial articular fracture arises from this. Evidently, a split or shearing fracture often gets caused by loading one side of the joint, whereas an avulsion fracture or torn ligament typically becomes caused by pulling on the ligamentous insertions on the opposing side.

Direct Forces

Axial loading forces cause one component to operate as a hammer on the other, impinging on the articular surface or, in more extreme cases, impinging with fractures to the metaphysis or even diaphysis. The fracture pattern depends on the kind of bone, the bone’s location, and the direction and magnitude of the force. Because of the damage that results from this, multi-fragmentary intra-articular fractures can occur. This injury compares to crushing. Serious soft tissue injuries are often related.

Evaluation of Intra-articular Fractures

In the event of high-energy injuries, doctors should examine the patient for related musculoskeletal and non-orthopedic injuries. Nevertheless, many systems or multiple bones can get damaged. Basically, Intra-articular fractures can result in joint subluxation or dislocation as well as severe deformities of the limb. To exclude any neurological or vascular damage, our doctors believe a thorough neurovascular evaluation should occur. Examining any accompanying compartment syndrome should occur.

Treatment of Intra-articular Fractures

The treatment approach for intra-articular fractures in children varies depending on the specific fracture, the child’s age, and other factors.

• Initial Step – Immobilization: The first step in the treatment process is immobilizing the joint to stabilize it. This critical measure helps prevent further injury and sets the foundation for subsequent procedures.
• Imaging and Assessment: Following immobilization, imaging is performed to assess the extent of the fracture and any associated injuries. This step is essential for planning the most effective treatment strategy.
• Realignment Options: Treatment options may include closed reduction (non-surgical realignment) and open reduction (surgical realignment). The surgeon’s goal is to restore the joint’s alignment and provide stability while minimizing damage to the joint surface.
• Surgical Intervention: If imaging reveals torn ligaments or shattered bones, surgical intervention becomes necessary. This may involve fixation with hardware such as screws or pins to ensure proper reconstruction of the affected joint.

By understanding each step, from stabilization to potential surgical repair, caregivers can better prepare for the comprehensive care required for their child’s recovery.

Intra-articular Fracture Guiding Principles

The intra-articular fractures may cause stiffness, deformity, discomfort, and posttraumatic arthritis, according to the current operating room philosophy. Certainly, securing an anatomical reduction of the articular surface, reestablishing joint stability and correct axial alignment, and initiating early mobility are critical to prevent deformity and stiffness. Consequently, animal studies show that sustained passive motion followed by anatomical reduction and stable fixation with interfragmentary compression of an intra-articular fracture promotes hyaline cartilage repair. In addition, it is generally recognized that surgeons can repair an articular cartilage defect through the development of fibrous cartilage.

The following identifies the basic principles of treating intra-articular fractures:

• Joint stiffness comes from the immobilization of intra-articular fractures using a plaster cast.
• Increased stiffness occurs as the outcome of immobilizing intra-articular fractures using a plaster cast, open reduction, and internal fixation.
• Closed manipulation and traction influence depressed articular fragments but do not diminish them.
• The instability that comes from their displacement in major articular depressions appears permanent because they do not fill with fibrocartilage.
• To restore joint congruency, doctors should reduce and securely fix articular fragments.
• To stop the repositioning of the decreased articular segments, surgeons must repair the metaphyseal deficiencies beneath them with a structural bone graft or replacement.
• In order to position the limbs properly and avoid joint loading, the surgeon should displace and decrease metaphyseal and diaphyseal.
• To avoid joint stiffness and guarantee articular healing and recovery, doctors should allow mobility. This calls for reliable internal fixation.

Non-operative Treatment

Many different fractures might benefit from this therapy. Presently, the conventional course of therapy requires early mobility after immobilization.

Surgery Should Begin Shortly After Intra-articular Damage

• Open fractures
• Irreducible fracture-dislocations
• Linked with neurovascular injuries
• Articular fractures related to compartment syndromes

Severe soft tissue damage normally occurs in intra-articular fractures, and as a result, surgeons will postpone operations until healing occurs. Delays might range from a few days to two or three weeks. If an excessive amount of delay occurs, the surgeon knows that restoring the joint as quickly as possible will ensure a faster and better result.  In these situations, guarantees the reduction of the articular surfaces while exposing as little skin as possible during external fixation. Aligning and fixing articular fragments should only need minor surgery, and lag screws frequently act as implants. When the delay is expected, any metaphyseal fracture or deformity is not addressed at this stage. Both intra-articular and metaphyseal procedures are performed at the same time in situations when the soft tissue conditions appear good and recovery is possible in 5-7 days.

Mechanism and Procedure for Fixing Intra-articular Fractures

Preserving the blood flow to all of the bone pieces and the soft tissues provides the strategy for the successful repair of articular injuries. Surgeons accomplish this goal by staging intra-articular and metaphyseal procedures, indirect reduction methods, percutaneous lag screw insertion, and, if necessary, the buttressing of these fractures in hybrid frames. It goes without saying that the skin should appear healthy at the time of surgery. The initial surgical procedure for reconstructing intra-articular fractures involves anatomical reduction of the articular surface. The articular cartilage’s depressed areas need raising and repairing.

After the articular fragments are dis-impacted and raised, surgeons will use a bone transplant to repair the metaphyseal defect that remains. In these circumstances, autogenous cancellous bone remains the ideal. To prevent axial overload, surgeons must buttress the metaphysis and the diaphyseal components must undergo repair in order to initiate early motion. Before closure, the surgeon should repair other intra-articular structures. In cases of compartment syndrome, vascular repairs, open fractures, etc., doctors may use hybrid external fixation instead of the typical use of plates for buttressing. It’s crucial to avoid tensing up the skin. Closing the synovium and capsule would protect the articular cartilage from drying out and would also cover any exposed tendon or nerve. After five days, some wounds need secondary closure. Surgeons consider using Skin-covering flaps when skin closure does not appear as an option.

Conclusion

A child’s broken joint requires treatment by an orthopedic surgeon who understands the complex workings of the bones, tendons, ligaments, and muscles. Medical City Children’s Orthopedics and Spine Specialists with offices in Arlington, Dallas, Flower Mound, Frisco, and McKinney, TX are familiar with the latest surgical techniques for even the most difficult fractures to treat, including complex unhealed fractures. Our orthopedic specialists provide individualized treatment programs that cover every aspect of your care, including diagnosis, treatment, rehabilitation, and aftercare. The type of fracture your child has and the location of the injury will determine your course of treatment.

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Footnote:

Science Direct: Intra-articular Fractures: