Intra-articular Fracture

Many of the studies reporting good outcome following intra-articular fractures of the distal tibial physis are of short follow-up. In triplane fractures there does appear to be a symptomatic deterioration... 

Intra-articular fractures with less than 4 mm disruption of the facet joint and extra-articular fractures can be treated adequately with cast immobilisation for 4-6 weeks (Beaty and Kasser 2006) (Figs. 16.3,16.4). As predicted by Sanders classification, displaced intra-articular fractures are likely to require operative intervention. However, bone remodelling in children under 10 years of age can lead to a congruent subtalar... 

These include fractures of the radial neck, lateral condyle, distal radius and subluxation of the radial head (Evans 1999a). Physeal fractures are rare and the majority of injuries are metaphyseal fractures. As with any other intra-articular fracture, it is important to restore the articular surface if the fracture is displaced. 

It should be noted that different departments have their own thresholds for intervention in the treatment of various injuries. It is therefore neither practical nor desirable to attempt to be overly dogmatic regarding the exact degree of displacement or angulation that requires operative intervention in a particular fracture. Intra-articular fractures should be reduced anatomically, and they may often require open reduction and internal fixation. 

Fractures involving the epiphysis and physis of the finger metacarpals are uncommon (Mahabir et al. 2001). Epiphyseal fractures are rare, and non displaced fractures may heal well (Fig. 19.19). Displaced split fractures of the epiphysis may need open reduction to restore articular congruity (Graham and Waters 2001). Intra-articular fractures of the epiphysis are important to identify as they are associated with joint effusions. If these effusions are under enough pressure, blood flow to the epiphysis maybe sufficiently compromised to cause avascular necrosis. Preventative joint aspiration may be considered (McElfresh and Dobyns 1983). 

Multislice CT is extremely sensitive in the detection of fractures, and source images together with rendered reconstructions can display the spatial relationship of fracture fragments in complex anatomic regions. Complementary CT examination of intra-articular fractures of the distal tibia caused in 64% of subjects a change in the surgical treatment, and in 82% additional information concerning the fracture characterization and classification (Burkhardt et al. 2003). 

Skeleton Renal phosphate diabetes associated with hypercalciuria may lead to osteomalacia or osteoporosis. Likewise, inflammatory or degenerative arthrosis is thought to be a late manifestation of Wilson s disease. (354) Often, these developments are combined with intra-articular calcium deposits and chondromalacia, in particular patellar chondromalacia. Bone fractures are frequently observed even with minor traumas. Calcification may occur in articular cartilage, capsule and tendinous insertions, and deposits of calcium pyrophosphate dihydrate can appear in the intervertebral disks. 

Anderson D.D., Bell A.L., Gaffney M.B. et al. 1996. Contact stress distributions in malreduced intra-articular distal radius fractures. /. Orthop. Trauma 10 331. 

Zimmermarm, R., Gabl, M., Lutz, M., Angermann, P., Gschwentner, M., Pechlaner, S. 2003. Injectable calcium phosphate bone cement Norian SRS for the treatment of intra-articular compression fractures of the distal radius in osteoporotic women. Arch Orthop Trauma Surg 123(1), 22-27. 

Finally, CT is helpful for those children whose fractures have radiologically healed, but whose limbs or joints have not regained the degree of function expected. Reformatted images may show unsuspected retained intra-articular loose bodies or bone overgrowth, which is hindering limb or joint movement. 

Approximately 30% of pelvic fractures seen on CT can be missed on plain films (Resnik et al. 1992 Berg et al. 1996). In particular, AP radiographs may miss sacroiliac diastasis, acetabular, intra-articular and vertical shear fractures (Montana et al. 1986 ... 

CT is important for detecting small fractures of the acetabulum, looking for acetabular displacement and also for detecting intra-articular foreign bodies. 

Osteoarthritis can occur following a traumatic dislocation, the incidence ranges from 15%-50% and this may be related to the site of the initial injury, the presence of intra-articular loose bodies and the degree of activity following the dislocation. Simple dislocations have a better prognosis than those with an associated fracture (Figs. 13.2,13.3). 

Osteonecrosis is the commonest complication of hip fractures in children and the occurrence is increased if there is significant fracture displacement and compromise of blood supply at the time of fracture. Immediate reduction, internal fixation and removal of intra-articular haematoma may reduce the risk of osteonecrosis but this has not been confirmed. 

These fractures are uncommon in children accounting for less than 0.05% of all paediatric fractures (Van Frank et al. 1998). The usual mechanism is a fall from a height but unlike adults these fractures can occur following low energy trauma and stress fractures have been reported (Schmidt and Weiner 1982 Wiley 1981). Extra-articular fractures are more common than intra-articular in the skeletally immature (Inokuchi et al. 1998). Up to one third of children have associated injuries - most commonly another lower extremity fracture, with vertebral fractures being much less frequent than in adults (Schmidt and Weiner 1982). 

Displaced fractures that are intra-articular require reduction and internal fixation to restore joint congruency and prevent early degenerative changes. As with all high energy injuries these must be observed to exclude compartment syndrome. 

Until the trochlea ossifies, this fracture is difficult to differentiate from an epicondylar fracture but as this is an intra-articular injury, there is normally a positive fat pad sign. 

Injuries with the elbow flexed during a fall occur as the olecranon is stressed over the fulcrum of the trochlea as the triceps attempt to resist the force acting on the distal ulna (Fig. 18.20). The line of fracture is oblique and intra-articular. This mechanism may also produce an extensor avulsion of the apophysis. 

Middle and Proximal Phalanges 285 Condyle Fractures (Intra-articular) 285 Phalangeal Neck Fractures 286 Phalangeal Shaft 286 Proximal Phalanx 286 Volar Plate and... 

TypeD fractures are intra-articular Salter-Harris 111 or IV injuries of the proximal thumb metacarpal, resembling the adult Bennett s fracture (Fig. 19.32). These injuries are fortunately not common, as they can be very difficult to treat. Open reduction and internal fixation are often required... 

McElfresh EC, Dobyns JH (1983) Intra-articular metacarpal head fractures. J Hand Surg [Am] 8 383-393 Mizuta T, Benson WM, Foster BK, Paterson DC, Morris LL (1987) Statistical analysis of the incidence of physeal injuries. J Pediatr Orthop 7 518-523... 

---