Called intra-articular fracture, the line which is wholly or partially located in the cavity of the joint. Intraarticular fracture isolated as a separate pathology which often requires a different approach in the diagnosis, treatment strategy and rehabilitation activities than other traumatic injuries of the skeleton.
Despite the more pronounced difficulty than in the standard fracture, intra-articular fracture can be treated not only through operational techniques, but using conservative.
With intraarticular fractures observed pathological or traumatic violation of the integrity of the bones inside the joint capsule. This injury in the clinic is difficult. The main difficulty lies in the violation of congruency (correct match) of the articular surfaces of two or more bones involved in the formation of the joint. And just how exactly was matched to the articular surface, and depends on the restoration of motion in the joint. Often even seemed simple intra-articular fracture is likely to cause a disability of the person.
One of the main differences between intra-articular from extra-articular fracture is that the violation is observed by not only the bony elements but by the entire joint as an integrated structure.
Intra-articular fracture can occur equally in large and small joints. The greatest value in light of the long-term effects are intra-articular fractures of the large joints of the extremities – shoulder, elbow, hip and knee.
The origin of intra-articular fracture is a little different from the etiology (causality) of standard fracture.
Intra-articular fracture can be:
- traumatic – due to the effects on bone of any external traumatic factor;
- pathological – develops due to the fact that bone tissue weaken, their strength decreases and the fracture can occur literally by itself, without external influence (and in fact, due to the pressure of body weight on weakened bone).
Traumatic intra-articular fracture is much more common than pathological.
The cause of intra-articular fracture can be an injury:
- in car accidents;
- in case of natural disasters and technogenic catastrophes.
Household, sports, industrial injuries, which can lead to the formation of intra-articular fracture, can be:
- random – the circumstances of their occurrence are regarded as an accident;
- caused intentionally.
Intra-articular fracture can occur in almost any mechanism of injury of the knee – often:
- the fall (particularly on an outstretched limb);
- twisting limbs;
- a direct blow;
- indirect effects (mainly affects small joints, the elements of which lose strength in the background of any disease or pathological conditions).
In almost all cases, excluding domestic injury, there is a high probability of Multisystem trauma. Thus, intra-articular fracture can be combined with such injuries as:
Against the background of polytrauma, when quite often it is necessary primarily to support the activities of the vital organs, the occurrence of intra-articular fracture can depart on the second plan.
Intraarticular fractures of the neck and the head of the humerus is mainly observed in the elderly.
Their immediate cause is the fall in:
- designated hand;
Intra-articular fractures of the elbow can be diagnosed at any age, but most cases occur in children and young people who lead an active lifestyle.
The immediate cause of the occurrence of such a fracture is often the fall on:
- straightened hand;
- the elbow bent.
Intra-articular fractures in a wrist joint also occur in people of all ages, but the maximum in most cases are diagnosed in children or the elderly. The proximate cause of this injury is falling on a stretched hand with the support hand.
Intra-articular injuries of the neck and the femoral head are often observed in elderly patients and occur mainly due to the fall in the joint area.
Intra-articular fractures of the knee joint often occur in athletes and adults of middle working age (from 28 to 45 years). The mechanism of their occurrence can be very different from a direct fall on the knee before tucking and direct blow to the joint.
Intraarticular ankle fractures are diagnosed in patients of almost all age groups, most often caused by tucking foot.
The development of the pathology
To understand why intra-articular fracture is a specific type of fracture, it is necessary to imagine the anatomical structure of the joint.
Each joint consists of two or more ends of bones that meet each other in the form of the articular surface. They are connected by a capsule and ligaments, which are connective tissue structures.
The articular capsule forms the joint cavity, which is separated from the other anatomic structures nearby. The ligaments inside and outside the capsules – they hold the bones and prevent them too far shifted from the original position. The ends of the bones are covered by cartilage – thanks to its natural smoothness, they are able to freely slide relative to each other.
The inside of the joint (the glenoid cavity) is a small quantity of biological fluid – it acts as a lubricant. The main function of a lubricant is:
- facilitate the sliding of the articular surfaces;
- delivery of nutrients to cartilage.
All of these anatomical structures together form a kind of hinge, the elements of which are independent of each other.
So if you had intraarticular fracture of the violations will cover all or almost all structures of the joint:
- during the fracture violated the integrity not only of bones but the articular cartilage;
- blood out of bone fragments that are embedded in the joint cavity, poured into it – is formed hemarthrosis;
- due to the accumulation of blood the joint capsule is stretched, in response, developing a reactive swelling of the capsules, it becomes inflamed. This inflammation is aseptic, but can join in pathogenic infection (for example, gut microflora, which is in the chronic infectious foci), therefore further developing infectious-inflammatory process;
- the integrity of the joint capsule and ligaments may be disrupted at the time of the fracture, and later due to the impact of her sharp bone fragments.
Note that very often the consequence of intra-articular fracture is a difficulty or limitation of motion of the joint. This is due to the launch of the pathological mechanism. The bone fragments are displaced and become incongruent (i.e., not match each other, do not fit on the form). The shift occurs for two reasons – because of the direct action of the traumatic agent, and because of the influence of the attached muscles that pull fragments of bone in different directions. If this offset shape of the articular ends is not to restore or repair inaccurately, the mechanism of the articular hinge “breaks”, it causes limitation of motion of the joint (up to the full “jamming”).
The situation is exacerbated if the traumatic agent damages the surface of the articular cartilage. Because of this, the smoothness of the articular surfaces is lost, they RUB against each other, they formed small cracks, which become more pronounced and aggravated by the friction of the articular surfaces. Such pathological processes can lead to the development of osteoarthritis (non-inflammatory destruction of the articular surfaces and joint replacement in General).
Intraarticular fracture of the elbow, knee, hip and ankle joints is more likely than extra-articular, for the reason that the violation of their integrity will not allow you to do basic movements.
Intra-articular fractures of the elbow are regarded as severe for the following reasons:
- joint configuration is complex – it generates a lot of constituent parts;
- when repositioning of the elbow joint (the folding of fragments of broken bones into a single unit) are technical difficulties;
- to retain the fragments after reduction at fracture of the joint is problematic (due to the pull of the attached muscles).
With intraarticular fracture of the olecranon happening a large amount of the typical damage, which can develop by themselves or in combination with each other. This:
- standard fractures;
The most common fractures of the elbow include:
- razmyshlyaya fractures;
- fracture of the olecranon;
- fracture of the head of the radius.
To perelomova, which constitute the morphological basis for intra-articular injuries of the olecranon, is a fracture of Montega – a combination of a fracture of the ulna in the upper or middle third of the dislocated head of the radius.
Of all traumatic injuries of the hip joint to the category ranked as the most difficult fractures:
- the neck of the femur;
- the head of the femur.
The reason is that this site is supplied worse in comparison with other parts of the bones forming the hip, and other bones in General. Due to the lack of nutrients bone fragments are fused, but only “sealed” to each other – in the role of “bonding” unreliable substrate acts as scar tissue.
The complexity of intra-articular fractures of the knee and ankle joints is also due to their rather complex structure. In addition, the ankle falls load more than all the previously mentioned joints – due to the fact that he keeps all the body and limbs.
Intra-articular bone lesions within the shoulder and wrist joints, usually occur without the complexities that are characteristic of the elbow, hip and ankle joints. Reposition of bone fragments, in this case, pursue a more just, and in the long term such fractures rarely end with the formation of contractures. But sometimes difficulties occur during repositioning of bone fragments resulting from fracture.
Most often it happens in such clinical circumstances, such as:
- the formation of a large number of fragments (three or more);
- the combination of large and small fragments;
- significant displacement of the bone fragments.
For such reasons it is difficult to treat not only intra-articular fractures of the shoulder and wrist joints, but also violation of integrity of bone structures of other sites.
The symptoms of intra-articular fracture
The main features of intra-articular fractures are:
- the mobility of fragments.
Characteristics of pain:
- localization in the fracture site and around the joint;
- distribution radiating (give) to the surrounding tissue;
- nature – aching, vykruchivatsya;
- intensity – strong, at times intolerable, requiring the use of narcotic analgesics;
- the emergence of a permanent from the moment of the fracture. In complex cases (e.g., in polytrauma) patient may not feel pain at the fracture site, they may appear later.
Mobility of bone fragments in intra-articular fracture is determined not always. The most common reason for this is the unavailability of intra-articular structures to explore. As an example – it is impossible to test the intercondylar Eminence with intraarticular tibia fracture.
In addition to the General symptoms that are characteristic of all types of fractures, there are features of signs of articular fractures in the first place, this:
- the characteristic deformity of the joint;
- change the relationship (distance) between the bone projections (identification points).
With intraarticular fractures of the large joints there is often a haemarthrosis. In this case, the pain can be more pronounced, as the blood accumulates in the enclosed space of the joint and presses on its structure.
The severity of any of the above symptoms are quite variable and may not correlate with the size of the joint. In General, it depends on such nuances as:
- the location of the damage;
- its type;
- the number of fragments;
- the degree of displacement of bone fragments;
- the presence of associated injuries.
To suspect the presence of intra-articular shape of the fracture is often difficult, as symptoms may not differ from the clinical picture of extra-articular fracture. Therefore, to obtain more detailed information necessary to attract additional diagnostic methods.
The results of the physical examination the following:
- on examination – soft tissue in the area of the fracture is swollen, the skin may be hyperemic (reddened), the patient is not able to demonstrate the functionality of the joint (due to the violation of its structure and of the pain syndrome);
- palpation – the fracture is sharply painful palpation confirmed the swelling of tissues. Crepitus (“chrustenice” due to the displacement of bone fragments) are often difficult to detect, since bone fragments inside the joint capsule.
Instrumental methods of investigation used in the diagnosis of intra-articular fracture, the following:
- x-ray examination due to the fact that x-ray equipment is available even in small clinics, the method remains the most popular method of diagnosis of intra-articular fractures. With the help of x-ray picture reveals a fracture, specify the plane of the bone injury, the position of the bone fragments, the available fragments of the fracture. The image is made from several perspectives. If necessary, the study is carried out in special styling and tangential (oblique) projections;
- computed tomography of the temporomandibular joint (CT) – computer sections will help with greater accuracy than x-ray examination, to assess the condition of the joint, to detect the fracture and to analyze its characteristics;
- magnetic resonance imaging (MRI) – its purpose and capabilities are the same as CT, but MRI will allow better assessment of the condition of the soft tissues affected by intra-articular fracture (joint capsule, ligaments, and so on);
- arthroscopy in the joint cavity enter the arthroscope (a type of endoscopic equipment with an optical system and lighting), visually assess the condition of the articular surfaces, reveal the fracture. Arthroscopy is performed in difficult cases of intra-articular fractures;
- arthrocentesis is performed to detect blood in the joint cavity.
Laboratory research methods of particular value in the diagnosis of intra-articular fracture have not. Apply in the case that the fracture is pathological – they reveal changes characteristic of the disease that led to weakness of bone tissue, resulting in a fracture.
Differential diagnosis of
Differential diagnosis of intra-articular fractures is carried out with extra-articular injuries of the bones, which are close to the joint.
The main complications of intra-articular fracture are:
- violation of the functional capacities of the joint;
- contracture – a stiffness;
- ankylosis – complete immobilization of the joint.
Treatment of intra-articular fracture
In case of detection of intra-articular fractures in most of the cases required hospitalization in the trauma Department.
Basic principles of treatment of this pathology is the following:
- the most accurate mapping of the bone fragments, the renewal of the natural structure of the joint;
- possible fixation.
When bone injuries without displacement a plaster bandage.
If bone fragments have shifted, conduct:
- skeletal traction – traction of the injured limb with the help of spokes, conducted through the bone, and cargo, which, overcoming the contraction of the muscles and literally pulling the bone fragments apart, helps them be installed in the correct position;
- surgery – joint cavity is opened, fragments correlate, record one of the appropriate methods.
The purpose of both methods – exact repositioning of the protruding fragments.
Is the preferred surgical treatment because it allows:
- to resume movement sooner;
- to avoid the formation of immobilization (fixation) of the contractures that develop due to prolonged immobilization of the injured limb.
After fusion of bone fractures during the rehabilitation period are assigned:
Massage in the rehabilitation period with intraarticular fracture prescribed, assessing individual properties of the organism – it should be borne in mind that sometimes it causes the development of excess callus (especially in children).
Methods, warning intraarticular fracture is:
- avoiding exposure to traumatic factors and situations in which the risk of injury increases;
- strengthening bone. It is possible to achieve proper nutrition and physical activity.
The prognosis for intra-articular fractures varies and depends on many factors – the specific type of the affected joint, degree of trauma, tissue regenerating abilities.
Course, treatment, and recovery in intra-articular fractures are often more severe than in extra-articular. After intra-articular fractures in the later period often develop contractures (stiffness of joint). But with the right choice of treatment strategy and appropriate rehabilitation measures function of the affected joint are restored in full.