Intraarticular fracture

Intraarticular fracture
Example of an intraarticular fracture of the medial malleolus extending in the talocrural ankle joint
SpecialtyOrthopedics

An intraarticular fracture is a bone fracture that typically run parallel to the joint surface which the break crosses into the surface of a joint, into the articular cartilage. [1]This always results in damage to the cartilage, an area of limited healing capability.[2] Compared to extraarticular fractures, intraarticular have a higher risk for developing long-term complications, such as posttraumatic osteoarthritis.[3] For the majority of these fractures, anatomic reduction is vital to maintain the integrity of the joint surface.[4]

Pathophysiology

Articular cartilage is composed of 60-80% water and components of collagens. Its functions are to maintain structure with a lifetime of stress and repetition of movement. Biological repair and cellular turnover is therefore limited leading to the restricted response to traumatic injury. Destruction of the cartilage leads to an activation of an inflammatory cascade leading to regeneration or destruction of the cartilage, the basis of posttraumatic osteoarthritis.[5]

These fracture patterns are likely a result of shearing, rotatory, or tangential forces applied to the joint producing segments of both bone and cartilage. The fracture generally run parallel to the joint surface and may be displaced or non displaced. Fragments of this fracture undergoes two pathways depending on size and degree of displacement: resorption or loose body formation. If there is vascular communication of the fracture fragment, there is a chance the body will continue to supply that fragment and it will be remained attached to the bone. If there is a disruption of vasculature in the fragment, secondary ossification will occur and the fragment will become a loose body in the joint. With both pathways, there is a continued risk of posttraumatic arthritis and changes to load distribution to the joint.[6]

Signs and symptoms

Generally, fractures are a result of traumatic injury, underlying pathology, or overuse. Fractures are painful though there are no pain receptors in the bone. This is a result of damage to the periosteum and endosteum, hematoma formation, soft tissue injury, and contraction of nearby muscle groups in response to disturbed anatomy. Physical signs include obvious deformity, inability to bear weight or use the limb, bruising, and swelling.[7]

Complications

Fractures generally heal to full functional capacity via primary or secondary bone healing.[8] Common complications of intrarticular fracture include:

  • posttraumatic osteoarthritis
    • As mentioned, damage to the chondral surface of the joint has a high risk of posttraumatic arthritis if the joint is not returned to native alignment.[5]
  • malunion
    • When bones are not set back into close to native alignment there is a risk of healing in a malformed position.
  • nonunion
    • If there is not adequate blood flow to provide healing factors to the fracture or there is too much movement at the area of injury there is risk of not healing.
    • Diabetes, smoking, and peripheral vascular disease increase risk of nonunion.
  • avascular necrosis
    • When fractured, blood supply can be disrupted to certain bones or areas of bone causing that portion of bone to die and necrose.
    • Examples include the femoral head of the hip joint and the scaphoid of the wrist.
  • joint stiffness and pain
    • Damaged soft tissue leads to build up of scar tissue which can make joints stiff and painful.[7]

Diagnosis

As with most medical evaluation and diagnosis, history and physical examination is vital to making an accurate diagnosis. Radiographic evaluation is the gold standard to diagnosing a fracture and creating a treatment plan.[8] If there is concern for fracture extension into the joint that is not adequately visualized on radiographs, a Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) should be considered. MRI is especially useful to classify or grade degree of condral damage. Advanced imaging, CT or MRI is a common modality for surgical planning.[1]

[6]See also[7]

[4]References

  1. ^ a b Bohndorf K (1999). "Imaging of acute injuries of the articular surfaces (chondral, osteochondral and subchondral fractures)". Skeletal Radiology. 28 (10): 545–60.
  2. ^ "Intraarticular Fracture Discussion".
  3. ^ McKinley, Todd O.; Borrelli, Joseph; D’Lima, Darryl D.; Furman, Bridgette D.; Giannoudis, Peter V. (2017-03-25). "Basic Science of Intraarticular Fractures and Posttraumatic Osteoarthritis". Journal of Orthopaedic Trauma. 24 (9): 567–570. doi:10.1097/BOT.0b013e3181ed298d. ISSN 0890-5339. PMC 3662545. PMID 20736796.
  4. ^ a b Azar, F. M., Beaty, J. H., & Canale, S. T. (Eds.) (December 2020). Campbell's Operative Orthopaedics (14th ed.). Elsevier. ISBN 9780323672177.{{cite book}}: CS1 maint: multiple names: authors list (link)
  5. ^ a b Schenker ML, Mauck RL, Ahn J, Mehta S (2014). "Pathogenesis and prevention of posttraumatic osteoarthritis after intra-articular fracture". Journal of Amercian Academic Orthopedic Surgery. 22 (1): 20–28 – via PubMed.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  6. ^ a b Milgram, JW; Rogers, LF; Miller, JW (1978-04). "Osteochondral fractures: mechanisms of injury and fate of fragments". American Journal of Roentgenology. 130 (4): 651–658. doi:10.2214/ajr.130.4.651. ISSN 0361-803X. {{cite journal}}: Check date values in: |date= (help)
  7. ^ a b c Danielle Campagne (September 2022). "Overview of Fractures". mdmanuals.com. Archived from the original on 12 October 2022. Retrieved 12 October 2022.
  8. ^ a b Rockwood, Charles A, David P Green, and Robert W Bucholz (2006). Rockwood and Green’s Fractures in Adults (6th ed.). Philidelphia: Lippincott Williams & Wilkins. ISBN 9780781746366.{{cite book}}: CS1 maint: multiple names: authors list (link)

Further reading

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