Intraarticular fracture is a fracture, the fracture line of which is completely or partially located in the joint cavity. It requires a special approach to diagnosis, treatment and rehabilitation. The distinctive features of such fractures are the involvement in the pathological process not only of the damaged bone, but also of the entire joint, a possible violation of the congruence of articular surfaces, as well as a high probability of contractures and stiffness in the long term. Distinctive signs are edema, pain and hemarthrosis, crepitation is possible. The diagnosis is made on the basis of symptoms and radiographic picture, sometimes CT and MRI of the joint are required. Treatment can be both conservative and operative.
ICD 10
S42.2 S52.6 S72.0 S82.1
Meaning
Intraarticular fracture is a bone injury inside the joint capsule. This is a complex injury that requires increased attention from an orthopedic traumatologist and a special approach to treatment, since the volume of movements depends on how accurately the articular surfaces have been restored. It can occur in the area of any joints, both large and small. Intraarticular fractures of large joints of the extremities have the greatest clinical significance due to possible long-term consequences.
Causes
The cause may be a household or sports injury (fall, twisting of a limb, indirect impact or direct impact), as well as a road accident, a fall from a height, a natural disaster or an industrial injury. In all cases, with the exception of domestic and sports injuries, there is a high probability of combined or combined damage. Intraarticular fractures can be combined with other fractures of limb bones, blunt abdominal trauma, traumatic brain injury, pelvic fractures, trauma to the genitourinary organs and chest injuries.
Fractures of the neck and head of the humerus, as a rule, occur in the elderly and are the result of a fall on the withdrawn arm, shoulder or elbow. Elbow joint injuries can be observed at any age, but are more common in children and young patients who lead an active lifestyle. The cause is usually a fall on a straightened arm or bent elbow. Fractures in the wrist joint can also occur in people of all ages, however, the vast majority of patients are children or the elderly. A typical mechanism of injury is falling on a straightened arm with support on the palm.
Fractures of the neck and femoral head are characteristic of elderly people and are the result of a fall. Knee joint injuries are more common in athletes and people of working age, the mechanism of injury can be different, from falling on the knee to twisting and direct impact. Ankle fractures are observed in patients of all ages and usually occur when the leg is turned up.
Pathanatomy
The joint consists of two or more bone ends that match each other in shape, which are connected to each other by means of a capsule and ligaments. The capsule forms a cavity isolated from other anatomical formations. Inside and outside the capsule there are ligaments that hold the bones, not allowing them to shift too much. The ends of the bones are covered with smooth cartilage, thanks to which the bones can slide freely relative to each other. Inside the joint there is a small amount of fluid – lubricant that facilitates sliding and delivers nutrients to the cartilage tissue. All anatomical structures together form a kind of hinge.
With intraarticular fractures, the pathological process extends to all or almost all structures. Along with the bone, the integrity of the articular cartilage is violated. Blood from the fragments pours into the joint cavity, hemarthrosis occurs. The capsule stretches and becomes inflamed. In addition, the capsule and ligaments may rupture immediately at the moment of traumatic impact or be damaged by bone fragments. Due to the effect of the traumatic force and the pull of the muscles, the bone fragments shift and become incongruent (mismatched, not matching each other in shape). If the shape of the articular ends is not restored or restored insufficiently accurately, in the future this will lead to limited movements. In addition, insufficient smoothness of the articular surfaces in combination with the consequences of damage to other structures can cause the development of arthrosis.
Any intraarticular fracture requires a serious approach to treatment. However, due to the wide prevalence and severity of possible consequences, fractures in the area of large joints: elbow, knee, hip and ankle are of the greatest clinical importance. The severity of fractures of the elbow joint is due to its complex configuration, a large number of typical intraarticular injuries, which include both ordinary fractures (transcondylar fractures, fracture of the elbow process, fracture of the beam head) and dislocation fractures (Montage fracture, Montaigne fracture), as well as difficulties in repositioning and retaining fragments.
Among the skeletal injuries of the hip joint, fractures of the neck and femoral head are particularly dangerous – this area is poorly supplied with blood, so the fragments do not fuse, but only “grip” together with scar tissue. The severity of fractures in the knee and ankle joints is explained by their complex configuration and the importance of full functional recovery of these segments. Intraarticular fractures in the area of the shoulder and wrist joint, as a rule, are easier to reposition and less often end in the formation of contractures. Nevertheless, in some cases, especially with a large number of fragments and a significant displacement of bone fragments, such injuries can also present difficulties in treatment and rehabilitation.
Symptoms
As with other fractures, such injuries cause intense pain, swelling and impaired limb function. The mobility of fragments is not always detected, which may be due to both the features of the injury and the inaccessibility of intra-articular structures (for example, the intercondylar elevation in a tibial fracture) for direct examination. In addition to common signs, intraarticular fractures are characterized by joint deformation and a violation of the relationship between bone protrusions (identification points). With fractures in the area of large joints, hemarthrosis is determined. The severity of each of these symptoms may vary and depends on the type and location of the injury, the degree of displacement of bone fragments, severity and many other factors.
Diagnostics
The diagnosis of an intraarticular fracture is made on the basis of clinical and radiological signs. To clarify the plane of the fracture and the position of the fragments, along with images in standard projections, radiographs are often performed in special stowings and tangential projections. If necessary, the patient is referred for CT of the joint, MRI of the joint and arthroscopy.
Treatment
In most cases, hospitalization in the department of traumatology and orthopedics is required. Treatment is based on the principles of the most accurate restoration of the normal anatomical position of the fragments and the minimum possible fixation period. In case of fractures of the knee joint, one or more punctures are performed at the initial stage. If other joints are damaged, punctures are usually not required. Plaster dressing is more often used for fractures without displacement. When fragments are displaced, as a rule, skeletal traction is applied or surgical intervention is performed. Preference is usually given to operative techniques, since they allow early resumption of movement and avoid the development of immobilization (fixation) contractures.
Due to the variety of intraarticular fractures, the treatment method is always chosen taking into account the specific pathology. During the rehabilitation period, the patient is necessarily referred for physical therapy and physiotherapy. Indications for massage are determined individually, because in some cases, especially in children, this method of treatment can provoke the formation of excessive bone corns.