Category Archives: orthopedic bracing

Sacral Fractures

By  aenriquez  published  April 25, 2019

The sacrum is formed by the fusion of 5 sacral vertebrae and articulates with 5th lumbar vertebra proximally and coccyx distally, and with ilia at sacroiliac joints bilaterally. It contains 4 foramina which transmit sacral nerves (L5-S5), which are responsible for the functions of anal sphincter tone / voluntary contracture, bulbocavernosus reflex and perianal sensation. As an osseous structure, sacrum transmits the load distributed by the first sacral segment through iliac wings to the acetabulum.

Sacral fractures are quite common, occurring in up to 45% of pelvic ring injuries related to high energy trauma (in young adults) or low energy falls (in elderly). They are often underdiagnosed and as a consequence, they are frequently mistreated and lead to serious complications such as neural damage (25% of all cases).

Transverse sacral fractures also have a high incidence of nerve dysfunction

The presence of a neurologic deficit is the most single most important factor in predicting the outcome. Untreated fractures with neurologic deficits lead to symptoms of lower extremity motor/sensory deficits and/or urinary/rectal/sexual dysfunction.

Sacral fractures are classified according to the Denis classification. Zone 1 fractures (50% of all) are lateral to the foramina and are least related to a nerve injury. Zone 2 fractures are through foramina, and based on whether they are stable or unstable, have an increased risk of nonunion, nerve damage and poor functional outcome. Fractures that are medial to foramina are associated with the highest rate of neurological deficit (60%), such as bowel, bladder, and sexual dysfunction. Transverse sacral fractures also have a high incidence of nerve dysfunction.  The u-type sacral fractures result from axial loading and represent spino-pelvic dissociation; these too have a high incidence of neurologic complications.

The clinical diagnosis begins with taking a proper history – motor vehicle accident or fall from height are the most common causes of these fractures, but repetitive stress, insufficiency fracture in osteoporotic adults are also important predisposing factors. The most prominent symptom is peripelvic pain. The physical exam should include testing for pelvic ring stability by internally and externally rotating iliac wings, palpating for subcutaneous fluid mass indicative of lumbosacral fascial degloving, as well as performing a vaginal exam in women to rule-out open injury. A focused neurologic, vascular and rectal exams are also important to assess the degree of tissue damage.

Radiographs are required to diagnose a sacral fracture, although only 30% show sacral fractures. CT is by far the diagnostic study of choice for proper assessment of the fracture, while MRI is considered when neural compromise is suspected.

Nonoperative management includes progressive weight bearing with orthosis if needed, and can only be considered in patients with <1 cm displacement and no neurologic deficit, and in cases of insufficiency fractures. Surgical fixation (without decompression) should be considered if there is a displaced fracture >1 cm with associated soft tissue compromise and persistent pain after non-operative management, and also if there is displacement of fracture after non-operative management. Surgical fixation with decompression is the treatment of choice whenever there is evidence for neurologic injury.

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Wrist Splint for Fracture

By  aenriquez  published  December 18, 2018

The wrist is subject to fractures due to falling with outstretched or flexed hand. This can happen in a car, bike, skiing accident or with certain other sports activities. There are two bones in the forearm including the radius and ulna. The radius is on the thumb side. A fracture of the radius near the wrist is called a distal radius fracture.

 

Splinting is one choice for immobilizing the fracture and is commonly used for wrist fractures, reduced joint dislocations, sprains, soft tissue injury, and post-laceration repairs. Splints are mainly to immobilize and protect the injured wrist, aid in healing and decrease pain. Splints are primarily used for extremity injuries. Good anatomical fracture alignment is important.

 

There are a variety of splints used to treat fractures of the wrist and forearm. The splint used depends on the location of the fracture. These splints include:

  • Volar short arm splint
  • Dorsal short arm splint
  • Single sugar-tong
  • Long arm posterior
  • Double sugar-tong
  • Long arm

For immediate treatment, a splint may be applied to reduce pain and provide some comfort

There are two types of distal radius fractures called a Colles or Smith fracture. Determining the break depends on the angle at which the break occurs.

  • Colles fracture: results from a direct impact on the palm of the hand; a bump in the wrist results from the distal radius shifting toward the back of the hand.
  • Smith fracture is less common and can result from impact to the back of the wrist; a bump in the palm side of the wrist results when the distal radius shifts toward the back of the hand.

 

Wrist fracture symptoms include:

  • immediate pain when area is touched
  • bruising and swelling
  • deformity

 

Treatment for a distal radius fracture is dependent on several factors. For immediate treatment, a splint may be applied to reduce pain and provide some comfort. If the fracture is displaced it is put back into correct alignment under local anesthetic before application of the splint.  Additional factors influencing treatment are:

  • whether bones have shifted (displaced)
  • if there are multiple fractures presentation
  • involvement of the joint
  • ulnar fracture with injury to median nerve
  • whether it is the dominant hand
  • occupation and activity level

 

Once the fracture is in good position, a splint or cast is applied. The splint (or cast) will remain in place for approximately 6 weeks. A removable splint will be worn after that to allow physical therapy to regain proper wrist function and strength. X-rays may be taken at 3 weeks and 6 weeks to assess healing of fractures that were reduced or unstable.

 

It is still important to be aware of potential complications that require additional monitoring. Complications from immobilization include:

  • joint stiffness
  • muscle atrophy
  • complex regional pain syndrome

 

The fractured extremity should be immediately evaluated if:

  • pain worsens or does not improve after medications
  • cast or splint becomes damaged, breaks, or gets wet
  • hands/fingers feel numb or cold
  • hands/fingers turn blue or white
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Implications Of An Untreated Stress Fracture

By  aenriquez  published  June 26, 2018

If you have pain in a bone that is unrelenting and associated with exercise or work then you might have suffered a stress fracture. These injuries seem innocent enough but can have significant implications if left alone and not looked at by a professional.

What is a stress fracture?

A fracture (as many of us will know) is a broken bone. A complete fracture splits the bone into two or more pieces whilst a partial fracture doesn’t. However, a stress fracture is a broken bone caused by repetitive and repeated compressive stresses to it. It can occur from a small number of high load repeated stresses and a high number of low load stresses (ie a marine with a heavy backpack running for a few miles versus a distance runner pounding the pavement for over 100 miles a week).

What happens if you leave it untreated?

This all depends on where the fracture is and whether it is in a high or low-risk site. In the worst case scenario, the stress fracture can develop into a full fracture causing displacement of the bone, nonunion (where the bone doesn’t heal properly) or fracture propagation (where the fracture becomes bigger and bigger). These complications are likely to occur at high-risk sites. High-risk sites for a stress fracture include:

  • Any stress fractures in the spine but particular the region of the lumbar spine known as the pars interarticularis
  • Hip and thigh fractures in the femoral head
  • Knee and leg fractures of the patella or the tibia
  • Ankle and foot fractures in the:
    • Medial malleolus
    • Talus
    • Tarsal navicular
    • Base of second metatarsal

A fracture (as many of us will know) is a broken bone

Some sites have a low risk of complication and these include:

  • Second and fourth metatarsal shafts (bones in the feet)
  • Posteromedial tibial shaft (part of the lower leg bone)
  • Proximal Humerus
  • Humeral shaft (arm)
  • Ribs
  • Sacrum (bottom of the spine)

How should it be managed?

If you or somebody you know suspects you might be suffering from a stress fracture then get in contact with a specialist orthopedic clinic immediately for evaluation. They will assess what the best treatment is, but the general principle is that the sooner treatment is given the better the outcome. They will decide between conservative and surgical treatment for the fracture. Usually conservative is chosen in low-risk fractures in those whose livelihood does not depend on getting better immediately. However, if an individual has a fracture in a high-risk site or their livelihood depends upon being active (ie a highly competitive athlete or a laborer on their feet all day) then it may be decided that surgery is the best option.

Conservative treatment usually consists of:

  • Pain control with medications
  • A splint that stops weight bearing on the fractured site
  • A reduction in activity until the fracture has healed
  • A slow and gradual increased in activities once the patient is pain-free
  • Exercises to help with rehab

 

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Benefits of Orthopedic Bracing

By  aenriquez  published  March 22, 2018

Braces and splints are useful for chronic and acute conditions alike. They can also be used for prevention of injury. There is much scientific evidence that supports the use of braces and splints.

Unloader Knee Brace

The unloader (valgus) knee brace is often used for pain reduction in people with osteoarthritis of the medial compartment of the knee. These braces are designed to apply an outside (external) force to reduce the load on the medial (central) knee compartment, which reduces pain. Improved joint proprioception also helps to relieve pain. In a study involving 120 patients with knee osteoarthritis and varus deformity, researchers found that the unloader knee brace helped relieve pain and improve functional status. The benefits of this brace were found to be greater than a hinged brace.

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