Dr Amit Chakraborty, Feb 2020
Introduction:
Sports and activity-related injuries are a common presentation, both in the emergency department as well as in a GP surgery. These injuries range from minor cuts, bruises, and sprains through to major compound fractures of long bones. The management is varied depending on the anatomy and the severity of the injury. Generally, the management can be classified in bony and soft tissue injury categories.
Bony injuries:
Bony injuries generally result from a more severe form of trauma. Common injuries include fall on outstretched hand, twisted ankle, impact injuries from accidents etc. A few factors are commonly taken into consideration when assessing a fracture. X rays are usually a good place to start.
When managing a fracture, a key consideration is the functional significance of the injury. A fracture is assessed in terms of the number of fragments (simple versus comminuted), the degree of displacement and/or angulation (mild, moderate, severe), involvement of weight-bearing bones (such as pelvis, femur, tibia or the spine), involvement of articular surfaces, as well as the degree of soft tissue injury (open, compound fractures).
Simple, non-weightbearing, minimally displaced fractures can be conservatively managed in an outpatient setting, whereas fractures of the major bones such as femur, vertebral bodies may require hospital admission and urgent surgical intervention.
If the degree of displacement is likely to cause complications, it is generally transfixed with plate and screws or rods. If a highly functional weight-bearing joint is involved in a fracture (such as the ankle joint, it is generally fixed with hardware such as plate and screws.
Occasionally, the amount of soft tissue injury may also determine whether a fracture requires surgical intervention. If a tendon or ligament is caught between the fracture fragments, it is unlikely that the fracture will heal in an acceptable position. In these cases, surgical intervention may be necessary.
A plain radiograph is often the first diagnostic test ordered in a suspected fracture case. The radiologist will usually comment on the type of fracture, the degree of displacement or angulation, the involvement of articular surfaces and any associated soft tissue injuries. In most cases if a fracture is present, a fracture clinic follow-up is a good idea. If a fracture requires orthopaedic intervention, the radiologist is often able to recommend that in the report.
Soft tissue injury:
Soft tissue injuries often result from relatively minor trauma. It can also result from an injury to a skeletally immature individual whose bones can withstand greater bending or shear forces without fracturing.
If a fracture is not present on a plain radiograph, a diagnosis of soft tissue injury is made. Unfortunately, a radiograph does not provide the details and the exact nature of the soft tissue injury.
Generally, soft tissue injuries require a period of immobilisation, compression, elevation, and analgesia. Once the initial symptoms settle, an MRI study is the best way to investigate if a ligament or a tendon is injured. Some joints are easily accessible by ultrasound. Due to the ease of access and cost considerations, an ultrasound examination may be beneficial in assessing certain regions. Examples include the ankle joint, the wrist, the small joints of hand etc. However, MRI remains as the investigation of choice for other larger joints such as the knee, hip, shoulder and the small joints of the foot.
In most mild to moderate injuries, conservative management usually yields excellent results. If, however, a major stabilising structure of a particular joint is injured, a repair may be necessary. Often internal structures of the large joints such as knee or hip and/or shoulder will require surgical correction.
Summary:
When assessing a fracture or a soft tissue injury, consideration is given to the functional significance of the fracture i.e. how likely is the fracture to heal in a functionally acceptable manner, whether the healing process will be interfered with by the function of that particular body part (such as carrying weight), whether associated soft tissue injury will interfere with satisfactory healing, as well as whether a functionally significant and/or weight-bearing joint is involved in the fracture.
Our radiologists bring years of combined experience and expertise in managing and accessing fractures. We are very happy to be contacted to discuss fractures and their management options with our referrers.