Uncommon names for common fractures

By Bob Matoba

Prehospital providers frequently encounter patients with various fractures and related injuries. What might be surprising is some orthopedic injuries are recognized by specific medical designations. In this article, we’ll cover actual EMS cases to illustrate orthopedic fractures that have specific medical designations that many EMS providers may not be familiar with.

Malgaigne fractures

You are called to a parking structure on a 23-year-old male who has tumbled down 10-12 concrete stairs. The patient is complaining of pain to the head, neck, back and hip. The pain associated with all these areas is aggravated by palpation and movement. It is difficult to validate, but you notice there may be shortening of the patient’s right leg. The patient denies loss of consciousness and has good circulation, movement and sensation of all extremities.

Based on the mechanism of injury and patient presentation, what type of injury do you think is associated with a Malgaigne fracture?

A Malgaigne fracture is a vertical pelvic injury that involves multiple breaks of the pelvic bone. It typically involves one half of the pelvis, which is comprised of a dislocation of the sacroiliac joint on the back and a fracture of the pubic rami on the front. This results in an unstable unilateral fragment of the pelvis which contains the acetabular hip joint.

Based on the injury pattern, a common clinical presentation for a Malgaigne fracture is leg shortening on the affected side [1]. If the patient presents with shortening of one leg, it is important the EMS provider NOT mistake a Malgaigne fracture for a hip fracture. Although hip fractures are significant injuries, patients typically do not lose as much blood volume as with an unstable hip fracture.

Correlating probable mechanism of injury for a Malgaigne fracture is crucial to identifying the injury. Malgaigne fractures are caused by shearing forces to the pelvis. Here are the two most common mechanism of injuries associated with shearing forces to the pelvis:

• Vertical falls where one foot hits the ground prior to the other
• Tumbling falls where one foot hits the ground prior to the other, at the end of the tumble

Management strategies for a Malgaigne fracture are similar to any unstable pelvic fracture. The primary goal is stabilization of the fracture and prevention of further hemorrhage loss. Pelvic stabilization with a mechanical device or pelvic sheet wrap is indicated for any patient with pelvic instability. Circumferential stabilization of a Malgaigne fracture lessens the potential for blood loss and reduces the patient’s pain by limiting movement of the injured pelvis.

Chance fractures

You are called to the scene of a two-car head-on auto accident. There is major damage to the front end of the vehicle. Your patient is an 18-year-old male complaining of pain to the face, neck and lumbar spine. The pain associated with all these areas is aggravated by palpation and movement. The patient is missing an upper front tooth and you notice a 2” laceration to the chin. The patient denies loss of consciousness and states he was wearing his seatbelt. The patient has good circulation, movement and sensation of all extremities.

In retrospect, two days after the accident, the patient admitted to wearing his seatbelt with the shoulder restraint under his arm rather than over his shoulder.

Based on the mechanism of injury and patient presentation, what type of injury do you think is associated with a Chance fracture?

A Chance fracture is an injury to the posterior structures of the lumbar vertebrae. It typically is caused by hyperflexion forces to the posterior elements of the lumbar spine. This type of force can result in fractures to the posterior portion of vertebral bones and/or tearing of the ligaments that support the posterior portion of the lumbar spinal column. This ultimately leaves the lumbar spinal cord susceptible to injury or further damage.

The most common mechanism of injury for a Chance fracture is higher energy front-end vehicle accidents with one of these mitigating factors:

• The restrained passenger fails to properly use the seatbelt by slipping the shoulder strap under the shoulder and arm
• Failure of the shoulder restraint

Both of these mitigating factors cause the patient’s torso to be thrown forward while his or her pelvis is restrained in place. This results in excessive force being directed on the posterior structures of the lumbar spine.

Patients suffering from a Chance fracture also have an increased incidence of intra-abdominal injuries [2]. This is caused by compression of the abdominal cavity by the pelvic seat-restraint. Due to anatomical differences from adults, pediatric populations appear to be at a 50% greater risk for intra-abdominal injuries [3]. It would be prudent to have an increased index of suspicion for intra-abdominal injuries if the presence of a Chance fracture is suspected.

Management strategies for a Chance fracture revolve around stabilizing the spinal column. This is one situation where full-body spinal immobilization would be indicated. Due to the nature of Chance fractures, EMS providers also need to consider these two treatment modalities:

• Avoid excessive flexion of lower extremities while moving and immobilizing the patient
• Avoid excessive twisting of the torso while moving and immobilizing the patient

Due to the lack of support along the posterior aspect of the lumbar spinal column, both of these treatment modalities help prevent further damage to the spinal cord in a patient who has suffered a Chance fracture.

Jefferson fractures

You are called to a recreation center on a 15-year-old male involved in a diving accident. A lifeguard on scene states the patient hit his head while diving into the shallow end of the pool. The patient is complaining of pain to the top of his head and a little neck stiffness. The pain associated with his neck is not aggravated by palpation and movement. Your assessment reveals a 3-4” hematoma to the top of the patient’s head with a slight increase in pain to palpation. The patient denies loss of consciousness and has good circulation, movement and sensation of all extremities.

As a side note, the patient initially refused treatment and transport but later recanted and was transported.

Based on the mechanism of injury and patient presentation, what type of injury do you think is associated with a Jefferson fracture?

A Jefferson fracture is an injury to the first cervical vertebrae. It frequently involves more than one fracture within the vertebrae. Jefferson fractures are rare in children under 8 years of age [5]. The fracture may also damage arteries in the neck which may result in the following conditions:

• Lateral medullary syndrome, which is caused by ischemia in the lateral portion of the medulla oblongata – common symptoms may include difficulty swallowing, slurred speech, and the inability to sense temperature [6]
• Horner’s syndrome, which is characterized by a unilateral constricted pupil, unilateral drooping of the eyelid on the same side and an apparent inset eyeball on the affected side [7]
• Ataxia, which may include lack of muscle coordination, abnormal gait, difficulty with speech and abnormal eye movements

Jefferson fractures are caused by axial loading forces. Here are some common mechanisms of injuries associated with axial loading:

• Head striking the windshield
• Diving into shallow water
• Strong rotation of the head
• Head impacting against the roof of vehicles
• Whiplash related injuries
• Falls from playground equipment
• Impacts to the vertex of the head

Axial loading forces cause the fractured sections of the first cervical vertebrae to disperse outward and away from the spinal cord. Due to the nature of these forces, patients with Jefferson fractures typically present with intact neurologic function. As a result of these varying mechanisms, Jefferson fractures can be stable or unstable, but seldom in between [8].

Management strategies for a Jefferson fracture revolve around immobilizing the cervical spine. Due to the nature of Jefferson fractures, EMS providers also need to consider these treatment modalities:

• Minimize the rotational movement of the head
• Minimize the extension and flexion of the cervical spine
• Avoid Trendelenburg positioning to prevent further axial loading force

Correlate clinical presentation to treatment modalities

Malgaigne, Chance and Jefferson fractures are not commonly used medical designations within the EMS profession, but they are caused by specific mechanisms of injury. It would be beneficial for EMS providers to consider these mechanisms and correlate them to the clinical presentation of their patients. This way, patients can benefit from the modified treatment modalities required to properly manage these fractures.

About the author

Bob Matoba serves as lead Instructor for the St. Anthony Paramedic Academy in Lakewood, Colorado. He has been involved in EMS for over 37 years. His career has spanned many aspects of the EMS profession, first as an EMT for a private ambulance company, all the way to the EMS chief for a fire department. He strives to provide education that has relevance and takes pride in continuing to be an actively practicing paramedic on an ambulance.

References

1. Bucholz, R.W. The pathological anatomy of Malgaigne fracture-dislocations of the pelvis. The Journal of Bone and Joint Surgery. (March 1981, 63(3):400-4004)
2. Muna, A., Hessa, A., Laila, H. Let’s review Chance fracture. BMJ Case Reports. (February 2015, 10.1136/bcr-2014-206924)
3. Reid, A.B., Letts, R.M., Black, G.B. Pediatric Chance Fractures: association with intra-abdominal injuries and seatbelt use. The Journal of Trauma. (April 1990, 30(4): 384-391).
4. Lee, C., Woodring, J.H., Unstable Jefferson variant atlas fractures: an unrecognized cervical injury. American Journal of Neuroradiology. (November 1991, 12(6): 1105-1110).
5. Marlin, A., Williams, G.R., Fletcher, L. Jefferson fractures in children. Journal of Neurosurgery. (February 1983, 12(2))
6. Aminoff, M. Encyclopedia of the Neurological Sciences. (Academic Press. April 2014, p. 744)
7. Kennard, C. Neuro-ophthalmology: Handbook of Clinical Neurology. (Elsevier. June 2011, p. 452).
8. Kesterson, L., Benzel, E., Orrison, W., Coleman, J. Journal of Neurosurgery. (August 1991, 75(2)).