A fracture is a break, typically in a bone. If the broken bone punctures the skin, it is then called an ‘open’ or ‘compound’ fracture. Fractures often occur due to car accidents, falls, or sports injuries. Other causes are low bone density and osteoporosis, which cause the weakening of the bones. Overuse can also cause stress fractures, which are very small cracks in the bone.
An osteochondral fracture (also known as an articular cartilage injury) occurs when a piece of the smooth surface on the end of the bone fractures. This condition takes place in a joint when the articulating cartilage (chondro) and part of the underlying bone (osteo) break off the bone itself and become a fragment. If the fragment stays in place, it is considered stable, however, if it breaks loose then it is labeled as unstable.
Unstable fractures can move around in the joint and cause pain as well as other symptoms. Additionally, these fragments, or loose bodies, may vary in size. Usually, as the size of the fragment increases the more symptomatic a patient will become. This type of injury most commonly occurs in young adults or adolescents due to the bone being softer and more prone to fracture in this way.
An osteochondral fracture can theoretically take place in any joint, but typically the kneecap or talus are the joints where this injury occurs more often. A mechanism of the injury most often occurs in a weight-bearing position with a twisting or torquing force on the joint. Another possible cause of the fracture happens with lateral dislocation of the patella. When the patella is pushed back into place, the quadriceps will fire and this can cause a compressive force as the patella moves off over the lateral femoral condyle and cause a piece of the bone to fracture off.
Causes & Symptoms
There are many types of osteochondral fractures that can happen mainly in the knee and ankle, and each type can have slight variations. The following types of fractures include:
- Open fracture – A fracture in which the bone breaks through the skin and can be seen outside the leg. Or there is a deep wound that exposes the bone through the skin. This is also known as a compound fracture.
- Closed fracture – A fracture that does not break the skin. This is often called a simple fracture.
- Complete fracture – A complete break of the bone causing it to be separated into two or more pieces.
- Stable fracture – The broken ends of the bone line up and have not moved out of place.
- Displaced fracture – There is a gap between the broken ends of the bone. Repairing a displaced fracture may require surgery.
Certain causes that can lead to the fracture can result in different ways:
- Injuries can cause minor bruising of the cartilage in the joints.
- Injuries can also cause a slight tear in the cartilage. Fluid from the joint may then leak down below the cartilage and go between the cartilage and bone. This can cause cartilage delamination. This means the cartilage begins to lift away from the bone.
- Injuries may cause an enormous tear in the cartilage and cause a cartilage flap to develop. This would irritate the joint lining causing inflammation or synovitis.
- Some injuries will not only affect the cartilage but the bone beneath it. This can cause a bruise or a bone contusion to the bone itself. When associated with a cartilage tear, this becomes more problematic.
As mentioned earlier, osteochondral fractures are mainly caused by either the patella or the talus. Therefore, these two types of osteochondral fractures on the talus / patella may be the result of the following:
- Falls – Falling directly on the kneecap can cause an osteochondral fracture. Falls may occur while walking, running, or participating in exercise programs or sports. They may also occur due to being tripped or pushed.
- Muscle imbalance – Strong quadriceps and weak hamstrings can cause the quadriceps tendon to place an excessive amount of force on the patella. If a quadriceps/hamstring muscle imbalance is not corrected, it can lead to an osteochondral fracture.
- Motor vehicle accident (MVA) – During a motor vehicle accident, the knee may slam against the dashboard or seat and the patella may fracture. In severe cases, the crushing injuries common in car accidents may cause breaks that require surgical repair.
- Missteps – Sometimes just putting your foot down wrong can result in a twisting injury that can cause a broken bone.
- Falls (ankle) – Tripping or falling can break bones in your ankles, as can landing on your feet after jumping down from a slight height.
The signs and symptoms you would experience would depend on the degree of injury to the cartilage, bone, joint lining, and ligaments. The worse the injury, the more symptomatic you will become. Therefore, some symptoms may include:
- Chronic swelling of the ankle joint.
- Stiffness in the joints especially upon getting up from sitting or getting out of bed in the morning.
- A feeling of locking when the ankle moves. A clicking sound may also be heard and felt.
- A feeling that the ankle is going to give out or twist even if the ankle ligaments are completely intact.
- Pain with the motion of the ankle joint is significant, not allowing a person to perform general activities, especially sports.
Who gets an Osteochondral Fracture?
Usually, a patient may be at higher risk of osteochondral fracture if he or she experiences one or a combination of the following:
- Sports – The stresses, direct blows, and twisting injuries that occur in sports such as basketball, football, gymnastics, tennis, and soccer can cause osteochondral fractures in the ankle.
- Smoking – Studies have shown that cigarette smoking can lower the recovery speed of healing after an osteochondral fracture.
- Certain conditions – Having decreased bone density (osteoporosis) can put you at risk of injuries to your joints.
- Intense activity level – Whether you are a trained athlete or someone who just started exercising, suddenly boosting the frequency or duration of your exercise sessions can increase your risk of an osteochondral fracture.
- Improper sports equipment – Faulty equipment, such as shoes that are too worn or not properly fitted, can contribute to osteochondral fractures or falls. Improper training techniques, such as not warming up and stretching, also can cause ankle injuries.
How does it affect you? How serious is it?
Even after a successful treatment plan, some patients with osteochondral fractures may experience long-term complications, such as:
- Chronic pain – Long-term pain in the front of the knee is common with osteochondral fractures. While the cause of this pain is not completely understood, it is likely that it is related to arthritis, stiffness, and muscle imbalance.
- Muscle weakness – Some patients may have permanent weakness of the quadriceps muscle in the front of the thigh after a fracture. Some loss of motion in the knee, including both straightening (extension) and bending (flexion), is also common.
- Post-traumatic arthritis – Post-traumatic arthritis is a type of arthritis that develops after an injury. Even when your bones heal normally, the articular cartilage covering the bones can be damaged, leading to pain and stiffness over time.
Recommended Treatment, & Rehabilitation
It can be quite challenging to diagnose an osteochondral injury. Many scans may miss the damage caused by the fracture, which is also masked by the sprain or trauma that caused the injury. A physician will examine the joint for instability and range of motion. An X-ray may be ordered, but a cartilage tear is difficult to see on an X-ray, so a magnetic resonance imaging (MRI) or computed tomography (CT) scan may be required.
In some cases, both an MRI and CT are needed to diagnose an osteochondral fracture. During the midst of the diagnosis, your physician will grade your bone and cartilage status on a scale and determine the level of damage based on its findings with the equipment provided. This grade will help a physiotherapist as he or she will work to develop a specific treatment program specific to your condition and needs. Some of these treatment plans may include:
If an osteochondral fracture is left untreated, it may worsen over a period of time. Therefore, your physiotherapist will work to help prescribe the best activities and exercises. He or she will design an exercise plan to help and not harm your joint. The ultimate goal of the program is to restore function and health. Imaging done at certain times may also help ensure that your cartilage and bone can handle specific loads.
One of the most common symptoms of a fracture is the limited motion of the injured joint, so, your therapist will assess for any movement limitations. They will compare the affected joint’s movement to the other side of your body and expected normal ranges. Based on your results, your physiotherapist may guide you through exercises to restore normal motion.
Limit weight-bearing activities
Your physiotherapist may recommend decreasing the total weight you put on your affected leg if you have an osteochondral fracture in your ankle or knee. This can include using a bike or swimming instead of running. They may even ask you to use crutches or a wheelchair instead of walking to avoid further complications.
Your physiotherapist may use hands-on therapy to gently move and stretch muscles and joints. Manual therapy helps to improve motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own. Manual therapy may help to restore the joint’s regular motion in people with osteochondral fractures.
Compression sleeves around the affected joint may help reduce pain and swelling. If surgery is needed, your physiotherapist will likely recommend using braces to manage the amount of motion allowed after surgery.
Regular exercise to restore strength and mobility to your knee / ankle and a gradual return to everyday activities are important for your full recovery after an osteochondral fracture. Here are some exercise examples after a fracture has been done:
Straight leg raises
Lie on your back and bend your uninjured knee so your foot is flat on the floor. Tighten your injured thigh and lift your straight leg to the height of your opposite knee. Lastly, hold for 2 seconds at the top and slowly lower back to the starting position. Repeat this exercise with 3 sets of 5-20 repetitions.
Sit in a stable chair and bend your knee back as far as possible. Then hold it for 5 seconds and then return it to the resting position. Repeat this stretch with 3 sets of 5-20 repetitions.
Shin muscle stretch
Sit in a chair, with both feet flat on the floor. Bend your affected leg behind you so that the top of your foot near your toes is flat on the floor and your toes are pointed away from your body. Hold the stretch for at least 15-30 seconds, then repeat 2-4 times a day.
Alternative & Homeopathic Treatment
Certain homeopathic treatments depend on the type of osteochondral fracture. Therefore, here are a few options you can try to boost your recovery of the condition:
- Immobilization – A cast or splint may be used to help keep the foot and ankle from moving and allow the injury to heal.
- Medications – Oral non-steroidal anti-inflammatory medications (NSAIDs) or pain-relieving creams may help reduce pain and inflammation.
- Ice / heat application – Applying an ice pack for 20-30 minutes can help reduce swelling and inflammation. Additionally, heat packs are useful to increase blood circulation.
- Foot shower – Placing your affected foot in a bucket filled with warm water can help relieve your foot pain and increase blood flow. Adding Epsom salt will increase recovery speed.