Complex fracture: a clinical case of thermography

Complex fracture: a clinical case of thermography

03/03/2022 By: Alejandro del Estal Home

Thermography has been used in fracture assessment for decades. However, the complex fracture, unlike the simple fracture, has a number of characteristics that make it a pathological condition with extraordinary thermal behavior.

A few months ago we talked about a clinical case of a patella fracture. In it we showed the typical profile of a fracture after 4 weeks. We also had the opportunity to follow the athlete from before the injury, during the fracture itself (where we guided the treatment by helping the diagnosis) until her recovery.

In today’s chapter, we will briefly review the scientific evidence on fractures and thermography and we will show a clinical case of a complex fracture.

Thermal behavior of single fracture

Perhaps one of the most illustrative studies in this field is that of Haluzan et al. (2015), which shows the thermal evolution of a fracture in all its phases. In figure 1, we can see that the fracture starts with hyperthermic behavior, in other words, at the moment of injury, the tissues heat up. This heating continues to increase until the first month and from then on, a long decline in asymmetry begins. According to most studies, this thermal asymmetry can be maintained for months, almost chronically.

simple fracture thermography
Figure 1. Evolution of the thermal asymmetry of fractures. Adapted from Haluzan et al. (2015).

In addition, thermography has a usefulness that goes beyond injury monitoring: it aids diagnosis. Numerous studies have shown a high efficacy of thermography in the process of rule-out fractures. Reed et al (2020), Ćurković et al (2015) o Sanchís-Sanchís et al (2015) have shown that by making a comparison by asymmetries, the clinician is able to determine that the patient does not have a fracture, thus saving the patient a radiation dose for diagnosis with radiography. Reed et al (2020) further added that according to their analysis, there is a statistically significant difference for fractures, but not for sprains, thus guiding treatment more effectively.

But is this evolution what we find in cases of complex fractures? We advance content by revealing this phrase:

‘Time’ does not always mean ‘healing’. ‘Acute’ does not always mean ‘recent’. If the physiology of the tissue is still affected, thermography shows this clearly.

Alejandro del Estal

Clinical case of complex fracture

In today’s case, we have a patient who suffered a fall from a high height while cleaning the windows of his house from the outside, which resulted in a proximal femur fracture with a comminuted internal tibial plateau fracture. In this case, we will focus on the complex fracture, the tibia fracture. In addition to this, there was a bone consolidation problem, probably related to tobacco and alcohol abuse habits.

In today’s case, we have a patient who suffered a fall from a high height while cleaning the windows of his house from the outside, which resulted in a proximal femur fracture with a comminuted internal tibial plateau fracture. In this case, we will focus on the complex fracture, the tibia fracture. In addition to this, there was a bone consolidation problem, probably related to tobacco and alcohol abuse habits.

Unfortunately, he had another fall after 6 months, a slip in this case, which made him need surgery. During the surgery an intraosseous gamma nail was inserted in the femur. In addition, during his hospitalization he suffered from a fairly significant infection of the scar, all the way down the side of the thigh to the knee, which left him with significant mobility and strength consequences.

At the time of his arrival at the physiotherapy office and the thermographic analysis (almost two years after the accident), he has the following signs and symptoms:

  • Very reduced ROM with a hard ending
  • Very pronounced valgus
  • Chronic pain (6/10 EVA constant)
  • Significant loss of muscle mass in the thigh and lower leg
  • Asymmetrical gait with a crutch on the healthy side

Thermographic analysis of the complex fracture

Once the patient’s signs and symptoms are known, we will understand figure 2, which shows the thermographic analysis of the patient’s legs, knees and feet, where several features are noteworthy:

  • We observed a severe asymmetry in the ROI (region of interest) of the knee and in several of the ROIs of the knee protocol. In this way, we act as a diagnostic aid, as this indicates to us that the patient is still in an active phase of the injury, despite the recovery time of more than two years.
  • There is obvious compensation in the healthy leg, probably due to the asymmetrical gait, which is evident in the musculature of the thigh and leg on the healthy side. In addition, it is remarkable that the sole of the foot on the healthy side also has a significant asymmetry, probably for the same reason. The most important thing is to monitor the asymmetries, hoping to reduce them, as little by little more weight will be placed on the injured side.
  • Monitoring these asymmetries will allow us to better understand the effect of treatment and assess the risk of injury on healthy areas, such as stress fractures in the long bones of the foot or leg or patellar or Achilles tendinopathy, because of the strong association with treatment load. This will allow us to act from an injury prevention perspective.
fracture thermography
Figure 2. Thermograms and avatars of a patient with a complex fracture of the tibial plateau of the left leg.

Comparison of simple vs. complex fracture

During a follow-up of several weeks, we can see the obvious thermal difference between these two types of fractures. In figure 3, we observe a clear difference in severity from the beginning, where the complex fracture:

  1. experiences a much greater thermal asymmetry,
  2. which continues to increase for a longer time,
  3. starts to decrease later
  4. and remains more asymmetric for longer.
complex fracture
Figure 3. Comparison of the evolution of the thermal asymmetry of the knee ROI of a simple fracture versus a complex fracture.

Conclusion

With this clinical case, we intend to explain what we mean when we say that an injury can remain in an acute phase despite months of evolution, as the tissue tries to recover. When we are faced with cases like this, we must bear in mind that both diagnosis and treatment are more complex than in a simple fracture, something that we demonstrate with thermography. In general, we will find greater thermal asymmetry and a more prolonged evolution over time.


References


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Europa Thermohuman ThermoHuman has had the support of the Funds of the European Union and the Community of Madrid through the Operational Programme on Youth Employment. Likewise, ThermoHuman within the framework of the Export Initiation Program of ICEX NEXT, had the support of ICEX and the co-financing of the European Regional Development Fund (ERDF).

CDTI Thermohuman has received funding from the Centre for the Development of Industrial Technology (CDTI), in participation with the European Regional Development Fund (ERDF), for the R+D activities involved in creating a new tool, based on thermography, for the prediction and prevention of rheumatoid arthritis. See project detail.