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Bone Fracture and healing
Prof. Mamoun KremliAlMaarefa College
Definition of Fracture
A break in the continuity bone
Often associated with soft tissue injury Soft tissue injuries might be more serious
than the fracture
Etiology
Motor Vehicle Accident Fall Sport injuries Vigorous Exercise Bone Diseases
Osteoporosis Osteomyelitis Cyst, …
Etiology
Motor Vehicle Accident Fall Sport injuries Vigorous Exercise Bone Diseases
Osteoporosis Osteomyelitis Cyst, …
Etiology
Motor Vehicle Accident Fall Sport injuries Vigorous Exercise Bone Diseases
Osteoporosis Osteomyelitis Cyst, …
Etiology
Motor Vehicle Accident Fall Sport injuries Vigorous Exercise Bone Diseases
Osteoporosis Osteomyelitis Cyst, …
Etiology
Motor Vehicle Accident Fall Sport injuries Vigorous Exercise Bone Diseases
Osteoporosis Osteomyelitis Cyst, …
Types of Fracture
Ordinary Caused by a force Normal bone
Pathological Caused by trivial force Diseased (weak) bone
Types of Fracture
Ordinary Caused by a force Normal bone
Pathological Caused by trivial force Diseased (weak) bone
Osteoporosis Osteomyelitis Tumour, cyst, ..
Types of Fracture
Incomplete Fracture line is incomplete Only one cortex is broken
Complete Fracture line is complete Bothe cortices are broken
www.childrensmemorial.org/
www.childrensmemorial.org/
Types of Fracture
Incomplete Green-stick
One cortex is broken Other cortex is bent
In children
Lee P et al. Radiographics 2004;24:1009-1027
Types of Fracture
Complete Simple:
One fracture line Two bone fragments
Comminuted: More than one fracture line More than two bone fragments More soft tissue injuries
Types of Fracture
Complete Simple:
Hairline (Fissure) In repeated stress e.g. march fracture in
metatarsals Transverse Oblique Spiral
Types of Fracture
Complete Comminuted:
Butterfly Segmental Multiple fragments Compression
Types of Fracture
Undisplaced Normal alignment
maintained
Displaced Deformed from
normal alignment
Types of Fracture
Closed Skin intact
Compound (Open) Skin not intact Communicating to
outside
Types of long bone fractures
Metaphyseal Diapyseal Articular Epiphyseal
(children)
Sign and Symptoms of Fracture
Pain Swelling Deformity Local tenderness Loss of function
Diagnostic Evaluation
X-ray The most useful
MRI, CT-scan In suspected cases In intra-articular fractures
Fracture Healing
Stages of fracture healing: Hematoma Inflammation Repair Remodeling
1. Hematoma
Bleeding caused by vessel rupture Hematoma collects Bone at fracture edges dies
Rockwood and Green
2. Inflammation
Inflammatory cells accumulate Inflammatory mediators (cytokines) New blood vessels proliferate
Rockwood and Green
2. Inflammation
Mesenchymal cells accumulate After 1 week forms granulation tissue Osteoclasts remove necrotic bone at
fragment ends growth factors stimulate the proliferation and
differentiation of mesenchymal stem cells Formation of connective tissue
3. Repair
Connective tissue differentiates Cartilage and fibrous tissue form
Soft callus formation (2-3 weeks) Movement at fracture stimulates more callus
Rockwood and Green
3. Repair - Tissue Differentiation
connective tissue
granulation tissue
Giemsa stain
3. Repair Vascular and cellular response leads to tissue
differentiation and mineralization resulting in restoration of mechanical integrity
Fibrocartilage mineralizes (converts callus to woven bone)
Tissue Differentiation Cascade
Cartilage formation BoneMineral deposition
Masson-Goldner
Callus Formation
Periosteal callus forms along the periphery of the fracture site
Intramedullary callus forms in the center of the fracture site Endochondral ossification at the site of the
fracture hematoma
Chemical and mechanical factors stimulate callus formation and mineralization
Callus Formation Stability adequate in axial plane Angulation can still occur
fracture ends linked together by soft callus hard callus stage starts & lasts until fragment
ends are firmly united by new bone (3-4 m)
www.landesbioscience.comRockwood and Green
4. Remodeling
Woven bone slowly replaced by lamellar bone (few months to years) Medullary cavity is reconstituted Bone is restructured in response to stress and
strain
Fracture healing - summary1. Inflammation
Hematoma Mesenchymal cells
2. Soft callus Granualation tissue Fibro-cartilage
3. Hard callus Intramembranous bone
formation Enchondral ossification
4. Remodelingbony bridging
Fracture healing - summary
Summary
Prerequisites for Bone Healing
Adequate blood supply Adequate mechanical stability
If either is lost: results in delay in bone healing or no healing
occurs Smoking causes delay in bone union or
nonunion
Complications of fractures
Early: Shock Compartment syndrome Fat embolism Deep vein thrombosis, embolism Infection
Delayed Malunion Delayed union / Nonunion
Complications of fractures
Shock loss of blood Fractured femur could bleed 2L easily Fractured Pelvis could bleed 4L easily Open fractures with vascular injuries
What is the normal blood volume? How much bleeding could be tolerated?
Complications of fractures
Compartment syndrome The compression of nerves, blood
vessels, and muscle inside a closed body space (compartment)
Causes tissue death from lack of oxygenation due to the blood vessels being compressed by the raised pressure within the compartment
More common in Forearm and leg (why?)
Complications of fractures
Deep Vein Thrombosis, Embolism Caused by
Increased pressure in compartment Interrupted venous return Hematoma
Complications of fractures
Infection: More in open fractures
Depends on amount of contamination and tissue necrosis
Possible in closed fractures
Complications of fractures
Delayed Malunion: deformity Delayed union Non-union
Management of fractures
First aid: ABC Other injuries Cover wounds Bone immobilization Definitive treatment of fracture
Management of fractures
Assessment Type, location and severity of fracture Soft tissue damage Age and health status of patient Affection of other parts or organs
Management of fractures
Goals: To regain and maintain correct position and
alignment. To regain the function of involved part. To return the patient to usual activities in the
shortest time and at the least expenses.
Definitive treatment of fractures
Conservative Simple fractures More in children
Operative More complex fractures Articular fractures More in adults
Conservative - closed reduction
Is the most common non surgical method for managing a simple fracture.
Splints: as upper extremity bones do not bear weight,
splints may be sufficient to keep bone fragments in place.
Conservative - closed reduction
Casts : A cast is an immobilizing device made up of
layers of plaster or fiber glass. Allows early mobility and reduces pain
Conservative - closed reduction
Traction: Application of a pulling
force to a part of the body Uses a system of ropes,
and weights to provide reduction, alignment and rest
Open reduction / internal fixation
Achieves perfect reduction Permits early mobilization
It is often preferred for elderly patients who are susceptible complications of immobility
Best for adults and in intra-articular fractures Uses pins, screws, rods, plates, .. After bone union, the metal may be removed,
depending on the location and type of fracture
Examples of internal fixation
Screws Wires Nails
Open reduction, internal fixation
Forearm fractures in adults (Plates)
Nail in Tibial Fractures
Intramedullary Nail
Plate for comminuted Femur fracture
Intra-articular fracture
External fixation
Ideal for open fractures where wound care is needed and operation is hazardous Often used temporarily until wounds recover
Image fromC. Turen MD
External fixationNail later
Summary
What is a fracture Types of fractures Fracture healing and requirements Management