Introduction To Fracture, Bone Healing and Complication: Prof - DR Jameel - Tahseen Mehsen Trauma and Orthopedics Surgeon

Introduction to fracture,
bone healing and

complication
Prof.Dr Jameel.Tahseen Mehsen
Trauma and Orthopedics surgeon
fracture
is a break in the structural continuity of bone.
• It may be no more than a crack (incomplete)
Here the bone is incompletely divided and the periosteum remains in
continuity. greenstick fracture the bone
• more often the break is complete and the bone fragments are displaced
(complete).
*If the overlying skin remains intact it is a closed (or simple) fracture
* if the skin is breached it is an open (or compound) fracture that’s mean its
liable to contamination and infection.
Mechanism of injury
Most fractures are caused by sudden and excessive force, which may be direct or indirect.
* direct blow usually splits the bone transversely
Damage to the overlying skin is common; the fracture pattern will be comminuted.
* indirect force the bone breaks at a distance from where the force is applied
NOTE: The above description applies mainly to the long
bones. A cancellous bone, such as a vertebra or the
calcaneum, when subjected to sufficient force, will split or be
crushed into an abnormal shape.
HOW FRACTURES ARE DISPLACED
After a complete fracture the fragments usually become displaced,
*partly by the force of the injury
*partly by gravity and
*partly by the pull of muscles attached to them.
Displacement is usually described in terms of translation, alignment, rotation and altered length:
• Translation (shift) – The fragments may be shifted sideways, backward or forward in relation to each other, such that the
fracture surfaces lose contact.
• Angulation (tilt) – The fragments may be tilted or angulated in relation to each other. Malalignment, if uncorrected, may
lead to deformity of the limb.
• Rotation (twist) – One of the fragments may be twisted on its longitudinal axis; the bone looks straight but the limb ends
up with a rotational deformity.
• Length – The fragments may be distracted and separated, or they may overlap, due to muscle spasm, causing shortening of
the bone.
HOW FRACTURES HEAL
natural’ form of healing in tubular bones; in the absence of rigid

fixation, it proceeds in five stages:
1-Haematoma formation
2-inflammation and cellular formation
3-callus formation
4-consolidation
5-remodelling
HEALING BY CALLUS
This is the ‘natural’ form of healing in tubular bones; in the absence of rigid fixation, it proceeds in five stages:
1. Tissue destruction and haematoma formation – Vessels are torn and a haematoma forms around and within the
fracture.
2. Inflammation and cellular proliferation – Within 8 hours of the fracture there is an acute inflammatory reaction with
migration of inflammatory cells and the initiation of proliferation and differentiation of mesenchymal stem cells from the
periosteum.
3. Callus formation – The differentiating stem cells provide chrondrogenic and osteogenic cell populations they will start
forming bone and, in some cases, also cartilage. The thick cellular mass, with its islands of immature bone and cartilage,
forms the callus. As the immature bone (or ‘woven’ bone) becomes more densely mineralized, movement at the fracture
site decreases progressively and at about 4 weeks after injury the fracture ‘unites’.
4. Consolidation – With continuing osteoclastic and osteoblastic activity the woven bone is transformed into lamellar
bone.. This is a slow process and it may be several months before the bone is strong enough to carry normal loads.
5. Remodelling – The fracture has been bridged by a cuff of solid bone. Over a period of months, or even years, this crude
‘weld’ is reshaped by a continuous process of alternating bone resorption and formation..
CLINICAL FEATURES
1.HISTORY
*There is usually a history of injury, followed by inability to use the injured limb.
*The patient’s age and mechanism of injury are important. If a fracture occurs with trivial trauma, suspect a
pathological lesion.
*Pain
GENERAL SIGNS
Follow the ABCs: look for,
Airway obstruction,
Breathing problems,
Circulatory problems and Cervical spine injury.
LOCAL SIGNS
Injured tissues must be handled gently. To elicit crepitus or abnormal movement is unnecessarily painful;
x-ray diagnosis is more reliable.
A systematic approach is always helpful:
• Examine the most obviously injured part.

• Test for artery and nerve damage.
• Look for associated injuries in the region.
• Look for associated injuries in distant parts
Look
Swelling, bruising and deformity may be obvious, but the important point is whether the skin is intact; if the skin is broken
and the wound communicates with the fracture, the injury is ‘open’ (‘compound’).
Note also the posture of the distal extremity and the colour of the skin (for tell-tale signs of nerve or vessel damage).
Feel
The injured part is gently palpated for localized tenderness. Some fractures would be missed if not specifically looked for,
e.g. the classical sign of a fractured scaphoid is tenderness on pressure in the anatomical snuff-box., and in high-energy
injuries always examine the spine and pelvis.
Vascular and peripheral nerve abnormalities should be tested for both before and after treatment.
Move
Crepitus and abnormal movement may be present, It is more important to ask if the patient can move the joints distal to
the injury
X-RAY
X-ray examination is mandatory.
Remember the rule of twos:
• Two views –at least two views (anteroposterior and lateral) must be taken.
• Two joints – In the forearm or leg, one bone may be fractured and angulated. Angulation, however, is impossible unless the
other bone is also broken, or a joint dislocated. The joints above and below the fracture must both be included on the x-ray
films.
• Two limbs – In children, the appearance of immature epiphyses may confuse the diagnosis of a fracture; x-rays of the
uninjured limb are needed for comparison.
• Two injuries – Severe force often causes injuries at more than one level. Thus, with fractures of the calcaneum or femur it is
important to also x-ray the pelvis and spine.
• Two occasions – Some fractures are difficult to detect soon after injury, but another x-ray examination a week or two later
may show the lesion. Common examples are
Undisplaced fractures of the distal end of the clavicle,

scaphoid,
femoral neck and
lateral malleolus,
stress fractures
physeal injuries wherever they occur.
Plain film radiography ( x.ray)
Interpretation :
1. Patient. Name , age , date.

2. Region and views.
3. Soft tissues.
a. generalised changes
b. Localised changes
4. Bone.
a. generalised changes.
b. localised
5. joints. Articulating bones, joint space,erosion.
SPECIAL IMAGING
Sometimes the fracture – or the full extent of the fracture – is not apparent on the plain x-ray.
Computed tomography (CT) may be helpful in lesions of the spine or for complex joint fractures; indeed, these cross
sectional images are essential for accurate visualization of fractures in ‘difficult’ sites such as the calcaneum or acetabulum.
Magnetic resonance imaging (MRI) may be the only way of showing whether a fractured vertebra is threatening to
compress the spinal cord.
Radioisotope scanning is helpful in diagnosing a suspected stress fracture or other undisplaced fractures.
TREATMENT OF CLOSED FRACTURES
• Reduce.
• Hold.
• Exercise.
The available methods of holding reduction are:
• Continuous traction.
• Cast splintage.
• Functional bracing.
• Internal fixation.
• External fixation.
General complications:
1-Bleeding hypovolaemic shock.?

2-fat embolism?
3-cardiorespiratory failure?
4-DVT and pulmonary Embolism.?
5-Multiple organ failure or dysfunction syndrome (MODS).?
6-crush syndrome?
7-tetanus?
LATE
COMPLICATIONS
DELAYED UNION
NON-UNION
MALUNION
GROWTH DISTURBANCE
Nonunion
Causes When dealing with the problem of non-union, four questions must be
addressed. They have given rise to the acronym CASS:
1. Contact – Was there sufficient contact between the fragments?

2. Alignment – Was the fracture adequately aligned, to reduce shear?
3. Stability – Was the fracture held with sufficient stability?
4. Stimulation – Was the fracture sufficiently ‘stimulated’? (e.g. by encouraging
weight bearing).
There are, of course, also biological and patient related reasons that may lead to
non-union:
(1) poor soft tissues (from either the injury or surgery);
(2) local infection;
(3) associated drug abuse, anti-inflammatory or cytotoxic immunosuppressant
medication and
(4) non-compliance on the part of the patient.
MALUNION
When the fragments join in an unsatisfactory position
(unacceptable angulation, rotation or shortening) the fracture is
said to be malunited.
Causes are
failure to reduce a fracture adequately,
failure to hold reduction
THANK YOU

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Introduction to fracture,

bone healing and

natural’ form of healing in tubular bones; in the absence of rigid

A systematic approach is always helpful:

• Examine the most obviously injured part.

Undisplaced fractures of the distal end of the clavicle,

1. Patient. Name , age , date.

1-Bleeding hypovolaemic shock.?

1. Contact – Was there sufficient contact between the fragments?

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