Fractures & Fracture

Healing
 Definition

• A bone fracture (# or Fx) is a medical condition in which

a bone is cracked or broken; it is a break in the continuity
of bone.

• Fractures occur when a bone can't withstand the

physical force exerted on it.

• Bone fracture may be caused by traumatic incident, or

also can occur as a result of certain medical conditions
that weaken the bones, that may be localized or
generalized.
 Classification
• In orthopedic medicine, fractures are classified as closed
or open (compound) and simple or multi-fragmentary

• Closed fractures are those in which the skin is intact.

• open (compound) fractures involve wounds that

communicate with the fracture and may expose bone to
contamination, may be from inside or outside.
 Principles of fractures
Classification

• Closed Fracture
(simple ):

Does NOT
communicate with
external environment
 Principles of fractures
Classification

• Open Fracture
(compound ):-

Communicate with
external environment

Infection !!
 Classification
• Simple fractures are fractures that only occur along one
line, splitting the bone into two pieces.

• multi-fragmentary fractures involve the bone splitting into

multiple pieces.
 Description
• Transverse Fracture- A fracture that is at a right angle to the bone's
long axis.
• Oblique Fracture- A fracture that is diagonal to a bone's long axis.
• Spiral Fracture- A fracture where at least one part of the bone has
been twisted.
• Compacted Fracture- A fracture caused when bone fragments are
driven into each other.
• Comminuted Fracture.
• Double or segmental Fx, occur at two levels with free segment
between them.
 Description

• Incomplete Fracture- A fracture in which the bone fragments are still

partially joined.
• Greenstick fractures in children, the spriny bone in childhood, buckles
on the side opposite to the causal force, where periosteum remains
intact.
• a compression fracture, an example of a compression fracture is when
the front portion of a vertebra in the spine collapses due to
osteoporosis.
• Reduction is not required in vertebral body fracture,But it is necessary
when the fractures are part of joint.
 Classification
Complete
Incomplete
Greenstick fracture
 Description

• A stable fracture is one which is likely to stay in a good

(functional) position while it heals.
• An unstable Fx is likely to angulate or rotate before healing
and lead to poor function in the long term.
• a fracture of the bony components of the joint is called
fracture-dislocation.
– E.g. shoulder fracture dislocation and elbow fracture
dislocation.
• Burst fracture, occur in vertebra due to severe violence,
acting vertically on a straight spine.
 Fracture Mechanics
• Amount of Force:-
* Magnitude = Nonpathological
* Trivial force = Non-pathological

• Direction of Force:-
* Direct Force
* Indirect Force
Fracture mechanics
• Bending
• Axial Loading
- Tension
- compression
• Torsion
Fracture Mechanics
Bending load:
• Compression strength
greater than tensile
strength
• Fails in tension
Fracture Mechanics
Combined bending &
axial load
• Oblique fracture
• Butterfly fragment
 Fracture Mechanics
Force due to
Resisted
Muscle
Action:

“Avulsion”
Transverse
pattern
 Fracture Mechanics
Indirect Force
On Long
Bones:-
1) Twisting Force

Spiral Line
 Fracture Mechanics
Indirect Force
On Long
Bones:-

2) Angulating Force

Transverse pattern
 Fracture Mechanics
Indirect Force
on Long Bones

3) Angulating
+ Axial compression

Transverse line
+ Triangular
“Butterfly”
 Fracture Mechanics
Indirect Force
on Long Bones

4) Angulating
+ Axial compression
+ Twisting forces

(short oblique pattern)

 Fracture Mechanics
Indirect Force
On Long
Bones:-
5) Vertical
compression

comminuted
 Fracture Mechanics
Direction of
Force
On Cancellous
Bones:-
Direct OR Indirect
Comminuted
Pattern
Burst
 Pathological Fractures
• Fracture within an abnormal bone structure due
to:
1- congenital diseases (O.I).
2- Infection (osteomyelitis).
3- Fracture through a cyst .
4- Metabolic diseases ( Osteoporosis,
Osteomalacia, Pagets disease).
5- Primary bone tumours.
6- Metastatic bone tumours.
 Diagnosis
I- HISTORY

II- EXAMINAION
A- General
B- Local

III- INVESTIGATIONS
 Diagnosis
I- HISTORY

1) Trauma
* Pathological (trivial)
* Non-pathological ( magnitude)
2) Mechanism
* Fall from height,
* RTA, pedestrian, Driver….?
 Diagnosis
I- HISTORY
3) Complaint:
a) Pain sharp, increase by
movement, Not radiating
b) Loss of Function
c) Deformity
d) Symptoms of complications
e) Other organs: head, chest, abdomen
 Diagnosis

II- EXAMINATION

A- General examination

B- Local examination
 Diagnosis
A- General examination :

1) Signs resulting from fracture or trauma:

a) Vital signs, Shock A,B,C
b) Associated Head, Chest, Abdomen
2) Signs related to cause of fracture:
Pathological # …CA Lung, Prostate..
 Diagnosis
B- Local Examination
• LOOK : Skin damage, deformity, swelling
• FEEL : Localized tenderness
• MOVE : Abnormal movement, crepitus
• DO :
a) Special tests : Circulation & Nerves
b) Measurements : shortening
[Always compare]
 Diagnosis
INVESTIGATIONS X-RAY:-
A- Essential requirements:
1) Two views
AP & Lateral.

2) Two joints
Above & below #.
 Diagnosis
INVESTIGATIONS
X-RAY:-
B- Occasional Requirements
* Two Limbs “ Compare “
Diagnosis
 Diagnosis
C- Description of X-ray :
1) Situation : side, site, localization
2) Pattern : line of fracture
3) Displacement :
a) Shift : lateral,medial,anterior,posterior
b) Tilt : angulations
c) Twist : rotation , internal, external
d) Shortening: overriding, impaction
 Fracture in children
• Different from those in adults.

• Children's bones are more malleable,

allowing a plastic type of "bowing" injury.
 Fracture in children
• The periosteum is thicker than in adults and
usually remains intact on one side of the fracture
which helps to:

1. stabilize any reduction,

2. decreases the amount of displacement, and
3. lower incidence of open fractures in children
than in adults.
 Fracture in children
• Healing is more rapid.
• Open reduction is rarely indicated.
• High remolding rate.
• Growth disturbance.
• Often missed (poor communication).
• X-rays of both limbs for comparison.
 Fracture in children
Physeal Injuries
• 30% of the fractures
• twice as often in the upper
extremities as in the lower
extremities.
• Salter-Harris classification: based
on the radiographic appearance of
the fracture
 Fracture in children
Birth Fractures

• most commonly in the clavicle, humerus, hip,

and femur.
• They rarely require surgery but frequently are
diagnosed as pseudopalsy, infection, or
dislocation.
 Fracture in children
Fractures Caused by Child Abuse

• Between birth and 2 years of age.

• Multiple fractures in different stages of healing

are almost always indicative of child abuse.

• Multiple areas of large ecchymoses in different

stages of resolution (from black and blue to
brown and green) also are pathognomonic of
child abuse.
 Fracture in children
• The most common sites of
fractures caused by child
abuse are the humerus,
tibia, and femur

• bone scan or a skeletal

survey generally is
indicated
 Pathological Fractures

Diagnosis:
History:
1- insignificant amount of trauma.
2- constitutional symptoms.
3- history of malignancy.
 Pathological Fractures
• Examination :
A / General: S/S of malignancy or
infection.

B / Local :
1- tenderness, pain, swelling.
2- muscle spasm and deformity is
minimal.
 Pathological Fractures
• Investigation:
A/ Radiology:
1- X-rays of the lesion , MRI, CT-scan.
2- X-ray / CT-chest ( pulmonary Mets.)
3- Bone Scan.
B/ Laboratory:
1- CBC & dif., ESR, CRP.
2- Acid phosphatase P, B J P,
3- LDH, ec..
 Pathological Fractures
• Management:
• Aim: to make patient more functional and
pain free for the remaining life span.

• Early operative stability should be carried

out.

• Chemotherapy, Radiation, Hormonal.

 Pathological Fractures
• Indication for prophylactic fixation due to
(metastasis):
1- involvement of the cortex.

2- increased pain.

3- pure lysis.

4- weight bearing area.

 Pathological Fractures

• Pathological Fracture:-

Fracture abnormal bone

Cyst, Tumour, Infection
 Pathological Fractures
• Pathological fracture.
 Fracture Management
GENERAL AIM :
To Save the Life of Patient

LOCAL AIM : Rapid Recovery

* Of Injured Part
* Of Its Function
 Management.

GENERAL management :
LIFE THREATENING Inj.
Shock , Head, Chest, Abdomen
LOCAL management Dangers to viability :
* Ischaemia
* Infection
 Management.

*SAVE LIFE

*SAVE LIMB

*SAVE FUNCTION
 Management.

SAVE FUNCTION
1) REDUCTION
2) IMMOBILISATION
3) SOFT TISSUE TREATMENT
4) FUNCTIONAL ACTIVITY &
REHABILITATION
 Management.

I- Reduction – Methods:

• Should be Under Anesthesia

• Closed or Open
• Study X-Ray and direction of force
• The basic Maneuvers :
* Traction
* Reverse mechanism of Inj
* Direct pressure
 Management.
I- Reduction - Standards

• Anatomical Reduction is Ideal for all

• Anatomical Reduction is a MUST in :
* Dislocation
* Intra-articular fractures
* Fractures Both bones Forearm
• X-Ray Image Intensifier help control reduction
• Remember to Assess Reduction after 10 Days !
 Management.

Reduction Standards cont…

• Reduction can be “Acceptable” if :-
* Alignment will NOT affect Function
* Remolding CAN correct deformity
• Remolding can correct :-
*Angular NOT Rotational deformities
*Children MORE than Adults
 Management.

I- Reduction - Timing
• Immediate R. is a MUST in:
* Vascular Inj
* Spinal Cord or Nerve Inj
• Urgent R. in OPEN fractures ; “Save Limb”
• Dislocations Need Urgent reduction for Pain
• CLOSED fractures CAN wait If Facilities do
not permit Urgent management
 Management.

II- Immobilization

“Life is Movement, and

Movement is Life”

Do NOT Immobilize Any Joint Unnecessarily

 Management.

II- Immobilization –Methods

• Plaster of Paris
• Traction
• Internal Fixation
• External Fixator
 Open fractures.
• Fracture site
communicate with the
external enviroment.

• Emergency
management.

• Infection will occur

with delayed or
inadequate treatment.
 Gustilo & Anderson Open Fracture
Classification
• Grade I : - Pin point wound < 1 cm
- Minimal soft tissue
- Simple fracture
• Grade II : - wound > 1 cm
- Moderate soft tissue damage
- Simple or comminutive fracture line
• Grade III : - Dirty wound
• - extensive soft tissue damage
IIIa : - Bone opened with soft tissue loss
IIIb : - Bone exposed, periosteal stripping
IIIc : - Vessel injury
 Open fractures.
General care:

• ATLS (save life, save limb, then save

function (.

• Antibiotics directed against staphylococci

(most common), and as needed.

• Tetanus prophylaxis.
 Open fractures.
Local care :
1. Clean.
2. Irrigation: Dilution is the Solution For pollution
3. Debridement.
4. Decontamination of the bone.
5. Closure???.
6. Immobilize.
Bone (Fracture) Healing
BONE
Two forms of bone tissue
 Cortical or compact bone
 Cancellous or trabecular bone
Two types of bone
(mechanical & biological properties)
 Woven or immature bone
 Lamellar or mature bone
WOVEN BONE
 More rapid rate of deposition & resorption
 Irregular woven pattern of matrix collagen fibril
 Four times the number of osteocyte per unit volume
 Irregular pattern of matrix mineralization

Less stiff & more easily deformed

 Bone Healing
• Direct
– Primary bone healing
– Cutting cones
– Seen with absolute stability
• Indirect
– Secondary bone healing
– Callus formation; resorption at fx site;
– Seen with relative stability
 Direct Bone Healing
Absolute Stability
• Compression of two anatomically
reduced fracture fragments.
• No displacement of the fracture under functional load.
• Examples:
– Lag screw
– Plate => compression, buttress,
• Tension band
 Indirect Bone Healing
Relative Stability
• Motion between fracture fragments that is compatible
with fracture healing.
• Motion is below the critical strain level of tissue repair.
• Examples:
– IM nails
– Bridge plate
– External Fixator
 Direct Bone Healing

 Gap healing
 Haversian remodeling

Osteoclast resorb fracture line deposition osteoblast

Blood vessels formation

The new bone matrix + New Haversian Systems

osteocytes or primary osteons
• Primary bone healing
after rigid fracture
fixation. Contact healing
occurs in the cortex
underlying the plate, by
direct Haversian
remodeling. Layers of
bone are first laid down
perpendicular to the long
axis of the bone, and are
then replaced by
longitudinally oriented
osteons by cutting cones
progressing across the
gap.
 Indirect stages

Inflammation

Repair:
soft/hard
callus

Remodelling
 Indirect Bone Healing
Indirect Stages:
1. Inflammation
– 1-7 days
2. Soft callus
– 3 weeks Repair
3. Hard callus
– 3 – 4 months
4. Remodeling
– months => years
 Indirect bone healing

1. Inflammation
– Begins w/ fx and ends w/ fibrous tissue or cartilage
formation.
– Hematoma is formed, becomes organized,
granulation tissue formation.
.
 Indirect Bone Healing
1. Inflammation
Fracture damages the bone, blood vessels,
bone matrix and surrounding soft tissue

-Dilatation blood vessel

- Plasma exudat
 Haematoma
- inflammatory cells
 Inflammatory
Release by - PMN lecocytes
mediators
platelets inj.cells - Macrophages
- Lymphocytes
 Indirect Bone Healing
1. Inflammation
Macrophage - Cytokines (PDGF, TGF ß )
- Interleukin 1 & 6
Degranulating - Prostaglandin E2 (PGE2)

platelets release

Invitiation of the repair process

Indirect Bone Healing
1. INFLAMMATION
Inflammatory Necrosis Tissue and Exudate Resorbed

Fibroplasty & Chondrocytes Appears

Produce new matrix

(The fracture callus)
 Indirect bone healing

2. Soft callus
Begins in 3 to 4 days with the appearance of
granulation tissue, matures into fibrous tissue
and firbrocartilage, stabilizes site w/ internal
and externalcallus, pain and inflammation end.
 Indirect bone healing

3. Hard callus
Mineralization and conversion to bone.
Endochondral ossification of fibrocartilage
forming cancellous bone.
Indirect Bone Healing:
Callus
 Indirect Bone Healing
4. Remodeling
– Begins in middle of repair phase, continues until
fx clinically healed
– Osteoclastic tunneling (cutting cones) in concert
with osteoblast deposition
– Can continue up to 7 years
– Remodeling based on stresses (Wolff’s law(
 Remodeling
• Hueter-Volkmann law
– in the skeletally immature, bone growth is
relatively inhibited in areas of increase
pressure and relatively stimulated in areas
of decreased pressure or tension
• Wolff’s law
– the remodeling of bone or soft tissue is
influenced and modulated by mechanical
stress
 Rough estimation fracture
healing time
Bone Healing Time
Clavicle 3-8 weeks
Scapula 6 weeks
Rib 4 to 5 weeks
Humerus 4-10 weeks
Radius & ulna 6 weeks
Metacarpal 3 to 4 weeks
Fingers 2-3 weeks
Pelvis 4 - 6 weeks
 Rough estimation fracture
healing time
Bone Broken Healing Time
Femur 12 weeks
Patella 4-6
weeks
Tibia,fibula 10-24
weeks
Metatarsal 5 to 6
weeks
Toe 2 to 4
 Nicotine
Blood
supply NSAIDs Age
Nutrition Comorbidity

Vascular injury
Soft tissue
envelope
Functional Level
Nerve Function Soft tissue
attachments to
Hormones Factors in bone
Growth Factors fracture Stability
Sterility healing Site/location
Local pathology Energy
eg Ca
Bone Loss
Type of bone
Bone loss
FACTORS IN BONE HEALING

Patient Variables

* Age
* Nutrition
Healing process needs

- Energy
- Proteins & carbohydrates
FACTORS IN BONE HEALING

Patient variables

* Systemic hormones
- Corticosteroid ( )
- Growth hormone
- Thyroid hormone
- Calcitonin
- Insulin
Rate fracture healing
- Anabolic steroids
- DM
- Rickets Frame healing

* Nicotine

- Inhibit fracture healing ( Vascularization?)

FACTORS IN BONE HEALING
Tissue Variables
* Cancellous or cortical bones
* Bone necrosis
* Bone disease

Pathologic fracture

 Osteoprosis
 Osteomalacia
 Primary malignant bone tumors
 Metastatic bone tumors
 Benign bone tumors
 Bone cysts
 Osteogenesis imperfecta
 Paget’s disease
 Fibrous dysplacia
 Hyperparathyroidism
* Infection
 FACTORS IN BONE HEALING

Treatment Variables

• Apposition of fracture fragments

• Loading & micromotion
 Loading a fracture site stimulates bone formation
 Micromotion promotes fracture healing
FACTORS BONE HEALING
Treatment Variables

• Fracture stabilization
-Traction
Facilitate fracture healing by
- Cast Imm Preventing repeated disruption of
- Ext.Fixation Repair tissue
- Int.Fixation

Potential disadvantage of int.fixation :

 Surgical exposure disrupted hematoma,
blood supply
 Risk of infection
 Rigid fixation alter fracture remodeling,
bone density
FACTORS IN BONE HEALING
Treatment Variabel
Bone Grafts
• Cancellous graft
– Quick to revascularize
– “Creeping substitution”
• Cortical graft
– Slow remodelling process which weakens then
re-strengthens
• Synthetic graft
– Calcium phosphate, silicon, aluminum
– Mainly osteoconductive
 Principles of fractures
Fracture repair

• Fracture repair is a tissue regeneration process rather than a healing

process the injured bone is replaced by bone.

• The process of repair varies according to:

-The type of bone involved.
-The amount of movement at the fracture.
-The closeness of the fracture surfaces.
In tubular bone the pattern of repair shows striking difference than
cancellous one.

• Two types of tubular bone repair:

– Healing by callus
– Healing without callus
 Principles of fractures
Healing by callus

1- Tissue destruction and

hematoma formation.

• Disruption of blood
vessels
A hematoma forms
around and within
fracture
• Few millimeters of the
fracture surfaces dies.
 Principles of fractures
Healing by callus

2- Inflammation and
subperiosteal and
endosteal cellular
proliferation.

• Need 8 hours.
• Proliferation of
fibroblasts, mesechymal
cells, and osteoproginetor
cells.
• New vessels formation.
 Principles of fractures
Healing by callus

3- Callus formation.

• Chondrogenic and osteogenic

activity.
• Cartilage in the periphery,
woven bone near the bone
ends.
• Marked increase in vascularity.
• Osteoclast activity.
• At the end the pain disappears
and the fragments are rigid w/o
movement.
 Principles of fractures
Healing by callus

4- Consolidation.

• The primitive woven bone

is transformed into
lamellar bone by
osteoclastic and
osteoblastic activity.
• Need several months
before the bone is strong
enough to carry normal
loads.
 Principles of fractures
Healing by callus

5- Remodeling.
Callus is reshaped: the
bone along the lines of
stresses are
strengthened while bone
outside these lines
removed.
 The medullary canal is
reformed.
 The remodeling depends
on age that Fx
remodeling in children is
so perfect.
 Principles of fractures
Healing without callus

• Callus is formed as a response to movement at the

fracture side, to stabilize the fragments rigidly.

• Primary bone healing occurs directly between the 2

fragments without callus formation, when the fracture site
is absolutely immobile.

• Primary bone healing can occur in 2 instances:

◦ Naturally in impacted fractures of the cancellous bone.
◦ In cortical fractures where the 2 fragments are in
complete contact and rigidly fixed by metal
device(plates, screws or intramedullary nails).
 Principles of fractures
• Cutting cones consist of:

- Capillary bud (2)

- Osteoclasts (1)
- Osteoblasts (3)
- Osteoblasts lay down new
osteons (4)
 Principles of fractures
repair of cancellous bone

• Cancelous bone has spongy texture with open meshwork

of trabeculae, allowing easier penetration by vessels and
bone forming cells.

• The broader area of contact between the fragments with

good blood supply allow healing in shorter period of time
w/o need for callus formation.
 Principles of fractures
Rate of union

• Favorable factors.
– The age.union occur in 3-5 weeks in children while it
needs 3-5 months an adult.
– Type of bone.cancellous is better healer.
– Good blood supply.
– Immobilization.
– adequate nutrition (including calcium intake)
 Principles of fractures
Rate of union

• Unfavorable factors.
– Impairment of blood supply.
– Infection
– Excessive movement.
– Presence of tumor.
– Synovial fluid in intraarticular Fx.
– Interposition of soft tissue.
– Any form of Nicotine.
 Principles of fractures
Approach

• History.
– Hx of trauma, deformity, pain, inability to use the limb.

Remember:
Fx is not always at the site of impact.
Some Fx do not need severe violence.
Certain fracture will not affect the function of the limb, like
greenstick fracture or scaphoid fracture.
 Principles of fractures
approach

• Examination.
General medical condition should be evaluated to exclude
shock and brain injury.
The vital signs should be observed and followed up.
Inspection.
expose the area
inspect for any swelling, bruising, colour or
deformity.
special attention is to be paid to the wound in skin-if
present. Is it superficial or deep.
 Principles of fractures
approach

• Palpation, for tenderness, distal pulses, temperature and

crepitus on movement.
• Vascular injuries are surgical emegency.
• Sensation should be examined distally.
• Compartment syndrom.

• Movement, of the joint distal to the affected area; crepitus

and abnormal movement indicates a fracture.
 Principles of fractures
approach

• Examination of the viscera.

Liver and spleen in case of rib fracture.

Bladder and urethra in case of pelvic fracture.

Neurological examination for head and spinal injury.
 Principles of fractures
approach

• Investigation
Imaging.
1. X-ray criteria in fracture.
Two views, AP and lateral.
Two joints.
Two limbs.
Two injuries, like calcaneal fracture you have to
suspect vertebral fracture.
.
 Principles of fractures
approach

2-CT scan and MR.

spinal, pelvic and calcaneal fractures.
3-Radioisotope scan.
scaphoid and stress fractures.
 Principles of fractures
Test of union

• Clinical and radiological tests are used to ensure that the

fracture is UNITED.
• Clinical.
– Absence of mobility.
– Absence of tenderness.
– Absence of pain.
Radiological-X-ray criteria.
1-visible callus bridging both fragment.
2-contiuity of bone trabeculae across the fracture.
 Complications
•Delayed union.
•Non union.
•Joint involvement - ankylosis
•Abnormal position – arthritis.
•Bone necrosis – nutrient artery
•Involucrum formation.
•Pseudoarthrosis
 COMPLICATIONS
• Boney Complications:
• Delayed Union:-
• Healing Slow but Active, Remove the cause!
• Fracture Site Tender
• X- Ray little Callus, Medulla Open
• Non Union:-
• Reparative process Stopped, Need Intervention
• Painless, Abnormal Movement, Psudoarthrosis!
• X- Ray: Sclerosis, Blocked Medulla.
 COMPLICATIONS

• Delayed Union & Nonunion Causes:-

• Local :-
1. Poor Blood Supply
2. Soft Tissue Interposition
3. Infection
4. Inadequate Immobilization
5. Over-Distraction
6. Pathology, Tumors
 COMPLICATIONS
Delayed Union &Nonunion
Causes:-
• General:-
• Nutrition
• Bone Disease
• Old Age
 COMPLICATIONS

• Malunion:-
• 1- Primary Neglected #

• 2- After Reduction! Watch

X-Ray After 10 Days.

• 3- Epiphyseal Growth plate

Cause Deformities…Time

Coxa Vara
 COMPLICATIONS
• Avascular Necrosis:-
• Death of Bone from;
* Impairment or
* Loss of blood Supply

• Anatomical Sites:------

• Sclerosis = X-Ray Dense

• Delayed or Nonunion
 COMPLICATIONS

• Myositis Ossificans:-
“Not myo! or itis! “

• Heterotopic Ossification
• May follow minor trauma
• Susceptibility
• Elbow ; Knee; Hip
 COMPLICATIONS
• Myositis Ossificans:-
•
• Pain & Limitation of movement
• X-Ray Calcification then Ossification
• After severe Head Injuries
• Prevention : Avoid Passive Massage
• Rest Susceptible site after injury
• May Need Excision When Mature
• There is Primary Congenital Form !
• “Myositis Ossificans Progressiva”
 COMPLICATIONS

• Compartment Syndrome :
elevation of the interstitial pressure in a
closed osseofascial compartment that
results in microvascular compromise.
• The most common causes of acute
compartment syndrome are:
fractures
Thank you