I.

INTRODUCTION

Fracture

A fracture is a break in the continuity of bone and is defined according to its type
and extent. Fractures occur when the bone is subjected to stress greater than it can
absorb. Fractures are caused by direct blows, crushing forces, sudden twisting motions
and even extreme muscle contractions. When the bone is broken, adjacent structures
are also affected, resulting in soft tissue edema, hemorrhage into the muscle and joints,
joint dislocations, ruptured tendons, severed nerves and damaged blood vessels. Body
organ maybe injured by the force that caused the fracture or by fracture fragments.

A Complete fracture involves a break across the entire cross-section of the bone
and is frequently displaced (removed from normal position). In an incomplete fracture,
the break occurs through only part of the cross-section of the bone. A comminuted
fracture is one that produces several bone fragments. A closed fracture (simple fracture)
is one that does not cause a break in the skin. An open fracture (compound or complex
fracture) is one in which the skin or mucous membrane wound extends to the fracture
bone. Open fractures are graded according to the criteria:

Grade I is a clean wound less than 1 cm long.

Grade II is a larger wound without extensive soft tissue damage.

Grade III is highly contaminated, has extensive soft tissue damage, and is the
most severe.

Different types of bone fractures:

Multi-fragmentary fracture: In this the bone splits into multiple pieces.

Compression Fracture: A compression fracture is a closed fracture that occurs
when two or more bones are forced against each other. It commonly occurs to
the bones of the spine and may be caused by falling into a standing or sitting
position, or a result of advanced osteoporosis.
Avulsion Fracture: An avulsion fracture is a closed fracture where a piece of
bone is broken off by a sudden, forceful contraction of a muscle. This type of
fracture is common in athletes and can occur when muscles are not properly
stretched before activity. This fracture can also because of an injury.
Impacted Fracture: An impacted fracture is similar to a compression fracture,
yet it occurs within the same bone. It is a closed fracture which occurs when
pressure is applied to both ends of the bone, causing it to split into two fragments
that jam into each other. This type of fracture is common in car accidents and
falls.
 Stress Fracture: It is a common overuse injury. It is most often seen in athletes
who run and jump on hard surfaces such as runners, ballet dancers and
basketball players.
Compression fracture of the spine: It is common in individuals with
osteoporosis. Often no identifiable injury causes it. This results in significant pain
and disability.
Rib fractures: If you experience pain while breathing you probably have a rib
fracture. In this condition you also have tenderness and shallow breathing.

 Complete Fracture: in this the bone fragments separate

completely.
 Incomplete Fracture: in this the bone fragments are still
partially joined.
 Linear Fracture: in this the fracture is parallel to the
bone's long axis.
 Transverse Fracture: in this the fracture is at a right
angle to the bone's long axis.
 Oblique Fracture: in this the fracture is diagonal to a
bone's long axis.
 Spiral Fracture: in this at least one part of the bone has
been twisted.
 Comminuted Fracture: in this the fracture results in
several fragments.
 Compacted Fracture: in this the fracture is caused when
bone fragments are driven into each other.

Clinical Manifestations

The clinical manifestations of fracture are pain, loss of function, deformity,

shortening of extremity, crepitus, and local swelling and discoloration. Not all of these
clinical manifestations are present in every farcture. The diagnosis of a fracture is based
on patient’s symptoms, physical signs, and the x-ray findings.

Pain

The pain is continous and increase in severity until the bone fragments are
immobilized. The muscle spasm that accompanies fracture is a type of natural splinting
designed to minimize further movement of the fracture movement.

Loss of Function

After a fracture, the extremity cannot function properly because normal functions
of the muscles depend on the integrity of the bones to which they are atteched. Pain
contributes to the loss of the function. In addition, abnormal movement (false
movement) may be present.
Deformity

Displacement, angulation, or rotstion of the fragments in fracture of the arm or

leg causes a deformity (either visible or palpable) that is detectable when the climb is
compared with the uninjured extremity. Deformity also results from short tissue swelling.

Shortening

In fractures of the long bones, there is actual shortening of extremity because of

the contraction of the muscles that are attached above and below the site of the
fracture.

Shortening

In fractures of the long bones, there is actual shortening of the extremity because
of the contraction of the muscles that are attached above and below the site of the
fracture. The fragments aften overlap by as much as 2.5 to 5cm (1 to 2 inches).

Crepitus

When the extremity is examined with the hands grating sensation called crepitus
can be felt. It is caused by the rubbing of the bone fragments against each other.

Swelling and Discoloration

Localized swelling and discoloration of the skin (ecchymosis) occurs after a

fracture as a result of trauma and bleeding into the tissues. These signs may not
develop for several hours after the injury.

II. MusculoSkeletal System

 The Health and proper functioning of musculoskeletal system is interdependent
with that of the other body systems. The bony structure provides protection of vital
organs including the brain heart and lungs. The bony skeleton provides a sturdy
framework to support body structures. The bone matrix stores calcium, phosphorus,
magnesium and flouride. More than 98% of the total body calcium is present in the
bone. In addition the red bone marrow located within the bone cavities produces red
and white blood cells in the process called hematopoieses. Joints hold the bone
together and allow the body to move. The muscles attached to the skeleton contract,
moving the bones and producing heat which helps to amintain body temperature.

 Structure and function of the skeletal system

There are 206 bones in the human body, divided into four categories:
 Long bones (femur)
 Short bones (metacarpals)
 Flat bones (sternum)
 Irregular bones (vertebrae)

 Cartilage – tough, elastic, avascular tissue.

 Tendons – A connective tissue that attaches muscle to bone.
 Ligament – A connective tissue that attaches bone to bone.
 Bones are constructed of cancellous (trabecular) or cortical (compact) bone
tissue.

 Long bones – are designed for weight bearing and movement.

Structure of Long Bone:
 Diaphysis – shaft of long bones
 Epiphysis – ends of long bones
 Epiphyseal plate – separates the epiphyses from the diaphysis and is the center
for longitudinal growth in children.
 Metaphysis – is the region in a mature bone where diapgysis joins epiphysis.
 Articular Carticular Cartilage – a thin layer of hyaline cartilage covering the
epiphysis where the bone forms a joint with another bone.

 Short bones – cancellous bone covered by a layer of compact bone. It includes

carpals and tarsals.
 Flat bones – important sites for hematopoiesis. It includes sternum, ribs and
bone of the cranium.
 Irregular Bones – Bone with no definite shape. The thinner part consists of two
plates of compact bone with cancellous bone sorrounded by layer of compact
bone. It includes vertebrae, hyoid bone, some of facial bone, calcaneus.
 Sesamoid Bone – Rounded bone which develops in the capsule of joints and
tendons. The fuction is to eliminate friction and improve mechanical advaqntage
at a joint.
  Bone is composed of cells, protein matrix, and mineral deposits. The cells are of
three basic types:
 Osteoblasts – function in bone formation by secreting bone matrix.
 Osteocytes – mature bone cells.
 Osteoclasts – multinuclear cells involved in destroying, resorbing and
remolding bone.
 Osteon – microscopic functioning unit of mature cortical bone.
 Lamellae – mineralized bone matrix.
 Periosteum – dense, fibrous membrane covering the bone.
 Endosteum – thin, vascular membrane that covers the marrow cavity of long
bones and the spaces in cancellous bone.
 Bone marrow – vascular tissue located in the medullary cavity of long bones
and in flat bones. Responsible for producing red and white blood cells.

Bone Formation

Bone begins to form long before birth. Ossification is the process in which bone
matrix (collagen fibers and ground substance) is formed and hardening minerals (e.g
calcium salts) are deposited on the collagen fibers. The collagen fibers give tensile
streght to the bone and the calcium provides compressional streght. The two basic
process of ossification: endochondral and intramembranous. Most bones in the body
are formed by endochondral ossification in which cartilage-like tissue (osteoid) is
formed, resorbed and replaced bybthe bone. Intramembranous ossification occurs
when bonr develops within the membrane as in the bones of the face and skull.

Time period Bones affected

Third month of embryonic
Ossification in long bones beginning
development
Most primary ossification centers have appeared in the
Fourth month
diaphyses of bone.
Birth to 5 years Secondary ossification centers appear in the epiphyses
5 years to 12 years in
Ossification is spreading rapidly from the ossifcation centers
females,
and various bones are becoming ossified
5 to 14 years in males
Bone of upper limbs and scapulae becoming completely
17 to 20 years
ossified
Bone of the lower limbs and os coxae become completely
18 to 23 years
ossified
Bone of the sternum, clavicles, and vertebrae become
23 to 25 years
completely ossified
By 25 years Nearly all bones are completely ossified
Bone Maintenance

Bone is a dynamic tissue in a constant state of turnover-resorption and formation. The

important regulating factors that dtermine the balance between bone formation and
bone resorption include local stress, vitamin D, parathyrooid hormone, calcitonin and
blood supply.

Local Stress (weight bearing) acts to stimulate bone formation and remodeling. Weight-
bearing bones are thick and strong. Without weight-bearing or stress as in prolong bed
rest, the bone loses calcium (resorption) and becomes osteopenic and weak. The weak
bone may fracture easily. Biologically active vitamin D (calcitriol) functions to increase
the amount of calcium in the blood by promoting absorption of calcium from the
gastrointestinal tract. It laso facilitates mineralization of osteoid tissue. A deficiency af
vitamin D results in the bone mineralization deficit, deformity and fracture.

Parathyroid hormone and calcitonin are the major hormonal regulators of calcium
homeostasis. Parathyroid hormone regulates the concentration of calcium in the blood
in part by promoting movement of calcium from the bone. In response to low calcium
levels in the blood, increased levels of parathyroid hormone prompt the mobilization of
calcium the demineralization of the bone and the formation of the bone cysts. Calcitonin
secreted by the thyroid gland in response to elevated blood calcium levels, inhibits bone
resorption and increase the deposit of calcium in the bone.

Blood supply to the bone also affects bone formstion. With diminished blood supply and
hyperemia (congestion), osteogenesis (bone formation) and bone density decrease.
Bone necrosis occurs when the bone deprived of blood.

Bone Healing

Most fractures heals through the combination of intramembranous and endochondral

ossification process. When a bone is fractured the bone frasgments are merely patched
together with scar tissue. Instead, bone regenerates itself.

Fracture Healing occurs in 4 areas, including:

 Bone marrow, where endothelial cells rapidly undergo transformation amd

osteoblastic bone-forming cells.
 Bone cortex, where new osteons are formed
  Periosteum, where hard callus/bone is formed through intramembranous
ossification peripheral to the fracture, and where cartilage model is formed
through endochondral ossification adjacent to fracture site.
 External soft tissue, where bridging callus (fibrous tissue) stabizes fracture.

Buckwalter (2000) summarized the process of fracture healing into six stages stimulated
by the release and activation of biologic regulators and signaling molecules:

1. Hematoma and inflammation: The body response is similar to that after injury
elsewhere in the body. There is bleeding into the injured tissue and formation of
a fracture hematoma. The hematoma is the source of signaling molecules such
as cytokenis, transforming growth factor (PDGF) which initiates the fracture
healing process. The fracture fragments ends become devitalized because of the
interrupted blood supply. Thhe injured area is invaded by macrophages which
debrie the area. Inflammation, swelling, and pain are present. The inflammatory
stage last several days and resolves with decrease in pain and swelling.
2. Angiogenesis and Cartilage formation: Under the influence of signaling
molecules, cell proliferation and differentiation occur. Blood vessels and cartilage
overlie the fracture.
3. Cartilage Calcification: Chondrocytes in the cartilage callus form matrix vesicles
which regulate calcification of the cartilage. Enzymes within these matrix vesicles
prepare the cartilage for calcium release and deposit.
4. Cartilage Removal: The calcified cartilage is invaded by blood vessels and
becomes resorbed by chondroblasts and osteoblasts. It is replaced by woven
bone similar to that growth pllate.
5. Bone Formation: Minerals continue to be deposited until the bone is firmly
reunited. With major adult long bone fractures, ossification takes 3-4 months.
6. Remodeling: The final stage of fracture repair consist of remodeling the new
bone into its former structural arrangement. Remodeling may take months to
years depending on the extent of bone modification needed, the function of the
bone and fuctional stresses of the bone. Cancelous bone heals and remodels
more rapidly than does compact cortical bones.

Serial x-ray films are used to monitor the progress of bone healing. The type of bone
fractured the adequacy of blood supply, the surface contact of the fragments and
genera health of a person influence the rate of fracture healing. Adequate
immobilization is essential until there is x-ray evidence of bone formation with
ossification.

Structure and Function of Articular System

 The junction of two or more bones is called a joint (articulation). There are threee
basic kinds of joints: Synarthrosis, amphiarthrosis and diarthrosis joints. Synarthrosis
joints are immovable as exemplified by the skull sutures. Amphiarthrosis joints such as
the vertebral joints and the symphysis pubis, allow limited motion. The bones of
amphiarthrosis joints are joined by fibrous cartilage. Diarthrosisjoints are freely movable
joints.

Types of diarthrosis joints:

1. Ball and socket joints, best exemplified by the hip and the shoulder permit full
freedom movement.
2. Hinge joints permit bending in one direction only and are best exemplified by
elbow and knee.
3. Saddle joints allow movement in two planes at right angles at each other. The
joint at the base of the thumb is a saddle, biaxial joint.
4. Pivot joints are characterized by the articulation between the radius and ulna.
They permit rotation for such activity as turning a doorknob.
5. Gidding joints allow for limited movement in all directions and are represented by
joints of the carpal bones in the wrist.

The ends of the articulating bones of a typical movable joint are covered with
smooth hyaline cartilage. The tough fibrous sheath called the joint capsule
surrounds articulating bones. The capsule is lined with a membrane, the synovium
which secretes the lubricating and shock-absorbing synovial fluid into the joint
capsule. Therefore, the bone surfaces are not direct contact. In some synovial joints
such as knee, fibrocartilage disks such as medial meniscus are located between the
articular cartilage surfaces. These disks provide shock absorption.

Ligaments bind the articulating bone together. A bursa is a sac filled with synovial
fluid that cushions the movement of tendons, ligaments and bones at point of
friction. Bursae are found at the elbow, shoulder, knee and some other joints.

 Fracture  First-aid
  Depends on type & location of fracture

For open fractures

 Control bleeding before treatment

 Rinse and dress the wound

For open / closed fractures

 Check the breathing 

 Calm the person 
 Examine for other injuries
 Immobilize the broken wound 
 Apply ice to reduce pain / swelling
 Consult a doctor 

   DO NOT

 Massage the affected area

 Straighten the broken bone 
 Move without support to broken bone
 Move joints above / below the fracture
 Give oral liquids / food

Medical Management of Fractures

The principles of fracture treatment include reduction, immobilization, and

regaining normal function and streght through rehabilitation.

Read more: Fracture-First Aid and Emergency Treatment Guide

http://www.medindia.net/patients/Firstaid-fracture.htm#ixzz1EnDUr1XO