FRACTURE

• Fracture is a break in the continuity in the

bone
• It may be a crack,a crumpling or a splintering
of the cortex
 TYPES OF FRACTURE
BASE ON ETIOLOGY BASED ON DISPLACEMENT
• TRAUMATIC F RACTURE • UNDISPLACED
• PATHOLOGICAL FRACTURE • DISPLACED
• STRESS FRACTURE TRANSLATION( shift)
ANGULATION (tilt )
NROTATION (twist)
 Traumatic Fracture
• Fracture of bone occurs due to alleged history
of trauma.
• In a normal bone
 Pathological fracture
• A pathological fracture is one that occurs
when normal integrity and strength of bone
have been compromised by invasive disease
or destructive process
 STRESS FRACTURE
Stress fracture is a fatigue-induced fracture of
the bone caused by repeated stress over time.
These are the result of accumulated trauma
from repeated submaximal loading, such as
running or jumping.
 TYPES OF FRACTURE
BASED ON RELATIONSHIP WITH
EXTERNAL ENVIRONMENT BASED ON PATTERN
• CLOSED # • TRANSVERSE
• OPEN # • SPIRAL
• COMMINUTED
• SEGMENTAL
Open fracture
Closed fracture
 PREREQUISITES FOR BONE HEALING
• Adequate blood supply
• Adequate mechanical stability
 MECHANISM OF BONE FORMATION
• CUTTING CONES
• ENDOCHONDRAL OSSIFICATION
• INTRAMEMBRANOUS OSSIFICATION
 FRACTURE HEALING
• PRIMARY FRACTURE HEALING
• SECDONDARY FRACTURE HEALING
 FRACTURE HEALING IN A CORTICAL
BONE
• STAGES-
1)HAEMATOMA FORMATION
2)INFLAMMATION
3)SOFT CALLUS FORMATION
4)HARD CALLUS FORMATION
5)REMODELLING

Ref-Rockwood and green’s fracture in adults

 HAEMATOMA FORMATION
• At the time of injury,bleeding from bone &
soft tissues
 INFLAMMATION
• Inflammatory cells appear in the haematoma
,bone ends die back for a few millimetres
• 1-7days
 SOFT CALLUS FORMATION
• 2-3WEEKS
• Cell population changes to osteoblasts,
• Over time callus calcifies and woven bone
appears in fracture callus
 HARD CALLUS
• 3-4months
• When the fracture ends are linked together
,the hard callus starts and lasts until the
fragments are firmly united
• 1st form peripheral to fracture &moves
centrally
 REMODELLING
• Woven bone is replaced by laminar bone
• Newly formed bone is remodelled to resemble
the normal structure
 FRACTURE HEALING IN CANCELLOUS
BONE
• Cancellous bone appears to heal mainly via
direct, membranous bone formation that
occurs freely in the marrow, probably mostly
arising from local stem cells.
• K/as inter-trabecular bone formation.
• No cartilage is seen
• Less sensitive to antiinflammatory treatment
than shaft fractures.
• no cartilage is seen,
• Inter-trabecular bone formation seems to be
less sensitive to anti-inflammatory treatment
than shaft fractures.
PATHOLOGICAL
FRACTURE
METASTATIC PATHOLOGICAL HIP FRACTURE
 ETIOLOGICAL CLASSIFICATION OF
PATHOLOGICAL FRACTURES
• INFECTIVE DISORDER- 1)Chronic pyogenic osteomyelitis
2)Chronic tubercular osteomyelitis
• TUMORS DISORDER-1)Metastasis 2)Cystic lesion like
simple bone cyst and aneurysmal bone cyst
2)Malignant tumor-
osteosarcoma,chondrosarcoma,multiple myeloma.
• METABOLIC DISORDER-osteoporosis,osteomalacia and
hyperparathyroidism
• GENETIC AND DYSPLASTIC DISORDER-1)Fibrous
dysplasia,osteogenesis imperfecta,osteopetrosis
• IATROGENIC,DRUGS
 PATHOLOGICAL FRACTURE IN
CHILDREN
• Metabolic diseases,infection,tumors
• Mc benign bone tumor causing pathological
fracture in children-unicameral bone
cyst,aneurysmal bone cyst,fibrous
dysplasia,nonossifying fibroma

• https://www.researchgate.net/publication/236267533_Pathological_fract
ures_in_children
 PYNCODYSOSTOSIS
• AR,LSD
• Causing skeletal dysplasia
• Incomplete remodeling in fracture healing because of
cathepsin k deficiency.
• INTRAMEMBRANOUS BONE FORMATION>
ENCHONDRAL BONE FORMATION
• It seems prudent to strive for direct bone
healing(intramembranous) instead of indirect bone
healing.

• https://www.sciencedirect.com/science/article/pii/S0972978X1930
0479?via%3Dihub
PYNCODYSOSTOSIS
 PATHOLOGICAL FRACTURE IN
OSTEOMYELITIS
• Inflammatory response of osteomyelitis leads
to dysfunction of osteoblast and osteoclast.
• RANKL is a critical regulator of bone
remodeling and regeneration by controlling
osteoclast formation and activity
• High levels of RANKL in OM. due to bacterial
Ag and secreted products, or in an indirect
response to exaggerated tissue inammation
• Osteoblasts > pro inflammatory osteoclast
modulating 6,13 factors and participate in the
osteolytic process by internalizing bacteria
• Osteomyelitis >compression of vascular
channels local release of nitric oxide>cell
death
• Osteoblasts undergo apoptosis and necrosis
by exposure to bacteria or tnf @ and ifn Y
• High chance of reinfection
• The overall fracture healing rate- 35%
• group that survived longer than six months-74% of
fractures united
• . A life expectancy of longer than six months - primary
factor determining osseous healing .
• A total radiotherapy dose of 3000 rad or less did not
inhibit callus formation.
• Internal fixation improved the rate of fracture union by
23% as compared with cast immobilization

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6050999/
FRACTURE HEALING IN OSTEOPOROSIS
• Osteoporosis develop fractures in
-Vertebral bodies
-Corticocancellous junction of long bones
-#through the shaft of long bones in elderly
Mice lacking SLIT3
are unable to heal
skeletal fracture
substance, which is
best known for
spurring nerve
growth, called SLIT3,
both reversed the
bone-weakening
effects of
osteoporosis and
helped fractures
heal when
administered in
mice.
• expression of bmp2 and smad4 is lower in
patients of senile osteoporotic fractures
• Osteoporosis, which causes bones to thin and
become brittle, leads to nearly 9 million
fractures worldwide each year, or one every
three seconds, according to the International
Osteoporosis Foundation

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6050999/
 OSTEOMALACIA
Osteoid>osteon
Callus formation is
delayed d/t lack of
calcium

https://courses.washingt
on.edu/bonephys/hyper
calU/opmal2.html
OSTEOGENESIS
IMPERFECTA
-Normal bone healing in most
of the # but progressive long
bone deformity is a frequent
consequence of either fracture
malunion or deformity d/t
abnormal type 1
collagen(COL1A1 & COL1A2
GENE MUTATION)
-DIAPHYSEAL #
-DEFORMITY
-DIFFERENT STAGES OF
FRACTURE HEALING

file:///C:/Users/AIIMS/Downloads
/slikovne_metode_kod_osteogen
esis_imperfecta%20(2).pd
 BONE METASTASIS CAUSING
FRACTURE
3 types of bony metastasis
• 1)osteolytic-kidney & thyroid cancer- triggers
osteoclasts to weakens bone and cause
fracture-early callus is formed
• 2)osteoblastic-prostate cancer,medullary
cancer thyroid-makes new bone
• 3)both types-breast cancer
• Tumor cells secrete factors that interact with
host cells in the bone microenvironment
and affect the cycle of normal bone turnover
• Multiple lytic and blastic lesions are noted
throughout
the thoracolumbar spine, consistent with
breast cancer. Note the
collapse of vertebrae even in blastic
metastases.

Rockwood and green’s fracture in adults

 MIREL’S CRITERIA FOR RISK OF
PATHOLOGICAL FRACTURE

Score
Criteria[1]
1 2 3
Site Upper limb Lower limb Peritrochanteric
Pain Mild Moderate Functional
Lesion Blastic Mixed Lytic
Size <⅓ ⅓-⅔ >⅔
A score of 1 to 3 is given for four criteria and summed together. A score
greater than 8 suggests prophylactic internal fixation prior to irradiation.

Rockwood and Green’s fracture in adults

UNICAMERAL BONE CYST
Proximal
humerus,femur,tibia
lytic metadiaphyseal
leison,not crossing physis
Fracture through leison is
common
Following fracture ,there
will be features of fracture
callus and new bone
formation

Rockwood and Green’s

fracture in adults
multiple myeloma
nondisplaced
fracture through the lateral
cortex of the femur with pain

cephalomedullary
intramedullary nail
coursing
the distal femoral lesion
with cement augmentation

Rockwood and Green’s

fracture in adults
 DRUGS CAUSING FRACTURES
• Drugs causing osteoporosis following pathological
fracture
• Synthetic glucocorticoid-It is associated with
reduced activity of the cells that break down
bone,which.e.g.prednisone,dexamethasone,hydr
ocortisone)
• Breast cancer drugs-@spine and wrist #-
anastrozole,letr,exemestane
• Prostate cancer drugs
• Heartburn drugs-proton pump inhibitors
• Depo provera
• Excessive thyroid hormone replacement
• Anti seizure and mood altering drugs-
phenytoin(decrease vit
d),antidepressants,benzodiazepins
• Diuretics-furosemide
• @adrenergic blockers-tamsulosin
ATYPICAL FRACTURE BY BISPHOSPHONATES
 PROGNOSIS OF PATHOLOGICAL
FRACTURES
• Pathological fractures of long bones can be
satisfactorily treated with internal fixation with
adequate adjuvant therapy.
• The fracture union depends on multiple factors,
including the nature of the primary malignancy,
survival duration, etc.
• Pathological fracture of the long bones should be
treated by using interlocking nails, even though
the origin of the cancer such as myeloma or lung
cancer is an unfavourable disease.
• Pathological fractures associated with multiple
myeloma have a favourable union rate among all
the common metastasis.
• Large lytic lesions should be prophylactically
fixed with a nail or plate to avoid pathological
fracture, if the Mirels’ score is high (>8).
• A bone biopsy in large lytic lesions may be
associated with a pathological fracture and hence
must be performed carefully and only if
absolutely necessary
THANK YOU