fracture

Dr thit lwin

 Definition Fracture is a break in the structural continuity of bone. Closed Open: : if the overlying skin remain intact if the skin is breached

 Fracture may result from 1. single traumatic accident

(a) direct (b) indirect

2. repetitive stress 3. abnormal weakening of bone (pathological fracture) Indirect force1. twisting-spiral fracture 2. tension -transverse fracture 3. bending -butterfly fragment 4. compression- short oblique fracture 5. pulling -avulsion fracture

transverse

segmental

spiral
4

 Clinical feature History of injury-mechanism, trivial trauma, associated injury: numbness, blood in urine, abdominal pain, transient loss of consciousness General sign - shock - associated damage to brain & spiral cord, viscera - predisposing cause ( Paget's disease) Look , Feel, Move, Measure, X-ray

Fractures
Classifications Open Closed, complete Incomplete Impacted Comminuted Displaced By Direction Transverse Oblique Spiral Angulated

Significance of Fracture Description

Why? Examples of Fracture
Angulated Communiuted Oblique Stress Fx Compression

Describe these fractures. Include location and type.

COMPLICATIONS OF FRACTURES
Early
General Other injuries PE FES/ARDS Infection

Late

Bone

Soft-tissues

Chest infection UTI Bed sores Non-union Malunion AVN Plaster sores/WI Tendon rupture N/V injury Nerve compression Compartment syn. Volkmann contracture

WHEN IS THE FRACTURE HEALED?

Clinically Upper limb Lower limb 6-8 weeks 12-16 weeks 3-4 weeks 6-8 weeks

Adult Child Radiologically Bridging callus formation Remodelling Biomechanically

Cardinal symptoms Pain Deformity swelling Bony tenderness Abnormal movement

Primary Bone Healing

callus is not formed at all and requires rigid stabilization Rigid stabilization suppresses the formation of a callus in either cancellous or cortical bone divided into gap healing and contact healing.

 Gap Healing ( two stages). Firstly, the width of the gap is filled by direct bone formation. An initial scaffold of woven bone is laid down, followed by formation of lamellar bone as support. The orientation of the new bone is transverse to the original lamellar bone orientation. In the second stage, which happens after several weeks, longitudinal Haversian remodeling reconstructs the necrotic fracture ends and the newly formed bone to replace the woven bone with osteons of the original orientation. In the end, the normal bone structure results.

 Contact Healing Contact healing occurs where fragments are in direct apposition and osteons can grow across the fracture site, parallel to the long axis of the bone. osteoclasts on one side of the fracture undergo a tunnelling resorptive response, forming cutting cones that cross the fracture line. This tunnelling allows the penetration of capillaries and eventually the formation of new haversian systems. These blood vessels are then accompanied by endothelial cells and osteoprogenitor cells for osteoblasts leading to the production of osteons across the fracture line eventually leading to regeneration of the normal bone architecture.

 Secondary bone healing It occurs when there is no rigid fixation of the fractured bone ends, which leads to the development of a fracture callus. It includes an inflammatory phase, a reparative phase, and a remodeling phase.

 1. Inflammatory Phase - a hematoma (localized blood collection) forms within the fracture site during the first few hours and days. - Inflammatory cells infiltrate the bone, which results in the formation of granulation tissue , vascular tissue (for blood delivery to the new bone), and immature tissue (which will specialize to form a bridge of tough connective tissue). - this stage can last 2 4 weeks after a fracture

 2. Repair Phase - this is the stage where the fracture gets healedthat is, the bone ends become joined and stabilized. The cells of the body that are capable of changing into bone cells are activated or fired up to do so, and they start laying down new bone tissue. This tissue, called fracture callus, is weak; and has to be protected. The hardening of the cartilage begins at each end of the fracture and sweeps toward the center. - during this stage, the new blood vessels for the new growth are also developed. But its during this stage that nicotine from smoking can really slow down this blood vessel growth, which will impact, in a negative way, how the bone heals. - this stage can last 1 2 months after a fracture

 Remodelling Stage - this is the stage where the body changes the weak bone material into strong bone material. Because this new material is so strong, the body does not need a lot of it, and it will remodel the fracture callus down to normal sized bone. The bone should be restored to its original shape, structure, and mechanical strength. - remodelling of the bone occurs slowly over months to years and is helped along by mechanical stress (i.e. weight bearing) placed on the bone

hematoma and cartilaginous bony callus re-modeling granulation tissue callus &cartilaginous remnants

Physiology of Bone Healing

Inflammation
Occurs immediately after fracture Mechanical stability is achieved by presence of hematoma Callus forms by bridging the fracture site Takes 2-3 days

Reparation
Callus size increases to unite fracture site and reduce bone motion Callus begins mineralization and eventually matures into lamellar bone -> bony union occurs Takes 4-12 weeks

Remodeling
Characterized by Wolffs Law Fully restore anatomical configuration of bone Takes 6 months to 1 year in adults