Fracture and Principles of Bone Healing and Management

FRACTURE

FRACTUREDANIELLE G. DEVILLERES, PTRPDEFINITIONAny break in the continuity of the boneUsed interchangeably with the term broken boneCLASSIFICATIONACCORDING TO SOFT TISSUE INVOLVEMENT

OPEN (COMPOUND) FRACTURE Fracture with communication to outside environment

CLOSED FRACTUREFracture without communication to outside environmentCLASSIFICATIONACCORDING TO MECHANISM

PATHOLOGIC FRACTUREFracture caused by pre-existing illness

STRESS FRACTUREFracture caused by repeated, unaccustomed loading and inadequate muscular supportCLASSIFICATIONACCORDING TO MECHANISM

TRAUMATIC FRACTUREFx caused by sustained traumaCLASSIFICATIONACCORDING TO PATTERN

TRANSVERSE FRACTURESFracture caused by simple angulatory forces

SPIRAL FRACTURESFracture caused by torsionCLASSIFICATIONACCORDING TO PATTERN

OBLIQUE FRACTURESFracture that is diagonal to a bones long axis

LINEAR FRACTURESFracture that is parallel to the bones long axis

CLASSIFICATIONACCORDING TO PATTERN

COMPRESSION/ WEDGE FRACTURESUsually in vertebraeFront portion collapses due to osteoporosisCLASSIFICATIONACCORDING TO PATTERN

IMPACTED FRACTUREFracture caused when bone fragments are driven into each other

AVULSION FRACTUREFracture where a fragment of bone is separated from the main massCLASSIFICATIONACCORDING TO FRAGMENTS

INCOMPLETEBone fragments are still partially joinedCrack does not completely traverse the width of bone

COMPLETE Bone fragments separates completely

CLASSIFICATIONACCORDING TO FRAGMENTS

COMMINUTED FRACTURESFracture where bone is broken into 3 or more fragments

CLASSIFICATIONACCORDING TO ANATOMICAL LOCATION

Skull FractureMandibular FxNasal FxBasilar Skull Fx


Spinal FractureJeffersons FxFracture of C1

Hangmans FxFracture of C2


Spinal FractureFlexion Teardrop FxFx of the anteroinferior aspect of a cervical vertebrae

Clayshovelers FxFx through the spinous process of a vertebra occuring at any lower cervical or upper thoracic


Spinal FractureChance FxCompression injury to the anterior portion of the verbetral body with concomitant distraction injury to posterior elements


Spinal FractureDens (Odontoid) FxType I avulsion fx at tip of dens at site of alar ligamentsType II fx at base of dens without extension to body of C2Type III fx at body of C2 not involving the dens


Rib FractureSternal FractureShoulder FractureClavicular FxScapular Fx


Arm FractureHumerusSupracondylar Fx


Arm FractureForearm UlnarMonteggia FxFx of the proximal third of the ulnaWith dislocation of the head of the radius


Arm FractureForearm RadiusGaleazzi FxFx of the radiusDislocation of the distal radioulnar joint


Arm FractureForearm RadiusColles FxDistal fx of the radiusDorsal (posterior) displacement of the wrist and hand


Arm FractureForearm RadiusSmiths FxDistal fx of the radiusVolar (ventral) displacement of the wrist and hand


Arm FractureForearm RadiusBartons FxIntra articular fx of the distal radiusDislocation of the radiocarpal joint


Arm FractureHandScaphoid FxRolando FxComminuted intra articular fx through the base of the 1st MC bone


Arm FractureHandBennetts FxFx of the base of the 1st MC bone with extends into the CMC jointBoxers FxFracture at the neck of a metacarpal


Pelvic FractureHip boneDuverney FxIsolated pelvic fx involving the iliac wing


Femoral FractureHip fracture ( femur bone and not the hip )


Patella Fracture


Crus FractureTibiaBumper FxFx of the lateral tibial plateauCaused by forced valgus applied to the knee


Crus FractureTibiaSegond FxAvulsion fx of the lateral tibial condyle

Gosselin FxFractures of the tibial plateau into anterior and posterior fragments


Crus FractureTibiaToddlers FxUndisplaced and spiral fracture of the distal third to distal half of tibia


Crus FractureFibulaMaisonneuve FxSpiral fx of the proximal third of the fibulaAsso. With a tear of the distal tibiofibular syndesmosis and the interosseous membrane


Combined Tibia and Fibula FractureTrimalleolar FxInvolving lateral malleolus, medial malleolus and the distal posterior aspect of tiba


Combined Tibia and Fibula FractureBimalleolar FxInvolving lateral malleolus and medial malleolusPotts Fx


Foot FractureLisfranc FxOne or all MT are displaced from tarsus

Jones FxFx of the proximal end of the 5th MT


Foot FractureMarch FxFx of the distal 3rd of one of the MT due to recurrent stressCalcaneal Fx

CLASSIFICATIONPEDIATRIC CLASSIFICATIONGreenstick (Torus)IncompleteOccurs on flexible bonesBends and fractures only outer edgeEpiphyseal Fx located at site of epiphysisSometimes with associated dislocationGUSTILO ANDERSON CLASSIFICATION (OPEN FX)TYPE I Wound : 10cmSevere contaminationSevere crushing component

TYPE III BWound : >10cmSevere contaminationSevere loss of tissues

GUSTILO ANDERSON CLASSIFICATION (OPEN FX)TYPE III CWound : >10cmSevere contaminationNeurovascular injury

SALTER AND HARRIS CLASSIFICATION (EPIPHYSEAL PLATE FRACTURE IN CHILDRENTYPE IFx only on the cartilage plate

TYPE IIPlate + triangular segment of the metaphysis

TYPE IIIFx traverses the bony epiphysis and involves the cartilage plateSALTER AND HARRIS CLASSIFICATION (EPIPHYSEAL PLATE FRACTURE IN CHILDRENTYPE IVEpiphysis + growth plate + metaphysisOften causes growth arrest

TYPE VNot apparent on xrayCrushing of part of growth plateDIAGNOSISHISTORYDetails of accidentto know type of forces involvedTime and place of injuryAge of patientHistory of pain or deformity preceding FxIn OPEN FracturesCheck for immunization to tetanusHistory of recent respiratory infection or of cardiac and renal difficultiesDIAGNOSISPHYSICAL EXAMINATIONSeverely injured patientsRespiratory difficultiesObstruction produced by edema from soft tissue injury about the face and neckForeign bodiesAccumulated secretions in respiratory tract

DIAGNOSISPHYSICAL EXAMINATIONSeverely injured patientsAcute hemorrhageObvious if externalVenous bleeding can usually be controlled by direct pressure through a sterile dressing placed in woundMild arterial bleeding can be controlled in same manner Larger arterial bleeding needs clamping in the ER

DIAGNOSISPHYSICAL EXAMINATIONSeverely injured patientsShockManifested by cold and clammy skinRapid and thready pulseLowered blood pressureResult of blood lossAlso a result of burns, crush injury, overwhelming bacterial infection, and toxic conditions

DIAGNOSISPHYSICAL EXAMINATION (Detailed)1st stepObservationLacerationsAbrasionsSwellingDeformity

DIAGNOSISPHYSICAL EXAMINATION (Detailed)2nd stepPalpationTendernessIndurationDeformitySkull and jaw cervical spine clavicles SC and AC joint shoulder humerus elbow wrist and hand

DIAGNOSISPHYSICAL EXAMINATION (Detailed)2nd stepRib cage and sternum thoracic and lumbar spine sacrum and SI joints ischial tuberositiesIliac crests trochanters pubis thigh patella knee tibia ankle and foot toes

DIAGNOSISPHYSICAL EXAMINATION (Detailed)2nd stepCirculation is evaluatedTemperatureColor changesPulse

Cranial nerve functionMouthEyes Ears

DIAGNOSISPHYSICAL EXAMINATION (Detailed)2nd stepAuscultation of chest Palpation of abdomen

DIAGNOSISPHYSICAL EXAMINATION (Detailed)3rd stepFocus on injured areaSwellingDeformitiesAngulationShorteningRotation Check circulation distal to Fx site

BONE HEALINGProliferative physiological process in which the body facilitates the repair of a bone fractureBONE HEALINGReactive PhaseInflammatory phasePresence of blood cells within the tissues adjacent to injury

Granulation tissue formationBlood vessels constrictHematoma or blood clot is formed (cells within the blood clot and cells adjacent to the injury site dies)Fibroblasts survive and replicate = forms the granulation tissueBONE HEALINGReparative PhaseCartilage callus formationCells of periosteum replicate and transformPeriosteal cells proximal to the fracture gap develop into chondroblasts (form hyaline cartilage)Periosteal cells distal to the fracture gap develop into osteoblasts (develop woven bone)Fibroblasts within granulation tissue develop into chondroblasts

BONE HEALINGReparative PhaseCartilage callus formationThese 2 new tissues grow until they unite with their counterparts from other parts of the fractureFormation of FRACTURE CALLUS

BONE HEALINGReparative PhaseLamellar bone depositionReplacement of hyaline and woven bone into lamellar boneWoven bone = Bony substitutionHyaline cartilage = Endochondral ossificationBegins soon after the collagen matrix of either tissue becomes mineralizedMineralized matrix is penetrated by channels, each containing a microvessel and numerous osteoblasts

BONE HEALINGReparative PhaseLamellar bone depositionOsteoblasts form new lamellar bone in the form of trabecullar boneEventually all of the woven bone and cartilage becomes trabecullar bone

BONE HEALINGRemodelling PhaseSubstitutes the trabecullar bone with compact boneTakes 3 to 5 years depending on many factorsBONE HEALINGComplications of Wound HealingDelayed union3-4 months after injuryPoor blood supply or infection

Non-union>6 months after injuryBone loss or wound contamination

MalunionImproper immobilizationFACTORS THAT INFLUENCE HEALINGFactors Ideal Problematic Age, yearsYouthAdvanced age (>40 y)ComorbiditiesNoneMultiple medical comorbidities (eg, diabetes)MedicationsNoneNonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroidsSocial factorNonsmokerSmokerNutritionWell nourishedPoor nutritionFracture typeClosed fracture, neurovascularly intactOpen fracture with poor blood supplyTraumaSingle limbMultiple traumatic injuriesLocal factorsNo infectionLocal infectionPRINCIPLES OF FRACTURE TREATMENTREDUCTIONMAINTENANCE OF REDUCTIONPRESERVATOIN/ RESTORATION OF FXNPRINCIPLES OF FRACTURE TREATMENTREDUCTIONBy manipulationMC

By tractionApplied over a period of several hours or daysCommonly applied for femoral shaft fx and cervical spine injuriesPRINCIPLES OF FRACTURE TREATMENTREDUCTIONBy surgeryFragments caught in soft tissueInternal fixation is anticipatedPRINCIPLES OF FRACTURE TREATMENTMAINTENANCE OF REDUCTIONBy external fixationCastsSplints = MC is POP

By tractionSkin traction

Fracture and Principles of Bone Healing and Management

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hand classificationaccording

radius classificationaccording

avulsion fx

avulsion fracturefracture

fragment of bone

fracture fracturedanielle

tip of dens