Principles of fractures

Principles of fracturesPrinciples of fracturesMohammad Ararawi

Principles of fracturesPrinciples of fracturesDefinition

A bone fracture (sometimes abbreviated # 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.

Principles of fracturesPrinciples of fracturesClassification

In orthopedic medicine, fractures are classified as closed or open (compound) and simple or multi-fragmentary (formerly comminuted).

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 fracturesPrinciples of fracturesClassification

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.

Principles of fracturesPrinciples of fracturesDescriptionDescription Complete Fracture- A fracture in which bone

fragments separate completely. 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.

Principles of fracturesPrinciples of fracturesDescriptionDescription

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.

Greenstick fracture of radius Greenstick fracture of radius and ulnaand ulna

Principles of fracturesPrinciples of fractures

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.

Principles of fracturesPrinciples of fractures

Displacement of the fracture fragmentsDisplacement of the fracture fragments

The two main fragments of fracture are commonly displaced

The causes of displacement are:• Primary impact• Gravity• Muscle pull

The following Displacements are recognized:• Shift (translation) of the distal fragment.• Angulation (alignment) of the distal

fragment in relation to proximal one or the opposite.

• Rotation (twist) one fragment may be rotated on its longitudinal axis.

Principles of fracturesPrinciples of fracturesclassificationclassification

The OTA devised an elaborate classification system to describe the injury accurately and guide treatment. There are five parts to the code:

1-Bone: Description of a fracture starts by naming the bone

2-Location: the part of the bone involved.

3-Type: It is important to note whether the fracture is simple or multifragmentary and whether it is closed or open.

4-Group: The geometry of the fracture is also described by terms such as transverse, oblique, spiral, or segmental.

5-Subgroup: Other features of the fracture are described in terms of displacement, angulation and shortening.

Principles of fracturesPrinciples of fracturesfractures caused by sudden injury in a normal bone.fractures caused by sudden injury in a normal bone.

Majority of the fractures.Caused by single excessive force.According to the force:

1-direct force:A-Direct blow that cause a transverse

Fx with damage to skin.B-Crushing force that cause

comminuted Fx with extensive damage to soft tissue.

Principles of fracturesPrinciples of fracturesfractures caused by sudden injury in a normal bone.fractures caused by sudden injury in a normal bone.

2-Indirect force.The bone breaks at a distance from where

the force is applied.A-Rotational force, leading to spiral fracture.B-Bending force, leading to transverse fracture.C-Bending with compression, leading to transverse fracture with butterfly third segment.D-Rotation, bending and compression combined, leading to oblique fracture.E-Pulling force, in which a tendon pull, causes avulsion fracture.

Principles of fracturesPrinciples of fracturesStress fracture-fatigue fractureStress fracture-fatigue fracture

Divided into two categories.◦ fatigue fractures, is caused by the

application of abnormal stress or torque on a bone that has normal elastic resistance, The stress placed on bone causes resorption and microfractures.

◦ insufficiency fractures, On the other hand, occurs when normal muscular activity stresses a bone that is deficient in mineral or elastic resistance

Can occur any where but most commonly 2nd metatarsal followed by Fibula and Tibia.

Principles of fracturesPrinciples of fracturesStress fracture-fatigue fractureStress fracture-fatigue fracture

Clinically, Pain with gradual onset, examination will show local tenderness after weeks there will be swelling.

X-ray, MRI and Bone scan.

Principles of fracturesPrinciples of fracturespathological fracturepathological fracture

Occur through a bone that is weakened by a disease.

Fx occur either spontaneously or from trivial violence.

Local or Generalized disorder of skeleton.

Principles of fracturesPrinciples of fracturespathological fracturepathological fracture

Local causesBone infection (osteomyelitis).

Benign tumors (enchondroma, giant cell tumor).

Malignant tumor (osteosarcoma , Ewing sarcoma and metastatic carcinoma).

Principles of fracturesPrinciples of fracturesGeneralized causes

Congenital (osteogenesis imperfecta).

Diffuse affection of bone (osteoporosis, rickets, uremic osteodystrophy)

Other causes (Polyostotic fibrous dysplasia, Paget’s disease, Gaucher’s disease).

Principles of fracturesPrinciples of fracturesGrowth plate injuryGrowth plate injury

Three types of injuries.◦Simple separation.◦Fractures that cross the growth

plate.◦Crush injury.Over 10 % of fractures in children

involve the growth plate.

Principles of fracturesPrinciples of fractures Salter-Harris classificationSalter-Harris classification

Type I:The whole growth plate

is separated.No growth disturbances

Type II:The growth plate is

separated carrying with it a triangular metaphyseal fragment.

No growth disturbances.The most common

injury.

Principles of fracturesPrinciples of fractures Salter-Harris classificationSalter-Harris classification

Type III:Part of the growth

plate is separated.May lead to growth

disturbances.Type IV:Separation of part of

the growth plate with a metaphyseal fragment.

May lead to growth disturbances.

Principles of fracturesPrinciples of fractures Salter-Harris classificationSalter-Harris classification

Type V:Crushing of part or

all of the growth plate.

Growth disturbances and growth arrest are very common.

The most dangerous injury.

Principles of fracturesPrinciples of fractures Fracture repairFracture 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 fracturesPrinciples of fracturesHealing by callusHealing 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 fracturesPrinciples of fractures

Healing by callusHealing 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 fracturesPrinciples of fracturesHealing by callusHealing 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 fracturesPrinciples of fracturesHealing by callusHealing 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 fracturesPrinciples of fracturesHealing by callusHealing 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 fracturesPrinciples of fracturesHealing without callusHealing 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 fracturesPrinciples of fracturesCutting cones consist of: - Capillary bud (2) - Osteoclasts (1) - Osteoblasts (3) - Osteoblasts lay down new osteons (4)

Principles of fracturesPrinciples of fracturesrepair of cancellous bonerepair 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 fracturesPrinciples of fracturesRate of unionRate 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 fracturesPrinciples of fracturesRate of unionRate 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 fracturesPrinciples of fracturesApproach

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 fracturesPrinciples of fracturesapproach

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 areainspect 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 fracturesPrinciples of fracturesapproach

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 fracturesPrinciples of fracturesapproach

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 fracturesPrinciples of fracturesapproach

InvestigationImaging.

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.

Two occasions, like stress and scaphoid fractures.

Principles of fracturesPrinciples of fracturesapproach

Special views,◦ Calcaneal view, shoulder dislocation needs

axial view and acetabular fractures need 45 degree tilt view.

2-CT scan and MR.spinal, pelvic and calcaneal fractures.

3-Radioisotope scan.scaphoid and stress fractures.

Principles of fracturesPrinciples of fracturesTest 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.

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