1. Fracture and fracture healing Jongkolnee Settakorn, MD, MSc, FRCPath

2. Objectives บอกลักษณะของ bone fracture ชนิด ต่างๆ * วินิจฉัย bone fracture แบบง่ายๆ จาก การดู film x-ray * บอกกลไก fracture healing * บอกปัจจัยที่เกี่ยวข้องกับ fracture healing * ทราบภาวะแทรกซ้อนของ bone fracture สามารถประมวลความรู้ทั้งหมดเข้าด้วยกัน เพื่อประยุกต์ใช้กับผู้ป่วยต่อไปในอนาคต

3. Scopes Description of bone fracture Mechanism and incidence of bone fracture Fracture healing Treatment Complication

4. Bone fracture (broken bone) Definition: –A disruption in the integrity of a living bone –A break in the continuity of bone Involving –Bone strength –Site of bone –Force –Direction of force

5. Description of bone fracture

6. Common terms used to describe fractures Bone, location Skin integrity Extent Displacement Angulation Rotation Morphology Energy Joint involvement Soft tissue involvement

7. Site Bone names (femur, tibia,..) Bone location Proximal Shaft Distal Epiphysis Metaphysis Diaphysis Growth plate http://www.nytimes.com/imagepages/2007/08/01/health/adam/8856Fracturetypes2.html

8. http://www.drrathresearch.org/clinical_studies/condition_bonefracture_print.html

9. Skin Closed fracture (intact skin) Open fracture (wound on skin with bone exposure) http://www.lamrt.org.uk/incidents05.html

10. Extent –Complete fracture: separate completely –Incomplete (greenstick) fracture: partially joined

11. http://www.nytimes.com/imagepages/2007/08/01/health/adam/8856Fracturetypes2.html

12. Displacement Anterior Posterior Medial Lateral Proximal  shortening (gapping) Distal  lengthening (gapping)

13. http://www.merck.com/mmpe/sec21/ch309/ch309b.html

14. Angulation and rotation Anterior angulation Posterior angulation Medial angulation Lateral angulation Internal rotation External rotation

15. http://www.merck.com/mmpe/sec21/ch309/ch309b.html

16. Morphology Linear fracture: parallel to long axis of bone Transverse fracture: cut cross the long axis Oblique fracture: diagonal to the long axis Spiral fracture: twisted Compression fracture: common in vertebrae Compact (impacted) fracture: bone fragments are driven into each other Pathologic fracture: with underlying bone lesion

17. http://www.merck.com/mmpe/sec21/ch309/ch309b.html

18. Energy Low energy: simple fracture (one line, two pieces) High energy: multi-fragmentary fracture or comminuted fracture

19. http://www.nytimes.com/slideshow/2007/08/01/health/ 100077Bonefracturerepairseries_3.html

21. Joint and growth plate involvement Extraarticular Intraarticular

22. http://www.merck.com/mmpe/sec21/ch309/ch309b.html

23. Soft tissue involvement: nerve, vessel, muscle, fat, skin damage http://www.emedicine.com/Orthoped/topic636.htm

25. Classification of fracture, for Communication among clinicians Decision making Potential problems Treatment options Predicting outcome Documentating cases

26. OTA Classification Oestern and Tscherne Classification of closed fractures Gustilo and Anderson classification of open fractures Salter-Harris classification of epiphyseal plate injury

27. OTA Classification The Orthopaedic Trauma Association Classification system to describe the injury accurately and guide treatment Standard for orthopedics surgeon Classification adaptable to the entire skeletal system Allows consistency in research

28. To Classify a Fracture: OTA Which bone? Where in the bone is the fracture? Which type? Which group? Which subgroup?

29. Oestern and Tscherne Classification of closed fractures GradeSoft tissue injuryBony injury 0MinimalSimple fracture pattern Indirect injury to limb 1Superficial abrasion/Mild fracture pattern contusion 2Deep abrasion with skinSevere fracture pattern or muscle contusion Direct trauma to limb 3Extensive skin contusionSevere fracture pattern or crush Severe damage to underlying muscle Subcutaneous avulsion, compartmental syndrome

30. Gustilo and Anderson classification of open fractures (type I – type III) Type I: –Clean wound smaller than 1 cm in diameter –Simple fracture pattern –No skin crushing Type II: –a laceration larger than 1 cm –No significant soft tissue crushing –Fracture pattern may be more complex.

31. Gustilo type I

32. Type III: –Contamination : soil,water, yard,fecal –Open segmental fracture or a single fracture with extensive soft tissue injury –Any opened fracture older than 8 hours Type IIIA: adequate soft tissue coverage of the fracture despite high energy trauma or extensive laceration or skin flaps. Type IIIB: inadequate soft tissue coverage with periosteal stripping. Soft tissue reconstruction is necessary. Type IIIC: any open fracture that is associated with vascular injury that requires repair.

33. Gustilo typeIII

34. Salter-Harris classification of epiphyseal plate injury

36. Mechanism and incidence of fracture

42. http://orthoinfo.aaos.org/topic.cfm?topic=a00412 Fracture distal radius, Colles fracture

45. http://thedoctornotes.blogspot.com/2008/04/ilizarov-method-2.html Opened fracture right tibial shaft

48. Fracture healing

49. Prerequisites for Bone Healing Adequate blood supply Adequate mechanical stability Proper bone metabolism Periosteum Bone marrow

50. Fracture healing process Absolute stability : Direct (primary) bone healing: rigidly stabilized fracture with fracture surface held in contact eg. transverse diaphyseal fracture of radius and ulnar treated by ORIF Relative stability : Indirect (secondary) bone healing: unstable closed fracture, not rigidly stabilized eg. closed clavicle fracture without surgery Inadequate stability : non union (pseudoarthrosis)

51. 1. Healing with absolute stability - Rigidly contact between bone ends - Gaps

52. Rigidly contact between bone ends Lamellar bone can form directly across the fracture line –A cluster of osteoclasts cut across the fracture line –Osteoblasts (following the osteoclasts) deposit new bone –Blood vessels follow the osteoblasts –New haversian system formation

53. Gaps between bone ends Prevent direct extension of osteoclast –A Osteoblasts fill the defects with woven bone –A cluster of osteoclasts cut across the woven bone –Osteoblasts (following the osteoclasts) deposit new bone –Blood vessels follow the osteoblasts –New haversian system formation

54. 2. Healing with relative stability - Hematoma - Granulation tissue - Soft callus - Hard callus - Remodeling

55. Hematoma between the fracture ends, in medullary canal, subperiosteal, around bone Death bone at both ends of fracture site due to loss of nutrition Inflammatory mediators from platelets, dead cells Inflammtory cells migrate to the fracture site  cytokine  angiogenesis and stem cells migration  fibroblasts, chondroblasts, osteoblasts Vascular dilatation  edema Granulation tissue formation

58. Primitive mesenchymal cells (stem cells) at fracture site  proliferation / differentiation into fibroblasts, chondroblasts, osteoblasts =Soft callus= Matrix (collagen, woven bone, cartilage) = Cartilaginous callus = Bone replaces cartilage by enchondral ossification = hard callus =

61. =Remodeling = Replacement of woven bone by lamellar bone - Osteoclastic resorption - Formation of new bone along line of stress

64. http://www.bonefixator.com/

66. Variables that influence fracture healing Injury variables Patients variables Tissue variables Treatment variables

67. Injury variables Open fractures Segmental fractures Intra-articular fracture Severity of injury Soft tissue interposition Damage to blood supply Single limb or multiple injuries

68. Patient variables Age Co-morbidities e.g. diabetes Nutrition Systemic hormones Drugs Nicotine and other agents

69. Tissue variables Bone necrosis Bone disease Infection Supply

70. Treatment variables Apposition of fracture fragments Loading and micromotion Fracture stabilization Treatments that interferes with healing

71. Treatment and complication

72. Treatment General aim of management –Control hemorrhage –Pain relief –Prevent ischemia-reperfusion injury –Remove contamination –Reduction –Immobilization For maximal function and minimized complication

73. Treatment Non operative therapy –Casting after an appropriate closed reduction –Traction (rarely used) Skin traction Skeletal traction Surgical therapy –Open reduction and internal fixation (ORIF) Kirschner wires (K-wires) Plates and screws Intramedullary nails –External fixation

74. :www.flickr.com/photos/onepointzero/529498016/www.flickr.com/photos/onepointzero/529498016/

75. http://www.emedicine.com/Orthoped/topic636.htm

77. หน้า : www.rad.washington.edu/.../orthopedic-hardwarewww.rad.washington.edu/.../orthopedic-hardware

78. http://www.emedicine.com/Orthoped/topic636.htm

80. Complications of fracture Neurologic and vascular injury Compartment syndrome: anterior leg Infection: open fracture and surgery Thromboembolic events Avascular necrosis: femoral head and neck Post-traumatic arthritis Delay union, non-union, malunion

81. Complications Cast –Pressure ulcers –Thermal burns –Thrombophlebitis –Prolonged cast disease: circulatory disturbances, inflammation, osteoporosis, chronic edema, soft tissue atrophy, joint stiffness

82. Complications Traction  lack of patient mobility –Pressure ulcers –Pulmonary / Urinary infection –Permanent footdrop contracture –Peroneal nerve palsy –Pin tract infection –Thromboembolic events (deep vein thrombosis, pulmonary embolism)

83. Complications External fixator –Pin tract infection –Pin loosening or breakage –Interference with joint motion –Neurovascular damage –Malalignment –Delay union or malunion