1. Bone Fracture and healing Prof. Mamoun Kremli AlMaarefa College

2. Definition of Fracture A break in the continuity bone Often associated with soft tissue injury  Soft tissue injuries might be more serious than the fracture

3. Etiology Motor Vehicle Accident Fall Sport injuries Vigorous Exercise Bone Diseases  Osteoporosis  Osteomyelitis  Cyst, …

4. Etiology Motor Vehicle Accident Fall Sport injuries Vigorous Exercise Bone Diseases  Osteoporosis  Osteomyelitis  Cyst, …

5. Etiology Motor Vehicle Accident Fall Sport injuries Vigorous Exercise Bone Diseases  Osteoporosis  Osteomyelitis  Cyst, …

6. Etiology Motor Vehicle Accident Fall Sport injuries Vigorous Exercise Bone Diseases  Osteoporosis  Osteomyelitis  Cyst, …

7. Etiology Motor Vehicle Accident Fall Sport injuries Vigorous Exercise Bone Diseases  Osteoporosis  Osteomyelitis  Cyst, …

8. Types of Fracture Ordinary  Caused by a force  Normal bone Pathological  Caused by trivial force  Diseased (weak) bone

9. Types of Fracture Ordinary  Caused by a force  Normal bone Pathological  Caused by trivial force  Diseased (weak) bone Osteoporosis Osteomyelitis Tumour, cyst,..

10. Types of Fracture Incomplete  Fracture line is incomplete  Only one cortex is broken Complete  Fracture line is complete  Bothe cortices are broken www.childrensmemorial.org/

11. Types of Fracture Incomplete  Green-stick One cortex is broken Other cortex is bent In children Lee P et al. Radiographics 2004;24:1009-1027

12. Types of Fracture Complete  Simple: One fracture line Two bone fragments  Comminuted: More than one fracture line More than two bone fragments More soft tissue injuries

13. Types of Fracture Complete  Simple: Hairline (Fissure)  In repeated stress  e.g. march fracture in metatarsals Transverse Oblique Spiral

14. Types of Fracture Complete  Comminuted: Butterfly Segmental Multiple fragments Compression

15. Types of Fracture Undisplaced  Normal alignment maintained Displaced  Deformed from normal alignment

16. Types of Fracture Closed  Skin intact Compound (Open)  Skin not intact  Communicating to outside

17. Types of long bone fractures Metaphyseal Diapyseal Articular Epiphyseal (children)

18. Sign and Symptoms of Fracture Pain Swelling Deformity Local tenderness Loss of function

19. Diagnostic Evaluation X-ray  The most useful MRI, CT-scan  In suspected cases  In intra-articular fractures

20. Fracture Healing Stages of fracture healing:  Hematoma  Inflammation  Repair  Remodeling

21. 1. Hematoma Bleeding caused by vessel rupture  Hematoma collects  Bone at fracture edges dies Rockwood and Green

22. 2. Inflammation Inflammatory cells accumulate Inflammatory mediators (cytokines) New blood vessels proliferate Rockwood and Green

23. 2. Inflammation Mesenchymal cells accumulate  After 1 week forms granulation tissue  Osteoclasts remove necrotic bone at fragment ends  growth factors stimulate the proliferation and differentiation of mesenchymal stem cells Formation of connective tissue

24. 3. Repair Connective tissue differentiates Cartilage and fibrous tissue form  Soft callus formation (2-3 weeks)  Movement at fracture stimulates more callus Rockwood and Green

25. 3. Repair - Tissue Differentiation connective tissue granulation tissue Giemsa stain

26. 3. Repair  Vascular and cellular response leads to tissue differentiation and mineralization resulting in restoration of mechanical integrity  Fibrocartilage mineralizes (converts callus to woven bone)

27. Tissue Differentiation Cascade Cartilage formation Bone Mineral deposition Masson-Goldner

28. Callus Formation Periosteal callus  forms along the periphery of the fracture site Intramedullary callus  forms in the center of the fracture site  Endochondral ossification at the site of the fracture hematoma Chemical and mechanical factors stimulate callus formation and mineralization

29. Callus Formation Stability adequate in axial plane Angulation can still occur  fracture ends linked together by soft callus  hard callus stage starts & lasts until fragment ends are firmly united by new bone (3-4 m) www.landesbioscience.com Rockwood and Green

30. 4. Remodeling Woven bone slowly replaced by lamellar bone (few months to years)  Medullary cavity is reconstituted  Bone is restructured in response to stress and strain

31. Fracture healing - summary 1. Inflammation  Hematoma  Mesenchymal cells 2. Soft callus  Granualation tissue  Fibro-cartilage 3. Hard callus  Intramembranous bone formation  Enchondral ossification 4. Remodeling bony bridging

32. Fracture healing - summary Summary

33. Prerequisites for Bone Healing Adequate blood supply Adequate mechanical stability If either is lost:  results in delay in bone healing or no healing occurs Smoking causes delay in bone union or nonunion

34. Complications of fractures Early:  Shock  Compartment syndrome  Fat embolism  Deep vein thrombosis, embolism  Infection Delayed  Malunion  Delayed union / Nonunion

35. Complications of fractures Shock  loss of blood  Fractured femur could bleed 2L easily  Fractured Pelvis could bleed 4L easily  Open fractures with vascular injuries  What is the normal blood volume?  How much bleeding could be tolerated?

36. Complications of fractures Compartment syndrome  The compression of nerves, blood vessels, and muscle inside a closed body space (compartment)compartment  Causes tissue death from lack of oxygenation due to the blood vessels being compressed by the raised pressure within the compartment  More common in Forearm and leg (why?)

37. Complications of fractures Deep Vein Thrombosis, Embolism  Caused by Increased pressure in compartment Interrupted venous return Hematoma

38. Complications of fractures Infection:  More in open fractures Depends on amount of contamination and tissue necrosis  Possible in closed fractures

39. Complications of fractures Delayed  Malunion: deformity  Delayed union  Non-union

40. Management of fractures First aid: ABC Other injuries Cover wounds Bone immobilization Definitive treatment of fracture

41. Management of fractures Assessment  Type, location and severity of fracture  Soft tissue damage  Age and health status of patient  Affection of other parts or organs

42. Management of fractures Goals:  To regain and maintain correct position and alignment.  To regain the function of involved part.  To return the patient to usual activities in the shortest time and at the least expenses.

43. Definitive treatment of fractures Conservative  Simple fractures  More in children Operative  More complex fractures  Articular fractures  More in adults

44. Conservative - closed reduction Is the most common non surgical method for managing a simple fracture. Splints:  as upper extremity bones do not bear weight, splints may be sufficient to keep bone fragments in place.

45. Conservative - closed reduction Casts :  A cast is an immobilizing device made up of layers of plaster or fiber glass.  Allows early mobility and reduces pain

46. Conservative - closed reduction Traction:  Application of a pulling force to a part of the body  Uses a system of ropes, and weights to provide reduction, alignment and rest

47. Open reduction / internal fixation Achieves perfect reduction Permits early mobilization  It is often preferred for elderly patients who are susceptible complications of immobility  Best for adults and in intra-articular fractures  Uses pins, screws, rods, plates,..  After bone union, the metal may be removed, depending on the location and type of fracture

48. Examples of internal fixation Screws Wires Nails

49. Open reduction, internal fixation Forearm fractures in adults (Plates)

50. Nail in Tibial Fractures Intramedullary Nail

51. Plate for comminuted Femur fracture

52. Intra-articular fracture

53. External fixation Ideal for open fractures where wound care is needed and operation is hazardous  Often used temporarily until wounds recover Image from C. Turen MD

54. External fixation Nail later

55. Summary What is a fracture Types of fractures Fracture healing and requirements Management

58. Rockwood and Green