Download MBBS Orthopaedics PPT 8 General Outline of Fractures And Fracture Healing Lecture Notes

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Learning objectives

? Anatomy

? Types of fractures

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? Mechanism of injury

? Morphology of various fracture types

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? General healing principles

? Types of healing

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Anatomy

? Bone has been divided into-
a. Epiphysis
b. Metaphysis

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c. Diaphysis

Types of bone

? Cancellous/Spongy

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? Cortical/Compact


Fractures

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? Break in the structural continuity of bone

Types of Fracture

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? Divided into

? Complete
? Incomplete

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Types of Fractures

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? Based on aetiology-
A. Traumatic
B. Pathological
C. Stress

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Types of fractures

? Based on Displacement-
A. Undisplaced
B. Displaced- Translation,

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angulation, twisting


Types of Fractures

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? Based on relationship to external environment

A. Closed

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B. Open

? Based on Pattern

A. Spiral

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B. Oblique

C. Transverse

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D. Communited

E. Segmental

Open fracture

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Open fracture

Mechanism

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? Injury

? Repeated Trauma

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? Pathological Fracture
Injury

? Low velocity

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? High velocity


Mechanism

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Some fracture patterns reveals the dominant

mechanism:

Spiral pattern- twisting

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Oblique- compression
Triangular- bending
Transverse- tension

Extent of displacement

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? Force of injury

? Effects of gravity

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? Pull of muscles attached to site


Repeated trauma

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? Occur in normal bone, subject to repeated heavy loading, typical y

in athletes, dancers or military personnel.

? Drugs like steroids and methotrexate

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Stress fracture
PATHOLOGICAL FRACTURES

? Occurs in a bone that is made weak by some disease.

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? Causes-

Inflammatory- Osteomyelitis

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Neoplastic- giant cell tumor, Ewing's sarcoma, secondaries

Pathological fracture

? Miscel aneous bone conditions- simple bone cyst, anuerysmal bone

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cyst, metastasis

? Hereditary- Osteogenesis imperfecta, Osteopetrosis

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? Other acquired generalised diseases- Osteoporosis, osteomalacia,

rickets
Pathological fracture

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Fracture healing

? Process of proliferative physiological process in which body

facilitates healing with various cells and growth factors

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? Cells- Osteoblast, Osteoclast main cells

? Various growth factors

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HISTORY

?

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In 1975, Cruess and Dumont proposed that fracture healing may be considered

to consist of three overlapping phases: an inflammatory phase, a

reparative phase, and a remodeling phase

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? In 1989, FROST proposed the stages of fracture healing

five stages.

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stage of hematoma
stage of granulation tissue
stage of cal us
stage of consolidation
stage of remodel ing

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HEALING BY CALLUS

? STAGE 1: TISSUE DESTRUCTION AND

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HEMATOMA FORMATION

- lasts for 7 days
- blood leaks out of torn vessels and forms

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a hematoma between and around
fracture

- periosteum and local soft tissues are

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stripped off

- ischaemic necrosis ? death of some

osteocytes with sensitization of the

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remaining precursor cel s


? STAGE 2: INFLAMMATION AND CELLULAR

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PROLIFERATION/GRANULATION TISSUE

- lasts for 2-3 weeks
- precursor cel s form cel s that

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differentiate and organize to provide

vessels, fibroblasts, osteoblasts etc

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- soft granulation tissue formed between

fracture fragments, providing anchorage

to fracture

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- hematoma is slowly absorbed and fine

new capillaries grow into the area

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? STAGE 3: CALLUS FORMATION

- lasts for 4-12 weeks
- granulation tissue differentiates and

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creates osteoblasts, laying down

intercellular matrix impregnated with

calcium salts

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- formation of callus/woven bone
- provides good strength to the fracture,

decreasing the movements at the fracture

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site and causes union in about 4 weeks
? STAGE 4: CONSOLIDATION

- takes 1-4 years for the bone to become

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strong enough to carry weight

- with continuing osteoclastic and

osteoblastic activities, the woven bone

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gets transformed into lamel ar bone

- osteoblasts fill in the remaining gap

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between the new bone and the

fragments to strengthen the bone

? STAGE 5: REMODELLING

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- stage where the bone is gradually

strengthened

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- shapening of the cortices occurs at the

endosteal and periosteal surfaces

- al these occur when the person starts

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resuming his activities ie bearing weight

and muscle forces

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- thicker lamel ae are laid down where high

stresses are present, unwanted buttresses

are carved away and medullary cavity is

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reformed
Types for Bone Healing

? Direct (primary) bone healing

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? Indirect (secondary) bone healing
Direct Bone Healing

? Mechanism of bone healing seen when there

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is no motion at the fracture site (i.e. absolute

stability)

? Does not involve formation of fracture callus

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? Osteoblasts originate from endothelial and

perivascular cells

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Components of Direct Bone

Healing

? Contact Healing

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? Direct contact between the fracture ends al ows healing

to be with lamel ar bone immediately

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? Gap Healing

? Gaps less than 200-500 microns are primarily fil ed with

woven bone that is subsequently remodeled into lamel ar

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bone

? Larger gaps are healed by indirect bone healing

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(partial y fil ed with fibrous tissue that undergoes

secondary ossification)
Direct Bone

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Healing

Indirect Bone Healing

? Mechanism for healing in fractures that

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have some motion, but not enough to

disrupt the healing process.

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? Bridging periosteal (soft) cal us and

medul ary (hard) cal us re-establish

structural continuity

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? Cal us subsequently undergoes

endochondral ossification

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? Process fairly rapid - weeks
Q1

? A patient has come to our emergency with fracture tibia of right side

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with wound on anteriomedial aspect of shin of tibia of 3 cm. the

wound can be closed by primary suturing as appear on secondary

examination. Patient had an rta 2 hours back. Please classify the

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fracture according to gustilo Anderson classification?

a. Grade I
b. Grade II

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c. Grade II a
d. Grade II b

Q2

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? How is direct fracture healing differ from indirect fracture healing?
a. Stage of hematoma
b. Stage of callus formation
c. Stage of remodeling
d. Stage of consolidation

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Q3

A 70 year old male patient developed pain in his left shoulder while

turning in bed. He is a known case of pulmonary malignancy and is on

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chemotherapy for the same. Xray shows a lytic lesion in the proximal

humerus with a fracture. How will you classify this fracture/
a. Traumatic fracture

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b. Pathological fracture
c. Stress fracture
d. None of the above

Q4

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? A football player twisted his ankle when his foot got stuck in the ditch

on the ground. The foot was fixed and the whole weight of the body

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acted on the ankle. If he has swelling and tenderness on the lateral

side of ankle. What kind of fracture do you expect in the fibula?

a. Transverse fracture

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b. Spiral fracture
c. Oblique fracture
d. Communited fracture
Q5

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While doing a closed nailing in a case of closed fracture shaft of femur

what kind of healing do you expect in this case?
a. Direct healing
b. Indirect healing

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c. Combination of direct and indirect healing
d. None of the above