? 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. DiaphysisTypes 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. CommunitedE. Segmental
Open fracture
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Open fracture
Mechanism
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? Injury
? Repeated Trauma
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? Pathological FractureInjury
? Low velocity
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? High velocityMechanism
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Some fracture patterns reveals the dominantmechanism:
Spiral pattern- twisting
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Oblique- compressionTriangular- 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 siteRepeated trauma
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? Occur in normal bone, subject to repeated heavy loading, typical yin 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, secondariesPathological 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 consideredto 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 hematomastage 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 aroundfracture
- 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 betweenfracture 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 downintercellular 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 thefragments 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 theendosteal 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 highstresses 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 healingDirect Bone Healing
? Mechanism of bone healing seen when there
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is no motion at the fracture site (i.e. absolutestability)
? 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 BoneHealing
? 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 undergoessecondary ossification)
Direct Bone
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HealingIndirect 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 andmedul 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 - weeksQ1
? 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. thewound 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 ad. 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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Q3A 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 fracturec. 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 lateralside of ankle. What kind of fracture do you expect in the fibula?
a. Transverse fracture
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b. Spiral fracturec. Oblique fracture
d. Communited fracture
Q5
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While doing a closed nailing in a case of closed fracture shaft of femurwhat 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 healingd. None of the above