Fracture and fracture
healing
Jongkolnee Settakorn, MD, MSc,
FRCPath
Objectives
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บอกลักษณะของ bone fracture ชนิดต่ างๆ *
วินิจฉัย bone fracture แบบง่ ายๆ จากการดู film x-ray *
บอกกลไก fracture healing *
บอกปั จจัยที่เกี่ยวข้ องกับ fracture healing *
ทราบภาวะแทรกซ้ อนของ bone fracture
สามารถประมวลความรู้ทงั ้ หมดเข้ าด้ วยกัน เพื่อประยุกต์ ใช้ กับ
ผู้ป่วยต่ อไปในอนาคต
Scopes
• Description of bone fracture
• Mechanism and incidence of bone
fracture
• Fracture healing
• Treatment
• Complication
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
Description of bone fracture
Common terms used to describe
fractures
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Bone, location
Skin integrity
Extent
Displacement
Angulation
Rotation
Morphology
Energy
Joint involvement
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
http://www.drrathresearch.org/clinical_studies/condition_bonefracture_print.html
Skin
• Closed fracture (intact skin)
• Open fracture (wound on skin with bone
http://www.lamrt.org.uk/incidents05.html
exposure)
Extent
– Complete fracture: separate completely
– Incomplete (greenstick) fracture:
partially joined
http://www.nytimes.com/imagepages/2007/08/01/health/adam/8856Fracturetypes2.html
Displacement
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Anterior
Posterior
Medial
Lateral
• Proximal  shortening (gapping)
• Distal  lengthening (gapping)
http://www.merck.com/mmpe/sec21/ch309/ch309b.html
Angulation and rotation
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Anterior angulation
Posterior angulation
Medial angulation
Lateral angulation
• Internal rotation
• External rotation
http://www.merck.com/mmpe/sec21/ch309/ch309b.html
Morphology
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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
http://www.merck.com/mmpe/sec21/ch309/ch309b.html
Energy
• Low energy: simple fracture (one line, two
pieces)
• High energy: multi-fragmentary fracture or
comminuted fracture
http://www.nytimes.com/slideshow/2007/08/01/health/
100077Bonefracturerepairseries_3.html
Joint and growth plate involvement
• Extraarticular
• Intraarticular
http://www.merck.com/mmpe/sec21/ch309/ch309b.html
Soft tissue involvement: nerve, vessel,
muscle, fat, skin damage
http://www.emedicine.com/Orthoped/topic636.htm
Classification of fracture, for
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Communication among clinicians
Decision making
Potential problems
Treatment options
Predicting outcome
Documentating cases
• OTA Classification
• Oestern and Tscherne Classification of
closed fractures
• Gustilo and Anderson classification of open
fractures
• Salter-Harris classification of epiphyseal
plate injury
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
To Classify a Fracture: OTA
• Which bone?
• Where in the bone
is the fracture?
• Which type?
• Which group?
• Which subgroup?
Oestern and Tscherne Classification of
closed fractures
Grade Soft tissue injury
Bony injury
0
Minimal
Simple fracture pattern
Indirect injury to limb
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Superficial abrasion/
Mild fracture pattern
contusion
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Deep abrasion with skin Severe fracture pattern
or muscle contusion
Direct trauma to limb
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Extensive skin contusion Severe fracture pattern
or crush
Severe damage to underlying muscle
Subcutaneous avulsion, compartmental syndrome
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.
Gustilo type I
• 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
Gustilo typeIII
Salter-Harris classification
of epiphyseal plate injury
Mechanism and incidence of fracture
Fracture distal radius, Colles fracture
http://orthoinfo.aaos.org/topic.cfm?topic=a00412
Opened fracture right tibial shaft
http://thedoctornotes.blogspot.com/2008/04/ilizarov-method-2.html
Fracture healing
Prerequisites for Bone Healing
• Adequate blood supply
• Adequate mechanical
stability
• Proper bone metabolism
• Periosteum
• Bone marrow
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
1. Healing with absolute stability
- Rigidly contact between bone ends
- Gaps
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
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
2. Healing with relative stability
- Hematoma
- Granulation tissue
- Soft callus
- Hard callus
- Remodeling
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
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 =
=Remodeling =
Replacement of woven bone by lamellar bone
- Osteoclastic resorption
- Formation of new bone along line of stress
http://www.bonefixator.com/
Variables that influence fracture
healing
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Injury variables
Patients variables
Tissue variables
Treatment variables
Injury variables
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Open fractures
Segmental fractures
Intra-articular fracture
Severity of injury
Soft tissue interposition
Damage to blood supply
Single limb or multiple injuries
Patient variables
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Age
Co-morbidities e.g. diabetes
Nutrition
Systemic hormones
Drugs
Nicotine and other agents
Tissue variables
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Bone necrosis
Bone disease
Infection
Supply
Treatment variables
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Apposition of fracture fragments
Loading and micromotion
Fracture stabilization
Treatments that interferes with healing
Treatment and complication
Treatment
• General aim of management
– Control hemorrhage
– Pain relief
– Prevent ischemia-reperfusion injury
– Remove contamination
– Reduction
– Immobilization
• For maximal function and minimized
complication
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
:www.flickr.com/photos/onepointzero/529498016/
http://www.emedicine.com/Orthoped/topic636.htm
http://www.emedicine.com/Orthoped/topic636.htm
หน้า: www.rad.washington.edu/.../orthopedic-hardware
http://www.emedicine.com/Orthoped/topic636.htm
http://www.emedicine.com/Orthoped/topic636.htm
Complications of fracture
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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
Complications
• Cast
– Pressure ulcers
– Thermal burns
– Thrombophlebitis
– Prolonged cast disease: circulatory
disturbances, inflammation, osteoporosis,
chronic edema, soft tissue atrophy, joint
stiffness
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)
Complications
• External fixator
– Pin tract infection
– Pin loosening or breakage
– Interference with joint motion
– Neurovascular damage
– Malalignment
– Delay union or malunion