Introduction to Fractures

Ass. Prof. Dr.Zaidw.Al-Shahwanii Consultant Orth.Surgeon MB.CHB. FICMS (orth.)

Definition

A fracture is a complete or incomplete break in a bone resulting from the application of excessive force. ( i.e a fracture usually results from traumatic injury to bones causing the continuity of bone tissues or bony cartilage to be disrupted or broken ). Up to the age of 50, more men suffer from fractures than women because of occupational hazards. However, after the age of 50, more women suffer fractures than men because of osteoperosis


Fracture classifications include ;-. 1). Simple fractures (more recently called "closed") are not obvious as the skin has not been ruptured and remains intact. 2) Compound fractures (now commonly called "open") break the skin, exposing bone and causing additional soft tissue injury and possible infection.

3) complete fractures if the break is completely through the both bone cortex,, 

which can classify according to Identification of a fracture line .as in linear, oblique, transverse, longitudinal, and spiral fractures or according to the positions of bony fragments these are described as comminuted, non-displaced, impacted, overriding, angulated, displaced, avulsed, and segmental.

Mechanism of injury by the forced applied : (a) spiral pattern (twisting); (b) short oblique pattern (compression); (c) triangular ‘butterfly’ fragment (bending) & (d) transverse pattern (tension). Spiral and some (long) oblique patterns are usually due to low-energy indirect injuries; bending and transverse patterns are caused byhigh-energy direct trauma A
B
C
A
D



4) Incomplete or "greenstick“ if the fracture occurs partly across a bone shaft & it is often the result of bending or crushing forces applied to a bone. Such an angulation force tends to bend the bone at one cortex and to buckle or break it at the other, thus producing an in complete fractureThe bone is bent just like a tree branch. You can reduce the fracture by reversing the force of bending. The fracture is peculiar to children, whose bones, especially before the age of ten, are springy and resilient..

Compression fracture: 

fracture of cancellous bone (as in the vertebrae or the pelvis). It compresses the material of the cancellous bone into a smaller size. In this type of fracture because the spongy bone substance is crushed almost to powder it can't be restored fully to its original trabecular form. Thus in case of compression fracture it is wisely to accept the altered shape of the bone as permanent and to concentrate upon restoring function, rather than to attempt to restore the bone to its original form

Causes & Symptoms :-

1) External extreme truma .. individuals with a very high activity level have a greater risk of fractures. This group includes children and athletes participating in contact sports., below 50 years # more common in men <Sings & Symptoms1) intense pain Pain that prevents the use of a limb may also indicate a break. 2) Swelling due to fracture haematoma An open fracture is often accompanied by bleeding or bruising 3) Deformity misshapen limb, point to a possible fracture 4) loss of function If a leg is fractured, there will usually be difficulty bearing weight on it. 5) Numbness & parasthesia In severe fractures, there may be a loss of pulses below the fracture site and a resultant numbness, tingling, or paralysis in the feet, hands, fingers, or toes below the site. 6) Signs of shock as dizziness, sweating, disorientation, or thirst

Diagnosis Diagnosis begins immediatelyboth clinicaly & radiologicaly

1) A thorough medical history and physical exam completed by a physician 2) Observation of signs &symptoms of fractures with a history of truma 3) An x ray of the injured area is most commonly used to determine the presence of a bone fracture. Any x-ray series performed involves at least two views of the area to confirm the presence of the fracture because not all fractures are apparent on a single x ray. Some fractures are often difficult to see and may require several views at different angles, the initial x ray may not show any fractures, but if it is repeated seven to 14 days later .X-ray should always involve joint above & a joint below the injured area .Rule of Two(2 Veiw ,2 Limb,2occasion ,2 person) .

sometimes are required to demonstrate fracture ,, In the event of stress fracture(micro-fractures due to excessive stresss), a tuning fork can provide a simple, inexpensive test,, also are helpful in detecting stress fractures. In this diagnostic procedure, ,, rarly ,Bone scans, ((a radioactive tracer is injected into the bloodstream and images are taken of specific areas or the entire skeleton by CT or MRI.)), being use to detect a fractures

BONE

There are two types of bone tissue: compact and spongy. The names imply that these two types are of different density, how tightly the tissue is packed together.

There are three types of cells that contribute to bone homeostasis. Osteoblasts are bone-forming cell, osteoclasts resorb or break down bone, and osteocytes are mature bone cell,,, An equilibrium between osteoblasts &osteoclasts maintains bone tissue.

TYPES1) Healing by callus formation (secondary healing);- 

Include Phases of fracture healing There are three major phases of fracture healing, two of which can be further sub-divided to make a total of five phases; 1. Reactive Phase i. Fracture and inflammatory phase ii.Granulation tissue formation 2. Reparative Phase iii. Callus formation iv. Lamellar bone deposition 3. Remodeling Phase v. Remodeling to original bone contour

Reactive phase

After fracture, the first change seen by light and electron microscopy is the presence of blood cells within the tissues which are adjacent to the injury site. Soon after fracture, the blood vessels constrict, stopping any further bleeding..Within a few hours after fracture, these extravascular blood cells, known as a "hematoma", form a blood clot. All of the cells within the blood clot degenerate and die.. ,only the fibroblasts survive and replicate. They form a loose aggregate of tissue cells, interspersed with small blood vessels, known as granulation tissue

Reparative phaseii- Callus formation

In (3-7 )Days after fracture, the cells of the periosteum replicate and transform. The periosteal cells proximal to the fracture gap develop into chondroblasts and form hyaline cartilage. The periosteal cells distal to the fracture gap develop into osteoblasts and form woven bone( internal & external callus ). The fibroblasts within the granulation tissue also develop into chondroblasts and form hyaline cartilage .. These two new tissues grow in size until they unite with their counterparts from other pieces of the fracture. This process forms fracture callus, By the end the fracture gap is bridged by the hyaline cartilage and woven bone, restoring some of its original strength.


Cont .--- reparative phase iv. Lamellar bone deposition ( Consoldation )
5. The next phase is the replacement of the hyaline cartilage and woven bone with lamellar bone. This is known as Endochondral ossification …. 6. The lamellar bone begins forming soon after the collagen matrix of woven bone & hylain tissue becomes mineralized. By deposition of calcium & minerals ,,, a vascular channels" with many accompanying osteoblasts started then to penetrate the mineralized matrix. 7. These osteoblasts form new lamellar bone upon the recently exposed surface of the mineralized matrix. 8. This new lamellar bone is in the form of trabecular bone..Eventually, all of the woven bone and cartilage of the original fracture callus is replaced by trabecular bone, restoring most of the bone's original strength.

Remodeling

. The remodeling process substitutes the trabecular bone with compact bone. The trabecular bone is first resorbed by osteoclasts, creating a shallow resorption pit known as a "Howship's lacuna". Then osteoblasts deposit compact bone within the resorption pit. Eventually, the fracture callus is remodelled into a new shape which closely duplicates the bone's original shape and strength.

Fr. HealingReactive ph.Reparartive ph.Remodelling

Time factorRepair of fractures is a continuous process and no specific even signifies the moment of union.
Rate of repair depends on: Age: healing in children is as twice faster as in adult. Type of bone: fracture of scaphoid or neck of the femur is delayed Type of fracture: transverse fracture takes more time to heal than spiral fracture because in spiral fracture there greater fr. Surface area reacting than in transverse fracture so there are more osteoblastic and osteoclastic activity. State of blood supply & Patient general condition Proper contact and apposition of fractured fragments Adequate immobility or fixation of the fracture Absence of infection viii. Early and good management

Expected time of healing in adult UPPER limb LOWER limb
Callus visible
2-3 weeks
2-3 weeks
UNION
4-6 weeks
8-12 weeks
Consolidation
6-8 weeks
12-16 weeks
Children expected healing time is half of the adult
Causes of non-union can be: Wide separation of fractured fragments Soft tissue interposition between the fragments Poor local blood supply Excessive movement of the fractured fragments Local infection as in compound fracture or after surgical operation Continuous pull of the fragments by a muscle as in avulsion fracture of patella or olecranon. Delayed or poor management In debilitated, elderly or sometimes chronically diseased patients

2)Healing by direct repair (primary bone healing) it occurs when the fracture fragments are accurately reduced and rigidly immobilized where direct capillary growth and new bone laid across the fracture line (without callus) as in primary healing of the skin. It occurs in fracture of cancellous bone as in compression fracture or fractures that are internally or externally fixed that the fracture line is so minimal.

Ass.Prof. Dr. Zaid Al- Shahwanii Consultant Orthopedic Surgeon

Treatment

Prevention is the most effective way to avoid fractures. Wearing protective helmet, or using protective equipment, such as safety gear, while playing sports may greatly reduce the risk of a fracture a Broken bones need to be treated as soon as possible by a specializt 2)Temporary measures include applying ice packs to injured areas, and the use of aspirin or non steroidal anti-inflammatories (NSAIDS) to reduce pain and swelling. Initial first aid for a fracture may include splinting, control of blood loss, and monitoring of vital signs, such as breathing and circulation. 3) Immobilization of the fracture site can be done internally or externally Immobilization by external fixation uses splints, casts, or braces; Open reduction is surgery that is usually performed by an orthopedist Internal fixation devices, such as metal screws, plates, and pins, hold the bones in place as they heal. Open reduction is most often used for open, severe, or comminuted fractures which can be treated by external fixation . Fractures with little or no displacement of the bones do not usually require such surgery.

 The primary treatment of compound fractuers includes:-  A) Early operative debridement procedure  B) Bone stabilization
A ) Early Operative Debridement include Exploration of the wound to define the zone of injury Removal of devitalized tissue as non-viable skin and muscle, and mechanical lavag for any foreign article’s as clothes,missels & shells, mud &dirts Fasciotomy should be performed & evacuation of haematoma Removal of Small to medium-sized avascular bone fragments The initial primary traumatic wound should be left open while operative extension of the initial wound may be primarily , sutured Extensive soft tissue damage should be reinspected and additional debridement performed within24-48 hours

Bone stablization

Casting .. Traction either (skin or skeletal ) . External fixation with or without minimal internal fixation.. Internal fixation if the condition allow. are the main lines for treating a war injured patient with compound fracture

Advantage Is a simple and safe method for fracture holding, especially for the lower limb It can be used for initial and definitive stabilization and allows easy wound access and joint mobilization. It gives a rapid callus formation. Disadvantages long bed rest,leading to resp.&urinary infection plus bed sore Difficult access to the buttock and posterior aspect of thigh and leg, Male-union ((difficulties in getting a perfect alignment of the fracture)) Traction can be applied in different forms: gallows traction for femur fractures in babies up to 3 years or 15 kg of body weight, skin traction for older children & adult patient SKELETAL or pin-Traction for pelvis ,femur & tibial fracture

Traction skin or skeletal traction


External Fixators Give a very good results when correctly applied for the correct indications in most of the cases ,,but it’s not the only way to treat all fractures in war surgery,
External fixation is the primary form of initial long-bone fracture stabilization for soldiers treated in battlefield hospitals or civilian victims of explosions& accident’s Once the patient is in a stable environment, the receiving surgeon can either continue with external fixation specially if an extended periods of time are needed to deride wounds adequately,,,, or select a different treatment method for definitive treatment as intra-medullary nailing (IM-nailing)

Types of External Fixator

Indication For External Fixator
1)Open compound fracture 2)Multiple fractures 3)Fracture +vascular injuries 4) Fracture pelvis 5)Periarticular fracture 6)Bone sliding & bone lengthening 7)Pathalogical # as bone Tu. ,,osteomylitis.

Advantage of external fixator

1) easily applied considering the corridors 2) no soft tissue stripping 3) easily removed . 4)Ease the patient transfer & movement 5)Free & Mobil joint above & the joint below 6)Help other specialties to interfer. (plastic & neruo-surgery.) ,

Disadvantage of external fixator

1)Pin tract infection 2) Mal –union 3) Non-union 4) injury to neuro_vascular bundle 5)fracture through pin tract. 6)broken pin 7)losening of the clamps

Gustilo classification of Open Fr.

I - Low energy- wound less than 1 cm, minimal contamination ,comminution, and soft-tissue damage (infection rat 0-2 %) II - Wound greater than 1 cm (2-5 ) with moderate soft tissue damage, minimal periosteal stripping wound bed is moderatedly contaminated; (infected rate 2-5 %) III- High energy –wound greater ((5- 10 0r more )) with extensive soft tissue damage A - Severe soft-tissue damage and substantial contamination; coverage adequate , segmental fracture with displacement or fracture with diaphyseal segmental loss;no neuro – vascular injury (infection rate10 -15%) B - same as above + soft tissue is inadequate for cover and requires regional or free flap usually associated with major nerve injury. ( infection rat 15- 25%) C - same as the above + arterial injury ( infection rat 25-50 %)

Closed fracture To align the fragments as it is more important than perfect opposition except in intra-articular fractures where perfect reduction is a must.MethodsClosed method: reducing the fracture without opening the site of fracture. It is done for minimally displaced fracture and most fractures in children. It must be done under anaesthesia. This is done by:• Pulling on the distal fragment in the longitudinal line of the bone so that the distal fragment is away from the proximal one• Reverse the direction of the force that caused the fracture• Align any other plane displacements as nearly as possible to their correct position.2. Open reduction: if you are not successful in the previous one. Indications:• Failure to reduce the fracture by the closed method• Intra-articular fracture that requires perfect reduction• Avulsion fracture (the fragments are pulled apart by one of the muscles attached to them) e.g. in patellar fracture the fragments can be pulled by the action of quadriceps muscle. The choice of the method depends upon the site and pattern of the fracture.

B . Immobilise To hold the reduction; aiming at: 1. Relief pain 2. Prevent displacement or angulation of the fragments 3. Ensure good position for union 4. Promote soft tissue healing 5. Allow free movements of the unaffected part Methods: 1. Continuous traction; in some fractures - notably those of the shaft of the femur and certain fractures of the shaft of the tibia - it may be difficult or impossible to hold the fragments in proper position by a plaster or external splint alone. This is particularly so when the plane of the fracture is oblique or spiral, because the elastic pull of the muscles tends to draw the distal fragment proximally so that it overlaps the proximal fragment. In such a case the pull of the muscles must be balanced by continuous traction upon the distal fragment, either by weight or by some other mechanical device. 2. Cast splintage: apply POP (plaster of Paris). Plaster of Paris is hemihydrated calcium sulphate. 3. Functional bracing: it is made up of plastic material that consists of two segments joint by a hinge to avoid joint stiffness.

Gypsona consists of a leno-weave gauze fabric that is coated with a blend of the alpha and beta forms of calcium sulphate hemihydrate (plaster of Paris), together with binders and accelerators. The use of a leno-weave gauze is claimed to provide stability to the bandage, and reduce distortion and creasing during application.

4. Internal fixation: it is usually desirable in adults. It achieves good reduction and immobility and the complications will be less.Indications• Fracture that can't be treated by other mains.• Unstable fracture that is known to unite poorly• Pathological fracture• Poly-traumatised patient to decrease the risk of RDS• Fracture in a patient with nursery difficultiesMethods of internal fixation:• Plate held by scews• Bone graft held by screws• Intramedullary nail• Nail-plate (combined nail and plate)• Transfixation screws• Circumferential wires or bands• Suture through attached soft tissues

medicin san effronteriesاطباء بلا حدودAmman 2006 DIAGNOSIS OF HEALING Clinical The limb is less swollen, the bruising disappears, no abnormal movement and the patient can move the limb. Radiological X ray shows the callus and obliteration of fracture line