Fracture
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Fracture Baoheng
Definition of fracture
A fracture is present when there is loss of continuity in the substance of a bone
A fracture is defined as a linear deformation or discontinuity of bone produced by forces that exceed the ultimate strength of the material
Causes of fractures
Direct force In these instances a force which the bone cannot resist applied at or near the site of fracture. Indirect force Most fractures result when force is transmitted from a distant point of impact to a site where the bone fails. Fatigue fractures Stresses,repeated with excessive frequency to a bone, may result in fracture
Classification of fractures
Closed fracture. Fracture that does not communicate with the outside.
Open fracture. Fracture that communicates with the external environment.
Incomplete fractures
Hairline fractures: result from minimal
trauma which is just great enough to produce a fracture but not severe enough to produce any significant displacement of the fragments.
Greenstick fractures: occur in children.
The less brittle bone of the child tends to buckle on the side opposite the causal force. Tearing of the periosteum and of the surrounding soft tissues is often minimal.
Greenstick fractures
Complete fractures
Transverse fractures: The fractures run either at right angles to the long axis of a bone, or with an obliquity of less than 30°. Oblique fractures: The fractures run at an obliquity angle of 30° or more. Spiral fractures: The line of the fracture curves round the bone in a spiral. Comminuted fractures: there are more than two fragments.
Complete fractures
Impacted fractures: A fracture is impacted when one fragment is driven into the other. Compression fractures: occur in cancellous bone which is compressed beyond the limits of tolerance. Depressed fractures: occur when a sharply localised blow depresses a segment Epiphyseal Separation: a break in the region of the epiphyseal plate (physis, growth plate) of the child. This may damage the growing bone and result in angular and/or length discrepancy.
Pathological Fracture
a break in a bone weakened by disease such as osteoporosis, infection, or a bone cyst. Less force is required to produce these fractures than to produce one in a normal bone.
Stable fractures: Hairline fractures,
greenstick fractures, impacted fractures, compression fractures,et al.
Unstable fractures: Oblique fractures, spiral fractures, comminuted fractures
Displacement
Angulation
Shortening
Seperation
Axial rotation
Lateral displacement
The clinical manifestations
General:
Shock
Fever
Local: Pain, swelling, difficulty using or moving the injured area in a normal manner Deformity,abnormal movement,crepitus
Radiographic examination
Two plane: AP and lateral Two side: Comparison Two times Two joints:
SCT
MRI
Introsseous fracture
This 39 y/o female fell off a ladder. Approximately two weeks after the injury she presented with heel pain. Selected plain xray and MRI images are shown above. The decreased T1 signal and increased T2 signal within the calcaneus are consistent with an occult intraosseous fracture. The suspected basic pathology is trabecular disruption with edema and hemorrhage.
Complications
Immediate complications shock Hemorrhage, Damage to arteries and nerves Damage to surrounding soft tissues
Christopher Reeve
Early complications
Wound infection Fat embolism: FES results when embolic marrow fat macroglobules damage small vessel perfusion leading to endothelial damage in pulmonary capillary beds leading to respiratory failure and ARDS like picture DIC( Disseminated intravascular coagulation ) Exacerbation of general illness. Compartment syndrome
Compartment syndrome
The cardinal signs of pain, pallor, pulselessness, and paresthesias are present to variable degrees. Pain with passive stretch of muscles is one of the more reliable indicators of compartment syndrome, and accurate diagnosis is readily made by measurement of intracompartmental pressures using a slit catheter. Pressures in the range of 30 to 40 mmHg constitute an indication for fasciotomy.
In
patients with prolonged ischemia due to arterial compromise, prophylactic fasciotomies of all compartments distal to the vascular injury should be done concomitantly with reestablishment of perfusion, regardless of whether signs of compartment syndrome are present.
Late complications,
Bed sores Deformity, Anchylosis Osteoarthritis Aseptic necrosis Ischemic contracture Hypostatic pneumonia Traumatic chondromalacia Reflex sympathetic dystrophy
Bone healing process
Bone is a dynamic biological tissue composed of metabolically active cells that are integrated into a rigid framework.
Bone healing process
Healing occurs in three distinct but overlapping stages: 1) the early inflammatory stage; 2) the repair stage; 3) the late remodeling stage.
In the inflammatory stage, a hematoma develops within the fracture site during the first few hours and days. Inflammatory cells (macrophages, monocytes, lymphocytes, and polymorphonuclear cells) and fibroblasts infiltrate the bone under prostaglandin mediation.
This results in the formation of granulation tissue, ingrowth of vascular tissue, and migration of mesenchymal cells.
The primary nutrient and oxygen supply of this early process is provided by the exposed cancellous bone and muscle.
The use of antiinflammatory or cytotoxic medication during this 1st week may alter the inflammatory response and inhibit bone healing.
As vascular ingrowth progresses, a collagen matrix is laid down while osteoid is secreted and subsequently mineralized,which leads to the formation of a soft callusaround the repair site.
Eventually, the callus ossifies, forming a bridge of woven bone between the fracture fragments. Alternatively, if proper immobilization is not used, ossification of the callus may not occur,and an unstable fibrous union may develop instead.
Fracture healing is completed during the remodeling stage in which the healing bone is restored to its original shape, structure, and mechanical strength. Remodeling of the bone occurs slowly over months to years and is facilitated by mechanical stress placed on the bone.
As the fracture site is exposed to an axial loading force, bone is generallylaid down where it is needed and resorbed from where it is not needed. Adequate strength is typically achieved in 3 to 6 months.
Definition of fracture
A fracture is present when there is loss of continuity in the substance of a bone
A fracture is defined as a linear deformation or discontinuity of bone produced by forces that exceed the ultimate strength of the material
Causes of fractures
Direct force In these instances a force which the bone cannot resist applied at or near the site of fracture. Indirect force Most fractures result when force is transmitted from a distant point of impact to a site where the bone fails. Fatigue fractures Stresses,repeated with excessive frequency to a bone, may result in fracture
Classification of fractures
Closed fracture. Fracture that does not communicate with the outside.
Open fracture. Fracture that communicates with the external environment.
Incomplete fractures
Hairline fractures: result from minimal
trauma which is just great enough to produce a fracture but not severe enough to produce any significant displacement of the fragments.
Greenstick fractures: occur in children.
The less brittle bone of the child tends to buckle on the side opposite the causal force. Tearing of the periosteum and of the surrounding soft tissues is often minimal.
Greenstick fractures
Complete fractures
Transverse fractures: The fractures run either at right angles to the long axis of a bone, or with an obliquity of less than 30°. Oblique fractures: The fractures run at an obliquity angle of 30° or more. Spiral fractures: The line of the fracture curves round the bone in a spiral. Comminuted fractures: there are more than two fragments.
Complete fractures
Impacted fractures: A fracture is impacted when one fragment is driven into the other. Compression fractures: occur in cancellous bone which is compressed beyond the limits of tolerance. Depressed fractures: occur when a sharply localised blow depresses a segment Epiphyseal Separation: a break in the region of the epiphyseal plate (physis, growth plate) of the child. This may damage the growing bone and result in angular and/or length discrepancy.
Pathological Fracture
a break in a bone weakened by disease such as osteoporosis, infection, or a bone cyst. Less force is required to produce these fractures than to produce one in a normal bone.
Stable fractures: Hairline fractures,
greenstick fractures, impacted fractures, compression fractures,et al.
Unstable fractures: Oblique fractures, spiral fractures, comminuted fractures
Displacement
Angulation
Shortening
Seperation
Axial rotation
Lateral displacement
The clinical manifestations
General:
Shock
Fever
Local: Pain, swelling, difficulty using or moving the injured area in a normal manner Deformity,abnormal movement,crepitus
Radiographic examination
Two plane: AP and lateral Two side: Comparison Two times Two joints:
SCT
MRI
Introsseous fracture
This 39 y/o female fell off a ladder. Approximately two weeks after the injury she presented with heel pain. Selected plain xray and MRI images are shown above. The decreased T1 signal and increased T2 signal within the calcaneus are consistent with an occult intraosseous fracture. The suspected basic pathology is trabecular disruption with edema and hemorrhage.
Complications
Immediate complications shock Hemorrhage, Damage to arteries and nerves Damage to surrounding soft tissues
Christopher Reeve
Early complications
Wound infection Fat embolism: FES results when embolic marrow fat macroglobules damage small vessel perfusion leading to endothelial damage in pulmonary capillary beds leading to respiratory failure and ARDS like picture DIC( Disseminated intravascular coagulation ) Exacerbation of general illness. Compartment syndrome
Compartment syndrome
The cardinal signs of pain, pallor, pulselessness, and paresthesias are present to variable degrees. Pain with passive stretch of muscles is one of the more reliable indicators of compartment syndrome, and accurate diagnosis is readily made by measurement of intracompartmental pressures using a slit catheter. Pressures in the range of 30 to 40 mmHg constitute an indication for fasciotomy.
In
patients with prolonged ischemia due to arterial compromise, prophylactic fasciotomies of all compartments distal to the vascular injury should be done concomitantly with reestablishment of perfusion, regardless of whether signs of compartment syndrome are present.
Late complications,
Bed sores Deformity, Anchylosis Osteoarthritis Aseptic necrosis Ischemic contracture Hypostatic pneumonia Traumatic chondromalacia Reflex sympathetic dystrophy
Bone healing process
Bone is a dynamic biological tissue composed of metabolically active cells that are integrated into a rigid framework.
Bone healing process
Healing occurs in three distinct but overlapping stages: 1) the early inflammatory stage; 2) the repair stage; 3) the late remodeling stage.
In the inflammatory stage, a hematoma develops within the fracture site during the first few hours and days. Inflammatory cells (macrophages, monocytes, lymphocytes, and polymorphonuclear cells) and fibroblasts infiltrate the bone under prostaglandin mediation.
This results in the formation of granulation tissue, ingrowth of vascular tissue, and migration of mesenchymal cells.
The primary nutrient and oxygen supply of this early process is provided by the exposed cancellous bone and muscle.
The use of antiinflammatory or cytotoxic medication during this 1st week may alter the inflammatory response and inhibit bone healing.
As vascular ingrowth progresses, a collagen matrix is laid down while osteoid is secreted and subsequently mineralized,which leads to the formation of a soft callusaround the repair site.
Eventually, the callus ossifies, forming a bridge of woven bone between the fracture fragments. Alternatively, if proper immobilization is not used, ossification of the callus may not occur,and an unstable fibrous union may develop instead.
Fracture healing is completed during the remodeling stage in which the healing bone is restored to its original shape, structure, and mechanical strength. Remodeling of the bone occurs slowly over months to years and is facilitated by mechanical stress placed on the bone.
As the fracture site is exposed to an axial loading force, bone is generallylaid down where it is needed and resorbed from where it is not needed. Adequate strength is typically achieved in 3 to 6 months.
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