Lec.

1: Principles of Fracture
A fracture is a break in the structural continuity of bone.

Classifications:

 Complete and incomplete fractures

 According to fractures’ etiology
 Open and closed fractures

If the overlying skin remains intact, it is a closed (or simple) fracture; if the
skin or one of the body cavities is breached; it is an open (or compound)
fracture, liable to contamination and infection.

Pathology of fractures:

Fractures result from:

1. A single highly stressful, traumatic incident;

2. Repetitive stress of normal degree persisting to the point of mechanical
fatigue; or
3. Normal stress acting on abnormally weakened bone (a so-called
'pathological' fracture).
 Note: causes include tumors (primary or secondary [more
common]; metabolic conditions such as hyperparathyroidism,
Paget’s disease, and osteoporosis (most common); inflammatory
conditions such as osteomyelitis; cystic changes; etc.

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Types of fractures:

1) Complete fractures. The bone is completely broken into two or more

fragments. These types of fractures may be:
 Transverse,
 Oblique,
 Spiral,
 Impacted fracture (the fragments are jammed tightly together and the
fracture line is indistinct).
 A comminuted fracture is one in which there are more than two
fragments; because there is poor interlocking of the fragments, these
fractures are often unstable.

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Note: An avulsion fracture occurs when a tendon responds to a strong muscle
contraction by pulling off the piece of bone to which it is attached.

Note: a segmental fracture consists of a segment of the shaft isolated by

proximal and distal lines of fracture.

2) Incomplete fractures. The bone is incompletely divided and the

periosteum remains in continuity. These types of fractures may be:

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  A greenstick fracture: the bone is buckled or bent (like snapping
a green twig); this is seen in children.
 Stress fractures also may be incomplete, with the break initially
appearing in only one part of the cortex.
 Compression fractures occur when cancellous bone is crumpled.
This happens in adults, especially in the vertebral bodies.

3) Physeal fractures. Fractures through the growing physis

are a special case. Damage to the cartilaginous growth plate may
give rise to progressive deformity out of all proportion to the
apparent severity of the injury.

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Note: Most open fractures are caused by some type of high-energy event—
such as a gunshot or motor vehicle accident.

Fractures displacement:

After a complete fracture the fragments usually become displaced, partly by

the force of the injury, partly by gravity and partly by the pull of muscles
attached to them.

Types of displacement are:

1. Translation (shift): The fragments may be shifted sideways,
backward or forward in relation to each other, such that the
fracture surfaces lose contact.
2. Alignment (angulation)
3. Rotation (twist)
4. Altered length: The fragments may be distracted and separated, or
they may overlap, due to muscle spasm, causing shortening of the
bone.

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Soft-tissue damage:

 Low-energy (low-velocity) fractures cause only moderate soft-tissue

damage; the classic example is a closed spiral fracture.
 High-energy (high-velocity) Fractures cause severe damage; examples are
segmental and comminuted fractures.

Fracture healing:

Fractures heal by two different methods: with callus or without.

1) Healing by callus: in the tubular bone and in absence of rigid fixation,

healing proceeds in five stages:

1. Tissue destruction and hematoma formation: Vessels are torn and

a hematoma forms around and within the fracture.
2. Inflammation and cellular proliferation: Within 8 hours of the
fracture there is an acute inflammatory reaction with proliferation
of cells under the periosteum and within the breached medullary
canal (note: the inflammatory cells clean up dead tissue)
3. Callus formation: The thick cellular mass, with its islands of
immature bone and cartilage, forms the callus or splint on the
periosteal and endosteal surfaces.
 Note: Fibroblasts from the periosteum invade the fracture site
and produce collagen fibers. In addition, cells from the
periosteum develop into chondroblasts and begin to produce
fibrocartilage in this region. These events lead to the
development of a fibrocartilaginous (soft) callus, a mass of
repair tissue consisting of collagen fibers and cartilage that
bridges the broken ends of the bone. In areas closer to well-
vascularized healthy bone tissue, osteoprogenitor cells
develop into osteoblasts, which begin to produce spongy
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 bone trabeculae. The trabeculae join living and dead portions
of the original bone fragments. In time, the fibrocartilage is
converted to spongy bone, and the callus is then referred to
as a bony (hard) callus.
4. Consolidation: The woven bone is transformed into lamellar bone.
5. Remodeling: The bone re-assumes something like its normal shape
(note: lasts months to years)

 Note: The core of fracture healing is the remodeling process,

which involves osteoclastic bone resorption and osteoblastic
bone formation. Maintaining a dynamic balance between the
activities of osteoclasts and osteoblasts is necessary for
effective and adequate bone repair. Wolff’s law states that
bone remodels in response to mechanical stress.

2) Healing without callus: when the fracture is absolutely immobile, new

bone formation occurs directly between the fragments.

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The time factor:

Fracture 'union' is incomplete repair and it is not safe to subject the

unprotected bone to stress; 'consolidation' is also less than complete repair,
but it allows unprotected function; only after remodeling and the restoration
of normal bone density is the process of repair is complete.

The rate of repair depends upon:

o Type of bone
o Type of fracture
o State of blood supply
o Patient's general constitution
o Patient's age

Clinical features: (note: the diagnosis is made based on clinical features and
imaging findings)

Note: fractures present with pain, loss of function, deformity, swelling (due to
hematoma??), bruising, crepitus, redness, etc. You should be able to
differentiate and true trauma and a malingering patient.

1) History: ask for

 Patient's age
 Injury

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  Mechanism of injury
 Inability to use the injured limb
 Deformity
 Pain, bruising and swelling
 Associated injuries
 Previous injuries
 Other musculoskeletal abnormalities
 General medical history

2) Examination:

Priority must be given to dealing with the general effects of trauma

a) Look for: swelling, bruising, deformity, whether skin is intact, posture
of distal extremity and color of skin.
b) Feel for: localized tenderness and distal pulsation.
c) Move: passive movement to elicit crepitus and abnormal movement,
active movement of the joints distal to the injury.

3) Imaging (x-ray): remember rule of twos:

o Two views: anteroposterior and lateral views

o Two joints: the joint above and the joint below the fracture
o Two limbs: x-ray of uninjured limb for comparison, especially in
children.
o Two injuries: fractured calcaneum (heel) and spine.
o Two occasions: Some fractures are notoriously difficult to detect soon
after injury, but another x-ray examination a week or two later may
show the lesion.

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 Other imaging: CT (note: In orthopaedic trauma, CT scans help diagnose
injuries around a joint, particularly if the fracture involves the joint’s
surface), MRI, three dimensional reconstructed images and radioisotope
scanning.
4) Secondary injuries: thoracic injuries, spinal cord injuries, pelvic and
abdominal injuries.
5) Testing for fracture union: encouraging signs of healing are:
 Absence of pain during daily activities
 Absence of tenderness at the fracture site,
 Absence of pain on stressing the fracture (a gentle bending
movement),
 Absence of mobility at the fracture site
 X-ray signs of callus formation

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Fractures in children:

Factors should be taken in consideration:

1) In very young children, the bone ends are largely cartilaginous and
therefore do not show up in x-ray images.
2) Children's bones are less brittle, and more liable to plastic deformation,
than those of adults.
3) The periosteum is thicker than in adult bones; this may explain why
fracture displacement is more controlled. Cellular activity is also more
marked, which is why children's fractures heal so much more rapidly than
those of adults. The younger the child, the quicker is the rate of union.
4) Non-union is very unusual.
5) Bone growth involves modelling and remodeling processes. This makes
for a considerable capacity to reshape fracture deformities (other than
rotational deformities) over time.
6) Damage to the growth plate can have serious consequences.

Injuries of the physis:

Note: the physis is the growth plate, a cartilaginous disc separating the
epiphysis and the metaphysis.

More than 10% of childhood fractures involve injury to the physis (or growth
plate). Salter and Harris classification involves the following types: -
 Type I: A transverse fracture through the hypertrophic or calcified Zone of
the plate.
 Type II: This is similar to type I, but towards the edge the fracture deviates
away from the physis and splits off a triangular piece of metaphyseal bone.
 Type III: A fracture running partly along the physis and then veering off
through the epiphysis into the joint.
 Type IV: As with type 3, the fracture splits the epiphysis, but it continues
through the physis into the metaphysis.
 Type V: A longitudinal compression injury of the physis. There is no visible
fracture, but the growth plate is crushed. (Note: following this fracture,
growth arrest is common. This fracture is often diagnosed retrospectively,
when disturbance of physeal growth becomes apparent as limb

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 deformity[1]. When this type of injury is suspected and it is difficult to
ascertain from radiographs whether a type V fracture has occurred, MRI
may be helpful in identifying this injury[1].)

Joint injuries:
 Sprain is any painful wrenching (twisting or pulling) of a joint.
 Strain implies stretching or microscopic tearing of some fibers in the
ligament.
 Ruptured ligament when the ligament is completely torn and the joint is
unstable.
 Dislocation means that the joint surfaces are completely displaced and are
no longer in contact.
 Subluxation implies a lesser degree of displacement, such that the
articular surfaces are still partly apposed.
 Recurrent dislocation: If the ligaments and joint margins are damaged,
repeated dislocation may occur.
 Habitual (voluntary) dislocation: Some patients acquire the knack of
dislocating (or subluxating) the joint by voluntary muscle contraction.
Ligamentous laxity may make this easier.

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Note: Dislocated joints constitute orthopaedic emergencies or urgencies for
two reasons. First, the joint dislocation can compromise the blood and
nutrient flow to the articular cartilage, causing permanent damage
incrementally with time (the most sensitive to this is the hip joint). Second,
the dislocation can cause significant soft-tissue damage and put the limb at
risk (such as a traumatic knee dislocation).

Side-note – Looser zones: Looser zones, also known as cortical infractions,

Milkman lines or pseudofractures, are wide, transverse lucencies with
sclerotic borders traversing partway through a bone, usually perpendicular to
the involved cortex, and are associated most frequently with osteomalacia
and rickets. Looser zones occur in the same locations as insufficiency fractures
in weight-bearing bones: pubic rami, medial femoral neck, and medial
proximal femoral shaft.

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