CASE TITLE: FRACTURE

A fracture is a complete or incomplete break in the continuity of a bone, an epiphyseal plate, or cartilaginous
surface.

I. Related Anatomy
Bone tissues make up 18% of the weight of the human body. The entire framework of bones and their cartilages
constitute the skeletal system.
● 206 bones in the adult skeletal system
○ Axial skeleton = 80 bones
○ Appendicular skeleton = 126 bones

Function of bones and the skeletal system:

● Supports soft tissues and provides attachment for skeletal muscles.
● Protects internal organs
● Assist in movement along with skeletal muscles
● Stores and releases minerals
● Contains red bone marrow, which produces blood cells
● Contains yellow bone marrow, which stores triglycerides(fats)

Types of bones based on their shapes and locations:

● Long bone – has greater length than width, consists of a shaft and a variable number of extremities, and is
slightly curved for strength. (Ex. Humerus, tibia, fibula, femur, phalanges, radius, ulna)
● Short bones – are somewhat cubed-shaped and are nearly equal in length and width. (Ex. Carpal bones
and tarsal bones)
● Flat bones – are generally thin and composed of two nearly parallel plates of compact bone tissue enclosing
a layer of spongy bone tissue. (Ex. Sternum, ribs, and scapula)
● Irregular bones – have complex shapes and cannot be grouped into any of the categories. (Ex. Vertebrae,
hip bones, and calcaneus)
● Sesamoid bones – shaped like a sesame seed. Develops in certain tendons where there is considerable
friction, tension, and physical stress. (Ex. patella)
● Sutural bones – are small bones located in sutures (immovable joints) between certain cranial bones.

Macroscopic structures of the bone:

● Diaphysis – is the bone’s shaft or body
● Epiphysis – are the distal and proximal end of the bone.
● Metaphysis – are the regions in a mature bone where the diaphysis joins the epiphysis
● Articular cartilage – is a thin layer of hyaline cartilage covering the part of the epiphysis where the bone
forms an articulation with another bone
● Periosteum – is a tough sheath of dense irregular connective tissue that surrounds the bone surface
wherever it is not covered by articular cartilage
● Medullary cavity/ marrow cavity – is the space within the diaphysis that contains fatty yellow bone marrow
in adults
● Endosteum – is a thin membrane that lines the medullary cavity. It contains a single layer of bone-forming
cells and a small amount of connective tissue
Four types of cells present in the bone tissue:
● Osteogenic cells - unspecialized stem cells derived from mesenchyme, the tissue from which all connective
tissues are formed. They are the only bone cells that undergo cell division
● Osteoblast - bone building cells, they synthesize and secrete collagen fibers and other organic components
needed to build the extracellular matrix of bone tissue. They initiate calcification.
 ● Osteocytes - mature bone cells, are the main cells in bone tissue and maintain its daily metabolism, such
as the exchange of nutrients and wastes with the blood.
● Osteoclast - here the cell releases powerful lysosomal enzymes and acids that digest the protein and
mineral components of the underlying bone matrix. “Resorption” , the breakdown of bone extracellular
matrix, is part of the normal development, growth, maintenance, and repair of bones.

Spongy Bone
● Does not contain osteons
● Does not refer to the texture of the bone,
only its appearance
● Trabeculae – consists of lamellae
arranged in an irregular lattice of thin
columns

Compact Bone
● Strongest form of bone tissue
● Osteons – components of compact bone
tissue are arranged into repeating units
● Blood vessels, lymphatic vessels, and
nerves from the periosteum penetrate
compact bone through transverse
perforating or Volkmann’s canal
● Vessels and nerves of the perforating
canals connect with the central or
Haversian canal
● Concentric lamellae – rings of calcified
extracellular matrix much like the rings of
a tree trunk
● Interstitial lamellae – fragments of older
osteons that have been partially
destroyed during bone re building

II. Epidemiology
In children: Those who are under the age of 10 is more likely to have a greenstick fracture that
occurs when the bone is bent and then fails on the side subjected to compression

In adults: Usually produced by indirect trauma or violence applied to the bone that is mostly cancellous. Another
common site are the vertebral bodies. In general, one or more of the lower thoracic or upper lumbar bodies.
Osteoporosis (women>men)

III. Etiology
(Orthoinfo)
The most common causes of fractures are:
● Trauma. A fall, motor vehicle accident, or tackle during a football game can all result in fractures.
● Osteoporosis. This disorder weakens bones and makes them more likely to break.
● Overuse. Repetitive motion can tire muscles and place more force on bone. This can result in stress
fractures. Stress fractures are more common in athletes.

Injury caused fractures - occurs in bones previously free from disease

● Direct trauma or violence - Damages surrounding soft tissues
 Examples:
- Tapping forces applied to the tibia produces an oblique fracture.
- Crushing injuries results in a fragmented fracture of the tibia and fibula.
- Penetrating direct injury from a high velocity gunshot blast destroys bone and soft tissues.
● Indirect trauma or violence - Significantly produces less damage to the bone and soft and hard tissues
Examples:
- An abduction force applied to the knee causes a compression to the external tibial condyle.
- A forceful contraction of the rotator muscles of the shoulder avulses the greater tuberosity of the humerus.
- Falling on the outstretched hand causes a fracture of the head of the radius
● Bone diseases - Can cause a destruction of a bone. May weaken the bone to such a degree that trivial trauma
can produce a pathologic fracture
Examples:
- Fracture of the femur invaded by an osteogenic sarcoma
- Fracture of the humerus through a bone cyst
- Fracture of the tibia and fibula in a case of osteogenesis imperfecta
- Fracture of the the shaft of the femur in case of bone metastasis from a breast cancer
● Repeated stresses or fatigue - No bone disease is demonstrable. Most frequently encountered in the bones of
the lower extremity. Often seen in the three middle metatarsal bones, shaft of the tibia, and the neck of the
femur

IV. Pathophysiology
● Direct injury – direct blow to a bone fractures it at the site of impact
● Indirect injury - force is applied at one point and fracture occurs at a site remote from the impact
● Transverse or oblique fracture – the force tends to bend a long bone
● Compression fracture – compressive forces crush a soft spongy bone

Types:

Closed It does not communicate with the

Fracture external environment

Open The fracture site communicates

Fracture with the external environment
andis treated from the beginning
as an infected wound

Transverse Produced by a bending force

Fracture applied directly to the fracture site
with associated soft tissue injury

Oblique Produced by a torsional force with

Fracture an upward thrust

Spiral Produced by a twisting or rotary

Fracture force that result in less soft tissue
injury

Impacted Produced by indirect violence,

Fracture which drives the bone fragments
firmly together
 Avulsion Produced by forcible resisted
Fracture contraction of a muscle mass,
which pulls of a fragment of bone
at its site of insertion

Fracture- In addition to a fracture of one or

dislocation more of the bony components of a
joint, there is subluxation or
dislocation of the joint

Comminuted Produced by severe direct

Fracture violence. There are always more
than two fragments

Segmental Result in fractures proximal and

Fracture distal segment s of the bone with a
long, devascularized segment in
between

Stages of fracture healing:

● Impaction - the dissipation of the energy from an insult.
● Induction - the stage when cells that possess osteogenic capabilities are activated. Least well understood
stage of bone healing
● Inflammation - begins shortly after impact and lasts until some fibrous union at the fracture site occurs.
There is a disruption of the blood supply and formation of a fracture hematoma, as well as a decrease in
oxygen tension and pH.
● Soft callus stage - begins when the pain and swelling subside and lasts until the bony fragments are united
by fibrous or cartilaginous tissue. This period is marked by a great increase in vascularity, ingrowth of
capillaries into the fracture callus, and increase in cellular proliferation.
● Hard callus stage - begins when the fracture ends are maintained by a sticky, hard callus and ends when
the fragments are united with a new bone. This period corresponds to the period of clinical and radiological
fracture healing.
● Remodeling stage - begins when the fracture is both clinically and radiologically healed. It ends when the
bone has returned to its normal state and the patency of the medullary canal has been restored

(Physiopedia)
Three main phases:

● Inflammatory Phase (hours-days)

○ Immediately at the time of fracture, the space between the ends of the fracture is filled with blood,
forming a hematoma. This prevents additional bleeding and provides structural and biochemical
support for the influx of inflammatory cells.
○ Takes approximately a week, forming a primary callus which is non-mineralized.
● Reparative Phase (Days-weeks)
○ The primary callus is transformed into a bony callus by the activation of osteoprogenitor cells. These
cells lay down woven bone which stabilizes the fracture site.
○ Soft callus is organized and remodeled into hard callus over several weeks. Soft callus is plastic
and can easily deform or bend if the fracture is not adequately supported. Hard callus is weaker
than normal bone but is better able to withstand external forces and equates to the stage of "clinical
union"
 ● Remodeling Phase (months-years)
○ longest phase and may last several years.
○ Represents the gradual formation of compact cortical bone with greater biomechanical properties.
This allows for the reduction of the width of the callus.

V. Ancillary and Laboratory Tests

● X-ray
○ Adequate x-rays of the injured area are essential for diagnosis
○ At least two views taken at right angles to each other
○ Always include joints proximal and distal to the fracture on the x-ray
○ Oblique and other special view are necessary to reveal the fracture
● Doppler flow studies - to assess the state of the circulation of the limb.
● Nerve conduction velocity test - to assess for presence or absence of any nerve deficit

VI. Ocular Inspection

● Ambulatory c AD (LE) s (UE)
● A/C/C
● Body type
● In apparent pain (localized and is aggravated by movement)
● (+) Swelling
● (+) Ecchymosis
● (+) wound/injuries (open fracture)
● (+) Deformity
● Gait deviation: Antalgic/three-point
● Postural deviation
● Orthosis: braces/splints

VII. Palpation
● Hyperthermic
● Normotonic
● (+) Tenderness
● (+) Muscle guarding
● (+) Muscle weakness
● (+) LOM
● Edema
● (-) muscle spasm, taut bands, nodules

VIII. ROM
(+) LOM on affected limb → AP d/t pain

IX. MMT
(+) muscle weakness on surrounding muscles d/t immobilization

X. Neurologic Evaluation
DTR: Normoreflexive
Sensory Assessment: Intact superficial and deep sensation unless there is nerve affectation

XI. Special Tests for the case

R/O:
● Ok sign (-) AINS
XII. Postural Analysis
● Guarding posture
● Affected limb is immobilized in splint

XIII. Gait Analysis

● Antalgic gait
● Three-point-gait

XIV. Anthropometric measurement

● MBM
● Grip and pinch strength
● Figure of eight
● LGM

XV. Functional Assessment

● Pt’s functional level would depend on the type of fracture and severity.

Conditions influencing rate of healing

Favorable conditions:
● Fracture at ends of bone, where bone is cancellous and blood supply is excellent
● There is adequate blood supply to both fragments
● Soft tissue injury is minimal, and fracture reduction is end to end
● Long spiral fracture has been caused by indirect torsional loading with minimal soft tissue damage
● Fracture site is free of infection
● Muscle function is encouraged by weight-bearing, which also promotes impaction and contributes to
extraosseous revascularization of the fracture site

Unfavorable conditions:
● Severe comminution of the affected bone and damage to surrounding soft tissues
● Bone lost by injury or surgical excision
● Distraction of bone ends by traction
● Impairment or loss of blood supply to one or both fragments
● Infection
● Wide separation of fracture ends

XVI. Differential Diagnosis

● Osteoporosis
○ A disease characterized by low bone mass and deterioration of bone tissue, particularly trabecular
(cancellous) bone; this leads to increased bone fragility and fracture risk.

Clinical Manifestations:
Osteoporotic Fracture:
- Midthoracic spine
- Upper-Lumbar spine
- Hip (proximal femur)
- Distal Forearm (Colles Fracture)

Decreased in height (more than 11” shorter than maximum adult height)
 - Kyphosis
- Dowager’s Hump
- Decreased activity tolerance
- Early satiety

● Dislocation
○ A complete separation of a joint.
○ Results from indirect mechanisms when the force is transmitted along the bone to its articulation.
Rarely is a joint dislocated by a direct blow
○
● Subluxation
○ A partial separation of a joint.
○ Results from laxity of the supporting structures surrounding the joints. Such laxity may be caused
by congenital or traumatic conditions or by joint effusions or disuse muscle atrophy

Clinical Manifestation for Subluxation And Dislocation:

● Pain
● Inflammation (swelling, redness, heat, pain at rest)
● Muscle spasm
● Loss of function

XVII. Problem List

● Localized pain and is tender to touch
● Swelling
● LOM
● Muscle weakness
● Decrease proprioception
● Poor balance
● Antalgic gait
● Difficulties in performing ADLs and IADLs

XVIII. Short-Term Goals

● Eliminate swelling and pain allowing patient to perform AROM s elicitation of pain
● Increase muscle strength on affected limb by being able to lift at least 2lbs of weight
● Increase standing balance by being able to shift 50% of weight on the affected leg
● Improve gait by ambulating c AD at least 3 rounds
XIX. Long-Term Goals
● Regain normal gait pattern by being able to ambulate s AD
● Regain (N) muscle strength by being to lift weight equal to the tolerated of the unaffected limb
● Return to previous activities by being able to perform ADLs and IADls s difficulties, as well as elicitation of
pain

XX. Electro-modalities
● TENS
● FES

XXI. Hydro-modalities
● Ice/cold pack
● Cryotherapy
● HMP
● Contrast bath
XXII. Therapeutic Exercise
Period of Immobilization:
● AROME of distal joints x 10 reps x 1 set to decrease effects of immod. And maintain function
● PREs to major muscle groups not immobilized c weights x 10 reps x 1 set to maintain strength and ROM
in major muscle groups
● Ambulation training c AD to Increases patients functional capability and independence

Post-immobilization:
● AROME to maintain active mobility
● Gentle Isometric exercises to initiate active exercise regimens
● PJM grade II and IV yo Increases joint and soft tissue mobility
● PREs c weights x 10 reps for 2 set (or AT) to Increases strength and muscle endurance
● Ambulation training c partial weight bearing to provides protection until radiologically healed

XXIII. Orthosis and Prosthesis

● Shoulder brace
● Splints
● Cast: Plaster, synthetic, brace

XXIV. Home Exercise Program

● Ankle pumps decrease swelling
● Ankle draw: A-Z, a-z to increase proprioception
● PREs
○ Wrist curls
○ Bicep curls
○ Tricep curls
○ Military press
● CKC
○ Squat
○ Lunges
Notes
Identification of a fracture is by:
● Site: diaphyseal, metaphyseal, epiphyseal, intra-articular
● Extent: complete or incomplete
● Configuration: transverse, oblique or spiral, comminuted
● Relationship of the fragments: undisplaced, displaced
● Relationship to the environment: closed(skin intact), open(object penetrating the skin)
● Complications: local or systemic, related to the injury or the treatment

Abnormal healing fracture:

● Malunion - fracture heals in an unsatisfactory position resulting in bony deformity
● Delayed union - fracture takes longer than normal to heal
● Nonunion - fracture fails to unite with a bony union