Fracture and Joint injuries

A fracture is a break in structural continuity of bone

Surrounding soft tissues: local edema, inflammatory reactions, severe soft-tissue damage,
vascular impairment

Causes
1. Fracture due to sudden trauma
● a single highly stressful, traumatic incident
● direct force: bone breaks at the point of impact
● indirect force: bone breaks at a distance from where the force is applied
○ e.g. spiral # of tibia and fibula due to torsion of the leg
○ e.g. vertebral compression # due to sudden, severe spinal flexion
○ e.g. avulsion # due to violent traction by muscle, tendon or ligament
2. Stress or fatigue #
● repetitive stress of normal degree persisting to the point of mechanical fatigue --> cracks
● most often in tibia, fibula or metatarsals, esp. athletes, dancers
3. Pathological #
● Normal stress acting on abnormally weakened bone
● e.g. osteoporosis (skeletal insufficiency), Paget’s disease (birttle bone), bone tumors
(osteolytic lesions)

Types of fracture
1. Complete fracture
● bone completely broken into >=2 fragments
● transverse #: remain in place after reduction
● Oblique and spiral #: tend to slip and redisplace even if the bone is splinted
● Impacted #: fragments jammed tightly together and fracture line indistinct
● Comminuted #: >2 fragments, poor interlocking of fragments so often unstable
2. Incomplete fracture
● bone incompletely divided and periosteum remains in continuity
● Greenstick #: bone buckled/ bent, seen in children, reduction is easy and healing is
quick
● Stress #: may be incomplete, break initially appear in only one part of cortex, but takes
as long to heal as complete #
● Compression #: when cancellous bone is crumpled, in adults esp. vertebral bodies

Healing of fracture
1. Healing by callus
● In tubular bone w/o rigid fixation
● Callus is the response to mvoement at # site, to stabilized the fragments as rapidly as
possible
● 1) Tissue destruction and haematoma formation
● 2) Inflammation and cellular proliferation
○ within 8 hrs, clotted haematoma slowly absorbed, capillaries growth
 ● 3) Callus formation
○ chondrogenic and osteogenic cells
○ fracture unites as the woven bone slowly mineralized
● 4) Consolidation
○ woven bone --> lamellar bone
○ slow process
● 5) Remodeling
○ months to years, alternating bone resorption and formation
2. Healing without callus
● if # site immobile, e.g. impacted # in cancellus bone or # immbolized by int. fixation
● new bone formation directly between fragments
● gaps between fracture surface are invaded by new capillaries and bone-forming cells
growing in from edges
● For crevices that are narrow (<200um), osteogenesis produce lamellar bone c.f. wider
gaps filled first by woven bone then remodelled to lamellar bone

Healing by callus ensures mechanical strength

Healing w/o callus means tahere is a long period during which the bone depends entirely upon
metal implant for its integrity, and implant diverts stress away from the bone --> osteoporotic
and not recover fully until the metal is removed

Rate of repair
1. type of bone (cancellous bone heals faster than coritical bone)
2. type of fracture (transverse # takes longer than spiral fracture)
3. state of blood supply (poor circulation?)
4. patient’s condition
5. patient’s age

Average time for # healing

UL LL

Callus visible 2-3 wks 2-3 wks

Union 4-6 wks 8-12 wks

Consolidation 6-8 wks 12-16 wks

Delayed union and non-union:

● distraction and separation of fragment
● interposition of soft-tissue between fragments
● excessive movement at # site
● poor local blood supply
● severe damage to soft tissues which makes them non-viable
● infection
● abnormal bone
Cell proliferation predominantly fibroblastic and bone fragments remain mobile
“pseudoarthrosis”