Orthopedic traumatology

parts of a long bone in

a child with the open
epiphyses. In an adult,
the epiphyses would
either be closed and
not seen or evidenced
by a sclerotic scar.
 Fractures

A fracture is present when there’s loss of

continuity in the substance of a bone.
The term covers all bony disruptions,
ranging from situation when a bone is
broken into many fragments (multi-
fragmentary or comminuted fx) to
hairline and even microscopic fracture.
Types of fractures
 Simple (closed), compound (open).
 Displaced , un-displaced, impacted.
 Direct , indirect, ms violence.
 Traumatic, pathological (insufficiency fx.).
 Complete, incomplete e.g. fissure, buckling (torus fx.),
greenstick, hairline, stress fx, fatigue fx
 Spiral, transverse, oblique, segmental, butterfly, split,
comminuted.
 Associated joint injuries: dislocation or subluxation.
Green stick
Spiral fracture
Comminuted fracture
Comminuted Greenstick Transverse
fracture fracture fracture

Pathological
fracture Spiral fracture Compression
Remember
 Stress fractures (chronic repetitive
trauma)
 Fatigue fractures (normal bone,
Abnormal activity)
 Insufficiency fractures (abnormal
bone, Normal activity).
 Specific types of fractures

Open fracture.
Intra-articular fracture.
Pathological fracture.
Tapping fracture.
Crush fracture.
Penetrating fracture.
 Open fracture
 It’s a fracture communicated with the exterior environment, infection
is inevitable.
 Types: open from within, from without
 Must be managed within the 1st 6 hours.
 Prophylactic antibiotic against tetanus and gas gangrene.
 Prompt wound debridement.
 Early definitive wound cover.
 Stabilization of the fracture
 P.S. not all open injuries are associated with open fx
 Open fracture with
breaching of the skin
Open fracture
open from within

Open from without

Articular fracture
It’s a fracture extending to
the articular surface.
Treatment of this type of
fracture is important and it
has to be anatomically
reduced to avoid post-
traumatic osteoarthritis
 Mitchell and Shepard [1980]
demonstrated experimentally that
anatomical reduction and
interfragmentary compression
fixation of an intra-articular
fracture, followed b continuous
motion, can lead to true hyaline
cartilage healing.
 Salter et al. [1980] demonstrated that
immobilization of an injured joint
leads to stiffness and articular
cartilage degeneration, due to lack of
nutrition and the formation of pannus.
Further experiments revealed that the
use of continuous passive motion
(CPM) facilitated the repair of full-
thickness articular cartilage defects in
immature rabbits.
Pathological fracture

It’sa fracture in a bone with

abnormal composition or
abnormal architecture and
usually caused by low energy
trauma that would leave a
normal bone intact.
Tapping fractures

 Caused by direct force over a small area

 Usually produce transverse fx line.
 Associated with little soft tissue damage
 Example: night stick fx.
Crush fractures

 Caused by direct trauma

 Produced be large force over a large area
 Associated with extensive soft tissue damage
 Usually produce transverse, comminuted fx line.
Penetrating fractures

 Caused by direct trauma

 Like missle, gun shots
 High velocity, low velocity
 Extensive comminution
 Associated with soft tissue damage
Types of ligamentous injury

1- avulsion injury: i.e the ligament is avulsed from either its tibial or femoral
attachments with or without bony avulsion.
2- mid-substance injury: i.e. tear within the ligament substances.
*Grade I: microscopic insult.
*Grade II: partial tear
*Grade III: complete or full thickness tear
Trauma in children

 Fractures in growing bones are subject to influences which do

not apply to adults
1. In very young children, the bone ends are largely
cartilagenous and therefore do not show up in x-ray images.
Fractures at these areas are difficult to diagnose and imaging
both limbs may be needed for comparison.
2. Children’s bones are less brittle, and more liable to plastic
deformation, than those of adults, hence the frequency of
incomplete fx. Are common among children comparing to
those occurring in adults.
 3. The periosteum is thicker than in adult bones; this may
explain why fracture displacement is more controlled. And
cellular activity is also more marked, which is why children’s
fractures heal so much rapidly than those of adults. The younger
the child, the quicker is the rate of union. Femoral shaft fx in
infants will heal within 3 weeks, and in young children in 4-6
weeks, compared to 14 weeks or longer in adults.
 4. Non-union is very unusual.
 5. Remodeling rate is faster.
 6. Damage to the growth plate can have serious consequences.
However rapidly and securely the fracture might heal.
Salter-Harris classification of
physeal injuries
 Grade I: slipped epiphysis.
 Grade II: slipped epiphysis with triangular piece fracture of
metaphysis.
 Grade III: fracture of epiphysis with intact metaphysis.
 Grade IV: fracture of both epiphysis and metaphysis.
 Grade V: compression injury of the physis.

Growth disturbance is unremarkable in Grades I,II due to unusual

affection of the growing zone of the physis, but may result in
growth arrest or asymmetrical growth in Grades III, IV, and V
 Remember some rules

 Physis is weaker to slip than the bone to break or the joint to dislocate.
 Any intra-articular fx must be anatomically reduced to avoid post-traumatic
osteoarthritis and stiffness.
 Do not open a close fx and do not close an open fx.
 When the trauma force is perpendicular to the axis of the bone, the line of fx
would be probably transverse. And when it’s parallel to the axis of the bone, the
fx line would probably be oblique, spiral, split, etc…
Bone Healing

Bone healing is a unique process which resembles

embryonic bone development. Fracture healing can
be divided into two major categories:
1. Primary (direct, cortical) bone healing
2. Secondary (indirect, spontaneous) bone healing
which is more common.
  SECONDARY BONE HEALING
 Secondary fracture healing is characterized by spontaneous fracture healing in
the absence of rigid fixation of the fracture site, and it is the more common method of
bone healing. Secondary healing can be easily divided into three phases;
1. An inflammatory phase
2. A reparative phase
3. A remodeling phase
Inflammatory Phase

Immediately following the injury, an inflammatory response is elicited, which peaks in 48 h

and disappears almost completely by 1 wk post fracture. This inflammatory reaction helps to
immobilize the fracture in two ways:
a. Pain causes the individual to protect the injury and
b. Swelling hydrostatically keeps the fracture from moving.
Reparative Phase

The reparative phase occurs before the inflammatory phase subsides, and lasts for several
weeks. The result of this phase will be the development of a reparative callus tissue in and
around the fracture site, which will eventually be replaced by bone. The role of the callus is to
enhance mechanical stability of the site by supporting it laterally.
Remodeling Phase

 The remodeling phase is the final phase in fracture healing and begins with the
replacement of woven bone by lamellar bone and the resorption of excess callus. Although
this phase represents the normal remodeling activity of bone, it may be accelerated in the
fracture site for several years.
Primary bone healing

 requires rigid stabilization with or without compression of the

bone ends. Unlike secondary bone healing, this rigid
stabilization suppresses the formation of a callus in either
cancellous or cortical bone. Because most fractures occurring
worldwide either are untreated or are treated in a way that
results in some degree of motion (sling or cast
immobilization, external or intramedullary fixation), primary
healing is rare. Although some have considered this type of
healing to be a goal of fracture repair, in many ways it is not
shown to be advantageous over secondary bone healing
Enhancing Fracture Healing

 Several methods could be used to enhance bone

fracture healing. The approaches could be biological
(grafting) or mechanical (physical forces e.g. weight
bearing & exercises) and biophysical enhancement
(US & LASER). This will be discussed in detail at
the corresponding lecture.
Thanks