Fractures

Introduction

 A fracture is a break in the structural continuity of

bone.

 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.
Causes of fractures
 The causes of fractures could be:
1. Injury:
 Can be due to direct or indirect forces
 Fracture patterns suggesting causal mechanisms: spiral
pattern(twisting), short oblique pattern(compression),
triangular ‘butterfly’ fragment(bending), transverse
pattern(tension),
 Spiral and some (long) oblique patterns are usually due to
low energy indirect injuries whereas, bending and transverse
patterns are caused by high energy direct injuries.

2. Repetitive stress
3. Abnormal weakening of the bone(pathological fracture).
Types of fractures
 Complete fractures: the bone is split into two or more
fragments
 Transverse fracture: the fragments usually remain in place
after reduction
 Oblique/spiral fracture: shorten or re-displace even after
bone splinting
 Impacted: indistinct fracture line with fragments jammed
together tightly
 Comminuted fracture: often unstable(poor interlocking of
fragments), with more than two fragments.
 Incomplete fractures: bone is incompletely divided and
the periosteum remains in continuity
 Greenstick fracture: bone is buckled or bent(like snapping
a green twig); seen in children whose bones are springy
than those of adults.
 Compression fractures: occur when cancellous bone is
crumpled; usually in vertebral bodies, calcaneum and
tibial plateau .
Classification of fractures
 In alphanumeric classification developed by Muller and
colleagues:
 The first digit specifies the bone: 1-humeurs, 2-
radius/ulna, 3-femur, 4-tibia/fibula, 5-spine, 6-pelvis, 7-
hand, 8-foot
Displacement of fractures

 Translational: shift
 Angulation: tilt
 Rotation: twist
 Length : distraction or compression
Healing of fractures

 Healing by callus
 Natural form of healing in tubular bones
 In absence of rigid fixation, proceeds in following stages:
1. Tissue destruction and hematoma formation: there is tissue
damage and bleeding at fracture site; the bone end die back
for few millimeters.
2. Inflammation and cellular proliferation: inflammatory cells
appear in the hematoma.
3. Callus formation: the cell population changes to osteoblasts
and osteoclasts; dead bone is mopped up and woven bone
appears in the fracture callus.
4. Consolidation: woven bone is replaced by lamellar bone and
the fracture is solidly united.
5. Remodelling: the newly formed bone is remodeled to
resemble the normal structure.
 Healing by direct union
 Callus is the response to movement at the fracture site. It
serves to stabilize the fragments as soon as possible – a
necessary precondition for bridging the bone.
 If a fracture site is absolutely immobile, such as a fracture
stabilized by metal implants, there is no stimulus for callus
formation. Instead, osteoblastic new bone formation occurs
between the fracture ends. The gap is invaded by new
capillaries and osteoprogenitor cells growing in from the
edges, and new bone is laid down on exposed surface. This is
gap healing.
 Where the crevices are very narrow(less then 200µm),
osteogenesis produces lamellar bone; wider gaps are first
filled by woven bone which is then remodeled to lamellar
bone. By 2-3 weeks the fracture is solid enough to allow
penetration and bridging of the area by the remodeling units,
i.e. osteoclastic ‘cutting cones’ followed by osteoblasts.
Where the exposed fracture surfaces are in close contact and
rigidly fixed by the outset, internal bridging occasionally occur
without intermediate stages. This is contact healing.
 Healing by callus, though less direct has distinctive
features then indirect healing method. It ensures
mechanical strength when the bone end heals and with
increasing stress the callus grows stronger and stronger.
 On the other hand, with rigid fixation, the bone
depends entirely on the implants for it’s integrity for
longer period. Moreover, the implant diverts stress
away from the bone that may lead to bone becoming
osteoporotic and delayed recovery until the implant is
removed.