a) Common bone fractures.

i. Based on fracture pattern.

1. Closed (Simple) fracture – Bone breaks but does not pierce the skin.

2. Greenstick fracture – Incomplete break, common in children (bone bends and

cracks).

3. Comminuted fracture – Bone shatters into multiple pieces.

4. Oblique fracture – Diagonal break across the bone.

5. Transverse fracture – Straight horizontal break.

6. Spiral fracture – Twisting force causes a helical break (common in sports

injuries).

7. Avulsion fracture – Ligament or tendon pulls off a piece of bone.

8. Open (Compound) fracture – Bone breaks and protrudes through the skin
(higher infection risk).

9. Hairline fracture – A small crack in the bone (often due to overuse).

 According to bone location.

1. Clavicle fracture – Often from falls or direct impact.

2. Distal radius fracture – Wrist fracture from falling on an outstretched hand.
3. Hip fracture – Common in elderly individuals with osteoporosis.
4. Femur fracture – High-impact trauma (e.g., car accidents).
5. Ankle fractures – Often involve the tibia, fibula, or talus.
6. Tibial shaft fracture – Common in high-impact sports.
 7. Metatarsal fractures – Stress fractures in runners.
8. Vertebral compression fracture – Seen in osteoporosis patients.
9. Scaphoid fracture – Small wrist bone fracture, often missed on X-rays.
10. Rib fractures – Due to trauma (e.g., car accidents, sports).
ii. High-risk fractures.
1. Femoral neck fracture – Can disrupt blood supply to the hip.
2. Skull fractures – May lead to brain injury.
3. Pelvic fractures – Often due to high-impact trauma (risk of internal bleeding).
b) Classification of fractures.

1. Closed (Simple) Fracture

Definition:
 The bone breaks,
but the skin
remains intact.
No external wound connecting to the fracture

site. Characteristics:
✔ No skin penetration
✔ Lower infection risk
✔ Generally less severe than open fractures
✔ Healing is often faster due to preserved soft tissue
coverage

Common Causes:
 Falls (e.g., wrist fractures in osteoporosis)
 Sports injuries (e.g., tibial stress fractures)
Blunt trauma (e.g., car accidents without skin

breakage) Treatment:
 Non-surgical: Casting, splinting, or bracing
Surgical: If displaced (ORIF—Open Reduction Internal

Fixation) Complications:
 Compartment syndrome (swelling increases pressure in
muscles)
 Delayed union/non-union (if improperly treated)
2. Open (Compound) Fracture

Definition:
 The broken bone pierces through the skin, creating an external wound.
High risk of infection and complications.

Gustilo-Anderson Classification (Severity Grades):

Infection
Grade Description Risk Treatment Complexity

Clean wound <1 cm, minimal soft Simple debridement +

I tissue damage Low fixation

Wound 1-10 cm, moderate Aggressive cleaning +

II contamination Moderate stabilization

Often requires multiple

III Severe damage: High surgeries

- IIIA Adequate soft tissue coverage

Extensive soft tissue loss, requires

- IIIB flap/graft

- IIIC Vascular injury needing repair

Common Causes:
 High-energy trauma (car accidents, gunshot wounds)
 Penetrating injuries (industrial accidents, falls onto sharp objects)

Immediate Treatment:

1. Emergency Care:
o Cover wound with sterile dressing
 o Antibiotics (e.g., cefazolin + gentamicin for Grade III)
o Tetanus prophylaxis if needed

2. Surgical Management:
o Debridement (removal of dead tissue and contaminants)
o Stabilization (external fixator or ORIF)
o Soft tissue reconstruction (flaps/grafts if needed)

Complications:
 Osteomyelitis (bone infection, 5-30% risk in Grade III)
 Non-union or malunion (delayed healing due to infection/poor blood supply)
 Chronic pain or disability

Key Differences Between Open and Closed Fractures

Feature Closed Fracture Open Fracture

Skin Integrity Intact Broken

Infection Risk Low High (up to 30% in severe cases)

Emergency Care Splinting + imaging Antibiotics + urgent surgery

Healing Time Faster (6-12 weeks) Slower (may take months)

Surgical Need Sometimes Almost always

c) Patterns of fracture
1. Transverse Fracture

Break runs straight across the bone (90° to long axis)

Cause: Direct blow (e.g., ulna fracture from blocking impact)

2. Oblique Fracture

Diagonal break (angled across bone)

Cause: Combined bending + compression forces

3. Spiral (Torsion) Fracture

Corkscrew-shaped break from twisting force

Red Flag: Common in non-accidental pediatric trauma

d) Causes of joint diseases and fracture

1. Osteoarthritis (OA)
o Primary OA: Age-related wear and tear (most common in knees, hips, hands).
o Secondary OA: Post-traumatic (e.g., after ACL tear), obesity, or genetic
predisposition.

2. Neuropathic Arthropathy (Charcot Joint)

o Caused by loss of joint sensation (diabetes, syphilis, spinal cord
injury).

3. Rheumatoid Arthritis (RA)

o Autoimmune attack on synovium → joint destruction.
 4. Gout & Pseudogout
o Gout: Uric acid crystal deposition (big toe, knees).
o Pseudogout: Calcium pyrophosphate crystals (wrist, knees).

5. Septic Arthritis
o Bacterial infection (Staphylococcus, Streptococcus) → rapid joint destruction.

6. Osteoporosis-Related Arthritis
o Bone loss → secondary joint degeneration.

7. Hemophilic Arthropathy
o Recurrent bleeding into joints (knees, elbows) in hemophilia.

II. Causes of Fractures

Fractures occur when

mechanical forces
exceed bone strength.

A. Traumatic Fractures

8. Direct Trauma
o High-
energ
y: Car
accide
nts,
falls
from
height
.
o Low-
energ
y:
Simple
falls
(e.g.,
hip
fractur
es in
elderly
).

9. Indirect Trauma
o Twisting
(spiral
C. Stress Fractures

6. Fatigue Fractures
o Repetitive stress (e.g., runners’ tibial fractures).

7. Insufficiency Fractures
o Weak bones under normal stress (osteoporosis, osteomalacia).

8. Growth Plate Injuries (Salter-Harris Fractures)

o Trauma affecting the physis in children.

9. Non-Accidental Trauma (Child Abuse)

o Spiral fractures in non-walking infants are suspicious.

III. Overlapping Causes (Joint Disease + Fractures)

Condition Effect on Joints Effect on Bones

Osteoporosis Secondary arthritis Fragility fractures (hip, spine)

Rheumatoid Arthritis Erodes cartilage & bone Osteoporotic fractures

Diabetes Charcot joint (neuropathic) Increased fracture risk

Chronic Steroid Use Avascular necrosis (hips) Osteoporosis → fractures

e) Investigations for bone fracture.

Clinical Assessment

A. History:
 Mechanism of injury (e.g., fall, trauma, sports-related)
 Pain characteristics (localized, worsening with movement)
 Risk factors (osteoporosis, malignancy, steroid use)

B. Physical Examination:
 Deformity, swelling, bruising
  Tenderness on palpation
 Loss of function (inability to bear weight/move limb)
 Neurovascular assessment (check for compartment syndrome, nerve damage)

2. Imaging Investigations

A. Primary Imaging (First-Line)

Modality Best For Limitations

-Poor for soft

- First-line for most fractures tissue/marrow lesions
X-ray (Radiography) -Evaluates alignment, -May miss early
displacement, comminution stress fractures

-Pediatric fractures (e.g.,

buckle fractures) - Operator-dependent
Ultrasound (POCUS)
- Guided reduction in ER - Limited for deep bones

B. Advanced Imaging (If X-ray Inconclusive or Complex Cases)

Modality Indications Advantages

- Comminuted/intra-articular -3D
fractures (e.g., tibial plateau, pelvis) reconstruction
CT Scan - Pre-surgical planning possible
- Occult fractures (e.g., scaphoid) -Detects
subtle fractures

-Soft
tissue/ligament/marrow - No radiation
MRI involvement -Excellent for
- Stress fractures (early occult fractures
detection)
- Pathological fractures (tumor,
infection)
Modality Indications Advantages

Bone - Stress fractures (e.g., runners) - High sensitivity but

Scan (Scintigraphy) - Metastatic bone disease low specificity

3. Laboratory Tests (For Pathological/Complex Fractures)

 CBC: Infection (↑ WBC) or anemia (chronic disease/malignancy)
 ESR/CRP: Inflammation (osteomyelitis, malignancy)
 Calcium/Vitamin D: Metabolic bone disease (osteomalacia)
 Alkaline Phosphatase: Bone turnover (Paget’s disease, healing)
 Serum Electrophoresis: Multiple myeloma (if pathological fracture suspected)

4. Special Investigations

Scenario Test Purpose

Wound culture +
Open Fracture antibiotics Rule out infection

Non-union/Delayed
Healing Biomarkers (P1NP, CTX) Assess bone turnover

Look for multiple healing

Child Abuse Suspected Skeletal survey (X-rays) fractures

f) Calculation of bone density.

Bone density is a measure of the amount of minerals (mainly calcium and phosphorus)
contained in a specific volume of bone. It helps assess bone strength and the risk of fractures,
especially in conditions like osteoporosis.

Bone density is typically calculated using a Dual-Energy X-ray Absorptiometry (DEXA or DXA)
scan. The scan measures the amount of calcium and minerals in a specific area of bone, often in
the hip, spine, or wrist.
The result is given as:

BMD (Bone Mineral Density) in grams per square centimeter (g/cm²).

T-score: Compares the patient's BMD to that of a healthy young adult.

Z-score: Compares the patient’s BMD to what is expected for their age, sex, and size.

T-score interpretation:

Normal: -1.0 or above

Osteopenia: Between -1.0 and -2.5

Osteoporosis: -2.5 or lower

g) Healing process of a joint
disorder and fractures.

The repair of a bone fracture

involves the following phases
(Figure 6.9):

1 Reactive phase. This phase is an early inflammatory phase. Blood vessels crossing the fracture
line are broken. As blood leaks from the torn ends of the vessels, a mass of blood (usually
clotted) forms around the site of the fracture. This mass of blood, called a fracture hematoma
(hē′-ma-TO- -ma; hemat- = blood; -oma = tumor), usually forms 6 to 8 hours after the injury.
Because the circulation of blood stops at the site where the fracture hematoma

forms, nearby bone cells die. Swelling and inflammation occur in response to dead bone cells,
producing additional cellular debris. Phagocytes (neutrophils and macrophages) and osteoclasts
begin to remove the dead or damaged tissue in and around the fracture hematoma. This stage
may last up to several weeks.

2a Reparative phase: Fibrocartilaginous callus formation. The reparative phase is characterized

by two events: the formation of a fibrocartilaginous callus, and a bony callus to bridge the gap
between the broken ends of the bones.

Blood vessels grow into the fracture hematoma and phago-cytes begin to clean up dead bone
cells. 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 (fi- brō-kar-ti-LAJ-i-nus), a mass of repair tissue consisting of collagen fibers and cartilage
that bridges the broken ends of the bone. Formation of the fibrocartilaginous callus takes about
3 weeks.

2b Reparative phase: Bony callus formation. In areas closer to well-vascularized healthy bone
tissue, osteoprogenitor cells develop into osteoblasts, which begin to produce spongy 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. The bony callus lasts about 3 to 4 months.

3 Bone remodeling phase. The final phase of fracture repair is bone remodeling of the callus.
Dead portions of the original fragments of broken bone are gradually resorbed by osteoclasts.
Compact

bone replaces spongy bone around the periphery of the fracture. Sometimes, the repair process
is so thorough that the fracture line is undetectable, even in a radiograph (x-ray). However, a
thickened area on the surface of the bone remains as evidence of a healed fracture.

Clinical Connection

Treatments for Fractures

Treatments for fractures vary according to age, type of fracture, and the bone involved. The
ultimate goals of fracture treatment are realignment of the bone fragments, immobilization to
maintain realignment, and restoration of function. For bones to unite properly, the fractured
ends must be brought into alignment. This process, called reduction, is commonly referred to as
setting a fracture. In closed reduction, the fractured ends of a bone are brought into alignment
by manual manipulation, and the skin remains intact. In open reduction, the fractured ends of
a bone are brought into alignment by a surgical procedure using internal fixation devices such
as screws, plates, pins, rods, and wires. Following reduction, a fractured bone may be kept
immobilized by a cast, sling, splint, elastic bandage, external fixation device, or a combination of
these devices.

Although bone has a generous blood supply, healing sometimes takes months. The calcium and
phosphorus needed to strengthen and harden new bone are deposited only gradually, and bone
cells generally grow and reproduce slowly. The temporary disruption in their blood supply also
helps explain the slowness of healing of severely fractured bones. Some of the common types
of fractures are shown n Table 6.1

6.6 Fracture an

Inflammatory Phase (Acute

Phase) Duration: 1–7 days

The body’s immune system
responds to injury or disease.

Signs: Swelling, redness, pain, heat, and limited

movement. Purpose: Remove damaged tissues and start

healing.

2.Proliferative or Repair

Phase Duration: Days to weeks

The body starts repairing the damaged joint tissue.

Fibroblasts produce collagen and new connective tissue.

New blood vessels form to nourish the area.

3.Remodeling or Maturation

Phase Duration: Weeks to months

New tissue is strengthened and reshaped.

Joint function begins to improve.

Physiotherapy and controlled movement

help restore mobility and strength.

4. Functional Recovery

Restoring range of motion, muscle

strength, joint stability, and functional
ability.

Requires rehabilitation, lifestyle changes, and sometimes medications or surgery depending

on the disorder.
h) Management of fractures.

The management of joint diseases (like osteoarthritis, rheumatoid arthritis) and fractures
requires a team-based approach. This ensures comprehensive care addressing pain, mobility,
function, mental health, and social needs.

1. Orthopedic Surgeon

Role: Diagnoses and performs surgery if needed (e.g., joint replacement, internal fixation of
fractures).

Fractures: Manages alignment, stabilization, and healing.

Joint Diseases: May offer joint debridement or replacement for severe cases.

2. Physiotherapist

Role: Restores mobility, strength, and function.

Joint Diseases:

Reduces stiffness and pain through manual therapy, exercise.

Prescribes joint-protective strategies.

Fractures:

Prevents muscle wasting during immobilization.

Guides progressive rehabilitation post-immobilization or surgery.

3. Occupational Therapist

Role: Assists in resuming activities of daily living.

Joint Diseases:

Suggests joint protection techniques and energy conservation.

Recommends adaptive equipment (e.g., reachers, splints).

Fractures:

Helps regain upper limb function, especially in hand/wrist

fractures.

4. Nurse

Role: Provides bedside care, wound care, and patient education.

Monitors for complications like infection, deep vein thrombosis.

Coordinates between different disciplines.

5. Pharmacist

Role: Ensures appropriate medication management.

Advises on anti-inflammatory drugs, pain relief, osteoporosis medications.

Educates patients on medication adherence and side effects.

6. Dietitian

Role: Provides nutritional guidance to support healing.

Joint Diseases:
Recommends anti-inflammatory diets.

Fractures:

Promotes calcium, vitamin D, and protein-rich diets to

enhance bone healing.

7. Psychologist or Counselor

Role: Supports emotional well-being.

Helps patients cope with chronic pain, disability, or post-surgical anxiety.

Provides cognitive behavioral therapy if needed.

8. Social Worker

Role: Connects patients with community resources.

Assists in discharge planning, home modifications, or arranging rehabilitation.

9. Radiologist

Role: Performs and interprets imaging (X-rays, MRIs, CT scans).

Critical for diagnosis, monitoring healing, and surgical planning.

i) Mobilization of Fractures and Joints

Mobilization is the therapeutic process of restoring movement to a joint or fractured limb. It is

an essential part of rehabilitation to prevent stiffness, muscle wasting, and joint contractures
after injury or surgery.

Mobilization involves controlled, guided movements to restore joint range of motion, muscle
strength, and function. It can be:

Passive (therapist moves the joint)

Active-assisted (patient helps with the movement)

Active (patient moves independently)

Mobilization After a Fracture

Early Phase (Immobilization Period)

Immobilization (using casts, splints, or internal fixation) is required to allow the bone to heal.

Mobilization during this period includes:

Isometric exercises to prevent muscle wasting.

Mobilization of nearby joints (e.g., shoulder and wrist during arm fracture).

Circulatory exercises to reduce swelling and prevent clots.

Post-Immobilization Phase

After the bone has healed sufficiently:

Gradual mobilization of the fractured limb begins.

Start with passive and assisted active range of motion.

Progress to full active movement and strengthening.

Mobilization in Joint Disorders

Joint diseases like osteoarthritis or rheumatoid arthritis lead to joint stiffness and pain.

Mobilization helps by:

Reducing joint stiffness

Increasing synovial fluid flow

Improving joint nutrition

Maintaining functional range of motion

Techniques Used:

Manual joint mobilization by a physiotherapist (e.g., Maitland or Kaltenborn techniques).

Range of motion exercises: active and passive.

Hydrotherapy: reduces pain and allows easier movement.

Stretching: to prevent contractures and maintain muscle length.

Principles of Mobilization

Begin mobilization as early as medically safe.

Always respect pain, swelling, and healing stage.

Progress from non-weight bearing to partial, then full weight-bearing, based on tolerance.

Combine with strengthening, balance, and gait training.

Benefits of Mobilization

Prevents complications like joint stiffness, atrophy, poor circulation.

Speeds up recovery and helps restore independence.

Improves joint health and overall functional mobility.

j) Complications of Fractures
Fractures, if not properly treated or if healing is delayed, can lead to several complications.
These may be local (at the fracture site) or systemic (affecting the whole body).
Early (Immediate or Acute) Complications
a. Hemorrhage (Severe Bleeding)
Can occur if major blood vessels are damaged.
Common in pelvic, femoral, or humeral fractures.
May lead to hypovolemic shock.
b. Nerve Injury
Nerves near the fracture can be compressed or
cut.
E.g., radial nerve injury in humerus fracture, sciatic nerve in pelvic fractures.
Can result in numbness, tingling, or paralysis.
c. Compartment Syndrome

Increased pressure in a closed muscle compartment.

Causes pain, numbness, and muscle damage.

Requires emergency surgical intervention (fasciotomy).
d. Fat Embolism Syndrome
 Fat droplets from bone marrow enter the bloodstream, especially in long bone fractures.
Can lodge in the lungs, causing respiratory distress.
Signs include chest pain, shortness of breath, confusion, and rash.
e. Deep Vein Thrombosis (DVT)

Blood clots form in deep veins, commonly in the legs.

Can lead to pulmonary embolism if the clot travels to the lungs.
2. Late Complications (During or After Healing)
a. Delayed Union

Fracture takes longer than normal to heal.

Causes: poor blood supply, infection, or poor immobilization.
b. Non-Union

Fracture fails to heal completely.

Forms a "false joint" (pseudarthrosis).
Requires surgical intervention like bone grafting.
c. Malunion
Bone heals in a wrong position.
May cause deformity or functional limitation.
Correction may require re-fracture and realignment.
d. Joint Stiffness and Contractures

Prolonged immobility leads to loss of joint movement.

Common in fractures near joints.
Requires physiotherapy for recovery.
e. Avascular Necrosis

Blood supply to the bone is cut off, leading to bone tissue death.
Common in femoral neck fractures, scaphoid, and talus.
May need joint replacement.
3. Infection
Mostly seen in open fractures or post-surgery (osteomyelitis).
Signs include fever, swelling, pus, and pain.
Requires antibiotics or surgical cleaning.

k) How Fractures Affect Functional Mobility

Pain and Swelling Limit Movement

Pain is often severe at the fracture site, especially during movement.

Swelling and inflammation around the joint or muscle make it difficult to move.

Pain causes muscle guarding, reducing the willingness or ability to walk, lift, or perform tasks.

2. Loss of Range of Motion (ROM)

Immobilization (e.g., casts or splints) leads to joint stiffness.

Prolonged disuse can reduce flexibility and cause contractures (tightened muscles and joints).

A stiff joint limits activities like walking, dressing, bathing, or lifting.

3. Muscle Weakness and Atrophy

Disuse during immobilization results in muscle wasting (atrophy).

Loss of strength affects:

Upper limbs: reduced grip, poor lifting ability.

Lower limbs: poor standing balance, walking difficulty.

Even after bone healing, muscle recovery takes time.

4.Impaired Balance and Coordination

Especially in lower limb or pelvic fractures.

A person may need supportive devices

(crutches, walkers).

Poor weight distribution leads to fear of

falling, affecting mobility confidence.

5. Gait Abnormalities

Fractures in legs, pelvis, or spine lead to altered walking patterns.

Common gait issues:

Limping

Shortened stride length

Unequal weight-bearing

These lead to fatigue,

slower movement, and
poor endurance.

6. Loss of Independence
A person may struggle with:

Climbing stairs

Going to the toilet

Cooking or cleaning

Need for assistance

increases, which
can impact mental
health.

7. Psychological
Effects

Fear of re-injury
reduces the
willingness to
move.

Anxiety, depression, or frustration due to limited mobility.

Social isolation if unable to leave home independently.

8. Long-Term Disability (if poorly managed)

Non-union, malunion, or complications like joint stiffness or nerve injury may result in
permanent loss of function.

May need lifelong assistive devices or modifications at home.

l) Preventive strategies for fractures

1. Optimizing Bone Health:

Adequate Calcium Intake: Calcium is a primary building block of bone. Ensure sufficient intake
through diet (dairy products, leafy green vegetables, fortified foods) or supplementation if
necessary, especially during childhood, adolescence, and older age.

Sufficient Vitamin D: Vitamin D helps the body absorb calcium. Obtain it through sunlight
exposure (with skin protection), diet (fatty fish, egg yolks, fortified foods), or supplementation.

Regular Weight-Bearing Exercise: Activities that make you work against gravity (walking,
running, dancing, weightlifting) stimulate bone density.

Avoid Smoking: Smoking impairs bone health and slows down fracture healing.

Limit Excessive Alcohol Consumption: Heavy alcohol use can interfere with bone formation and
increase the risk of falls.

Maintain a Healthy Weight: Being underweight increases the risk of fractures, while being
overweight or obese can put excessive stress on joints and increase fall risk.
Bone Density Screening (DEXA Scan): Individuals at higher risk of osteoporosis (older adults,
postmenopausal women, those with certain medical conditions or medication use) should
undergo bone density testing as recommended by their doctor.

Medications for Osteoporosis: For individuals diagnosed with osteoporosis or osteopenia with
high fracture risk, medications prescribed by a doctor can help increase bone density and
reduce fracture risk.

2. Preventing Falls:

Falls are a major cause of fractures, especially in older adults.

3. Home Safety Modifications:

Remove tripping hazards like loose rugs, clutter, and electrical cords.

Ensure adequate lighting, especially in hallways and stairwells.

Install grab bars in bathrooms (near the toilet and in the shower/tub).

Use non-slip mats in the bathroom and kitchen.

Make sure stairs have secure handrails on both sides.

4. Vision Care:

Regular eye exams and appropriate corrective lenses can improve balance and reduce the risk
of tripping.

5. Medication Review:

Certain medications can cause dizziness or drowsiness, increasing fall risk. Review medications
with a doctor or pharmacist.

6. Balance and Strength Training:

Exercises that improve balance (e.g., Tai Chi, yoga, single-leg stands) and lower body strength
(e.g., squats, leg raises) can significantly reduce fall risk

7. Assistive Devices:

Use canes or walkers if needed for stability. Ensure they are the correct size and used
properly.

8. Footwear:

Wear well-fitting, supportive shoes with non-slip soles. Avoid walking in socks or slippers.

9. Address Underlying Medical Conditions:

Conditions like neuropathy, arthritis, and cardiovascular issues can affect balance and increase
fall risk. Manage these conditions effectively.

10. Be Aware of Surroundings:

Pay attention to uneven surfaces, wet floors, and other potential hazards when walking.