ORTHOPEDIC

Lec. 2 .

Fractures:
Fracture is a break in the structural continuity of bone. If the overlying skin remains intact it is
closed or simple Fracture. If the skin or one of the body cavity is breached, it is open or
compound Fracture. HIGH-ENERGY INJURY OPEN INJURY

Causes of Fracture:
1. Single traumatic incidence: Most fractures are caused by sudden & excessive force, which
may be:
A) Direct force: The bone breaks at the point of impact; the soft tissues also must be
damaged, fracture line usually transverse or comminuted.
B) Indirect force: The bone breaks at a distance from where the force is applied, soft tissue
damage usually not found.
Types of indirect force:
A. Bending + Compression Fracture large butterfly.
B. Bending force Fracture with small butterfly fragment.
C. Twisting force Spiral fracture.
D. Compression force Short oblique fracture.
E. Tension (distraction) Transverse fracture or avulsion fracture.
F. Combination Comminuted fracture.

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2. Repetitive stress (stress or fatigue fracture):
Cracks can occur in bone due to repetitive stress. This is most often seen in the tibia, fibula or
metatarsal especially in athletes, dancers & army recruits who go on long route marches.
3. Pathological fracture:
It is a Fracture that occurs in a diseased bone. The bone is weakened by a change in its structure,
(e.g. osteoporosis & Paget disease) or presence of a lytic lesion (e.g. bone cyst or metastasis).

Types of Fractures:
Divided into:

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1) Complete Fracture: It is Fracture that involves both cortices &the bone is completely broken
into 2 or more fragment. According to the direction of the Fracture line it involve many
patterns:
Transverse Fracture: The Fracture line is transverse & the fragment remains in place after
reduction.
Oblique Fracture: the Fracture line is oblique & the fragment tends to slip & redisplaced.
Spiral Fracture: the Fracture line like the oblique but it is longer.
Impacted Fracture: the 2 ends are jammed together & the Fracture line is indistinct.
Segmental Fracture: there are 2 lines with one segment in between.
Comminuted Fracture: in which there are more than 2 fragments.
2) Incomplete Fracture: it is Fracture that involve one cortex & the bone is incompletely
divided & the periosteum remain intact:
Greenstick Fracture: the bone is buckled or bent (like snapping a green twig), it is seen in
children, reduction is easy & healing is quick.
Compression Fracture:-occur when cancellous bone is crumpled, this happen in adult,
especially in vertebral bodies. Closed reduction impossible and some residual deformity are
inevitable.

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Types of Fracture displacement:
Fractures become displaced due to:
1. Trauma itself.
2. Gravity.
3. Muscles pull.
We have 4 types of fracture displacement:
1. Shift (translation): the fragments may be shifted side way, backward or foreword in
relation to each other.
2. Tilt (angulation): the fragments make an angle with each other & if not corrected may
lead to deformity of the limb.
3. Twist (rotation): one of the fragments may be rotated in its longitudinal axis. The bone
looks straight but the limb ends up with a rotational deformity.
4. Shortening ( length): due to overlapping of the fragment by muscle spasm.

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Healing of the fracture:
Bone healing is of 2 types depending on the presence or absence of mobility across the fracture
site:
1. Primary bone healing (contact healing): it is direct healing of the fractured bone without
callus formation; occurs when there is no mobility across the site of the fracture and the
fragments are held rigidly together in intimate contact by internal fixation.
2. Secondary bone healing: it is healing by callus formation; it is more common and stronger
than primary healing and occurs when there is some movement across the fracture site
(callus is formed in response to movement not to the splints). It proceeds in 5 stages:
A) Haematoma formation: vessels are torn and hematoma forms around and with in
the fracture; the bone die at its ends (1-2 mm) due to cut of their blood supply.
B) Cellular proliferation: within the 1st 8hr there will be an acute inflammatory
reaction with proliferation of cells from periosteum and endosteum. The fragment
ends are surrounded by cellular tissue, which bridges the fracture site. The clotted
hematoma is slowly absorbed and fine new capillaries grow into the area.
C) Callus formation: the proliferative cells are potentially chondrogenic (form cartilage)
and osteogenic (form bone). These will form the cartilage and immature bone
(woven bone), so the thick cellular mass with its islands of woven bone and cartilage
form the callus on the periosteal and endosteal surfaces. As the woven bone
becomes more densely mineralized, movement at the fracture site decrease and the
fracture unite.
D) Consolidation: continuing osteoblastic and osteoclastic activity, the woven bone is
transferred into lamellar bone. This is slow process and it may take several months
before the bone is strong to carry loads.
E) Remodeling: it is reshaping of bone by continuous process of alternating bone
resorption and formation. The process take period of month or even years and the
medullary cavities is reformed.

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Rate of bone healing:
Repair of the bone is a continuous process and it depends on:
1. Type of the bone: cancellous bone heals faster than cortical bone because it has more
blood supply.
2. Type of the Fracture: spiral and oblique Fracture heal faster than transverse Fracture,
because of wide surface contact.
3. Blood supply: poor circulation mean slow healing.
4. General constitution: healthy bone heals faster.
5. General patient condition: deplitated and malnourished patient lead to slow healing.
6. Age: children twice faster in healing than adults.
Average time of fracture healing:
A rough guide for Fracture healing of tubular bone in adults as follow:
Lower Limb (wk) Upper Limb (wk)
Visible callus 2-3 2-3
Union 8 - 12 4-6
Consolidatio 12 16 6-8
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I said, Bones united in 6 weeks, double for the lower limb, half for children.
Testing for fracture union:
Clinically:
1. Absence of pain at Fracture site.
2. Absence of pain on stressing the fracture site.
3. Absence of tenderness at the fracture site.
4. Absence of movement across the fracture site.
Radiologically:
1. Presence of callus formation.
2. Bone bridging across the fracture.
3. Trabiculation across the fracture.
NB: If the fracture is internally fixed we depend only on radiological union and especially the sign
at trabecular continuity. Even then it wise to wait for several more months before removing the
fixation implants.

Personality of the Fracture

SPECIFIC TO FRACTURE
1. Energy of injury
2. Open or closed
3. Articular, metaphyseal or diaphyseal
4. Stable or unstable
SPECIFIC TO PATIENT
1. Age
2. Dominance
3. Precipitating factors
4. Occupation
5. Hobbies
6. Complicating factors (Osteoporosis, diabetes, smoking etc.)