Fractures, bone healing & principles of tx. of fractures
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This document discusses fractures and bone healing. It begins by providing statistics on common fractures, noting that fractures of the extremities are most common and the rates differ between age groups and sexes. It then describes different types of fractures based on the force and displacement. The document outlines the process of bone healing in four stages. It also discusses evaluating and treating fractures, including determining if reduction is needed, how to hold the reduction through various fixation methods, and indicators that a fracture has fully healed. Complications of fractures are noted. The goal is to restore optimal function while preventing issues and allowing early rehabilitation.
Fractures, bone healing & principles of tx. of fractures
- 1. Fractures and Bone Healing Dr. Muhammad Salman
- 2. Statistics • Fractures of extremities most common • More common in men up to 45 years of age • More common in women over 45 years of age Before 75 years wrist fractures (Colles‟) most common • After 75 years hip fractures most common
- 3. Types of fractures Magnitude and direction of force Closed – Bone fragments do not pierce skin Open/compound – Bone fragments pierce skin Displaced or undisplaced
- 4. Transverse fracture Usually caused by directly applied force to fracture site
- 5. Spiral or Oblique Caused by violence transmitted through limb from a distance (twisting movements)
- 6. Greenstick Occurs in children: bones soft and bend without fracturing completely
- 7. Crush fractures Fracture in cancellous bone: result of compression (osteoporosis)
- 8. Avulsion fracture Caused by traction, bony fragment usually torn off by a tendon or ligament. What muscle group attaches to this bony prominence and what nerve also runs in close proximity? Forearm flexors (common flexor origin) ulnar nerve
- 9. Fracture dislocation/subluxation Fracture involves a joint: results in malalignment of joint surfaces.
- 10. Impacted fracture Bone fragments are impacted into each other.
- 11. Comminuated fracture Two or more bone pieces - high energy trauma
- 12. Comminuated fractures can require serious hardware to repair.
- 13. Stress fracture Abnormal stress on normal bone (fatigue fracture) or normal stress on abnormal bone (insufficiency fracture).
- 14. Functions of the X-ray Localises fracture and number of fragments Indicates degree of displacement Evidence of pre-existing disease in bone Foreign bodies or air in tissues May show other fractures MRI, CT or ultrasound to reveal soft tissue damage
- 15. How to Handle Fractures Reduction Open reduction – Allows very accurate reduction – Risk of infection – Usually when internal fixation is needed Manipulation – Usually with anaesthesia Traction – Fractures or dislocation requiring slo
- 16. Holding the reduction 4-12 weeks External fixation Internal fixation – Intermedually nails, compression plates Frame fixation
- 17. External fixation Used for fractures that are too unstable for a cast. You can shower and use the hand gently with the external fixator in place.
- 18. Frame fixation Allows correction of deformities by moving the pins in relation to the frame.
- 20. Bone Healing 1. Fracture hematoma – blood from broken vessels forms a clot. – 6-8 hours after injury – swelling and inflammation to dead bone cells at fracture site
- 21. 2. Fibrocartilaginous callus (lasts about 3 weeks (up to 1st May)) – new capillaries organise fracture hematoma into granulation tissue - „procallus‟ – Fibroblasts and osteogenic cells invade procallus. – Make collagen fibres which connect ends together – Chondroblasts begin to produce fibrocatilage,
- 22. 3. Bony callus (after 3 weeks and lasts about 3-4 months) – osteoblasts make woven bone.
- 23. 4. Bone Remodeling Osteoclasts remodel woven bone into compact bone and trabecular bone – Often no trace of fracture line on X-rays.
- 26. GOALS OF FRACTURE TREATMENT Restore the patient to optimal functional state Prevent fracture and soft-tissue complications Get the fracture to heal, and in a position which will produce optimal functional recovery Rehabilitate the patient as early as possible
- 27. HOW FRACTURES HEAL In nature Regeneration vs repair Three phases of healing by callus Rapid process, rehabilitation slow, low risk With operative intervention (reduction + compression) Primary bone healing Slow process, rehabilitation rapid, high risk With operative intervention (nailing or external fixation) Healing by callus Rapid process, rehabilitation rapid, lesser risk
- 28. FACTORS AFFECTING FRACTURE HEALING The energy transfer of the injury The tissue response Two bone ends in opposition or compressed Micro-movement or no movement Blood Supply (scaphoid, talus, femoral and humeral head) Nerve Supply No infection The patient The method of treatment
- 31. DESCRIBING THE FRACTURE Mechanism of injury (traumatic, pathological, stress) Anatomical site (bone and location in bone) Configuration Displacement three planes of angulation translation shortening Articular involvement/epiphyseal injuries fracture involving joint dislocation ligamentous avulsion Soft tissue injury
- 32. MINIMALLY DISPLACED DISTAL RADIUS FRACTURE
- 34. MANAGEMENT OF THE INJURED PATIENT Life saving measures Diagnose and treat life threatening injuries Emergency orthopaedic involvement Life saving Complication saving Emergency orthopaedic management (Day 1) Monitoring of fracture (Days to weeks) Rehabilitation + treatment of complications (weeks to months)
- 35. LIFE SAVING MEASURES A Airway and cervical spine immobilisation B Breathing C Circulation (treatment and diagnosis of cause) D Disability (head injury) E Exposure (musculo-skeletal injury)
- 36. EMERGENCY ORTHOPAEDIC MANAGEMENT Life saving measures Reducing a pelvic fracture in haemodynamically unstable patient Applying pressure to reduce haemorrhage from open fracture Complication saving Early and complete diagnosis of the extent of injuries Diagnosing and treating soft-tissue injuries
- 38. DIAGNOSING THE SOFT TISSUE INJURY Skin Open fractures, degloving injuries and ischaemic necrosis Muscles Crush and compartment syndromes Blood vessels Vasospasm and arterial laceration Nerves Ligaments Joint instability and dislocation
- 40. TREATING THE SOFT TISSUE INJURY All severe soft tissue injuries………equire urgent treatment Open fractures , Vascular injuries, Nerve injuries, Compartment syndromes, Fracture/dislocations After the treatment of the soft tissue injury the fracture requires rigid fixation A severe soft-tissue injury will delay fracture healing
- 41. DIAGNOSING THE BONE INJURY Clinical assessment History Co-morbidities Exposure/systematic examination “First-aid” reduction Splintage and analgesia Radiographs Two planes including joints above and below area of injury
- 42. TREATING THE FRACTURE I Does the fracture require reduction? Is it displaced? Does it need to be reduced? (e.g. clavicle, ribs, MT‟s) How accurate a reduction do we need? alignment without angulation (closed reduction - e.g. wrist) anatomic (open reduction - e.g. adult forearm )
- 45. TREATING THE FRACTURE II How are we going to hold the reduction? Semi-rigid (Plaster) Rigid (Internal fixation) What treatment plan will we follow? When can the patient load the injured limb? When can the patient be allowed to move the joints? How long will we have to immobilise the fracture for?
- 46. DIFFERENT TYPES OF RIGID FRACTURE FIXATION
- 47. TREATING THE FRACTURE III Operative Non-optve Rehabilitation Rapid Slow Risk of joint stiffness Low Present Risk of malunion Low Present Risk of non-union Present Present Speed of healing Slow Rapid Risk of infection Present Low Cost ? ?
- 48. INDICATIONS FOR OPERATIVE TREATMENT General trend toward operative treatment last 30 yrs Improved implants and antibiotic prophylaxis, Use of closed and minimally invasive methods Current absolute indications:- Polytrauma Displaced intra-articular fractures Open #‟s #‟s with vascular inj or compartment syn, Pathological #‟s Non-unions Current relative indications:- Loss of position with closed method, Poor functional result with non-anatomical reduction, Displaced fractures with poor blood supply, Economic and medical indications
- 49. WHEN IS THE FRACTURE HEALED? Clinically Upper limb Lower limb Adult 6-8 weeks 12-16 weeks Child 3-4 weeks 6-8 weeks Radiologically Bridging callus formation Remodelling
- 50. REHABILITATION Restoring the patient as close to pre-injury functional level as possible May not be possible with:- Severe fractures or other injuries Frail, elderly patients Approach needs to be:- Pragmatic with realistic targets Multidisciplinary Physiotherapist, Occupational therapist, District nurse, GP, Social worker
- 51. COMPLICATIONS OF FRACTURES Early Late General Other injuries Chest infection PE UTI ARDS Bed sores Bone Infection Non-union Malunion Soft-tissues Plaster sores Tendon rupture N/V injury Nerve compression Compartment syn. Volkmann contracture