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.

19. Internal fixation

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.

25. PRINCIPLES OF
TREATMENT OF
FRACTURES

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

29. HIGH-ENERGY
INJURY

30. LOW ENERGY INJURY

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

33. COMMINUTED
PROXIMAL-
THIRD
FEMORAL
FRACTURE
WITH
SIGNIFICANT
DISPLACEMEN
T

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

39. SEVERE SOFT-TISSUE INJURY

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

52. Enough for today….!!!
