Fracture: General Features,

Terms, Diagnosis and Bone

Healing
 Fracture

Fracture: structural break in continuity

Produce some degree of soft tissue injury
Mechanism:
– Twisting  spiral
– Compression  oblique
– Bending  butterfly
– Tension  transverse
Physical Factors in the Production of
Fractures
Cortical bone as a structure can withstand
compression and shearing forces better
than tension forces (bending, twisting,
straight pull)
In Children : tension failure on the convex
side and only bending on the concave side
(greenstick fracture)
Physical Factors in the Production of
Fractures
Cancellous bone (spongiosa) is more
susceptible to crushing (compression) force
than is cortical bone
In Children : compression fracture may
merely “buckle” the thin cortex surrounding
the cancellous bone of the metaphysic
(buckle / torus fracture)
Descriptive Terms Pertaining to
Fractures
• Site ( diaphyseal, metaphyseal, epiphyseal, or
intra-articular, fracture dislocation )
• Extent, complete or incomplete ( include crack
or hairline, buckle and greenstick fractures ).
• Configuration. Transverse, oblique and
comminuted fracture
Descriptive Terms Pertaining to
Fractures
• Relationship of the fracture fragments to
each other. Undisplaced or displaced.
Displaced following six ways :
– Translated ( shift sideways ) - Distracted
– Angulated - Overriding
– Rotated - Impacted
• Relationship of the fracture to the external
environment. Closed or open
• Complications. Uncomplicated or complicated
Associated Injury to the Periosteum

Periosteum is an osteogenic sleeve

surrounding bone
It is thicker, stronger and more osteogenic
during the growing years of childhood
Children: thick, easily separated from bone
not readily torn across
Adult: thin, more firmly adherent to bone 
more readily torn across
Associated Injury to the Periosteum

The periosteal sleeve usually remains intact

in at least one side (except in severely
displaced fractures in older children and
adults)  as the intact periosteal hinge
An advantage in reducing the fracture and in
maintaining the reduction
A relatively intact osteogenic sleeve across
the fracture site and aids fracture healing
History

• History of injury
• Inability to use the injured limb
• The mechanism of injury are important
• The fracture is not always at the site of the
injury
• Trivial trauma  suspect a pathological lesion
• Pain, bruising, swelling are common symptoms
• Deformity is much more suggestive
Mechanism of Injury
Mechanism of Injury
General Signs

• Primary survey  secondary survey

• ATLS
• Airway obstruction, Breathing problems,
Circulatory problems and Cervical spine injury

Life saving
Local Signs

• Injured tissues must be handled gently

• To elicit crepitus or abnormal movement is
unnecessarily painful
• A systematic approach :
– examine the most obviously injured part;
– test for artery and nerve damage;
– look for associated injuries in the region;
– look for associated injuries in distant parts.
Local Signs

LOOK
• Swelling, bruising, deformity, angulation,
lumps, limb shortening, bleeding (open),
discolored skin around the affected area
• The intact skin & soft tissue involvement 
open (compound) or closed
• The distal extremity and the color of the skin
Local Signs

FEEL
• Gently palpated for localized tenderness/pain,
swelling, tense, deformity, steps on bone,
crepitus, instability.
• The associated injuries also should be felt
• Vascular and peripheral nerve abnormalities
should be tested for both before and after
treatment.
Local Signs

MOVE
• Loss/decrease of function of the affected part
• Active and passive movement
• Abnormal movement (false movement)
• Abnormal range of movement
• Muscle power
• It is more important to ask if the patient can
move the joints distal to the injury.
False movement
Diagnostic Imaging

• The rule of twos:

– Two views
– Two joints
– Two limbs
– Two injuries
– Two occasions
• Special imaging : CT, MRI, arteriography,
radioisotope scanning
Normal Healing of Fractures

• Growth factors secreted by local cells at the

fracture site are involved in the fracture healing
• TGF-β superfamily : insulin like growth factor
(IGF), platelet derived growth factor (PDGF),
and individual bone morphogenetic proteins
(BMPs)
• Interleukins (IL) : group of cell-regulating
molecules (cytokines)  enhance fracture
repair
 HEALING OF A FRACTURE IN
CORTICAL BONE
(DIAPHYSEAL BONE; TUBULAR BONE)
Initial Effects of the Fracture

Blood vessels Ring of

Fracture Clotting
torn avascular

eventually bone resorption Dead bone at

replaced by and new bone each fracture Osteocytes die
living bone deposition surface
Early Stages of Healing from Soft Tissues

• The repair cells are osteogenic cells that

proliferate from the deep layer of the
periosteum to form an external callus, and to a
lesser extent from endosteum to form an
internal callus
• Severely periosteum torn  ingrowth of
undifferentiated mesenchymal cells in the
surrounding soft tissues
Early Stages of Healing from Soft Tissues

• early stages: ↑ osteogenic cells  an extremely

rapid growth of osteogenic tissue
• the first few weeks, the fracture callus consists
of a thick enveloping mass of osteogenic tissue
• callus does not contain bone and is radiolucent
• The callus, initially soft and almost fluid in
consistency firmer like a slowly setting glue,
and the fracture site becomes “stickier”
Early Stages of Healing from Soft Tissues

Histologically
• osteogenic cells differentiate into osteoblasts,
 primary woven bone
• osteogenic cells differentiate into chondroblasts
 cartilage initially
Stage of Clinical Union

• A temporary external and internal callus

(primary woven bone and cartilage)
endochondral ossification
• fracture callus becomes firm, no movement at
the fracture site  clinical union
• X-ray : bone in the callus but the fracture line
is still apparent
Stage of Consolidation (Radiographic
Union)
• temporary callus is replaced by mature lamellar
bone and the excess callus is resorbed 
consolidated (radiographic union)
• residual angulation, displacement, or
overriding become smoothed off or remodeled
by the process of simultaneous bone deposition
and bone resorption
Healing of a Fracture in Cortical Bone
With Rigid Internal Fixation
• there is no stimulus for the production of either
external callus from the periosteum or internal
callus from the endosteum
• directly between the cortex of one fracture
fragment and the other fracture fragment
(primary bone healing)
Healing of a Fracture in Cortical Bone
With Rigid Internal Fixation
• osteoclastic "cutter heads" cross the
microscopic fracture site and are followed by
new bridging osteons
• the healing is direct by the formation of new
osteons through haversian remodeling to the
axis of the bone
 HEALING OF A FRACTURE IN
CANCELLOUS BONE
(METAPHYSEAL AND CUBOIDAL BONES)
• principally through the formation of an internal
or endosteal callus
• rich blood supply to the thin trabeculae of
cancellous bone  little necrosis of bone
occurs at the fracture surfaces
• The osteogenic repair cells of the endosteal
covering of trabeculae proliferate to form
primary woven bone in the internal fracture
hematoma
• internal callus fills the open spaces of the
spongy cancellous fracture surfaces
• Thus, early fracture healing in cancellous bone
occurs at sites of direct contact between the
cancellous fracture surfaces by means of
endosteal callus
• Once union, the fracture is clinically united and
spreads across the entire width of the bone
• Then, the woven bone is replaced by lamellar
bone consolidated
• Eventually the trabecular pattern is re-
established by internal remodeling of bone
Healing of a Fracture in Articular
Cartilage
• the hyaline cartilage of joint surfaces is
extremely limited in its ability to either heal or
regenerate
• heals by fibrous scar tissue or fails to heal at all
• The scar leads to local degenerative arthritis
• Any irregularity (step off) that produces joint
incongruity leads inevitably to degenerative
arthritis
Time Required for Uncomplicated
Fracture Healing
Important factors:
• age of the patient
– related to the osteogenic activity of periosteum and
endosteum
• site and configuration of the fracture
• initial displacement
• the blood supply to the fracture fragments
Abnormal Healing of Fractures

• Malunion
• Delayed union
• Non union
– Fibrous union
– Pseudoarthrosis
Thank You…