SEMINAR ON BONE FRACTURE

07/25/2021 1
GROUP MEMBERS

ALFIYA REDWAN
AYNALEM THOMAS
BEREKET ORSANGO
BITSIT DEMEKE
DEGELE LENDEBO
FEVEN DANIEL

07/25/2021 2
Outline
Introduction
Classifications of fracture
Fracture healing
Diagnosis and investigations of fracture
Management
Pediatrics fracture
Complications

07/25/2021 3
Introduction
Bone
Bone is extremely dense tissue that makes
up the body’s skeleton.
Bone has three components;
◦ Cells, minerals and protein matrix
1. Cells
◦ Osteoblasts:-function in bone formation
by secreting bone matrix.

07/25/2021 4
Cont

 Osteoclasts :- bone resorption cell involved

in removal or destruction of bone tissue.
 Osteocytes:- Mature cell of bone involved
in bone maintenance
 Chondroblasts; increase the diameter of
affected tissue and maintains bone growth

07/25/2021 5
Cont’

2. Mineral deposits; e.g. Calcium and

phosphorous

3. Protein matrix;
◦ Collagen fiber can give Strength.

◦ Proteoglycans work for transportation.

◦ Glycoprotein's promote calcification.

07/25/2021 6
Types of bone
Lamellar bone; which has regular parallel
arrangement of collagen and is
mechanically strong.
Woven bone; which has randomly
oriented collagen fiber and is
mechanically weak.
Lamellar bone is further classified in to;
Trabecular bone; found at the end of
bones, softer and more flexible.
07/25/2021 7
Cont
Compact bone; denser and stronger bone
that provides rigidity and support.

Functions of bone;
Support the whole body
Protect organs
Provides movement
Stores minerals
Forms Blood cells

07/25/2021 8
FRACTURE
Fracture is complete or incomplete
disruption in the continuity of bone
structure.
Fracture occurs when the bone is
subjected to stress greater than it can
absorb.

07/25/2021 9
Classification of fracture
Based on etiology;
Traumatic fracture- trauma is the most common cause
of fractures and is usually due to sudden excessive
force. Example; fracture resulting from automobile
injury or falling from a height.

Pathological fracture; those fractures occurring

because of underlying bony or systemic disease that
causes abnormal weakening of the bone. Example;
Fractures through a bone weakened by metastasis.
Osteoporosis is the most common cause.

07/25/2021 10
Based on soft tissue involvement

Closed fracture- a fracture that remains

encased within the skin and musculature
that surrounds it.
Open fracture – a fracture with a break in
the skin and underlying soft tissue where
there is penetration of the bone through the
skin surface. This fracture carries a higher
risk of infection.

07/25/2021 11
Gustillo Anderson Classification of
open fracture

Grade 1 - skin opening of 1cm or less, minimal

muscle contusion.
Grade 2 - skin laceration 1-10cm, moderate soft
tissue damage
Grade 3
• Grade 3a - extensive soft tissue
laceration(10cm) but adequate bone coverage
• Grade 3b - extensive soft tissue injury with
periosteal stripping
• Grade 3c - vascular injury requiring repair
07/25/2021 12
Radiological Classification (Based on pattern of fracture )

Transverse fracture; fracture

perpendicular to the long axis of the bone
Oblique fracture; fracture that travels on a
diagonal path across the long axis of the
bone
Spiral fracture; fracture that wraps around
the bone

07/25/2021 13
Cont

Comminuted fracture; fracture that has multiple

components or small pieces
Segmental fracture; more than one fracture at different
sites in the same bone
Depression fracture; represent areas in which
multiple fracture lines intersect.
Avulsion fracture; a fracture that occurs at a point
of tendon insertion where the portion of adjoining
bone is pulled away.

07/25/2021 14
Cont

Impacted fracture; is where the trabecular

structure of the bone has been pushed together
along the long axis of the bone leading to
compression.
Greenstick fracture; fracture in which the bone
bends and breaks. Common in a young, soft
bone(in childrens)
Torus fracture; fracture due to a force acting on
the longtidunal axis of the bone.

07/25/2021 15
07/25/2021 16
Classifications based on fragments

Incomplete fracture; in which the bone

fragments are still partially joined.
Complete fracture; in which the bone
fragments separate completely.

07/25/2021 17
Fracture healing
 It is a physiological process in which the
body facilitates the repair of bone fracture.
 The healing process is mainly detremined
by the periosteum.
 The periosteum is a membrane that covers
the outer surface of bones.
 It contains fibroblasts and progenitor cells
from which chondroblasts and osteoblasts
develop respectively.
07/25/2021 18
Cont

There are three major phases to fracture

healing;
Inflammation
Repair
Remodeling

07/25/2021 19
Inflammation

 Soon after fracture, blood vessels constrict to stop

any further bleeding.
 Extra vascular blood cells form a blood clot known
as hematoma. These cells release cytokines and
increase capillary permeability.
 While cells with in the clot degenerate and die,
fibroblasts survive and replicate.
 The fibroblasts form loose aggregate of cells with
small blood vessels known as granulation tissue.
 This tissue reduces strain across the fracture site.

07/25/2021 20
Repair
 Seven to nine days after fracture, both
Periosteal cells near to the fracture and
fibroblasts develop into chondroblast which
forms hyaline cartilage.
 The periosteal cells distal to the fracture and
develop in to osteoblasts that form woven
bone. Mean while fracture callus forms
during the process.
 Eventually the hyaline cartilage and woven
bones bridge the fracture gap by restoring
some of the strength.
07/25/2021 21
Cont
 The woven bone and hyaline cartilage are
replaced by highly organized and stronger
bone known as lamellar bone.
 These lameral bones are in the form of
trabecular bones which are spongy and
flexible in character.
 Eventually all of the woven bones and
cartilages are replaced by trabecular bone
restoring most of the bone’s original strength.

07/25/2021 22
Remodeling
 The remodeling process substitutes
trabecular bone with compact bone which
is much denser.
 Eventually the fracture callus is
remodeled into a new shape that
duplicates the bone’s original shape and
strength.
 This phase may take 3 to 5 years
depending on factors such as age and
other conditions.
07/25/2021 23
Factors affecting bone healing
Poor blood supply
The degree of injury
Presence of infection
Age
Pre existing bone malignancy

07/25/2021 24
Diagnosis of Fracture
Clinical
 History
History of injury
Pain, swelling and bruising
Loss of function and deformity
Associated injury
 Blood in the urine
 Shortness of breath

07/25/2021 25
Cont
P/E
Look for airway, breathing and circulation
Tenderness
Abnormal Mobility & creptus
Evaluate the overlying skin
Neurovascular evaluation distal to injury site

07/25/2021 26
Investigations
Lab:- CBC

- Blood group and Rh

IMAGING
CT/MRI
Angiography
X-ray examination

07/25/2021 27
X-ray examination
confirms diagnosis of fracture
Shows displacement & pattern of fracture
To decide the technique of treatment

 Remember rules of two

Two views – AP & LATERAL
Two joints – joints above and below the fracture
Two limbs – for comparison
Two injuries – severe forces often causes injuries more
than one
Two occasions-after 2 weeks b/c some fracture are not
seen immediately .

07/25/2021 28
Management
1. General Rx
Stabilization of the patient,primary survey
 Airway
 Breathing & oxygenation
 Circulation & control of bleeding
 Pain control
 Analgesics
 Splint
2. Definitive treatment
Three fundamental principles
1. Reduction
2. Maintenance of reduction
3. Rehabilitation

07/25/2021 29
1. Reduction
 This is bringing the fractured bone to normal or
near normal anatomic position.
 Types of reduction
◦ Closed reduction
◦ Open reduction
 Reduction should be done as soon as possible
because fracture reduction is difficult as the
injury begins healing.

07/25/2021 30
Closed reduction

Bringing bone fragment in contact with

out any surgery by using manual traction
and manipulation.
 Anesthesia may be used.
 It can be healed in the desired position by
applying immobilizing device.
07/25/2021 31
Open reduction

It is reducing fracture fragments through a

surgical process.
Internal fixation devices such as wire,
screw, plate and the like may be used to
hold the bone fragments in position until
it heal.

07/25/2021 32
2.Maintenance of reduction
To keep the fracture fragment in acceptable
position.
Methods
 Cast splintage
 Internal fixation
 Continuous traction
o Skin traction
o Skeletal traction
 External fixation
07/25/2021 33
Cast splintage
1. Short arm cast
◦ Extend below the elbow to the basis of the thumb.
2. Long arm cast
◦ Extend from the upper fold of the axilla to the base of the thumb.
3. Short leg cast
Extend from below the knee joint to the base of the toes.

4. Long leg cast

 Extends from the junction of the upper and middle third of
the thigh to the base of the toes.
It includes the knee joint.

5. Body cast
 Encircle the entire trunk

07/25/2021 34
07/25/2021 35
Casting material
Non plastic:- Called fiber glass cast
◦ Lighter, stronger, water resistance and it
diminished skin problem.

Plaster :- should wet in cool water, apply

it smoothly to the body.

07/25/2021 36
Continuous Traction
The application of pulling force to a part of the body.
Purpose

◦ To pull fractured bones in to place

◦ To immobilize reduced bone
◦ To minimize muscle spasm
◦ To reduce deformity
◦ To reduce bone overlapping

07/25/2021 37
Skin Traction

A traction applied to the surrounding skin .

Used to control muscle spasm and to
immobilize an area before surgery.
Accomplished by using a weight to pull on
traction tape or a foam boot attached to the
skin.

07/25/2021 38
07/25/2021 39
Skeletal traction

A traction directly applied to the bone by using Metal

pin or wire inserted through the bone distal to the
fracture by avoiding nerve, blood vessel , muscle,
tendons and joints.
Used occasionally to treat fracture of the femur, tibia
and cervical spine.
Usually uses 7 to 12 Kg to achieve the therapeutic
effect.
07/25/2021 40
07/25/2021 41
Internal fixation
 Bone fragments are fixed by implementing implants.
 Inter fragmentary screws
 Plates,pin and screws
 Wires
 Intra medullary nail
 Indications
 Closed methods failed
 Unstable fracture
 Pathological fracture
 Complications
 Infection
 Non-union
 Implant failure

07/25/2021 42
07/25/2021 43
External fixation
 Fracture can be held by pins above and below the
fracture, attached to the external frame.
 Indications
Stabilization of fracture with severe soft tissue
damage
Severe multiple fracture
Pelvis fracture
 Complications
Damage to Soft tissue
Over distraction
Pin track infection

07/25/2021 44
07/25/2021 45
3. Rehabilitation
 The process of regaining normal activity.
 Edema is controlled.
 Weightbearing exercise.
Exercise
 Preserve joint movement
 Restore muscle power
 Functional activity
 Neurovascular status (circulation, motion and
sensation) is monitored routinely

07/25/2021 46
Pediatrics fracture
Itis a medical condition in which the
bone of a child is cracked or broken.
The bone of children’s heals faster than
adult’s because it is covered with thicker
and denser periosteum.
Growth plate are the areas where the
bones grow.
In childrens growth plates are open so it
can easily be managed.
07/25/2021 47
Cont
The bones of a child are more likely to
bend than to break.
Pediatrics fracture can be classified as
complete and incomplete.
There are also physeal fractures, fractures
involving the growth plate.
There are three forms of incomplete
fractures; greenstick, torus and bow
fracture.
07/25/2021 48
Cont
Greenstick fracture; transverse fracture
which extends into the mid portion of the
bone and becomes oriented along the
longitudinal axis of the bone without
disrupting the opposite cortex.
Torus fracture; it is usually the result of a
force acting on the longitudinal axis of the
bone, it mainly involves the distal radial
metaphysis.

07/25/2021 49
Cont

Salter Harris fracture; a fracture that involves

the growth plate of a bone.
A Salter-Harris Type I injury is a simple
transverse fracture of the physis separating
epiphysis from the metaphysis.
A Salter-Harris Type II fracture contains a
component of fracture through the growth
plate in continuity with a fracture of the
metaphysis.
07/25/2021 50
Cont’
Salter-Harris Type III fracture occurs
through the physis and exits through the
growth plate.
While a Salter-HarrisType IV fracture line
extends the physis from the metaphysis
into the epiphysis entering a joint.
A Salter-Harris Type V fracture crushes
the physis itself.

07/25/2021 51
Complications
Infection; predominantly occurs in open
fractures.
Vascular damage
Haemarthrosis
Visceral damage
Fat embolism

07/25/2021 52
Cont
Damage to the surrounding skin or tissue
Compartment syndrome;
Non union; No progression of healing with in
six months of fracture.
Mal union; healing occurs but it has angular
deformity.
Delayed union; Healing occurs but at a slower
rate than normal.

07/25/2021 53
References

Bailey and love’s 26th edition

Schwartz’s principles of surgery 10 th
edition

07/25/2021 54
THANK YOU

07/25/2021 55