Bone Fractures

 Most fractures occur to the shaft of long bones

 Bone is well vascularized and highly innervated
 Heals relatively rapidly when ends are well approximated (6 weeks or less)
 Healed bone often stronger than original due to external calcification

Fracture Types
 simple (closed) - little or no bone displacement
 compound - fracture ruptures the skin & bone protrudes
 green stick - occurs mostly in children whose bones have not calcified or hardened
 transverse - crack perpendicular to long axis of the bone - displacement may occur
 oblique - diagonal crack across the long axis of the bone - u chance of displacement
 spiral - diagonal crack involving a "twisting" of the bone about the longitudinal axis
o (occurs in skiing when bindings are too tight)
 comminuted (blowout) - "crushing" fracture - more common in elderly - may require
 screws, rods, & wires - may cause permanent discrepancy in leg length
 impacted - one end of bone is driven up into the other - may result in length discrepancy
 depressed - broken bone is pressed inward (skull fracture)
 avulsion - fragment of bone is pulled away by tendon (Hip flexors, adductors)
 Points to Remember with Regard to Fracture Healing

Fractures are treated by reduction (realignment) & immobilization

 In most cases, simple fractures heal completely in approximately 6 - 8 weeks

 o bones of elderly heal slower because of poor circulation

Two types of bone healing: Primary & Secondary (both usually occur at some level)

o Primary - healing without external fibrocartilagenous callus formation

 Seen with rigid (exact) internally or externally fixated reductions
 Similar to haversion remodelling (normal homeostatic bone metabolism)
 Rate of healing the same as secondary bone healing
o Secondary - healing with a small gap between bone ends
 External fibrocartilagenous callus forms, leaving area of u girth upon healing

Steps in Fracture Healing

 1.) Inflammatory Phase/. Formation of a fracture hematoma

 Immediately after the fracture, there is a sharp fracture line with associated soft tissue swelling. At the fracture
Site, there is abundant hematoma with beginning fibroblastic penetration.
o Bleeding from bone, bone periosteum, & tissues surrounding the bone
 formation of fracture hematoma & initiation of inflammatory response
o Induction (stimulus for bone regeneration) - caused by:
 d Oxygen r bone necrosis (fractured bone becomes hypoxic immediately)
 disruption of & creation of new bioelectrical potentials
o Inflammatory response - lasts between days 2- 9 following injury:
 phagocytes & lysosomes clear necrosed bone and other debris
 a fibrin mesh forms and “walls off” the fracture site
 serves as “scaffold” for fibroblasts and capillary buds
  capillaries grow into the hematoma
 in a fracture, the new blood supply arises from periosteum
o normally 3/4 of blood flow in adult bone arises from endosteum
o in children, normal blood flow already comes from preisoteum r u healing

2.) Fibrocartilagenous callus Formation

o Lasts an average of 3 weeks

o Fibroblasts and osteoblasts arrive from periosteum & endosteum
o Within 2-3 days, fibroblasts produce collagen fibers that span the break
 This tissue is called Fibro - Cartilagenous Callus and serves to “splint” the bone
 FCC is formed both in and around the fracture site
 Osteoblasts in outer layer of FCC begin to lay down new hard bone
 in a non-immobilized fracture, the FCC has poor vascularization
 poor vascularization r d bone production r incomplete periosteum at repair site

3.) Hard Boney Callus Formation & Ossification

o Weeks to months
o Fracture fragments are joined by collagen, cartilage, & then immature bone
 Osteoblasts form trabelcular bone along fracture periphery (external callus)
 Trabecular bone is then laid down in the fracture interior (internal callus)
o Ossification (mineralization) starts by 2-3 weeks & continues for 3-4 months
 Alkaline phosphatase is secreted by osteoblasts
 blood serum levels serve as an indicator of the rate of bone formation
 o In non-Immobilized fractures, more “cartilage” than bone is laid down
 this must later be replaced by normal cancellous bone
 results in a longer healing time and fractured area remains weak for a longer period
o Fractures should be reduced (immobilized) within 3-5 days
 Immobilization: Cast Disease
o Most changes are reversible
o Muscle Atrophy
o d calcium content in surrounding bone
o resorption and weakening of tissues at sites of ligament attachments
o no stress forces on an immobilized joint r thinning of articular cartilage
o Adhesions r joint stiffness
o loss of peripheral autonomic vascular control r hair loss -shiny mottled skin
o sensory dissociation (light touches interpreted as painful)

Therapeutic Implications for Treating Fractures

 Active ROM exercises to joints above and below immobilized region

 Resistive ROM exercises to muscle groups that are not immobilized
 Once the cast or immobilization device has been removed:
o gentle but progressive resistance exercises of all immobilized joints
o evaluate strength of joint(s) and compare to non-injured counterparts
 return to vigorous activity only after strength discrepency < 15%
Traction, orthopedic: The use of a system of weights and pulleys to gradually change the position of a bone. It may be used in
cases of bone injury or congenital defect, to prevent scar tissue from building up in ways to limit movement, and to prevent
contractures in disorders such as cerebral palsy or arthritis.

An orthopedic cast is merely a cast made traditionally from cotton bandages soaked in plaster of Paris. In a few minutes the
bandages harden, forming a protective layer around an injured area, usually a broken or badly sprained bone. Sometimes the bone
is reset prior to placing an orthopedic cast. The cast’s function will then be to hold the bone in place to heal.

Upper extremity casts

Left Arm cast from a wrist injury

Upper extremity casts are those which encase the arm, wrist, and/or hand. A long arm cast encases the arm from the hand to
about 2 inches below the arm pit, leaving the fingers and thumbs free. A short arm cast, in contrast, stops just below the elbow.
Both varieties may, depending on the injury and the doctor's decision, include one or more fingers or the thumb, in which case it is
called a finger spica or thumb spica cast

Lower extremity casts are classified similarly, with a cast encasing both the foot and the leg to the hip being called a long leg cast,
while one covering only the foot and the lower leg is called a short leg cast.

A walking heel may be applied, or a canvas or leather cast shoe provided to the patient who is expected to walk on the
immobilized limb during convalescence (referred to as being weight bearing).
Cylinder Cast include the upper and lower arm and the elbow, but leaves the wrist and hand free, or the upper and lower leg and
the knee, leaving the foot and ankle free.

Body casts, which cover the trunk of the body, and in some cases the neck up to or including the head (see Minerva Cast, below) or
one or more limbs, are rarely used today, and are most commonly used in the cases of small children, who cannot be trusted to
comply with a brace, or in cases of radical surgery to repair an injury or other defect. A body cast which encases the trunk (with
"straps" over the shoulders) is usually referred to as a body jacket.

A cast which includes the trunk of the body and one or more limbs is called a spica cast, just as a cast which includes the "trunk" of
the arm and one or more fingers or the thumb is

pantaloon casts, are occasionally seen to immobilize an injured lumbar spine or pelvis, in which case the trunk portion of the cast
usually extends to the armpits.

An external fixation device may be used to keep fractured bones stabilized and in alignment. The device
can be adjusted externally to ensure the bones remain in an optimal position during the healing process.
This device is commonly used in children and when the skin over the fracture has been damaged.

External fixation is a device worn outside the body. This device, which is also called a fixator, is connected to the bone with bone
screws or pins. The pins pass through the skin and sometimes the muscles, to connect the external fixator to the bone. Two or more
pins are placed on either side of the break in the bone. These hold the bone in place and anchor the fixator securely. Sometimes
wires are used with the pins, or in place of pins, to secure the bone pieces. The doctor uses the fixator to place the broken

bone in its correct position until bone healing occurs then the fixator is removed. This may take about 6 weeks for a simple

fracture, and up to one year or longer for a more complicated fracture. Using external fixation as a treatment to heal your fracture
may help you return to your normal activities more quickly.

An internal fixation device may be used to keep fractured bones stabilized and in alignment. The device is inserted surgically to
ensure the bones remain in an optimal position during and after the healing process.

An internal fixator refers to the implant (medicine) used in internal fixation of bones during orthopedic surgery. The concept of
internal fixation dates to the mid 1800's.[1]

An internal fixator may be made of stainless steel or titanium.

Types of internal fixators include bone screws and metal plates, pins, rods, Kirschner wires and intramedullary devices such as
the Kuntscher nail and interlocking nail.

Open Reduction Internal Fixation (ORIF) is a medical procedure. Open reduction refers to open surgery to set bones, as is
necessary for some fractures. Internal fixation refers to fixation of screws and/or plates to enable or facilitate healing.
Rigid fixation prevents micromotion across lines of fracture to enable healing and prevent infection, which happens when implants
such as plates (e.g. Dynamic Compression Plate) are used.

Open Reduction Internal Fixation techniques are often used in cases involving serious fractures such as comminuted or displaced
fractures.