Bone: Fracture Patterns

Bone Healing Fracture Management

PTP 521Musculoskeletal Diseases and

Disorders

Objectives

• Describe forces involved in fracturing a bone• Describe common bone fracture patterns• Differentiate between fracture patterns by

discussing forces involved• Discuss three different types of fracture

classification• Discuss bone healing • Discuss fracture management

Fractures:• Break in the continuity of

the bone

• Physical Therapy Practice Pattern 4G: Impaired Joint Mobility, Muscle Performance and Range of Motion Associated With Fracture

Risk Factors or Consequences of Pathology – Guide to PT Practice

• Bone demineralization

• Hormonal changes

• Medications

• Menopause

• Nutritional deficiency

• Prolonged immobilization or non-weight bearing state

• Trauma

Causes:

• 1. External forces: • 2. Internal forces: nutrition • 3. Pathology: at risk to fracture other bones.

Clinical Manifestations: Signs and Symptoms of a Fracture

1. Signs: – **Deformity of the bone– **Edema – **Ecchymosis: is the

swelling, purple-blue color.

– **Loss of general function and/or mobility

• WB?

2. Symptoms:– **Pain– **Point tenderness over

fracture site– Increase symptoms with

vibration or tapping

** Most Common Manifestations

Body Structure Dysfunction, Activity Limitations or Participation Limitations – PT Guide to Practice

• Inability to access community

• Limited Range of Motion: body structure/dysfunction.

• Muscle weakness from immobilization: body structure/dysfunction

• Pain with functional movements and activities: activity limitation

Fracture Descriptions

1. Site of fracture2. Extent of fracture3. Fracture Alignment4. Direction of Fracture Lines5. Special Features of Fractures6. Associated Abnormalities7. Special Types of Fractures

Site of the FractureA. Diaphyseal :

B. Metaphyseal:

C. Epiphyseal:

D. Intra-articular:

E. Fracture-Dislocation:

Trauma Registry System of Fracture Classification

A. Long bones 1) intra-articular

2) extra-articular

B. Flat bones1) intra-articular

2) body or extra-articular

Extent of the Fracture

A. Complete: fracture which breaks both

cortex-harder to heal, poorer alignment.

B. Incomplete: fracture which breaks only one cortex

Fracture Alignment:

Fracture patterns predicted by the external force and bones inherent characteristics.

Load: application of force, type of load can determine fracture type.

Common Loads:1) Tension: pull2) Compression: WB3) Bending: a little flexibility in bone. 4) Torsion:

Fracture Alignment

• Position: Relationship of fragments to their normal anatomical structure– Need 2 x-rays at 90 degrees to each other to see a fracture.

• Alignment: Distal segment in relation to proximal segment• Relationship of the longitudinal axis of one fragment to the other

• Apposition: The placement of two bone segments in close proximity

Position: Fracture Alignment

A. Non-displaced: Fracture segments are in good alignment and don’t require any intervention for alignment

B. Displaced: Loss of apposition between segments

Relationship of Fracture Fragments to Each Other

B. Displaced: fracture whose ends are separated due to:1. Force of the injury: high (more likely to displace) vs

low

2. Gravity

3. Pull of muscles attached to the bone: muscle spasm (often after injury) so may pull bone out of alignment (often rotation)

Types of Displacement

a. Shifted: Apposition is present– Bones usually unite– Fractures surfaces may

not be in contact with one another in one plane

– Medial, Lateral, Anterior, Posterior, Superior or Inferior to each other

• Fracture in a 2 year old• Where is the fracture?

– Femur• What direction is it

shifted? – Lateral Displacement

• The image on the right was taken at the time of injury, with the leg in a fiberglass cast.

• b. Angulated: tilted, if not corrected, could lead to a

deformity in the limb

Types of Displacement

c. Rotated: bone looks straight but one limb is rotated about its longitudinal axis

Types of Displacement

d. Distracted: ends are separated and pull apart from each other

d. Issue is with soft tissue going between the ends, then can’t heal.

Types of Displacement

e. Overriding: – muscle spasms with

the injury – the bones are

pulled past each other

– shortens the bone

Direction of Fracture Lines

• Reference: longitudinal axis of the bone

• Irregular shaped bones are referenced by the cortex of the bone

Naming of Fracture Patterns

• Depends upon – Load – what type

– Direction of fracture lines

Basic Patterns

1)Transverse Fracture– Fracture is perpendicular

to the long axis of the bone

– Load: bending force• Low energy• Stable, fracture fragments

usually remain in place

Basic Patterns

2) Longitudinal: fracture line runs parallel to the long axis of the bone

• Load: may be a repetitive stress or an extension of an oblique fracture

• Risk: Tibial Longitudinal Fractures: runners, jumpers (basketball players) and old women

Basic Patterns

3. Oblique fracture: diagonal break across the bone

– Load: axial compression, bending and torsion force

• Moderate energy

Basic Patterns

4) Spiral Fracture: fracture is jagged, pointed ends, can have soft tissue damage

– Load: torsion force• Low energy

• oblique Spiral

Comminuted

Butterfly fracture

– Load: axial compression and bending force

• Moderate energy• Butterfly Fractures

occur on side of concavity of the fracture

Comminuted

Segmental Fracture– Comminuted

fracture, bone in more than two parts

– 3-100 or more

Special Features of Fractures

• Impacted: fractured bone is driven into itself, shortens the bone

• Impactions – Load: axial compression

force• Variable energy is

required• Fracture lines can be

indistinct as the fracture ends are jammed together

Basic Patterns

Avulsion Fractures

http://sacs.vetmed.ufl.edu/notes/CROSS/response.htm

Associated Abnormalities

• Subluxations: Partial dislocation, still within the confines of the joint capsule

• Dislocations: bones are completely disarticulated, outside the joint capsule

Fracture dislocation of the ankle, BoneandSpine.com

Special Types of Fractures

• Stress fractures

• Pathologic fractures

• Periprosthetic fractures

• Bone graft fractures

Types of Incomplete Fractures seen in Children

A. Greenstick Fracture

B. Plastic Bowing: low load, prolonged stress.

C. Torus Fracture (Buckle): load is really high so folds in on itself.

Salter-Harris Classification of Children’s Epiphyseal Fractures

• Type I: separation of epiphyseal plate

• Type II: separation of epiphyseal plate plus metaphyseal wedge fracture

• Type III: separation of epiphyseal plate plus epiphyseal wedge fracture

• Type IV: metaphyseal and eipiphyseal fracture fragment

• Type V: impaction fracture of epiphyseal plate and adjacent surfaces

Salter Harris Classifications

• Rang’s type VI:• Involves the epiphysis

at the outside periphery of the bone – perichondrial ring

• May cause an osseous bridge between the metaphysis and epiphysis.

Ogden’s VII

• Tip of the epiphysis• Articular surface is

involved• Increases risk of OA

later in life.

Ogden VIII

• Metaphysis fracture that disrupts the blood flow to the epiphyseal plate

Ogden IX

• Avulsion fracture of the periosteum which can influence the growth plate and/or vascular supply to the epiphyseal plate

Closed Fracture Descriptors

• Closed (simple): fracture that doesn’t break the skin

• Tscherne Classification

– Grade 0: no soft tissue damage, indirect forces, torsion fractures

– Grade 1: superficial abrasion or contusion caused by fragment pressure from within. Mild to moderate fracture severity

– Grade 2: deep contaminated abrasion, local skin or muscle contusion from direct trauma

• Grade 3: skin extensively contused, crushed muscle, severe muscle damage, vascular injury, compartment syndromes are common

Open Fracture Descriptors

• Open fractures (compound): open wound is present

• Gustillo Classification

– Type I: wound is less than 1 cm long, low energy trauma, minimal soft tissue damage, no signs of crush injury

– Type II: wound is more than 1 cm long, slight to moderate crush injury, no extensive soft tissue damage, flap or avulsion

– Type III: extensive wound and soft tissue damage, greater degree of fracture comminution and instability, high degree of contamination

Fracture Complications

A. Uncomplicated: fracture that heals uneventfullyB. Complicated:

1) nonunion: failure of the bone fragments to unite2) malunion: healing of a fracture occurs, but a deformity results3) delayed union: healing at a fracture site that progresses too slowly compared to the norms4) posttraumatic OA: altered joint mechanics due to

an intra-articular fracture or malunion

Complications

• Open fracture complications – Infections• Compartment Syndrome: 5 P’s

– Pain, Pallor, Paresthesia, Paralysis, Pulselessness• Nerve Injury• Arterial Injury• Infection• Complex Regional Pain Syndrome• Limb Length Discrepancy

Life Threatening Complications (Open or Closed)

1) Fat embolism: stroke2) Hemorrhage3) Pulmonary embolism: air bubbles4) Gas Gangrene: when muscle tissue dies, so

amputation is only way to stop it. 5) Tetanus: bacteria that first sign is slok-jaw,

rigidity of all muscle.

Cortical Bone Healing After a Fracture: Inflammatory Stage

1) Fracture gap is < 10uM

– Osteoclasts are present only when the bony ends die back

– If gap is small (< 10 uM) – no bone death will take place and the healing occurs with Haversian remodeling

– No osteoclasts are present

– If gap is greater than 10uM, Haversian remodeling can’t occur and the regular healing takes place

2) Fracture gap is > 10uM– 0 – 3 days after a fracture– Mesenchymal cells arrive, produce a fibrous

tissue that envelops both ends of the fracture site

– Macrophages are present to clean out the debris

– Hematoma is beginning to be absorbed– Fibrin clot develops between the fracture ends

Proliferative Stage:

1) Soft Callus Formation:– Cells: osteogenic and chondrogenic cells, osteoclasts– Clinical Union: callus has united at the fracture site– No movement at fracture site– Fracture is NOT normal in strength– Callus: contains fibroblasts, blood vessels, cartilage and

new bone– Mechanical characteristics change

Reparative Stage:

2) Ossification phase:– Callus is absorbed and replaced by bone– Trabecular patterns begin to appear across the

fracture site– Early Union: Trabecular fracture pattern is

identifiable and crosses the fracture lines

Reparative Stage:

3) Consolidation Phase: 14-40 days after a fracture– Osteoclasts and osteoblasts are filling in the gaps

between the fragments with new bone– Bone can now carry a normal load– Established Union: appearance of cortical

structure and remodeling occurs along the lines of stress

Remodeling Stage: 40 + days after a fracture

• 1) Begins when fracture site is stable

• 2) Reshaping of the bone with bone re- absorption

• 3) Wolfe’s Law

• 4) Fibrous Union: clinically stable, pain-free fracture site without radiological evidence of fracture lines remaining. Repair is complete when the bone density is normal

Cancellous Bone Healing

• Heals with little to no callus formation as long as the bone ends are close together.

• Direct osteoblastic activity: creeping substitution

• * if fracture ends aren’t close together, the bone will heal with callus formation as a hematoma will fill in the gap between the bony ends

Time Line for Fracture Healing

www.davidnelson.md/Fractures_in_general.html

Variables Influencing Healing

www.davidnelson.md/Fractures_in_general.html

Fracture Healing Considerations

A. Age: kids heal twice as fast as adultsB. Site and configuration of the fracture

1) Cancellous bone heals faster than cortical bone

2) Spiral fractures heal faster than transverse fractures

3) UE heals faster than LE

C. Blood supply1) Poor circulation causes poor healing

• Smoking• Vascular diseases

2) Major difference between stable and unstable fractures is the vascularization which

occurs between days 3 and 5

Time Frame for Fracture Healing

UE LE

Callus visible by x-ray

2-3weeks 2-3 weeks

Ossification 4-6 weeks 8-12 weeks

Consolidation 6-8 weeks 12-16 weeks

Fracture Treatment

1. Reduction– Reduce as quickly as possible because swelling

may make reduction more difficult– Try not to wait longer than 24 hours– Alignment is more important than apposition,

overlap is acceptable– If fracture involves the articular surfaces, patient

may get degenerative arthritis after several years due to force redistribution on articular cartilage

A. Closed reduction:• All minimally displaced fractures, most

fractures in children• Done under anesthesia, procedure for fracture

reduction:1) distal part of the limb is pulled in line with the bone2) reposition of bony fragments3) alignment is adjusted in each plane4) checked with radiography after the reduction

B. Open Reduction:

Open the patient up in surgery to align the bone better 1) done when a closed reduction fails2) when there is difficulty in controlling the fragments3) soft tissue is in between the fracture ends.4) large articular fragments need positioning5) avulsion fractures with the fragments held apart, may be due to muscle spasms

2. Splinting a Fracture

A. Continuous traction– 1) gravity alone– 2) skin traction– 3) skeletal traction– 4) complications

Splinting a Fracture

B. Cast Splinting 1) Complications:

a. tight castb. pressure soresc. skin abrasion /

laceration

C. Functional Bracing

D. Internal Fixation1) Indications:

a. Fracture can’t be reducedb. Fracture is unstablec. Fracture unites poorlyd. Pathological fracturee. Multiple traumasf. Age, disease processes, disabilities present

Splinting a Fracture

2) Types of Internal Fixation

a. Rods/Nails

b. Compression plates

d. Pins, Wires, Screws

c. Buttress plates

3) Complicationsa. Infectionb. Non-unionc. Implant failured. Re-fracture

E. External Fixation

1) Indicationsa. Fracture with severe

soft tissue damageb. Fracture with nerve

or blood vessel damage

c. Severely comminuted/unstable fracture

d. Pelvic fracturee. Infected fracture site

2) Benefitsa. Allows patient to be more mobileb. Maintains fracture alignment and lengthc. Stress-sharing device

3) Complications:a. Infections at pin trackb. Delayed union

References:

Greenspan A. Orthopedic Imaging, A Practical Approach, 4th ed. Lippincott, Williams and Wilkens, Philadelphia. 2004

McKinnis L. Fundamentals of Musculoskeletal Imaging, 3rd ed. FA Davis. Philadelphia, 2010.