FRACTURE

I. Definition

 Fracture
-any break in the continuity of the bone.
- an interruption or disruption on the normal continuity of the bone that
results from excessive force/stress or pathology that has weakened done.
 Open/compound fracture
- a fracture where there is a communication with the outside of
environment.
-the fracture site is communicates with the skin surface
 Closed/simple fracture
- fracture in which the skins remains in intact and there is no
communication between the bone and the outside.

II. Related Anatomy

 Bone or osseous tissue- contains an abundant extracellular matrix that

surrounds widely separated cells.

 Structure of the bone:

  Diaphysis- is the bone’s shaft or body- the long main portion of the bone
 Epiphyses- are the proximal and distal ends of the bone
 Metaphyses- are the regions between the diaphysis and epiphysis.
 Articular cartilage- is a thin layer of hyaline cartilage covering the part
of the epiphysis where the bone forms an articulation.
-reduces friction and absorbs shock at freely movable
joints
 Periostium- surrounds the external bone in the surface wherever it is not
covered by articular cartilage. The periosteum also protects the bone,
assists in fracture repair, helps nourish bone tissue and serves an
attachment point for ligaments and tendons.
 Medullary cavity or marrow cavity- is a hollow, cylindrical space
within the diaphysis that contains fatty yellow bone marrow in adults.
 Endosteum- is a thin membrane that lines the internal bone surface
facing the medullary cavity.

 Developmental of the bone

 Membranous/ intramembranosus/mesenchymal or dermal bone
-is the simpler of the two methods of bone formation
-formed by direct transformation of condense mesenchyme or primitive
connective tissue,
 Endochodral / intracartilagenous/cartilage bone
- formed by replacing a pre-formed cartilage model.

 Compact bone (substansia compacta) - contains few spaces and is the

strongest from the bone tissue.
 Osteon / harvesian system- functional unit of the bone.
 Haversian canal- longitudinal channels.
 Volkmann’s canal- transverse or oblique channels interconnecting one
harvesian canal to another.
 Lacunae –cavities filled with osteocytes that are uniformly spaced
throughout the interstitial substance of the bone.
 Canaliculi- slender,branching tubular passage interconnecting the
lacunae.
-essential for nutrition of bone cells.

 Spongy bone(substantia spongiosa)

-makes up most of the inferior bone tissue of short, flat and irregularly
shaped of the bones and most of the epiphysis of long bones.
-composed of lamellae but with thin trabeculae.
 -absent of harvesian system

 Cellular component of bone:

 Osteogenic cells
-unspecialized stem cells derived from mesenchyme, the tissue from which
almost all connective tissue are formed.
-they are the only bone cells to division.
-the resulting cells develop into osteoblast.
 Osteoblast
-are bone-building cells.
-responsible for bone formation
-they synthesize and secrete the collagen fibers and other organic
components needed to build the extracellular matrix of bone tissue.
 Osteocytes
–mature bone cells.
-Main cells in the bone tissue and maintain its daily metabolism, such as the
exchange of the nutrients and wastes with the blood.
 Osteoclast
- are huge cells derived from the fusion of as many as 50 monocytes and are
concentrated in the endosteum.

 Composition of the bone

 Hydroxyapatite
-attributes to the hardness of the bone.
-compose of the Ca, phosphate and carbonate
-an inorganic component 70% of the weight of bone, the rest of which are
20%organic and 10%water
 Type I collagen
-90% of the organic component of bone.
-also found in skin, tendon, blood vessels bone.

 Epidemiology

 Clavicular Fracture
- Childhood under 25 years old
- 8% middle third of clavicle
- 15% lateral 1/3 of clavicle
- 5% medial 1/3 of clavicle
  6% of fracture involved carpal bones
- 70% carpal fracture involve the scaphoid
- 80% middle third of scaphoid
- 15% proximal third of scaphoid
- 4% distal third of scaphoid
- 1% distal tubercle
 The most fracture site was the distal forearm with a peak in girls and boys at
11-12 years of age.
 Hip fracture: mostly affected are the elderly 60-70 y/o
 The sex specific incidence was 43 to 74 for boys and girls respectively with
the incident ratio of 1:7
 Distal forearm fracture-24% followed by
 Tibia/fibular shaft 13%
 Forearm shaft 11%

III. ETIOLOGY

o Pathologic fracture
-occur in bones weakened by preexisting disease such as tumor, cysts,
osteomyelitis, or osteoporosis
o Traumatic fracture
 Direct- fracture at the site of impact
 Indirect- fracture caused by a force transmitted to the bone from some
parts of the body.
 Muscular traction- fracture caused by sudden contraction of a muscle.
• Trauma
• Motor vehicle accidents
• Assault
• Overuse (marathon runners, military); sudden changes in
training (duration, intensity)
• Participation in sports, including dance (recreational or competitive)
• Advanced age
• Women: postmenopausal osteoporosis; military: stress fractures
• Men: hypogonadism (erectile dysfunction, prostate cancer)
IV. PATHOPHYSIOLOGY
I. According to completeness
 Incomplete
 Greenstick fracture- occurs in children, in which the bone is bent
and broken only part of the way through its shaft,
  Fissured fractured- a mere splint of the bone without displacement
of the bone fragments.
 Perforating fracture- (+)hole such as bullets
 Depressed- saucer or gutter shaped in which a problem of a bone is
driven inward towards the body.
 Complete
 Impacted fracture- broken ends driven into each other
 Comminuted fracture- bone broken to a several pieces or fragments.
 Complicated fracture- (+) injury to some organs or important
structure near the fracture site

II. According to displacement

1. Transverse fracture- fracture surface is perpendicular to the long
axis; caused by angulatory force
2. Oblique fracture- fracture surface forms an angle with the axis of the
shaft.
3. Spiral fracture- break coils around the bone due to torsional force.
4. Comminuted fracture
 Lateral displacement
 Angulated displacement
 Overlapped displacement
 Rotational displacement

Types of union:

 Delayed union
 occurs fracture fails to consolidate in the time required for union to take
place
 healing process is retarded, however ,forming a firm union is still possible in
sufficient length of time

Causes:

- inaccurate reduction – alignment of fracture

- inadequate or interrupted immobilization
- serve local traumatization
- impairment of bone circulation
- (+) infection
- Loss of bone substance
- Distraction or separation of bone fragments

 Malunion – union in poor position

 - Malalignment of fracture site at the time of immobilization
- Mobility of fracture site at the time of immobilization

 Non-union – present when process of bone repair have ceased after having failed
to form a firm union
- No fracture should be considered ununited until atleast 6
months
- Pseudoarthrosis – sometimes used interchangeably with non –
union
- Special form of non – union in which bone ends, covered by
fibrocartilage, are separated by a cleft or false joint,
surrounded by a pseudocapsule than often contains synovial
fluid

Specific types of fracture:

 Jefferson’s fracture/ Burst fracture of atlas

 burst fracture of ring atlas
 MOI: usually a sequelae of another cervical spine injury
 Hangman’s fracture/Traumatic spondylolisthesis of axis
 MOI: hyperextension and axial compression
 Flexion teardrop fracture
 Retropulsion of the larger portion of a vertebral body into the spinal canal
detatched from an anterior fragment (teardrop)
 Subaxial cervicalspine (C3 – C7)
 Most severe flexion compression injury
 Burst fracture of spine
 fracture of the anterior and middle columns with fragment displaced into
neural canal.
 Scapular Fracture
 Tenderness over the scapular and acromial region
 MOI: direct blow in the shoulder usually after a significant traumatic evident.
 Clavicular fracture
 Pain in the shoulder region
 May or may not have an obvious deformity.
 Majority occur in childhood and adults <25 y/o
 MOI: most common direct blown and FOOSH
 Proximal humerus fracture
 Loss of sensation in lateral deltoid region for axillary nerve
 MOI: FOOSH
 Humeral shaft fracture
  Severe arm pain, swelling and deformity
 MOI: direct trauma MVA, FOOSH
 Distal humerus fracture
 swelling, ecchymosis and pain at the elbow
 MOI: FOOSH and direct impact
 Supracondylar fracture
 involves the area above the condyles of femur and humerus Radius
 Volkmann ischemic contracture- common complication
 MOI: Extension injury/FOOSH – with varus or valgus force at the time of
impact
Flexion Type: force directed against the posterior aspect of a flexed elbow
 Olecranon Fracture
 Swelling and ecchymosis with an obvious deformity
 Pain on gentle ROM
 Termed “fracture elbow”
 MOI: direct blow to the elbow; Fall on the elbow with the elbow flexed
 Radial head fracture
 LOM of elbow flexion, extension, pronation and supination
 Pain, swelling, ecchymosis around the elbow
 MOI: Most common – foosh; Dislocation of elbow
 Radial shaft fracture
 Most common fracture of the wrist disial radial fracture
 Dupuytrens fracture/Galleazi’s fracture – fracture of distal radius with
dislocation of distal ulna
 Ulnar shaft fracture
 Fracture of distal radioulnar joint may also damage triangular fibrocartilage
complex
 MOI: FOOSH and direct blow
 Monteggia fracture
 Fracture of diaphysis (upper third) of ulna with dislocation of radial head
 Night stick fracture
 Isolated fracture of diaphysis of ulna resulting from directblow
 Colles fracture
 transverse fracture of the lower 3rd of the radius accompanied by a breaking
off of the ulnar styloid process.
 usually due to a fall an outstretch arm.
 Dinner fork/Silver fork deformity - dorsal angulation and shortening result in
a hump on the wrist
 Extra articular fracture of distal radius with dorsal angulation with radial
shortening
  Most common fracture of the wrist
 Smith’s fracture or “reverse colle’s fracture”
 Extra articular fracture or distal with volar angulation
 Volarly displaced bending fracture of the distal radius
 Barton’s fracture
 involves the distal articular surface of radius which may be accompanied by
dorsal dislocation of carpus of the radius
 Intra articular shear fracture with either dorsal or volar angulation
 Inherently unstable
 Scaphoid fracture
 most commonly fractured carpal bone
 Bennets fracture
 involves the first metacarpal bone that runs obliquely through the base of the
bone and CMC joint
 Oblique fracture subluxation of the base of the thumb metacarpal joint
 Rolando’s fracture
 Intra articular fracture at the base of the first metacarpal
 Can be viewed as the bennett’s fracture with second large dorsal fragment
creating T or Y shaped pattern
 Boxer’s fracture/ street fighter fracture –
 involves 1 or more MC bone; especially the 4th and 5th
 Most common: 5th metacarpal neck shaft
 MOI: usually seen after a person strikes and a wall or another person with
poor technique
 Anterior vertebral body avulsion fracture of spine
 Accompanied by fractures of posterior columns
 Generally stable fracture
 MOI: Excessive lumbar spine hyperextension
 Ischial tuberosity avulsion fracture
 Most common in gymnasts, hurdlers and dancers
 Origin of hamstring is pulled away
 MOI: forceful hamstring contraction with knee in extension and hip in
flexion
 Pelvis fracture
 almost always multiple fractures or combined with joint dislocations
 often occur on the pubic rami, acetabula, region of the SI joint and the ala of
the illum
 Malgaines fracture –
 superior and inferior pubic rami with fracture dislocation of sacroiliac joint
 Patellar fracture
  Most commonly at central or lower third of patella
 Fracture configuration may be transverse comminuted (stellate) vertical
osteochondral, or polar
 Fibular fracture
 Commonly occur 2 – 6 cm proximal to the distal end of the lateral malleolus
 Often associated with fracture dislocations of the ankle joint
 MOI: foot is forced into excessively inverted position
 Jones fracture
 transverse fracture through the base of 5th metatarsal
 nutcracker fracture/cuboid fracture
 comminuted compression fracture of the cuboid with associated avulsion of
navicular bone
 March fracture
 common on poorly conditioned military personel after long marches
 stress fracture of 1 or more metatarsal shaft due to excessive marching
 Ostochondral fracture of talar bone
 shear force on the anterolateral surface of talus causing shallow lesion
 Compressive force on the posteromedial surface causing deep lesion
 Lisfranc joint fracture
 Commonly misdiagnosed as lateral ankle sprain
 Traumatic disruption of tarsometatarsal joint
 Unimalleolar fracture
 Fracture of medial or lateral malleolus
 MOI: trauma on the positioned in: supination abduction supination – ER
pronation abduction – pronation – ER
 Bimalleolar fracture
 Fracture of BOTH medial and lateral malleolus
 Trimalleolar fracture
 Fracture of medial malleolus lateral malleolus and posterior aspect of the
distal libial articular surface
 Medial epicondyle fracture
 Avulsion fracture of apophysitis of medial epicondyle
 Common in adolescents
 Common in throwing athletes between 8-12 y/o
 MOI: forced and repetitive valgus injury to the elbow as in throwing
 Segond fracture
 Avulsion fracture of the anterolateral margin of the lateral tibial plateau
 Distinguished by “lateral capsular signs” on radiographs
 Avulsion of tibial tubercle
 Disruptions of tibial apophysis or proximal tibial epiphysis
  Avulsion fracture of 5th metatarsal tuberosity
 Common injury in athletes (basketball, tennis players)
 MOI: landing of foot in supinated position; Sudden and violent inversion of
foot.

V. CLINICAL MANIFESTATION
 Abnormal mobility
 Crepitus- heard at the fracture site; most reliable diagnostic sign of
fracture
 Swelling- this is due to inflammation
 Edema
 Bruising or ecchymosis- purplish patch caused by extravasation of blood
into the subcutaneous tissue.
 Pain
 Tenderness
 Absence of active motion due pain
 Muscle spasm
 Deformity
o Angulation
o Shortening
o Rotation

VI. DIFFERENTIAL DIAGNOSIS

 Slipped Capital Femoral Epiphysis
- Represents a unique type of instability of the proximal femoral growth
plate.
- The patient may report hip pain, medial thigh pain, and/or knee pain.
 Shoulder Hand Syndrome
 ACL & PCL Injury
 Subluxating shoulder
 Glenohumeral instability
 Patellar subluxation or dislocation
 Posterior interosseus syndrome.
 MCL injury
 PCL injury
 Acromioclavicular arthritis
 Posterior dislocation

VII. PROGNOSIS
  In general fracture in children heal in 4-6 weeks
 In adolescent- 6-8 weeks
 In adults 10-18 weeks
 These process from fracture to full restoration of the bone will take weeks
to months depending on the type of fracture, location, vascular supply
health and age individual.

Stages of fracture healing:

This complex process of fracture healing can be broken down into five stages:

 hematoma formation
 cellular proliferation
 callous formation
 ossification
 consolidation and remodeling

Factors affecting Repair:

o Age – younger patients have faster healing process because of their active
periosteum which accelerates the healing process
o Type of fracture
o Vascularity/vascularization
o Immobilization
o Infection
o Severity of injury
o Size and shape of bone
o General condition of patients
o Location of fracture
o Limbs affected – upper extremity heals more rapidly than lower extremity due
to:
A. UE have comparatively smaller bones than the LE
B. UE receive more blood supply; UE are non – weight bearing

VIII. DIAGNOSTIC PROCEDURE

 X-rays
 MRI-is a gold standard for identifying the stress injuries in lower
extremity. Especially during the early stage.
 CT Scan-is the imaging technique of choice to identify pathologic stress
fracture
  Radionuclide bone scanning (scintigraphy)- has become a useful imaging
studies because it can demonstrate subtle changes in the bone metabolism
long before the conventional radiography.

IX. MEDICAL MANAGEMENT

 Pharmacological management
 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAID’s)

o Ibuprofen (Advil, Ibuprin, Motrin)

o Ketoprofen (Oruvail, Orudis, Actron)
o Naproxen (Anaprox, Naprelan, Naprosyn)
 Surgical management
 Reduction
 Closed- the commonest method for the restoring of fractural
long bone
 Open- used when fracture are caught within soft tissue
-perform by open operation
 Fixation- this is design to maintain reduction and to prevent any
harmful stress until union has occurred.
 External fixator
 Plaster cast- most common
 Resin or fiber glass
 Cast/braces hinge cast- easily cast and removal
 External rigid- done by drilling wire or pin percutaneously
 Internal fixator
 Transition screw
 Bone compression plating- obtainbed with use of plates and
screw or pins
 Intramedullary rod or nailing-inserted throughout the whole
length of the medullary cavity.
 Traction
 Kyphoplasty- using a flourescope the surgeon locates the spinal cord,
insert the needle into the vertebra and vertebral body as close into the
vertebra, and inflates the tiny balloon at the tip of the needle, pushing
the vertebral body as close to its normal position and leaving the
define cavity that can be filled.
 Bone grafting- to enhance a bone repair can be applied during the
repair stage of bone formation
 Autogenous bone-taken from the patient: is superior ilium
 Homogenous bone-taken from the another person
 PT Management:
 Use of active exercise to improve joint mobility and increase muscle
strength.
 Massage or improving sin condition and relieving edema.
 SWD,MWD, HMP- to relief pain and promote circulation.
 ES- leads to increase in proteoglycans synthesis in bone matrix, matrix
calcification and proliferation of osteoblasts also adds meticulous
fracture care and improves fracture healing.
 Ultrasound
 Gait Training