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Bone fractures and healing
Dr AMMAR JAWAD, MBChB, MPH
IMS
Management & Science University
Blood Supply to Bone:
Musculoskeletal Injuries
• Contusion
▫ Damage to soft tissue , sub-q structures, and muscle
• Strains
▫ Tear to the muscul...
Fractures
• A bone fracture is a medical condition in which
there is a break in the continuity of the bone
• While many fr...
• The proper healing of a fracture depends on whether
or not, the blood supply and cellular components of
the periosteum a...
Causes of fractures
• 1-traumatic
• 2-pathological
pathological
• The second common times in life for fractures to
occur are during elderly
Symptoms
• A visibly out-of-place or misshapen limb or joint
• Swelling, bruising, or bleeding
• Intense pain
• Numbness a...
Fracture Types
FRX or FX
• Fractures are often classified according to the position of the bone ends after the
break:
Open...
Common Types of Fractures
Table 6.2.1
Common Types of Fractures
Table 6.2.2
Common Types of Fractures
Table 6.2.3
avulsion fracture separation of a small fragment of
bone cortex at the site of attachment of a ligament or
tendon.
• Closed fractures are those in which the skin is intact,
while Open fractures involve wounds that
communicate with the fr...
Open (compound) fractures
• High risk of infection
• Can be associated with gross soft tissue damage, severe
haemorrhage o...
Fracture Healing
• The natural process of healing a fracture starts when
the injured bone and surrounding tissues bleed.
•...
Fracture Healing
• The blood vessels also bring fibroblasts in the walls
of the vessels and these multiply and produce
col...
Fracture Healing
• At this stage, some of the fibroblasts begin to lay
down bone matrix (calcium) in the form of insoluble...
Fracture Healing
• This initial "woven" bone does not have the strong
mechanical properties of mature bone.
• By a process...
Healing times
• Neonatal period
▫ 2-4 weeks
• Early childhood
▫ 4 weeks
• Later childhood
▫ 6-8 weeks
• Adolescence
▫ 8-12...
Healing in Bone:
1D - Hematoma formation (fibrin mesh)
3D - Inflammation – PDGF, IL, TGF
1W - Soft callus – granulation, m...
Stages of wound healing
Time after injury
Hemostasis
Inflammation
Proliferation
Resolution/ Remodeling
PMNs, Macrophages, ...
Healing in Bone:
Healing in Bone:
Bone Fracture Repair
Bone Fracture Repair (cont’d)
STAGES OF BONE FRACTURE
REPAIR
Bone fracturesBone fractures
Compound Fracture
Fracture Head of Humerus
Immobilization – Plaster cast
Bone healing: Callus
Factors affecting Healing:
• Systemic & Local factors
• Immobilization
• Improper reduction – abnormal position
• Infectio...
Bone Fractures & Healing
Complications:
• Delayed healing.
• Non healing.
• Joint involvement – ankylosis (stiffness of a joint due to
abnormal adh...
• Involucrum formation. (a layer of new bone growth
outside existing bone usually in OM )
• Fat embolism
• DVT/PE
• Bed so...
• Malunion
▫ Healing of fragments of a fracture in a faulty position.
• Delayed union
▫ Any fracture that takes longer to ...
Treatment of fracture
• 1) Reduce
• 2) Maintain reduction (+ hold until union)
• 3) Rehabilitate – restore function
• 4) P...
Reduction
• Does the fracture
require reduction?
▫ Is it displaced?
▫ Does it need to be
reduced?
Reduction
• If necessary, what reduction technique?
• 1) Closed reduction
▫ Need anaesthesia/sedation, analgesia, x-ray fa...
Maintain reduction
• Necessary?
1) Relieve pain
2) Prevent mal-union – nature heals the fracture, we
keep it in a good pos...
Nutritional Effects on Bone
• Normal bone growth/maintenance cannot occur
without sufficient dietary intake of calcium and...
Nutritional Effects on Bone
• What can you do to take care of your skeletal
system?
Hormonal Effects on Bone
• Growth hormone, produced by the pituitary gland,
and thyroxine, produced by the thyroid gland,
...
• Clinical Conditions
• Osteomalacia
▫ Literally “soft bones.”
▫ Includes many disorders in which osteoid is produced but ...
Rickets
Osteoporosis
▫ Group of diseases in which bone resorption occurs at a faster
rate than bone deposition.
▫ Bone mass drops ...
Skeletal System
Gigantism
▫ Childhood hypersecretion of growth hormone by the
pituitary gland causes excessive growth.
Acromegaly
• Acromegaly
▫ Adult-hood hyper-secretion of GH causes overgrowth
of bony areas still responsive to GH such as ...
• When you were born, you had more than 300 bones.
By the time you stop growing, you’ll have 206.
Definitions
• 1. osteohypertrophy: overgrowth of bone.
• 2. osteosarcoma: tumor of the bone.
• 3. osteosclerosis: abnormal...
P M S 2  Fractures And  Healing
P M S 2  Fractures And  Healing
P M S 2  Fractures And  Healing
P M S 2  Fractures And  Healing
P M S 2  Fractures And  Healing
P M S 2  Fractures And  Healing
P M S 2  Fractures And  Healing
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P M S 2 Fractures And Healing

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P M S 2 Fractures And Healing

  1. 1. Bone fractures and healing Dr AMMAR JAWAD, MBChB, MPH IMS Management & Science University
  2. 2. Blood Supply to Bone:
  3. 3. Musculoskeletal Injuries • Contusion ▫ Damage to soft tissue , sub-q structures, and muscle • Strains ▫ Tear to the musculotendinous unit • Sprains ▫ Trauma to joint, ligament may be completely torn or stretched • Dislocation ▫ Displacement of the normal position
  4. 4. Fractures • A bone fracture is a medical condition in which there is a break in the continuity of the bone • While many fractures are the result of high force impact or stress, bone fracture can also occur as a result of certain medical conditions that weaken the bones, such as osteoporosis, certain types of cancer, or osteogenesis imperfecta, where the fracture is then termed pathological fracture
  5. 5. • The proper healing of a fracture depends on whether or not, the blood supply and cellular components of the periosteum and endosteum survive.
  6. 6. Causes of fractures • 1-traumatic • 2-pathological
  7. 7. pathological • The second common times in life for fractures to occur are during elderly
  8. 8. Symptoms • A visibly out-of-place or misshapen limb or joint • Swelling, bruising, or bleeding • Intense pain • Numbness and tingling • Broken skin with bone protruding • Limited mobility or inability to move a limb
  9. 9. Fracture Types FRX or FX • Fractures are often classified according to the position of the bone ends after the break: Open (compound): Bone ends penetrate the skin. Closed (simple): Bone ends don’t penetrate the skin. Comminuted: Bone fragments into 3 or more pieces. Common in the elderly (brittle bones). Greenstick: Bone breaks incompletely. One side bent, one side broken. Common in children whose bone contains more collagen and are less mineralized. Spiral: Ragged break caused by excessive twisting forces. Sports injury/Injury of abuse. Impacted: One bone fragment is driven into the medullary space or spongy bone of another bone
  10. 10. Common Types of Fractures Table 6.2.1
  11. 11. Common Types of Fractures Table 6.2.2
  12. 12. Common Types of Fractures Table 6.2.3
  13. 13. avulsion fracture separation of a small fragment of bone cortex at the site of attachment of a ligament or tendon.
  14. 14. • Closed fractures are those in which the skin is intact, while Open fractures involve wounds that communicate with the fracture and may expose bone contamination (need antibiotics). • They require urgent surgical treatment. • This involves removal of all dirt, contamination and dead tissue.
  15. 15. Open (compound) fractures • High risk of infection • Can be associated with gross soft tissue damage, severe haemorrhage or vascular injury
  16. 16. Fracture Healing • The natural process of healing a fracture starts when the injured bone and surrounding tissues bleed. • The blood coagulates to form a blood clot situated between the broken fragments. • Within a few days blood vessels grow into the jelly- like matrix of the blood clot. • The new blood vessels bring white blood cells to the area, which gradually remove the non-viable material.
  17. 17. Fracture Healing • The blood vessels also bring fibroblasts in the walls of the vessels and these multiply and produce collagen fibres. • In this way the blood clot is replaced by a matrix of collagen. • Collagen's rubbery consistency allows bone fragments to move only a small amount unless severe or persistent force is applied.
  18. 18. Fracture Healing • At this stage, some of the fibroblasts begin to lay down bone matrix (calcium) in the form of insoluble crystals. • This mineralization of the collagen matrix stiffens it and transforms it into bone. • Healing bone callus is on average sufficiently mineralized to show up on X-ray within 6 weeks in adults and less in children.
  19. 19. Fracture Healing • This initial "woven" bone does not have the strong mechanical properties of mature bone. • By a process of remodeling, the woven bone is replaced by mature "lamellar" bone. • The whole process can take up to 18 months, but in adults the strength of the healing bone is usually 80% of normal by 3 months after the injury.
  20. 20. Healing times • Neonatal period ▫ 2-4 weeks • Early childhood ▫ 4 weeks • Later childhood ▫ 6-8 weeks • Adolescence ▫ 8-12 weeks
  21. 21. Healing in Bone: 1D - Hematoma formation (fibrin mesh) 3D - Inflammation – PDGF, IL, TGF 1W - Soft callus – granulation, matrix. 3-6W - Callus – ossification, woven bone 8+W - Re-modeling – absorb/deposit, strength, lamellate.
  22. 22. Stages of wound healing Time after injury Hemostasis Inflammation Proliferation Resolution/ Remodeling PMNs, Macrophages, Lymphocytes Reepithelialization, Angiogenesis, Fibrogenesis, Vessel regression, Collagen remodeling Fibrin clot, platelet deposition 1D 3D 1wk 6wk 8wk
  23. 23. Healing in Bone:
  24. 24. Healing in Bone:
  25. 25. Bone Fracture Repair
  26. 26. Bone Fracture Repair (cont’d)
  27. 27. STAGES OF BONE FRACTURE REPAIR
  28. 28. Bone fracturesBone fractures
  29. 29. Compound Fracture
  30. 30. Fracture Head of Humerus
  31. 31. Immobilization – Plaster cast
  32. 32. Bone healing: Callus
  33. 33. Factors affecting Healing: • Systemic & Local factors • Immobilization • Improper reduction – abnormal position • Infection. Debris, dead tissue in wound • Joint involvement
  34. 34. Bone Fractures & Healing
  35. 35. Complications: • Delayed healing. • Non healing. • Joint involvement – ankylosis (stiffness of a joint due to abnormal adhesion and rigidity of the bones of the joint) • Abnormal position – arthritis. • Bone necrosis – nutrient artery
  36. 36. • Involucrum formation. (a layer of new bone growth outside existing bone usually in OM ) • Fat embolism • DVT/PE • Bed sores • Depression/PTSD • Tetanus • Infections
  37. 37. • Malunion ▫ Healing of fragments of a fracture in a faulty position. • Delayed union ▫ Any fracture that takes longer to heal than the average fracture at that anatomic location. • Non-union ▫ The fracture healing process has completely stopped and the fragments will remain un-united even with prolonged immobilization.
  38. 38. Treatment of fracture • 1) Reduce • 2) Maintain reduction (+ hold until union) • 3) Rehabilitate – restore function • 4) Prevent or treat complications
  39. 39. Reduction • Does the fracture require reduction? ▫ Is it displaced? ▫ Does it need to be reduced?
  40. 40. Reduction • If necessary, what reduction technique? • 1) Closed reduction ▫ Need anaesthesia/sedation, analgesia, x-ray facilities, equipment, knowledge ▫ Used for minimally displaced fractures and most fractures of children  1) Distal part of limb pulled in line of bone  2) As fragments disengage, they are repositioned (reverse original direction of deforming force)  Alignment adjusted in each plane • 2) Open reduction ▫ Above + theatre staff + additional equipment ▫ Risks
  41. 41. Maintain reduction • Necessary? 1) Relieve pain 2) Prevent mal-union – nature heals the fracture, we keep it in a good position 3) Minimise non-union – maintenance of reduction should be continuous
  42. 42. Nutritional Effects on Bone • Normal bone growth/maintenance cannot occur without sufficient dietary intake of calcium and phosphate salts. • Calcium and phosphate are not absorbed in the intestine unless the hormone calcitriol is present. Calcitriol synthesis is dependent on the availability of the (Vitamin D) which synthesized in the skin or obtained from the diet. • Vitamins C, A, K, and B12 are all necessary for bone growth as well.
  43. 43. Nutritional Effects on Bone • What can you do to take care of your skeletal system?
  44. 44. Hormonal Effects on Bone • Growth hormone, produced by the pituitary gland, and thyroxine, produced by the thyroid gland, stimulate bone growth. ▫ GH stimulates protein synthesis and cell growth throughout the body. ▫ Thyroxine stimulates cell metabolism and increases the rate of osteoblast activity.
  45. 45. • Clinical Conditions • Osteomalacia ▫ Literally “soft bones.” ▫ Includes many disorders in which osteoid is produced but inadequately mineralized.  Causes can include insufficient dietary calcium  Insufficient vitamin D fortification or insufficient exposure to sun light. • Rickets ▫ Children's form of osteomalacia ▫ More detrimental due to the fact that their bones are still growing. ▫ Signs include bowed legs, and deformities of the pelvis, ribs, and skull.
  46. 46. Rickets
  47. 47. Osteoporosis ▫ Group of diseases in which bone resorption occurs at a faster rate than bone deposition. ▫ Bone mass drops and bones become increasingly porous. ▫ Compression fractures of the vertebrae and fractures of the femur are common. ▫ Often seen in postmenopausal women because they experience a rapid decline in estrogen secretion; estrogen stimulates osteoblast and inhibits osteoclast activity.
  48. 48. Skeletal System
  49. 49. Gigantism ▫ Childhood hypersecretion of growth hormone by the pituitary gland causes excessive growth.
  50. 50. Acromegaly • Acromegaly ▫ Adult-hood hyper-secretion of GH causes overgrowth of bony areas still responsive to GH such as the bones of the face, feet, and hands. • Pituitary dwarfism ▫ GH deficiency in children resulting in extremely short long bones and maximum stature of 4 feet.
  51. 51. • When you were born, you had more than 300 bones. By the time you stop growing, you’ll have 206.
  52. 52. Definitions • 1. osteohypertrophy: overgrowth of bone. • 2. osteosarcoma: tumor of the bone. • 3. osteosclerosis: abnormal hardening or eburnation of bone. • 4. osteoporosis: progressive reduction in quantity of bone. • 5. osteopenia: decreased calcification or density of bone.

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