Fracture and fracture healing
description
Transcript of Fracture and fracture healing
Fracture and fracture healing
Jongkolnee Settakorn, MD, MSc, FRCPath
Objectives
• บอกลั�กษณะของ bone fracture ชนิ�ดต่�างๆ *• วิ�นิ�จฉั�ย bone fracture แบบง�ายๆ จากการด�
film x-ray *• บอกกลัไก fracture healing *• บอกปั�จจ�ยที่� เก� ยวิข"องก�บ fracture healing *• ที่ราบภาวิะแที่รกซ้"อนิของ bone fracture• สามารถปัระมวิลัควิามร�"ที่�)งหมดเข"าด"วิยก�นิ เพื่, อ
ปัระย-กต่.ใช"ก�บผู้�"ปั1วิยต่�อไปัในิอนิาคต่
Scopes
• Description of bone fracture
• Mechanism and incidence of bone fracture
• Fracture healing
• Treatment
• Complication
Bone fracture (broken bone)
• Definition: – A disruption in the integrity of a living bone
– A break in the continuity of bone
• Involving– Bone strength
– Site of bone
– Force
– Direction of force
Description of bone fracture
Common terms used to describe fractures• Bone, location• Skin integrity• Extent• Displacement• Angulation• Rotation• Morphology• Energy• Joint involvement• Soft tissue involvement
SiteBone names (femur, tibia, ..)
Bone location• Proximal
• Shaft
• Distal
• Epiphysis
• Metaphysis
• Diaphysis
• Growth platehttp://www.nytimes.com/imagepages/2007/08/01/health/adam/8856Fracturetypes2.html
http://www.drrathresearch.org/clinical_studies/condition_bonefracture_print.html
Skin
• Closed fracture (intact skin)
• Open fracture (wound on skin with bone exposure) http://www.lamrt.org.uk/incidents05.html
Extent
– Complete fracture: separate completely
– Incomplete (greenstick) fracture: partially joined
http://www.nytimes.com/imagepages/2007/08/01/health/adam/8856Fracturetypes2.html
Displacement
• Anterior
• Posterior
• Medial
• Lateral
• Proximal shortening (gapping)
• Distal lengthening (gapping)
http://www.merck.com/mmpe/sec21/ch309/ch309b.html
Angulation and rotation
• Anterior angulation
• Posterior angulation
• Medial angulation
• Lateral angulation
• Internal rotation
• External rotation
http://www.merck.com/mmpe/sec21/ch309/ch309b.html
Morphology• Linear fracture: parallel to long axis of bone
• Transverse fracture: cut cross the long axis
• Oblique fracture: diagonal to the long axis
• Spiral fracture: twisted
• Compression fracture: common in vertebrae
• Compact (impacted) fracture: bone fragments are driven into each other
• Pathologic fracture: with underlying bone lesion
http://www.merck.com/mmpe/sec21/ch309/ch309b.html
Energy
• Low energy: simple fracture (one line, two pieces)
• High energy: multi-fragmentary fracture or comminuted fracture
http://www.nytimes.com/slideshow/2007/08/01/health/100077Bonefracturerepairseries_3.html
Joint and growth plate involvement
• Extraarticular
• Intraarticular
http://www.merck.com/mmpe/sec21/ch309/ch309b.html
Soft tissue involvement: nerve, vessel, muscle, fat, skin damage
http://www.emedicine.com/Orthoped/topic636.htm
Classification of fracture, for
• Communication among clinicians
• Decision making
• Potential problems
• Treatment options
• Predicting outcome
• Documentating cases
• OTA Classification
• Oestern and Tscherne Classification of closed fractures
• Gustilo and Anderson classification of open fractures
• Salter-Harris classification of epiphyseal plate injury
OTA Classification
• The Orthopaedic Trauma Association
• Classification system to describe the injury accurately and guide treatment
• Standard for orthopedics surgeon
• Classification adaptable to the entire skeletal system
• Allows consistency in research
To Classify a Fracture: OTA
• Which bone?
• Where in the bone is the fracture?
• Which type?
• Which group?
• Which subgroup?
Oestern and Tscherne Classification of closed fractures
Grade Soft tissue injury Bony injury0 Minimal Simple fracture pattern
Indirect injury to limb1 Superficial abrasion/ Mild fracture pattern
contusion2 Deep abrasion with skin Severe fracture pattern
or muscle contusionDirect trauma to limb
3 Extensive skin contusion Severe fracture patternor crushSevere damage to underlying muscleSubcutaneous avulsion, compartmental syndrome
Gustilo and Anderson classification of open fractures (type I – type III)
• Type I: – Clean wound smaller than 1 cm in diameter
– Simple fracture pattern
– No skin crushing
• Type II: – a laceration larger than 1 cm
– No significant soft tissue crushing
– Fracture pattern may be more complex.
Gustilo type I
• Type III: – Contamination : soil ,water , yard ,fecal– Open segmental fracture or a single fracture with
extensive soft tissue injury– Any opened fracture older than 8 hours
Type IIIA: adequate soft tissue coverage of the fracture despite high energy trauma or extensive laceration or skin flaps.
Type IIIB: inadequate soft tissue coverage with periosteal stripping. Soft tissue reconstruction is necessary.
Type IIIC: any open fracture that is associated with vascular injury that requires repair.
Gustilo typeIII
Salter-Harris classification
of epiphyseal plate injury
Mechanism and incidence of fracture
http://orthoinfo.aaos.org/topic.cfm?topic=a00412
Fracture distal radius, Colles fracture
http://thedoctornotes.blogspot.com/2008/04/ilizarov-method-2.html
Opened fracture right tibial shaft
Fracture healing
Prerequisites for Bone Healing
• Adequate blood supply
• Adequate mechanical stability
• Proper bone metabolism
• Periosteum
• Bone marrow
Fracture healing process• Absolute stability : Direct (primary) bone healing:
rigidly stabilized fracture with fracture surface held in contact
eg. transverse diaphyseal fracture of radius and ulnar treated by ORIF
• Relative stability : Indirect (secondary) bone healing: unstable closed fracture, not rigidly stabilized
eg. closed clavicle fracture without surgery• Inadequate stability : non union (pseudoarthrosis)
1. Healing with absolute stability
- Rigidly contact between bone ends
- Gaps
Rigidly contact between bone ends
• Lamellar bone can form directly across the fracture line– A cluster of osteoclasts cut across the
fracture line
– Osteoblasts (following the osteoclasts) deposit new bone
– Blood vessels follow the osteoblasts
– New haversian system formation
Gaps between bone ends
• Prevent direct extension of osteoclast– A Osteoblasts fill the defects with woven bone
– A cluster of osteoclasts cut across the woven bone
– Osteoblasts (following the osteoclasts) deposit new bone
– Blood vessels follow the osteoblasts
– New haversian system formation
2. Healing with relative stability
- Hematoma
- Granulation tissue
- Soft callus
- Hard callus
- Remodeling
Hematoma between the fracture ends, in medullary canal, subperiosteal, around bone
Death bone at both ends of fracture site due to loss of nutrition
Inflammatory mediators from platelets, dead cells
Inflammtory cells migrate to the fracture site cytokine angiogenesis and stem cells migration fibroblasts, chondroblasts, osteoblasts
Vascular dilatation edema
Granulation tissue formation
Primitive mesenchymal cells (stem cells) at fracture site proliferation / differentiation into fibroblasts, chondroblasts, osteoblasts
=Soft callus=
Matrix (collagen, woven bone, cartilage)
= Cartilaginous callus =
Bone replaces cartilage by enchondral ossification
= hard callus =
=Remodeling =
Replacement of woven bone by lamellar bone
- Osteoclastic resorption
- Formation of new bone along line of stress
http://www.bonefixator.com/
Variables that influence fracture healing
• Injury variables
• Patients variables
• Tissue variables
• Treatment variables
Injury variables
• Open fractures
• Segmental fractures
• Intra-articular fracture
• Severity of injury
• Soft tissue interposition
• Damage to blood supply
• Single limb or multiple injuries
Patient variables
• Age
• Co-morbidities e.g. diabetes
• Nutrition
• Systemic hormones
• Drugs
• Nicotine and other agents
Tissue variables
• Bone necrosis
• Bone disease
• Infection
• Supply
Treatment variables
• Apposition of fracture fragments
• Loading and micromotion
• Fracture stabilization
• Treatments that interferes with healing
Treatment and complication
Treatment• General aim of management
– Control hemorrhage– Pain relief– Prevent ischemia-reperfusion injury– Remove contamination– Reduction– Immobilization
• For maximal function and minimized complication
Treatment• Non operative therapy
– Casting after an appropriate closed reduction– Traction (rarely used)
• Skin traction• Skeletal traction
• Surgical therapy– Open reduction and internal fixation (ORIF)
• Kirschner wires (K-wires)• Plates and screws• Intramedullary nails
– External fixation
:www.flickr.com/photos/onepointzero/529498016/
http://www.emedicine.com/Orthoped/topic636.htm
http://www.emedicine.com/Orthoped/topic636.htm
หน้�า: www.rad.washington.edu/.../orthopedic-hardware
http://www.emedicine.com/Orthoped/topic636.htm
http://www.emedicine.com/Orthoped/topic636.htm
Complications of fracture• Neurologic and vascular injury
• Compartment syndrome: anterior leg
• Infection: open fracture and surgery
• Thromboembolic events
• Avascular necrosis: femoral head and neck
• Post-traumatic arthritis
• Delay union, non-union, malunion
Complications
• Cast– Pressure ulcers
– Thermal burns
– Thrombophlebitis
– Prolonged cast disease: circulatory disturbances, inflammation, osteoporosis, chronic edema, soft tissue atrophy, joint stiffness
Complications
• Traction lack of patient mobility– Pressure ulcers
– Pulmonary / Urinary infection
– Permanent footdrop contracture
– Peroneal nerve palsy
– Pin tract infection
– Thromboembolic events (deep vein thrombosis, pulmonary embolism)
Complications
• External fixator– Pin tract infection
– Pin loosening or breakage
– Interference with joint motion
– Neurovascular damage
– Malalignment
– Delay union or malunion