Fracture and fracture healing

1. Fracture and fracture healing Jongkolnee Settakorn, MD, MSc, FRCPath

2. Objectives • บอกลักษณะของ bone fracture ชนิดต่างๆ * • วินิจฉัย bone fracture แบบง่ายๆ จากการดู film x-ray * • บอกกลไก fracture healing * • บอกปัจจัยที่เกี่ยวข้องกับ fracture healing * • ทราบภาวะแทรกซ้อนของ bone fracture • สามารถประมวลความรู้ทั้งหมดเข้าด้วยกัน เพื่อประยุกต์ใช้กับผู้ป่วยต่อไปในอนาคต

3. Scopes • Description of bone fracture • Mechanism and incidence of bone fracture • Fracture healing • Treatment • Complication

4. 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

5. Description of bone fracture

6. Common terms used to describe fractures • Bone, location • Skin integrity • Extent • Displacement • Angulation • Rotation • Morphology • Energy • Joint involvement • Soft tissue involvement

7. Site Bone names (femur, tibia, ..) Bone location • Proximal • Shaft • Distal • Epiphysis • Metaphysis • Diaphysis • Growth plate http://www.nytimes.com/imagepages/2007/08/01/health/adam/8856Fracturetypes2.html

8. http://www.drrathresearch.org/clinical_studies/condition_bonefracture_print.htmlhttp://www.drrathresearch.org/clinical_studies/condition_bonefracture_print.html

9. Skin • Closed fracture (intact skin) • Open fracture (wound on skin with bone exposure) http://www.lamrt.org.uk/incidents05.html

10. Extent • Complete fracture: separate completely • Incomplete (greenstick) fracture: partially joined

11. http://www.nytimes.com/imagepages/2007/08/01/health/adam/8856Fracturetypes2.htmlhttp://www.nytimes.com/imagepages/2007/08/01/health/adam/8856Fracturetypes2.html

12. Displacement • Anterior • Posterior • Medial • Lateral • Proximal  shortening (gapping) • Distal lengthening (gapping)

13. http://www.merck.com/mmpe/sec21/ch309/ch309b.html

14. Angulation and rotation • Anterior angulation • Posterior angulation • Medial angulation • Lateral angulation • Internal rotation • External rotation

15. http://www.merck.com/mmpe/sec21/ch309/ch309b.html

16. 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

17. http://www.merck.com/mmpe/sec21/ch309/ch309b.html

18. Energy • Low energy: simple fracture (one line, two pieces) • High energy: multi-fragmentary fracture or comminuted fracture

19. http://www.nytimes.com/slideshow/2007/08/01/health/ 100077Bonefracturerepairseries_3.html

21. Joint and growth plate involvement • Extraarticular • Intraarticular

22. http://www.merck.com/mmpe/sec21/ch309/ch309b.html

23. Soft tissue involvement: nerve, vessel, muscle, fat, skin damage http://www.emedicine.com/Orthoped/topic636.htm

25. Classification of fracture, for • Communication among clinicians • Decision making • Potential problems • Treatment options • Predicting outcome • Documentating cases

26. OTA Classification • Oestern and Tscherne Classification of closed fractures • Gustilo and Anderson classification of open fractures • Salter-Harris classification of epiphyseal plate injury

27. 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

28. To Classify a Fracture: OTA • Which bone? • Where in the bone is the fracture? • Which type? • Which group? • Which subgroup?

29. Oestern and Tscherne Classification of closed fractures Grade Soft tissue injury Bony injury 0 Minimal Simple fracture pattern Indirect injury to limb 1 Superficial abrasion/ Mild fracture pattern contusion 2 Deep abrasionwith skin Severe fracture pattern or muscle contusion Direct trauma to limb 3 Extensive skin contusion Severe fracture pattern or crush Severe damage to underlying muscle Subcutaneous avulsion, compartmental syndrome

30. 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.

31. Gustilo type I

32. 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.

33. Gustilo typeIII

34. Salter-Harris classification of epiphyseal plate injury

36. Mechanism and incidence of fracture

42. Fracture distal radius, Colles fracture http://orthoinfo.aaos.org/topic.cfm?topic=a00412

45. Opened fracture right tibial shaft http://thedoctornotes.blogspot.com/2008/04/ilizarov-method-2.html

48. Fracture healing

49. Prerequisites for Bone Healing • Adequate blood supply • Adequate mechanical stability • Proper bone metabolism • Periosteum • Bone marrow

50. Fracture healingprocess • 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)