Fracture Healing Flashcards
What are the three stages of bone healing?
Bone Healing
- Inflammation: happens right away, hematoma brings in hematopoietic cells, osteoclasts etc.
- Reparative (soft callous and hard callous): endochondral ossification, mesenchymal progenitor cells
- Remodeling
How long does it take for metaphyseal bone to heal vs. cortical bone?
- 6 wks to heal for metaphyseal bone
- Wrist, ankle, proximal humerus
- 12 wks to heal for cortical bone
- Humeral shaft, radial and ulnar shafts
- May take 16-24 wks for femur and tibia to heal
Describe the mechanism of bone remodeling.
Bone Remodeling
- Bone responds to stress by altering its mechanical characteristics (Wolff’s Law)
- Bone hypertrophy due to increased stress
- Bone resorption due to decreased stress
- Stress-shielding: the resorption of bone in response to a stiff implant
- Regenerates tissue and repairs without scar
What impacts do fractures have on bone?
Fractures
- Rupture vessels within and outside of bone
- Disrupt to the Haversian system
- Soft tissue damage with loss of periosteal vessles
- Bone necrosis at ends of fragments
What 3 factors do you need for bone healing?
Biology fracture
Soft tissue cover
Fractures tability
What are the indications for fracture surgery?
Indications for Fracture Surgery
- Open fractures
- Articular fractures
- Polytrauma
- Patient mobilization
- Joint mobilization
- Correction of alignment
List the factors that promote bone healing.
Promoters of Bone Healing
- Youth
- Calcium and Vitamin D
- Stress
- Electric stimulation
- Ultrasound
- Anabolic hormones
- BLOOD SUPPLY = the most important factor in fracture healing
List the factors that delay bone healing.
Factors that delay bone healing
- Poor blood supply to the bone
- Age
- Calcium and vitamin D deficiency
- Tobacco dependence
- NSAIDs and corticosteroid use
- Excessive bone gap or excessive motion
What is involved in the primary survey of a patient who has just undergone massive trauma?
Primary Survvey
A. Airway with c-spine protection
B. Breathing
C. Circulation with hemorrhage control
D. Disability
E. Exposure/Environment
A 32 year old male arrives in the ER with an open fracture of the tibia. What is your management plan?
Open Fracture Management Plan
- Intravenous antibiotics
- Tetanus toxoid (if they haven’t been vaccinated or received a booster, give antibody and vaccine)
- Remove large pieces of foreign debris
- Keep NPO (in case they need surgery)
- Obtain informed consent (for surgery)
- Decide if operative or non-operative
- Non-operative: closed, extra-articular, undisplaced
- Stable operative: open, intra-articular, displaced, unstable
Describe the Salter-Harris classification of growth plate injuries.
Salter-Harris Classification
- Type I: transverse fracture through the growth plate
- Type II: transverse fracture through the growth plate and an oblique or vertical fracture through the metaphysis, most common type and accounts for 75% of all physeal injuries
- Type III: transverse fracture through the growth plate and a vertical fracture through the epiphysis
- Type IV: vertical fracture through all three components, metaphysis, physis and epiphysis
- Type V: compression, crushing of the growth plate
You are about to assess a 3 month old patient with a potential femoral fracture. You are suspicious of a non-accidental trauma. What red flags might you be looking for that would increase your suspicions?
Red Flags for NATs
- Subdural hematoma
- Shaken baby syndrome
- Failure to thrive
- Unlikely/inconsistent story regarding MOI
- Fractures = femur fracture in non-walking child, ribs, spinous processes, sternum, skull, bucket handles, corner fractures (avulsion fractures)
- Visceral injury in non-infants
- Young age
- Poor social situation
- Delayed presentation of illness/injury
- Delayed developmental milestones
- Low weight
- Descried as a “difficult” baby
- Multiple previous hospitalizations
- Other sites of injury
During your assessment of the 3 month old patient with a potential femoral fracture you notice crepitus on the infants back, suggesting healing of past fractures. You also note that the child is underweight. What steps do you take from here?
Management plan in suspected NATs
- Tell family that the injuries do not make sense to you and that you are concerned
- Admit child to hospital (to remove from parental care during investigations); if you are not at the Children’s Hospital, send child in ambulance to the hospital and alert the emergency physician in advance of your suspicions
- Alert any other necessary authorities of your suspicions
- Do skeletal survey (full body X-ray) to assess for other injuries
- Do eye exam to assess for retinal hemorrhages/detachment secondary to shaken baby syndrome
- Do bone scan
