Power Point 2 Flashcards
fracture
structural break in the continuity of bone, epiphyseal plate, or cartilagenous joint surface
fracture: structural break in the continuity of bone, epiphyseal plate, or cartilagenous joint surface
- typically accompanied by injury to surrounding soft tissue
- that injury not appreciated on x-ray
- clinical significance of the fracture may be defined by the bone itself, or possibly by ht surrounding soft tissue that was injured
load characteristics of a bone include
- direction of the applied force
- magnitude of the load
- rate of load application
load characteristics of a bone include: direction of the applied force
tension compression bending torsion sheer
basic biomechanics
- majority of fx to cortical bone the result of tension failure
- bending
- axial loading (tension, compression)
- torsion
fracture mechanism for bending loads
- compression strength greater than tensile strength
- fails in tension
fracture mechanism for torsion
- the diagonal in the direction of the applied force is in tension - cracks perpendicular to this tension diagonal
- spiral fracture 45 degrees to long axis
cortical bone fracture types
impacted
depressed
cortical bone fracture types: depressed
broken bone is pressed inward (ie skull fracture)
etiologies of fractures
direct trauma
indirect trauma
continuous stress
pathological fracture
etiologies of indirect trauma fractures
- by transmission of stress
- by muscular contraction
etiologies of pathological fractures
because of cortical desruption which resulted from bone diseases such as osteomyelitis and benign, malignant, or metastitic lesions of bone, the fracture happened with slight trauma
describing the fracture
- anatomical site
- configuration displacement
- articular involvement/epiphyseal injuries
- soft tissue injury
describing the fracture: configuration displacement
- three planes of angulation
- translation
- shortening
describing the fracture: articular involvement/epiphyseal injuries
- fracture involving joint
- disloaction
- ligamentous avulsion
site: diaphysis
shaft
site: epiphyseal
one end of a long bone
site: metaphysis
growth plate region
site: medullary cavity
marrow cavity
site: endosteum
lining of marrow cavity
site: periosteum
tough membranecovering bone but not the cartilage
extent of fracture
incomplete
complete
extent of fracture: incomplete
crac hairline buckle greenstick simple (closed): little or no bone displacement
displacement of fracture
angular lateral shortening separated rotational distracted overriding impacted
close fractured
- fracture is not exposed to the environment
- all fractures have some degree of soft tissue injury
- commonly classified according to the Tscherne classification
- don’t underestimate the soft tissue injury as this affects treatment and outcome!
Tscherne Classification
Grade 0
grade 1
grade 2
grade 3
grade 0 fracture
- minimal soft tissue injury
- indirect injury
grade 1 fracture
- injury from within
- superficial contusions or abrasions
grade 2 fracture
- direct injury
- more extensive soft tissue injury with muscle contusion, skin abrasions
- more severe bone injury (usuallly)
grade 3 fracture
- severe injury to soft tissues
- degloving with destruction of subcutaneous tissue and muscle
- can include a compartment syndrome, vascular injury
open fracture
a break in hte skin and underlying soft tissue leading directing into or communicating with the fracture and its hematoma
open fracture: a break in the skin and underlying soft tissue leading directing into or communicating with the fracture and its hematoma
- commonly described by the Gustilo system
- routinely applied to all types of open fractures
- emphasis on size of skin injury
- fracture healing, infection and amputation rate correlate with the degree of soft tissue injury
type I open fracture
- inside-out injury
- clean wound
- minimal soft tissue damage
- no significant periosteal stripping
type II open fracture
- moderate soft tissue damage
- outside-in mechanism
- higher energy injury
- some necrotic muscle, some periosteal stripping
Type IIIA open fractures
- high energy
- outside-in injury
- extensive muscle devitalization
- bone coverage with existing soft tissue not problematic
Type IIIB open fracture
- high energy
- outside-in injury
- extensive muscle devitalization
- requires a local flap or free flap for bone coverage and soft tissue closure
- periosteal stripping
complications of open fractures
- infection
- avascular necrosis
- DVT
- fat embolism
- RSD
- mal-union (deformity of shortening)
- non-union
- injury to large vessels
- nerve compression/entrapment
- compartment syndrome
fracture healing
- unique, integrated, and highly reproducible process
- closely related to external factors (mechanics)
- motion at the fracture site results in endochondral ossification (secondary bone healing)
- stability at the fracture site results in intramembranous ossification (primary bone healing)
- most of the time there is a combination of the two processes with one more prominent than another
two types of bone healing
- primary, healing without external fibrocartilagenous callus formation
- secondary, healing with a small gap between bone ends
primary bone healing
- seen with rigid (exact) internally or externally fixated reductions
- no callus process
- bone is (stress protected)
- rate of healing the same as secondary bone healing
healing fractures (secondary intention)
- stage of haematoma
- stage of sub-periosteal and endosteal cellular proliferaion (external callus and internal callus)
- stage of callus formation
- stage of consolidation
- stage of remodelling
salter-harris fractures
- salter-harris fractures are fractures through a growth plate (physis); therefore, they are uinque to pediatric patients
- several types of fractures have been categorized by the involvement of the physis, metaphysis, and epiphysis
- the classification of the injury is important because it affect the treatment of the patient and provides clues to possible long-term complications
classifications of salter-harris fractures
I - V
Type I salter-harris fracture
- pure epiphyseal separation
- if non-displaced, joint effusion may be only sign
type II salter-harris fracture
metaphyseal fracture + epiphyseal separation
type III saltar-harris fracture
epiphyseal fracture
type IV saltar-harris fracture
vertically oriented fx thur epiphysis + metaphysis
type V saltar-harris fracture
crush injury of epiphysis (not detected acutely)
principles of fracture of managment
reduction
immobilization
rehabilitation
first, do no harm
goals of fracture treatment
- restore the patient to optimal functional state
- provent fracture and soft-tissue complications
- get the fracture to heal, and in a position whihc will produce optimal functional recovery
- rehabilitate the patient as early as possible
theraoy during immobilization
- reduce edema - to prevent the adhesion formation
- assist the maintenance of the circulation, active exercise either by static or isotonic muscle activity
- maintain muscle function by active or static contraction
- maintain joint range where possible
- maintain as much function as allowed by the particular injury and the fixation
- teach the patient how to use special appliances such as crutches, sticks, frames, and how to care for these or any other apparatus
therapeutic implicatiosn for treating immobilized fractures
- active ROM exercises to joints above and below immobilized region
- ISOMs
- resistive ROM exercises to muscle groups that are not immobilized
therapeutic implications for fractures once the cast or immobilization device has been removed
- gentle but progressive resistance exercises of all immobilized joints
- evaluate strength of joints(s) and compare to non-injured couterparts
- return to vigorous activity only after strength descrepency < 15%
bone graft substitutes and groth factors
- allograft
- calcium sulfate
- calcium phosphate
- collagen-calcium phosphate composite
- polymer
- BMP with matrix carrier
