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Introduction of Fracture

content1. Definition2. Classification3. Cause4. Clinical feature of fracture5. Healing process of fracture6. Influencing factors on fracture union7. Healing period of fracture8. Complication of fracture

Bone Development

• 인체조직중가장늦게발생• 성인 bone의원형은임신 3개월태생기• Ossification(osteogenesis): embryo• Bone growth : early adulthood(to increase

in size). But, ossification in adults serves mainly for bone remodeling and repair.

Formation of the bony skeleton

• Intramembranous ossification• Endochondral ossification Primary ossification center Secondary ossification center

Definition

• An interruption in the continuity of the bone which may be a complete break or an incomplete break.

골절의분류

• 해부학적위치-epiphysis, metaphysis, diaphysis…intra articular…proximal,shaft,distal…특수한명칭 femur의경우 head, neck, trochanter, supracondylar, condylar

• 골절의정도-완전 , 불안전 greenstick, torus(buckle(융기:피질이뒤틀림 ))골절

• 골절면의방향 – transverse, oblique, spiral, longitudinal• 골절편수 –단순혹은 linear fx 와 comminuted fx(2개이상의골절선이만나골절편이 3개이상인경우) segmental fx는별도두 개의완전한골절이한뼈에동시에존재하는경우

골절의분류

• 골절편의전위여부-불완전이나완전골절이라도전위가없는경우undisplaced fx. 근위부골편을기준으로원위부골편의위치에따라서구분. Angulation , shearing, rotation, distraction, overriding, impaction

• 골절의안전성 : 한번정복되면재전위를일으키는경향이적은골절 stable(횡상이나짧은사상골절), unstable (긴사상골절이나나선상골절)

• 개방창을동반유무- open , closed

손상기전에따른분류(Direct)

• Tapping fx. 적은힘이짧은시간에좁은면적에적용, 주로횡상, 전완부나하퇴부의두뼈중한뼈만손상외력의대부분을뼈에서흡수하므로연부조직의손상은경미하다. Nightstick fracture(야경봉)

• Crush : 큰힘이넓은부위에작용. 광범위한연부조직손상동반, 심한분쇄상혹은횡상골절, 전완부와하퇴부에서두뼈가같은부위에서골절.

• Penetrating : 큰힘이좁은부위에작용, 540~750 m/s속도는고속총탄 : 광범위한연부조직손상과함께분쇄골절, 저속은연부조직손상적고골절을일으키나총탄이뼈속에박혀버린다.

손상기전에따른분류(Indirect)• Avulsion, tension : tendon의강한힘으로뼈가떨어져나감. 주관절이나슬관절이신전근에의해긴장되어있을때갑자기굴곡력이작용하거나, 족근관절의외반외회전손상시내과가삼각인대의견인에의해생길수있다.

• Angulation : 장골에굴곡성외력이작용하면외력에가까운쪽에서는 compression이먼쪽에서는 tension이작용하는데골은장력보다압박력에강하므로장력을받는부위가먼저골절이일어나고골절선은골장축에직각으로진행한다. 또한이두면사이에는장력과압력이모두작용하지않는 neutral plane이존재하며이면은점차외력에가까운쪽으로이동하게되며압력을받는쪽에나비형골편이생기기도한다.

손상기전에따른분류(Indirect)• Rotation : 분필을비틀어부러뜨릴때처럼장관골에회전력을받아골절이일어나면원위부에서하중과같은방향으로측면으로돌아근위부로연결되는나선과그양단을장축과평행으로연결하는직선의두요소를가진특징적인나선형골절을보인다.

• Compression: 실험적으로균질성원주에장축으로압력을가하면장축에 45도의각을이루는골절이발생그러나장관골은균질성이아니므로순수한의미의압박골절은드믈다따라서견고한골간부가골간단속으로감입되는형태를보인다.

손상기전에따른분류(Indirect)

• 각형성회전성압박 : 장관골에굴곡성외력과회전력이가해지면사상축에굴곡력이작용한것과같이사상골절을일으키며여기에장축에일치하는압박력이더해지면장축에 45도각도를이루는방향으로전단력에의해골절이쉽게일어난다.

• 병적, fatigue

Why classify fractures?

• Classification or description of fractures is only used when the classification or description is useful in providing treatment or outcomes

Types of classifications

• Anatomic description• AO classification• Salter-Harris classification• Gustillo open fracture classification

Anatomic description of fractures

• Described in specific order• Type• Comminution• Location• Displacement

Anatomic description - Type• Type is the over all

fracture pattern• Examples are:

Simple, spiral, segmental

Anatomic description -Communition

• Comminution is the measure of the number of pieces of broken bone that there are.

• Examples are: non-comminuted or mildly comminuted or severely comminuted

Anatomic description - Location

• Location is the anatomic location of the fracture usually described by giving the bone involved and location on the bone

• Examples are: distal radial shaft, proximal 1/3 humeral shaft, intra-articular distal tibial

Anatomic description -Displacement

• Displacement is the amount the pieces of a fracture have moved from their normal location

• Can be displaced or non-displaced• Subdivided into 3 sub-categories:

translation, angulation, and shortening

Displacement - Translation• Translation is

sideways motion of the fracture - usually described as a percentage of movement when compared to the diameter of the bone.

Displacement - Angulation• Angulation is the

amount of bend at a fracture described in degrees. Also described with respect to the apex of the angle.

Displacement - Shortening• Shortening is the

amount a fracture is collapsed expressed in centimeters. Sometimes called bayonete apposition.

Anatomic description

Anatomic description• Simple, transverse,

non-communited midshaft radial and ulnar fracture with 30 degrees apex radial angulation.

Anatomic description

Anatomic description• Simple, transverse,

non-communited distal radial and ulnar fracture with 100% radial translation, 45 degrees apex ulnar angulation and 2 cm of shortening.

Müller AO Classification of Fractures – Long Bones

• The first number represents the long bone: 1. Humerus 2. Radius & ulna 3. Femur 4. Tibia & fibula • The next defines the bone segment. 1. Proximal 2. Middle 3. Distal 4. (Malleolar) • The proximal and distal segments are defined as a square whose sides

are equal to the maximum widge of the epiphysis (except for proximal femur 31- and malleolar area 44-).

• The next letter, A,B or C, designates the fracture type. For diaphyseal fractures these are simple (A), wedge (B) or complex (C). For proximal and distal segments these are extra-articular (A), partial articular (B) and complete articular (C).

• Arbeitsgemeinschaft für Osteosynthesefragen

• (German for Association for the Study of Internal Fixation), also AO Foundation

AO Classification

AO Classification - Type A

• Type A fracture are extra-articular• 1 - Avulsion fracture• 2 - Complete fracture• 3 - Comminuted fracture

AO Classification - Type B

• Type B fracture are intra-articular single condyle fractures

• 1 - Simple• 2 - Crush/depression• 3 - Comminuted - split depression

AO Classification - Type C

• Type C fractures are intra-artucular both condyle fractures

• 1 - Simple• 2 - Crush/depression• 3 - Comminuted - split depression

Salter-Harris Classification

• Only used for pediatric fractures that involve the growth plate (physis)

• Five types (I-V)

Salter-Harris type I fracture• Type I fracture is

when there is a fracture across the physis with no metaphysial or epiphysial injury

Salter-Harris type II fracture• Type II fracture is

when there is a fracture across the physis which extends into the metaphysis

Salter-Harris type III fracture• Type III fracture is

when there is a fracture across the physis which extends into the epiphysis

Salter-Harris type IV fracture• Type IV fracture is

when there is a fracture through metaphysis, physis, and epiphysis

Salter-Harris type V fracture• Type V fracture is

when there is a crush injury to the physis

Gustillo classification

• The Gustillo classification is used to classify open fracture - ones in which the skin has been disrupted

• Three grades that try to quantify the amount of soft tissue damage associated with the fracture

Open fractures - grade 1

• wound less than 1 cm w/ minimal soft tissue injury

• wound bed is clean• bone injury is simple w/ minimal

comminution• w/ IM nailing, average time to union is 21-

28 weeks

Open fractures - grade 2

• wound is greater than 1 cm w/ moderate soft tissue injury

• wound bed is moderately contaminated• fracture contains moderate comminution• w/ IM nailing, average time to union is 26-

28 weeks

Open fractures - grade 3A

• wound greater than 10 cm w/ crushed tissue and contamination

• soft tissue coverage of bone is usually possible

• w/ IM nailing, average time to union is 30-35 weeks

Open fractures - grade 3B

• wound greater than 10 cm w/ crushed tissue and contamination

• soft tissue is inadequate and requires regional or free flap

• w/ IM nailing, average time to union is 30-35 weeks

Open fractures - grade 3C

• is fracture in which there is a major vascular injury requiring repair for limb salvage

• fractures can be classified using the MESS

• in some cases it will be necessary to consider BKA following tibial fracture

Classification1. Classification as severity

1) Complete fracture① Simple or closed Fx. : no or small displacement,

less than 3 bone fragment.② Impacted Fx. : femur neck Fx.③ Comminuted Fx. : a number of bone fragment,

more than 3 bone fragment.④ Open or compound Fx. ⑤ Complicated Fx. : affect near soft tissue or organ⑥ Compression Fx. : vertebra

Classification2) Incomplete Fx.① Greenstick Fx.② Fissured Fx.③ Perforating Fx.④ Depressed Fx.

Classification

2. Classification as type1) Transverse Fx. : stable fracture2) Spiral Fx.3) Oblique Fx. : unstable Fx.4) Longitudinal Fx.

Classification

3. Classification as displacement1) Lateral displacement2) Angulation displacement3) Overlapping fracture4) Rotation displacement

cause1. Trauma

1) Direct blow2) Fall down3) Indirect : outstretched hand4) Stress and fatigue fracture by repeated minor trauma : metatarsal, tibia,

fibular2. Pathological fracture

1) Carcinoma2) Osteogenesis imperfecta3) Infection4) Osteoporosis5) Avascular necrosis of bone6) Metabolic bone disease : rickets, osteomalacia7) RA8) tuberculosis9) PMD

Osteogenesis imperfecta• (OI and sometimes known as Brittle Bone Disease)

is a genetic bone disorder. People with OI are born without the proper protein (collagen), or the ability to make it, usually because of a deficiency of Type-I collagen.[1] People with OI either have less collagen than normal or the quality is poorer than normal. As collagen is an important protein in bone structure, this impairment causes those with the condition to have weak or fragile bones.[2]

• As a genetic disorder, OI is an autosomal dominantdefect. Most people with OI receive it from a parent but it can also be an individual (de novo or "sporadic") mutation. 7형까지있음

Collagen• Type-I collagen is the most abundant collagen of the human body.It is present in scar tissue, the end product when tissue heals by repair.It is found in tendons, the endomysium of myofibrils and the organic part of bone

and teeth. skin, artery walls, fibrocartilage, and the organic part of bones and teeth.

• Type-II collagen is the basis for articular cartilage and hyaline cartilage.It makes up 50% of all protein in cartilage and 85-90% of collagen of articular

cartilage.

• Type II collagen does form fibers. This fibrillar network of collagen allows cartilage to entrap the proteoglycan aggregate as well as provide tensile strength to the tissue.

Type 1, 5 가이상엘러스단로스증후군

과형성: scleroderma

2000

Ehlers-Danlos syndrome

• Ehlers-Danlos syndrome is a group of rare genetic disorders affecting humans and domestic animals caused by a defect in collagen synthesis. Depending on the individual mutation, the severity of the disease can vary from mild to life-threatening. There is no known cure. Treatment is supportive.

• The disease is named after two doctors, Edward Ehlers of Denmark, and Henri-Alexandre Danlosof France, who identified it at the turn of the 20th century. [1]

Clinical feature of fracture1. Crepitus2. Pain3. Deformity4. Swelling5. Marked local tenderness6. Muscle spasm7. Loss of function8. Shock9. Discoloration of skin10. Vessel or nerve injury

Healing process of fracture1. Stage of hematoma(inflammation stage)

1) Hematoma is formed at the fracture site2) Blood clot

2. Stage of sub-periosteal and endosteal cellular proliferation1) Hematoma subside

3. Stage of callus formation1) Proliferating cells mature as osteoblast or chondroblast2) Osteoblast lay down an collagen3) Formation of immature bone – callus

4. Stage of consolidation1) Change of primary callus to bone

5. Stage of remodeling1) Bone is strengthened along the lines of stress

Influencing factors on fracture union

1. Type of bone1) Cancellous bone > Compact bone 2) Upper limb : 3~12 weeks3) Lower limb : 12~18 weeks(femur 4~5 months)

2. Classification of fracture1) Type of fracture line2) Degree of displacement

3. Blood supply4. Fixation5. Age6. Degree of the bone loss7. Infection8. Nerve injury9. Soft tissue injury10. immobilization

Healing period of fracture

1. Period : depend on type, site1) Femur shaft Fx.① Infant : 3 weeks② 8 yrs : 8 weeks③ 12 yrs : 12 weeks④ 20 yrs : 20 weeks

2. Malunion ; union in abnormal position1) Spastic paralysis2) Inaccurate reduction3) Ineffective immobilization4) Accompany with soft tissue injury5) Lack of attention

Healing period of fracture3. Delayed union ; healing is take longer than would be expected.

1) Severe anemia2) Osteomyelitis3) Disturbance of blood supply to fracture site4) Ineffective reduction and immobilization5) Loss of bone fragment

4. Nonuion ; distinct pathological change pseudo-arthrosis, filled with fibrous tissue. No callus formation. Radiological evidence of nonunion.1) Severe injury of soft tissue2) Loss of bone fragment3) Ineffective blood supply4) Infection5) Ineffective reduction and immobilization6) Bone disease7) Articular fracture

Complication of fracture

1. General complication1) Shock2) Cardiopulmonary arrest3) Bleeding4) Fat embolism5) Pulmonary embolism6) Deep vein thrombosis7) tetanus

Tetanus• is a medical condition that is characterized

by a prolonged contraction of skeletal muscle fibers. The primary symptoms are caused by tetanospasmin, a neurotoxinproduced by the Gram-positive, obligate anaerobic bacterium Clostridium tetani.(파상풍균)

Complication of fracture2. Local complication

1) Bone and articular① Local infection② Malunion③ Refracture④ Epiphyseal injury⑤ Shortening of the limb⑥ Joint stiffness⑦ Recurrent dislocation⑧ Avascular necrosis⑨ Post traumatic osteoarthritis

Complication of fracture2) Soft tissue

1) Skin injury2) Muscle and tendon injury3) Nerve injury4) Vascular injury5) Visceral injury6) Volkmann`s ischemic contracture7) Adhesion8) Sudeck`s atrophy

① This complication occur after the fixation is removed② Usually seen of the lower end of radius fracture③ Severe pain on attempting movement④ Hand swellen⑤ Skin appears shiny⑥ Hand feels cold⑦ Recovery slow and may take several months

9) Myositis ossification(heterotrophic bone formation)

Volkmann`s ischemic contracture

• Definition: Volkmann's contracture is a deformity of the hand, fingers, and wrist caused by injury to the muscles of the forearm.

• Causes, incidence, and risk factors:Volkmann's contracture occurs when there is a lack of blood flow (ischemia) to the forearm, usually caused by increased pressure that results from swelling (compartment syndrome).

• Trauma to the arm, including a crush injury or fracture, can lead to swelling that compresses blood vessels and can decrease blood flow to the arm. A prolonged decrease in blood flow will injure the nerves and muscles, causing them to shorten and become stiff (scarred).

• When the muscle shortens, it pulls on the joint at the end of the muscle just as it would if it were normally contracted, but because it is stiff the joint remains bent and cannot straighten. This condition is called a contracture.

Reflex Sympathetic Dystrophy: CRPS type I

• A syndrome of pain and tenderness,usually to a hand or foot, associatedwith vasomotor instability, skin changes and rapid development of bony demineralisation (osteoporosis). Frequently will follow a localised trauma, stroke or peripheral nerveinjury.

• 여러병변에의해서 autonomic change로인해사지의뼈와피부의통증, hyperesthenia, vasomotor disturbance, dystrophic change가일어나는증상군으로자체가정확하게분류되기어렵다 Shoulder hand syndrome Posttraumatic pain syn. Minor causalgia : CRPS type II : obvious nerve damage Sympathalgia Traumatic angiospasm Reflex algodystrophy complex regional pain syndrome(CRPS)

Principles of management

1. First aid : prevent any further damage occurring.

2. Principles of treatment by the surgeon3. Physical therapy management

Principles of treatment by the surgeon1. Reduction

1) Closed reduction2) Reduction by traction3) Open reduction

2. Immobilization or fixation1) Aims

① To maintain the reduction② To promote healing③ To relieve pain

2) Type① External fixation

A. External splinting : extensive damageB. Cast (plaster of paris)C. Cast brace(functional bracing)D. Traction: femur and tibia Fx. Cervical fracture.

a. Skin tractionb. Percutaneous tractionc. Skelectal traction

② Internal fixationa. Wire fixationb. Pin fixatonc. Screw fixation- spinal fx. Oblique Fx.d. Plates fixatione. Intramedullary nail

3. protection

Physical therapy management1. Physical therapy during immobilization

1) Reduce edema : minimizing the formation of adhesion and joint stiffness① Elastic bandage or stocking② Elevation③ Massage④ Active or passive exercise⑤ Cold therapy

2) Assist the maintenance of circulation to the area and prevent deep vein thrombosis

3) Maintain muscle function by active or static contraction to prevent atrophy

4) Maintain joint range where possible5) Maintain as much function6) Teach the patient how to use and care for crutch, cane7) Prevent bed sore : position change8) Prevent pulmonary complication : breathing Ex.

Physical therapy management

2. Physical therapy after the removal of fixation

1) Reduce any swelling and pain2) Regain full ROM3) Regain muscle power4) Reeducation full function