Orthopedics: Fractures and Bone Healing

There is a lot of things to consider when a pt comes into the ER with a fracture. Do you know when you to treat with an OPEN or CLOSED reduction?

Bones can heal either by 'Healing Per Primam' or secondary healing with callus formation (much more common).
Healing per primam is direct healing of bone with tunneling of osteoclasts and migration/colonization of the tunnel with osteoblasts (no callus formation).

Secondary healing/callus formation stages:

1. Hematoma 
2. Granulation tissue 
3. (Soft callus) Cartilaginous callus formation 
4. (Hard Callus) Bony callus and cartilaginous remnants (lammellar bone deposition)
5. Remodelling to original bone contour 

Stephen Pearson strain theory, classification of fracture with regards to healing:

> Narrow simple line  > OPEN reduction

Requires absolute stability, usually a surgical fix with plates and screw so there is zero movement of bone fragments. healing per primam

e.g. this type of healing is ideal for fractures where we don't want a callus for example, joint fractures, fractures of the epiphysis (a callus would restrict movement). 

> Wide complex line  > CLOSED reduction

Requires relative stability, fix fracture with plaster cast or erfix etc. healing is by secondary bone healing with callus formation.

e.g. comminuted fractures, fractures with gaps and mutiple fragments.

Describing a fracture short version DOCTOR:

Displaced vs. non-displaced Open vs. closed Complete vs. incomplete Transverse fracture vs. linear fracture Open Reduction vs. closed reduction

Describing a fracture long version PLASTER OF PARIS:

Plane Location Articular cartilage involvement Simple or comminuted Type (eg Colles') Extent Reason Open or closed Foreign bodies disPlacement Angulation Rotation Impaction Shortening

Principles of fracture management FRIAR:

First aid Reduction Immobilisation Active Rehabilitation

Fracture description version three BLT LARD: *just think of BLT sandwiches, i'd fracture my arm for one of those now

Bone
Location on bone
Type of fracture
Lengthening
Angulation
Rotation
Displacement

There are a tonne of factors that will affect the healing rates of a fracture:

• Age (children heal faster than adults)
• Active life (sportsmen/women heal faster)(immobility will slow healing)
• Absence of gravity *
• Nutrition
• Hormones (GH, estrogens, corticosteroids for example will slow healing)
• Smoking, alcohol abuse, infections *
• Hypovitaminosis (A, C, D, K) *
• Drugs; antiinflammatories, antihypertensives, anticoagulants *
• Diabetes, anemia, neuropathies *

* these factors will slow bone healing

as well as many local factors:

• type of bone
• denervation
• local damage (to the soft tissue of vascularity)
• bone loss
• surgery (exposure, damage, stability of fixation, gap, weightbearing)
• infections, necrosis, tumours

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