Bone Healing Module

1. Describe the normal sequence of bone healing

Fracture happens when continuity of bone is broken and blood supply
is interrupted
Happens when force applied to bone is greater than capability of bone
to maintain its intergrity, can also happen with lesser forces applied to
abnormal bone (pathological fracture), or repetitive sub-maximal
forces applied to normal bone (stress fracture)
Steps
I.
Inflammation
o Hematoma and local cell death where vessel disruption has
resulted in ischemia
o Area infiltrated by inflammatory cells local swelling and warmth.
o Inflammatory cells release lysosomal enzymes and other
mediators
o Fibroblasts, mesenchymal cells and osteoprogenitor cells
o Inflammation at peak 48 hours after fracture
o In this phase for several days
II.
Repair
o Begins few days after injury and persists a few months: two
phases
o Phase one = soft callus formation: lasts for six weeks after
injury. Bony fragments united by fibrinogous tissue = woven bone.
Fracture may still angulate if no external support takes at least
10 days so callus to become visual on radiograph
o Phase two = hard callus formation woven bone transformed to
lamellar bone takes ~3 months
III.
Remodeling
o Bone replaced 10-18% of skeleton replaced every year but
accelerated in children and fracture repair. Woven bone converted
to lamellar bone and medullary canal is reconstituted
2. Identify factors which influence the rate and success of bone healing

3. Recognize abnormal patterns of bone healing

Non-Union Fracture: delayed if union not seen at 6 month mark, described as
non-union. Two types
Atrophic: little callus formed, responds to bone grafting or
implementation of donor bone
Hypertrophic: obvious callus but continued instability often results
from increased motion at fracture site- do surgical stabilization
If non-union persists and remains mobile false joint or
pseudoarthrosis may form
Stress Fractures: imbalance of bone formation and healing, often seen in
young healthy individuals and repetitive physical activity
Common sites = tibea, metatarsal and femoral neck
Plain radiographs may be negative
Bone scans or MRI are diagnostic
Treat with immobilization
Textbook Page 232-249

Identify key features in the history of a patient with musculoskeletal

injury.
Identify key physical findings in a patient presenting with a
musculoskeletal injury
Select appropriate diagnostic tests in patients presenting with a
suspected musculoskeletal injury.
List factors which influence the rate and success of bone healing
Describe a general management protocol for patients with fractures or
dislocations

A. Fractures
Fracture is a break or loss of continuity in bone
Describe fractures according to the following
Type
o Open: puncture through skin, need immediate treatment to
prevent infection
o Closed: overlying skin or mucosa is intact
o Stress fracture: repeated submaximal stress
o Pathologic fracture: Minimal trauma to abnormal bone (i.e.
osteoporosis)
Site: describe bone affected and specific location
o Epiphysis, metaphysis or diaphysis
o Diaphysis heals more slowly described in 1/3s (proximal, middle
or distal)
Pattern: suggests type and amount of kinetic energy
o Transverse = low energy, from direct blow or ligament avulsion.
Stress and pathological fractures often have this pattern
o Spiral or oblique = rotating/twisting injury

Comminuted/multifragmented = more than two fragments. If

middle fragment triangular called butterfly, if cylindrical called
segmental. Imply large forces and greater damage to blood
supply
o Impacted: seen in metaphyseal bone, low impact, two bone
fragments jammed together
o Compression: trabecular or cancellous bone is crushed
Displacement: fractured bone fragments may be displaced
o Anterior-posterior, medial-lateral, or length (shortening or
distraction)
o Position of distal fragment always named relative to proximal
o Angulation is relationship between long axis of distal fragment
to long axis of proximal. Described by two conventions
Direction to which distal fragment is inclined
Location of the fracture angle apex is described
o Varus: deformity apex away from midline
o Valgus: deformity apex towards midline
o Rotational deformity also expressed by identifying distal
fragment as related to proximal
o

Salter-Harris Classification of Growth Plate Fractures: in children growth plate

(physis) is between epiphysis and metaphysis
Type I: separation of epiphysis from metaphysis
Type II: passes through growth plate and exits metaphysis
Type III: extends from growth plate to epiphysis to enter the joint
Type IV: extends from metaphysis through growth plate to epiphysis
o Type III and IV are intra-articular and have highest incidence of
growth disturbance if not properly managed
Type V: crushing of epiphyseal growth plate
All growth plate fractures must be followed one year radiographically
post-surgery
Evaluation of Patients with MSK Trauma
Fracture suggested by history of injury, or in children limp or refusal to
use extremity
Symptoms: pain, swelling, deformity
Bony tenderness or crepitus suggests fracture
Assess vascular integrity and neurological status
2 MOST IMPORTANT clinical features of fracture (assessed before xray): open or closed, is neurovascular status compromised
Complete radiological exam includes
o Two views of infected bone at right angles
o Visualization of joint above and joint below injured area
o Radiological examination of known injury associations (e.g. knee
injury and hip dislocation)
o If not visualized radiographically but is clinically suspected,
reassess

Principles of Fracture Management

Treat life-threatening conditions first, then check integrity of neural and
vascular sites distal to fracture
MSK injuries must be splinted in field: splint stays on for transport and
must immobilize joint above and below fracture site
All open fractures treated as contaminated: do culture and cover with
sterile dressing, tetanus prophylaxis (if necessary) and antibiotic
treatment.
Patient prepared for surgery, necrotic tissue is debrided. 48-72 hours
later wound reopened for debridement of subsequently necrotic tissue
Two principles of fracture care:
Reduction: reduce deformity of fracture.
o Closed method: manipulation of fracture into functional position
o Open method: fracture is surgically exposed and manipulated
directly. When closed method fails or fracture is intra-articular
Maintenance of Reduction: maintain alignment until healing complete
o Facture immobilization: plaster or fibroglass cast
o Continuous traction applied through skin (foam rubber boot),
skeleton (pin inserted in bone distal to fracture site), or gravity
(activity through dependent extremity)
o Complications associated with casts and traction: circulatory
impairment, nonunion and peripheral nerve injury, ulcers, joint
stiffness and muscle atrophy
o Internal fixation devices: pins, screws, plates, etc. Enhances
early patient mobility but complications include surgical
exposure and refrature through screw holes after hardware is
removed
o External fixation: minimally invasive- threaded pins placed in
bone above and below fracture site and attached to external
frame. Complications = pin tract infection and delayed union

Rehabilitation of Function
Limb immobilized in position of max function use isometric exercises.
ROM exercise for adjacent joints. After cast removed active ROM and
resistive muscle strengthening
Speed of rehab depends on rate and quality of fracture healing.
Dependent on: amount of energy imparted to bone at time of injury,

type of bone, integrity of soft tissue envelope and patients general

health and age
Bone healing evaluated clinically (fracture no longer tender on
palpation) and radiologically (distinct bony trabeculae cross fracture
site)

Complications of Fracture Healing

I ) Local
Infection: higher incidence in open fractures
Delayed union: healing is slower than usual
Nonunion: incomplete healing, may form pseudoarthrosis (false joint)
Malunion: heals with deformity causes functional or cosmetic
impairment
Avascular necrosis: blood supply to bone injured by trauma e.g. head
of femur
Growth disturbances: children, growth may cease or continue
asymmetrically, do radiograph at one year anniversary
Post-traumatic arthritis: complication of displaced intra-articular
fractures and indirectly from severe angular deformity
II) Systemic Complications
Not common, usually result from trauma in general, include sepsis,
shock, tetanus, etc.
B. Joint Subluxation and Dislocation
Sublaxation: joints partially out of contact
Dislocation: joints completely out of contact
Diagnosis, evaluation & Treatment
Reluctance to move joint, held in typical posture, need to do
neurovascular evaluation, radiograph in dislocated position
Can be described as open or closed, distal head described in relation to
proximal
Realigned by traction
C. Common MSK Injuries
I) Upper Extremity
Carpal scaphoid fracture: most common of carpal bones, often after fall
on outstretched hand, if tenderness in anatomical snuff box treat (even
if radiograph negative), bone scan, CT or follow up radiograph at 7-14
days confirms. Cast for undisplaced and open reduction and internal
fixation for displaced
Distal radius fracture: also from falling on hand, transverse fracture of
distal radius proximal to wrist = Colles (common in elderly
osteoporotic patients), treated by longitudinal traction to hand,
manipulation into flexion and ulnar deviation, and splint from elbow to
palm. Do radiograph at 10 days. Evaluate median nerve. Should-hand
syndrome (shoulder and finger stiffness) common complication in
elderly

Olecranon fracture: direct blow to elbow, cannot extend it

Pulled Elbow: when child pulled forcibly by hand, impingement of
anular ligament on radial neck, treatment = flex elbow and supinate
hand
Supracondylar humerus fracture = fall on outstretched hand with
elbow extended, distal fragment displaced posteriorly, neurovascular
complications b/c brachial artery and medial/radial nerves become
entrapped, can cause compartment syndrome b/c of ischemia
Shoulder dislocation: humeral head anterior to fossa in 90%, axillary
nerve and artery can be hurt, test axillary nerve sensory over deltoid
patch and motor of deltoid. Reduction achieved by gradual shoulder
abduction with longitudinal traction. Posterior dislocation rare but
should be considered in all patients with shoulder symptoms after
electrocution or a seizure
2) Lower Extremity
Hip fractures: common in elderly. Common types are: i)femoral neck:
blood supply can be damaged, higher incidence of nonunion, treatment
by reduction or surgically fixed ii) intertrochanteric: outside hip joint,
good blood supply, reduced under radiographic guidance
Femoral shaft fractures: usually from high energy trauma and blood
loss is considerable, pelvis and hip must also be assessed, treat by
interlocked intermedullary nailing
Hip Dislocations: often occur in motor vehicle accidents when knee
strikes dashboard hip driven posteriorly out of acetabulum socket and
sciatic nerve may stretch, all patients assessed for foot drop and
reduced urgently risk of avascular necrosis of femoral head
Tibea and fibular shaft fractures: tibea fractures often opened and
contaminated, risk of compartment syndrome, key clinical sign in
unconscious patient is pain out of proportion to injury. Treat by closed
reduction and above-the-knee cast immobilization. Also external
fixation
Ankle injuries: mechanism of injury can be inferred from fracture line.
Transverse= pulling off force. Medial malleolus is transverse =
abduction, lateral malleolus = adduction. Spinal fracture is rotatory
force. Coronal plane spiral fracture = lateral malleolus pattern, foot
externally rotated on leg and body. Anatomic open reduction with
internal fixation
3) Spinal and Pelvic Fractures
Spinal fractures: spinal stability is critical concept in treatment. Also
perform neuro assessment
Pelvic fractures: high velocity trauma and can be associated with blood
loss and multi organ system injuries. Emergency pelvic stabilization
and external fixation essential. 2 goals are to stop bleeding and permit
sitting stability to facilitate pulmonary physiotherapy
D. Traumatic Amputations and Replantation
Completely severed digits and limbs can be re-attached
Children have better prognosis

Rule of thumb: greater the amount of muscle attached to the

amputated part, the poorer the prognosis

E. Compartment Syndrome
Bleeding and tissue swelling inside compartment- local acidosis, cell
injury and edema. Muscle and nerve necrosis can result. Classic signs
are 4 Ps: pain, parenthesia, paralysis, pallor. Do fasciotomy