This document provides an overview of musculoskeletal injuries, focusing on fractures. It discusses the healing process for bones, classifications of fractures, and typical timescales for fracture healing. The functions and composition of bone tissue are explained. The stages of fracture healing are outlined, from initial inflammation and hematoma formation to remodeling. Principles of fracture management include reduction, immobilization, and rehabilitation. Complications of fractures like infection, malunion, and nonunion are also reviewed.

1. HN Unscheduled and Emergency Care
Topic: Musculoskeletal
Topic Number:7

2. Learning Outcomes
By the end of this lecture you should be able to
discuss:
• the healing process in bone.
• classifications of fracture.
• the normal timescales for the stages of healing.
• factors that affect healing.
• In-hospital principles of management of fractures.

3. Fractures

4. Functions and Composition of Bone
Tissue components
• 25% water
• 25% protein fibres
(notably collagen)
• 50% mineral salts
(Primarily Calcium
Phosphate)
• Strong yet lightweight
Functions
• Support and Protection
• Assist movement
• Mineral "bank" (Ca & Phosphate)
• Blood cell production - haemopoesis
(red marrow)
• Energy storage - adipose tissue
(yellow marrow)

5. Fracture healing: Stage 1
 Blood vessels and
nerves are ruptured
 Haematoma formation
 Macrophages remove
dead cell tissue

6. Fracture healing: Stages 2 and 3
• Chondrocytes and
fibroblasts form ‘soft
callus’
• Fracture unites – stage 3

7. Fracture healing: Stage 4
• Hard callus formation and
consolidation
• Callus becomes mineralized
into woven bone
• Osteoblasts lay down bone

8. Fracture healing: Stage 5
• Remodeling
• Osteoclasts erode surface to
allow osteoblasts to lay
down further bone
• Callus is reshaped along
lines of stress

9. Fracture healing timescales
Stage Features Time
Inflammation Site protection & clearance
Healing process begins
0 – 2 weeks
Callus formation Scaffold for new bone
Soft  hard
Fluffy opacity on x-ray
2 – 3 weeks
Union Bridging by cartilage / immature bone
Fracture stable but weak
4 – 6 weeks
Consolidation All callus replaced by bone
Immature bone  lamellar bone
Bone secure
6 – 8 weeks
Remodelling Continued osteoblast / osteoclast activity
Reshaping to best density and shape
 1 – 2 years

10. Remodelling

11. Classification of Fractures: Aetiology
1. Direct violence
2. Indirect violence
Spontaneously e.g following a muscle contraction – avulsion
3. Pathological
Abnormally weak bone: tumours, cysts, osteoporosis
4. Fatigue/stress
Commonest in 2nd metatarsal in young adults (march #), also tibia in
runners and vertebrae in fast bowlers

12. Fracture types

13. Classification of Fractures:
Open or closed
• Also known as compound
and simple
• Closed fractures – no
open wound

14. Clinical Examination
• History
• Pain over # site
• Loss of function
• Deformity
• Crepitus
• Swelling
• Radiographically – at least
two different views
• Stress films, CT, MRI, bone
scans

15. Principles of Management
1. Reduction
2. Immobilisation
3. Rehabilitation

16. Stabilisation – simple external
Collar & cuff splint
Cast/ POP

17. Stabilisation – external
pneumatic cast
Functional brace

18. Stabilisation - traction

19. External fixation
Halo brace
Ilizarov frame

20. Internal fixation
Dynamic hip screw

21. Immediate Complications Following a
Fracture
• Injury to major blood vessels  haemorrhage
• Damage and injury to surrounding soft tissues i.e. nerves,
viscera, ligaments, tendons, joints
• Compartment syndrome

22. Early Complications
• Infection-– open fracture
• Pulmonary embolism – fatal !

23. Late complications
 Delayed union (3-4/12)/ Mal union/ non union:
Smokers, Alcoholics, DM
 Fear of WB
• Avascular necrosis – # NOF
• Shortening – especially in children when epiphyseal plate
disruption has occurred
• CRPS (complex regional pain syndrome)– on removal of
POP
• Secondary osteoarthritis

24. Mal-union
Healing with faulty
shape
Non-union
Healing process stops
Avascular necrosis
Ischaemia 
bone death

25. Back to the case study
Introduction to Hip Fractures
•Hip fracture is the most common serious injury in
the elderly population and the most common
reason for being admitted to an orthopaedic
ward. It is a major cause of mortality and morbidity.
•Approximately 75,000 hip fractures treated each
year in the UK.
•More common in women.
•One-year mortality after hip fracture is estimated
to be as high as 30%.
•It has been estimated that hip fracture costs the
NHS £1.4 billion per year.
•It is an example of a fragility fracture (most often
secondary to osteoporosis) – accounting for as
many as 87% of all fragility fractures.
•Neck of femur fractures are intracapsular hip
fractures.

26. Key Features of a NOF Fracture
Clinical Features
•History
– Usually a fall
accompanied by pain.
– Be aware that injuring
force can be trivial.
– In a younger patient,
considerable force
(e.g. motor vehicle
collision) is usually
involved.
Clinical Examination
•External rotation and
shortening of affected
limb (but not always).
•Adduction may also
accompany these findings.
•Important to look for
other injuries.

27. Fracture location

28. Management of a NOF Fracture
•Initial treatment:
•Assess vital signs and treat appropriately. Patients may well have been on the ground
for some time and be hypothermic, dehydrated and may have developed pressure
sores.
•Relieve pain with analgesia if required (Entonox, morphine and/or paracetamol).
•Consider immobilisation
•Prepare for ongoing treatment
•Patients can lose as much as 2 litres of blood as a result of a hip fracture

29. Presentation – questions and understanding – slides
in chat and poll – how collaborate session…
• Typically elderly female why?
• Often caused by a low energy fall why?
• Hip pain (but not always) why?
• Shortened and externally rotated leg why?
• Unable to weight bear why?
• Discuss the risk factors for Osteoporosis and how they may be
present in this case.
http://www.nhs.uk/Conditions/osteoporosis/Pages/Introduction.aspx

30. Questions for NOF fractures: risk factors
Lets give the answers - summing up
• Give answers
• Why is Osteoporosis a potential risk factor? We need to give answers to all of these
• Dementia – why is dementia a consideration in hip fractures?
• Poor mobility / vision – how do these contribute?
• Why are patient medications a contributory factor?
– We need to highlight -
– What was the “sloppy slippers campaign?”
– What can you do as a paramedic to prevent falls in the elderly?
– What preventative measures are currently available?
– Why aren’t these patients taken straight to orthopedics?

31. Why is Osteoporosis a potential risk
factor?
98% of hip fractures are due to
falls
Osteoporosis Falls
95% of hip fractures are due to
osteoporosis
From: Cryer and Patel 2001

32. What risk factors does ‘Mary’ have for Osteoporosis?
Being female, elderly, a smoker, regular alcohol
consumption and having previously had children.
For example:
Female: Bone loss occurs as a results of estrogen deficiency in postmenopausal
women
Elderly: Estrogen-independent age-related mechanisms (eg hyperparathyroidism)
Smoking: ‘The strongest evidence of the effects of smoking in decreasing bone mineral
density comes from a meta-analysis which considered 29 studies and concluded that
roughly one in eight hip fractures is attributable to cigarette smoking. Current smokers
lose bone at faster rates than non-smokers, and by age 80 this can translate into 6%
lower bone mineral density. Hip fracture risk among smokers is greater at all ages but
rises from 17% greater at age 60 to 71% at age 80 and 108% at age 90’
http://www.who.int/tobacco/research/osteoporosis/en/
Alcohol: Chronic alcohol use has been associated with decreased BMD in the femoral
neck and lumbar spine and is commonly listed as a risk factor for osteoporosis

33. Menopause and Osteoporosis
National Osteoporosis Society Key Facts and Figures
Prevalence increases from 2% at 50yrs to 25% at 80yrs

34. Osteoporosis
Most common osteoporotic fracture
sites:
•Spinal (>60,000 each yr in UK)
•Wrist (>50,000 each yr in UK)
•Hip (>120,000 each yr in UK)
National Osteoporosis Society Key Facts and Figures

35. Dementia – why is dementia a
consideration in hip fractures?
Dementia is an independent risk factor for sustaining a hip fracture with studies
highlighting that up to 50% of hip fracture patients have dementia. The reasons that
dementia sufferers sustain hip fractures are due to osteoporosis and the increased risk of
falling due to a plethora of reasons (such as physical weakness, gait changes, poor balance,
memory impairment, poor judgement, visual misperception, clutter, fatigue, medication
side effects, restlessness, discomfort or pain, hunger or thirst, a need to use the bathroom,
boredom and loneliness).
Age and Ageing. Hip fracture risk and subsequent mortality among Alzheimer's disease patients in the United Kingdom, 1988–2007. Accessed September 25, 2012.
http://ageing.oxfordjournals.org/content/40/1/49.abstract?sid=02dbc022-d8eb-4fb3-a547-3f781daf1540
Please view the following youtube video of the National Clinical Director for Dementia
Professor Alistair Burns talking about fragility fractures and the association with dementia.
http://www.youtube.com/watch?v=aco_Ft97gvE

36. Poor vision – how does this contribute to hip fractures?
‘Visual impairment is one of the biggest known risk factors for falls and
hip fractures. Vision loss can decrease visual acuity, contrast sensitivity,
glare sensitivity, colour discrimination, and the ability to adapt in
different lighting conditions. These vision impairments may cause an
individual not to see hazards that are present, thereby causing a fall,
stumble, or trip.’

37. Poor mobility – how does this contribute to hip fractures?
• Gait and balance disorders
affect many elderly people and
these impairments are a
significant risk factor for falls,
and are associated with about a
3 fold increase in falls risk. Even
the use of an assistive device for
walking is associated with a 2.5
fold increased risk of falling.
• Reduced mobility also leads to
loss of muscle function and
confidence increasing the risk of
falling and hip fracture
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38. Why are patients’ medications a contributory factor for falls?
Please watch this video which highlights how
certain medications can cause falls:
https://www.youtube.com/watch?v=hCsa2bmvr
nw
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39. End of presentation
© Pearson College 2013