It shows a little about fracture, its classification and deals about fracture healing to some extent.

1. Fracture, classification
and Fracture healing
Dr Dipendra Maharjan

2. What do you see???
Fig. A Fig. B

3. Fracture
 A disruption or break in
the continuity of the
structure of bone
 Traumatic injuries
account for the majority
of fractures

4. How does a fracture occur?
 Results from
 Injury
 Direct (soft tissue injury is common)
 Indirect
 Twisting
 Compression
 Bending
 tension
 Repetitive stress
 Abnormal weakening

5. Classification of fracture
 On the basis of etiology
 On the basis of displacement
 On the basis of communication with external
environment
 On the basis of site of fracture
 On the basis of fracture morphology
 On the basis of stability

6. ‘
 On the basis of
etiology
 Traumatic
 Atraumatic
 Pathological
 Stress
fracture
 Insufficiency
fracture
Stress Fracture
Pathological Fracture
Insufficiency Fracture
Traumatic Fracture

7. Un-displaced Fracture
 On the basis of displacement
 Un-displaced
 Displaced
 Translation
 Angulation
 Rotation
 Length
Displaced Fracture

8.  On the basis of communication with external
environment
 Closed Fracture
 Open Fracture

9.  On the basis of site of fracture
 Epiphyseal fracture
 Metaphyseal
 Diaphyseal
 Upper third
 Middle third
 Lower third
 Junctional

10.  On the basis of fracture morphology
 Transverse
 Spiral
 Oblique
 Comminuted
 Impacted
 Segmental
 Avulsion

11.  On the basis of stability
 Stable
 Occur when a piece of the
periosteum is intact across
the fracture
 Unstable
 Grossly displaced
 Periosteum completely torn

12. AO Classification

13. AO classification

14. Fracture Healing
 Proliferative physiological
state
 Restores the tissue to its
original physical and
mechanical properties
 Influenced by a variety of
systemic and local factors

15. Types of Fracture Healing
 Primary Healing (Direct)
 Secondary Healing (Indirect)
 Distraction Osteogenesis

16. Primary Healing
 Osteonal Healing
 Involves direct attempt by the cortex
to reestablish itself
 Gaps in reduction heal by vessel
ingrowth-mesenchymal cells-
osteoblasts-osteoclast cutting cones
 Direct contact areas heal by cutting
cones allowing passage of vessels
 Resembles normal remodelling
 Occurs only with anatomic reduction &
rigid fixation

17. Secondary healing
 Enchondral Healing
 Response of periosteum/ external soft tissues
 Recapitulation of embryonic intramembranous
ossification and endochondral ossification
 Intramembraneous= peripheral to fracture
 Endochondral= adjacent to fracture
 Motion enhances periosteal response
 External soft tissue forms bridging callus
(Periosteal bridging callus)

18. STAGES OF FRACTURE HEALING
Cortical bone(FROST 1989)
 Inflammation phase
 Stage of Hematoma Formation 1-
2 Days
 Stage of Inflammation 2-7 Days
 Stage of Granulation
 Reparative phase
 Stage of Soft Callus Formation 1-
3 Weeks
 Stage of Hard Callus Formation 3-
6 Weeks
 Remodelling Phase >8. Weeks
 Stage of Remodelling stage
(Consolidation)
 Stage of Modelling stage
(Remodelling)

19. Inflammation Phase
 Hematoma (fibrin clot)
 Macrophages
 Inflammatory leukocytes
 Osteoprogenitor cells
 Hematopoietic cells secrete growth factors
 Granulation tissue

20. Reparative phase
 Primary callus response (2 weeks)
 Inflammation triggers cell division and angiogenesis
 Chondrocytes secrete collagen and proteoglycans
 Creates fibrocartilage
 Bone formation
 Soft callus turns to hard callus (lamellar bone)

21. Re-modelling phase
 Begins during the middle of the repair phase
 Continues up to years
 Allows the bone to assume its normal configuration
 Wolff’s law
 The stresses on the bone is directly proportional to
remodelling

22. Growth Factors
 Bone Morphogenic Protein
 Osteoinductive
 Mesenchymal cells to osteoblasts
 Transforming growth factor beta
 Induces mesenchymal cells and osteoblast to produce
type II collagen
 Regulates cartilage and bone formation in fracture callus

23.  Insulin like growth factor II
 Promote cell proliferation and matrix synthesis by
chondrocytes and osteoblasts
 Responsible for formation of fracture callus
 Platelet derived growth factor
 Stimulate osteoblast or osteoprogenitor cell activity
 Promote bone formation

24. Principles of Fracture Healing

25. Stability and fracture Healing
 Stability determines strain
 Stain
 Strain is defined as change in fracture gap divided by the fracture gap (ΔL/L)
 Highest fracture site strain is seen in a simple fracture
 Stability
 Absolute stability
 Relative stability
 Strain determines type of healing
 Strain less than 2% results in primary bone healing (endosteal healing).
 Strain 2% to 10% results in secondary bone healing (enchondral ossi cation).
 Strain greater than 10% does not permit bone formation.

28. The End!!!