This document discusses bone fractures, fracture healing, and injuries to the growth plate. It covers the causes, symptoms, and types of fractures. The stages of fracture healing are described, including hematoma formation, callus formation, and remodeling. Factors that can influence healing are also outlined. The structure and zones of the growth plate are explained. Different types of injuries to the growth plate are classified and their treatment and potential complications are discussed.

1. FRACTURE,
HEALING,
GROWTH PLATE
DR. MUHAMMAD JAWAD
PGR ORTHOPAEDICS
SHL

2. • BONE FRACTURE
• CAUSES
• SYMPTOMS
• FRACTURE TYPES
• MANAGING A FRACTURE
• HEALING/REPAIR/UNION
• TYPES OF HEALING
• SEQUENCE OF FRACTURE HEALING
• FACTORS AFFECTING HEALING
• GROWTH PLATE
• INJURY TYPES

3. WHAT IS FRACTURE?
• Any break in continuity of bone cortex is fracture
But
• An injury that fractures bone not only damages its
cells , blood vessels and bone matrix but also
surrounding tissues, including periosteum and muscles.

4. CAUSES
• Trauma
• Pathological Fractures
• Repetitive Stress

5. SYMPTOMS
• pain
• inability to move or put weight on the injured body part
• swelling
• bruising
• bleeding (if there is open wound)
• deformity

6. TYPES OF FRACTURE
FRACTURE
SKIN PENETRATION
COMPOUND
SIMPLE
ORIENTATION
LINEAR
TRANSVERSE
POSITION
DISPLACED
UNDISPLACED
BREAK
COMPLETE
INCOMPLETE

7. • COMPOUND FRACTURE
• SIMPLE FRACTURE

8. • LINEAR FRACTURE
• TRANSVERSE FRACTURE

9. • DISPLACED FRACTURE
• UNDISPLACED FRACTURE

10. • COMPLETE FRACTURE
• INCOMPLETE FRACTURE

11. PATTERN OF FRACTURE LINE
• TRANSVERSE
• OBLIQUE
• SPIRAL
• COMMINUTED
• SEGMENTAL

12. MANAGEMENT OF FRACTURE
• IN THE ER
• HISTORY
• AGE & SEX
• Children and elderly
• Post-menopausal women: osteoporosis/pathological fractures
• HISTORY OF TRAUMA

13. SYMPTOMS
• History of injury > inability to use the injured limb
• Pain
• Bruising
• Swelling
These are common symptoms but they don't distinguish a fracture from a soft-tissue injury

14. • Deformity
• Associated injuries inquiry
• Pain , swelling elsewhere
• Numbness/loss of movement
• Pallor/cyanosis
• Hematuria/abdominal pain
• Difficulty in breathing
• LOC

15. LOOK FOR, AND IF NECESSARY, ATTEND TO,
• Airway obstruction & Cervical spine injury
• Breathing problems,
• Circulatory problems
• exclude other previously unsuspected injuries

16. CLINICAL EXAMINATION SHOULD ALWAYS BE
CONSIDERED
• systematic approach is always helpful
• Examine the most obviously injured part.
• Test for artery and nerve damage.
• Look for associated injuries in the region.
• Look for associated injuries in distant parts.

17. • LOOK
• FEEL
• MOVE

18. RADIOGRAPHS
• RULE OF 2s
• 2 VIEWS
• 2 LIMBS
• 2 OCCASIONS
• 2 JOINTS
• 2 INJURIES

19. SPECIAL IMAGING
• COMPUTED TOMPGRPAHY
• MAGNETIC RESONANCE IMAGING

20. FINAL DESCRIPTION
• Diagnosing a fracture is not enough; the surgeon should describe it with its properties:
• Is it open or closed?
• Which bone is broken, and where?
• Has it involved a joint surface?
• What is the shape of the break?
• Is it stable or unstable?
• Is it a high-energy or a low-energy injury?
• In short, the examiner must learn to recognize what has been aptly described as the ‘personality’ of the
fracture.

21. IMMEDIATE TREATMENT FOR A BONE FRACTURE
• Casting
• Traction
• External Fixation
• Internal Fixation

22. FRACTURE HEALING AND REPAIR

23. PROCESS OF FRACTURE HEALING
• complex and sequential events that occur to restore injured bone to pre-injury state

24. • PREREQUISITES FOR BONE HEALING
• Adequate blood supply
• Adequate mechanical stability
• MECHANISM FOR BONE HEALING
• Direct (Primary) bone healing
• Indirect (Secondary) bone healing

25. DIRECT BONE HEALING
• Mechanism of bone healing seen when there is no motion at the fracture site (i.e. rigid internal fixation)
• Does not involve formation of fracture callus
• Osteoblasts originate from endothelial and perivascular cells
• A cutting cone is formed that crosses the fracture site
• Osteoblasts lay down lamellar bone behind the osteoclasts forming a secondary osteon
• Gradually the fracture is healed by the formation of numerous secondary osteons
• A slow process – months to years

27. LAMELLAR BONE VS WOVEN BONE
• Woven bone is characterized by haphazard
organization of collagen fibers and is mechanically
weak.
• Lamellar bone is secondary bone created by
remodeling of woven bone . Lamellar bone has a
regular parallel alignment of collagen into sheets
(lamellae) and is mechanically strong.

28. INDIRECT BONE HEALING
• Mechanism for healing in fractures that are not rigidly fixed.
• Bridging periosteal (soft) callus and medullary (hard) callus re-establish structural continuity
• Callus subsequently undergoes endochondral ossification
• Process fairly rapid - weeks

29. STAGES/SEQUENCE OF FRACTURE HEALING
• 1. Reactive phase
i. Fracture hematoma
ii. Inflammation & Granulation Tissue
• 2. Reparative phase
iii. Cartilage callus formation (Soft Callus)
iv. Lamellar bone deposition (Hard Callus)
• 3. Remodeling phase
v. Remodeling to original bone contour

30. HEMATOMA FORMATION & INFLAMMATION
• Last for less than 7 days
• Tissue disruption results in hematoma
at the fracture site
• Local vessels thrombose causing bony necrosis
at the edges of the fracture
• Increased capillary permeability results in
a local inflammatory milieu
• Osteoinductive growth factors stimulate the proliferation
and differentiation of mesenchymal stem cells

31. SOFT CALLUS
• 2-3 weeks
• After inflammation subsides fibroblasts and chondrocytes appear in the site leading to callus formation.
• Soft callus – forms in the central region of the fractured bone Primarily of cartilage and fibrous tissue.

32. HARD CALLUS
• 4-12 weeks
• Fibroblast deposit collagen in the granulation tissue
• Soft Callus is strengthened (Unorganized network of woven bone);
• Internal callus (grows quickly to create rigid immobilization)
• The hard callus lasts 3-4 months.
• Hard callus – a gradual connection of bone filament to the woven bone (Acts like a temporary splint)
• Bone is beginning to strengthen and immobilize
• If proper immobilization does not occur; cartilage will form instead of bone

33. • Callus is the first sign of union visible on x-ray after 3 weeks of #

34. OSSIFICATION & REMODELING
• 1- 4 Years
• It will occur with adequate immobilization
• Bone ends become crossed with a new Haversian system that will eventually lead to the laying down of
primary bone
• Fracture is bridged and united
• Remodeling hard callus to compact bone or woven bone is gradually converted to lamellar bone.
• May take a few years
• Medullary cavity is reconstituted
• Bone is restructured in response to stress and strain (Wolff’s Law)

36. BONE HEALING UNDER INTERFRAGMENTARY
MOVEMENT
• Fracture healing under interfragmentary movement occurs by callus formation that mechanically unites
the bony fragments
• The flexural and torsional rigidity of a fracture depends on the material properties and the second
moment of inertia (rigidity of the callus).
• Particularly the increase in callus diameter has a significant effect on the stabilization of the fracture.
• Linear relation to the mechanical quality of the callus tissue (E),
• The rigidity is proportional to the fourth power of the diameter (IBending = πd 4 / 6 4 , ITorsion = π d 4 / 3 2 )

37. • The interfragmentary movement under external loading decreases with healing time in relation to the
rigidity of the callus.
• Finally, the hard callus bridges the bony fragments and reduces the interfragmentary movement to such
a low level that a healing of the fracture in the cortex can take place
• When this has happened, the callus tissue is no longer required and is resorbed by osteoclasts.
• Finally, after a remodeling process, the shape and strength of the normal bone are reconstituted

39. FRACTURE HEALING UNDER INTERFRAGMENTARY
COMPRESSION
• compression preload +friction between the fragments > relative movement between the fragments is
avoided.
• Under this absolutely stable fixation, bone healing can occur by direct osteonal bridging of the fracture
line with minimally or no callus formation .
• In areas with direct contact, remodeling starts a few weeks after fracture fixation, which leads to
bridging of the fragments by newly formed osteons

40. • Haversian osteons with osteoclasts in their cutter heads resorb bone, create a tunnel that crosses the
fracture line, and fill the tunnel with new bone in a process of osteoblastic activity.
• In areas with a gap between the fragments, a filling of the gap by woven bone occurs as a first step
before theHaversian osteons can cross the fracture area . In reality a mixture of contact and gap healing
will occur.

43. • An advantage of absolute stability is that the blood vessels may cross the fracture site more easily and
lead to faster revascularization.
• In contrast to callus healing, there is no increased bone diameter under direct osteonal healing.
• This limits the load-bearing capacity of the healing bone, which consequently requires a longer period
of protection by the implant.

44. VARIABLES THAT INFLUENCE FRACTURE HEALING
• Injury Variables
• Open fractures
• Severity of Injury
• Intra-articular Fractures
• Segmental Fractures
• Soft Tissue Interposition
• Damage to Blood Supply

45. • Patient Variables
• Disease/Disorder
• Age
• Nutrition
• Hormones
• Nicotine

46. • Tissue Variables
• Form of Bone ( Cortical or Cancellous)
• Bone Necrosis
• Bone Disease
• Infection

47. • Treatment Variables
• Apposition of Fracture Fragments
• Loading & Micro Motion

48. GROWTH PLATE

49. • Hyaline cartilage plate in the metaphysis at each end of a long bone
• New bone growth takes place
• In adults the plate is replaced by an epiphyseal line, known as epiphyseal closure

52. ZONAL ARRANGEMENT
Zone of reserve
• Quiescent chondrocytes are
found at the epiphyseal end
Zone of proliferation
• Chondrocytes undergo rapid mitosis under
influence of growth hormone
Zone of maturation
and hypertrophy
•Chondrocytes stop mitosis, and begin to hypertrophy by
accumulating glycogen, lipids, and alkaline phosphatase
Zone of calcification
•Chondrocytes undergo apoptosis. Cartilaginous
matrix begins to calcify
Zone of ossification
•Osteoclasts and osteoblasts from the diaphyseal side break down
the calcified cartilage and replace with mineralized bone tissue

53. REAL PEOPLE HAVE CAREER OPTIONS !!
• Real Resting zone
• People Proliferative zone
• Have Hypertrophic cartilage zone
• Career Calcified cartilage zone
• Options Ossification zone

57. INJURIES OF THE PHYSIS
• In children, over 10 per cent of fractures involve injury to the physis (Apley 9th ed)
• 30% of fractures in Children involve a physis and most heal without any long term complications
( Campbell’s 13th ed)
• Relatively weak part of the bone, joint strains that might cause ligament injuries in adults are liable to
result in separation of the physis in children.

58. • Fracture usually runs transversely through the hypertrophic or calcified layer of the growth plate often
veering off into the metaphysis at one of the edges to include a triangular lip of bone
– little effect on longitudinal growth
– As growth takes place in the germinal and proliferating layers of the physis
• If the fracture traverses the cellular reproductive layers of the physis it may result in premature
ossification of the injured part and serious disturbances of bone growth

59. CLASSIFICATION
• Most widely used –Salter and Harris, which is based on the radiographic appearance

62. • Type 1 – transverse fracture through the hypertrophic or calcified zone of the plate
– Even if the fracture is quite alarmingly displaced, the growing zone of the physis is usually not injured
and growth disturbance is uncommon
• Type 2 – This is essentially similar to type 1, but towards the edge the fracture
deviates away from the physis and splits off a triangular metaphyseal fragment of bone
– referred to as the Thurston– Holland fragment

63. • Type 3 – Fracture that splits the epiphysis and then veers off transversely to one or the other side
through the hypertrophic layer of physis – Inevitably damages the ‘reproductive’ layers of the
physis (as these layers are closer to the epiphysis than the metaphysis) and may result in growth
disturbance
• Type 4 – fracture splits the epiphysis, but it extends into the metaphysis
– liable to displacement and a consequent misfit between the separated
parts of the physis resulting in asymmetrical growth

64. • Type 5 – A longitudinal compression injury of the physis
– No visible fracture but the growth plate is crushed and this may result in growth arrest
• Rang in 1969 has added a Type 6 – an injury to the perichondrial ring (the peripheral zone of Ranvier)
– carries a significant risk of growth disturbance
– Diagnosis is made usually in retrospect after development of deformity

65. MECHANISM OF INJURY
• Physeal fractures usually result from falls or traction injuries
• They occur mostly in road accidents and during sporting activities or playground tumbles

66. • More common in boys than in girls
• Usually seen either in infancy or between the ages of 10 and 12
• Deformity is usually minimal but any injury in a child followed by pain and tenderness near the joint
should arouse suspicion
• x-ray examination is essential

68. TREATMENT (APLEY)
• Undisplaced fractures
– treated by splinting the part in a cast or a close-fitting plaster slab for 2–4 weeks (depending on the
site of injury and the age of the child)
– check x-ray after 4 days and again at about 10 days is mandatory in order not to miss late
displacement with types 3 and 4 fractures
• Displaced fractures should be reduced as soon as possible
– With types 1 and 2 this can usually be done closed; the part is then splinted securely for 3–6 weeks

69. • Type 2 injury
The fracture does not traverse the width of
the physis. After reduction bone growth is not
distorted

70. • Displaced Types 3 and 4 fractures
– demand perfect anatomical reduction
– An attempt can be made to achieve this by gentle manipulation under general anaesthesia; if this is
successful, the limb is held in a cast for 4–8 weeks (the longer periods for type 4 injuries)
– If a type 3 or 4 fracture cannot be reduced accurately by closed manipulation, immediate open
reduction and internal fixation with smooth K-wires is essential
– The limb is then splinted for 4–6 weeks, but it takes that long again before the child is ready to
resume unrestricted activities

71. • Type 4 fracture
Treated immediately by open reduction
and internal fixation. Good result was obtained

72. • In this case accurate reduction was not
achieved and the physeal fragment remained
Displaced the end result was partial fusion of the physis
and severe deformity of the ankle

73. TREATMENT ( CAMPBELL’S)
• Many Type I and II can be managed Non-operatively
• Type III and IV usually require Open reduction and internal fixation
• Implants should not cross the physis ; Or else use the smallest diameter possible
• Remove as soon as the fracture is stable
• Parents need to be educated for the possibility of growth disturbance and long term follow-up
regardless of the injury type

76. COMPLICATIONS
• Growth Arrest – shortening , angular deformity or both
• Mostly due to bony bars that cross physis
• Central bars – Shortening
• Peripheral bars – Angulation
• Distal femur and distal tibia have higher rate
• Can be diagnosed using 3D CT or MRI

77. • Types 1 and 2 injuries if properly reduced
– Excellent prognosis
– Exceptions to this rule are injuries around the knee involving the distal femoral or proximal tibial
physis; both growth plates are undulating in shape, so a transverse fracture plane may actually pass
through more than just the hypertrophic zone but also damage the proliferative zone
• Malunion or non-union may also occur if the diagnosis is missed and the fracture remains unreduced
– e.g. fracture separation of the medial humeral epicondyle

78. • Types 3 and 4 injuries
– premature fusion of part of the growth plate or asymmetrical growth of the bone end
• Types 5 and 6 fractures
– premature fusion and retardation of growth

79. PREVENTION
• Decide if a child is ready for team sports. The American Academy of Pediatrics recommends team
sports only for children six years of age and older.
• – Mental and emotional ability: most children younger than six don't understand the concept and rules of
team play, and may not have the emotional development and eagerness to play.
• Check the gear. Equipment should be age appropriate and fit correctly. Worn items should be replaced.
• Teach children not to play through pain. It won’t make him tougher and it could cause her to make an
injury even worse.
• Warm up and stretch. Warm up and cool down exercises, such as stretching and light jogging, can help
minimize the chance of muscle strain or other soft tissue injuries during sports.
• Let injuries heal completely. When a growth plate has been injured, minimize long-term damage by
allowing the affected area to heal completely before participating in the sport again.