7) fx healing and ortho infections

fx definition

any structural break in continuity of bone

fx are accomplished by

significant soft tissue injury

soft tissue injury determines

severity of injury and speed of rehab

bones are much stronger in ________ than _______

- compression than tension

bone mineral is strongest in

compression

bone matrix is strongest in

tension

fx description

open or closed

site

Configuration

displacement

open fx

any break in the skin that extends down to bone

more soft tissue damage, takes longer to heal

open fx are more or less at risk for injection

more at risk for infection

closed fx

skin is intact

less infection risk, less soft tissue damage

fx site description

which bone

proximal, middle, distal

diaphyseal, metaphyseal, epiphyseal

intra- or extra-articular

fracture-dislocation

intra-articular fx

fx involving joint surface and surrounding area

fx configuration

incomplete

transverse

oblique

spiral

comminuted

comminuted fx

has more than two parts

more vascular and soft tissue injury

spiral fx is caused by what type of motion

plant and twist

Undisplaced fracture

buckle, hairline

impacted

displaced fx

lateral shift

angulation

lengthening or shortening

pediatric fx - type 1

fx through growth plate

pediatric fx - type 2

fx exits through metaphysis

Pediatric fx - type 3

fx exits through epiphysis (intra-articular)

Pediatric fx - type 4

Transverse across growth plate (intra-articular)

stages of fx healing

- inflammation

- soft callus

- hard callus

- remodeling

inflammation stage

lasts 1-3 days

- pain, swelling, heat

- fx hematoma clots at fx site

- inflammatory cells migrate into region

soft callus stage

early stage

clinical stability is poor

osteogenic "repair cells" from periosteum infiltrate hematoma

in the soft callus stage, chondroblasts

form cartilage callus

during the soft callus stage, is the callus visible on x-ray?

no

soft callus stage, osteogenic cells differentiate into

osteoblasts

cartilage callus is converted into

woven type bone

later on, at the end of the soft callus stage can the callus be seen on x-ray?

yes

- weeks 2-3

hard callus stage is about ______ weeks

6-12

hard callus stage

fracture sire no longer moves

cartilage is replaced by woven bone

callus is well developed on x-ray

remodeling phase proceeds for

years

wolff's law

bone responds to stress, becoming stronger

- osteoblasts lay down new bone along lines of stress

- osteoclasts resorb poorly located bone

factors that affect fx healing

age

site and configuration

initial displacement

blood supply

factors that affect healing - age

children heal much quicker

adolescents to older adults heal similarly

elderly only heal slower when malnourished or when they have medical conditions

metaphyseal bone heals faster than

diaphyseal bone because metaphyseal bone has better blood supply

comminuted fractures heal

slower

- greater soft tissue injury

- compromised blood supply to the fragments

pediatric growth plate injuries heal in _____ the time

half

- due to the cellular machinery is ready for healing

factors that affect healing - initial displacement

more displaced heals slower

more soft tissue damage

more vascular disruption

factors that affect healing - blood supply

fx need good blood supply to heal

scaphoid in wrist has _____ blood supply

poor

blood supply in tibia for healing

tibia is subcutaneous, not surrounded by muscle and has poorer blood supply

fx treatments

immobilization

closed reduction - immobilization, percutaneous fixation, external fixation

open reduction internal fixation (ORIF)

immobilization alone is used for

non-displaced fx

- cast or brace

displaced fx need to be

reduced (straightened)

closed reductions are performed by

manually realigning the fx without surgically opening the site

some type of anesthesia is typically used

Immobilization after reduction if stable

cast immobilization

immobilization after reduction if unstable

percutaneous or external fixation

percutaneous fixation

running small pins across the fx

external fixation

place pins on both sides of a fx site and connect them with an external bar

fx that cannot be reduced closed need to be

surgically opened

Open Reduction Internal Fixation (ORIF)

surgically procedure using plates and screws to hold fx in place

tissue healing and stress

tissues heal better with stress

stress stimulates osteoblasts and strengthens bones

motion lines up healing collagen fibers in anatomic orientation

common fx

proximal humerus

distal radious

scaphoid

hip

femur

tibia

ankle

proximal humeras fx

metaphyseal, extra-articular

most are stable and heal well

shoulder and elbow stiffness very common

early motion if possible

distal radius fx

metaphyseal, intra-articular

often need fixation to hold reduction

work on finger and elbow ROM early

scaphoid fx

very poor blood supply, artery enters the distal half only

takes 3-4 months to heal

stiffness from immobilization

hip fx

femoral neck - intra-articular, hemiarthroplasty

intertrochanteric - metaphyseal, ORIF

early mobilization, PWB

femur fx

diaphyseal

intra-medullary rod

early mobilization and WB

tibia fx

diaphyseal

closed reduction and casting or IM rod

poor blood supply, takes 3-4 months to heal

early mobilization for IM rod, delayed for casting

ankle fx

lateral malleolus, medial malleolus or bimalleolar fx

if unstable, needs ORIF

WBAT in cast at 2-4 weeks

Ankle stiffness common

complications with fx healing

malunion

nonunion

infection

compartment syndrome

complex regional pain syndrome - reflex sympathetic dystrophy (RSD)

malunion

fracture heals normally

unacceptable alignment

nonunion

fx does not show any sign of healing by 3 months

need to stimulate bone to heal

electrical stimulator

bone graft

improved immobilization

infection

possible after any surgical procedure

more common with open fx and people with diabetes

compartment syndrome

vascular compromised caused by extreme swelling

tissue pressure becomes higher than venous pressure

blood can get in, but it can't get out - blocked circulation

muscle compartment becomes ischemic and muscle dies

complex regional pain syndrome

pain, swelling, and autonomic dysfunction are all hallmarks

early complex regional pain syndrome

constant burning, aching, pain out of

proportion to injury; edema can rapidly

lead to joint stiffness

middle complex regional pain syndrome

cold, glossy skin with decreased ROM

late complex regional pain syndrome

atrophy and contractures

complex regional pain syndrome - stage 1

3-6 months

- Deep burning pain, edema which causes

stiffness, erythema, pallor or cyanosis, tremor,

dystonic posture

complex regional pain syndrome - stage 2

3-6 months

- diffuse severe pain, worsening stiffness, thin glossy skin, loss of hair

complex regional pain syndrome - stage 3

constant severe pain, skin is cool, pale and dry, subcutaneous tissue disappears, and fingers become narrow