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What are the systemic factors affecting fracture healing?



General health e.g. Diabetes

Generalised atherosclerosis

Drugs e.g. NSAIDs, steroids, EtOH

Smoking (high risk of non-union)


What are the local factors affecting fracture healing?

Degree of local trauma/bone loss: a comminuted fracture with soft tissue injury is slower to heal.

Area of bone affected: metaphyseal fractures heal faster than diaphyseal.

Abnormal bone (infection, tumour, irradiated): slower to heal

Degree of immobilization of fracture: motions at site delays healing

Disruption of vascular supply: delays healing


Describe Fractures using...


O: open (bone penetrated through skin and is exposed to air) vs closed,

L: location (which bone, anatomic orientation + landmarks)

D: degree (complex - complete cortical circumference involved, fragments are completely separated; incomplete: not fractured all the way through e.g. Greenstick fracture)

A: articular extension/involvement (intra-articular fractures, dislocation - loss of joint surface/articular congruity)

C: comminution, pattern (transverse, oblique, spiral, linear/longitudinal, segmented, comminuted, compression/impacted, distraction/avulsion)

I: intrinsic bone quality (normal or osteopenia - decreased density)

D: displacement, angulation, rotation


What are the goals of fracture treatment?

Restore the patient to optimal functional state

Prevent fracture and soft-tissue complications

Get the fracture to heal and in a position which will produce optimal functional recovery

Rehabilitate the patient as early as possible.


What are early fracture complications?

Local: nerve injury, vascular injury, compartment syndrome, avascular necrosis, infection, surgical

Systemic: hypovolaemia/shock, fat embolism, thromboembolism, acute respiratory distress syndrome, disseminate Intravascular coagulation


What are late fracture complications?

Local: delayed union, non-union, malunion, myosotis ossificans, re-fracture

Regional: osteoporosis, joint stiffness, chronic regional pain syndrome, abnormal biomechanics, osteoarthrosis, infection


What is Myositis Ossificans?

Bone formation in soft tissue which is difficult to treat


What is a sprain?

Damage to a ligament

Mechanism of injury: forces which stress the ligaments (I.e. Lengthen)

Initial management: RICE

Can take up to several weeks to heal

Complete (Grade 3); partial (Grade 2); Damaged fibres with continuity intact (Grade 1)

May present like a fracture with swelling, pain, bruising


What is a Dislocation?

Complete loss of continuity of the articulating surfaces of the joint.


What is Subluxation?

A partial loss of continuity of the articulating surfaces of the joint


What are the consequences of injury to a joint?




Loss of function

Cosmetically poor

Loss of limb


What do OA and RA commonly affect and what do they result in?

Osteoarthritis commonly affects weight-bearing joints e.g. Vertebral column, hips and knees

Rheumatoid arthritis usually affects small joints of the hand (although other joints in the limbs e.g. Wrist, elbow and shoulder) and vertebral column (cervical spine) may also be affected.

Both of them result in pain, deficient movement (disability) and deformity


What is the function of Articular Cartilage and what is its functional integrity dependent on?

Protective shock absorber for the underlying bone.

Functional integrity of articular cartilage in a healthy joint is dependent upon organised synthesis of appropriate amounts of cartilage matrix components by the chondrocytes.

As cartilage is avascular, the survival and the synthetic activity of the chondrocytes depends on the diffusion and transport of nutrients and metabolites through the cartilage matrix

Thus in a healthy tissue, there is a fine balance between synthesis and tissue breakdown with ongoing tissue turnover. When the balance is upset, there is loss of articular cartilage followed by a degenerative process.


Define OA and RA

OA: the articular cartilage and subchondral bone undergo destruction.

RA: systemic connective tissue disorder affecting the joint synovium which shows chronic inflammatory changes (synovitis) which eventually leads to invasion and erosion of underlying cartilage and subchondral bone.