Types of Fracture,symptoms,Healing stages,Management,Physiotherapy management

Fractures and musculo-skeletal injury to the musculo-skeletal system can result in damage to bones, joints, muscles and tendons. 

fracture is a break bone continuity . Fracture basis on aetiology like external environment, displacement of the fracture,  pattern of the fracture.

In addition, the neurovascular bundle of the limb may be damaged. This section will outline the broad principles used in the diagnosis and management of these injuries. These principles can be applied, with suitable modifications, in the management of any musculoskeletal injury.

The patient with multi trauma➤

 High-energy fractures and multiple sites of injury are in large part a disease of modern times, and most are caused by misuse of motor vehicles, industrial equipment, and cheap handguns. 

Road traffic accidents are reaching epidemic proportions in the developing nations, and it is estimated that by 2010, they will account for 25% of health care expenditures in those parts of the world. 

Fractures contribute significantly to the pathophysiology, morbidity, and mortality of the multiple trauma patient. This is particularly true in patients who have incurred fractures of major long bones or of the pelvis, which can result in substantial blood loss and may cause or worsen hemorrhagic shock. 

High-energy, markedly displaced fractures create a large amount of devascularized tissue that releases a large quantity of cytokines, which, in turn, cause changes in local and systemic hemodynamic regulation, activate the inflammatory system, alter metabolic pathways, and influence endothelial permeability and coagulation. 

A result, adult Respiratory distress syndrome (ARDS) or even Systemic inflammatory response syndrome (SIRS), a condition associated with generalized capillary leakage, multiple organ dysfunction, and high metabolic energy consumption, may develop.

 Early fracture fixation (within 24 to 48 hours) is beneficial and, for the multitrauma patient, decreases mortality and reduces the risk of pulmonary dysfunction and infectious complications. Further more, early fracture stabilization and patient mobilization decrease pain, facilitate nursing care, lower the incidence of skin breakdown, improve gastrointestinal (GI) function, and minimize the psychological effects of trauma. 

Whether early fracture fixation improves recovery of associated head injuries is controversial. Optimal care of the multiple trauma patient requires prioritization and constant communication and coordination between members of the trauma team. Therefore, patients with multiple injuries are best treated in trauma centers that have the multiple physicians and support staff capable of effectively managing these patients.

Clinical symptoms of fractures⬇⬇⬇⬇⬇
• Swelling, haematoma
• Deformity • Crepitation
• Impaired function
• Pathological movements
• Pain and tenderness

⧪PHYSIOLOGY OF MUSCULOSKELETAL REPAIR

Bone Fracture and Healing 

The ability of any given bone to resist applied forces depends on many factors, including the bone’s strength or density, the direction and rate of loading, the type of load applied, and the capability of surrounding muscles and ligaments to absorb part of the injury force.

Different loading modes result in different fracture patterns. For example........

➧Transverse fracture - loading the bone in tension typically 

➧Spiral fractures - whereas torsional forces produce . 

➧Short oblique fractures - are caused by axial (compressive) loading

➧Long oblique fracture - results from a combination of axial and rotational load.

➧A Y-shaped butterfly fracture -  pattern indicates a bending force

 Cortical bone and cancellous (trabecular) bone have different mechanical properties; however, both cortical and cancellous bones are stronger when loaded in compression compared with tension. The magnitude of the load required to fracture a bone is reduced in certain disease states that make bone weaker or more brittle, such as osteoporosis, metabolic bone disease, tumor, or infection. 

Bone healing is a complex, yet usually reliable, biologic process that has the unique result of complete regeneration of the supporting tissue (bone) rather than healing with scar tissue, as occurs in many other organs. Bone healing requires living tissues with adequate vascularity and involves sequential coordination of a large number of cell types and biologic signals. The process, as we understand it, is summarized in the following section, but the intricate details remain a fascinating mystery and an area of active research. 

 Four histologic stages of Fracture repair --

A) Inflammation 

B)  Soft callus

C)  Hard callus  

D) Remodeling 

➽The Inflammation  ⟶  stage begins immediately after injury and is characterized by pain, warmth, tenderness, instability, and, occasionally, fever. Bleeding from the fracture bone and associated soft tissue injury result in a “fracture hematoma,” release of cytokines, clot formation, and migration of acute inflammatory cells into the site of injury. osteoprogenitor ,mesenchymal cells, and  Fibroblastscells arrive shortly thereafter. The low pO2 at the fracture site promotes angiogenesis.                              

                     A) Inflammation 

Stage of inflammation  A hematoma forms as the result of disruption of intraosseous and surrounding vessels. Bone at the edges of the fracture dies. Bone necrosis is greater with larger amounts of soft tissue disruption. Inflammatory cells are followed by fibroblasts, chondroblasts, and osteoprogenitor cells. Low pO2 at the fracture site promotes angiogenesis.

➽The Soft callus ⟶  stage is a period of increased vascularity, resorption of necrotic bone ends, and development of a fibrocartilage callus (collar) that surrounds the fracture. The soft callus progressively widens and stiffens so that at the end of this stage, the bone ends are no longer freely mobile. 

                                     B)  Soft callus                

Stage of soft callus formation  Soft callus forms, initially composed of collagen; this is followed by progressive cartilage and osteoid formation.  

➽The Hard callus ⟶ stage involves calcification of the fibrocartilage and its conversion into woven bone. During this process, variable amounts of enchondral ossification (conversion of cartilage to bone) and intra membranous bone formation (direct deposition of bone onto surfaces) are noted. The amount of each depend on the degree of fracture displacement, as well as the type of fracture fixation. 

                                           

                                     C)  Hard callus   

Stage of hard callus formation Osteoid and cartilage of external, periosteal, and medullary soft callus become mineralized as they are converted to woven bone (hard callus)

➽Remodeling ⟶ the fourth and final stage of bone healing, may go on for months or years. Remodeling involves the change over of weaker, woven bone into stronger, lamellar bone by the synchronized function of osteoclasts and osteoblasts organized into “cutting cones” that move through the woven bone, reconstituting the haversian canal system and lamellar bone.

Remodeling also react to biomechanical forces, so that more bone is deposited in areas of greater mechanical stress (Wolff law). 

                                   D) Remodeling 

Stage of bone remodeling Osteoclastic and osteoblastic activity converts woven bone to lamellar bone with true haversian systems. Normal bone contours are restored; even angulation may be partially or completely corrected. 

Healing of small, stable defects in bone can proceed by direct, appositional (intramembranous) bone formation. Similarly, fracture lines that can be very well reduced and rendered stable by compression fixation may heal without significant callus formation through a combination of intramembranous bone formation and haversian remodeling across points of stable gap contact. 

Fracture healing at all stages is sensitive to the mechanical environment. The amount of interfragmentary motion or strain that occurs has a significant effect on the differentiation of tissues within the fracture gap, and if strain exceeds the tolerance of the tissue type present, healing may stall. Thus, the theory of “strain tolerance” postulates that only tissues able to tolerate the ambient mechanical strain can differentiate in a fracture gap. As the tissue evolves from loose fibrous tissue to cartilage to bone, the strain tolerance drops; thus, differentiation and progressive healing require progressively less strain or interfragmentary motion. In general, healing bones respond positively to controlled axial loading

 Open fractures and high-energy fractures associated with disruption of the surrounding soft tissues and vascular supply have a higher rate of delayed union or nonunion.

Other factors that delay bone healing 

➲Age 

➲Medical illnesses such as diabetes mellitus

➲Malnutrition

➲Poor oxygenation

➲Smoking

➲Long-term corticosteroid use

➲Deficiencies in vitamin D

➲Vitamin C

➲Retinoic acid

➲Growth hormone

➲Thyroid hormone

➲Aanabolic steroids

 Soft Tissue Healing Soft tissue (ie, muscle, ligament, and tendon) healing also proceeds in phases . Fracture fixation that allows early motion also has a beneficial effect on ligament and tendon healing, with more rapid reorientation of collagen bundles, as well as increased fibril size and density

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Management of fractures Conservative:
• 1. Reduction
• 2. Retention (immobilisation)
• 3. Physiotherapy

FRACTURE TREATMENT

These “bone setters” made the diagnosis by examination and history, and their treatments involved ➔Local application 

➡Poultices

➡Lotions

➡Ointments

➡Massage

➡Manual traction 

➡Manipulation

➡Bandages 

➡Splints

➡Rest

➞Closed methods. 

However, the surgical treatment of fractures was very limited and was usually unsuccessful until the introduction of anesthetic and aseptic techniques that lessened pain and the risk of infection.

New techniques, such as microvascular free tissue transfer, bone transport and limb lengthening, indirect reduction, and minimally invasive fracture surgery

 the goal of fracture treatment is to return patients to their preinjury activity level as quickly as possible while minimizing the risk of complications. 

The care of each patient must be individualized, taking into consideration patient factors such as age, occupation, medical health, and individual risk expectations, as well as injury-related factors such as the nature and number of injuries and concomitant soft tissue trauma.

Role and functions of physiotherapy
Role and Responsibility: 
The role of physiotherapy in fracture management is so valuable that none can boast of a 100% recovery without the attention and care by a physiotherapist.

. Objective of physiotherapy 
The objective is to restore to the maximum the function and the efficiency of the injured musculoskeletal complex along with other adjacent joints of the affected limb and to maintain or improve the functional capacity of the unaffected parts of the body.

 Fracture or joint dislocation two main stages:
(1) Immobilization: 
(a) Reduction of the fracture either by conservative or surgical approach
(b) Retention of the reduction

(2) Mobilization:
It is required when the joints adjacent to the fractured bone get stiff and painful because of prolonged immobilization.

Physiotherapeutic management of fractures
Return of normal to near-normal function following correct and timely management of a fracture is possible by simple methods of physiotherapy. But the physiotherapist faces a challenge in regaining the functional independence in a patient with complicated multiple fractures, mismanaged fractures, nonunions and fractures where surgery is contraindicated.

1. Management of a fracture: It could be surgical or conservative
2. Site of involvement: The body segment, e.g., upper extremity, lower extremity, trunk and their sub segments https://telegram.me/aedahamlibrary
3. Type of fracture: Simple, compound, comminuted
4. Associated problems: A fracture may be associated with joint complications, and injuries to the soft tissues like muscles, tendons, ligaments and nerves.

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