Professional Documents
Culture Documents
Fracture
The most common bone lesion is a fracture, which is defined as a
discontinuity of the bone. A force perpendicular to the long axis of the
bone results in a transverse fracture. A force along the long axis of the
bone yields a compression fracture. Torsional force results in spiral
fractures, and combined tension and compression shear forces cause
angulation and displacement of the fractured ends.
A force powerful enough to fracture a bone also injures adjacent soft
tissues. In this situation, there is often (1) extensive muscle necrosis;
(2) hemorrhage because of shearing of capillary beds and larger
vessels of the soft tissues; (3) tearing of tendinous insertions and
ligamentous attachments; and (4) even nerve damage, caused by
stretching or direct tearing of the nerve.
Fracture Healing is Divided into Inflammatory, Reparative, and
Remodeling Phases
The duration of each phase (Fig. 26-15) depends on the patient's age,
the site of fracture, the patient's overall health and nutritional status,
and the extent of soft tissue injury. Local factors, such as vascular
supply and mechanical forces at the site, also play a role in healing. In
the repair of a bone fracture, anything other than the formation of
bone tissue at the fracture site represents incomplete healing.
Pathology
The Inflammatory Phase
In the first 1 to 2 days after a fracture, rupture of blood vessels in the
periosteum and adjacent muscle and soft tissue leads to extensive
hemorrhage. Extensive bone necrosis at the fracture site also occurs
because of disruption of large vessels in the bone and interruption of
cortical vessels (i.e., Volkmann and haversian canals). Dead bone is
characterized by the absence of osteocytes and empty osteocyte
lacunae.
fluid, and form a jointlike structure. In such cases, the fracture never
heals and the jointlike material must be removed surgically for the
fracture to heal properly.
Fractures
Traumatic and nontraumatic fractures are some of the most common
pathologic conditions affecting bone. Fractures are classified as
complete or incomplete; closed (simple), when the overlying tissue is
intact; compound, when the fracture site communicates with the skin
surface; comminuted, when the bone is splintered; or displaced, when
the ends of the bone at the fracture site are not aligned. If the break
occurs in bone already altered by a disease process, it is described as a
pathologic fracture. A stress fracture is a slowly developing fracture
that follows a period of increased physical activity in which the bone is
subjected to new repetitive loadsas in sports training or marching in
military boot camp.
Bone is unique in its ability to repair itself; it can completely
reconstitute itself by reactivating processes that normally occur during
embryogenesis. Bone repair is a highly regulated process that can be
separated into overlapping histologic, biochemical, and biomechanical
stages. The completion of each stage initiates the next stage, and this
is accomplished by a series of interactions and communications among
the various cells and proteins located in the healing zone.
Immediately after fracture, rupture of blood vessels results in a
hematoma, which fills the fracture gap and surrounds the area of bone
injury. The clotted blood provides a fibrin mesh, which helps seal off
the fracture site and at the same time creates a framework for the
influx of inflammatory cells and ingrowth of fibroblasts and new
capillary vessels. Simultaneously, degranulated platelets and migrating
inflammatory cells release PDGF, TGF-, FGF, and other cytokines,
which activate the osteoprogenitor cells in the periosteum, medullary
cavity, and surrounding soft tissues and stimulate the production of
osteoclastic and osteoblastic activity.[28] Thus, by the end of the first
week, the hematoma is organizing, the adjacent tissue is being
modulated for future matrix production, and the fractured ends of the