155

FRACTURE
DEFINITION
Is a structural loss of continuity in the surface of the bone produced by forces
exceeding the modulus elasticity of the bone.
EPIDEMIOLOGY:
M=F
Greenstick Fxchildren are most likely affected
Pathologic Fx elderly 60-70 y/o; f>m over 90 y/o
ETIOLOGY:
PATHOLOGIC FRACTURE
Occur in bones weakened by pre-existing disease such as tumors, cysts, or
osteomyelitis.
TRAUMATIC FRACTURE
EXTERNAL CAUSATIVE FACTORS
1. Violence /Trauma- the bone is normal and the causative force maximal
Direct Violence- Fx due to blows or falls to which break occurs at the
point of impact with the ground or object.
Indirect Violence- occurs when the force is transmitted to the bone
through some parts of the body.
INTERNAL CAUSATIVE FORCES
1. Muscular action- ex. Fx in the patella due to a sudden contraction of the
quadriceps; Fx of the arm in throwing a ball or Fx of the humerus of women
wringing clothes.
PATHOMECHANICS OF A FRACTURE
The energy imposed on the human body by the forces of impact must be
absorbed by non-injury producing methods. The principal energy absorbing
mechanism in the body is a lengthening contraction of muscle.
Therefore, strong muscles provide good protection from fracture. Energy can
also be absorbed by protective gear such as helmets, pads, etc. but these along are
inadequate to absorb the entire force of an impact. Load is transmitted through these
protective materials and absorbed in part by the bodys own padding in the form of
muscle bulk, fats, bone and cartilage. If the energy at the time of impact is greater than
what can be absorbed by protective gear or lengthening contractions. Injury occurs first
to the soft tissue(bruise, strain) and then to bone or ligaments(fracture)
PATHOPHYSIOLOGY
In fracture, the actual damage to the bone consist of a break in the continuity
which results in damage to blood and lymphatic vessels. The periosteum will be
stripped off on the region of the injury and sometime it is torn but since it is a tough
fibrous membrane, it may remain intact. An intact periosteum is essential because it
traps the blood from the ruptured vessels that is essential from hematoma formation
needed in the repair process. Due to sharp edges of the broken bone or the force
impacted upon the body part, there are the damages on the surrounding soft tissue like
the torn muscle, muscle tearing of the fascia and other connective tissues, ruptured
blood vessels and considerable extravation of blood take place. Tissue debris and
blood clots as irritants and an inflammatory reaction occurs, neighboring small vessels
dilate and hyperemia results and the area affected is invaded by inflammatory cells.
Some salts are absorbed recalcification of the fracture bone ends may occur.
CLASSIFICATION OF FRACTURES
I.
ACCORDING TO COMPLETENESS
1. Incomplete Fx- cortex is broken in the convexity of the curve whereas the
bone on the concave is bent.
1.1 Greenstik Fx-bone is bent and broken only part of the way through its
shaft. Occur in children at an age when bones are soft and pliable.
1.2 Fissured- a mere split of the bone without displacement of the
fragments.
1.3 Perforating- there is a hole such as those made of bullets.
1.4 Interperoisteal Fx- Fx in which the periosteum is not disrupted.

156
1.5 Depressed- saucer or gutter shaped in which a fragment of bone is
driven inward. Seen frequently in fracture of the skull.
2. Complete Fx- there is separation in the apophysis.
2.1 Simple(closed fx)- it does not communicate with the skin or
.
mucous membrane. The fractured surface is protected from
contamination with the outside air.
2.2 Impacted- the broken bone ends are driven into each other
2.3 Comminuted- bone is broken into several pieces of fragments
2.4 Compound(open)- has communication between the fracture
surface and the skin and mucous membrane so that air and
bacteria maybe admitted hence causing infection.
2.5 Complicated- there is injury to some organs or important
structures near the fracture site.
2.6 Compression- usually in short bones, disruption of tissues;
causes collapse of involved bone
II.
ACCORDING TO DISPLACEMENT
1. Undisplaced- fragments or ends of fracture sites are not separated
2. Displaced- separation of bone fragments exists.
III.
ACCORDING TO PLANE OR FRACTURE SURFACE
1.Transverse Fx- the plane of the fracture surface is perpendicular to the axis of
the bones.
2.Oblique Fx- fracture surface forms an angle with the axis of the shaft.
Break runs in slanting direction of bones.
3.Spiral Fx- fracture surface is spiral and is produced by torsional stress
which fracture the bone
Note: The spiral and oblique fractures results from indirect violence and soft tissue
damage is often slight.
4.Butterfly Fx- center fragment of 2 disruptions in continuity of tissue
creates a triangular effect.
5.Comminution- 2 fragments or potential fragments are present
The displacement of the fragments may consist of:
a. Lateral displacement
b. Angulation- the fragments form an angle with each other instead of being a
line
c. Overlapping- resulting in the shortening of the bone
d. Rotation-or twisting of the distal fragments
A fracture is undisplaced when a plane of cleavage exist in the bone
without angulation or displacement. If separation of bone fragments exists,
the fracture is said to be displaced.
IV.
ACCORDING TO PATHOLOGIC FRACTURE
1. Agmetic- spontaneous fracture due to imperfect osteogenesis
2. Angulated- fracture in which fragments are angulated
3. Angulation- caused by angulations of spine or shaft of long bone
4. Apophyseal- Fx separating apophysis from bone where there is a strong
tendinous attachment
5. Articular- aka: intraarticular joint Fx; involves articular surface of a joint
6. Atrophic- spontaneous fx due to atrophy
7. Avulsion- caused by tearing away of bone fragment; ligamentous tendinous
attachment forcibly pulls away from the rest of the bone
8. Bending- results from bending of extremity
9. Bent Fracture- incomplete greenstick fx
10. Bursting fracture- fx resulting in multiple fragments usually at near end of
bone
11. Buttonhole- caused by perforation of bone by bullet
12. Capillary- hairlike fracture
13. Chip fracture- usually involves a bony process near a joint;presence of small
fragmental fx

157
14. Cortical- involves cortex of bone
15. Dentate- results in fragmented ends being serrated and opposing each other
16. Direct Fx-- fx resulting at specific point of injury and due to injury itself
17. Double fx- results in 2 segments with fx in 2 places
18. Dyscrasic Fx- caused by weakening of specific bone from debilitation
disease
19. Endocrine- resulting from weakness due to endocrine disorder
20. Epiphyseal- involves epiphyseal growth plate of long bone resulting
separation or fragmentation
21. Extracapsular- occur near joint but not directly involving or entering joint
capsule, extremely common in hip
22. Fatigue fracture- results from excessive physical activity
23. Fracture dislocation- involves bony structures of joints with associated w/
associated dislocation of same joint
24. Gunshot Fx- results from bullets or other missiles
25. Inflammatory- fx of bone weakened from inflammation
26. Infarction Fx- results in a small radiolouscent line commonly associated w/
metabolic dysfunction
27. Intracapsular Fx- fx within joint capsule
28. Intrauterine- occurs during fetal life
29. Lead pipe Fx- compression at point of impact & linear fx at opposite side;
aka; Torus Fx
30. Linear- extends parallel to long axis of bone w/ no displacement
31. Multiple Fx- fx of several bones fro one injury
32. Neoplastic- fx in bone weakened by neoplasm or malignancy
33. Neurogenic- results from destruction of nerve supply to specific bone
34. Occult Fx- accompanied by usual clinical signs
35. Periarticular- located near joint but not directly involving joint
36. Pressure- created by pressure resulting from tumor
37. Puncture- due to projectile creating loss of bone tissue w/o disruption of
continuity of involved bone
38. Sprain Fx- separation of tendon or ligament at its insertion
39. Y Fx- intercondylar fx shaped like a Y
V.
SPECIFIC TYPES OF FRACTURE
UPPER EXTREMITIES
RADIUS
Bartond Fx- fx distal articular surface of radius, maybe accompanied with
dorsal dislocation of carpus & small fragments
Chauffers Fx- fx of distal styloid process produced by twisting or
snapping injury
Colles Fx- extraarticular fx w/ dorsal displacement of distal fragment &
radial shift of wrist / hand
Dupuytrens Fx or Galleazi Fx- fx of distal radius w/ dislocation of the ulna
Moores Fx- Fx of distal radius associated w/ dislocation of the ulnar head
Peidmont Fx- an oblique fx of distal radius w/ fragments pulled into the
ulna
Smiths Fx- involves volar displacement & angulation of distal fragment
( reverse Colles Fx)
ULNA
Monteggias- fx of proximal half of ulna w/ dislocation of proximal radioulnar joint
HAND
Bennets Fx- fx of 1st metacarpal bone that run obliquely through the
base of bone and into the CMC jt.
Boxers Fx- fx of neck of 5th metacarpal
Mallet Fx- avulsion fx of dorsal base of distal phalanx

158
Quevairs fx- fx of navicular bone accompanied by lunate bone
dislocation.
A. LOWER EXTREMETIES
FEMUR
Intertrochanteric Fx- fx of proximal femur between greater and lesser
trochanters
Pillion Fx- T- shaped fx of distal femur w/ displacement of condyle
posterior to femoral shaft
Penurels Fx- fx of the proximal femoral neck w/ varying degree of
angulation
Subtrochanteric fx of the hip- fx of femur occurring transversely below
the lesser trochanter
TIBIA
Paratrooper fx- fx of the distal tibia & malleolus as a result of external
force on an ankle
FIBULA
Monterous Fx- fx of fibula asso.w/ diastasis ofankle mortise
Potts Fx- fx of the distal fibula usually of the spiral oblique type w/
asso. Ligamentous damage or medial malleolus injury
Cotton Fx or Di-malleoli fx- involves medial & lateral malleoli &
posterior ligament of tibia
FOOT
Lisfranc FX- fx dislocation of the foot
March Fx- stress fx of one or more metatarsal shaft usually attributed
to excessive marching
Rolandos Fx- comminuted fx of the base of the 1st metacarpal
SPINE
Hangmans Fx- fx through pedicle of C2
Jeffersonss Fx- bursting type of fx @ the ring of the atlas
Malgaigne Fx- fx dislocation of SI joint.
OTHERS:
Butterfly fx- a center fragment of disruption in continuity of tissue
creates a triangular effect
Condylar Fx- fx of round end of hinge joint usually occurs at distal
hemerusor femur
Epicondylar fx- involves the medial and lateral epicondyle of long bone
Fissure Fx- resulting in cracks extending in one cortex of bone but
does not end through entire bone
Intercondylar fx- fx between condyles of bone
Subcapital fx- fx occurring distal to the head of bone
Supracondylar fx- involves the area between the condyles of the
humerus or femur
Transcondylar fx- occurring transversely & distal to epicondyle
CLINICAL MANIFESTATIONS
1. Abnormal mobility- motion in a limb at a point in a direction in which
it does not normally reach.
2. Crepitus- one of the most reliable sign; a sound produced by the
friction of one fragments moving into the other
3. Swelling- in the vicinity of the fx as the result of extravasation of
blood and serum in the tissue.
4. Bruising or Ecchymosis- presence of blood in the subcutaneous
tissue and leads to discoloration in the tissue
5. Deformity- signifies a change in the position or shaped of the limb
that is due to alterations in the bony structure. Search for the
deformity should be the first step.
6. Pain- at the time of injury and afterwards, both spontaneous and
upon movt of the fixed limb is a constant accompaniment of fracture

159
7. Tenderness- amount of tenderness varies greatly in different
persons & also varies directly with the amount of injury to the soft
tissue & w/ the elapsing after injury.
8. Absence of active movement
9. Muscle spasm- during asttempt to move the extremity.
10. Characteristic attitude
11. Soft tissue edema- present in surrounding structure; fx site may feel
warm to touch
12. Excesive motion- present especially if the site is not near a joint or is
not splinted by surrounding soft tissue structure
13. Open wounds- may sometimes mask degree of damage
14. Neurovascular impairment-due to fragmentation
COMPLICATIONS
1. Neurovascular injuries- injuries involving both nerve & blood vessels
2. Infection- invasion of the body by disease-producing organisms
3. Acute Respiratory Distress Syndrome
4. Compartment Syndrome
5. Osteomyelitis-inflammation of bone, especially of the marrow caused by
bacterial infection
6. Avascular necrosis- is a dse.resulting from a temporary loss of the blood
supply of the bone
7. Joint stiffness, Reflex Sympathetic Dystrophy, Non-union or delayed union,
malunion, Post-traumatic arthritis, Growth deformity
MEDICAL AND SURGICAL MANAGEMENT
Dependent on:
1.type of injury and fracture
2.age & general health of patient
3.severity of displacement & associated tissue damage
Ability to Reduce Fracture Dependent on:
1. Degree of displacement
2. Whether fracture is open or closed
Aims of the surgeon & those who cooperate with him:
1. To obtain accurate anatomical alignment in order to promote good repair
2. To restore perfect function of the limb
All fractures are now x-rayed as a matter of routine and the x-rays
are later used to ascertain whether reduction has been maintained,
how union is progressing, whether internal fixation is holding, or
whether a bone graft has been taken.
Three Great Principles of Fracture Treatment:
I. Reduction- undertaken to regain perfect realignment of the fragments
A. Closed- i.e by manipulation under anesthesia. Most common
method of restoring the alignment of fractured long bones.
B. Open-i.e performed by operation; used when a manner of reduction
by manipulation is impossible or dangerous.
II. Fixation- designed to maintain reduction, and thus prevent any harmful stress until
union has occurred
Three forms of fixation:
A.External Splintage-most common method of maintaining reduction;
this includes plaster of paris,thoma splint, strapping or bandages.
B.Internal Splintage- applied by open operation, the fragments being
fixed together by steel or silver plates, screws or nails. The
disadvantage is it converts fx into open ones & infection may arise.
C. Traction- this combines reduction with fixation and is used
particularly for overlap. This is used for fractures which cannot
be immobilized sufficiently by cast. This, however requires the
pt. to be in bed for several day. Traction can be applied in 2
days.

160
* Skin Traction- usually applied by means of adhesive or
reinforced foam rubber strips & encircling elastic bandage
used when not more than 5 or 6 lbs. is required.
Types of skin traction
1. Bucks extension traction- used for longitudinal pull. Used to exert
traction on the long axis of the lower limb.
2. Bryants- this is for children under 3 years. This is for the fracture of
the femoral shafts in infants.
3. Russels traction-this is for older children
* Skeletal Traction- it can be applied to distal areas
such as ankle.The stronger traction required is 20-50lbs.
Used in the treatment of femoral Fx, dislocation, &
Fx of cervical spine.
NOTE: Proper use of traction is also needed to ensure ealier union of fracture. Traction
maybe used throughout the period of Fx healing. It is discontinued when union becomes
strong enough to prevent angulation within a cast.
III. Protection- even though union has occurred, Fx cannot withstand stress until
solidification is established. It is necessary therefore to protect the fx that is likely to be
subjected to a rotation strain, or to traction, such as those occurring at the elbow or
knee.
Principle of Treatment:
1. Circulation must be adequate for the formation of the callus
2. Joint mobility & msc. power must be maintained on the free joint.
PT EVALUATION
1. Before Casting
a. Ocular inspection-look out for signs of swelling, edema, ecchymosis, leg
length discrepancy, blanching or cyanosis.
b. Palpation- tenderness, diminished or absence, of pulse distal to the injury,
coolness, etc.
c. Sensory Test- any sensory loss or impairments can be detected
d. X-ray- to determine the exact site of the Fx & to see the actual gap
e. ADL Test- for walking, sitting balance
2. After Casting
a. ROM- determine increase or decrease on ROM
b. Ocular Inspection- see signs of skin irritations
c. MMT- determine increase or decrease in muscle power
d. Sensory Testing- see sensory impairments in affected extr.
e. X-ray- to see if there is union
f. Palpation- look for presence of tender areas
g. Muscle Bulk Measurement- to denote muscle atrophy
h. Postural test- any deviations are present
i. ADL- for improvement or training
PT MANAGEMENT
1. Rest- must be placed first in the list bec. it is the most important & should be
used not only in the beginning of the treatment but also during the convalescence
period whenever the joint becomes stiff & more so during the regimen of active or
passive movement.
2. Active Movt- movement is more important in the restoration not only of motion of
a joint but also of tone and power to the muscles. Exercise should be started as
soon as possible after the injury, usually on the 2nd or 3rd day, it should not be
carried to a point where they cause more than very slight pain.
3. Heat- to cause dilatation of blood vessels in the area and thus increasing
circulation; and to relieve pain
*Common methods of applying heat
= superficial heating modalities such as hot packs,whirlpool baths
= deep heating modalities such as US & diathermy

161
4. Massage- done after casting. Used principally in preparation of active muscular
exercise & joint movts. Persistent within sufficient vigor & over long enough time,
may have a distinct benefit in increasing the circulation in the part where it is
impaired. It should not be undertaken until firm union has been obtained.
5. Progressive- Resistive Exercise- best & most important form of physical therapy.
Done first against gravity or even with gravity lessened by water & as the union
becomes firm, the exercises are done against resistance. The amount of
resistance is increased as the strength of the muscle improves.
TREATMENT DURING IMMOBILIZATION
A. Clinical Consideration during the period of immobilization
1. With immobilization, there is a connective tissue weakening, articular
cartilage degeneration, mm trophy and contracture devts. as well as
sluggish circulation. Structures in the related area should be kept in a state
as near to normal as possible by using appropriate exercises w/o
jeopardizing alignment of fx site.
2. If bed rest or immobilization in bed is required, as with skeletal trxn,
secondary physiologic changes will occur systematically throughout the
body. General exercises for the uninvolved positions positions can minimize
these.
3. If there is a LE fx, alternate modes of ambulation need or to be taught to the
patient who is allowed of device and gait pattern will depend on the fx site,
the type of immobilization, and the fxnal capabilities of the pt.
B. TREATMENT CONSIDEARATION DURING THE PERIOD OF
IMMOBILIZATION
1. Problems summarized:
a. initially, inflammation and swelling
b. in the immobilized area, progressive degeneration & decrease circulation
c. potential overall body weakening if on bedrest & method of immobilization
used
2.Treatment goals and plan of care
GOAL
PLAN OF CARE
= effects of inflammation
= ice, elevation
= effects of immobilization
= intermittent msc.setting
= if pt is confined to bed, maintain
= resistive ROM to major
strength & ROM in major msc.groups msc. groups not immobilized
= teach fnxl adaptation
= use of assistive or supportive
devices for ambulation/ bed mobility
FINAL REHABILITATION AFTER IMMOBILIZATION
A. Clinical Considerations after the period of
There will be decrease of ROM, muscle atrophy and joint pain the structure that
has been immobilized.
Activities should be initiated carefully in order not to traumatized the weakened
structures. Initially, the patient will experience pain as movement begins, but it
should be progressively decrease as joint movement, muscle strength & ROM
progressively improve.
If there was soft tissue damaged the time of fx, an inelastic scar will form,
leading to increase ROM or pain when stretched is placed on the scar. The scar
tissue will have to be mobilized to gain pain-free movt.
To determine if there is clinical or radiologic healing, consult with the referring
physician. Until the fx site is radiologically healed, use care anytime stress is placed
to fx site
When progressing stretching and strengthening exercises & fnxl activities, use
the guidelines and goals that follow.
SUB-ACUTE STAGE
( Day 4 to 14 or 21)
GOALS
PLAN OF CARE
a. control pain, edema, & jt. swelling
a. monitor response of tissue to

162
exercise progression; decrease
intensity if inflammation inc.
b. progressively inc.soft tissue,
b. progress from passive to AAROM
muscle & joint mobility.
to AROM w/n pain limits. Gradually
inc. mobility of scar. Progressively
inc. mobility of structure if they are
tight.
c. strengthening supporting & related c. initially, progress isometric ex w/n
structures.
Pt. tolerance, begin cautiously with
mild resistance. As ROM, jt. play &
healing improve, progress to
isotonic ex. with resistance
progressing as tolerated.
d. maintain integrity & fxn of
d. apply PREs depending on
associated areas
proximity to & effect on the
primary lesion. Gradually
decrease the amount of support
from assistive devices as strength
increases.
CHRONIC STAGE
(begin bet. Day 14 to 21 and last until there is pain-free fxnl use of the part)
GOALS
PLAN OF CARE
a. decrease pain from stress on
a. modalities; selective of limiting
contractures & or adhesions
structures.
b. increase soft tissue, muscle
b. selective stretching, soft tissue
and or joint mobility
passive stretch & massage jts.,
capsule, & selected ligaments.
Cross- fiber massage; active
Stretching or flexibility techniques
c. strengthening supporting and
c. limited range jt. play, isometric ex. at
related structures
various angles of the range; when
joint play is good; resistive isotonic
ex.
d. progress fnxl independence
d. assistive devices until ROM is fnxl
with good jt. play & msc. strength.
Ambulation, stair climbing, or other
Appropriate activities.progressive
Strengthening ex. & training
Activities until the muscle are
Strong enough for the persons
Fnxl level
B. PT MANAGEMENT
1. Use of active exercises to improve joint mobility and increase muscle strength
2. Massage for improving skin condition and relieving edema.
3. SWD, MWD, HMP to relieve pain and promote circulation
4. Gait training
FACTORS AFFECTING REPAIR
1. type of Fx- a simple line or direction of breakage has a higher percentage of
repair.
2. Vascularity- blood supply to the area also affects the degree of repair in the Fx
site.
3. Immobility- early immobilization affects healing time
4. Infection- the presence of infection usually produce in the healing process.
5. Soft tissue interposition- the presence of soft tissue between the bone ends will
prevent healing.
6. Severity of injury.
7. Size of the bone

163
8. General condition of the patient.
STAGES OF FRACTURE HEALING
INFLAMMATORY RESPONSE
- time of injury to 24-72 hours
Injured tissues and platelets release vasoactive mediators, growth factors and other
cytokinesis. These cytokinesis influence cell migration, proliferation, differentiation and
matrix synthesis. Growth factors recruit fibroblasts, mesenchymal cells and
osteoprogenitor cells to the fracture site. Macrophages, PMNs & mast cells( 48hr)
arrive at the fracture site to begin the process of removing the tissue debris.
REPARATIVE RESPONSE
- 2 days to 2 weeks
Vasoactive substances (Nitric Oxide & Endothelial Stimulating Angiogenesis Factor)
cause neovascularisation & local vasodilation. Undifferentiated mesenchymal cells
migrate to the fracture site and have the the ability to form cells which in turn form
cartilage, bone or fibrous tissue
The fracture hematoma is organized and fibfoblasts and chondroblasts appear between
the bone ends and cartilage is formed ( Type II collagen). The amount of callus formed
is inversely proportional to the amount of immobilization of the fracture. In the fracture
that are fixed with rigid compression plates there can be primary bone healing with little
or no visible callus formation.
Types of Callus:
External (bridging) callus
From the fracture haematoma
Ossifies by endochondral ossification to form
woven bone
Internal (medullary) callus
Forms more slowly and occurs later
Periosteal callus
Forms directly from the inner periosteal cell layer
Ossifies by intramembranous ossification to form
woven bone
REMODELLING
- middle of repair phase up to 7 years
Remodelling of the woven bone is dependent on the mechanical forces applied to
it( Wolffs Law- form follow function) Fracture healing is complete when there is
repopulation of the medullary canal.
Cortical bone
Remodelling occurs by invasion of an osteoclasts cutting cone which is then followed
by osteoblasts which lay down new lamellar bone(osteon)
Cancellous bone
Remodelling occurs on the surface of the trabeculae to become thicker
FACTORS INFLUENCING BONE HEALING
Systemic
Local
Age
Degree of local trauma
Hormones
Degree of bone loss
Functional activity
Vascular injury
Nerve function
Type of bone fractured
Nutrition
Degree of immobilization
Drug (NSAID)
Infection
Local pathologic condition
HORMONAL INFLUNCES ON BONE HEALING
HORMONE
EFFECT
MECHANISM
Cortisone
Decrease
Decrease callus production
Calcitonin
Increase
Unknown
TH/ PTH
Increase
Bone remodelling
GH
Increase
Increased callus volume
Androgens
Increase
Increased callus volume