General principles of fracture management: Bone healing and fracture description
- Anthony Beutler, MD
Anthony Beutler, MD
- Associate Professor, Department of Family Medicine
- Uniformed Services University
- Mark B Stephens, MD
Mark B Stephens, MD
- Professor, Department of Family Medicine
- Uniformed Serviced University
Competent fracture care requires a basic knowledge of bone biology and healing, a systematic approach to fracture evaluation and description, and a practical understanding of basic splinting and casting techniques. The general principles of bone healing and proper fracture description will be reviewed here. Fractures that are complicated, high risk, or unresponsive to appropriate conservative management should be promptly referred to an orthopedic surgeon.
For information on specific fractures, please see the relevant topic reviews. Stress fractures and pediatric fractures are reviewed separately. (See "Overview of stress fractures" and "General principles of fracture management: Fracture patterns and description in children".)
BIOLOGY OF BONE HEALING
Bone is a composite structure with mineral and organic components. The mineral component contains calcium, phosphate, and hydroxyl ions which are organized into a compound called hydroxyapatite (Ca5(PO4)3(OH)). This mineral skeleton provides the strength, stiffness, and rigidity characteristic of bone. The organic or protein component consists primarily of type I collagen, which lends tensile strength and resiliency. The outer covering of bone, the periosteum, provides the vascular supply that plays an essential role in fracture healing. The periosteum in children is substantially thicker and more robust than in adults, accounting in part for the more rapid healing of pediatric fractures [1,2]. (See "Normal skeletal development and regulation of bone formation and resorption".)
Bone healing is usually divided into three slightly overlapping stages: inflammatory, reparative, and remodeling [2-7]. It is difficult to provide an approximate time frame for each phase because healing rates vary widely according to age and comorbidities. As an example, a simple toe fracture in a healthy young child may heal completely in four weeks while the same fracture in a 65 year old smoker may not heal completely for several years.
The initial inflammatory phase is dominated by vascular events. Following a fracture, a hematoma forms which provides the building blocks for healing. Subsequently, reabsorption occurs of the 1 to 2 mm of bone at the fracture edges that have lost their blood supply. It is this bone reabsorption that makes fracture lines become radiographically distinct 5 to 10 days after injury. Next, multipotent cells are transformed into osteoprogenitor cells, which begin to form new bone.
- Eiff MP, Hatch RL. Fracutre Management for Primary Care, 3rd, Elsevier Saunders, Philadelphia 2012. p.26.
- Wilkins KE. Principles of fracture remodeling in children. Injury 2005; 36 Suppl 1:A3.
- Jones ET. Skeletal growth and development as related to trauma. In: Skeletal Trauma in Children, 3rd, Green NE, Swiontkowski MF. (Eds), Saunders, Philadelphia 2003. p.6.
- McGowan HJ. Sports Medicine Reource Manual, 1st, Seidenberg P, Beutler AL. (Eds), Saunders, Philadelphia 2007. p.147.
- Macmahon P, Eustace SJ. General principles. Semin Musculoskelet Radiol 2006; 10:243.
- Tsiridis E, Upadhyay N, Giannoudis P. Molecular aspects of fracture healing: which are the important molecules? Injury 2007; 38 Suppl 1:S11.
- Dimitriou R, Tsiridis E, Giannoudis PV. Current concepts of molecular aspects of bone healing. Injury 2005; 36:1392.
- Buckwalter JA, Glimcher MJ, Cooper RR, Recker R. Bone biology. I: Structure, blood supply, cells, matrix, and mineralization. Instr Course Lect 1996; 45:371.
- Gaston MS, Simpson AH. Inhibition of fracture healing. J Bone Joint Surg Br 2007; 89:1553.
- Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984; 24:742.
- BIOLOGY OF BONE HEALING
- FRACTURE DESCRIPTION
- Location: bone and aspect
- Orientation: Transverse, oblique, and spiral
- Displacement and angulation
- Fractures with multiple parts
- - Comminution versus segmentation
- - Compression and impaction
- Open versus closed fractures
- PRECISE "RADIOGRAPHIC" DESCRIPTION
- SUMMARY AND RECOMMENDATIONS