Fracture, rupture ligament and capsul

dr. Rendra Leonas ,Spot, FiCS, (k) spine, M Humkes

Anatomy of the Bone

A. Anatomical structures Bones form the skeleton of the body (frameworked) Locomotor system and allow the body to be supported against gravity and to move and function in the world. Bones also protect some body parts
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B. Physiological organ Bone marrow is the production center for blood product Reservoir of calcium and is always undergoing change under the influence of hormones

 Bone is not a stagnant organ. Parathyroid hormone increases blood calcium levels by leeching calcium from bone, while calcitonin has the opposite effect, allowing bone to accept calcium from the blood.

Types of bone tissue

compact tissue - the harder, outer tissue of bones. cancellous tissue - the sponge-like tissue inside bones. subchondral tissue - the smooth tissue at the ends of bones, which is covered with another type of tissue called cartilage
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Bone Composition
Cells
Osteocytes Osteoblasts Osteoclasts

Extracellular Matrix
Organic (35%)
Collagen (type I) 90% Osteocalcin, osteonectin, proteoglycans, glycosaminoglycans, lipids (ground substance)

Inorganic (65%)
Primarily hydroxyapatite Ca5(PO4)3(OH)2
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Bone Biomechanics
Bone is anisotropic - its modulus is dependent upon the direction of loading. Bone is weakest in shear, then tension, then compression. Ultimate Stress at Failure Cortical Bone
Compression Tension Shear < 212 N/m2 < 146 N/m2 < 82 N/m2

Bone Biomechanics
Bone is viscoelastic: its force-deformation characteristics are dependent upon the rate of loading. Trabecular bone becomes stiffer in compression the faster it is loaded.

Bone Mechanics
Bone Density Subtle density changes greatly changes strength and elastic modulus Density changes Normal aging Disease Use Disuse
Cortical Bone

Trabecular Bone

Figure from: Browner et al: Skeletal Trauma 2nd Ed. Saunders, 1998.

Basic Biomechanics
Bending Axial Loading
Tension Compression

Torsion
Bending Compression Torsion

What causes a fracture?

When outside forces are applied to bone it has the potential to fail. Fractures occur when bone cannot withstand those outside forces. Fracture, break, or crack all mean the same thing.

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FRACTURE
Definition :
A fracture, whether of a bone, an epiphyseal plate or a cartilaginous joint surface, is simply a structural break in its continuity.
must be consider : surrounding soft tissue around the fracture site

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Definition
Break in the structural continuity of the bone No More than a crack, a crumpling or a Splintering of the cortex Most often the break is compleate displaced
Appley; Principles of fracture

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What causes of the pain ?

The nerve endings that surround bones contain pain fibers and and these fibers become irritated when the bone is broken or bruised. Broken bones bleed, and the blood and associated swelling (edema) causes pain. Muscles that surround the injured area may go into spasm when they try to hold the broken bone fragments in place, and these spasms cause further pain.
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 where in the bone the break has occurred, Descriptions of fractures can be how the bone fragments are aligned, and confusing. They are based on: whether any complications exist. Is open or closed Next, there needs to be a description of the fracture line. Does the fracture line go across the bone (transverse), at an angle (oblique) or does it spiral? Is the fracture in two pieces or is it comminuted, in multiple pieces?
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Fracture Mechanics

Figure from: Browner et al: Skeletal Trauma 2nd Ed, Saunders, 1998.

Fracture Mechanics
Bending load:
Compression strength greater than tensile strength Fails in tension

Figure from: Tencer. Biomechanics in Orthopaedic Trauma, Lippincott, 1994.

Fracture Mechanics
Torsion
The diagonal in the direction of the applied force is in tension cracks perpendicular to this tension diagonal Spiral fracture 45 to the long axis

Figures from: Tencer. Biomechanics in Orthopaedic Trauma, Lippincott, 1994.

Fracture Mechanics
Combined bending & axial load
Oblique fracture Butterfly fragment

Figure from: Tencer. Biomechanics in Orthopaedic Trauma, Lippincott, 1994.

Fracture Mechanics
1. Fracture Callus
1. Moment of inertia proportional to r4 2. Increase in radius by callus greatly increases moment of inertia and stiffness

1.6 x stronger

Figure from: Browner et al, Skeletal Trauma 2nd Ed, Saunders, 1998.

0.5 x weaker
Figure from: Tencer et al: Biomechanics in Orthopaedic Trauma, Lippincott, 1994.

Fracture Mechanics
Time of Healing
Callus increases with time Stiffness increases with time Near normal stiffness at 27 days Does not correspond to radiographs

Figure from: Browner et al, Skeletal Trauma, 2nd Ed, Saunders, 1998.

Stages of Fracture Healing

Inflammation Repair Remodeling

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Inflammation
Tissue disruption results in hematoma at the fracture site Local vessels thrombose causing bony necrosis at the edges of the fracture Increased capillary permeability results in a local inflammatory milieu Osteoinductive growth factors stimulate the proliferation and differentiation of
mesenchymal stem cells
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Repair
Periosteal callus forms along the periphery of the fracture site
Intramembranous ossification initiated by preosteoblasts

Intramedullary callus forms in the center of the fracture site

Endochondral ossification at the site of the fracture hematoma

Chemical and mechanical factors stimulate callus formation and mineralization

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Repair

Figure from Brighton, et al, JBJS-A, 1991.

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Remodeling
Woven bone is gradually converted to lamellar bone Medullary cavity is reconstituted Bone is restructured in response to stress and strain (Wolffs Law)

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Mechanisms for Bone Healing

Direct (primary) bone healing Indirect (secondary) bone healing

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Direct Bone Healing

Mechanism of bone healing seen when there is no motion at the fracture site (i.e. rigid internal fixation) Does not involve formation of fracture callus Osteoblasts originate from endothelial and perivascular cells

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Direct Bone Healing

A cutting cone is formed that crosses the fracture site Osteoblasts lay down lamellar bone behind the osteoclasts forming a secondary osteon Gradually the fracture is healed by the formation of numerous secondary osteons A slow process months to years

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Components of Direct Bone Healing

Contact Healing
Direct contact between the fracture ends allows healing to be with lamellar bone immediately

Gap Healing
Gaps less than 200-500 microns are primarily filled with woven bone that is subsequently remodeled into lamellar bone Larger gaps are healed by indirect bone healing (partially filled with fibrous tissue that undergoes secondary ossification)
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Direct Bone Healing

Figure from http://www.vetmed.ufl.edu/sacs/notes

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Indirect Bone Healing

Mechanism for healing in fractures that are not rigidly fixed. Bridging periosteal (soft) callus and medullary (hard) callus re-establish structural continuity Callus subsequently undergoes endochondral ossification Process fairly rapid - weeks
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Ligament

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Ligament Anatomy
Type 1 collagen (70%) Elastin Extracellular matrix Hierarchical structure Fibrils > fibres >subfascicular unit >fasciculus Longitudinal fasciculi (MCL, LCL) Helical fasciculi (ACL, PCL)
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Anatomic Features
Bonding Crimping Random collagen alignment Complex blood supply Diffusion from synovium Proprioception and nociception

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Biomechanics
Laxity Stiffness Strength Viscoelastic behavior (creep, stress relaxation, hysteresis) Dynamic properties

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Ligament Injury
Ligament - fibrous dense connective tissue binds bones
injuries to these structures may be a precursor to osteoarthritis has functional subunits that tighten or loosen depending on joint position is not densely innervated or densely vascularized
do contain some blood vessels and nerves in outer covering (epiligament) do contain proprioceptors do transmits pain signals via type C fibers

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Ligament Injury
in bone-ligament-bone structures, ligament is the weakest link
weakest near ligament insertion (adolescent & osteoporotic exceptions)

ligaments are not readily weakened by inactivity (takes many weeks)

ligaments show only a 10% - 20% u in tensile strength with exercise

It is currently not known whether any modalities aid in ligament healing

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surgical repair not done unless ends are significantly far apart
length of repair scar does not affect final functionality or tensile strength
unless ends are far apart: r extra-long scar r d joint stability & u joint laxity

ACL tears most often result in ends unopposed r surgery required

surgical repair restores only about 80% - 90% of original tensile strength
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Functional Sub-units of the Lateral Collateral Ligament - Left Knee

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Ligament Sprain
Ligament sprain classifications grade I - slight incomplete tear - no notable joint instability grade II - moderate / severe incomplete tear - some joint instability one ligament may be completely torn grade III - complete tearing of 1 or more ligaments - obvious instability surgery usually required

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In most cases, more than 1 ligament share loads around a joint

most sprains involve more than one ligament - example: ankle
most common sprain: ankle inversion accompanied by plantar flexion
primary ligaments: anterior talofibular and calcaneofibular ligaments

if sprain is severe, backup structures may sometimes be involved

backup structures: posterior talofibular ligament & peroneal tendons

most common knee sprain: valgus force to knee r medial collateral tear
backup structure: anterior cruciate (cruciates blood supply inferior to collaterals)

joint instability in knee sprain likely to be evident only in injury position repeat injuries not only tear healed areas but backup structures as well
prevention of re-injury is of critical importance

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General Ligament Exam

Difficult acutely Early exam beneficial Pt. relaxed Displacement Endpoint quality Compare

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Ligament healing
Immobilization
Loading dramatically affects recovery of normal mechanical properties Decrease strength Insertion site vs. midsubstance

Exercise
Favourable effect

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Ligament Healing
Stage Inflammatory (days 0 - 4) Pathology - Healing Treatment Implications Intra-articular injury RICE (Protect & Immobilize <48 hrs) intra-articular pressure & hemarthrosis Immobilize (r d osteoarthritis) Extra-articular injury NSAID drugs subcutaneous hematoma light passive ROM exercise (>48 hrs) Fibrin clot is formed in ligament tears in minutes exercises that cross the joint (straight leg raises for ACL injury) fibroblasts & angiogenic cells scar matrix macrophages remove damaged ligament debris decent tensile strength within 3 weeks progress to full active ROM exercise resistance & weight bearing exercise intensity of all types of exercises biomechanical evals began at 3 wks progression of activity (intensity & duration)

Fibroplastic Proliferation (day 4 - weeks)

Remodeling Maturation (weeks to years)

density of scar matrix replacement of initial or inferior collagen tissues strength of molecular bonds of scar matrix near maximum strength reach within 1 year ** but not back to 100% of original

Healed Ligament never attain pre-injury tensile strength due to: d # of hydroxypyridinium cross linkages in collagen u quantity of type V (inferior) collagen r d collagen fibril diameter u amount of fat cells, blood vessels, loose & disorganized collagen in the scar 46

Capsule

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Definition
A fibrous, membranous, or fatty sheath that encloses an organ or part, such as the sac surrounding the kidney or the fibrous tissues that surround a joint.

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Anatomy
Each capsule consists of two layers: an outer layer (stratum fibrosum) composed of avascular white fibrous tissue an inner layer (stratum synoviale) which is a secreting layer, and is usually described separately as the synovial membrane

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Disease
Apart from obvious involvement in injuries such as dislocations and fracture dislocations, abnormalities capsule itself may affect the functioning of the joint and predispose to other joint diseases. Laxity of the capsule is a common cause of dislocations

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Disease
The mobility of a joint can be affected
adhesive capsulitis, which may occur after trauma the capsule becomes thickened adherent to adjacent structures, Preventing normal motion

'frozen shoulder'
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Treatment
Laxity may have to be surgically treated by stapling folds of the capsule to adjacent bony structures in order to restrict motion, especially in the shoulder Torn repair

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