Anatomy and Physiology The skeletal system includes all of the bones and joints in the body.

Each bone is a complex living organ that is made up of many cells, protein fibers, and minerals. The skeleton acts as a scaffold by providing support and protection for the soft tissues that make up the rest of the body. The skeletal system also provides attachment points for muscles to allow movements at the joints. New blood cells are produced by the red bone marrow inside of our bones. Bones act as the bodys warehouse for calcium, iron, and energy in the form of fat. Finally, the skeleton grows throughout childhood and provides a framework for the rest of the body to grow along with it. Functions of the Skeletal System 1. Support and Protection The skeletal systems primary function is to form a solid framework that supports and protects the body's organs and anchors the skeletal muscles. The bones of the axial skeleton act as a hard shell to protect the internal organs - such as the brain and the heart from damage caused by external forces. The bones of the appendicular skeleton provide support and flexibility at the joints and anchor the muscles that move the limbs. 2. Movement

The bones of the skeletal system act as attachment points for the skeletal muscles of the body. Almost every skeletal muscle works by pulling two or more bones either closer together or further apart. Joints act as pivot points for the movement of the bones. The regions of each bone where muscles attach to the bone grow larger and stronger to support the additional force of the muscle. In addition, the overall mass and thickness of a bone increase when it is under a lot of stress from lifting weights or supporting body weight. 3. Hematopoiesis

Red bone marrow produces red and white blood cells in a process known as hematopoiesis. Red bone marrow is found in the hollow space inside of bones known as the medullary cavity. Children tend to have more red bone marrow compared to their body size than adults do, due to their bodys constant growth and development. The amount of red bone marrow drops off at the end of puberty, replaced by yellow bone marrow. 4. Storage

The skeletal system stores many different types of essential substances to facilitate growth and repair of the body. The skeletal systems cell matrix acts as our calcium bank by storing and releasing calcium ions into the blood as needed. Proper levels of calcium ions in the blood are essential to the proper function of the nervous and muscular systems. Bone cells also release osteocalcin, a hormone that helps regulate blood sugar and fat deposition. The yellow bone marrow inside of our hollow long bones is used to store energy in the form of lipids. Finally, red bone marrow stores some iron in the form of the molecule ferritin and uses this iron to form hemoglobin in red blood cells. 5. Growth and Development Ossification is the process by which bone is formed. Some bones (e.g. the flat bones of the skull) are formed in one stage from the connective tissue. This process is known as intramembranous or direct ossification. Other bones (e.g. short bones) are formed from the cartilaginous model of the future bone developed in the embryo, being dissolved and replaced by bone cells. This process is known as endochondral or indirect ossification most bones are formed this way.

The skeleton begins to form early in fetal development as a flexible skeleton made of hyaline cartilage and dense irregular fibrous connective tissue. These tissues act as a soft,

growing framework and placeholder for the bony skeleton that will replace them. As development progresses, blood vessels begin to grow into the soft fetal skeleton, bringing stem cells and nutrients for bone growth. Osseous tissue slowly replaces the cartilage and fibrous tissue in a process called calcification. The calcified areas spread out from their blood vessels replacing the old tissues until they reach the border of another bony area. At birth, the skeleton of a newborn has more than 300 bones; as a person ages, these bones grow together and fuse into larger bones, leaving adults with only 206 bones. Flat bones follow the process of intramembranous ossification where the young bones grow from a primary ossification center in fibrous membranes and leave a small region of fibrous tissue in between each other. In the skull these soft spots are known as fontanels, and give the skull flexibility and room for the bones to grow. Bone slowly replaces the fontanels until the individual bones of the skull fuse together to form a rigid adult skull. Long bones follow the process of endochondral ossification where the diaphysis grows inside of cartilage from a primary ossification center until it forms most of the bone. The epiphyses then grow from secondary ossification centers on the ends of the bone. A small band of hyaline cartilage remains in between the bones as a growth plate. As we grow through childhood, the growth plates grow under the influence of growth and sex hormones, slowly separating the bones. At the same time the bones grow larger by growing back into the growth plates. This process continues until the end of puberty, when the growth plate stops growing and the bones fuse permanently into a single bone. The vast difference in height and limb length between birth and adulthood are mainly the result of endochondral ossification in the long bones.

The skeletal system in an adult body is made up of 206 individual bones. These bones are arranged into two major divisions: the axial skeleton and the appendicular skeleton. The axial skeleton runs along the bodys midline axis and is made up of 80 bones in the skull, hyoid, auditory ossicles, ribs, sternum, and the vertebral column. The appendicular skeleton is made up of 126 bones in the upper and lower limbs and the pelvic and pectoral (shoulder) girdles. Axial Skeleton 1. Skull

The skull is composed of 22 bones that are fused together except for the mandible. These 21 fused bones are separate in children to allow the skull and brain to grow,

but fuse to give added strength and protection as an adult. The mandible remains as a moveable jaw bone and forms the only movable joint in the skull with the temporal bone. The bones of the superior portion of the skull are known as the cranium and protect the brain from damage. The bones of the inferior and anterior portion of the skull are known as facial bones and support the eyes, nose, and mouth. 2. Hyoid and Auditory Ossicles

The hyoid is a small, U-shaped bone found just inferior to the mandible. The hyoid is the only bone in the body that does not form a joint with any other bone it is a floating bone. The hyoids function is to help hold the trachea open and to form a bony connection for the tongue muscles. The malleus, incus, and stapes - known collectively as the auditory ossicles - are the smallest bones in the body. Found in a small cavity inside of the temporal bone, they serve to transmit and amplify sound from the eardrum to the inner ear. 3. Vertebrae

26 vertebrae form the vertebral column of the human body. They are named by region cervical (neck), thoracic (chest), lumbar (lower back), sacrum, and coccyx (tail bone). There are seven cervical vertebrae, twelve thoracic, five lumbar, one sacrum, and one coccyx. With the exception of the singular sacrum and coccyx, each vertebra is named for the first letter of its region and its position along the superiorinferior axis. For example, the most superior thoracic vertebra is called T1 and the most inferior is called T12. 4. Ribs and Sternum

The sternum, or breastbone, is a thin, knife-shaped bone located along the midline of the anterior side of the thoracic region. The sternum connects to the ribs by thin bands of cartilage called the costal cartilage. There are 12 pairs of ribs that together with the sternum form the ribcage of the thoracic region. The first seven ribs are known as true ribs because they connect the thoracic vertebrae directly to the sternum through their own band of

costal cartilage. Ribs 8, 9, and 10 all connect to the sternum through cartilage that is connected to the cartilage of the seventh rib, so we consider these to be false ribs. Ribs 11 and 12 are also false ribs, but are also considered to be floating ribs because they do not have any cartilage attachment to the sternum at all. Appendicular Skeleton 1. Pectoral Girdle and Upper Limb

The pectoral girdle connects the upper limbs (arms) to the axial skeleton and consists of the left and right clavicles and left and right scapulae. The humerus is the bone of the upper arm. It forms the ball and socket joint of the shoulder with the scapula and forms the elbow joint with the lower arm bones. The radius and ulna are the two bones of the forearm. The ulna is on the medial side of the forearm and forms a hinge joint with the humerus at the elbow. The radius allows the forearm and hand to turn over at the wrist joint. The lower arm bones form the wrist joint with the carpals, a group of eight small bones that give added flexibility to the wrist. The carpals are connected to the five metacarpals that form the bones of the hand and connect to each of the fingers. Each finger has three bones known as phalanges, except for the thumb, which only has two phalanges. 2. Pelvic Girdle and Lower Limb

Formed by the left and right hip bones, the pelvic girdle connects the lower limbs (legs) to the axial skeleton. The femur is the largest bone in the body and the only bone of the thigh (femoral) region. The femur forms the ball and socket hip joint with the hip bone and forms the knee joint with the tibia and patella. Commonly called the kneecap, the patella is special because it is one of the few bones that are not present at birth. The patella forms in early childhood to support the knee for walking and crawling. The tibia and fibula are the bones of the lower leg. The tibia is much larger than the fibula and bears almost all of the bodys weight. The fibula is mainly a muscle attachment point and is used to help maintain balance. The tibia and fibula form the ankle joint with the talus, one of the seven tarsal bones in the foot.

The tarsals are a group of seven small bones that form the posterior end of the foot and heel. The tarsals form joints with the five long metatarsals of the foot. The each of the metatarsals forms a joint with one of the set of phalanges in the toes. Each toe has three phalanges, except for the big toe, which only has two phalanges. Types of Bone 1. Long Bone- consists of diaphysis, epiphysis and medullary cavity. 2. Short Bone- contains more spongy bone than compact; generally cube shape. 3. Flat Bone- thin and flat; has two thin layers of compact bone with spongy bone between them; red blood cells are manufactured here. 4. Irregular Bone- do not fall into proceeding categories, are not symmetrical. Structure of a long bone: 1. Diaphysis is the bones shaft or the body the long bone, cylindrical, main portion of the bone. 2. Epiphyses distal and proximal ends of the bone. 3. Metaphyses regions in mature bone where the diaphysis of the bone to grow in length. 4. Articular cartilage thin layer of the hyaline cartilage covering the epiphysis where the bone forms an articulation with the other bone. 5. Periosteum tough sheath surface wherever it is not covered by articular cartilage. 6. Medullary Cavity or marrow cavity is the space within the diaphysis that contains fatty yellow bone marrow in adults. 7. Endosteum thin membrane that lines the medullary cavity. It contains a single layer of bone-forming cells and a small amount of connective tissue. Anatomy of the Spine Functions of the Spine The three main functions of the spine are to:

Protect the spinal cord, nerve roots and several of the bodys internal organs. Provide structural support and balance to maintain an upright posture. Enable flexible motion.

Regions of the Spine

Typically, the spine is divided into four main regions: cervical, thoracic, lumbar and sacral. Each region has specific characteristics and functions. Cervical Spine The neck region of the spine is known as the Cervical Spine. This region consists of seven vertebrae, which are abbreviated C1 through C7 (top to bottom). These vertebrae protect the brain stem and the spinal cord, support the skull, and allow for a wide range of head movement. The first cervical vertebra (C1) is called the Atlas. The Atlas is ring-shaped and it supports the skull. C2 is called the Axis. It is circular in shape with a blunt peg-like structure (called the Odontoid Process or dens) that projects upward into the ring of the Atlas. Together, the Atlas and Axis enable the head to rotate and turn. The other cervical vertebrae (C3 through C7) are shaped like boxes with small spinous processes (finger-like projections) that extend from the back of the vertebrae. Thoracic Spine Beneath the last cervical vertebra are the 12 vertebrae of the Thoracic Spine. These are abbreviated T1 through T12 (top to bottom). T1 is the smallest and T12 is the largest thoracic vertebra. The thoracic vertebrae are larger than the cervical bones and have longer spinous processes. In addition to longer spinous processes, rib attachments add to the thoracic spines strength. These structures make the thoracic spine more stable than the cervical or lumbar regions. In addition, the rib cage and ligament systems limit the thoracic spines range of motion and protect many vital organs. Lumbar Spine The Lumbar Spine has 5 vertebrae abbreviated L1 through L5 (largest). The size and shape of each lumbar vertebra is designed to carry most of the bodys weight. Each structural element of a lumbar vertebra is bigger, wider and broader than similar components in the cervical and thoracic regions. The lumbar spine has more range of motion than the thoracic spine, but less than the cervical spine. The lumbar facet joints allow for significant flexion and extension movement but limit rotation. Sacral Spine The Sacrum is located behind the pelvis. Five bones (abbreviated S1 through S5) fused into a triangular shape, form the sacrum. The sacrum fits between the two hipbones connecting the spine to the pelvis. The last lumbar vertebra (L5) articulates (moves) with the sacrum.

Immediately below the sacrum are five additional bones, fused together to form the Coccyx (tailbone). The Pelvis and the Skull Although not typically viewed as part of the spine, the pelvis and the skull are anatomic structures that closely inter-relate with the spine, and have a significant impact on the patients balance. Spinal Curves When viewed from the front (Coronal Plane) the healthy spine is straight. (A sideways curve in the spine is known as scoliosis.) When viewed from the side (Sagittal Plane) the mature spine has four distinct curves. These curves are described as being either kyphotic or lordotic. A kyphotic curve is a convex curve in the spine (i.e. convexity towards the back of the spine). The curves in the thoracic and sacral spine are kyphotic. A lordotic curve is concave (i.e. concavity towards the back of the spine), and is found in the cervical and lumbar levels of the spine. Vertebral Structures All vertebrae consist of the same basic elements, with the exception of the first two cervical vertebrae. The outer shell of a vertebra is made of cortical bone. This type of bone is dense, solid and strong. Inside each vertebra is cancellous bone, which is weaker than cortical bone and consists of loosely knit structures that look somewhat like a honeycomb. Bone marrow, which forms red blood cells and some types of white blood cells, is found within the cavities of cancellous bone. Vertebrae consist of the following common elements: Veterbral Body The largest part of a vertebra. If looked at from above it generally has a somewhat oval shape. When looked at from the side, the vertebral body is shaped like an hourglass, being thicker at the ends and thinner in the middle. The body is covered with strong cortical bone, with cancellous bone within.

Pedicles These are two short processes, made of strong cortical bone, that protrude from the back of the vertebral body. Laminae Two relatively flat plates of bone that extend from the pedicles on either side and join in the midline. Processes There are three types of processes: articular, transverse and spinous. The processes serve as connection points for ligaments and tendons.

The 4 articular processes link with the articular processes of adjacent vertebrae to form the facet joints. The facet joints, combined with the intervertebral discs, allows for motion in the spine. The spinous process extends posteriorly from the point where the two laminae join, and acts as a lever to effect motion of the vertebra.

Endplates The top (superior) and bottom (inferior) of each vertebral body is coated with an endplate. Endplates are complex structures that blend into the intervertebral disc and help support the disc. Intervertebral Foramen The pedicles have a small notch on their upper surface and a deep notch on their bottom surface. When the vertebrae are stacked on top of each other the pedicle notches form an area called the intervertebral foramen. This area is of critical importance as the nerve roots exit from the spinal cord through this area to the rest of the body. Facet Joints The joints in the spinal column are located posterior to the vertebral body (on the backside). These joints help the spine to bend, twist, and extend in different directions. Although these joints enable movement, they also restrict excessive movement such as hyperextension and hyper-flexion (i.e. whiplash).

Each vertebra has two facet joints. The superior articular facet faces upward and works like a hinge with the inferior articular facet (below). Like other joints in the body, each facet joint is surrounded by a capsule of connective tissue and produces synovial fluid to nourish and lubricate the joint. The surfaces of the joint are coated with cartilage that helps each joint to move (articulate) smoothly. Intervertebral Discs Between each vertebral body is a "cushion" called an intervertebral disc. Each disc absorbs the stress and shock the body incurs during movement and prevents the vertebrae from grinding against one another. The intervertebral discs are the largest structures in the body without a vascular supply. Through osmosis, each disc absorbs needed nutrients. Each disc is made up of two parts: the annulus fibrosis and the nucleus pulposus.

Annulus Fibrosus The annulus is a sturdy tire-like structure that encases a gel-like center, the nucleus pulposus. The annulus enhances the spines rotational stability and helps to resist compressive stress. The annulus consists of water and layers of sturdy elastic collagen fibers. The fibers are oriented at different angles horizontally similar to the construction of a radial tire. Collagen gains its strength from strong fibrous bundles of protein that are linked together. Nucleus Pulposus The center portion of each intervertebral disc is a filled with a gel-like elastic substance. Together with the annulus fibrosus, the nucleus pulposus transmits stress and weight from vertebra to vertebra. Like the annulus fibrosus, the nucleus pulposus consists of water, collagen and proteoglycans. However, the proportion of these substances in the nucleus pulposus is different. The nucleus contains more water than the annulus. The Spinal Cord and Nerve Roots

The spinal cord is a slender cylindrical structure about the width of the little finger. The spinal cord begins immediately below the brain stem and extends to the first lumbar vertebra (L1). Thereafter, the cord blends with the conus medullaris that becomes the cauda equina, a group of nerves resembling the tail of a horse. The spinal nerve roots are responsible for stimulating movement and feeling. The nerve roots exit the spinal canal through the intervertebral foramen, small openings between each vertebra. The brain and the spinal cord make up the Central Nervous System(CNS). The nerve roots that exit the spinal cord/spinal canal branch out into the body to form the Peripheral Nervous System (PNS). Between the front and back portions of the vertebra (i.e. the mid-region) is the spinal canal that houses the spinal cord and theintervertebral foramen. The foramen are small openings formed between each vertebra. These holes provide space for the nerve roots to exit the spinal canal and to further branch out to form the peripheral nervous system. Brain Stem Connects the spinal cord to other parts of the brain.

Spinal Cord Carries nerve impulses between the brain and spinal nerves. Cervical Nerves (8 pairs) These nerves supply the head, neck, shoulders, arms, and hands. Thoracic Nerves (12 pairs) Connects portions of the upper abdomen and muscles in the back and chest areas. Lumbar Nerves (5 pairs) Feeds the lower back and legs. Sacral Nerves (5 pairs) Supplies the buttocks, legs, feet, anal and genital areas of the body. Dermatomes Areas on the skin surface supplied by nerve fibers from one spinal root. Ligaments, Muscles and Tendons Ligaments Ligaments and tendons are fibrous bands of connective tissue that attach to bone. Ligaments connect two or more bones together and also help to stabilize joints. Tendons attach muscle to bone. They vary in size and are somewhat elastic. The system of ligaments in the vertebral column, combined with the tendons and muscles, provides a natural type of brace to help protect the spine from injury. Ligaments keep a joint stable during rest and movement. Further, ligaments help to prevent injury from hyper- extension and flexion movements. Anterior Longitudinal Ligament (ALL) Primary spine stabilizer. About one inch wide, the ALL runs the entire length of the spine from the base of the skull to the sacrum. It connects the front (anterior) of the vertebral body to the front of the annulus fibrosis. Posterior Longitudinal Ligament (PLL) Primary spine stabilizer. About one inch wide, the PLL runs the entire length of the spine from the base of the skull to sacrum. It connects the back (posterior) of the vertebral body to the back of the annulus fibrosis. Supraspinous Ligament

This ligament attaches the tip of each spinous process to the other. Interspinous Ligament This thin ligament attaches to another ligament, called the ligamentum flavum, that runs deep into the spinal column. Ligamentum Flavum The strongest ligament. This yellow ligament is the strongest one. It runs from the base of the skull to the pelvis, in front of and between the lamina, and protects the spinal cord and nerves. The ligamentum flavum also runs in front of the facet joint capsules. Muscles and Tendons The muscular system of the spine is complex, with several different muscles playing important roles. The primary function of the muscles is to support and stabilize the spine. Specific muscles are associated with movement of parts of the anatomy. For example, the Sternocleidomastoid muscle assists with movement of the head, while the Psoas Major muscle is associated with flexion of the thigh. Muscles, either individually or in groups, are supported by fascia. Fascia is strong connective tissue. The tendon that attaches muscle to bone is part of the fascia. The muscles in the vertebral column serve to flex, rotate, or extend the spine. Readings A fracture is a break in the bone or cartilage. It usually is a result of trauma. It can however, be a result of disease of the bone that leads to weakening, such as osteoporosis, or abnormal formation of the bone from congenital diseases at birth, such as osteogenesis imperfecta. Fractures are classified according to their character and location. Examples of classification includes: spiral fracture of the femur," "greenstick fracture of the radius," "impacted fracture of the humerus," "linear fracture of the ulna," "oblique fracture of the metatarsal," "compression fracture of the vertebrae," and "depressed fracture of the skull."

Fractures are named according to their severity, the shape of position of the fracture line. Among the common kind of fractures are the following: BROAD OR GENERAL CLASSIFICATION: Open (compound) Fracture the broken ends of the bone protrude through the skin. Conversely, a closed (simple) fracture does not break the skin. Closed- skin is intact but the bone is broken. Greenstick fracture (Incomplete Fracture) a partial fracture in which one side of the bone is broken and the other side bends: occurs only in children, whose bones are not yet fully ossified and contain more organic material than inorganic material. Complete- if the break completely disrupts the continuity of tissue across the entire with of the bone. Complicated- bone fracture has penetrated on internal structure. ACCORDING TO APPEARANCE: Impacted fracture one end of the fracture bone is forcefully driven into the interior of the other. Simple- bone is broken into two fragments only. Comminuted fracture the bone splinters at the site of impact, and smaller bone fragments lie between the two main fragments. Depressed- the fragments are driven inward. Compressed- bone collapses under excessive fracture.

ACCORDING TO DIRECTION OF THE FRACTURE LINE Transverse- break is straight across the bone Linear- break is along the shaft Oblique- break is diagonal Spiral- break encircles

SPECIAL TYPES OF FRACTURE Potts fracture a fracture of the distal end of the lateral leg bone, with serious Smiths fracture- reverse of Colles fracture. Monteggias facture- fracture of the proximal 3rd of ulna, associated with radial head dislocation. Bennettes fracture- fracture of the base of the thumb, associated with dislocation of metacarpal joint of thumb. Pilon fracture- fracture of the ankle. Cotton fracture- fracture of the malleolus of distal tibia. Galleazzis fracture- fracture of the distal 3rd of radius with associated radiu-ulnar dislocation. Malgaignes fracture- double fracture of the pelvic ring causing instability in the pelvis. Hangmans fracture- fracture of the posterior element of the cervical vertebra with the dislocation of C1 and C2. Neer fracture- fracture of the shoulders and humerus in which the bones are broken into 3 or more fragments.

Pathologic Fracture A pathologic fracture occurs when a bone breaks in an area that is weakened by another disease process. Causes of weakened bone include tumors, infection, and certain inherited bone disorders. There are dozens of diseases and conditions that can lead to a pathologic fracture. Cause The two primary abnormalities that produce pathological fractures include weakness of the bones and destruction of the bones. Weakness comes from altered metabolism of calcium, vitamin D and parathyroid hormone. Destruction of the bone comes from tumors and infections. Due to the majority of the weight being supported by the front of the spine, these fractures often collapse the vertebral column producing a kyphotic deformity. Risk factors

Individuals at increased risk for pathological fractures of the vertebrae include those with underlying infection, metabolic bone disease, or cancerous lesions that may weaken bone. Elderly individuals are at greater risk for pathological vertebral fractures than younger individuals because of the increase in chronic disease, metabolic disease, and age-related bone degeneration in this population. Osteoporosis is a major contributor to pathological fracture, especially in postmenopausal women with osteoporosis. Risk factors for osteoporosis include being female, elderly, or white; having an estrogen deficiency; and smoking. Manifestations Pain and swelling are the hallmarks of fractures. If a bone can no longer mechanically support the muscles which are attached to it, the function of that portion of the body may be limited. The vertebral bodies are common sites for pathological fractures to occur. Here, deformity of the spine may develop. Loss of height is seen. If the damaged bones impact the nervous system, they can lead to weakness, numbness and paralysis. When the vertebral bodies collapse, the spine may become deformed and angled forward. This produces a condition referred to as kyphosis. The deformity causes increased stress on the already damaged spine that can further increase the degree of kyphosis. A gibbus, or prominence of the spine, may be felt where the kyphosis occurs. Treatment Treatment is determined primarily by the underlying bone pathology. Osteoporotic fractures generally heal normally with conservative treatment to reduce pain. If deformity is significant, bone cement (polymethyl methacrylate) may be injected into the bone to stabilize the fracture (vertebroplasty), or the deformity may first be reduced, after which bone cement is injected to stabilize the fracture (kyphoplasty). Supplemental medical treatment to prevent fractures (e.g., exogenous calcium, hormone therapy, an appropriate exercise regimen) may be recommended for individuals with osteoporosis. In elderly patients with osteoporotic disease and age-related degeneration of bone, early mobilization is recommended after pathologic fracture to reduce associated morbidity and mortality (Reiter). In general, pathologic fractures secondary to infection or tumor will not begin to heal until the individual receives treatment for the infection or tumor. Most fracture pain responds to medication. Some type of orthotic (brace or corset) may be recommended for comfort. Ice (or heat), whirlpool treatments, if available, and gentle massage may also be recommended. Surgical treatment of pathologic vertebral fracture is rare. STAGES OF BONE HEALING

1. Formation of fracture hematoma Because of the fracture, blood vessels crossing the fracture line are broken. This include vessels in the periosteum, haversian system, medullary cavity, and perforating canals. As blood leaks from the torn ends of the vessels, it forms a clot around the site of the fracture. This clot is called fracture hematoma, usually forms around 6-8 hours after the injury. Because the circulation of blood stops at the site where the fracture hematoma forms, nearby bone cells die. Swelling and inflammation occur in response to dead bone cells. Producing additional cellular debris. Blood capillaries grow into the blood clot, and phagocytes and osteoclasts begin to remove the dead or damaged tissue in and around the fracture hematoma. This stage may last up to several weeks. 2. Fibrocartilaginous callus formation The infiltration of new blood capillaries into the fracture hematoma helps organize it into an actively growing connective tissue called a procallus. Next, fibroblast from the periosteum and osteogenic cells from the periosteum, endosteum, and red bone marrow invade the procallus. The fibroblast produce collagen fibers, which helps connect the broken ends of the bone. Phagocytes continue to remove cellular debris. Osteogenic cells develop into condroblasts in areas of avascular healthy bone tissue and begin to produce fibrocartilage. Eventually, the procallus is transformed into a fibrocartilaginous callus, a mass of repair tissue that bridges the broken ends of the bone. Formation of the cartilaginous callus takes about 3 weeks. 3. Bony callus formation In areas to well-vascularized healthy bone tissue, osteogenic cells develop into an osteoblasts, which begin to produce spongy bone trabeculae. The trabeculae join living and dead portions of the original bone fragments. In time, the fibrocartilage is converted to spongy bone, and the callus is then referred to bony callus. The bony callus lasts about 3-4 months. 4. Bone remodeling The final phase of bone repair is bone remodeling of the callus. Dead portions of the original fragments of broken bone are gradually resorbed by osteoclasts. Compact bone replaces spongy bone around the periphery of the fracture. Sometimes, the repair process is so thorough that the fracture line is undetectable even in a radiograph. Often, a thickened area on the surface of he bone remains as an evidence of a healed fracture, and a healed bone is eventually stronger that it was before the break.

Diagnostic Procedures

X-ray - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. Magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body. Computed tomography scan (Also called a CT or CAT scan.) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

Treatments 1. Reduction- putting the bone back to its proper alignment. a. Open- involves insertion of screws, pins, rods, wires, nails and plates to keep the bones in its position as it heals. b. Closed-it involved manipulation of the fragments by manual traction, pressure or rotation to lock the ends of fragments together to restore normal bone alignment. 2. Traction- refers to a set of mechanisms for straightening broken bones or relieving pressure on the spine and skeletal system. Purposes: 1. 2. 3. 4. 5. 6. For immobilization. For support. To reduce fracture. To lessen pain and muscle spasm. To prevent and correct deformity. To maintain good body alignment.

Principles of Traction: 1. 2. 3. 4. 5. The patient must be in supine position. There must be a continuous traction. There must be a counter traction. The line of pull must be in line with the line of deformity. Friction must be avoided.

Methods of applying traction: 1. Manual- applied to the body by the hand by the operator using a firm, steady pull. 2. Mechanical- applied to either skin or bones with the use of ropes pulleys or weights. a. Skin traction- either skin adhesive( this is applied to the skin using adhesive tapes, elastic bandages and spreader) or non- adhesive( applied to the body using devices like canvas, laces, buckles, or leather straps.) b. Skeletal Traction- applied to the bones using pines, wires or tongs. 3. Immobilization- to hold bone fragments in contact with each other until healing takes place. Methods by which immobilization can be achieved: 1. Splinting 2. External fixator 3. casting