BONE (FRACTURE)

HEALING

BONE
Two forms of bone tissue
Cortical or compact bone
Cancellous or trabecular bone
Two types of bone
(mechanical & biological properties)
Woven or immature bone
Lamellar or mature bone

WOVEN BONE
More rapid rate of deposition & resorption
Irregular woven pattern of matrix collagen fibril
Four times the number of osteocyte per unit volume
Irregular pattern of matrix mineralization

Less stiff & more easily deformed

Bone Healing
Direct
Primary bone healing
Cutting cones
Seen with absolute stability
Indirect
Secondary bone healing
Callus formation; resorption at fx site;
Seen with relative stability

Direct Bone Healing

Absolute Stability
Compression of two anatomically
reduced fracture fragments.
No displacement of the fracture under
functional load.
Examples:
Lag screw
Plate => compression, buttress,

Tension band

Indirect Bone Healing

Relative Stability
Motion between fracture fragments that is
compatible with fracture healing.
Motion is below the critical strain level of
tissue repair.
Examples:
IM nails
Bridge plate
External Fixator

Direct Bone Healing

Gap healing
Haversian remodeling
Osteoclast resorb fracture line

deposition osteoblast

Blood vessels formation

The new bone matrix +

osteocytes

New Haversian
Systems or primary
osteons

after rigid fracture

fixation. Contact
healing occurs in the
cortex underlying the
plate, by direct
Haversian remodeling.
Layers of bone are
first laid down
perpendicular to the
long axis of the bone,
and are then replaced
by longitudinally
oriented osteons by
cutting cones
progressing across the
gap.

Indirect stages

Indirect Bone Healing

Indirect Stages:
1. Inflammation
1-7 days
2. Soft callus
3 weeks
3. Hard callus
3 4 months
4. Remodeling
months => years

Repair

Indirect bone healing

1.

Inflammation
Begins

w/ fx and ends w/ fibrous tissue or

cartilage formation.
Hematoma is formed, becomes organized,
granulation tissue formation.
.

Indirect Bone Healing

1. Inflammation
Fracture
damages the bone, blood vessels,
bone matrix and surrounding soft tissue

Haematoma
Inflammatory
mediators

Release by
platelets inj.cells

Dilatation blood ves

Plasma exudat
inflammatory cells
PMN lecocytes
Macrophages
Lymphocytes

Indirect Bone Healing

1. Inflammation
Macrophage
Degranulating
platelets release

- Cytokines (PDGF, TGF )

- Interleukin 1 & 6
- Prostaglandin E2 (PGE2)

Invitiation of the repair process

Indirect Bone Healing

1. INFLAMMATION
Inflammatory

Necrosis Tissue and Exudate Resorbed

Fibroplasty & Chondrocytes Appears

Produce new matrix

(The fracture callus)

Indirect bone healing

2. Soft callus
Begins in 3 to 4 days with the appearance of
granulation tissue, matures into fibrous tissue
and firbrocartilage, stabilizes site w/ internal
and externalcallus, pain and inflammation
end.

Indirect bone healing

3. Hard callus
Mineralization and conversion to bone.
Endochondral ossification of fibrocartilage
forming cancellous bone.

Indirect Bone Healing:

Callus

Indirect Bone Healing

4. Remodeling
Begins in middle of repair phase, continues
until fx clinically healed
Osteoclastic tunneling (cutting cones) in
concert with osteoblast deposition
Can continue up to 7 years
Remodeling based on stresses (Wolffs law)

Remodeling

Hueter-Volkmann law

in the skeletally immature, bone growth is

relatively inhibited in areas of increase
pressure and relatively stimulated in areas
of decreased pressure or tension

Wolffs law

the remodeling of bone or soft tissue is

influenced and modulated by mechanical
stress

Rough estimation fracture

healing time
Bone
Time
Clavicle
Scapula
Rib
weeks
Humerus
weeks
Radius & ulna
Metacarpal
weeks

Healing
3-8 weeks
6 weeks
4 to 5
4-10
6 weeks
3 to 4

Rough estimation fracture

healing time
Bone Broken
Healing Time
Femur
Patella
weeks
Tibia,fibula
weeks
Metatarsal
weeks
Toe
weeks

12 weeks
4-6
10-24
5 to 6
2 to 4

FACTORS IN BONE HEALING

Patient Variables
* Age
* Nutrition
Healing process needs
- Energy
- Proteins & carbohydrates

FACTORS IN BONE HEALING

Patient variables
* Systemic hormones
-

Corticosteroid ( )
Growth hormone
Thyroid hormone
Calcitonin
Insulin
Anabolic steroids
DM
Rickets

Rate fracture healing

Frame healing

* Nicotine
- Inhibit fracture healing ( Vascularization?)

FACTORS IN BONE HEALING

Tissue Variables
* Cancellous or cortical bones
* Bone necrosis
* Bone disease
Pathologic fracture

* Infection

Osteoprosis
Osteomalacia
Primary malignant bone tumors
Metastatic bone tumors
Benign bone tumors
Bone cysts
Osteogenesis imperfecta
Pagets disease
Fibrous dysplacia
Hyperparathyroidism

FACTORS IN BONE HEALING

Treatment Variables

Apposition of fracture fragments

Loading & micromotion
Loading a fracture site stimulates bone formatio
Micromotion promotes fracture healing

FACTORS BONE HEALING

Treatment Variables

Fracture stabilization
-

Traction
Cast Imm
Ext.Fixation
Int.Fixation

Facilitate fracture healing by

Preventing repeated disruption of
Repair tissue

Potential disadvantage of int.fixation :

Surgical exposure
blood supply
Risk of infection
Rigid fixation
bone density

disrupted hematoma,
alter fracture remodeling,

FACTORS IN BONE HEALING

Treatment Variabel
Bone Grafts
Cancellous graft
Quick to revascularize
Creeping substitution

Cortical graft

Slow remodelling process which weakens then

re-strengthens

Synthetic graft
Calcium phosphate, silicon, aluminum
Mainly osteoconductive

Complications
Delayed healing.
Non healing.
Joint involvement - ankylosis
Abnormal position arthritis.
Bone necrosis nutrient artery
Involucrum formation.
Pseudoarthrosis

THE END