PROBLEMS OF

FRACTURE REPAIR

G. Volpin, A.Gorsky
Dept Orthop. Surgery, Nahariya Hospital
ISRAEL
Fracture repair

Repair
R i off a ffractured
t d bone
b b
by fformation
ti off new bone
b th
through
h
proliferation of periosteal and endosteal cells
 Fracture repair
Bone heals more rapidly than cartilage because its blood supply is more
plentiful and there is rapid activation and turnover of bone cell types
FRACTURE REPAIR -
PROBLEMS

Repair of a fracture is
a progressive process:
Inflammation

Repair ( callus)

Remodeling
g
FRACTURE REPAIR - PROBLEMS

Repair of a fracture is a progressive

process ( X-RAY
X RAY ):
)
Fracture
Union

Consolidation

Bone remodeling ( up to 7 years)

UNION
It may b
be clinically
li i ll complete
l t bbutt
on X-ray -still incomplete repair.

X-ray show the fracture line still

clearly visible,
visible with fluffy callus
around it. Repair is therefore still
incomplete

It is not safe to subject

j the
unprotected bone to stress.
CO SO
CONSOLIDATION
O
This is a condition with
p
complete clinical and X-ray
y repair;
p ;
the calcified callus is ossified.

X-ray show the fracture line to be

almost obliterated and crossed by
bone trabeculae, with well- defined
callus around it.

Further protection is unnecessary.

REMODELLING

Continuous process of alternating

b
bone resorption
ti and
d fformation
ti

The medullar cavity is reformed.

Eventually, and especially in children,

the bone reassumes something like
its normal shape.
 FRACTURE REPAIR -
PROBLEMS
• Sometimes the normal process of
fracture repair is disturbed and the
bone fails to unite.

• 5% of 2 millions fractures
that occur p
per y
year become
nonunion (100 000 per year )

Heppenstall R.B.:
Fracture treatment and Healing.
Philadelphia, WB Saunders, 1986
Fracture repair-
problems
Fracture
Healing
y
Delayed Union

Nonunion

UNION Pseudoarthrosis

5% ( Heppenstal R.B. )
DELAYED UNION

If the normal time of

fracture repair is unduly
prolonged,
l d the
th term
t
“delayed union” is used.
DELAYED UNION
O
Time of union
union-
Perkin’s timetable
Spiral fracture in the upper limp –
for union 3 weeks,
for consolidation multiply by 2
( 3 X 2= 6 weeks )

For
o transverse
t a s e se fracture
actu e multiply
utpy
again by 2 ( 3 x 2x 2= 12 weeks)
Time of union
union-
Perkins’ timetable
A spiral fracture of lower limb –
6 weeks.

Transverse fracture multiple

again by 2 ( 6 x 2= 12 weeks )
Ti
Time off union
i
A more sophisticated formula is as
follows:

Spiral
S i l fracture
f t in
i th
the upper limb
li b takes
t k
6-8 weeks to consolidate;
th lower
the l li
limb
b needs
d twice
t i as llong
(12-16 weeks ).

Add 25% if the fracture is not spiral or

if it involves the femur.
DELAYED UNION

DELAYED UNION?

?
NONUNION?
NONUNION

1. A minimum of 9 months has

elapsed since injury and
the fracture shows no
visible progressive sign of
healing for 3 months –

FDA panel 1986

 NONUNION

2. Sclerosis develops around

the bone ends and medullar
canal.
canal
3. The bone ends are joined
3
by fibrous tissue- formation
of pseudoarthrosis.
 NONUNION

4. Failure to show any

progressive
i radiographic
di hi
appearance for at least
3 months after the period of time
when fracture union would be
h
have occurredd
 NONUNION Classification
NONUNION- Cl ifi ti

NONUNION

STRONTIUM 85 uptake
p

RICH Blood Supply POOR

Hypervascular
yp Avascular
NON UNION
NONUNION-
NONUNION
Hypervascular type

Elephant foot
“Elephant foot” Horse hoof
“Horse hoof” Oligotrophic
 NONUNION
Hypervascular or hypertrophic:

Are rich in callus and have rich blood

supply
pp y in the end of bones.

They result from insecure fixation or

premature
t weight
i ht bearing
b i i a reduced
in d d
fracture.

Failed enchondral ossification & type II

collagen predominates.
predominates
 NONUNION

Oligotrophic (Hypotrophic):

Callus is absent.

They typically occur after major

displacement of fracture, distraction
of fragment.
fragment
 NONUNION-
NONUNION
avascular type

Torsion
wedge Comminuted Defect Atrophic
NONUNION
Avascular or atrophic:
Ends of the fragments have become
osteoporotic
t ti andd atrophic.
t hi

The nonunion is inert and incapable of

biologic reaction. There is poor blood
supply to the ends of the fragments.

These are typically seen in tibial fracture

ttreated
eated by plate
p ate & sc
screws.
e s

These are usually final result when

i t
intermediate
di t fragments
f t are missing
i i .
 NONUNION

Comminuted nonunions:

There are characterized by the presence

of one or more intermediate fragments.

Typically these nonunions result in the

b
breakage
k off any plate
l t used
d ffor
stabilization
NONUNION

Defect nonunion:
These are characterized by the loss of
a fragment of the diaphysis.
The ends of the fragments are viable,
but there
t e e is
s no
o union
u o acacross
oss the
t e
defect. The ends of fragments
atrophic.
Occurs after open fracture,
sequestration in osteomyelitis and
resection
ti off b
bone.
C
Causes off nonunion
i

1. The injury:

a. Soft tissue loss

a
b. Bone loss
c. Intact adjacent bone
( forearm or leg )
d. Soft tissue interposition
C
Causes off nonunion
i

2. The bone:

a.
a Poor blood supply
b. Poor hematoma
c. Infection
d
d. Pathological lesion
C
Causes off nonunion
i

3. The surgeon:

a.
a Distraction
b. Poor splintage
c. Poor fixation
d
d. Impatience
C
Causes off nonunion
i

4. The patient:

a.
a Age
b. Poor medical condition
c. Smoking
d
d. Drugs ( Steroids
Steroids, NSAID
NSAID,
Ciprofloxacilin …)
 C
Causes off nonunion
i

Biological Factor Mechanical

Age Soft tissue
Nutritional level Stability
Vascular injury Location
Hormones Bone loss
Smoking Distraction
Medical condition
Nerve function
NSAID
Infection
C
Causes off nonunion
i

FACTOR

GENERAL LOCAL
C
CAUSES
S SOOF NONUNION
O O

General factor ( most important):

Diabetus mellitus ( collagen formation

i j
injured
d )).

Smoking ( depression of osteoblastic

function & vasoconstriction ).

Nutrition ( level of albumin &

transferin ).
 C
CAUSES
S SOOF NONUNION
O O
Local Factors:
• Position of fragments
g ( distraction )
• Status of soft tissue, bone
• Vascular status
• Fixation of fracture ( inadequate )

• Open fracture
• Infection
Biochemistry of fracture
healing
Step Collagen type
Mesenchymal I, II(III,V)
Chondroid II IX
II,
Chondroid-osteoid I,, II,, X
Osteogenic I
 G
Growth
th factors
f t off b
bone

1. Bone morphogenic protein

2. Transforming Growth Factor-
Beta
3. Insulin-Like Growth factor II
4. Platelet- Derived Growth
Factor
G
Growth
th factors
f t off b
bone

1. Bone Morphogenic Protein- BMP

Osteoinductive; induced
metaplasia of mesenchymal
cells
ll iinto
t osteoblast-
t bl t
BMP stimulates bone formation
G
Growth
th factors
f t off b
bone
2. Transforming Growth Factor- Beta
( TGF-b):
TGF b)

Regulates cartilage and bone

formation in fracture callus.

Also induced osteoblast to

synthesize collagen.
G
Growth
th factors
f t off b
bone

3. Insulin- Like Growth factor II

( IGF-II ):

Stimulates type I collagen,

cellular proliferation,
proliferation cartilage
matrix synthesis, and bone
f
formation.
ti
G
Growth
th factors
f t off b
bone

4. Platelet- Derived Growth Factor

( PDGF ):

Released from platelet, attract

inflamatory cells to the fracture
site (chemotaxic ).
Endocrine Effect on Fracture
Healing

Hormone Effect Mechanism

Cortisone
- Decreased
callus
proliferation
Calcitonin +? Unknown

TH/PTH + Bone
remodeling
Growth + Increase of
hormone callus volume
P i i l
Principles off ttreatment
t t

Fracture
healing malunion

Delayed Union

Nonunion

UNION Pseudoarthrosis
Principles of treatment
Prophylactic:

• Treatment
eat e t of
o general
ge e a factors
acto s
• Treatment of medical condition
• Stable fixation of fracture
• Minimal invasive fixation
• Treatment of soft tissue injury
• Aseptic & atraumatic surgery
• Time of immobilization
Delayed Union
Treatment

Is the signal
g to continue treatment of
the fracture until consolidation is
complete.
p

If union is delayed for more than 6

months and is no sign of callus
formation internal fixation and bone
formation,
grafting are indicated.
Dynamization
Dynamization
N
Nonunion-
i t
treatment
t t

Old patient & symptomless

nonunion in non
non- weight bearing
limp-
Treatment???
No treatment???
Nonunion-
Nonunion
Conservative treatment
• Functional bracing( hypertrophic )
• Electrical and electromagnetic
stimulation stimulation
• Low- intensity
y ultrasound

• Weight bearing
• Injection of Bone Morphogenic protein
in nonunion
Nonunion-
Nonunion
operative treatment
Hypervascular or hyperthrophic:

• Rigid fixation of the fragments.

• If angulatory deformity is not
present, these nonunions do not
have to be opened.
• Compression - distraction
osteogenesis by Ilizarov E.F.
 Nonunion
Nonunion-
operative
p treatment

Oligotrophic :

• Stable fixation
• Bone grafting for healing ( ? )
Nonunion
Nonunion-
operative
p treatment
Avascular or atrophic:
Open decortication ; Bone grafting
Stable fixation
Resection
esect o of
o nonunion
o u o & bone bo e
transport for filling of the large
defect
Prosthesis replacement
NONUNION TRATMENT
NONUNION-
NONUNION
NONUNION- TRATMENT
 BONE GRAFTS

•Bone cells within the graft may survive

the transplantation procedure and
synthesize new bone.

•This
This can only occur in case of fresh
autograft
BONE GRAFTING-
GRAFTING types
t

1. Autograft: Cancellous
Cortical

2 Allograft:
2. Fresh
Fresh- frozen

3. Demineralized bone matrix

4 Bone marrow
4.
5. Ceramics
BONE GRAFTING

1. Osteoinduction

2 Osteoconduction
2.

3. Osteogenic cells

4. Structural integrity
g y
 BONE GRAFTING

1 Osteoinduction:
1. O t i d ti Ability of a graft to
induce stem cells & osteoprogenitor cells to
differentiate to osteoblasts.
osteoblasts It may occur with
Auto & Allografts. Mediated by polypeptides as
BMP. Inactive
Inactive- by radiation
radiation+ autoclaing

2. Osteoconduction: Support attachment of

new osteoblasts &osteoprogenitor cells and
form of new blood vessels
The partially or completely replacing of
the graft by the host is named
INCORPORATION
BONE GRAFTING
GRAFTING-
Stages of graft healing
STAGES ACTIVITY

1 inflammation Chemotaxis stimulated

by necrotic debris
2 Osteoblast From precursor
differentiation
3 Osteoinduction Osteoblast/osteoclas
t function
4 O t
Osteoconduction
d ti N
New bone
b fforming
i
over scaffold
5 R
Remodeling
d li Process continues for
years
BONE GRAFTS SUBSTITUTES
BONE GRAFTS SUBSTITUTES

Allografts
Allogro- deminerelized bone matrix (DBM)

Dyanagraft- DBM & polymer

Ceramic based:
Osteoset - Calcium sulfates tab (left)
Aloomatrix Calcium sulfates tab + DBM (right)
Aloomatrix-

Hydroxyapetite based:
Proosteon- hydroxyapetite in either a particulate
Or a block, form by chenically treated sea corals.
NONUNION-
NONUNION
TREATMENT
3 Y.O. CHILD WITH NONUNION OF TIBIA
2,5
2 5 MONTHS LATER
NON UNION
NON UNION
NON UNION
NONUNION-
NONUNION
TREATMENT
NONUNION-
NONUNION
TREATMENT
NONUNION-
O O TREATMENT
NONUNION-
O O TREATMENT
MALUNION

When the fragments

f join in an
y position,
unsatisfactory p , such as:
unacceptable angulation, rotation
or shortening,
shortening the fracture is then
considered as MALUNITED.
MALUNION

FRACTURE

UNION in unsatisfactory position

MALUNION
MALUNION

CAUSES:

• Failure of proper & adequate

reducion
d i off fracture
f t ffragmentt
• Gradual collapse
p of comminuted or
osteoporotic bone
• Fail
Failure
re to maintain reduction
red ction during
d ring
healing process
MALUNION

Long- term effect:

• Mayy cause asymmetrical

y loading
g of
the joints above or below,

• Followed by gradual development of

secondary osteoarthritis.
osteoarthritis
MALUNION

Classification:

1. Shortening ( with overlap )

2 Angulation
2. A l ti
3. Rotation deformity
MAL UNION
MALUNION shortening
MALUNION- h t i
MALUNION-
angulation
 MALUNION treatment
MALUNION- t t t
Prophylactic:

Most important

Fractures should be reduced

as near to
anatomical alignment
as possible.
 MALUNION treatment
MALUNION- t t t

Long bones

• Angulation of more than 15

degrees or marked rotation
d f
deformity,
it may needd correction
ti
by remanipulation, or by
osteotomy and internal fixation
MALUNION treatment
MALUNION- t t t

In the lower limb

• shortening of more than 2.5

2 5 cm
is not acceptable and a limb
correction
ti procedure
d may b be
indicated.
MALUNION treatment
MALUNION- t t t

In children:

• Angular deformities near the

bone ends will usually remodel
with
ith time:
ti

• Rotational deformities will not.

REMODELING PROCESS
Thank You for Your Attention