Orthopaedic treatments should attempt to optimize the

cells, scaffold, molecules, and blood supply required for healing

Components of Fracture Healing

Fracture healing is a complex and dynamic process. One
of the unique characteristics of bone repair is that the bone
heals with new tissue that is indistinguishable from its
preinjured state. Further, bone repair occurs in the vast majority
of cases, with most fractures, treated in a myriad of ways,
progressing to union. However, delayed union and nonunion remain clinically
significant issues, with nearly 10% of fractures
having some degree of impaired healing.

In order to best understand the healing response, surgeons should

understand the basic components of cellular and molecular
repair. These components can be categorized as cells and tissues,
scaffold, blood supply, and molecules and their receptors (summarized in Table 4-
1).
Cells and Tissues Involved
in Fracture Healing
Progenitor Cells
(Periosteum and Endosteum)
Bone surfaces are covered by tissue layers called the periosteum (outer layer) and
the endosteum (inner layer), both of which are distinct fibrous layers rich in cells
and blood vessels. It has been recognized for nearly a century that
the periosteum responds to fracture through extensive cellular
proliferation.
The resulting pluripotent cells differentiate into either osteoblasts or chondrocytes,
depending on inflammatory signals and the local mechanical and vascular
environment, with increased mechanical stability favoring osteogenic
differentiation.
It has been shown that the periosteum provides a supply of osteoblasts, and is the
primary