MIDTERM: REHAB102- MSK
Rapid healing in hand compared to the
PART I:
BONE PHYSIOLOGY AND REPAIR
- “Bone is a living tissue, goes in the process
of bone turnover”
- 10 years to replace the skeletal components
- Rigid connective tissue; has a tensile
strength of a cast iron but 3x lighter and 10x
more flexible and elastic
- extra cellular rigidity (calcium
hydroxyapatite), flexibility (collagen fibers)
Function of Bones:
1. Mineral homeostasis
- (storage of for calcium, phosphorous,
sodium, magnesium)
2. House the hematopoietic (blood-forming)
elements
3. Mechanical Support
4.Determines the attributes of size and
shape
Components:
 Cellular elements (2%)
 Matrix (98%)
 ORGANIC MATRIX
(collagen)
 INORGANIC MATRIX
(calcium hydroxyapatite)
Cellular Elements:
 OSTEOBLAST
- Bone-forming cells
- Very active during growth or bone
repair
 OSTEOCYTES
- Semi-retired or inactive bone cells
- Bone-maintaining cells. Makes up
90% of all cellular elements in bone
 OSTEOCLASTS
- Opposite of osteoblast
- Breaks down bone (bone remodeling, or
when the body needs extra calcium)
MATRIX:
ORGANIC COMPONENTS (40%)
 Collagen (Type I)
 Proteoglycans
 Noncollagenous matrix protein
INORGANIC COMPONENTS (60%)
 Calcium hydroxyapatite
 Osteocalcium phosphate
CIRCULATION
- Receives 5% to 10% of total cardiac output
- Major determinant of fracture healing
Palmerola, Duke P. BSPT III GOODMAN CLUSTER A
(e.g.
distal ankle d/t inc blood supply in the hand)
(eg. Same as pt who smoke, since smoke
constricts and impedes blood supply)
- Major sources:
 Nutrient artery system
 Metaphyseal-epiphyseal system
 Periosteal system
*Periosteum
- soft tissue that surrounds the bone
- rich in blood supply
- contains osteoblasts
BONE TYPES
1. Lamellar Bone/ Mature, Normal Bone
 Cortical/ Compact Bone (80%)
- Strong bone
- Slow turnover rate (slower
healing)
- High elasticity
- Higher resistance to torsion et
bending
 Cancellous/ Trabecular/
Spongy Bone (20%)
- Not as strong
- Good for shock absorption
- Higher cells; higher turnover rate
(rapid healing)
2. Woven Bone/ Immature, may be
pathologic bone
BONE CLASSIFICATION BY SHAPE:
a) Long bone (most common)
b) Short bone
c) Flat bone (skull, sternum, pelvis)
d) Irregular bone
e) Sesamoid bone (unsual, embedded
in a tendon, improves biomechanics
through improving lever arm, biggest
patella (makes quads mm group fnx better
as a knee extensor.
*Long bone
- 2 parts; diaphysis et metaphysis
- Diaphysis (body or shaft); abundant in
Coritcal bones
- Metaphysis (distally or proximally then
widens up) (transition zone); Combination of
Cortical and Cancellous bone
- Epiphysis end part; abundant in Cancellous
bone
TISSUE SURROUNDING THE BONE:
1) BONE MARROW
- Source of progenitor cells
 Red marrow - creates the RBC
  Yellow marrow - fat and
inactive cells
2) PERIOSTEUM
- Connective tissue membrane that covers the
bone
 More thicker et highly
developed in children
 Contains cells that are capable
of becoming osteoblasts (to
form bone)
BONE FORMATION
Types of Bone Formation:
1. Endochondral Bone Formation/
Mineralization
2. Intramembranous Ossification
Palmerola, Duke P. BSPT III GOODMAN CLUSTER A
PART 2:
FRACTURE REPAIR OR HEALING
- “In any living tissue, once it’s injured,
body automatically repairs it, same for all
soft tissues”
STAGES OF FRACTURE HEALING
I. INFLAMMATION/
INFLAMMATORY PHASE
- Not always bad, first stage of healing
- 10% of time
- Inflammatory phase, presence of
(Hematoma; which carries protein that
will enhance healing)
- *Periosteum (important source of
Ostroprogenetor cells; cells for healing)
II. REPAIR/ REPARATIVE PHASE
- 40 % of time
 Primary callus forms within 2
weeks:
- Bridging (soft) callus (little collagen
and calcium hydroxic apatite, soft or
geline phase)
- Woven (hard) callus (hardens due to
calcium deposition)
- Medullary callus
 Amount of callus formation
varies with the method of treatment.
III. HEALING/ REMODELING PHASE
- 70% of time
- Begins during the middle of Repair
phase and continues long after the
fracture has healed
- Remodeling allows the bone to
assume its normal configuration and
shape based on its stresses (Wolff’s
Law).
*Osteoclasts starts to remove the
callus, then the bone follows the
pressure applied to it; once the bone
is fixed the body tries to remodel the
bone so that it can adopt to different
stresses
PART 3:
FAILURE IN FRACTURE HEALING
 Delayed Union
- The bone did not heal in the
normal amount of time
 Malunion
- Complete fracture healing but
the alignment is not optimal
 Non-union
- No union; failure of bone
healing
- has 2 types:
HYPERTROPHIC AND ATROPHIC
- Hypertrophic nonunion: Bone
 itself has an ability to heal, but - Disorders in parathyroid hormone
because of gross motion, it did not  Nicotine
unite. (+) Callus - Very common
- Atrophic nonunion: Impaired bone - Always ask the pt, check for second and
healing (seen in areas like distal tibia, third-hand smoke
smoking pt’s due to constriction) or
infection that limits healing. (-) Callus TISSUE VARIABLE
1. Bone type
VARIABLES IN BONE HEALING: 2. Bone necrosis
1. Injury Variables 3. Bone disease
2. Patient Variables 4. Infection
3. Tissue Variables
4. Treatment Variables  BONE TYPE
- What heals better, Cortical bone or
 Injury Variables Cancellous bone ? *Cancellous Bone
-”How severe the injury was ?”
- “Where is the injury ?”  BONE NECROSIS
 Patient Variables - Part of the bone dies
- “Does pt has diabetes ?” - In severe injuries: Bone are hit and
- co-morbidity factors shattered on impact, stripped blood
- (+) smoker supply then dies.
 Tissue Variables  Bone Disease
- The tissue itself - Vit D deficiency or rickets
 Treatment Variables - Osteogenesis imperfecta
- Tx done to the pt  Infection
- very common
INJURY VARIABLES: - often associated with atrophic nonunion
1. Open fractures
2. Severity of injury TISSUE VARIABLE
3. Intra-articular fractures 1. Apposition of fracture fragments
4. Segmental fractures 2. Loading and Micromotion
5. Soft-tissue interposition 3. Fracture stabilization
6. Damage to blood supply
 Loading and Micromotion
 Open fractures - “Micromotion a little bit of motion
- Complicated soft injury since it is open measured via micrometers, very very little
to the environment; high rate of infection motions in the fracture is actually good”
 Severity of injury - “Loading a little bit of stress on the
- Serious injury: Periostium layer is stripped fracture is also good”
off, severe lost of blood supply which will - Excessive load plus macromotion, the
result to poor healing. healing process will result not in bone
 Intra-articular fractures formation but fibrous tissue formation that
- Fx within joint can lead to pseudogout joint.
- Poor healing due to the synovial fluid that  Fracture Stabilization
prevents hematoma formation - Important to stabilize the fracture and
limit macromotion
PATIENT VARABLES - External Fixator or Antenna is used to
1. Age immobilize the fracture until bone heals
2. Nutrition
3. Systemic Hormones METHODS OF PROMOTING
4. Nicotine FRACTURE HEALING:
 Good fixation/ immobilization
 Age  Bone grafting
- Chances for recovery; young>old  Bone transport
 Nutrition  Electrical Fields (Galvanic Currents)
- Well nourished to supply healing  Ultrasound
 Systemic Hormones

Palmerola, Duke P. BSPT III GOODMAN CLUSTER A

 Good fixation/ immobilization
- Stable but not too stable to restrict
micromotion
- Fracture ends must be compressed:
load
 Bone grafting
- getting a piece of bone from own body or
a cadaver
 Bone transport
 Electrical Fields
- Galvanic current: DC currents, put near
the fracture to stimulate healing
 Ultrasound
- US creates vibration

Palmerola, Duke P. BSPT III GOODMAN CLUSTER A