Secondary healing occurs in fractures treated with stress sharing devices such as casts, Kirschner wires (K wires), intramedullary

rods, and external fixation devices. These devices align the bone fragments but do not compress the fracture gap, therefore allowing for some degree of motion. Secondary healing is te most common type of bone healing. Secondary healing involves not only the response of the bone itself but also of the periosteum and the soft tissue around the fracture site. The response from the periosteum is thought to be critical to callus formation and is enhanced by slight motion and inhibited by rigid fixation. Secondary healing is rapid and can bridge a gap as large as half of the diameter of the fractured bone. Fractures are considered clinically healed when the bone is stable and pain free. Roentgenographic/radiological healing has occurred when trabecular or cortical bone crosses the fracture site as evidenced by x-ray. Panjabi et al found by comparing radiographic evaluation of fracture healing to failure strength of healing osteotomies that the best radiological indicator of clinical healing was cortical continuity and the poorest indicator was the callus area. In general, radiographic information alone is not sufficient to accurately assess the biomechanical strength of a healing fracture. Stages of fracture healing.. fracture healing generally occurs in three stages. Inflammatory, repair and remodeling, although some authors break these into six stages. These stages may overlap and events that begin in one stage may continue into the following stage. The length of each stage varies with the location and severity of the fracture and associated injuries and other local and systemic factors. The inflammatory stage of fracture healing typically lasts 1-2 weeks. When a bone is injured, both the bone and its blood supply are disrupted. Disruption of the blood vessels in and around the bone leads to formation of a hematoma at the injury site. The organization of this hematoma is the first step of fracture repair. The hematoma causes various molecules and cells to initiate the healing process. Such molecules, including cytokines, interleukins and various growth factors, regulate the early stages of healing, including proliferation and differentiation. Open fractures, or those treated surgically may not have hematoma at the fracture site and may therefore heal more slowly. Soon after the hematoma forms, inflammatory cells, including neutrophils, acrophages, and phagocytes, invade the area. Along with osteoclasts, these cells remove the damaged and necrotic tissue near the distal adges of the fractures and lay the groundwork for the repair stage to begin. Radiographically, the fracture line becomes more visible as the necrotic material is removed, which is why some hairline fractures are not evident on x-ray until days after the initial injury. The repair stage usually begins within 2 weeks of the fracture and lasts several months. It is characterized by the differentiation of mesenchymal stem cells into cell types necessary for tissue restoration, including osteoblasts, osteoclasts, chondroblasts, fibroblasts and angioblasts. The fracture site is invaded by chondrocytes and fibroblasts, which lay down a matrix for the callus composed of collagen, glycosaminoglycan (GAG), and proteoglycans. Initially, soft callus composed mainly of fibrous tissue and cartilage with small amount of bone is formed. Osteoblasts then mineralize this soft callus, converting it to a hard callus and increasing the stability of the fracture. However, this immature bone is still weaker than normal bone, particularly in response to torque, and therefore must be protected.

although not rotational. giving it the ability to withstand the usual stresses placed on it. Over time. making the fracture site more stable. which can take months or years to complete. the medullary canal inside the bone reforms and angular. osteoblasts and osteoclasts replace the immature. whereas a midshaft femur fracture may require 6 months. Infection around a fracture not only compromises healing but may also lead to chronic infection of the bone known as osteomyelitis. Slow healing is known as delayed union and failure to heal is known as nonunion. Open fractures also tend to heal more slowly than closed fractures because of the amount of soft tissue damage and bone loss. During the remodeling stage. For example. For example. the overall density of the bones in the involved limb may be decreased for years. organized laminar bone. Radiographically. Prognosis for fracture healing. The location and stability of the fracture can also affect how much callus forms. During this stage. generally result from errors in this phase of healing. deformities may correct. a distal radial fracture is expected to heal within 6-8 weeks. By the end of remodeling. The ultimate goal of this stage is to restore the bone to its original strength and structure. This repair stage ends when the fracture is clinically stable. When a fracture fails to heal. Intraarticular fractures may also heal slowly because they can require surgical intervention to assure good joint alignment. Nonunion is generally defined as failing to heal after 6-8 months. A fibrous union formed . Some fractures heal more slowly than expected or fail to heal at all. In contrast. the fracture line is no longer visible radiographically and the bone at the fracture site should have the same stiffness as normal bone. the fracture line begins to disappear during this stage. disaphyseal fractures tend to form a large callus because they are not impacted and have a larger fracture gap and more periosteum.Delayed union or nonunion. areas of bone that sustain little stress are reabsorbed by osteoclasts. while more bone is laid down by osteoblasts in areas with high stress. there is a typical rate at which fractures heal and some predictable variability based on the location and nature of the fracture and the type of fixation. subsequent application of an excessive load to the whole bone generally does not cause a fracture at the original fracture site but rather above or below the fracture site. as well as fractures displacement and increased infection risk. Mechanical loading of the fracture site is needed to facilitate strong callus formation. The false joint or pseudoarthrosis may or may not be painful but will always be unstable. poorly organized bone with mature. Addititonally despite successful fracture healing. metaphyseal fractures tend to heal with little callus formation because there is little surrounding periosteum and because the interdigitation and impaction of the fracture keeps the site stable and limits the fracture gap. Fractures caused by high speed or high force impacts often heal slowly because there is more soft tissue and vascular damage in the area of the fracture and more fracture comminution. Because a fully healedfracture is often stronger than the surrounding bone. Although the length of time for fracture healing varies. fracture alignment and ultimately lamellar remodeling. cartilage or fibrocartilage forms over the fracture surfaces and the cavity between the fracture surfaces fills with fluid that resembles normal joint or bursal fluid. as described later in this chapter.

Nutrition also influences fracture repair as the energy required for the body to heal a fracture is substantial. those exposed to nicotine also healed more slowly and had a higher percentage of nonunions. including infections. Jensen et al found a 42% incidence of clinical or subclinical malnutrition in patients undergoing orthopedic procedures. nonsteroidal anti-inflammatory drugs (NSAIDs) and other medications. this union does not restore normal strength. long term steroid use. it has been shown that fracture callus strength is reduced in patients with protein deficiencies. proteoglycans and other matrix constituents.nicotine has also been shown to inhibit vascularization of bone grafts in rabbits although the exact mechanism remains unclear. NSAIDs are also thought to slow fracture healing. Fractures that would heal rapidly in wellnourished patients may fail to heal in patients with severe malnutrition. Therefore it is important that patients eat balanced diet to optimize their healing potential. Cigarette smoking interferes with osteoblasts activity. Corticosteroids can delay fracture healing and increase the risk for fractures. both of which can reduce blood flow to the fracture site. suggesting that administration of fluoroquinolones during the early stages of fracture repair may also compromise fracture healing in humans. Human who smoke have been found to have more complication with fracture healing. Clinical observation parallel these studies. Delayed healing is thought to be due to decreased synthesis of organic bone matrix components and slowed differentiation of osteoblasts from mesenchymal cells. smoking. In animal studies. Specifically. Diabetes is thought to impair fracture healing by causing a defect in collagen or collagen cross linking. Randomized controlled trials (RCTs) have shown that animals given these drugs after a fracture have fractures with less mature callus formation and decreased torsional strength and stiffness. especially early in the course of fracture repair. and poor nutrition. To synthesize large volumes of collagen. less likely than nonsmokers to achieve union. A doses dependent relationship was found between that particular NSAID and nonunion rates. It has been reported that a single long bone fracture can temporarily increase metabolic requirements by 20% to 25% and that multiple injuries or infections can increase this requirements by as much as dense cartilage or fibrocartilage band may also be an end result and although it will stabilize the fracture site and may be painless. and slower healing rates than their nonsmoking counterparts. Current smoker were twice as likely to develop osteomyelitis but were at no greater for developing other types of infection. . have also been shown to delay fracture healing. amputations and nonunions or malunions. specifically fluoroquinolones such as ciprofloxacin and levofloxacin. it is important that the clinician and the patient take into consideration that smoking may delay fracture healing and increase the risk of complications and thus contribute to a poorer functional outcome. With over 50 million smokers in the United States. Common risk factors for delayed fracture healing include diabetes mellitus. respectively. Nicotine can also impair healing by causing vasoconstriction and inhibiting angiogenesis. The evidence for this is from a variety of animal studies and one retrospective series using high doses of intramuscular ketorolac after spinal fusion in human subjects. Certain antibiotics. Castillo and colleagues evaluated healing in patients with traumatic unilateral open tibial fractures and found that current and previous smoker were 37% and 32%. cells need a steady supply of the components of these molecules specifically proteins and carbohydrates.

The amount of soft tissue damage also affects the rate of fracture healing. For some fractures. bone healing will be delayed. The presence of infection can also slow or prevent fracture healing. as well as the soft tissues.8 months for delayed closure.A patient s age can also influence the rate of fracture healing. Infection may cause necrosis of normal tissue. Therefore if the soft tissue envelope is damaged. For example. ischemic bone will not revascularization until the surrounding soft tissue envelope does so. as well as edema and thrombosis of blood vessels. comminution. The extrinsic blood supply of bone comes mainly from the muscles. or a large initial displacement. that surround it. a non displaced closed femoral fracture in a 3 year old child may be effectively managed with a cast with restoration of tissue structure and function in 6 weeks. Experimentally. Studies have shown that muscle damage slow bone healing. If the fracture site loses its intrinsic vascularity as result of periosteal stripping from surgery or injury. whereas a 70 year old patient may require surgery and may take up to 6 months for an outcome that is much less predictable. The average healing time 6 months for primary closure and 12. Infants have the most rapid rate of fracture healing and the rate of fracture healing declines with age. Fracture healing in adults and the elderly follows the same sequence but in the elderly it is often slower and less effective. Godina also found that delayed closure time increased total healing time. the extrinsic blood supply becomes imperative for fracture healing. . Most studies show that the incidence nonunion is higher with open fractures than with close fractures. age related changes and significant enough to alter the treatment patterns. The time for a bone to heal is greatly prolonged in fractures that have more soft tissue stripping or damage.