Fracture Healing

Dr Himanshu Gaur
MBBS,MS(Orthopaedics)
Consultant Orthopaedic,Joint Replacement & Arthroscopy
(Sports Injury) Surgeon
BCIMS,New Delhi
Fortis C Doc,Chirag Enclave,New Delhi
HCL Healthcare, Noida
Visiting Consultant- Fortis Noida
Fellowships
Knee Arthroplasty, Arthroscopy & Sports Medicine, Seoul, South
Korea
Shoulder & Elbow Arthroplasty, Arthroscopy and Sports Medicine,
Seoul, South Korea
Spine Surgery- ISIC, New Delhi
 Normal anatomy of Bone

Cross section:
 Periosteum
 Cortex -Cortical bone
 Medullary canal-
Cancellous/spongy bone
 Bone Composition
 Cells- Osteocytes,Osteoblasts,Osteoclasts
 Extracellular Matrix

Organic (35%)
Collagen (type I) 90%
Osteocalcin, osteonectin, proteoglycans,
glycosaminoglycans
 Inorganic (65%)-Primarily hydroxyapatite
 Types of Bone
Lamellar Bone-Collagen fibers arranged in
parallel layers in normal adult bone.Cortical bone-
Comprised of osteons (Haversian
systems).Osteons communicate with medullary
cavity by Volkmann’s canals
Woven Bone (Non-Lamellar)-Randomly
oriented collagen fibers. Weaker than lamellar
bone
Normally remodeled to lamellar bone
Seen at sites of fracture healing/ pathological
conditions
Fracture- Break in the structural continuity of
bone
Local signs of fracture

 – Deformity
 – Swelling

 – Bruising

 – Loss of function
 Causes of Fracture
 Trauma
 Stress Fracture

 Pathological fracture- Fracture occur with

minimal trauma/underlying bone is abnormal
 Osteoporosis
 Osteomalacia
 Paget's disease of bone
 Primary /Metastatic tumor
 Types of Fracture
Closed/Simple
Fracture- Does not
communicate with
external environment

Open/compound
Fracture - Communicate
with external environment
 Prerequisites for bone Healing

 Adequate blood supply

 Adequate mechanical stability

 Blood Supply
Fracture stimulates the release of growth
factors that promote angiogenesis and
vasodilation.
 Periosteal vessels

 Nutrient artery /Intramedullary

 Metaphyseal artery
 Adequate mechanical Stability
 Early stability promotes revascularization

 Inadequate stabilization may result in

excessive deformation at the fracture site
interrupting tissue differentiation to soft callus.
 Stages of Fracture healing

1. Haematoma formation
2. Inflammation
3. Consolidation-Soft Callus/Hard
Callus
4. Remodelling
 Mechanisms for Bone Healing

 Primary/Direct bone healing

 Secondary/Indirect bone healing

 Primary/Direct Bone Healing
 This bone healing seen when no motion at the
fracture site (i.e. absolute stability).No
Callus.Osteoblasts originate from endothelial
and perivascular cell
 Contact Healing- Direct contact between the
fracture ends allows healing to be with lamellar bone
immediately
 Gap Healing- Gaps less than 200-500 microns are
primarily filled with woven bone that is subsequently
remodelled into lamellar bone
Cont..Primay/Direct bone
healing
 Secondary/Indirect Bone
Healing
 Mechanism for healing in fractures that have
some motion, but not enough to disrupt the
healing process.
 Bridging periosteal (soft) callus and medullary
(hard) callus re-establish structural continuity
 Callus subsequently undergoes endochondral
ossification
Cont..Secondary/Indirect bone
healing
Stages of Fracture Healing
 Stages of Fracture healing

Stage 1-Hematoma Formation

 Hematoma forms in medullary canal and
surrounding soft tissue in first 24-48 hours
 Stages of Fracture healing
Cont..Stage 2 - Inflammation
 Growth factors -Osteoinductive growth factors
stimulate the proliferation and differentiation of
mesenchymal stem cells .The mesenchymal cells at
the fracture site proliferate, differentiate, and produce
the fracture callus consisting of fibrous tissue,
cartilage, and woven bone
 Stages of Fracture healing
Cont..Stage 2 - Inflammation
Growth factors
 Bone Morphogenic Protein(BMP)
 Insulin-like growth factor (IGF-1)
 Transforming growth factor (TGF) -Promotes
proliferation and differentiation of mesenchymal
precursors for osteoblasts, osteoclasts and
chondrocytes
 Vascular endothelial growth factor (VEGF)
 Fibroblast growth factor (FGF)
 Stages of Fracture healing

Cont..Stage 2 - Inflammation
Mesenchymal cells Osteoblasts
 Fibroblasts, osteoprogenitor cells produce
granulation tissue around fracture ends
 Osteoblasts proliferate
 By 1st-2nd week, abundant cartilage over
fracture site ie Soft Callus ready for
calcification.
 Stages of Fracture healing
Stage3 Consolidation
Soft Callus -Between 2 and 3 weeks after the injury new
bone begins to form. The new bone cannot be seen on x-
rays. This stage usually lasts until 4 to 8 weeks after the
injury. Chondrocytes secrete collagen and proteoglycans.
Fibrocartilage-SOFT CALLUS

 Increased instability results in increased callus size

 Tissues bridge fracture and decrease interfragmentary
strain
 Stages of Fracture healing

Hard Callus/Woven Bone -Between 4 and 8

weeks, the new bone begins to bridge the fracture.
Soft callus turns to hard callus by-
Intramembranous ossification- bone from fibrous
tissue
Endochondral ossification- bone from cartilage
This bony bridge can be seen on X-rays. By 8 to 12
weeks after the injury, new bone has filled the
fracture.
Intramembranous ossification/
Endochondral ossification

Intramembranous
ossification
 Stages of Fracture healing

Stage4 Bone Remodelling

 Woven bone is gradually converted to

lamellar bone
 Medullary cavity is reconstituted

 Bone is restructured in response to stress

and strain (Wolff’s Law)
 Stages of Fracture healing
Stage4 cont..Bone Remodelling
 8 to 12 weeks after the injury, the fracture site
remodels itself, correcting any deformities that
may remain as a result of the injury. This final
stage of fracture healing can last up to several
years.
The rate of healing and the ability to remodel a
fractured bone vary tremendously for each person
and depend on age, health, the kind of fracture,
and the bone involved. For example, children are
able to heal and remodel their fractures much
faster than adults.
 Healing of fractures
 Factors disrupting healing process:

 Displaced and comminuted fractures

 Infection

 Vascularinsufficiency
 Inadequate minerals and vitamins

 Inadequate immobilization
 Complications of Fracture
Early Complications
 Pain
 Infection
 Compartment Syndrome
 Stiffness
 Neurovascular injuries
Late Complications
Infection ,Delayed Union ,Malunion ,
Non Union, Post Traumatic Arthritis
 Complications of Fracture
Compartment syndrome:
 Severe swelling after a fracture can put so much
pressure on the blood vessels that not enough
blood can get to the muscles around the
fracture.
 The decreased blood supply can cause the
muscles around the fracture to die, which can
lead to long-term disability.
 Compartment syndrome usually occurs only
after a severe injury.
 Complications of Fracture

 Delayed union: A fracture that

takes longer to heal than expected

 Nonunion: A fracture that fails to

heal in a reasonable amount of time
 Complications of Fracture
 Causes of Delayed Union/Non-
union
 Stability of Fracture site-Inadequate
stability/Improper implant/Inadequate
apposition of fracture site
 Infection
General
 Nutrition
 Bone Disease
 Old Age
 Complications of Fracture
Malunion- A fracture that does
not heal in a normal alignment
 Complications of Fracture
 Growth abnormalities: A fracture in the
open physis, or growth plate, in a child, can
cause many problems.
Premature partial or complete closure of the
physis- One side of a bone or the whole
bone stops growing.
Thank
you