HEALING OF

A FRACTURES

HEALING OF A FRACTURE IN CORTICAL BONE ( DIAPHYSEAL BONE ; TUBULAR BONE )

The tiny blood vessels coursing through the canaliculi in the haversian system

are torn across at the fracture site

Normal clotts in tiny vessels Local internal bleeding

Intact anastomosing vessels within bone

Lose blood suply - Ring of avascular - Dead bone -- living bone through the process simultaneously of bone resorption and new bone deposition

 Osteoclasts line the spearhead of the cutting

cone for bone resorption Osteoblasts line the rear of the cutting cone for bone formation Resorption and formation occur simultaneously at 50-80 um/ day

 The AO teaching concerning fracture healing divided into :

1. Inflammatory 2. Soft Callus 3. Hard Callus 4. Remodelling

 Hematoma formation Torn blood vessels hemorrhage A mass of clotted blood (hematoma) forms at the fracture site Site becomes swollen, painful, and inflamed
1
Hematoma formation

Hematoma

Figure 6.14.1

 Fibrocartilaginous

callus forms Granulation tissue (soft callus) forms a few days after Internal callus the fracture (fibrous tissue and cartilage) Capillaries grow into the tissue and phagocytic cells begin cleaning debris

External callus

New blood vessels

Spongy bone trabeculae

2 Fibrocartilaginous callus formation

Figure 6.14.2

 The fracture callus, initially soft and almost fluid inconsistency, becomes progressively firmer like a slowly setting glue, and the

fracture site becomesstickier and less mobile.

Stages of clinical union

Forming a biological glue that gradually from temporary external and internal callus.
When fracture callus becomes sufficiently

firm that movement no longer occurs at the fracture site, the fracture is said to be clinically united ( clinical union) , but it no means been restored to its original strength

 Bony callus formation

New bone trabeculae

Bony callus of spongy bone

appear in the fibrocartilaginous callus Fibrocartilaginous callus converts into a bony (hard) callus Bone callus begins 3-4 weeks after injury, and continues until firm union is formed 2-3 months later

3 Bony callus formation

Figure 6.14.3

Stages of consolidation ( Radiographic Union )

Many months after fracture , when all the immature bone and cartilage of the temporary callus have been replaced by

mature lamellar bone, the fracture is said to be consolidated by sound bony union ( radiological union) Once bony union has been established , the now redundant mass of callus is gradually resorbed , and the bone eventually returns to almost its normal diameter

 Bone remodeling
Excess material on the

bone shaft exterior and in the medullary canal is removed Compact bone is laid down to reconstruct shaft walls

Healing fracture

4 Bone remodeling

Figure 6.14.4

Remodelling
Wolffs Law - Bone formed in response to mechanical load - Dynamization / staged destabilization

increased load can lead to increased bone formation - Lamellar bone and marrow cavity form Will reduce callus size Size and location can impede function Requires months to years.

Clinical union

Radiological union

Healing of A Fracture in Cortical Bone with Rigid Internal Fixation

The metallic device, such as a rigid plate,

remains in place, the bone underlying the plate continuous to be stress protected, because the normal stresses bypass the bone through the plate. During the ensuing few months, the healed bone must be protected from excessive stress until it regains its normal strength.

Healing of a Fracture in Cancellous Bone

Principally through the formation of an internal or endosteal callus, although the external or periosteal callus surrounding the

thin shell of cortex does play an important role, particularly in children. Union of the fragments proceeds more rapidly than in dense cortical bone.

Healing of A Fracture in Articular Cartilage

A fracture through articular cartilage either heals by fibrous scar tissue or fails to heal at all. If the fracture surfaces of the cartilage are

perfectly reduced, the thin scar leads to local degenerative arthritis It had healed by cartilage in only 20% of the intermittent active motion , compared to 80% of the CPM group

The factors to estimate healing time

Age of the patient
Site and configuration of the fracture Initial displacement of the fracture Blood Supply to the fragments