Bone Healing

Group J10, J11, J12

AUCMS-USU

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 OUTLINES
PHYSIOLOGICAL MECHANISM OF
BONE HEALING
DELAYED UNION
NONUNION
MALUNION

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BONE HEALING

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 Hematoma Formation (1st)
~ 4 days (acute inflammation)
Hematoma forms in medullary canal and
surrounding soft tissue in first 48-72 hours

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 Hematoma Form. continues
Dead bone and tissue
= inflammatory
reaction including
vasodilation, plasma
exudate, and
inflammatory cells

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 Cellular Formation Phase(2nd)
Periosteum:
- Fibrous layer fibroblast- collagen fiber
production
- Cambium layer pyogenic cells
chondroblast cartilage
. Fibrocartilaginous callus (soft callus)
collagen fibers + cartilage bridging the
broken ends.
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Cellular form. continued

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Stage of callus (3rd):
Osteoblast production of spongy bone trabeculae.
Fibrocartiliginous callus converted into spongy
bone (woven bone).

Stage of consolidation (4th ):

Woven bone is replaced by lamellar bone
Osteoclast gradually resorbed death bone cell

Stage of remodelling (5th)

Bone is strengthened
The shapening of cortices occurs at the endosteal
and periosteal surfaces
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 Healing of cancellous bone
The bone is of uniform spongy texture and
has no medullary cavity
So, there is a large area of contact
between the trabeculae
Union can occur directly between the bony
surfaces without having callus formation

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Factors affecting fracture healing :
Age
Sex
Type of bone
Pattern of fracture
Reduction
Immobilisation
Smoking

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 THE TIME FACTOR
Repair of a fracture is a continuous process and
there are no specific events signifying a
moment of union or consolidation

The ultimate test is the bones ability to

withstand the stresses placed upon it.

Union:
- Incomplete repair, the bone moves as one but
clinically is still a little tender and attempted
angulation is painful. The fracture is clearly visible
on X-Ray with fluffy callus 11
Testing for fracture union:
- Absence of pain during daily activity
- Absence of tenderness at the fracture site
- Absence of pain on stressing the fracture
(a gentle bending movement)
- Absence of mobility at the fracture site
- Xray signs of callus formation, then bone
bridging across the fracture, and finally
trabeculation across the old fracture site.

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Radiographic Determinants of Healing
(consolidation):
-restoration of cortical continuity (look for
healing on 4 cortices - AP and lateral views);
- loss of distinct fracture line;
- presence of callus

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- Consolidation: Incomplete repair, but the
calcified callus is ossified and attempted
angulation is painless. Further protection
is unnecessary
- Remodelling : complete repair

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Perkins timetable
For normal fracture healing:
A spiral fracture in the upper limb unites in
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double it for consolidation
double it again for the lower limb
double it again for a transverse fracture

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 Delayed union:
A fracture that has not united in what is
considered a reasonable amount of time
for a fracture of that type in that location.
Causes:
- Inadequate blood supply
- Infection (and in any open fracture)
- Insufficient splintage

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Nonunion

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 Nonunion
FDA defined nonunion as established
when a minimum of 9 months has elapsed
since fracture with no visible progressive
signs of healing for 3 months

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 Etiology of Nonunion
Host factors
Fracture/Injury factors
Initial treatment of injury factors
Complicating factor = Infection

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 TYPES
Hypertrophic non union
- the bone has good surrounding biological
support and ability to form new bone but
the fracture site has too much motion.
Atrophic non union
- Bone formation peters out altogether and
what one sees on xray are the tapered
ends of the fracture fragments with no sign
of attempted bridging.
- End of fragments become osteoporotic or
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atrophic due to poor blood supply
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Atrophic non union

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 Symptoms
Pain at the site of fracture
Tenderness
Swelling
Deformity
Abnormal movement; false joint
Instability

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 Diagnosis
History:
- Hx of a fracture treated/not treated
- Signs and symptoms
- Difficulty in bearing weight if lower limb
involvement
Test: In clinical d(x) of nonunion, examiner
elicits pain and/or motion at old fracture site
by exerting varus/valgus or anteroposterior
stress

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 Imaging:
- Plain x-rays -malunion or nonunion
- CT scan Fracture in difficult site- vertebral
column, acetabulum
- MRI
- Bone scan may help further define the
condition.

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 TREATMENT

Non surgical treatment:

Bone stimulator is the most common.
The device delivers ultrasonic or pulsed
electromagnetic waves that stimulate
healing.

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Patient places the stimulator on the skin over the non union
from 20 minutes to several hours daily. It must be used
daily to be effective.

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Surgical treatment
Indicated when non surgical method fails.
May also need second surgery if the first
surgery failed.
Bone graft

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Malunion

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 Malunion
Definition: Fragments join in an unsatisfactory position
( unacceptable angulation, rotation or shortening)
As one of the late complications of fracture
Causes:
Failure to reduce a fracture adequately
Failure to hold reduction while healing
proceeds
Gradual collapse of comminuted or
osteoporotic bone

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 Malunion

Clinical features:
Deformity usually obvious , but sometimes the
true extent of malunion is apparent only on x-ray
Rotational deformity can be missed in the femur,
tibia, humerus or forearm unless is compared
with its opposite fellow

X-ray are essential to check the position of the fracture while uniting
during the first 3 weeks so it can be easily corrected . CT scan, MRI, or
bone scan may help further define the condition.

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 Deformity of 5th metacarpal
5th Metacarpal shaft Oblique radiograph of the
malunion also becomes
malunion with dorsal hand shows dorsal
prominent when the fingers
angulation angulation
are flexed

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Examination of the patient's hand
with the fingers flexed may clearly
reveal a rotational deformity.

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 Treatment:

In adults
Fracture should be reduced as near to the anatomical
position as possible
Angulation more than 10- 15 degrees in long bone or
apparent rotational deformity may need correction by
re-manipulation or by osteotomy and internal
fixation

In children
Angular deformity near the bone ends often remodel
with time
Rotational deformity will not recovery with time

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 Treatment

In lower limb shortening

Shortening less than 2 cm: compensated by
shoe raise

Shortening more than 2 cm: limb length

equalization procedures

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 Prognosis
Treatment of malunion by ORIF usually has a
good outcome.
Osteotomy can reduce deformity and relieve
functional impairment
Minor degrees of malunion are common and
may not have a significant effect on function or
appearance.

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 Complications
Functional impairment with limited mobility.
Any malunion can put increased stress on other
joints causing pain and/or accelerated wear.
Nerve damage especially with an elbow fracture.
Malunion in a leg can produce abnormal gait.

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 References
American College of Occupational and Environmental
Medicine 2010
Apleys System Of Orthopaedics and Fractures 9th
Edition 2010
Apleys Concise System Of Orthopaedics and Fractures
3rd Edition 2005
Palaniappan Lakshmanan, Medscape 2012
Rockwood & Greens Fractures in Adults 6th Edition
2006

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Thank You..

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