Fracture healing

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Fracture healing

  1. 1. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings FRACTURE HEALING MALUNION NONUNION
  2. 2. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings STAGES IN FRACTURE HEALING
  3. 3. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings • Hematoma formation – Torn blood vessels hemorrhage – A mass of clotted blood (hematoma) forms at the fracture site – Site becomes swollen, painful, and inflamed Hematoma
  4. 4. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings • Fibrocartilagino us callus forms • Granulation tissue (soft callus) forms a few days after the fracture • Capillaries grow into the tissue and phagocytic cells begin cleaning debris Figure 6.14.2 2 Fibrocartilaginous callus formation External callus New blood vessels Spongy bone trabeculae Internal callus (fibrous tissue and cartilage)
  5. 5. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings • The fibrocartilaginous callus forms when: – Osteoblasts and fibroblasts migrate to the fracture and begin reconstructing the bone – Fibroblasts secrete collagen fibers that connect broken bone ends – Osteoblasts begin forming spongy bone – Osteoblasts furthest from capillaries secrete an externally bulging cartilaginous matrix that later calcifies
  6. 6. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings • Bony callus formation – New bone trabeculae 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 Figure 6.14.3 3 Bony callus formation Bony callus of spongy bone
  7. 7. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings • 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 Figure 6.14.4 4 Bone remodeling Healing fracture
  8. 8. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings
  9. 9. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings PATHOLOGY • REPAIR BEGINS WITH INFLAMMATION • WHICH RESULTS IN CHEMOTAXIS AND INFLAMMATORY CELLS LIKE POLYMORPHS,LYMPHOCYTES AND MACROPHAGES MIGRATE TO THE FRACTURE SITE • WHICH STIMULATE POLYPEPTIDE GROWTH FACTORS (TGF,PDGF)
  10. 10. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings • POLYPEPTIDE GROWTH FACTORS ACTS ON TARGET CELLS AND FACILITATES DNA SYNTHESIS AND CAUSES • CELL DIVISION AND PROLIFERATION • ANGIOGENESIS • COLLAGEN SYNTHESIS HEALING • STIMULATION OF STEM CELLS – OSTEOBLAST FORMATION
  11. 11. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings VARIABLES THAT INFLUENCE FRACTURE HEALING • INJURY VARIABLES • PATIENT VARIABLES • TISSUE VARIABLES
  12. 12. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings INJURY VARIABLES a) OPEN FRACTURES – soft tissue disruption,# displacement,significant bone loss delays # healing and can also result in infection & chronic osteomyelitis b) SEVERITY OF INJURY c) INTRA ARTICULAR FRACTURE : healing delays due to instability and prolonged immobilisation can result in joint stiffness also
  13. 13. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings a) SEGMENTAL FRACTURE – disrupts intramedullary blood supply to middle fragment b) SOFT TISSUE INTERPOSITION – compromises # healing c) DAMAGE TO BLOOD SUPPLY – causes significant delay in # healing. eg: femoral head,scaphoid,talus,distal tibia
  14. 14. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings PATIENT VARIABLES • AGE – infants,rapid rate of # healing • NUTRITION – cell migration,proliferation and matrix synthesis needs substantial energy. Malnutrition can also result in infection,wound dehiscence,impaired healing and slow rehabilitation • SYSTEMIC HORMONES – corticosteroids compromises # healing. Thyroid hormone,calcitonin,insulin are good • NICOTINE – cigarette smoking inhibit fracture healing
  15. 15. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings TISSUE VARIABLES • FORM OF BONE – opposed cancellous bone unite rapidly • BONE NECROSIS – if # is avascular-healing may be delayed.Prolonged use of corticosteroids and radiation can cause bone necrosis. • BONE DISEASES – osteoporosis,osteomalacia,bone tumours,pagets disease,bone cyst,osteogenesis imperfecta etc can influence # healing • INFECTION
  16. 16. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings TREATMENT VARIABLES • APPOSITION OF FRACTURE FRAGMENTS – decreasing fracture gap decreases volume of repair tissue needed for # healing • FRACTURE STABILISATION – traction, cast immobilisation,external fixation,internal fixation
  17. 17. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings TREATMENT THAT INTERFERES WITH HEALING • SURGERY – blood supply disruption and infection • INADEQUATE IMMOBILISATION • DISTRACTION OF FRACTURE FRAGMENTS BY EF/IF/TRACTION • REPEATED MANIPULATIONS • EXCESSIVE EARLY MOBILISATION
  18. 18. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings METHODS PROMOTING # HEALING • BONE GRAFT • BONE TRANSFER –to replace a lost portion of long bone diaphysis,surgeons perform corticotomy through normal bone creating a mobile bone segment and then uses an external fixation device to transfer the segment across the defect. As segment moves a column of bone forms behind it
  19. 19. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings • ELECTRICAL FIELDS – stimulate cell proliferation,synthetic function and promrte bone formation • ULTRASOUND – low intensity pulse ultrasound helps in # healing
  20. 20. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings NON UNION - failure of fracture to unite by bony continuity. DEFINITION: Non union is said to be established when a minimum of nine months has elasped since the injury and the fracture shows no radiologically visible progressive signs of healing continuously for three months
  21. 21. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings
  22. 22. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings DELAYED UNION • Where healing has not occurred at the expected time of union for the type and site of fracture
  23. 23. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings CLASSIFICATION • PALEY,S CLASSIFICATION- Type A – less than 1 cm boneloss Type B – more than 1cm bone loss • MULLER AND WEBER CLASSIFICATION Hypervascular nonunion Avascular non union
  24. 24. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings Hypervascular non union –fracture ends are viable and show biological reaction,hence stable internal fixation is enough no bone grafting required
  25. 25. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings AVASCULAR NON UNION – the fracture ends are not viable due to poor blood supply. Needs rigid internal fixation with bone grafting after decortication of non viable ends • Torse wedge non union – intermediate fragment has healed at one end and not at the other,seen in segmental # • Comminuted non union – in comminuted # • Defect/gap nonunion-in compound#,OM • Atrophic non union-ends are thin and sclerotic with excessive scar tissue in b/w
  26. 26. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings Causes for nonunion • Compound # • Infection • Segmental # • Distraction of # fragments • Soft tissue interposition • Ill advised open reduction • Insecure and inadequate fixation • General factors
  27. 27. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings Clinical features • h/o multiple injuries, open #, inadequqte trt etc • Symptoms : no pain/minimal pain,presence of deformity/loss of function • Signs : painless abnormal mobility,no crepitus,shortening,scars and sinuses,deformity,wasting of limb muscles etc
  28. 28. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings Investigations • Radiograph : gap b/w # fragments fragments are rounded/sclerotic amount of callus will be more (hypervascular) or less (avascular)
  29. 29. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings Management • Principles : • Non union is an absolute indication for surgery it requires open reduction rigid internal fixn and bone grafting • No role for conservative mngmnt • Other methods- electrical stimulation,interlocking nails and ilizarov,s technique
  30. 30. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings Bone grafting - types • Cancellous bone graft : defect less than 2.5 cm. It is better tolerated and rapidly revascularised • Cortical bone graft : it has a stabilising property and can be used for non union of shafts of any long bones. -single onlay: wen placed on one surface -dual onlay : wen placed on both the sides -sliding graft : wen a piece is slided from above to the fracture site
  31. 31. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings • Phemister bone graft : here, graft is placed subperiosteally.simple,blood supply is not disturbed. • It is placed posteriorly and is found to be useful in tibia
  32. 32. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings Electrical stimulation • Weak electric current of 20 mA delivered to # site by a cathode converts fibrous tissue to fibrocartilage wich gets ossified later by enchondral ossification. • 3 types : invasive – if cathode is placed inside the # site semi-invasive –when it is placed s/c non invasive – wen in corporated into the plaster cast externally. Union occurs in 85% of cases
  33. 33. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings Ilizarov,s technique • Best way to treat infected non union • Allows simultaneous correction of all deformities and bone loss
  34. 34. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings Mal union • Definition : when # fragment heals in an abnormal position,it is called malunion
  35. 35. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings
  36. 36. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings
  37. 37. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings • Causes cosmetically unsightly deformity • Alteration in posture and balance in lower limb fractures • It may cause shortening • May interfer with joint function • Altered wt bearing mechanism may lead to premature osteoarthritis of the hip and knee joints.
  38. 38. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings Causes • Trt methods : eg closed reduction • Improper immobilisation techniques • Trt by quacks • Multiple and multisystem injuries
  39. 39. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings Classification • Length malunion • Rotatory malunion • Angulatory malunion
  40. 40. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings Types • Significant mal union : interfers with function • Insignificant mal union : does not interfere with function
  41. 41. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings Clinical features • Deformity • Loss of function • Shortening • Muscle wasting
  42. 42. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings Treatment • Operative trt : if it affects function • Corrective osteotomy • Optimum time to carry out surgery : 6-12 months after the fracture
  43. 43. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings THANK YOU

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