Fracture healing

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Fracture healing

  1. 1. FRACTURE HEALING<br />Dr. NISHITH SHARMA<br />DEPT. OF ORTHOPAEDICS<br />NIMS MEDICAL COLLEGE & HOSPITAL<br />
  2. 2. INTRODUCTION<br />Fracture is a break in the structural continuity of bone or periosteum.<br /> The healing of fracture is in many ways similiar to the healing in soft tissue wounds except that the end result is mineralised mesenchymal tissue i.e. BONE.<br /> Fracture healing starts as soon as bone breaks and continues modelling for many years.<br />
  3. 3. The essential event in fracture healing is the creation of a bony bridge between the two fragments which can be readily be built upon and modified to suit the particular functional demands . <br />
  4. 4. Components of BONE Formation<br /><ul><li> Cortex
  5. 5. Periosteum
  6. 6. Bone marrow
  7. 7. Soft tissue</li></li></ul><li>Type of BONE formed<br /><ul><li> OSTEOCHONDRAL
  8. 8. INTRAMEMBERANOUS OSSIFICATION
  9. 9. OPPOSITIONAL NEW BONE FORMATION
  10. 10. OSTEONAL MIGRATION </li></ul> (Creeping Subsitituion)<br />
  11. 11. FACTORS EFFECTING<br />The TYPE , AMOUNT and LOCATION of bone formed depends upon-----<br /><ul><li> FRACTURE TYPE
  12. 12. GAP CONDITION
  13. 13. FIXATION RIGIDITY
  14. 14. LOADING
  15. 15. BIOLOGICAL ENVIRONMENT</li></li></ul><li>FRACTURE HEALING TYPES<br />Fracture healing is divided according to bone--<br />Cortical bone of the shaft. <br />Cancellous bone of the metaphyseal region of the long bones and the small bones.<br />
  16. 16. STAGES OF FRACTURE HEALING<br /><ul><li> TISSUE DESTRUCTION AND HAEMATOMA FORMATION
  17. 17. INFLAMATION AND CELLULAR PROLIFERATION
  18. 18. STAGE OF CALLUS FORMATION
  19. 19. STAGE OF COSOLIDATION
  20. 20. STAGE OF REMODELLING</li></li></ul><li>Tissue destruction and Hematoma formation<br />Torn blood vessels hemorrhage<br />A mass of clotted blood (hematoma) forms at the fracture site<br />Site becomes swollen, painful, and inflamed<br />
  21. 21. Tissue destruction and Hematoma formation<br />
  22. 22. INFLAMATION AND CELLULAR PROLIFERATION<br /> Within 8 hours inflammatory reaction starts.<br /> Proliferation and Differntiation of mesenchymal stem cells.<br />Secretion of TGF-B , PDGF and various BMP factors.<br />
  23. 23. Callus Formation<br />Fibrocartilaginous callus forms<br />Granulation tissue (soft callus) forms a few days after the fracture<br />Capillaries grow into the tissue and phagocytic cells begin cleaning debris<br />
  24. 24. Callus Formation Theory<br /> OSTEOPROGENITOR CELL present in all ENDOSTEAL and SUBPERIOSTEAL surface give rise to CALLUS.<br />CALLUS arises from NON-SPECIALISED CONNECTIVE TISSUE CELLS in the region of fracture which are induced into conversion to OSTEOBLASTS.<br />
  25. 25. Callus Formation<br />
  26. 26. STAGE OF CONSOLIDATION<br />New bone trabeculae appear in the fibrocartilaginous callus<br />Fibrocartilaginous callus converts into a bony (hard) callus<br />Bone callus begins 3-4 weeks after injury, and continues until firm union is formed 2-3 months later<br />
  27. 27. STAGE OF REMODELLING<br /><ul><li>Excess material on the bone shaft exterior and in the medullary canal is removed
  28. 28. Compact bone is laid down to reconstruct shaft walls</li></li></ul><li>Schematic drawing of the callus healing process. Early intramembranous bone formation (a), growing callus volume and diameter mainly by enchondral ossification (b), and bridging of the fragments (c). <br />Figure from Brighton, et al, JBJS-A, 1991<br />
  29. 29. A: Roentgenogram of a callus healing in a sheep tibia with the osteotomy line still visible (6 weeks p.o.). <br />B: Histological picture of a sheep tibia osteotomy (fracture model) after bone bridging by external and intramedullary callus formation. A few areas of fibrocartilage remain at the level of the former fracture line (dark areas). <br />
  30. 30. Variables Influence Fracture Healing<br />INJURY VARIABLES<br />Open Fractures<br /><ul><li>Impeding or preventing formation # Hematoma
  31. 31. Delaying formation repair tissue
  32. 32. Risk of infection</li></li></ul><li>INJURY VARIABLES<br />Intra articular fractures<br />If the alignment & congruity joint surface <br />is not restored<br /><ul><li>Delayed healing or non union
  33. 33. Joint stiffness</li></ul>*Segmental fractures<br />*Soft tissue interposition<br />* Damage to the blood supply<br />
  34. 34. Patient Variables<br /><ul><li>AGE
  35. 35. NUTRTION
  36. 36. HEALING PROCESS NEEDS</li></ul> Energy<br /> Proteins & carbohydrates<br />
  37. 37. Patient Variables cont….<br />Systemic hormones<br /><ul><li>Corticosteroid ( )
  38. 38. Growth hormone
  39. 39. Thyroid hormone
  40. 40. Calcitonin
  41. 41. Insulin
  42. 42. Anabolic steroids
  43. 43. DM
  44. 44. Hypervitaminosis D
  45. 45. Rickets</li></ul>Ratefracture healing<br />Rate fracture healing<br /><ul><li>Nicotine</li></ul>Inhibit fracture healing ( Vascularization?)<br />
  46. 46. Tissue Variables<br /><ul><li>Cancellous or cortical bones
  47. 47. Bone necrosis
  48. 48. Infection</li></li></ul><li>Bone disease<br /><ul><li>Osteoprosis
  49. 49. Osteomalacia
  50. 50. Primary malignant bone tumors
  51. 51. Metastatic bone tumors
  52. 52. Fibrous dysplacia
  53. 53. Benign bone tumors
  54. 54. Bone cysts
  55. 55. Osteogenesisimperfecta
  56. 56. Paget’s disease
  57. 57. Hyperparathyroidism </li></li></ul><li>Treatment Variables<br />Apposition of fracture fragments<br /> Loading & micromotion<br /><ul><li> Loading a fracture site stimulates bone formation
  58. 58. Micromotion promotes fracture healing</li></li></ul><li>Treatment Variables<br /><ul><li>Fracture stabilization
  59. 59. Traction
  60. 60. Cast Imm
  61. 61. Ext.Fixation
  62. 62. Int.Fixation</li></ul>Facilitate fracture healing by<br />Preventing repeated disruption of<br /> Repair tissue<br />
  63. 63. COMPLICATIONS OF FRACTURE HEALING<br />MALUNION<br /> DELAYED UNION<br /> NONUNION<br />
  64. 64. MAL UNION<br />A MALUNITED Fracture is one that has healed with the fragments in a non anatomical position.<br /> CAUSES<br />1INACCURATE REDUCTION<br />2 INEFFECTIVE IMMOBILIZATION<br />
  65. 65. MALUNION contd…<br /> MALUNION can IMPAIR FUCNTION by<br /><ul><li>ABNORMAL JOINT SURFACE
  66. 66. ROTATION or ANGULATION
  67. 67. OVERRIDING
  68. 68. MOVEMENT OF NEIGHBOURING JOINT MAY BE BLOCKED</li></li></ul><li>CHARACTERISTICS FOR ACCEPTABILITY OF FRACTURE REDUCTION<br /><ul><li>ALIGNMENT (MOST IMPORTANT)
  69. 69. ROTATION
  70. 70. RESTORATION OF NORMAL LENGTH
  71. 71. ACTUAL POSITION OF FRAGMENTS</li></ul> (LEAST IMPORTANT)<br />
  72. 72. ANALYSIS OF DEFORMITY<br />RIES and O’NEILLdeveloped TRIGNOMETRIC ANALYSIS of DEFORMITY and designed E-GRAPH to determine the true maximal deformity on AP and LATERAL X-Ray views.<br />
  73. 73. MALUNION contd….<br />Operative treatment for most malunited fracture should not be considered until 6 to 12 months but in INTRA ARTICULAR fracture early operative treatment is needed.<br /> Surgeon should look for before surgery--<br /><ul><li>OSTEOPROSIS
  74. 74. SOFT TISSUE
  75. 75. HOW MUCH FUNCTION CAN BE GAINED</li></li></ul><li>MALUNION contd….<br /> ILIZAROV TECHNIQUE is BEST <br /> Simultaneous restoration of<br /><ul><li>ALIGNMENT
  76. 76. ROTATION
  77. 77. LENGTH</li></li></ul><li>Delayed Union<br />The exact time when a given fracture should be united cannot be defined<br />Union is delayed when healing has not advanced at the average rate for the location and type of fracture (Btn 3-6 mths)<br />Treatment usually is by an efficient cast that allows as much function as possible can be continued for 4 to 12 additional weeks<br />
  78. 78. Delayed Union cont.<br />If still nonunited a decision should be made to treat the fracture as nonunion<br />External ultrasound or electrical stimulation may be considered<br />Surgical treatment should be carried out to remove interposed soft tissues and to oppose widely separated fragments <br />Iliac grafts should be used if plates and screws are placed but grafts are not usually needed when using intramedullary nailing, unless reduction is done open<br />
  79. 79. Nonunion<br />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”<br />Every fracture has its own timetable (ie long bone shaft fracture 6 months, femoral neck fracture 3 months) <br />
  80. 80. Delayed/Nonunion<br />Factors contributing to development:<br />Systemic<br />Local<br />
  81. 81. Delayed/Nonunion cont.<br />Systemic factors:<br />Metabolic<br />Nutritional status<br />General health<br />Activity level<br />Tobacco and alcohol use<br />
  82. 82. Delayed/Nonunion cont.<br />Local factors<br />Open<br />Infected<br />Segmental (impaired blood supply)<br />Comminuted<br />Insecurely fixed<br />Immobilized for an insufficient time<br />Treated by ill-advised open reduction<br />Distracted by (traction/plate and screws)<br />Irradiated bone<br />Delayed weight-bearing > 6 weeks<br />Soft tissue injury > method of initial treatment<br />
  83. 83. Nonunion cont.<br />Nonunited fractures form two types of pseudoarthrosis:<br />Hypervascular or hypertrophic<br />Avascular or atrophic<br />
  84. 84. Nonunion cont.<br />Hypervascular or Hypertrophic:<br />Elephant foot (hypertophic, rich in callus)<br />Horse foot (mildly hypertophic, poor in callus)<br />Oligotrophic (not hypertrophic, no callus)<br />Hypervascular nonunions. A, "Elephant foot" nonunion. B, "Horse hoof" nonunion. C, Oligotrophic nonunion (see text). (Redrawn from Weber BG, Cech O, eds: Pseudarthrosis, Bern, Switzerland, 1976, Hans Huber.) <br />
  85. 85. Nonunion cont.<br />Vascular or Atrophic<br />Torsion wedge (intermediate fragment)<br />Comminuted (necrotic intermediate fragment)<br />Defect (loss of fragment of the diathesis)<br />Atrophic (scar tissue with no estrogenic potential is replacing the missing fragment)<br />Avascular nonunions. A, Torsion wedge nonunion. B, Comminuted nonunion. C, Defect nonunion. D, Atrophic nonunion (see text). (Redrawn from Weber BG, Cech O, eds: Pseudarthrosis, Bern, Switzerland, 1976, Hans Huber.) <br />
  86. 86. Nonunion cont.<br />Classification (Paley et al)<br />Type A<2cm of bone loss<br /> A1 (Mobile deformity)<br /> A2 (fixed deformity)<br /> A2-1 stiff w/o deformity<br /> A2-2 stiff w/ fixed deformity<br />Type B>2cm of bone loss<br /> B1 with bony defect<br /> B2 loss of bone length<br /> B3 both<br />A, Type A nonunions (less than 1 cm of bone loss): A1, lax (mobile); A2, stiff (nonmobile) (not shown); A2-1, no deformity; A2-2, fixed deformity. B, Type B nonunions (more than 1 cm of bone loss): B1, bony defect, no shortening; B2, shortening, no bony defect; B3, bony defect and shortening. <br />
  87. 87. Nonunion cont.<br />Treatment:<br />Elecrical<br />Electromagnatic<br />Ulrasound<br />External fixation (ie deformity, infection, bone loss)<br />Surgical<br />Hypertrophic: stable fixation of fragments<br />Atrophic: decortication and bone grafting<br />According to classification:<br /> type A : restoration of alignment, compression<br /> type B : cortical osteotomy, bone transport or lengthening <br />
  88. 88. Nonunion cont.<br />Surgical guidelines:<br />Good reduction<br />Bone grafting<br />Firm stabilization<br />
  89. 89. Nonunion cont.<br />Reduction of the fragments:<br />Extensive dissection is undesirable, leaving periosteum, callus, and fibrous tissue to preserve vascularity and stability, resecting only the scar tissue and the rounded ends of the bones<br />External fixator, Intramedullary nailing, Ilizarov frame<br />
  90. 90. Nonunion cont.<br />Bone Grafting origins:<br />Autogenous “the golden standard”<br />Allograft<br />Synthetic substitute<br />
  91. 91. Nonunion cont.<br />Bone grafting techniques:<br />Onlay<br />Dual onlay<br />Cancellous insert<br />Massive sliding graft<br />Whole fibular transplant<br />Vascularized free fibular graft<br />Intamedullary fibular graft<br />
  92. 92. BONE GRAFTING contd….<br />CRITERTIA FOR SUCCESSFUL BONE GRAFT<br />OSTEOCONDUCTION<br />OSTEOGENICITY<br />OSTEOINDUCTION<br />
  93. 93. Nonunion of tibial shaft treated by dual onlay grafts <br />Dual onlay<br />
  94. 94. Massive sliding graft<br /> GILL MASSIVE SLIDING GRAFT<br />
  95. 95. Whole fibular transplant<br />Bridging of bone defect with whole fibular transplant. A, Defect in radius was caused by shotgun wound. B and C, Ten months after defect was spanned by whole fibular transplant, patient had 25% range of motion in wrist, 50% pronation and supination, and 80% use of fingers.<br />
  96. 96. Vascularized free fibular graft<br />Posteroanterior and lateral roentgenograms made 3 years after fibular transfer, showing excellent remodeling with fracture healing. (From Duffy GP, Wood MB, Rock MG, Sim FH: J Bone Joint Surg 82A:544, 2000<br />
  97. 97. Intamedullary fibular graft<br />Anteroposterior roentgenogram of humerus 5 months after insertion of fibular allograft and compression plating with a 4.5-mm dynamic compression plate revealing evidence of bridging callus formation and incorporation of the allograft. (From Crosby LA, Norris BL, Dao KD, McGuire MH: Am J Orthop 29:45, 2000.)<br />
  98. 98. Nonunion cont.<br />Stabilization of bone fragments:<br />Internal fixation (hypertrophic #): intamedullary, or plates and screws<br />External fixation(defects associated#):<br /> ie Ilizarov<br />
  99. 99. Internal fixation<br />Roentgenograms of patient with subtrochanteric nonunion for 22 years treated with locked second generation femoral nail. A, Preoperatively. B, Postoperatively.<br />
  100. 100. Ilizarov<br />Monofocal osteosynthesis with Ilizarov fixator for hypertrophic nonunions with minimal infection, as recommended by Catagni<br />Bifocal osteosynthesis with Ilizarov fixator after debridement of necrotic segments, as recommended by Catagni. <br />
  101. 101. Ilizarov cont.<br />Type IIIB open tibial fracture in 30-year-old man struck by automobile. Initial treatment was with four-pin anterior half-pin external fixator that was later converted to six-pin fixator; this fixator was removed because of persistent infection. B, One year after injury, infected nonunion with deformity. C, Shape of tibial deformity is duplicated by Ilizarov frame and is gradually corrected as nonunion is compressed. D, Union obtained at 4½ months. <br />
  102. 102. Nonunion cont.<br />Factors complicating nonunion<br />Infection<br />Poor tissue quality<br />Short periarticular fragments<br />Significant deformity <br />
  103. 103. Infection management<br />Treatment of nonunion of tibia in which sequestration or gross infection is present. A, Bone is approached anteriorly and is saucerized, incision is closed, and infection is treated with antibiotics by irrigation and suction. B and C, Tibia is grafted posteriorly. B, Skin incision. C, Tibia and fibula have both been approached posterolaterally. Posterior aspect of tibia (or tibia and fibula) is roughened and grafted with autogenous iliac bone<br />
  104. 104. Nonunion cont.<br /> Specific Bones<br />Metatarsals<br />Tibia<br />Fibula<br />Patella<br />Femur<br />Pelvis and acetabulum<br />Clavicle<br />Humerus<br />Radius<br />Ulna<br />
  105. 105.
  106. 106. THANK YOU<br />

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