1) Fracture healing involves several stages including hematoma formation, inflammation and cellular proliferation, callus formation, consolidation, and remodeling over several weeks to years. 2) There are two main types of fracture healing: direct/primary healing which occurs without callus formation, and indirect/secondary healing which involves callus formation to bridge the fracture. 3) Fractures have medicolegal importance in determining grievous hurt, establishing the mechanism of injury, differentiating ante- and post-mortem fractures, and assessing negligence. Puppe's rule can be used to determine the sequence of fractures.

1. FRACTURE HEALING
By
Dr.Nafeeya
Department Of Forensic Medicine and Toxicology

2. overview
• Introduction
• Anatomy of bones
• Pathophysiology of bone healing
• Stages of fracture healing
• Medicolegal importance

3. Introduction
• Fracture is a break in the structural
continuity of bone or periosteum.
• Fracture results in loss of its
mechanical stability and also
partial destruction of blood supply
• Fracture healing starts as soon as
bone breaks and continues
modelling for many years.

4. ANATOMY OF BONES
Parts of long bones:
Epiphyses: ends of a long bone that ossifies from secondary centers.
Diaphysis: shaft of long bones that ossifies from primary center
Metaphysis: part of diaphysis[zone of active bone growth]
Structural components of bone:
• Mineralized matrix
• Osteoblast, osteocytes, osteoclasts
• Periosteum
• Endosteum
• Medullary Cavity
• Bone Marrow

5. FRACTURE HEALING
DIRECT / PRIMARY:
• When there is direct contact between the bone ends, bone forms directly across the
fracture line , by direct extension of osteons.
• Does not involve formation of fracture callus.
• Mechanism of bone healing seen when there is no motion at the fracture site (i.e.
rigid internal fixation).
INDIRECT/SECONDARY:
• Callus formation
• This callus is later replaced by bone.
• Mechanism for healing in fractures that are not rigidly fixed.
• Bridging periosteal (soft) callus and medullary (hard) callus re-establish structural
continuity.
• It is comparable to healing of soft tissue by filling of gaps with vascular granulation
tissue

6. Healing of cancellous bones:
• Creeping substitution” - New blood vessels can invade trabeculae of
cancellous bone and bone opposition may take place directly on to the
surface of trabeculum.
• Heals at the point of direct contact: Cancellous bone certainly can unite
very rapidly, but it unites rapidly only at the points of direct contact.
• No bridging callus :Cancellous bone unites only by contact,not by
throwing out callus even when it is cut of due to dense attachment of the
periosteum.
• No death of osteocytes:blood supply is good and large surface area of the
trabecular spaces combined with relatively thin trabeculae, keep the
osteocytes nourished.
• Has tendency for late collapse :This lack of callus production by
cancellous bone explains the tendency to late collapse which have been
distracted.

7. Stages of fracture healing
• Tissue destruction and hematoma formation[Day-1]
• Inflamation and cellular proliferation[2weeks]
• Stage of callus formation[2-3 weeks]
• Stage of consolidation[3-6 weeks]
• Stage of remodeling[8-2yrs]

8. HEMATOMA FORMATION-1
• Blood vessels torn –haemorrhage
• A mass of clotted blood (hematoma)
forms at the fracture site
• Site becomes swollen, painful, and
inflamed

9. Day-1-Broken bones ,blood clots.

10. INFLAMATION AND CELLULAR
PROLIFERATION-2weeks
• Within [8 hrs-2weeks] inflammatory
reaction starts.
• Proliferation and Differentiation of
cells occurs.
• Secretion of TGF-B , PDGF and
various factors.

11. Day 7 - Chondrogenesis and inflammatory response at the fracture
site. chondrogenic response. bone formation from the periosteum.

12. Callus Formation 2-3 weeks
• Fibro-cartilaginous callus is
formed a few days after the
fracture
• Capillaries grow into the
tissue and phagocyte cells
begin cleaning debris
• Connecting bridge across a
bone fracture during repair.

13. Day 14 -Calcification of cartilage. callus and periosteal bone formation

14. CONSOLIDATION-[3-6weeks]
• New bone trabeculae appear
in the fibro-cartilaginous
callus, which then converts into a
bony callus.
• This occurs 3-6 weeks after
injury and continues until firm
union is formed 2-3 months later.

15. Day 21 - Most of the callus is composed of calcified cartilage

16. Remodelling[8-2yrs]
•Bone remodeling is a lifelong process
where mature bone tissue is removed
and new bone tissue is formed.
• Reshaping Or Replacement of bone
following injuries.
•4 phase -Bone remodeling:
1. Activation,
2. Resorption,
3. Reversal formation
4. Quiescence.

17. Days 28-35 after fracture. Calcified cartilage and
newly formed bone

18. Complications of fracture healing
Delayed union:
Healing of bone does not
take place in normal rates.
•Inadequate blood supply
•Several soft tissue
damage
•Infection
•Insufficient splintage
•Excessive traction

19. Medicolegal importance

20. • Grievious hurt 320 ipc
• Establising the mode of injury by analysing type of fracture
• Differentiate antemorterm and post-mortem fracture
• Age of fracture
• Medical negligence
• Battered baby syndrome
• Puppe’s rule

21. • Grievious hurt:-320 IPC
• Fracture or dislocation of a bone or teeth.
Mode of injury:
• Fall from height- thoracic and lumbar fracture ,ring fracture and
comminuted fracture are common
• RTA- shaft fractures more common
• Judicial hanging C1-C2 fracture common
• Old age- neck of femur fracture common

22. Features Antemorterm Postmorterm
Effusion of blood Present Absent
Muscles around fracture Lacerated
,edematous,contused
Not so
Signs of healing Present Absent
Histology Active cellular infiltration Not so
Sequelae Fat embolism Not so

23. Age of skull fractures
Healing of skull fractures Time since injury
Edges of fissures stick together 1weeks
Edges slightly eroded ,inner table of skull shows pitting 2weeks
Edges become smooth ,bands of osseous tissue formed 3-5weeks
Complete healing occurs 3months

24. Radiological changes-Features Time since injury wks
Rounded fracture margin 1
Subperiosteal new bone formation Less than 2
Soft callus 2
Calcified callus 4
Fracture margin resorption 4-6
Sclerosis 4-6
Bridging – partial 8
Decrease in fracture gap 8
Bridging -complete 10
Density of callus equal to surrounding compact bone 10
New bone formation incorporate into cortex 10
Remodelling 12
Radiological changes observed in healing

25. • Battered baby syndrome:
• Non accidental injury
• Direct beating -Skull fractures – occipito-
parietal region,
• Long bones- transverse and spiral fracture
common
• Traction lesions-periosteal hematomas,
epiphyseal separation,avulsion of metaphysis.
• Anteroposterior and side to side compression
of chest
• Rib fractures-NOBBING FRACTURE
• Delay in seeking treatment
• Can able to different stages of healing
• Autopsy-old fractures,epiphseal and
metaphyseal injury (stages of healing)

26. C.P.Sreekumar M.S (Ortho) vs S.Ramanujam on 1 May, 2009
Supreme Court Of India
• A CASE OF NEGLIGENCE
• A hairline fracture developed into displaced fracture due to wrong
handling in the hospital
• Performed a hemiarthroplasty on a young patient of 42 years
without consideration open reduction and internal fixation and
against established medical practices
• The post-operative infection was not properly treated with the result
that prosthesis got loosened within a period of two months.
• Compensation of rs.3 lac fine.

27. Madras High Court
A. Narayanan vs Dr .Saravanan on 24 February, 2020
• Condition did not improve and the swelling on his lower jaw increased.
• He suffered a fracture in his lower jaw.
• Broken stitching needle was embedded in his lower jaw during the suturing
procedure.
• The x-ray revealed the presence of the broken needle in the petitioner's lower jaw.
• Liable to compensate him for their negligence in performing the surgery which
resulted in a needle being broken and embedded in his jaw
• He is suffering great hardship and undergoing psychological trauma.
• Grant compensation and awarded a sum of rs.10,00,000/- as compensation on
account of medical negligence.

28. • Used to determine sequence of shots ,blunt
trauma or glass window shots.
Principle:
 Bullet will cause fracture line to radiate from hole it causes.
 The fracture line emanating from second bullet hole will stop at the line of first
hole.
 Fracture line emanating from third bullet will stop at the line caused by first
and second.
• Also applicable to blunt force caused by any objects,like iron rod,etc
• Also applicable to other flat bones-Sternum and hip bone
• Also determine sequence of shots in glass window or similar objects

29. references
• The essential of forensic medicine and toxicology.K.S.Narayana reddy
• Textbook of forensic medicine and toxicology –anil agarwal
• The essential orthopedics J.maheswari
• A Qualitative Analysis for Sex Determination in Humans
• The science of fracture healing thomas A. Einhorn,
• determination of medicolegal significance from suspected osseous and dental
remains
• J orthop trauma • volume 19, number 10 supplement, november/december 2005
• Maria L. Hillier,1 M.Sc. and Lynne S. Bell,2 Ph.D. Differentiating Human Bone
from Animal Bone: A Review of Histological Methods.J of forensic science
• Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue 23/ June
10, 2013
• Slice and algee-hewitt . modeling bone surface morphology for age estimation
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• Some Medico-Legal Aspects of the Fracture of Bone Sir Lenthal Cheatle,