1. Fracture healing involves inflammation, callus formation, consolidation, and remodeling. The type and location of bone formed depends on factors like fracture type, gap condition, fixation rigidity, and loading. 2. Fracture healing is divided into cortical bone healing and cancellous bone healing. Complications include malunion, delayed union, and nonunion. 3. Nonunion is established when a fracture shows no progressive healing for 3 months after at least 9 months. Treatment depends on the type of nonunion and may involve electrical stimulation, external fixation, or surgical techniques like bone grafting and internal or external fixation.

1. Dr. Armaan Singh

2. 
 Fracture is a break in the structural continuity of
bone or periosteum.
 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.
 Fracture healing starts as soon as bone breaks and
continues modelling for many years.
INTRODUCTION

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 .

4. Components of BONE
Formation
 Cortex
 Periosteum
 Bone marrow
 Soft tissue

5. 
 OSTEOCHONDRAL
 INTRAMEMBERANOUS OSSIFICATION
 OPPOSITIONAL NEW BONE FORMATION
 OSTEONAL MIGRATION
(Creeping Subsitituion)
Type of BONE formed

6. 
The TYPE , AMOUNT and LOCATION of bone formed
depends upon-----
 FRACTURE TYPE
 GAP CONDITION
 FIXATION RIGIDITY
 LOADING
 BIOLOGICAL ENVIRONMENT
FACTORS EFFECTING

7. Fracture healing is divided according to bone--
1. Cortical bone of the shaft.
2. Cancellous bone of the metaphyseal region of the long
bones and the small bones.
FRACTURE HEALING
TYPES

8. 
 TISSUE DESTRUCTION AND HAEMATOMA
FORMATION
 INFLAMATION AND CELLULAR
PROLIFERATION
 STAGE OF CALLUS FORMATION
 STAGE OF COSOLIDATION
 STAGE OF REMODELLING
STAGES OF FRACTURE
HEALING

9. 
Tissue destruction and
Hematoma formation
 Torn blood vessels
hemorrhage
 A mass of clotted
blood (hematoma)
forms at the
fracture site
 Site becomes swollen,
painful, and inflamed

10. 
Tissue destruction and
Hematoma formation

11. 
INFLAMATION AND CELLULAR
PROLIFERATION
 Within 8 hours
inflammatory reaction
starts.
 Proliferation and
Differntiation of
mesenchymal stem
cells.
 Secretion of TGF-B ,
PDGF and various BMP
factors.

12. 
Callus Formation
 Fibrocartilaginous
callus forms
 Granulation tissue (soft
callus) forms a few
days after the fracture
 Capillaries grow into
the tissue and
phagocytic cells begin
cleaning debris

13. 
Callus Formation
Theory
 OSTEOPROGENITOR
CELL present in all
ENDOSTEAL and
SUBPERIOSTEAL
surface give rise to
CALLUS.
 CALLUS arises from
NON-SPECIALISED
CONNECTIVE TISSUE
CELLS in the region of
fracture which are
induced into
conversion to
OSTEOBLASTS.

14. 
Callus Formation

15. 
STAGE OF
CONSOLIDATION
 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

16. 
STAGE OF
REMODELLING
 Excess material on the
bone shaft exterior
and in the medullary
canal is removed
 Compact bone is laid
down to reconstruct
shaft walls

17. 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).
Figure from Brighton, et al, JBJS-A, 1991

18. A: Roentgenogram of a callus healing in a sheep tibia with the
osteotomy line still visible (6 weeks p.o.).
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).

19. Variables Influence Fracture
Healing
INJURY
VARIABLES
Open Fractures
Impeding or preventing formation #
Hematoma
 Delaying formation repair tissue
 Risk of infection

20. INJURY VARIABLES
Intra articular
fracturesIf the alignment & congruity joint surface
is not restored
Delayed healing or non union
 Joint stiffness
* Segmental fractures
*Soft tissue interposition
* Damage to the blood supply

21. 
 AGE
 NUTRTION
 HEALING PROCESS NEEDS
Energy
Proteins & carbohydrates
Patient Variables

22. Patient Variables cont….
Systemic hormones
 Corticosteroid ( )
 Growth hormone
 Thyroid hormone
 Calcitonin
 Insulin
 Anabolic steroids
 DM
 Hypervitaminosis D
 Rickets
Inhibit fracture healing ( Vascularization?)
Nicotine
Ratefracture healing
Rate fracture healing

23. 
 Cancellous or cortical bones
 Bone necrosis
 Infection
Tissue Variables

24. 
 Osteoprosis
 Osteomalacia
 Primary malignant bone tumors
 Metastatic bone tumors
 Fibrous dysplacia
 Benign bone tumors
 Bone cysts
 Osteogenesis imperfecta
 Paget’s disease
 Hyperparathyroidism
Bone disease

25. 
Apposition of fracture fragments
Loading & micromotion
 Loading a fracture site stimulates bone formation
 Micromotion promotes fracture healing
Treatment Variables

26. 
 Fracture stabilization
 Traction
 Cast Imm
 Ext.Fixation
 Int.Fixation
Facilitate fracture healing by
Preventing repeated disruption of
Repair tissue
Treatment Variables

27. 
 MALUNION
 DELAYED UNION
 NONUNION
COMPLICATIONS OF
FRACTURE HEALING

28. 
A MALUNITED Fracture is one that has healed with
the fragments in a non anatomical position.
CAUSES
1 INACCURATE REDUCTION
2 INEFFECTIVE IMMOBILIZATION
MAL UNION

29. 
MALUNION can IMPAIR FUCNTION by
 ABNORMAL JOINT SURFACE
 ROTATION or ANGULATION
 OVERRIDING
 MOVEMENT OF NEIGHBOURING JOINT MAY BE
BLOCKED
MALUNION contd…

30. 
 ALIGNMENT (MOST IMPORTANT)
 ROTATION
 RESTORATION OF NORMAL LENGTH
 ACTUAL POSITION OF FRAGMENTS
(LEAST IMPORTANT)
CHARACTERISTICS FOR
ACCEPTABILITY OF
FRACTURE REDUCTION

31. 
 RIES and O’NEILL developed TRIGNOMETRIC
ANALYSIS of DEFORMITY and designed E-
GRAPH to determine the true maximal deformity on
AP and LATERAL X-Ray views.
ANALYSIS OF
DEFORMITY

32. 
 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.
 Surgeon should look for before surgery--
 OSTEOPROSIS
 SOFT TISSUE
 HOW MUCH FUNCTION CAN BE GAINED
MALUNION contd….

33. 
ILIZAROV TECHNIQUE is BEST
Simultaneous restoration of
 ALIGNMENT
 ROTATION
 LENGTH
MALUNION contd….

34. 
 The exact time when a given fracture should be
united cannot be defined
 Union is delayed when healing has not advanced at
the average rate for the location and type of fracture
(Btn 3-6 mths)
 Treatment usually is by an efficient cast that allows
as much function as possible can be continued for 4
to 12 additional weeks
Delayed Union

35.  If still nonunited a decision should be made to treat
the fracture as nonunion
 External ultrasound or electrical stimulation may be
considered
 Surgical treatment should be carried out to remove
interposed soft tissues and to oppose widely
separated fragments
 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
Delayed Union cont.

36. 
 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”
 Every fracture has its own timetable (ie long bone
shaft fracture 6 months, femoral neck fracture 3
months)
Nonunion

37. 
Factors contributing to development:
 Systemic
 Local
Delayed/Nonunion

38. 
Systemic factors:
 Metabolic
 Nutritional status
 General health
 Activity level
 Tobacco and alcohol use
Delayed/Nonunion cont.

39. 
Local factors
 Open
 Infected
 Segmental (impaired blood supply)
 Comminuted
 Insecurely fixed
 Immobilized for an insufficient time
 Treated by ill-advised open reduction
 Distracted by (traction/plate and screws)
 Irradiated bone
 Delayed weight-bearing > 6 weeks
 Soft tissue injury > method of initial treatment
Delayed/Nonunion cont.

40. 
Nonunited fractures form two types of pseudoarthrosis:
 Hypervascular or hypertrophic
 Avascular or atrophic
Nonunion cont.

41. Hypervascular or
Hypertrophic:
1. Elephant foot
(hypertophic, rich in
callus)
2. Horse foot (mildly
hypertophic, poor in
callus)
3. Oligotrophic (not
hypertrophic, no callus)
Nonunion cont.
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.)

42. Vascular or Atrophic
 Torsion wedge (intermediate
fragment)
 Comminuted (necrotic
intermediate fragment)
 Defect (loss of fragment of
the diathesis)
 Atrophic (scar tissue with no
estrogenic potential is
replacing the missing
fragment)
Nonunion cont.
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.)

43. Classification (Paley et al)
 Type A<2cm of bone loss
A1 (Mobile deformity)
A2 (fixed deformity)
A2-1 stiff w/o
deformity
A2-2 stiff w/ fixed
deformity
 Type B>2cm of bone loss
B1 with bony defect
B2 loss of bone length
B3 both
Nonunion cont.
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.

44. 
Treatment:
1. Elecrical
2. Electromagnatic
3. Ulrasound
4. External fixation (ie deformity, infection, bone loss)
5. Surgical
 Hypertrophic: stable fixation of fragments
 Atrophic: decortication and bone grafting
 According to classification:
type A : restoration of alignment, compression
type B : cortical osteotomy, bone transport or
lengthening
Nonunion cont.

45. 
Surgical guidelines:
 Good reduction
 Bone grafting
 Firm stabilization
Nonunion cont.

46. 
Reduction of the fragments:
 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
 External fixator, Intramedullary nailing, Ilizarov
frame
Nonunion cont.

47. 
Bone Grafting origins:
 Autogenous “the golden standard”
 Allograft
 Synthetic substitute
Nonunion cont.

48. 
Bone grafting techniques:
 Onlay
 Dual onlay
 Cancellous insert
 Massive sliding graft
 Whole fibular transplant
 Vascularized free fibular graft
 Intamedullary fibular graft
Nonunion cont.

49. 
CRITERTIA FOR SUCCESSFUL
BONE GRAFT
 OSTEOCONDUCTION
 OSTEOGENICITY
 OSTEOINDUCTION
BONE GRAFTING
contd….

50. 
Dual onlay
 Nonunion of
tibial shaft
treated by dual
onlay grafts

51. 
Massive sliding graft
GILL MASSIVE SLIDING
GRAFT

52. 
Whole fibular transplant
 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.

53. 
Vascularized free fibular
graft 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

54. 
Intamedullary fibular
graft 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.)

55. 
Stabilization of bone fragments:
 Internal fixation (hypertrophic #): intamedullary, or
plates and screws
 External fixation(defects associated#):
ie Ilizarov
Nonunion cont.

56. 
Internal fixation
 Roentgenograms
of patient with
subtrochanteric
nonunion for 22
years treated
with locked
second
generation
femoral nail. A,
Preoperatively. B,
Postoperatively.

57. Ilizarov
Bifocal osteosynthesis with Ilizarov
fixator after debridement of necrotic
segments, as recommended by Catagni.
Monofocal osteosynthesis with
Ilizarov fixator for hypertrophic
nonunions with minimal infection, as
recommended by Catagni

58. 
Ilizarov cont.
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.

59. 
Factors complicating nonunion
 Infection
 Poor tissue quality
 Short periarticular fragments
 Significant deformity
Nonunion cont.

60. 
Infection management
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

61. 
Specific Bones
 Metatarsals
 Tibia
 Fibula
 Patella
 Femur
 Pelvis and acetabulum
 Clavicle
 Humerus
 Radius
 Ulna
Nonunion cont.

63. THANK YOU