fracture healing, stages of fracture healing and complications

1. FRACTURE HEALING
By
y.v.vanaja
Lecturer
Vijay marie college of nursing

2. INTRODUCTION
• 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.

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. Healing fracture by callus formation
depends upon some clinical
considerations whether the fracture is
• Traumatic or pathological
• Complete or incomplete like green stick
fracture
• Simple or compound fracture

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

6. STAGES OF FRACTURE HEALING
Primary union of fractures:
• occurs in a few special situations when the ends of
the fracture are approximated as is done by
application of compression clamps.
• In these cases, bony union takes place with
formation of medullary callus without periosteal
callus formation

7. secondary union
Though it is a continuous process, secondary
bone union is described under the following 3
headings:
i) Procallus formation
ii) Osseous callus formation
iii) remodelling

8. Procallus formation
 steps involved in the formation of
procallus are
 Haematoma
 Local inflammatory response
 Ingrowth of granulation tissue
 Callus composed of woven bone and
cartilage

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
• occurs at the site of
injury with exudation
of fibrin, polymorphs
and macrophages.
• Macrophages clear
away the fibrin, RBC
and inflammatory
exudate and debris

12. Ingrowth of granulation tissue
• Begins with the neo
vascularization and
proliferation of mesenchymal
cells from periosteum and
endosteum
• A soft tissue is formed which
joins the ends of fractured
bone without much strength

13. Callus composed of woven bone and cartilage :
Starts with in the first few days.
 The cells of inner layer of the periosteum have
osteogenic potential and lay down collagen as well
as osteoid matrix in the granulation tissue.
 The osteoid undergoes calcification and is called as
woven bone callus and united to bridge the gap
between the ends giving spindle shape

14. Callus Formation

15. Osseous callus formation
– blThe woven bone is cleared
away by incoming
osteoclasts and the calcified
cartilage disintegrates.
– Newly formed blood vessels
and osteoblasts invade, laying
down osteoid which is
calcified and lamellar bone is
formed by developing the
haversian system
cvoncentrically around the
blood vessels

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. COMPLICATIONS OF
FRACTURE HEALING
• MALUNION
• DELAYED UNION
• NONUNION

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

21. 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”
• Every fracture has its own timetable (ie long
bone shaft fracture 6 months, femoral neck
fracture 3 months)

22. Delayed/Nonunion
Factors contributing to development:
• Systemic
• Local

23. Delayed/Nonunion cont.
Systemic factors:
• Metabolic
• Nutritional status
• General health
• Activity level
• Tobacco and alcohol use

24. Delayed/Nonunion cont.
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

25. Nonunion cont
Nonunited fractures form two types of
pseudoarthrosis:
• Hypervascular or hypertrophic
• Avascular or atrophic