HOW FRACTURES HEAL

Dr. Meilyna Sulphiana Alam - MEI PPDS I Bedah Fakultas Kedokteran Universitas Mulawarman

INTRODUCTION
Fracture healing can occur in two way :
1) Primary bone healing 2) Secondary bone healing

1.

Primary bone healing also known as Haversian remodelling occurs with absolute stability constructs

2.

Secondary bone healing A. Involves responses in the periosteum and external soft tissues. There are two types : Enchondral healing ; occurs with non-rigid fixation, as fracture braces, external fixation, bridge plating, intramedullary nailing, etc Intramembranous healing ; occurs with semi-rigid fixation, such as locked plating (in a non-absolute stability construct) B. Secondary bone healing can occur as either enchondral or intramembranous alone, or a combination of the two.

Most fractures are splinted, not to ensure union but to: (1) alleviate pain (2) ensure that union takes place in good position (3) permit early movement of the limb and a return of function. The process of fracture repair varies according to the type of bone involved and the

amount of movement at the fracture site.

 This is the natural form of healing in tubular bones, in the absence of rigid fixation, it proceeds in 5 stages: Tissue destruction and haematoma formation Inflammation and cellular proliferation Callus formation Consolidation Remodelling

TISSUE DESTRUCTION AND HAEMATOMA FORMATION

A disruption of the endosteal and periosteal blood supply following an injury causes haematoma formation in the vicinity of the fracture. This haematoma may occur as a localized collection of blood bounded by aperiosteal envelope. Provides source of hemopoieitic cells capable of secreting growth factors.

INFLAMMATION AND CELLULAR PROLIFERATION

Within 8 hours of the fracture acute inflammatory reaction migration of inflammatory cells (cytokines and various growth factors) initiation of proliferation and differentiation of mesenchymal stem cells from the periosteum, the breached medullary canal and the surrounding muscle. The clotted haematoma is slowly absorbed and fine new capillaries grow into the area.

CALLUS FORMATION
The differentiating stem cells provide chrondrogenic and osteogenic cell
populations the local biological and biomechanical environment start forming bone also includes osteoclasts mop up dead bone. The thick cellular mass, with its islands of immature bone and cartilage, forms the callus or splint on the periosteal and endosteal surfaces.

the immature fibre bone (or woven bone) becomes more densely mineralized,
movement at the fracture site decreases progressively and at about 4 weeks after injury the fracture unites.

 The formation of new bone is facilitated by avariety of osteoinductive factors; platelet-derived growth factor (PDGF) transforming growth factor (TGF ) insulin-like growth factor (IGF) basic fibroblast growth factor (BFGF) bone morphogenetic protein (BMP).

CONSOLIDATION
Continuing osteoclastic and osteoblastic activity the woven bone lamellar bone. The system is now rigid enough to allow osteoclasts to burrow through the debris at the fracture line, and close behind them. Osteoblasts fill in the remaining gaps between the fragments with new bone. This is a slow process and it may be several months before the bone is strong enough

to carry normal loads

REMODELLING
The fracture has been bridged by a cuff of solid bone. Over a period of months, or even years, this crude weld is reshaped by a continuous process of alternating bone resorption and formation. Eventually, and especially in children, the bone reassumes something like its normal shape.

VARIABLES THAT INFLUENCE FRACTURE HEALING

1. Internal variables blood supply (most important) head injury may increase osteogenic response 2. External variables Nicotine Diet Low intensity pulsed ultrasound (LIPUS) Bone stimulators COX-2

 Non-union
Sometimes the normal process of fracture repair is thwarted and the bone fails to unite. Causes of non-union are:
(1) distraction and separation of the fragments, sometimes the result of interposition of soft tissues between the fragments (2) excessive movement at the fracture line

(3) a severe injury that renders the local tissues nonviable or nearly so
(4) a poor local blood supply

 Hypertrophic nonunion
caused by inadequate immobilization with adequate blood supply typically heal once mechanical stability is improved

Atrophic non-union
caused by inadequate immobilization and inadequate blood supply

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