FRACTURE HEALING &

COMPLICATIONS

DR PANNA LAL SAHA

PROFESSOR
DEPARTMENT OF SURGERY
BGC TRUST MEDICAL COLLEGE

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.

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 .

Components of BONE
Formation
Cortex
Periosteum
Bone marrow
Soft tissue

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

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

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

Tissue destruction and

Hematoma formation

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.

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

Callus Formation Theory

CALLUS arises from

OSTEOPROGENIT
NON-SPECIALISED
OR CELL present in
CONNECTIVE
all ENDOSTEAL
TISSUE CELLS in
and
the region of
SUBPERIOSTEAL
fracture which are
surface give rise to
induced into
CALLUS.
conversion to
OSTEOBLASTS.

Callus Formation

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

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

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).

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).

COMPLICATIONS OF
FRACTURE HEALING

MALUNION

DELAYED UNION
NONUNION

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

MALUNION contd
MALUNION can IMPAIR FUCNTION
by
ABNORMAL JOINT SURFACE
ROTATION or ANGULATION
OVERRIDING
MOVEMENT OF NEIGHBOURING
JOINT MAY BE BLOCKED

CHARACTERISTICS FOR ACCEPTABILITY

OF FRACTURE REDUCTION

ALIGNMENT (MOST IMPORTANT)

ROTATION
RESTORATION OF NORMAL
LENGTH
ACTUAL POSITION OF FRAGMENTS
(LEAST IMPORTANT)

Delayed Union
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 cont.

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

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)

Delayed/Nonunion
Factors contributing to development:
Systemic
Local

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

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

Nonunion

cont.

Nonunited fractures form two types of

pseudoarthrosis:
Hypervascular or hypertrophic
Avascular or atrophic

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

Nonunion cont.
Specific Bones

Metatarsals
Tibia
Fibula
Patella
Femur
Pelvis and acetabulum
Clavicle
Humerus
Radius
Ulna

THANK YOU