Fracture Healing

-Dr.Sumit Bhosale
The healing of fracture is in many ways similar to the healing of soft tissue
wounds ,except that soft tissue heals with fibrous tissue,and the end result of bone
healing is
Mineralized mesenchymal tissue,i.e Bone.
A fracture begins to heal soon after a fracture occurs,through a continuous series of
stages.
STAGES IN FRACTURE HEALING OF CORTICAL BONE

• Stage of haematoma
• Stage of granulation tissue
• Stage of callus
• Stage of remodelling (formerly called consolidation)
• Stage of modelling (formerly called remodelling)
1.Stage of haematoma
This stage lasts up to 7 days. When a bone is fractured, blood leaks out through
torn vessels in the bone and forms a haematoma between and around the
fracture. The periosteum and local soft tissues are stripped from the fracture ends.
This results in ischaemic necrosis of the fracture ends over a variable length,
usually only a few millimetres. Deprived of their blood supply, some osteocytes die
whereas others are sensitised to respond subsequently by differentiating into
daughter cells. These cells later contribute to the healing process.
2.Stage of granulation tissue
This stage lasts for about 2-3 weeks. In this stage, the sensitised precursor cells (daughter
cells) produce cells which differentiate and organise to provide blood vessels, fibroblasts,
osteoblasts etc. Collectively they form a soft granulation tissue in the space between the
fracture fragments. This cellular tissue eventually gives a soft tissue anchorage to the
fracture, without any structural rigidity. The blood clot gives rise to a loose fibrous mesh
which serves as a framework for the ingrowth of fibroblasts and new capillaries. The clot is
eventually removed by macrophages, giant cells and other cells arising in the granulation
tissue.
From this stage, the healing of bone differs from that of soft tissue. In soft tissue healing the
granulation tissue is replaced by fibrous tissue, whereas in bone healing the granulation
tissue further differentiates to create osteoblasts which subsequently form bone.
3.Stage of callus
This stage lasts for about 4-12 weeks. In this stage, the granulation tissue
differentiates further and creates osteoblasts. These cells lay down an intercellular
matrix which soon becomes impregnated with calcium salts. This results in
formulation of the callus, also called woven bone. The callus is the first sign of
union visible on X-rays, usually 3 weeks after the fracture (Fig-2.4). The formation
of this bridge of woven bone imparts good strength to the fracture. Callus
formation is slower in adults than in children, and in cortical bones than in
cancellous bones.
4.Stage of remodelling:
Formerly this was called as the stage of consolidation. In this stage, the woven
bone is replaced by mature bone with a typical lamellar structure. This process of
change is multicellular unit based, whereby a pocket of callus is replaced by a
pocket of lamellar bone. It is a slow process and takes anything from one to four
years.
5.Stage of modelling
Formerly called the stage of remodelling. In this stage the bone is gradually
strengthened. The shapening of cortices occurs at the endosteal and periosteal
surfaces. The major stimulus to this process comes from local bone strains i.e.,
weight bearing stresses and muscle forces when the person resumes activity. This
stage is more conspicuous in children with angulated fractures. It occurs to a very
limited extent in fractures in adults.
HEALING OF CANCELLOUS BONES
The healing of fractured cancellous bone follows a different pattern. The bone is of
uniform spongy texture and has no medullary cavity so that there is a large area of
contact between the trabeculae. Union can occur directly between the bony
trabeculae. Subsequent to haematoma and granulation formation, mature
osteoblasts lay down woven bone in the intercellular matrix, and the two fragments
unite.
PRIMARY AND SECONDARY BONE HEALING

Primary fracture healing occurs where fracture haematoma has been disturbed, as
in fractures treated operatively. The bone heals directly, without callus formatiom,
and it is therefore diffcult to evaluate union on X-rays. Secondary fracture healing
occurs in fractures where fracture haematoma is not disturbed, as in cases treated
non-operatively. There is healing, with callus formation, and can be evaluated on
X-rays. It also occurs in fractures operated without disturbing the fracture
haematoma, as in fractures fixed with relative stability (e.g. comminuted fractures).
FACTORS AFFECTING FRACTURE HEALING
a) Age of the patient
Fractures unite faster in children. In younger children, callus is often visible on X-
rays as early as two weeks after the fracture. On an average, bones in children
unite in half the time compared to that in adults. Failure of union is uncommon in
fractures of children.
b) Type of bone:
Flat and cancellous bones unite faster than tubular and cortical bones.
c) Pattern of fracture:
Spiral fractures unite faster than oblique fractures, which in turn unite faster than
transverse fractures. Comminuted fractures are usually result of a severe trauma
or occur in osteoporotic bones, and thus heal slower.
d) Disturbed pathoanatomy:
Following a fracture, changes may occur at the fracture site, and may hinder the
normal healing process. These are: (i) soft tissue interposition; and (ii) ischaemic
fracture ends. In the former, the fracture ends pierce through the surrounding soft
tissues, and get stuck. This causes soft tissue interposition between the
fragments, and prevents the callus from bridging the fragments. In the latter, due
to anatomical peculiarities of blood supply of some bones (e.g. scaphoid),
vascularity of one of the fragments is cut off. Since vascularised bone ends are
important for optimal fracture union, these fractures unite slowly or do not unite at
all.
e) Type of reduction:
Good apposition of the fracture results in faster union. At least half the fracture
surface should be in contact for optimal union in adults. In children, a fracture may
unite even if bones are only side-to-side in contact (bayonet reduction).
f) Immobilisation
It is not necessary to immobilise all fractures (e.g., fracture ribs, scapula, etc).
They heal anyway. Some fractures need strict immobilisation (e.g., fracture of the
neck of the femur), and may still not heal.
g) Open fractures
Open fractures often go into delayed union and non-union
h) Compression at fracture site
Compression enhances the rate of union in cancellous bone. In cortical bones,
compression at the fracture site enhances rigidity of fixation, and possibly results
in primary bone healing.
Extra Pointers for Markers.
● Pathognomonic sign of traumatic and fresh fracture is crepitus.
● Most common cause of non-union is inadequate immobilisation.
● Markers of bone formation: Serum bone specific alkaline
phosphatase
Serum osteocalcin
Serum peptide of type 1 collagen
● Markers of bone resorption: Urine and serum crosslinked‘N’
telopeptide
Urine and serum crosslinked ‘C’ telopeptide
● Rate of mineralisation determined by labelled tetracycline.