Anatomy of Bone and

Fracture Healing
Kapilvastu Hospital
Dr. Ajay Kumar Chaudhary
Anatomy of Bone
• Bones may be classified into four types on the basis of their shape i.e.,
long, short, flat and irregular
• Structure of typical long bone:
-Epiphysis
-Diaphysis(shaft)
-Metaphysis
-Growth plate(Epiphyseal plate): There is thin plate of growth cartilage,
one at each end, separating the epiphysis from metaphysis. This is called
epiphyseal plate. At maturity, the epiphysis fuses with the metaphysis
and the epiphyseal plate is replaced by bone.
Microscopically, bone can be classified as either
woven and lamellar.

• Woven bone or( immature bone): characterized by random

arrangement of bone cells (osteocytes) and collagen fibres. Woven
bone is formed at periods of rapid bone formation i.e. initial stages of
fracture healing.
• Lamellar bone or (mature bone): It has an orderly arrangement of
bone cells and collagen fibres. Lamellar bone constitutes all bones,
both cortical and cancellous.
The difference is, that in cortical bone the lamellae are densely
packed, and in cancellous bone loosely.
-The basic structural unit of lamellar bone is the osteon.

• -It consists of a series of concentric

laminations or lamellae surrounding a
central canal, the Haversian canal.
These canals run longitudinally and
connect freely with each other and
with Volkmann's canals.
Structural composition of bone
a)Bone cells
b)Matrix
a) Bone cells: Three types
1. Osteoblasts: Concerned with ossification, these cells are rich in
alkaline phosphatase, glycolytic enzymes and phosphorylases
2. Osteocytes: These are mature bone cells which vary in activity, and
may assume the form of an osteoclast or reticulocyte. These cells
are rich in glycogen and PAS positive granules.
3. Osteoclasts: These are multi-nucleate mesenchymal cells
concerned with bone resorption. These have glycolytic acid
hydrolases, collagenases and acid phosphatase enzymes.
b) Matrix:
• Consistis of two types of material
1.Organic 2.Inorganic
-formed by collagen - primarily Ca & P especially
hydroxyapatite
[Ca10(PO4)6(OH)2]
-30-35% of dry weight of bone - 60-75% of dry weight of bone
BLOOD SUPPLY OF BONES
a) Nutrient artery: This vessel enters the bone around its middle and
divides into two branches, one running towards either end of the
bone. Each of these further divide into a leash of parallel vessels
which run towards the respective metaphysis.
b) Metaphyseal vessels: These are numerous small vessels derived
from the anastomosis around the joint. They pierce the metaphysis
along the line of attachment of the joint capsule.
c) Epiphyseal vessels: These are vessels which enter directly into the
epiphysis.
d) Periosteal vessels: The periosteum has a rich blood supply, from
which many little vessels enter the bone to supply roughly the
outer-third of the cortex of the adult bone.
Fracture Healing
A fracture begins to heal soon after it occurs, through a continuous series
of stages described below

STAGES IN FRACTURE HEALING OF CORTICAL BONE (FROST, 1989)

• 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:
- 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 fracture end necrosis over variable length.
- 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:
- Lasts for 2-3 weeks
- The sensitised precursor cells (daughter cells) produce cells which
differentiate and organise to provide blood vessels, fibroblasts,
osteoblasts etc.
- Fracture are still mobile
3. Stage of callus:
- Lasts for about 4-12 weeks.
- Mineralisation of granulation tissue.
- Callus radiologically visible usually after 3 weeks.
- Fracture clinically united, no more mobile.

4. Stage of remodelling: (formally called consolidation)

- Lasts for 1-2 years
- 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.
5. Stage of modelling (formally called remodeling)
- Lasts many years.
- Bone gradually strengthened.
- Modelling of endosteal and periosteal surfaces so that the fracture
site becomes indistinguishable from the parent bone.
Stage of fracture healing
HEALING OF CANCELLOUS BONE

- The bone is of uniform spongy texture and has no medullary cavity so

that there is a large area of contact between the bone.
- Union can occur directly between the bony surface without having to
pass through the stage of callus formation.
- Following 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

1. 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.
2. Type of bone: Flat and cancellous bones unite faster than tubular

and cortical bones.

3. Pattern of fracture: Spiral fractures unite faster than oblique
fractures, which in turn unite faster than transverse fractures.
Comminuted fractures are usually heal slower.
4. 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: 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
(ii) Ischaemic fracture ends: 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.
5. 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).
6. 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.
7. Open fractures: Open fractures often go into delayed union and non-
union.
8. Compression at fracture site: Compression enhances the rate of
union in cancellous bone. In cortical bones its not well understood.
THANK YOU FOR YOUR ATTENTION!!