1

Biomolecular in
fracture healing
Abdul Haris Nasrudin

Definition
Fracture: A break inboneor cartilage
Trauma
Disease ofbone osteoporosis,
Abnormal formation ofbonein a congenital disease
osteogenesis imperfecta ('brittlebonedisease')

Marshal 2012

Anatomy

Components of Bone Formation

Cortex
Periosteum
Bone marrow
Soft tissue
Scott broderict 2012

Factors of fracture healing

Activated Progenitor
cell &
undifferentiated
multipotent
mesenchymal
stem cells (MSCs)
osteoblast ,endotel
and osteoclast cells
(Vicram S 2013)

essential for the

formation of
a callus that
bridges the
fracture site
allowing
loads to be
transmitted
across the

extracellular
matrix that
provides the
natural scaffold
platelet-derived growth
factor(PDGF), fibroblast
growth factor (FGF),
insulin like growth factor1 (IGF-1), Parathyroid
Hormone (PTH), and the
transforming
growth factor-beta (TGFb) superfamily,bone
morphogenetic proteins
(BMPs) (Vicram S 2013)
Peter V Gianoudis :The diamond
concept 2012

Signaling molecules
Pro-inflammatory cytokines
Transforming growth factor-beta (TGF-b)
superfamily and others growth factors
Angiogenic factor
Rozalia Current concepts of molecular aspects of bone
healing 2010

Pro inflamatory cytokines

Interleukin-1 (IL-1) , Interleukin-6 (IL-6) and tumour necrosis factoralpha (TNF-a) and others :
activate respon to trauma and fracture healing cascade
chemotactil effect to inflamation cells
activate syntesis of extracelular matric and stimulate
angiogenesis
activate mesenchimal stem cell differentiation

peak secretion in first 24 hours

influenced remodelling phase

Transforming Growth Factor-beta

(TGF-b) superfamily and others
Include Bone Morphogenetic Proteins (BMPs), Transforming
Growth Factor-beta (TGF-b) and Growth Differentiation
Factors (GDFs)
At least 34 growth hormons
Each have different time expression and specific respons

Temporal expression and

characteristic
Of TGF beta superfamily
(rozalia dimetriou Current
concepts of molecular aspects of
bone healing 2010)

1
0

Bone Morphogenetic Proteins (BMPs)

Resepto
r serine

Negativ
e
feedbac
k

Co smad: common mediator ,I

smad:inhibitor

stimulate
undifferentiated
multipotent mesenchymal
stem cells (MSCs)
proliferation and
differentiated to be
osteoblast,
chondroosteogenesis
regulate apoptosis
R-Smad: Signal-transducing receptorregulated
osteoblast and
Smads

1
2

Angiogenic factor
Vascular Endothelial Growth Factors (VEGFs) express on
day 14
Potent stimulators of endothelial cell proliferation
Expressed during endochondral formation and bone
formation
Neo-angiogenesis which infiltrates along new
mesenchymal cells

1
1

Temporal expression
signaling molecules
(rozalia
dimetriou 2010)

1
3

FRACTURE HEALING PHASE

Prerequisites for Bone Healing :
Adequate blood supply
Adequate mechanical stability
Fracture healing (histopatology):
Primary (direct) and Secondary
(indirect)

1
4

cont

1
5

FRACTUR HEALING: DIRECT

/PRIMARY
Cutting cone formation

Reestablishes the continuity of osteons (the

haversian system) across the fracture line
without external callus formation
Osteoclasts create cutting cones to allow
revascularization, brings mesenchymal
(osteoprogenitor) cells osteoblasts
Need rigid stability and absolut contact of
the fragments
Intramembranous ossification (haversi
system formation) and direct cortical

Figure from http://www.vetmed.ufl.edu/sacs/notes

remodeling.

Mark B Wrinker
2016

1
6

FRACTUR HEALING: INDIRECT /SECONDARY

Dr. Susan E. Brown, PhD. How to Speed Fracture Healing. www.betterbones.com

1
7

Dr. Susan E. Brown, PhD. How to Speed Fracture Healing. www.betterbones.com

1
8

INFLAMASI (4 days-1 week)

Hematoma formation
Macrophages
Inflammatory leukocytes
(PMN,makrophage,limfosit)
Mast cellsbradikinin and trombosit
fibrin platelet derived growth factors
(PDGF) and TGF-p BMP
Necrosis of fragment fracturelisozim
release,PGE2 induce growth factors (TGF
beta,IGF etc)
Mesenchima cells (Osteoprogenitor cells)
from periosteum and soft tissue around

1
9

Signaling
molecules

inflamatio
n

Cartilage
formation and
periosteal
response

Cartilage
resorption and
primary bone
formation

Secondary
bone
formation
and
remodeling

Cytokines
IL-1

IL-6

TNF-

RANKL

OPG

MCSF

Angiogenic
Factors
VEGF A

VEGF B

VEGF C

VEGF D

Al Aql 2008

2
0

PROLIFERATION
Mesenchimal cells differentiatedChondroblastcollagen
and proteoglycanschondrocytechondroid-osteoid
phasecallushard callus
Primary callus response (2 weeks)
Growth factors :
Interleukin-1stimulate calcified callus
BMP-3:mesenchimal cellosteoblast,IGF 2 stimulate
proliferation osteoblast and cartillago
Prostaglandin stimulate osteoclast activity bone resorption
(prekusor bone formation)
SOFT
CALLUS

insulin-like growth factor-II"(IGF-II) stimulate proliferation

osteoblast and cartilago
Vascular Endothelial Growth Factors (VEGFs) neoangiogenesis

2
1

REPAIR
Enchondral ossification
Bone formation
Soft callus turns to hard callus (woven
bone)

HARD CALLUS

Inadequate immobilization exuberant

cartilaginous callus+wide distance inter
fractur fragment (+)non union

2
2

Signaling
molecules

inflamation

Cartilage
formation and
periosteal
response

Cartilage
resorption and
primary bone
formation

Secondary
bone
formation and
remodeling

TGF-
Superfamily
BMP-2
BMP-3
BMP-4

BMP-5

BMP-6

BMP-7

BMP-8

TGF- 2

TGF- 3

GDF-5

GDF-8

2
3

(rozalia
dimetriou 2010)

2
4

REMODELLING

Begins during the middle of the repair

phase
Continue up to 7 years
Allows the bone to assume its normal
configuration
The stresses on the bone is important
Wolffs Law :bone remodels in response
to stress
and strain
Woven bone replaced with lamillar bone

2
5

BONE REMODELLING CYCLE

Proliferation
osteoprogenitor cells
(periosteum and bone
marrow) "Determined
Osteoprogenitor Cells"
(DOPC)direct
ossification
intramembranosa
mineralised bone
restore bone
morphology
Bone medulla formed
and osteoblast
osteocyte (in the
matrix)

2
6

Mark Brinker :The Biological

Basis for Nonunions 2016

2
7

Factors influenced fracture healing

Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit cyclooxygenase2 (COX-2) enzime inhibit PGE2delay healing response (7 weeks longer)
Smokinginhibit callus formation and hard callus (4 weeks longer)
Uncontrolled diabetes melitusdecreased 29% tensile strenght and
50% stiffnes (after 2 weeks treatment) and callus formation < 50% than
control.Increased risk of non union (38% pada diabetes vs 27% pada non
diabetes)
Agedecrease BMP -2 expression and expression cyclooxigenase COX-2
75% (at age 52-56 y.o)
Bone stimulator
electrical stimulatorstimulate osteoblast
ultrasound stimulatorstimulate by stress (following wollf law)

2
8

THANKS YOU