BONE

Two forms of bone tissue

 Cortical or compact bone
 Cancellous or trabecular bone
Two types of bone
(mechanical & biological properties)
 Woven or immature bone
 Lamellar or mature bone
WOVEN BONE
More rapid rate of deposition & resorption
 Irregular woven pattern of matrix collagen fibril
 Four times the number of osteocyte per unit volume
 Irregular pattern of matrix mineralization

Less stiff & more easily deformed

• Direct
– Primary bone healing
– Cutting cones
– Seen with absolute stability
• Indirect
– Secondary bone healing
– Callus formation; resorption at fx site;
– Seen with relative stability
Absolute Stability
• Compression of two anatomically
reduced fracture fragments.
• No displacement of the fracture under functional load.
• Examples:
– Lag screw
– Plate => compression, buttress,
 Tension band
Relative Stability
• Motion between fracture fragments that is compatible
with fracture healing.
• Motion is below the critical strain level of tissue repair.
• Examples:
– IM nails
– Bridge plate
– External Fixator
 Direct Bone Healing

 Gap healing
 Haversian remodeling

Osteoclast resorb fracture line deposition osteoblast

Blood vessels formation

The new bone matrix + New Haversian Systems

osteocytes or primary osteons
 Primary bone healing
after rigid fracture
fixation. Contact healing
occurs in the cortex
underlying the plate, by
direct Haversian
remodeling. Layers of
bone are first laid down
perpendicular to the long
axis of the bone, and are
then replaced by
longitudinally oriented
osteons by cutting cones
progressing across the
gap.
Inflammation

Repair:
soft/hard
callus

Remodelling
Indirect Stages:
1. Inflammation
– 1-7 days
2. Soft callus
– 3 weeks Repair
3. Hard callus
– 3 – 4 months
4. Remodeling
– months => years
1. Inflammation
 Begins w/ fx and ends w/ fibrous tissue or
cartilage formation.
 Hematoma is formed, becomes organized,
granulation tissue formation.
.
 Indirect Bone Healing
1. Inflammation
Fracture damages the bone, blood vessels,
bone matrix and surrounding soft tissue

-Dilatation blood vessel

- Plasma exudat
 Haematoma
- inflammatory cells
 Inflammatory
Release by - PMN lecocytes
mediators
platelets inj.cells - Macrophages
- Lymphocytes
 Indirect Bone Healing
1. Inflammation
Macrophage - Cytokines (PDGF, TGF ß )
- Interleukin 1 & 6
Degranulating - Prostaglandin E2 (PGE2)

platelets release

Invitiation of the repair process

Indirect Bone Healing
1. INFLAMMATION
Inflammatory Necrosis Tissue and Exudate Resorbed

Fibroplasty & Chondrocytes Appears

Produce new matrix

(The fracture callus)
2. Soft callus
Begins in 3 to 4 days with the appearance of
granulation tissue, matures into fibrous tissue and
firbrocartilage, stabilizes site w/ internal and
externalcallus, pain and inflammation end.
3. Hard callus
Mineralization and conversion to bone.
Endochondral ossification of fibrocartilage forming
cancellous bone.
4. Remodeling
 Begins in middle of repair phase, continues until fx
clinically healed
 Osteoclastic tunneling (cutting cones) in concert with
osteoblast deposition
 Can continue up to 7 years
 Remodeling based on stresses (Wolff’s law)
 Hueter-Volkmann law
 in the skeletally immature, bone growth is
relatively inhibited in areas of increase pressure
and relatively stimulated in areas of decreased
pressure or tension
 Wolff’s law
 the remodeling of bone or soft tissue is
influenced and modulated by mechanical stress
Bone Healing Time
Clavicle 3-8 weeks
Scapula 6 weeks
Rib 4 to 5 weeks
Humerus 4-10 weeks
Radius & ulna 6 weeks
Metacarpal 3 to 4 weeks
Fingers 2-3 weeks
Pelvis 4 - 6 weeks
Bone Broken Healing Time
Femur 12 weeks
Patella 4-6 weeks
Tibia,fibula 10-24 weeks
Metatarsal 5 to 6 weeks
Toe 2 to 4 weeks
 Nicotine
Blood
supply NSAIDs Age
Nutrition Comorbidity

Vascular injury
Soft tissue
envelope
Functional
Level
Soft tissue
Nerve Function attachments to
Hormones Factors in bone
Growth Factors fracture Stability
Sterility
healing Site/location
Local pathology Energy
eg Ca Bone Loss
Type of bone
Bone loss
FACTORS IN BONE HEALING

Patient Variables

* Age
* Nutrition
Healing process needs

- Energy
- Proteins & carbohydrates
FACTORS IN BONE HEALING

Patient variables

* Systemic hormones
- Corticosteroid ( )
- Growth hormone
- Thyroid hormone
- Calcitonin
- Insulin
Rate fracture healing
- Anabolic steroids
- DM
- Rickets Frame healing

* Nicotine

- Inhibit fracture healing ( Vascularization?)

FACTORS IN BONE HEALING
Tissue Variables
* Cancellous or cortical bones
* Bone necrosis
* Bone disease

Pathologic fracture

 Osteoprosis
 Osteomalacia
 Primary malignant bone tumors
 Metastatic bone tumors
 Benign bone tumors
 Bone cysts
 Osteogenesis imperfecta
 Paget’s disease
 Fibrous dysplacia
 Hyperparathyroidism
* Infection
 FACTORS IN BONE HEALING

Treatment Variables

• Apposition of fracture fragments

• Loading & micromotion
 Loading a fracture site stimulates bone formation
 Micromotion promotes fracture healing
FACTORS BONE HEALING
Treatment Variables

• Fracture stabilization
-Traction
Facilitate fracture healing by
- Cast Imm Preventing repeated disruption of
- Ext.Fixation Repair tissue
- Int.Fixation

Potential disadvantage of int.fixation :

 Surgical exposure disrupted hematoma,
blood supply
 Risk of infection
 Rigid fixation alter fracture remodeling,
bone density
Bone Grafts
 Cancellous graft
 Quick to revascularize
 “Creeping substitution”
 Cortical graft
 Slow remodelling process which weakens then re-
strengthens
 Synthetic graft
 Calcium phosphate, silicon, aluminum
 Mainly osteoconductive
•Delayed healing.
•Non healing.
•Joint involvement - ankylosis
•Abnormal position – arthritis.
•Bone necrosis – nutrient artery
•Involucrum formation.
•Pseudoarthrosis