FRACTURE

HEALING
Dr. Nuri Aydn, Assoc. Prof.
Istanbul University
Cerrahpasa School of Medicine
Department of Orthopedics and Traumatology
nuri.aydin@istanbul.edu.tr

 Fracture is a break in the structural conLnuity

of the bone

GREEN STICK

COMPLETE

INCOMPLETE

Normal

Transverse Oblique

Spiral

Comminuated Avulsion Impacted Fissure GreensLck

 Local Signs of Fracture

Pain and tenderness
Deformity
Swelling
Bruising
Loss of funcLon

Fracture Mechanism
Single traumaLc event

Fracture Mechanism
RepeteLve stress

Fracture Mechanism
RepeteLve stress

Periosteal reacLon
No fracture seen

Fracture Mechanism
Abnormal weakening of
the bone
MetastaLc bone lesions
Osteoporosis
Senile
Radiotheraphy

Inamma&on

Repair
SoQ Callus
Hard Callus

Remodelling

STAGES OF FRACTURE HEALING

Repara&ve
Phase

Remodelling
Phase

INTENSITY OF RESPONSE

Inamma&on
Phase

10%

40%

70%

INFLAMMATION
Hematoma (brin clot)
Macrophages
Inammatory leukocytes
Osteoprogenitor cells
HematopoieLc cells secrete
growth factors

GranulaLon Tissue

REPAIR
Primary callus response (2 weeks)
InammaLon triggers cell division
and growth of new blood vessels
(Angiogenesis)

SOFT CALLUS

Chondrocytes secrete collagen

and proteoglycans
Creates brocarLlage

REPAIR
Enchondral ossicaLon
Bone formaLon
SoQ callus turns to hard
callus (woven bone)

HARD CALLUS

Primary CorLcal Healing

Osteonal healing
Resembles normal remodelling
Occurs with rigid immobilizaLon
Plate

Anatomic reducLon

Rigid ImmobilizaLon

No Visible Callus

Secondary CorLcal Healing

Enchondral healing
Closed treatment
Cast

There is movement at the

fracture site
Periosteal Bridging Callus

callus

REMODELLING
Begins during the middle of the repair phase
ConLnues up to 7 years
Allows the bone to assume its normal
conguraLon
The stresses on the bone is important (Wols
Law)

Bone Remodelling Cycle

REMODELLING

Woven bone replaces with lamellar bone

 WOLFFS LAW
If loading on a parLcular bone
increases,
the bone will remodel itself over Lme
to become stronger
AdapLve changes happen at the
internal architecture of the
trabeculae

Julius Wolff

Newborn

Newborn

Newborn

Newborn

Newborn

9 year old

Date of Injury

Date of Injury

Date of Injury

Date of Injury

AQer 3
months

Date of Injury

AQer 3
months

Date of Injury

AQer 5
months

Date of Injury

AQer 3
months

Date of Injury

AQer 5
months

AQer 12
months

Growth Factors of Bone

Bone Morphogenic Protein (BMP)
Transforming Growth Factor-beta (TGF-)
Insulin-Like Growth Factor II (IGF-II)
Platelet-Derived Growth Factor (PDGF)

Growth Factors of Bone

Bone Morphogenic Protein (BMP)
OsteoinducLve
Mesenchymal cells

Osteoblasts

Transforming Growth Factor-Beta (TGF-)

Induces mesenchmal cells and osteoblasts to
produce type II collagen
Regulates carLlage and bone formaLon in fracture
callus

What inuence Fracture Healing?

Biologic Factors

Age
Comorbid medical condiLons
FuncLonal level
NutriLonal status
Nerve funcLon
Vascular Injury
Health of soQ Lssue envelope
Sterility (open fractures)
Smoking
Extent of Bone Loss

 Mechanical Factors
SoQ Lssue aiachments to bone
Stability
Anatomic locaLon
Level of energy imparted

Endocrine Eects on Fracture Healing

Eect

Mechanism

Growth hormone +

Increased callus volume

TH/PTH

Bone remodelling

Calcitonin

+? Unknown

Cor&sone

Decreased callus proliferaLon

Systemic Factors

Ultrasound and Fracture Healing

Increases mechanical strength of callus

Mechanical energy is transmiied to the cells

RadiaLon and Fracture Healing

Decreases the cellularity
Reduces structural integrity

Electricity and MagneLc Fields

There are charged molecules
on bone and carLlage
Electrical sLmulaLon alters a
variety of cellular acLvity
SLmulate bone healing

2011

Healing

StaLc magneLc eld increases the

radiological callus in the rst two
weeks
PolarizaLon makes dierence in
results
No dierence in bone mineral
density

 THANK YOU
Dr. Nuri Aydn

nuri.aydin@istanbul.edu.tr