fracture healing
TRANSCRIPT
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FRACTURE HEALING
Dr. NISHITH SHARMADEPT. OF ORTHOPAEDICS
NIMS MEDICAL COLLEGE & HOSPITAL
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INTRODUCTION
• Fracture is a break in the structural continuity of bone or periosteum.
• The healing of fracture is in many ways similiar to the healing in soft tissue wounds except that the end result is mineralised mesenchymal tissue i.e. BONE.
• Fracture healing starts as soon as bone breaks and continues modelling for many years.
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The essential event in fracture healing is the creation of a bony bridge between the two fragments which can be readily be built upon and modified to suit the particular functional demands .
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Components of BONE Formation
Cortex
Periosteum
Bone marrow
Soft tissue
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Type of BONE formed
OSTEOCHONDRAL INTRAMEMBERANOUS OSSIFICATION OPPOSITIONAL NEW BONE FORMATIONOSTEONAL MIGRATION (Creeping Subsitituion)
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FACTORS EFFECTING
The TYPE , AMOUNT and LOCATION of bone formed depends upon-----
FRACTURE TYPE GAP CONDITION FIXATION RIGIDITY LOADING BIOLOGICAL ENVIRONMENT
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FRACTURE HEALING TYPES
Fracture healing is divided according to bone--
1. Cortical bone of the shaft.
2. Cancellous bone of the metaphyseal region of the long bones and the small bones.
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STAGES OF FRACTURE HEALING
TISSUE DESTRUCTION AND HAEMATOMA FORMATION
INFLAMATION AND CELLULAR PROLIFERATION
STAGE OF CALLUS FORMATION STAGE OF COSOLIDATION STAGE OF REMODELLING
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Tissue destruction and Hematoma formation
– Torn blood vessels hemorrhage
– A mass of clotted blood (hematoma) forms at the fracture site
– Site becomes swollen, painful, and inflamed
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Tissue destruction and Hematoma formation
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INFLAMATION AND CELLULAR PROLIFERATION
• Within 8 hours inflammatory reaction starts.
• Proliferation and Differntiation of mesenchymal stem cells.
• Secretion of TGF-B , PDGF and various BMP factors.
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Callus Formation
• Fibrocartilaginous callus forms
• Granulation tissue (soft callus) forms a few days after the fracture
• Capillaries grow into the tissue and phagocytic cells begin cleaning debris
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Callus Formation Theory
• OSTEOPROGENITOR CELL present in all ENDOSTEAL and SUBPERIOSTEAL surface give rise to CALLUS.
• CALLUS arises from NON-SPECIALISED CONNECTIVE TISSUE CELLS in the region of fracture which are induced into conversion to OSTEOBLASTS.
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Callus Formation
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STAGE OF CONSOLIDATION
– New bone trabeculae appear in the fibrocartilaginous callus
– Fibrocartilaginous callus converts into a bony (hard) callus
– Bone callus begins 3-4 weeks after injury, and continues until firm union is formed 2-3 months later
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STAGE OF REMODELLINGExcess material on the
bone shaft exterior and in the medullary canal is removed
Compact bone is laid down to reconstruct shaft walls
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Schematic drawing of the callus healing process. Early intramembranous bone formation (a), growing callus volume and diameter mainly by enchondral ossification (b), and bridging of the fragments (c).
Figure from Brighton, et al, JBJS-A, 1991
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A: Roentgenogram of a callus healing in a sheep tibia with the osteotomy line still visible (6 weeks p.o.). B: Histological picture of a sheep tibia osteotomy (fracture model) after bone bridging by external and intramedullary callus formation. A few areas of fibrocartilage remain at the level of the former fracture line (dark areas).
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Variables Influence Fracture Healing
INJURY VARIABLES
Open FracturesImpeding or preventing formation # Hematoma Delaying formation repair tissue Risk of infection
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INJURY VARIABLES
Intra articular fractures
If the alignment & congruity joint surface is not restored
Delayed healing or non union Joint stiffness
* Segmental fractures* Soft tissue interposition* Damage to the blood supply
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Patient Variables
AGENUTRTION HEALING PROCESS NEEDS Energy Proteins & carbohydrates
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Patient Variables cont…. Systemic hormones Corticosteroid ( ) Growth hormone Thyroid hormone Calcitonin Insulin Anabolic steroids DM Hypervitaminosis D Rickets
Inhibit fracture healing ( Vascularization?)Nicotine
Rate fracture healing
Rate fracture healing
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Tissue Variables
Cancellous or cortical bones
Bone necrosis
Infection
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Bone disease
Osteoprosis Osteomalacia Primary malignant bone tumors Metastatic bone tumors Fibrous dysplacia Benign bone tumors Bone cysts Osteogenesis imperfecta Paget’s disease Hyperparathyroidism
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Treatment Variables
Apposition of fracture fragments Loading & micromotion Loading a fracture site stimulates bone
formation Micromotion promotes fracture healing
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Treatment Variables
Fracture stabilization Traction Cast Imm Ext.Fixation Int.Fixation
Facilitate fracture healing byPreventing repeated disruption of Repair tissue
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COMPLICATIONS OF FRACTURE HEALING
• MALUNION
• DELAYED UNION
• NONUNION
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MAL UNION
A MALUNITED Fracture is one that has healed with the fragments in a non anatomical position.
CAUSES1 INACCURATE REDUCTION2 INEFFECTIVE IMMOBILIZATION
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MALUNION contd…
MALUNION can IMPAIR FUCNTION byABNORMAL JOINT SURFACEROTATION or ANGULATIONOVERRIDINGMOVEMENT OF NEIGHBOURING JOINT MAY
BE BLOCKED
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CHARACTERISTICS FOR ACCEPTABILITY OF FRACTURE REDUCTION
ALIGNMENT (MOST IMPORTANT) ROTATION RESTORATION OF NORMAL LENGTHACTUAL POSITION OF FRAGMENTS (LEAST IMPORTANT)
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ANALYSIS OF DEFORMITY
• RIES and O’NEILL developed TRIGNOMETRIC ANALYSIS of DEFORMITY and designed E-GRAPH to determine the true maximal deformity on AP and LATERAL X-Ray views.
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MALUNION contd….
• Operative treatment for most malunited fracture should not be considered until 6 to 12 months but in INTRA ARTICULAR fracture early operative treatment is needed.
• Surgeon should look for before surgery--OSTEOPROSISSOFT TISSUE HOW MUCH FUNCTION CAN BE GAINED
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MALUNION contd….
ILIZAROV TECHNIQUE is BEST Simultaneous restoration of
ALIGNMENT
ROTATION
LENGTH
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Delayed Union
• The exact time when a given fracture should be united cannot be defined
• Union is delayed when healing has not advanced at the average rate for the location and type of fracture (Btn 3-6 mths)
• Treatment usually is by an efficient cast that allows as much function as possible can be continued for 4 to 12 additional weeks
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Delayed Union cont.
• If still nonunited a decision should be made to treat the fracture as nonunion
• External ultrasound or electrical stimulation may be considered
• Surgical treatment should be carried out to remove interposed soft tissues and to oppose widely separated fragments
• Iliac grafts should be used if plates and screws are placed but grafts are not usually needed when using intramedullary nailing, unless reduction is done open
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Nonunion
• FDA defined nonunion as “established when a minimum of 9 months has elapsed since fracture with no visible progressive signs of healing for 3 months”
• Every fracture has its own timetable (ie long bone shaft fracture 6 months, femoral neck fracture 3 months)
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Delayed/Nonunion
Factors contributing to development:• Systemic• Local
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Delayed/Nonunion cont.
Systemic factors:• Metabolic• Nutritional status• General health• Activity level• Tobacco and alcohol use
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Delayed/Nonunion cont.
Local factors• Open• Infected• Segmental (impaired blood supply)• Comminuted• Insecurely fixed• Immobilized for an insufficient time• Treated by ill-advised open reduction• Distracted by (traction/plate and screws)• Irradiated bone• Delayed weight-bearing > 6 weeks• Soft tissue injury > method of initial treatment
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Nonunion cont.
Nonunited fractures form two types of pseudoarthrosis:
• Hypervascular or hypertrophic• Avascular or atrophic
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Nonunion cont.
Hypervascular or Hypertrophic:
1. Elephant foot (hypertophic, rich in callus)
2. Horse foot (mildly hypertophic, poor in callus)
3. Oligotrophic (not hypertrophic, no callus)
Hypervascular nonunions. A, "Elephant foot" nonunion. B, "Horse hoof" nonunion. C, Oligotrophic nonunion (see text). (Redrawn from Weber BG, Cech O, eds: Pseudarthrosis, Bern, Switzerland, 1976, Hans Huber.)
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Nonunion cont.
Vascular or Atrophic• Torsion wedge
(intermediate fragment)• Comminuted (necrotic
intermediate fragment)• Defect (loss of fragment
of the diathesis)• Atrophic (scar tissue
with no estrogenic potential is replacing the missing fragment)
Avascular nonunions. A, Torsion wedge nonunion. B, Comminuted nonunion. C, Defect nonunion. D, Atrophic nonunion (see text). (Redrawn from Weber BG, Cech O, eds: Pseudarthrosis, Bern, Switzerland, 1976, Hans Huber.)
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Nonunion cont.
Classification (Paley et al)• Type A<2cm of bone loss A1 (Mobile deformity) A2 (fixed deformity) A2-1 stiff w/o
deformity A2-2 stiff w/ fixed
deformity• Type B>2cm of bone loss B1 with bony defect B2 loss of bone length B3 both
A, Type A nonunions (less than 1 cm of bone loss): A1, lax (mobile); A2, stiff (nonmobile) (not shown); A2-1, no deformity; A2-2, fixed deformity. B, Type B nonunions (more than 1 cm of bone loss): B1, bony defect, no shortening; B2, shortening, no bony defect; B3, bony defect and shortening.
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Nonunion cont.
Treatment:1. Elecrical2. Electromagnatic3. Ulrasound4. External fixation (ie deformity, infection, bone loss)5. Surgical
• Hypertrophic: stable fixation of fragments• Atrophic: decortication and bone grafting• According to classification: type A : restoration of alignment, compression type B : cortical osteotomy, bone transport or lengthening
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Nonunion cont.
Surgical guidelines:• Good reduction• Bone grafting• Firm stabilization
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Nonunion cont.
Reduction of the fragments:• Extensive dissection is undesirable, leaving
periosteum, callus, and fibrous tissue to preserve vascularity and stability, resecting only the scar tissue and the rounded ends of the bones
• External fixator, Intramedullary nailing, Ilizarov frame
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Nonunion cont.
Bone Grafting origins:• Autogenous “the golden standard”• Allograft• Synthetic substitute
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Nonunion cont.
Bone grafting techniques:• Onlay• Dual onlay• Cancellous insert• Massive sliding graft• Whole fibular transplant• Vascularized free fibular graft• Intamedullary fibular graft
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BONE GRAFTING contd….
CRITERTIA FOR SUCCESSFUL BONE GRAFT
• OSTEOCONDUCTION
• OSTEOGENICITY
• OSTEOINDUCTION
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• Nonunion of tibial shaft treated by dual onlay grafts
Dual onlay
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Massive sliding graft
GILL MASSIVE SLIDING GRAFT
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Whole fibular transplant• Bridging of bone defect
with whole fibular transplant. A, Defect in radius was caused by shotgun wound. B and C, Ten months after defect was spanned by whole fibular transplant, patient had 25% range of motion in wrist, 50% pronation and supination, and 80% use of fingers.
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Vascularized free fibular graft• Posteroanterior
and lateral roentgenograms made 3 years after fibular transfer, showing excellent remodeling with fracture healing. (From Duffy GP, Wood MB, Rock MG, Sim FH: J Bone Joint Surg 82A:544, 2000
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Intamedullary fibular graft• Anteroposterior
roentgenogram of humerus 5 months after insertion of fibular allograft and compression plating with a 4.5-mm dynamic compression plate revealing evidence of bridging callus formation and incorporation of the allograft. (From Crosby LA, Norris BL, Dao KD, McGuire MH: Am J Orthop 29:45, 2000.)
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Nonunion cont.
Stabilization of bone fragments:• Internal fixation (hypertrophic #):
intamedullary, or plates and screws• External fixation(defects associated#): ie Ilizarov
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Internal fixation
• Roentgenograms of patient with subtrochanteric nonunion for 22 years treated with locked second generation femoral nail. A, Preoperatively. B, Postoperatively.
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Ilizarov
Bifocal osteosynthesis with Ilizarov fixator after debridement of necrotic segments, as recommended by Catagni.
Monofocal osteosynthesis with Ilizarov fixator for hypertrophic nonunions with minimal infection, as recommended by
Catagni
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Ilizarov cont.
Type IIIB open tibial fracture in 30-year-old man struck by automobile. Initial treatment was with four-pin anterior half-pin external fixator that was later converted to six-pin fixator; this fixator was removed because of persistent infection. B, One year after injury, infected nonunion with deformity. C, Shape of tibial deformity is duplicated by Ilizarov frame and is gradually corrected as nonunion is compressed. D, Union obtained at 4½ months.
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Nonunion cont.
Factors complicating nonunion• Infection• Poor tissue quality• Short periarticular fragments• Significant deformity
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Infection management
Treatment of nonunion of tibia in which sequestration or gross infection is present. A, Bone is approached anteriorly and is saucerized, incision is closed, and infection is treated with antibiotics by irrigation and suction. B and C, Tibia is grafted posteriorly. B, Skin incision. C, Tibia and fibula have both been approached posterolaterally. Posterior aspect of tibia (or tibia and fibula) is roughened and grafted with autogenous iliac bone
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Nonunion cont.
Specific Bones • Metatarsals• Tibia• Fibula• Patella• Femur• Pelvis and acetabulum• Clavicle• Humerus• Radius• Ulna
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THANK YOU
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