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    Bone Healing

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    FadliArif
    Bone healing is the body's natural process of repairing bone fractures. It generally involves reducing the displaced bone fragments and allowing the healing process to occur. There are several factors that can influence bone healing including adequate nutrition, age, bone type, drug therapy, and pre-existing bone diseases. The healing process is determined by the periosteum and involves two main types of healing: primary/direct healing which occurs with absolute stability and no gap formation, and secondary/indirect healing which is most common and involves endochondral ossification and callus formation when there is a gap or instability. Bone healing occurs in three main phases: reaction, repair, and remodeling over a period of months.

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    Bone Healing

    Uploaded by

    FadliArif
    166 views5 pages
    Bone healing is the body's natural process of repairing bone fractures. It generally involves reducing the displaced bone fragments and allowing the healing process to occur. There are several factors that can influence bone healing including adequate nutrition, age, bone type, drug therapy, and pre-existing bone diseases. The healing process is determined by the periosteum and involves two main types of healing: primary/direct healing which occurs with absolute stability and no gap formation, and secondary/indirect healing which is most common and involves endochondral ossification and callus formation when there is a gap or instability. Bone healing occurs in three main phases: reaction, repair, and remodeling over a period of months.

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    Bone healing is the body's natural process of repairing bone fractures. It generally involves reducing the displaced bone fragments and allowing the healing process to occur. There are several factors that can influence bone healing including adequate nutrition, age, bone type, drug therapy, and pre-existing bone diseases. The healing process is determined by the periosteum and involves two main types of healing: primary/direct healing which occurs with absolute stability and no gap formation, and secondary/indirect healing which is most common and involves endochondral ossification and callus formation when there is a gap or instability. Bone healing occurs in three main phases: reaction, repair, and remodeling over a period of months.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    166 views5 pages

    Bone Healing

    Uploaded by

    FadliArif
    Bone healing is the body's natural process of repairing bone fractures. It generally involves reducing the displaced bone fragments and allowing the healing process to occur. There are several factors that can influence bone healing including adequate nutrition, age, bone type, drug therapy, and pre-existing bone diseases. The healing process is determined by the periosteum and involves two main types of healing: primary/direct healing which occurs with absolute stability and no gap formation, and secondary/indirect healing which is most common and involves endochondral ossification and callus formation when there is a gap or instability. Bone healing occurs in three main phases: reaction, repair, and remodeling over a period of months.

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    © All Rights Reserved
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    Download as docx, pdf, or txt
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    Bone healing

    Definition
    Proliferative physiological process in which the body facilitates the repair of bone fracture
    Generally bone fracture treatment consist reduce displaced bone and waiting natural
    healing process to occur

    Factore integrity fracture healing :


    - Adequate nutrient
    - Age
    - Bone type
    - Drug therapy
    - Pre existing bone pathology

    Healing process is mainly determined by periosteum (connective tissue membrane covering


    the bone). periosteum one source of precursor cells develop into chondroblast – osteoblast
    that essential to healing bone.
    Other source : bone marrow, endosteum, small blood vessel, fibroblast

    Primary healing (direct healing)


    - Require anatomical reduction which is stable
    - Without any gap formation
    - Require remodeling lamellar bone, haversian canal and blood vessel
    - Without callus formation
    - Intramembranous healing
    - Occurs with absolute stability construct

    Contact healing
    - When the gap between bone end less than 0.01 mm
    - Interfragmentary strain less than 2 %
    Contact healing can occur
    - Cutting cone (consist of osteoclast, form across the fracture line, generating cavities
    at rate 50-100 micro/day
    - Osteoblast fill up the cavities with haversian system

    Gap healing
    If fracture gap 800 mikro – 1mm fx filled by osteoclast then by lamellar bone oriented
    perpendicular axis of bone. orientation lamellar bone is weak. Secondary healing required
    to re orient lamellar bone longitudinally. This process 3-8 weeks
    Secondary healing (indirect healing)
    - Most common
    - Consist endochondral ossification
    - Sometimes intramembranous ossification
    Mediated by periosteal layer bone, without callus formation
    - endochondral ossification
    deposition bone only occurs after mineralized cartilage
    - involves response in the periosteum and external soft tissue
    - occurs with non rigid fixation, external fixation, bridge plating, intramedullary nailing

    3 major phases fracture healing


    1. Reaction
    - inflammation
    - granulation tissue formation
    2. Repair
    - cartilage callus formation
    - lamellar bone deposition
    3. Remodelling

    Reaction
    Fracture  blood vessel constrict  stop bleeding  few hours extravascular blood cells
    form clot (hematom)  that act template for callus formation

    Including macrophage  release inflammatory mediator :


    - Cytokine ( tumor necrosis factor alpha)  TNF
    - IL 1, 6, 11,18
    Increase blood capillary permeability

    Inflammation peak 24 hours  complete 7 days


    IL 1 promotes formation callus & blood vessel
    IL 6 promote differentiation osteoblast & osteoclast

    Within this area  fibroblast replicate


    7-14 days they form aggregate of cells  interspersed small blood vessel (granulation
    tissue)  osteoclast move into reabsorb dead bone ends  other necrotic tissue is
    removed
    Fracture  inflammation process start rapidly  hematoma formation + inflammatory
    exudation from rupture blood vessel
    Bone necrosis seen at the end of fracture fragments  injury of soft tissue and
    degranulation platelet  release powerful cytokine  produce inflammatory response 
    (vasodilatation, hyperemia, migration proliferationof PMN, macrophage)

    Repair
    - 7-9 days after fracture cells of periosteum replicate & transform
    - periosteal cells proximal to(on the near side) fracture gap  develop chondroblast
     which form hyaline cartilage
    - periosteal cells distal (at the far end of) fracture gap  develop osteoblast  which
    form woven bone
    - fibroblast within granulation tissue  develop into chondroblast
    - 2 new tissue grow in size until they unite each other  (new mass heterogenous) 
    callus
    - callus formation peak 14 days
    - next phase endochondrial ossification  (replacement hyaline cartilage woven bone
    into lamellar bone
    - lamellar bone begins forming after collagen matrix become mineralized (the process
    induced IL 1 & TNF
    - mineralized matrix penetrated by microvessel and numerous osteoblast
    - osteoblast form  new lamellar bone
    - new lamellar bone form  trabecular bone
    - woven bone & cartilage original fracture callus  replaced by trabecular bone 
    restoring bone original strength
    Remodelling
    - begin 3-4 weeks after fracture, take 3-5 years to complete
    - trabecular bone resorbed by osteoclast  creating shallow resorption pit “howship
    lacuna”
    - osteoblast deposit compact bone within resorption pit
    - fracture callus remodeled into new shape  duplicate bone original shape and
    strength
    - this process can achieved by formation electrical polarity during partial weight
    bearing

    Obstruction – variables that influence healing


    Internal variable
    1. poor blood supply
    - leads to dead of osteocyte
    - depends on degree of fracture & disruption haversian system
    2. head injury
    increase osteogenic response
    3. condition of soft tissue
    4. infection
    5. age
    6. pre existing bone malignancy
    7. mechanical factors
    - poor alignment
    - less movement
    - excess mobility can disrupt bridging callus
    - slight biomechanical motion  improve callus formation
    - bony soft tissue attachment
    external variable
    1. nutrition
    - Vitamin D & calcium
    - 84% patient non union found metabolic issue (66% these patient had vitamin D
    deficiency)
    2. DM
    - affect repair & remodeling bone
    - decrease cellularity facture callus
    - delayed enchondral ossification
    - diminished strength fracture callus
    - fracture healing takes 1.6 times longer in diabetic patients
    3. Nicotine
    - decrease rate fracture healing
    - inhibit growth new blood vessel
    - smoker can take 70% longer to heal

    4. NSAID
    prolonged healing time because of COX enzyme inhibition
    5. Quinolone
    Toxic chondrocyte and diminished fracture repair

    Complication
    1. infection
    2. non union
    - no progression healing within six months
    - leave the limb with pain and instability
    3. malunion
    - healing bone with deformed position (angular, translation, rotational)
    4. delayed union
    - persistence fracture line
    - absence callus formation on xray
    - healing still occur but slower than normal

    Source :
     Brighton, Carl T. and Robert M. Hunt (1991), "Early histologic and ultrastructural changes
    in medullary fracture callus", Journal of Bone and Joint Surgery, 73-A (6): 832-847
     Brighton, Carl T. and Robert M. Hunt (1997), "Early histologic and ultrastructural changes
    in microvessels of periosteal callus", Journal of Orthopaedic Trauma, 11 (4): 244-253

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