Fracture healing by dr.v.r.vignesh
- 1. FRACTURE HEALING BY Dr VAITHILINGAM RAMAIYAH VIGNESH
- 2. NICHOLAS ANDRY •COINED THE TERM ORTHOPAEDICS •ORTHO MEANS CORRECT OR STRAIGHT •PAEDICS MEANS CHILD
- 3. BONE FRACTURE DEFINITION • MEDICAL CONDITION - DAMAGE IN CONTINUITY OF THE BONE
- 4. FEATURES • HEALING OF BONE FRACTURE IS SIMILAR TO HEALING OF SOFT TISSUE WOUND • HEALING ONSET OCCURS ONCE BONE IS FRACTURED AND IT CONTINUES TILL LIFE AS REMODELLING • COMMONLY IMMOBILIZATION IS NECESSARY FOR HEALING,FEW EXCEPTIONS- FRACTURE RIB.
- 5. • NOT MANDATORY FOR SURGEON TO IMPOSE IMMOBILITY FOR BONE FRACTURE, NATURE CAN DO SO BY CALLUS FORMATION IN RESPONSE TO MICROMOVEMENT. • MOST FRACTURES ARE SPLINTED, NOT TO ENSURE UNION BUT TO ALLEVIATE PAIN,& TO ENSURE THAT UNION TAKES PLACE IN GOOD POSITION AND PERMIT EARLY MOVEMENT OF LIMB . • PROCESS OF FRACTURE REPAIR VARIES ACCORDING TO TYPE OF BONE INVOLVED AND AMOUNT OF MOVEMENT AT FRACTURE SITE
- 7. HEALING OF CORTICAL BONE FRACTURE • HEALING BY CALLUS FORMATION -NATURAL FORM OF HEALING,IN ABSENCE OF RIGID FIXATION. • 5 STAGES, THEY ARE STAGES OF • HEAMATOMA FORMATION • GRANULATION TISSUE FORMATION • CALLUS FORMATION • CONSOLIDATION • REMODELLING
- 9. STAGE OF HAEMATOMA FORMATION • LASTS UPTO 1 WEEK • BETWEEN AND AROUND FRACTURE SITE • ISCHAEMIC NECROSIS - FRACTURE ENDS • PERIOSTEUM AND LOCAL SOFT TISSUE STRIPS FROM FRACTURE ENDS • SOME OSTEOCYTES DIES AND OTHERS ARE SENSITIZED TO RESPOND SUBSEQUENTLY BY DIFFERENTIATING INTO DAUGHTER CELLS WHICH CONTRIBUTE TO HEALING PROCESS
- 10. STAGE OF GRANULATION TISSUE • FROM 2ND TO 3RD WEEK • SENSITIZED PERCURSORS CELLS PRODUCE CELLS WHICH DIFFERENTIATE AND ORGANIZE TO PROVIDE BLOOD VESSELS,FIBROBLAST,OSTEOBLASTS ETC. • COLLECTIVELY THEY FORM A SOFT GRANULATION TISSUE IN THE SPACE BETWEEN FRACTURE FRAGMENT • THIS CELLULAR TISSUE EVENTUALLY GIVES A SOFT TISSUE ANCHORAGE TO FRACTURE,WITHOUT ANY STRUCTURAL RIGIDITY
- 11. • FRACTURED SITE-STILL MOBILE • FROM THIS STAGE,HEALING OF BONE DIFFERS FROM THAT OF SOFT TISSUE • i.e., IN SOFT TISSUE HEALING ,THE GRANULATION TISSUE IS REPLACED BY FIBROUS TISSUE • IN BONE HEALING THE GRANULATION TISSUE FURTHER DIFFERENTIATES TO CREATE OESTEOBLAST WHICH SUBSEQUENTLY FORM BONE
- 12. STAGES OF CALLUS FORMATION • USUALLY 4 TO 12 WEEKS • GRANULATION TISSUE DIFFERENTIATES FURTHER AND CREATES OSTEOBLASTS • THESE CELLS LAY DOWN AN INTERCELLULAR MATRIX WHICH SOON BECOMES IMPREGNATED WITH CALCUIM SALTS.(MINERALIZATION OF GRANULATION TISSUE) • RESULTS IN FORMATION OF CALLUS ,ALSO CALLED WOVEN BONE(WHICH IS RADIOLOGICALLY VISIBLE)
- 13. • CALLUS IS 1 ST SIGN OF UNION ON X –RAY,USUALLY 3 WEEKS AFTER FRACTURE. • FORMATION OF THIS BRIDGE OF WOVEN BONE IMPARTS GOOD STRENGTH TO FRACTURE • CALLUS FORMATION IS SLOWER IN ADULT THAN IN CHILDREN AND IN CORTICAL BONE THAN IN CANCELLOUS BONE. • FRACTURE CLINICALLY UNITED,AND IT IS NO MORE MOBILE.
- 14. STAGE OF CONSOLIDATION • WOVEN BONE IS REPLACED BY MATURE BONE WITH TYPICAL LAMELLAR STRUCTURE • THIS PROCESS OF CHANGE IS MULTICELLULAR UNIT BASED,WHEREAS A POCKET OF CALLUS IS REPLACED BY A POCKET OF LAMELLAR BONE. • IT IS SLOW PROCESS AND EXTEND ANYTHING FROM ONE TO FOUR YEARS. • IN THIS STAGE OUTLINE OF CALLUS BECOMES DENSE AND SHARPLY DEFINED.
- 15. STAGE OF REMODELLING • FRACTURED BONE WILL BEGRADUALLY STRENGTHENED. • SHAPENING OF CORTICES OCCURS AT ENDOSTEAL AND PERIOSTEAL SURFACE ,SO THAT FRACTURE SITE BECOME INDISTINGUISHABLE FROM PARENT BONE. • MAJOR STIMULUS COMES FROM LOCAL BONE STRAIN i.e., WEIGHT BEARING STRESSES AND MUSCLE FORCES WHEN PERSON RESUMES ACTIVITY. • THIS STAGE IS MORE CONSPICUOUS IN CHILDREN WITH ANGULATED FRACTURE • OCCURS TO A VERY LIMITED EXTENT IN FRACTURE IN ADULT
- 17. HEALING OF CANCELLOUS BONE • FOLLOW DIFFERENT PATTERN • BONE IS UNIFORM SPONGY TEXTURE AND HAS NO MEDULLARY CAVITY,SO THAT THERE IS A LARGE AREA OF CONTACT BETWEEN THE TRABECULAE. • UNION CAN OCCUR DIRECTLY BETWEEN THE BONE SURFACE WITHOUT HAVING TO PASS THROUGH THE STAGES OF CALLUS FORMATION. • FOLLOWING HEAMATOMA AND GRANULATION FORMATION,MATURE OSTEOBLAST LAY DOWN WOVEN BONE IN INTRACELLULAR MATRIX ,AND THE TWO FRAGEMENT THUS UNITES.
- 18. HEALING BY DIRECT UNION • CLINICAL AND EXPERIMENTAL STUDIES HAVE SHOWN CALLUS FORMATION OCCURS DUE TO MOVEMENT AT FRACTURE SITE. • THEY SERVE TO STABILIZE FRAGEMENTS AS RAPIDLY AS POSSIBLE – A NECESSARY PRECONDITION FOR BRIDGING BY BONE. • IF FRACTURED BONE IS ABSOLUTELY IMMOBILE , STIMULUS FOR CALLUS FORMATION WILL NOT BE PRESENT Eg., 1.IMPACTED FRACTURE IN CANCELLOUS BONE, 2.FRACTURE RIGIDLY IMMOBILIZED BY METAL PLATE. • SO OSTEOBLASTIC NEW BONE FORMATION OCCURS DIRECTLY BETWEEN THE FRAGMENTS.
- 20. • GAPS BETWEEN THE FRACTURES ARE INVOLVED BY NEW CAPILLARIES &OSTEOPROGENITORS CELLS GROWING IN FROM THE EDGES & NEW BONE IS LAID DOWN ON EXPOSED SURFACE (GAP HEALING). • WHERE CREVICES ARE VERY NARROW (< 200 MICRONS),OSTEOGENESIS PRODUCES LAMELLAR BONE,WIDER GAPS ARE FILLED FIRST BY WOVEN BONE,WHICH IS THEN REMODELLED TO LAMELLAR BONE. • IN 3-4 WEEKS ,FRACTURE IS SOLID ENOUGH TO ALLOW PENETRATION AND BRIDGING OF AREA BY BONE REMODELLING UNITS,i.e.,OSTEOCLASTIC (CUTTING CONES)FOLLOWED BY OSTEOBLAST. • WHERE THE EXPOSED FRACTURE ARE IN INTIMATE CONTACT AND HELD RIGIDLY FROM OUTSIDE ,INTERNAL BRIDGING MAY OCCASIONALLY OCCUR WITHOUT ANY INTERMEDIATE STAGES(CONTACT HEALING).
- 21. • HEALING BY CALLUS FORMATION,THOUGH LESS DIRECT (THE TERM INDIRECT COULD BE USED)HAS DISTINCT ADVANTAGES.IT ENSURES MECHANICAL STRENGTH WHILE BONE ENDS HEAL AND WITH INCREASING STRESS THE CALLUS GROWS STRONGER AND STRONGER (AN EXAMPLE OF WOLFF’S LAW). • WITH RIGID METAL FIXATION i.e., IN THE ABSENCE OF CALLUS FORMATION ,THERE IS A LONG PERIOD DURING WHICH THE BONE DEPENDS ENTIRELY UPON THE METAL IMPLANT FOR ITS INTERGRITY. • MOREOVER THE IMPLANT DIVERTS STRESS AWAY FROM BONE,WHICH BECOME OSTEOPOROTIC AND NOT RECOVER FULLY UNTIL METAL IS REMOVED.
- 23. FACTORS INFLUENCING FRACTURE HEALING • AGE • SEX • TYPE OF BONE • PATTERN OF FRACTURE • DISTURBANCE DUE TO PATHOANATOMY • TYPE OF REDUCTION • IMMOBILISATION • COMPRESSION OF FRACTURE SITE • ELECTRICAL STIMULATION • COMPOUNDING
- 24. UNION ,CONSOLIDATION,NON-UNION • REPAIR OF FRACTURE IS A CONTINUOUS PROCESS,ANY STAGES INTO WHICH IT IS DIVIDED ARE NECESSARILY ARBITRARY. • UNION:-IS AN INCOMPLETE REPAIR WHERE ENSHEATHING CALLUS IS CALCIFIED.CLINICALLY FRACTURE SITE WILL BE LITTLE TENDER AND THOUGH THE BONE MOVES IN ONE PIECE (AND IN THAT SENSE IS UNITED),ATTEMPTED ANGULATION IS PAINFUL. • X-RAY SHOWS THE FRACTURE LINE STILL CLEARLY VISIBLE,WITH FLUFFY CALLUS AROUND IT. • REPAIR IS INCOMPLETE AND IT IS SAFE TO SUBJECT THE UNPROCTED BONE TO STRESS.
- 25. CONSOLIDATION • COMPLETE REPAIR,WHERE CALCIFIED CALLUS IS OSSIFIED,CLINICALLY FRACTURE SITE IS NOT TENDER,NO MOVEMENT CAN BE OBTAINED AND ATTEMPTED ANGULATION IS PAINLESS. • X-RAY SHOWS FRACTURE LINE TO BE ALMOST OBLITERATED AND CROSSED BY BONE TRABECULAE,WITH WELL DEFINED CALLUS AROUND IT. • REPAIR IS COMPLETE AND FURTHER PROTECTION IS UNNECCESSARY.
- 26. NON UNION • SOMETIMES THE NORMAL PROCESS OF FRACTURE REPAIR IS THWARTED AND BONE FAILS TO UNITE. • CAUSES:- 1. DISTRACTION AND SEPARATION OF FRAGMENTS 2. INTERPOSITION OF SOFT TISSUES BETWEEN FRAGMENTS 3. EXCESSIVE MOVEMENT AT FRACTURE LINE 4. SEVERE INJURY THAT RENDER LOCAL TISSUE NON VIABLE OR NEARLY SO 5. POOR LOCAL BLOOD SUPPLY 6. INFECTION 7. SURGERY, IF ILL JUDGED
- 27. • NON UNION CAN BE ASEPTIC OR SEPTIC • ASEPTIC NON UNION CAN EITHER BE STIFF OR MOBILE AS JUDGED BY CLINICAL EXAMINATION • MOBILE NON UNION CAN BE FREE AND PAINLESS TO GIVE IMPREESION OF FALSE JOINT(PSEUDOARTHROSIS) • ON X-RAYS- NON UNION ARE TYPICAL • BY PRESENCE OF A LUCENT LINE BETWEEN BONE FRAGMENTS • SOMETIMES THERE IS EXUBERANT CALLUS TRYING BUT FAILING-TO BRIDGE THE GAP(HYPERTROPHIC NON- UNION)OR AT TIMES NONE AT ALL (ATROPHIC NON-UNION)
- 29. BONE MORPHOGENETIC PROTEIN • GROUP OF GROWTH FACTORS AND AS METABOLOGENS • INDUCE BONE AND CARTILAGE FORMATION • RHBMP-2 AND RHBMP-7 ARE FDA APPROVED • USED IN SPINAL FUSION,NONUNION,AND ORAL SX • CONTRAINDICATED ANTERIOR CERVICAL DISCECTOMY AND FUSION
- 30. BIBLIOGRAPHY • APLEY’S SYSTEM OF ORTHOPAEDICS & FRACTURES • CAMPBELL’S OPERATIVE ORTHOPAEDICS • ROCKWOOD AND GREEN’S FRACTURES IN ADULTS • ESSENTIALS OF ORTHOPAEDICS –RM SHENOY • ESSENTIAL ORTHOPAEDICS –J.MAHESHWARI