Bone fractures and repair

Prepared by

Dr. Ahmed zaher

Lecturer of pathology

Important definitions:
Complete fracture: in which the bone is split completely across..
Incomplete fracture: a fracture that does not extend through the full
transverse width of a bone.
Simple (closed) fracture: i.e. the overlying skin is intact.
Compound fracture: a fracture in which broken bone fragments lacerate
soft tissue and protrude through an open wound in the skin.
Comminuted fracture: a fracture in which the bone is crushed or broken
into numerous fragments.
Pathological fracture: a fracture of a bone already altered by a disease as:
1- Inflammatory diseases as osteomyelitis .....
2- Metabolic bone diseases as ....
3- Tumours (primary or secondry).
4- Bone cysts as hydatid cyst.

Bone repair
Bone is unique in its ability to repair itself. It can completely
reconstitute itself by reactivating processes that normally occur
during embryogenesis.
Mechanism of bone fracture repair: by the following steps,
Stage 1: hematoma is formed between ends of fractured bone.
Stage 2: inflammatory exudate (traunatic inflammation).
Stage 3: phagocytosis of damaged bone fragments, blood by
macrophages an osteoclasts. this process is associated with
release of growth factors (as PDGF, TGF-, FGF, and
interleukins) which control the subsequent steps of repair.
Stage 4: granulation tissue formation (procallus): granulation
tissue invades the area within one week. it consists of
capillaries and mesenchymal cells derived from periosteum
and endosteum.

Stage 5: provisional callus formation.

- during 3 weeks, some mesenchymal cells differentiate into
chondroblasts and others differentiate into osteoblasts.
- chondroblasts form cartilage islands, while osteoblasts produce
osteoid tissue (bone matrix and collagen fibers).
- Osteoblasts produce alkaline phosphatase enzyme leading to
deposition of calcium salts (transformation of osteoid tissue
into hard osseous woven bone).
- thus, the provisional callus consists of cartilage, osteoid tissue
and woven bone.
stage 6: permanent callus formation:
- more deposition of calcium leads to cartilage disintegration and
its invasion by osteoblasts.

- the woven (non lamellar) bone is gradually removed by

osteoclasts and replaced by lamellar bone composed of osteoid
tissue.
- calcification of osteoid tissue occurs together with deposition of
collagen bundles which are arranged in orderly lamellar
fashion (i.e. concentrically around blood vessels to form
Haversian system).
Stage 7: callus remodeling occurs thurough:
a) removal of the unnecessary internal and external callus (by
osteoclastic activity).
b) further adjustment of the intermediate callus (to give it optimal
size, strength and lamellar property)
N.B. Bone repair needs about 4-6 weeks.

A: Sages 1,2,3&4
B&C: Stage 5 (provisional callus).
D: Sage 6 (permanent callus). E: Stage 7 (Rmodeling).

Causes of imperfect bone repair and failuer of bony union:

Local factors:
1- Inadequate immobilization or malalignment.
2- pathological fracture as ....
3- Soft tissue interposition between the fracture ends.
4- Ischemia. 5- Infection.
General factors:
1- Old age.
2- Nutritional deficiencies.
3- Glucocorticoid therapy.
4- Diabetes mellitus.

Good luck