3rd MBBS

Integrated Curriculum

Fracture Healing

Bones

Dr. Ghaith J. Al Eyd

M.B.Ch.B., M.Sc., Ph.D., M.I.A.C.

GMU / Department of Pathology

Learning Objectives:
Review the anatomical regions and the histology of bone. Review the physiology of bone resorption & formation.

describe the types of fractures.

Describe the process of fracture healing. Describe the complications of fracture healing.

Anatomic Regions of Long Bone:

Bone Resorption and Formation:

Bone resorption and formation are coupled processes that are controlled by systemic factors and local cytokines, some of which are deposited in the matrix. Cytokines (e.g. BMPs, FGF, PDGF, insulin like growth factor, and TGF-) are key in the communication between osteoblasts and osteoclasts.

Fractures:
Traumatic and nontraumatic fractures are some of the most common pathologic conditions affecting bone. Fractures are classified as: Complete fracture. Incomplete fracture (green stick fracture): The bone is cracked, but not broken into two pieces. Closed (simple) fracture: The overlying tissue is intact. Compound fracture: The fracture site communicates with the skin surface. Comminuted fracture: The bone is splintered. Displaced fracture: The ends of the bone at the fracture site are not aligned.

Pathological fracture: The break occurs in bone already altered by a disease process.
Stress fracture: Slowly developing fracture that follows a period of increased physical activity in which the bone is subjected to new repetitive loads as in sports or marching in military boot camp.

Incomplete fracture Complete fracture

Displaced fracture Greenstick fracture Closed fracture

Compound fracture

Compound fracture

Comminuted fracture

Fracture Healing:
Bone is unique in its ability to repair itself; it can completely reconstitute itself by reactivating processes that normally occur during embryogenesis. Fracture healing is similar to wound healing except that the granulation tissue that has formed is to be converted to bone tissue. This is achieved by activation of osteoprogenitor cells and osteoclasts through mediators (Interleukins & growth factors) released from inflammatory cells and platelets.

Fracture Healing:
Immediately after fracture, rupture of blood vessels results in a hematoma, which fills the fracture gap and surrounds the area of bon injury. This is followed, in the first few days, by influx of inflammatory cells and, removal of necrotic debris. The hematoma undergoes organization by ingrowth of granulation tissue at the end of first week. This fusiform granulation tissue bump at the fracture site is called procallus or soft tissue callus. Callus: Granulation tissue (containing osteoprogenic cells, osteoblasts and osteoclasts) at the fracture turns into a mass of fibrous tissue, bone and cartilage, from which healed bone will arise. Maximal girth of callus is reached at the end of second or third week. Eventually it becomes bony callus and then remodels to look more or less like the original bone.

Fracture Healing:

Fracture Healing:

Fracture Healing:

Fracture Healing - Complications: Inadequate immobilization may lead to delayed union or non union. Pseudarthrosis: The ends of the bone did not heal back together with bone. At best, there is fibrous scar connecting the ends, and a "false joint" is created. Infection of fracture site in open fractures. If the fracture is comminuted, if the ends of the bones are much displaced, or if infection happens, don't expect good healing. Likewise, poorly-nourished people or osteoporotic people are likely to get bad results.