1. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings
FRACTURE HEALING
MALUNION
NONUNION

2. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings
STAGES IN FRACTURE
HEALING

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• Hematoma formation
– Torn blood vessels
hemorrhage
– A mass of clotted
blood (hematoma)
forms at the fracture
site
– Site becomes swollen,
painful, and inflamed
Hematoma

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• Fibrocartilagino
us callus forms
• Granulation
tissue (soft
callus) forms a
few days after
the fracture
• Capillaries grow
into the tissue
and phagocytic
cells begin
cleaning debris Figure 6.14.2
2 Fibrocartilaginous
callus formation
External
callus
New
blood
vessels
Spongy
bone
trabeculae
Internal
callus
(fibrous
tissue and
cartilage)

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• The fibrocartilaginous callus forms when:
– Osteoblasts and fibroblasts migrate to the
fracture and begin reconstructing the bone
– Fibroblasts secrete collagen fibers that connect
broken bone ends
– Osteoblasts begin forming spongy bone
– Osteoblasts furthest from capillaries secrete an
externally bulging cartilaginous matrix that later
calcifies

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• Bony callus formation
– 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 Figure 6.14.3
3 Bony callus
formation
Bony
callus of
spongy
bone

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• Bone remodeling
– Excess material on
the bone shaft
exterior and in the
medullary canal is
removed
– Compact bone is
laid down to
reconstruct shaft
walls
Figure 6.14.4
4 Bone remodeling
Healing
fracture

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9. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings
PATHOLOGY
• REPAIR BEGINS WITH INFLAMMATION
• WHICH RESULTS IN CHEMOTAXIS AND
INFLAMMATORY CELLS LIKE
POLYMORPHS,LYMPHOCYTES AND
MACROPHAGES MIGRATE TO THE
FRACTURE SITE
• WHICH STIMULATE POLYPEPTIDE
GROWTH FACTORS (TGF,PDGF)

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• POLYPEPTIDE GROWTH FACTORS ACTS ON
TARGET CELLS AND FACILITATES DNA
SYNTHESIS AND CAUSES
• CELL DIVISION AND PROLIFERATION
• ANGIOGENESIS
• COLLAGEN SYNTHESIS HEALING
• STIMULATION OF STEM CELLS –
OSTEOBLAST FORMATION

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VARIABLES THAT
INFLUENCE FRACTURE
HEALING
• INJURY VARIABLES
• PATIENT VARIABLES
• TISSUE VARIABLES

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INJURY VARIABLES
a) OPEN FRACTURES – soft tissue
disruption,# displacement,significant
bone loss delays # healing and can also
result in infection & chronic osteomyelitis
b) SEVERITY OF INJURY
c) INTRA ARTICULAR FRACTURE :
healing delays due to instability and
prolonged immobilisation can result in
joint stiffness also

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a) SEGMENTAL FRACTURE – disrupts
intramedullary blood supply to middle
fragment
b) SOFT TISSUE INTERPOSITION –
compromises # healing
c) DAMAGE TO BLOOD SUPPLY – causes
significant delay in # healing.
eg: femoral head,scaphoid,talus,distal
tibia

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PATIENT VARIABLES
• AGE – infants,rapid rate of # healing
• NUTRITION – cell migration,proliferation and
matrix synthesis needs substantial energy.
Malnutrition can also result in infection,wound
dehiscence,impaired healing and slow
rehabilitation
• SYSTEMIC HORMONES – corticosteroids
compromises # healing.
Thyroid hormone,calcitonin,insulin are good
• NICOTINE – cigarette smoking inhibit fracture
healing

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TISSUE VARIABLES
• FORM OF BONE – opposed cancellous bone
unite rapidly
• BONE NECROSIS – if # is avascular-healing
may be delayed.Prolonged use of corticosteroids
and radiation can cause bone necrosis.
• BONE DISEASES –
osteoporosis,osteomalacia,bone tumours,pagets
disease,bone cyst,osteogenesis imperfecta etc
can influence # healing
• INFECTION

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TREATMENT VARIABLES
• APPOSITION OF FRACTURE
FRAGMENTS – decreasing fracture gap
decreases volume of repair tissue needed
for # healing
• FRACTURE STABILISATION – traction,
cast immobilisation,external
fixation,internal fixation

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TREATMENT THAT INTERFERES
WITH HEALING
• SURGERY – blood supply disruption and
infection
• INADEQUATE IMMOBILISATION
• DISTRACTION OF FRACTURE
FRAGMENTS BY EF/IF/TRACTION
• REPEATED MANIPULATIONS
• EXCESSIVE EARLY MOBILISATION

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METHODS PROMOTING # HEALING
• BONE GRAFT
• BONE TRANSFER –to replace a lost
portion of long bone diaphysis,surgeons
perform corticotomy through normal bone
creating a mobile bone segment and then
uses an external fixation device to transfer
the segment across the defect.
As segment moves a column of bone
forms behind it

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• ELECTRICAL FIELDS – stimulate cell
proliferation,synthetic function and promrte
bone formation
• ULTRASOUND – low intensity pulse
ultrasound helps in # healing

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NON UNION
- failure of fracture to unite by bony
continuity.
DEFINITION:
Non union is said to be established when a
minimum of nine months has elasped
since the injury and the fracture shows no
radiologically visible progressive signs of
healing continuously for three months

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DELAYED UNION
• Where healing has not occurred at the
expected time of union for the type and
site of fracture

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CLASSIFICATION
• PALEY,S CLASSIFICATION-
Type A – less than 1 cm boneloss
Type B – more than 1cm bone loss
• MULLER AND WEBER CLASSIFICATION
Hypervascular nonunion
Avascular non union

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Hypervascular non union –fracture
ends are viable and show biological
reaction,hence stable internal fixation is
enough no bone grafting required

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AVASCULAR NON UNION – the fracture
ends are not viable due to poor blood supply.
Needs rigid internal fixation with bone grafting after
decortication of non viable ends
• Torse wedge non union – intermediate
fragment has healed at one end and not at
the other,seen in segmental #
• Comminuted non union – in comminuted #
• Defect/gap nonunion-in compound#,OM
• Atrophic non union-ends are thin and
sclerotic with excessive scar tissue in b/w

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Causes for nonunion
• Compound #
• Infection
• Segmental #
• Distraction of # fragments
• Soft tissue interposition
• Ill advised open reduction
• Insecure and inadequate fixation
• General factors

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Clinical features
• h/o multiple injuries, open #, inadequqte trt
etc
• Symptoms : no pain/minimal
pain,presence of deformity/loss of function
• Signs : painless abnormal mobility,no
crepitus,shortening,scars and
sinuses,deformity,wasting of limb muscles
etc

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Investigations
• Radiograph :
gap b/w # fragments
fragments are rounded/sclerotic
amount of callus will be more
(hypervascular) or less (avascular)

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Management
• Principles :
• Non union is an absolute indication for
surgery it requires open reduction rigid
internal fixn and bone grafting
• No role for conservative mngmnt
• Other methods- electrical
stimulation,interlocking nails and ilizarov,s
technique

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Bone grafting - types
• Cancellous bone graft : defect less than
2.5 cm. It is better tolerated and rapidly
revascularised
• Cortical bone graft : it has a stabilising
property and can be used for non union of
shafts of any long bones.
-single onlay: wen placed on one surface
-dual onlay : wen placed on both the sides
-sliding graft : wen a piece is slided from
above to the fracture site

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• Phemister bone graft : here, graft is placed
subperiosteally.simple,blood supply is not
disturbed.
• It is placed posteriorly and is found to be
useful in tibia

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Electrical stimulation
• Weak electric current of 20 mA delivered
to # site by a cathode converts fibrous
tissue to fibrocartilage wich gets ossified
later by enchondral ossification.
• 3 types : invasive – if cathode is placed
inside the # site
semi-invasive –when it is placed s/c
non invasive – wen in corporated into the
plaster cast externally.
Union occurs in 85% of cases

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Ilizarov,s technique
• Best way to treat infected non union
• Allows simultaneous correction of all
deformities and bone loss

34. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings
Mal union
• Definition : when # fragment heals in an
abnormal position,it is called malunion

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37. Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings
• Causes cosmetically unsightly deformity
• Alteration in posture and balance in lower
limb fractures
• It may cause shortening
• May interfer with joint function
• Altered wt bearing mechanism may lead to
premature osteoarthritis of the hip and
knee joints.

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Causes
• Trt methods : eg closed reduction
• Improper immobilisation techniques
• Trt by quacks
• Multiple and multisystem injuries

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Classification
• Length malunion
• Rotatory malunion
• Angulatory malunion

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Types
• Significant mal union : interfers with
function
• Insignificant mal union : does not interfere
with function

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Clinical features
• Deformity
• Loss of function
• Shortening
• Muscle wasting

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Treatment
• Operative trt : if it affects function
• Corrective osteotomy
• Optimum time to carry out surgery : 6-12
months after the fracture

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