Fracture Healing

Histologic features of bone

Types of Bone
• Normal Bone : Lamellar or mature

• Immature and pathologic bone:

woven, more random, more
osteocytes, increased turnover,
weaker

• Lamellar bone is stress oriented;

woven bone is not
Cortical (compact) bone

• Constitutes 80% of the skeleton

• Consists of tightly packed osteons or

haversian systems

• Connected by haversian (or Volkmann)

canals

• Contains arterioles, venules,

capillaries, nerves, possibly lymphatic
channels
• Interstitial lamellae: between osteons

• Fibrils connect lamellae but do not cross cement lines.

• Cement lines define the outer border of an osteon.

• Nutrition provided by intraosseous circulation through canals and canaliculi (cell processes of osteocytes)

• Characterized by slow turnover rate, higher Young’s modulus of elasticity, more stiffness
 Cancellous bone (spongy or
trabecular bone)
• Less dense, more remodeling
according to lines of stress (Wolff’s
law)

• Characterized by high turnover

rate, smaller Young’s modulus,
more elasticity
Types of Bones
MICROSCOPIC
SUBTYPES CHARACTERISTICS EXAMPLES
APPEARANCE
Structure is oriented
Lamellar Cortical along lines of stress Femoral shaft
Strong
More elastic than cortical Distal femoral metaphysis
Cancellous
Woven bone Embryonic skeleton
Immature
Not stress oriented Fracture callus
Random organization
Increased turnover Osteogenic sarcoma
Pathologic
Weak Fibrous dysplasia
Flexible
Cellular biology
Osteoblasts
• Appear as cuboid cells aligned in layers
along immature osteoid

• Are derived from undifferentiated

mesenchymal stem cells

• These stem cells line haversian

canals, endosteum, and
periosteum.

• Become osteoblasts under

conditions of low strain and
increased oxygen tension.
• Transcription factor RUNX2 and Bone Morphogenetic protein (BMP) direct
Mesenchymal cells to the osteoblast lineage.

• Core-binding factor α-1 and β-catenin also stimulate differentiation into osteoblast.
• Become cartilage under conditions of intermediate strain and low
oxygen tension

• Become fibrous tissue under conditions of high strain

• Have more endoplasmic reticulum, Golgi apparatus, and mitochondria

than do other cells (for synthesis and secretion of matrix)
• Bone surfaces lined by more differentiated,
metabolically active cells.

• Entrapped cells: less active cells in resting regions

• Maintain the ionic milieu of bone

• Disruption of the active lining cell layer activates

entrapped cells
 Osteoblasts produce the following:

• Alkaline phosphatase • Bone sialoprotein

• Receptor activator of nuclear factor

• Osteocalcin (stimulated by (NF)-κβ ligand (RANKL)
1,25dihydroxyvitamin
• Osteoprotegerin—binds RANKL to
• D [1,25(OH)2D3]) limit its activity

• Type I collagen
• Osteoblast activity stimulated by intermittent (pulsatile) exposure to parathyroid hormone (PTH)
• Osteoblast activity inhibited by TNF-α.
• Wnts - proteins that promote osteoblast survival and proliferation.

• Deficient Wnt causes osteopenia

• Excessive Wnt expression causes high bone mass.

• Wnts can be sequestered by sclerostin (Scl) and Dickkopf-related protein 1 (Dkk-1).

• Inhibiting sclerostin (romosozumab)or Dkk-1 will lead to increased bone mass

Osteocytes
• Constitute 90% of the cells in the mature skeleton

• Former osteoblasts surrounded by newly formed matrix

• High nucleus/cytoplasm ratio

• Long interconnecting cytoplasmic processes projecting through the

canaliculi

• Less active in matrix production than osteoblasts

• Important for control of extracellular calcium and phosphorus

concentration
• Directly stimulated by calcitonin, inhibited by PTH

• Sclerostin secreted by osteocytes helps negative feedback on

osteoblasts’ bone deposition

• Differentially regulated according to mechanical loading, with decreased

sclerostin in areas of concentrated strain

• Downregulation is associated with increased bone formation (via sclerostin

antibody).

• Potential for use in fracture healing, bone loss, osseous integration

of implants, and genetic bone diseases via upregulation of
sclerostin
Osteoclasts
• Multinucleated irregular
giant cells

• Derived from
hematopoietic cells in
macrophage lineage

• Monocyte progenitors form

giant cells by fusion

• Function - Bone resorption

• Stimulated primarily by RANKL binding to
RANK receptor on cell surface
• Osteoblasts (and tumor cells) express
RANKL Binds to receptors on osteoclasts
• Stimulates differentiation into mature
osteoclasts
• Inhibited by osteoprotegerin (OPG)
binding to RANKL
• Occurs both normally and in certain
conditions, including multiple myeloma
and metastatic bone disease
• Denosumab is a monoclonal antibody
that targets and inhibits RANKL
binding to the RANK receptor
 Resorption mechanism :
• Osteoclasts possess a ruffled (brush) border and surrounding clear zone
• Bind to bone surfaces through cell attachment (anchoring) proteins
• Integrin (αvβ3 or vitronectin receptor)

• Bone resorption occurs in depressions: Howship lacunae.

 Effectively seal the space below the osteoclast
 Synthesize tartrate-resistant acid phosphate
 Produce hydrogen ions through carbonic anhydrase
 Lower pH
 Increase solubility of hydroxyapatite crystals
 Organic matrix then removed by proteolytic digestion through activity of the lysosomal
enzyme cathepsin K
• Signaling :

• Have calcitonin receptors, which inhibit osteoclastic resorption

• Interleukin-1 (IL-1): potent stimulator of osteoclast differentiation and

bone resorption
• Found in membranes surrounding loose total joint implants

• In contrast, IL-10 suppresses osteoclasts

Matrix
Organic components: 40% of dry weight of bone

 Collagen (90% of organic components) Primarily type I

• Type I collagen provides tensile strength of bone

• Hole zones (gaps) exist within the collagen fibril between the ends of molecules.

• Pores exist between the sides of parallel molecules.

• Mineral deposition (calcification) occurs within the hole zones and pores.

• Cross-linking decreases collagen solubility and increases its tensile strength.

Proteoglycans

Matrix proteins (noncollagenous)

Osteocalcin: most abundant noncollagenous protein in bone

• Inhibited by PTH and stimulated by 1,25(OH)2D3

• Can be measured in serum or urine as a marker of bone turnover

Inorganic (mineral) components: 60% of dry weight of bone

Calcium hydroxyapatite [Ca10(PO4)6(OH)2]: provides compressive

strength

Calcium phosphate (brushite)

Tissues surrounding bone
Periosteum
• Connective tissue membrane that covers bone
• More highly developed in children

• Inner periosteum, or cambium, is loose and vascular and

contains cells capable of becoming osteoblasts.
• These cells enlarge the diameter of bone during growth and
form periosteal callus during fracture healing.

• Outer (fibrous) periosteum is less cellular and is contiguous

with joint capsules.
Bone marrow—source of progenitor cells; controls inner diameter of
bone

• Red marrow-
• Hematopoietic (40% water, 40% fat, 20% protein)
• Slowly changes to yellow marrow with age, first in
appendicular skeleton and later in axial skeleton

• Yellow marrow
• Inactive (15% water, 80% fat, 5% protein)
• Bone vascular supply :
• Bone receives 5%–10% of the cardiac output.
• Long bones receive blood from three sources (systems)

 Nutrient artery system (2/3)

• BP in the nutrient artery system is high.
• 60% of cortical bone vascularized by nutrient arteries

 Metaphyseal-epiphyseal system
• Arises from the periarticular vascular plexus (e.g., geniculate arteries)

 Periosteal system
• Consists mostly of capillaries that supply the outer third (at most) of the mature diaphyseal
cortex
• BP in the periosteal system is low.
• Physiologic features :
 Direction of flow
• Arterial flow in mature bone is centrifugal (inside to outside).
• When fracture disrupts the nutrient artery system, the periosteal system pressure
predominates and blood flow is centripetal (outside to inside).
• Flow in immature developing bone is centripetal because the highly vascularized
periosteal system is the predominant component.
• Venous flow in mature bone is centripetal.

 Regulation of bone blood flow

• Arterial system: great potential for vasoconstriction (from the resting state), less potential
for vasodilation

• Vessels within bone: have several vasoactive receptors (β-adrenergic, muscarinic,

thromboxane/ prostaglandin)
 Bone blood flow is the major determinant of how well a fracture heals.

• Initial response is a decrease in bone blood flow after vascular disruption at

the fracture site.

• Bone blood flow increases within hours to days (as part of the regional
acceleratory phenomenon), peaks at approximately 2 weeks, and returns to
normal in 3–5 months.

• Unreamed intramedullary nails preserve endosteal blood supply.

• Reaming devascularizes the inner 50%–80% of the cortex and delays

revascularization of the endosteal blood supply.
GROWTH FACTOR ACTION NOTES
Bone morphogenetic Osteoinductive; stimulates bone Target cells of BMP are the
protein formation undifferentiated perivascular
Induces metaplasia of mesenchymal cells; signals through
mesenchymal cells into serine-threonine kinase
osteoblasts Receptors
Intracellular molecules called
SMADs serve as signaling
mediators for BMPs
Transforming growth Induces mesenchymal cells to Found in fracture hematomas;
factor–β produce type II believed to regulate cartilage
collagen and proteoglycans and bone formation in fracture
Induces osteoblasts to synthesize callus; signals through serine/
collagen threonine kinase receptors
IGF-2 Stimulates type I collagen, cellular Coating porous implants with TGF-β
proliferation, enhances bone ingrowth
cartilage matrix synthesis, and Signals through tyrosine kinase
bone formation receptors
Platelet-derived Attracts inflammatory cells to the Released from platelets; signals
growth factor fracture site through tyrosine kinase
(chemotactic) receptors
Bone injury and repair :

• Fracture repair :
Stages of fracture repair :
1.Inflammation
• Fracture hematoma provides hematopoietic
cells capable of secreting growth factors.
• Subsequently, fibroblasts, mesenchymal
cells, and osteoprogenitor cells form
granulation tissue around the fracture
ends.
• Osteoblasts (from surrounding osteogenic
precursor cells) and fibroblasts proliferate.
2.Repair :

• Primary callus response within 2 weeks

• For bone ends not in continuity, bridging

(soft) callus occurs (After 2–3 weeks)

• Soft callus is later replaced through

enchondral ossification by woven bone
(hard callus) (3–4 months).

• Medullary callus supplements the

bridging callus, forming more slowly and
later.
• Fracture healing varies with treatment
• In an unstable fracture, type II collagen is expressed
early, followed by type I collagen.
• Amount of callus is inversely proportional to extent of
immobilization.
• Progenitor cell differentiation
 High strain promotes development of fibrous
tissue.
 Low strain and high oxygen tension promote
development of woven bone.
 Intermediate strain and low oxygen tension
promote development of cartilage
Types of bone formation
Enchondral Ossification
• Examples:
1. Embryonic formation of long bones
2. Longitudinal growth (physis)
3. Fracture callus
4. Bone formed with demineralized bone matrix
• Undifferentiated cells secrete cartilaginous matrix and
differentiate into chondrocytes.
• Matrix mineralizes and is invaded by vascular buds that bring
osteoprogenitor cells.
• Osteoclasts resorb calcified cartilage; osteoblasts form bone.
• Bone replaces the cartilage model
• Cartilage is not converted to bone.
Intramembranous ossification
• Occurs without a cartilage model

• Undifferentiated mesenchymal cells aggregate into layers (or

membranes), differentiate into osteoblasts, and deposit an
organic matrix that mineralizes.

• Examples:
1. Embryonic flat bone formation
2. Bone formation during distraction osteogenesis
3. Blastema bone (in young children with amputations)
 Appositional ossification
• Osteoblasts align on the existing bone surface and lay down new
bone.

• Examples:
• Periosteal bone enlargement (width)
• Bone formation phase of bone remodeling
Types of Bone formation
Types of ossification Mechanism Examples Diseases

Enchondral Bone replaces Cartilage Embryonic long bone Achondroplasia

formation
Physis- longitudinal
growth
Fracture Callus
Bone formed with
demineralized bone
matrix
Intermembranous Undifferentiated Embryonic flat bone Cleidocranial dysostosis
mesenchymal cells formation
differentiate into Distraction osteogenesis
Osteoblast then forms Blastema Bone
bone
Appositional Osteoblasts lay down new Periosteal Bone Pagets disease of bone
bone on existing bone enlargement Infantile
Bone formation phase of Hyperostosis(Caffey
bone remodelling disease)
Melorheostosis
3.Remodeling :
• Remodeling begins in middle of
repair phase and continues long
after clinical healing (up to 7
years).
• Allows bone to assume its normal
configuration and shape according
to stress exposure (Wolff’s law)
• Throughout, woven bone is
replaced with lamellar bone.
• Fracture healing is complete when
the marrow space is repopulated.
Bone remodeling
• Cortical bone and cancellous bone are continuously remodeled
throughout life by osteoclastic and osteoblastic activity.
• Wolff’s law: remodeling occurs in response to mechanical
stress.
• Increasing mechanical stress increases bone gain.
• Removing external mechanical stress increases bone loss, which is
reversible (to varying degrees) on remobilization.
• Piezoelectric remodeling occurs in response to electric charge.
• The compression side of bone is electronegative, stimulating
osteoblasts (formation).
• The tension side of bone is electropositive, stimulating osteoclasts
(resorption).
• Hueter-Volkmann law: remodeling occurs in small
packets of cells known as basic multicellular units (BMUs).
• Such remodeling is modulated by hormones and cytokines.

• Compressive forces inhibit growth; tension

stimulates it.

• Suggests that mechanical factors influence longitudinal

growth, bone remodeling, and fracture repair

• May play a role in scoliosis and Blount disease

Cortical bone remodeling

• Osteoclastic tunneling (cutting cones)

• The head of the cutting cone is made up of osteoclasts followed by capillaries
and osteoblasts.
• Followed by layering of osteoblasts and successive deposition of layers of
lamellae

Cancellous bone remodeling

• Osteoclastic resorption followed by deposition of new bone by osteoblasts

Cortical bone
remodeling
Biologic Factors Influencing Fracture Healing
• Patient age • Health of the soft tissue
• Comorbid medical envelope
conditions
• Sterility (in open
• Functional level
fractures)
• Nutritional status
• Nerve function- CGRP • Cigarette smoke

• Vascular injury • Local pathologic

• Hormones conditions
• Growth factors • Level of energy
imparted
• Type of bone affected
• Extent of bone loss
Mechanical Factors Influencing Fracture
Healing
• Soft tissue attachments to bone

• Stability (extent of immobilization)

• Anatomic location

• Level of energy imparted

• Extent of bone loss

Endocrine effects on fracture healing :
• Cortisone − Decreased callus proliferation
• Thyroid hormone, PTH + Bone remodeling
• Growth hormone + Increased callus volume

Head injury
• Can increase the osteogenic response to fracture
 Nicotine
• Decreases rate of fracture healing

• Inhibits growth of new blood vessels as bone is remodeled

• Increase risk of nonunion (increases risk of pseudoarthrosis

in spine fusion by 500%)

• Decreased strength of fracture callus

• Smokers can take ~70% longer to heal open tibial shaft

fractures versus non-smokers
Effect of radiation on bone
• High-dose irradiation causes long-term changes within the
haversian system and decreases cellularity.

Diet and fracture healing

• Protein malnutrition results in negative effects on fracture healing:
• Decreased periosteal and external callus
• Decreased callus strength and stiffness
• Increased fibrous tissue within callus
• In experimental models, oral supplementation with
essential amino acids improves bone mineral density in
fracture callus.
 Diabetes mellitus

• Affects the repair and remodeling of bone

• Decreased cellularity of the fracture callus

• Delayed endochondral ossification

• Diminished strength of the fracture callus

• Fracture healing takes 1.6 times longer in diabetic

patients versus non-diabetic patients
 HIV
• Higher prevalence of fragility fractures with associated
delayed healing

• Contributing factors

• Anti-retroviral medication

• Poor intraosseous circulation

• TNF-Alpha deficiency

• Poor nutritional intake

 Medications affecting healing

Bisphosphonates are recognized as a cause of

osteoporotic fractures - longer healing times for surgically
treated wrist fractures in patients on bisphosphonates long
term usage may be associated with atypical
subtrochanteric/femoral shaft fractures

Systemic corticosteroids
• Studies have shown a 6.5% higher rate of intertrochanteric
fracture non unions
Nonsteroidal anti inflammatory drugs
• Have adverse effects on fracture healing and healing of
lumbar spinal fusions
• Cyclooxygenase-2 (COX-2) activity is required for
normal enchondral ossification during fracture
healing.

Quinolone antibiotics
• Toxic to chondrocytes and inhibit fracture healing
Electricity and fracture healing

Definitions
1. Stress-generated potentials

2. Piezoelectric effect: tissue charges are displaced secondary to

mechanical forces.

3. Streaming potentials: occur when electrically charged fluid is

forced over a cell membrane that has a fixed charge

4. Transmembrane potentials: generated by cellular metabolism

• Types of electrical stimulation

• Direct current: stimulates an inflammatory like response,

resulting in decreased oxygen concentrations and increase in
tissue pH (similar to effects of an implantable bone
stimulator).

• Alternating current: “capacity-coupled generators”; affects

cyclic AMP (cAMP) synthesis, collagen synthesis, and
calcification during repair stage

• Pulsed electromagnetic fields (PEMFs): initiate

calcification of fibrocartilage (but not fibrous tissue)
Type of Fracture Healing Based on Type of Stabilization

• Cast (closed treatment) - Periosteal bridging callus and

interfragmentary enchondral ossification
• Compression plate - Primary cortical healing (cutting cone type
or haversian remodeling)
• Intramedullary nail
• Early: periosteal bridging callus; enchondral ossification
• Late: medullary callus and intramembranous ossification
• External fixator - Dependent on extent of rigidity:
• Less rigid: periosteal bridging callus; enchondral ossification
• More rigid: primary cortical healing; intramembranous ossification
Union
• Union is incomplete repair

• The ensheathing callus is calcified.

• The fracture site is painless on palpation and weight-bearing.

• X-rays show bridging callus.

• Repair is complete and further protection is unnecessary.

Delayed-union
• Delayed union means that fracture healing is not taking place at the
expected rate and time but healing is still possible.

• Additional effort should be aimed at achieving fracture healing as fast

as possible.

• Clinically, the fractured limb has local swelling and movement or

partial weight-bearing is painful.
Non-union
• Sometimes the normal process of fracture repair is thwarted and the
bone fails to unite.

• Unless there is bone loss, non-union is usually defined as fracture

that has not healed 9 months post operation and there is no visible
progress of healing during the last 3 months.
• Types of Aseptic Non Union – Atrophic and Hypertrophic

• Lucent line still present between the bone fragments

• Sometimes there is exuberant callus trying – but failing

– to bridge the gap (hypertrophic nonunion) or at times
none at all (atrophic non-union) with a withered
appearance to the fracture ends
Aseptic non union
• Causes of aseptic non-union are:
• (1) mechanical instability or
• (2) impaired vascularity.
• Aseptic non-unions can be either stiff or mobile as judged by clinical
examination.
• The mobile ones can be as free and painless as to give the impression
of a false joint (pseudoarthrosis).
Atrophic non union
• Lack of healing response

• Infection, prior radiation treatments to injured site, insufficient

vascular supply.

• TGF B1 marker for non union – decreased levels at 4 weeks –

impending nonunion

• Treat the underlying etiology

• Autologous bone grafting

Hypertrophic non union

• Biologic healing response present sometimes more robust than

normal healing

• Most common cause is the unstable mechanical environment

• So soft callus is unable to transition to osseous callus – leads to over

production of fibrous tissue – persistent hypertrophic cartilage

• Usually treated with ORIF

Septic non-union
• Occur with infected osteosynthesis.
• Inadequate immobilization with adequate blood supply -
Hypertrophic nonunion (failed enchondral ossification); type II collagen
predominates

• Inadequate immobilization without adequate blood supply -

Atrophic nonunion

• Inadequate reduction with displacement at the fracture site -

Oligotrophic nonunion
Distraction osteogenesis
• Definition: distraction-stimulated formation of bone

Clinical applications:
• Limb lengthening
• Deformity correction (via differential lengthening)
• Segmental bone loss (via bone transport)
• Biologic features:
• Under optimal stability, intramembranous ossification occurs.
• Under instability, bone forms through enchondral ossification.
• Under extreme instability, pseudarthrosis may occur.
Novel Approaches for Impaired Fracture
Healing
Low Intensity Pulsed Ultrasound (LIPUS)
• Exact mechanism for enhancement of fracture healing
is not clear
• Alteration of protein expression
• Elevation of vascularity
• Accelerates fracture healing and increases mechanical
strength of callus (including torque and stiffness)
• the beneficial ultrasound signal is 30 mW/cm2 pulsed-
wave
• Healing rates for delayed unions/nonunions has been
reported to be close to 80%
• Extracorporal shock wave therapy (ESWT)
• Wnt Signaling and Sclerostin - Romosozumab is an FDA-approved
humanized monoclonal antibody sclerostin inhibitor used to treat
osteoporosis in postmenopausal women at high risk of fracture
• PDGF- Promote bone growth
• Calcium-Based Bone Grafts
• Bioactive Glass
• Organic bone grafts- Organic bone grafts are nanocomposites of mainly type I collagen
mimicking the natural collagen scaffold
DIAMOND CONCEPT OF FRACTURE
HEALING