Fracture
healing is divided into three stages: the inflammatory stage, the healing stage, and the remodeling stage.
Inflammatory
stage
This stage begins as soon as your bone breaks. For the first two weeks after your injury, your body
will rush healing cells to the area to begin the process of fracture healing. At the end of this stage, the bone will have
started to knit together with fibrous tissue. You will not be able to see evidence of this tissue on your two-week x-ray,
but be assured that this “healing” process has begun.
Healing stage
After
the inflammatory stage, the healing stage begins. This stage usually lasts six weeks, but may last longer. For high-energy
injuries, like a fall from a tall height or a motor vehicle crash, this stage can last 16 weeks. At the beginning of this
stage, the body starts to lay down tissue that acts as the bone’s “building blocks.” Later in this stage,
the body starts to lay down bone. At the end of this stage, the body has actually bridged the fracture gap with new bone and
the bone is considered healed. Although the bone will now be strong enough to support your weight and activity, there is still
a long way to go in the injury’s healing process.
Remodeling stage
Once
the body has healed the fracture, its work is not done. The body wants to “remodel” the bone to make it strong.
You will notice once your fracture has healed that you can still see where the bone was broken on an x-ray image. In the remodeling
stage, the body attempts to make the bone look like it looked before it was broken. When children break bones, you cannot
see where they were broken within a few years. In adults, however, the process is never complete. During the first year after
the injury, the remodeling process is in full gear. This process generates considerable inflammation and causes both swelling
and mild pain.
After a traumatic injury, patients often expect that they will be completely better and back to normal
within a few weeks. Unfortunately, this is rarely the case — even for simple injuries. Take, for example, a little toe
fracture. A little toe fracture does not need a cast and heals with no treatment at all. For six weeks, though, it is too
painful to wear constricting shoes, and if you hit the toe while putting on your socks there is severe pain. The foot —
and the toe especially — remain swollen. After six weeks, the severe pain goes away, but the toe is still too swollen
to fit in shoes. The severe pain is replaced by aches and stiffness that increase with activity, an annoyance that will make
you want to limit your walking. The toe will remain swollen for a year, with the pain becoming less and less over time. However,
even after a year the toe will occasionally swell and ache with weather changes. You can probably now imagine the healing
process for larger bones.
Nutrients for healing bone fractures
flax oil for bone health
Bone healing may occur within 6 to 12 weeks; however, bone strength and the ability to sustain
a heavy load may take up a year to return . Once bone healing has occurred, the individual may resume full activities of daily
living. It is important to instruct the individual not to overload the fracture site until the bone has regained its full
strength. The treating physician should guide the resumption of heavy work and sports.
Both local and systemic variables influence the rate and degree of fracture healing. When normal healing occurs, but at
a slower rate than usual, it is termed delayed union. A complete cessation of the healing process, in which
fibrous tissue is never replaced by bony matrix, is termed nonunion.
Systemic
Factors Affecting Fracture Healing
Age: Young patients heal rapidly and have a remarkable
ability to remodel and correct angulation deformities. These abilities decrease once skeletal maturity is reached.
Nutrition:
A substantial amount of energy is needed for fracture healing to occur. An adequate metabolic stage with sufficient carbohydrates
and protein is necessary.
Systemic Diseases: Diseases like osteoporosis, diabetes, and those causing
an immunocompromised state will likely delay healing. Illnesses like Marfan’s syndrome and Ehlers-Danlos syndrome cause
abnormal musculoskeletal healing.
Hormones: Thyroid hormone, growth hormone, calcitonin, and others
play significant roles in bone healing. Corticosteroids impede healing through many mechanisms.
Local
Variables Affecting Fracture Healing
Type of bone: Calcellous (spongy) bone fractures
are usually more stable, involve greater surface areas, and have a better blood supply than do cortical (compact) bone fractures.
Cancellous bone heals faster than cortical bone.
Degree of Trauma: The more extensive the injury
to bone and surrounding soft tissue, the poorer the outcome. Mild contusions with local bone trauma will heal easily, whereas
severely comminuted injuries with extensive soft tissue damage heal poorly.
Vascular Injury: Inadequate
blood supply impairs healing. Especially vulnerable areas are the femoral head, talus, and scaphoid bones.
Degree
of Immobilization: The fracture site must be immobilized for vascular ingrowth and bone healing to occur. Repeated
disruptions of repair tissue, especially to areas with marginal blood supply or heavy soft tissue damage, will impair healing.
Intraarticular
Fractures: These fractures communicate with synovial fluid, which contains collagenases that retard bone healing.
Joint movement will cause the fracture fragments to more, further impairing union. When intraarticular fractures are comminuted,
the fragments tend to float apart owing to loss of soft tissue support.
Separation
of Bone Ends: Normal apposition of fracture fragments is needed for union to occur. Inadequate reduction, excessive
traction, or interposition of soft tissue will prevent healing.
Infection: Infections cause necrosis
and edema, take energy away from the healing process, and may increase the mobility of the fracture site.
Local
Pathology: Any disease process that weakens the musculoskeletal tissue, like osteoporosis or osteomalacia, may impair
union.
How long it takes for Broken Bones / Fractures to Heal
The following is a rough estimate to how long it will take for your poor broken bone to heal in a cast. Remember that if you smoke or drink alcohol
heavy, or required surgical correction, these times may be longer.
Bone Broken
Time for it to Heal
Collar bone (clavicle)
3-8 weeks
Shoulder blade (scapula)
6
weeks
Ribs
4 weeks
Upper arm (humerus)
4-10 weeks
Lower arm (radius,ulna)
6 weeks
Wrist
4-12 weeks
Fingers
4-6 weeks
Pelvis
4 - 6 weeks
Upper leg (femur)
12 weeks
Knee (patella)
4-6 weeks
Lower
leg (tibia,fibula)
10-24 weeks
Ankle
6 weeks
Foot
3
- 12 weeks
Toes
3 weeks
Legs
take so long to heal because they have to support the full weight of your body so they need to be pretty sturdy before you
can start using 'em.
All broken bones go through the same healing process. This is true whether a bone has been
cut as part of a surgical procedure or fractured through an injury.
The bone healing process has three overlapping
stages: inflammation, bone production, and bone remodeling.
Inflammation starts immediately after
the bone is fractured and lasts for several days. When the bone is fractured there is bleeding into the area, leading to inflammation
and clotting of blood at the fracture site. This provides the initial structural stability and framework for producing new
bone.
Bone production begins when the clotted blood formed by inflammation is replaced with fibrous
tissue and cartilage (known as “soft callus”). As healing progresses, the soft callus is replaced with hard bone
(known as “hard callus”), which is visible on x-rays several weeks after the fracture.
Bone remodeling,
the final phase of bone healing, goes on for several months. In remodeling, bone continues to form and becomes compact, returning
to its original shape. In addition, blood circulation in the area improves. Once adequate bone healing has occurred, weightbearing
(such as standing or walking) encourages bone remodeling.
How Long Does Bone Healing Take? Bone healing is a complex process. Speed and success differ among individuals. The time required for bone healing can be
affected by many factors, including the type of fracture and the patient's age, underlying medical conditions, and nutritional
status.
Bone generally takes 6 to 8 weeks to heal to a significant degree. In general, children's bones
heal faster than those of adults. The foot and ankle surgeon will determine when the patient is ready to bear weight on the
area. This will depend on the location and severity of the fracture, the type of surgical procedure performed, and other considerations.
What Helps Promote Bone Healing? If a bone will be cut during a planned surgical procedure, some steps can be
taken pre-and post-operatively to help optimize healing. The surgeon may offer advice on diet and nutritional supplements
that are essential to bone growth. Smoking cessation, and adequate control of blood sugar levels in diabetics, are important.
Smoking and high glucose levels interfere with bone healing.
For all patients with fractured bones, immobilization
is a critical part of treatment, because any movement of bone fragments slows down the initial healing process. Depending
on the type of fracture or surgical procedure, the surgeon may use some form of fixation (such as screws, plates, or wires)
on the fractured bone and/or a cast to keep the bone from moving. During the immobilization period, weightbearing is restricted
as instructed by the surgeon.
Once the bone is adequately healed, physical therapy often plays
a key role in rehabilitation. An exercise program designed for the patient can help in regaining strength and balance and
assist in returning to normal activities.
What Can Hinder Bone Healing? A wide variety of factors can slow down the healing process. These include:
Movement
of the bone fragments; weightbearing too soon
Smoking, which constricts the blood vessels and decreases circulation
Medical
conditions, such as diabetes, hormone-related problems, or vascular disease
Some medications, such as corticosteroids
and other immunosuppressants
Fractures that are severe, complicated, or become infected
Advanced age
Poor
nutrition or impaired metabolism
How Can Slow Healing be Treated? If the bone is not healing as well as expected or fails to heal, the
foot and ankle surgeon can choose from a variety of treatment options to enhance the growth of bone, such as continued immobilization
for a longer period, bone stimulation, or surgery with bone grafting or useof bone growth proteins.
In this kind of healing callus is not formed at all and requires
rigid stabilization with or without compression of the bone ends.
Rigid stabilization suppresses the formation of a
callus in either cancellous or cortical bone .
Because most fractures are managed in a way that results
in some degree of motion, primary healing per se is rare.
Primary bone healing can be divided into gap
healing and contact healing. Union occurs in both types.
Gap Healing
Gap healing occurs
in two stages.
Firstly, the width of the gap is filled by direct bone formation. An initial scaffold of woven bone is laid down, followed by formation of lamellar bone as support. The orientation of the new bone formed in this first stage is transverse to that of the original lamellar bone
orientation.
In the second stage, which happens after several weeks, longitudinal Haversian remodeling reconstructs
the necrotic fracture ends and the newly formed bone to replace the woven bone with osteons of the original orientation. In the end, the normal bone structure results.
Contact Healing
Contact healing
occurs where fragments are in direct apposition and osteons can grow across the fracture site, parallel to the long axis of
the bone.
When fracture fragments are in contact, osteoclasts on one side of the fracture undergo a tunneling resorptive
response, forming cutting cones that cross the fracture line.
This tunnelling allows the penetration of capillaries
and eventually the formation of new haversian systems. These blood vessels are then accompanied by endothelial cells and osteoprogenitor
cells for osteoblasts leading to the production of osteons across the fracture line eventually leading to regeneration
of the normal bone architecture.
Secondary bone healing
It occurs when there is no rigid fixation
of the fractured bone ends, which leads to the development of a fracture callus. It includes an inflammatory phase, a reparative
phase, and a remodeling phase.
Your bones are tough stuff — but even tough stuff can break. Like a wooden pencil, bones will bend under strain.
But if the pressure is too much, or too sudden, bones can snap. You can break a bone by falling off a skateboard or crashing
down from the monkey bars.
When a bone breaks it is called a fracture (say: frak-chur).
There's more than one way to break or fracture a bone. A break can be anything from a hairline fracture (a thin break in the
bone) to the bone that's snapped in two pieces like a broken tree branch.
Doctors describe fractures in the following ways:
A complete fracture
is when the bone has broken into two pieces.
A greenstick fracture is when the bone cracks on one
side only, not all the way through.
A single fracture is when the bone is broken in one place.
A
comminuted (say: kah-muh-noot-ed) fracture is when the bone is broken into
more than two pieces or crushed.
A bowing fracture,
which only happens in kids, is when the bone bends but doesn't break.
An open fracture is when the
bone is sticking through the skin.
What Happens When You Break a Bone?
It hurts to
break a bone! It's different for everyone, but the pain is often like the deep ache you get from a super bad stomachache or headache. Some people may experience sharper pain — especially with an open fracture. And if the fracture is small, a kid may
not feel much pain at all. Sometimes, kids won't even be able to tell that they broke a bone!
Breaking a bone is a big
shock to your whole body. It's normal for you to receive strong messages from parts of your body that aren't anywhere close
to the fracture. You may feel dizzy, woozy, or chilly from the shock. A lot of people cry for a while. Some people pass out
until their bodies have time to adjust to all the signals they're getting. And other people don't feel any pain right away
because of the shock of the injury (say: in-juh-ree).
If you think you or someone
else has broken a bone, the most important things to do are to:
stay calm
make sure the person who is hurt
is as comfortable as possible
tell an adult
if there are no adults around, call 911 or the emergency number in your area
The worst thing for a broken bone is to move it. This will hurt the person
and it can make the injury worse! In the case of a broken arm or leg, a grown-up may be able to cushion or support the surrounding
area with towels or pillows.
One super-important tip: If you're not sure what bone is broken or you think the neck or
back is broken, do not try to move the injured person. Wait until a trained medical professional has arrived!
What
Does the Doctor Do?
To treat the broken bone, the doctor needs to know which kind of fracture it is. That's where X-rays come in handy. X-rays give doctors a map of fractures so that they can set the bones back in their normal position.
With
breaks in larger bones or when a bone breaks in more than two pieces, the doctor may need to put in a metal pin — or
pins — to help set it. For this operation, you'll get some medicine so you'll be asleep and unable to feel any pain.
When your bone has healed, the doctor will remove the pin or pins.
After your bone has been set, the next step is usually
putting on a cast, the special bandage that will keep the bone in place for the 1 to 2 months it will take for the break to mend. Casts are
made of bandages soaked in plaster, which harden to a tough shell (that's why they last so long!).
Sometimes casts are
made of fiberglass or plastic — and some are even waterproof, which means you can still go swimming and get them wet!
And sometimes they come in cool colors or patterns that you can choose.
How Do Broken Bones Heal?
Your
bones are natural healers. At the location of the fracture, your bones will produce lots of new cells and tiny blood vessels
that rebuild the bone. These cells cover both ends of the broken part of the bone and close up the break until it's as good
as new.
What Should You Do When the Cast Comes Off?
Can you
believe they use a saw to remove your cast? The funny thing is this saw doesn't hurt your skin at all. It might even tickle!
Once the cast is off, the injured area will probably look and feel pretty weird. The body part that was in a cast might look
strange at first. The skin might be pale, dry, or flaky. Body hair might look darker and the body part itself might look smaller
because you might have lost some muscle while it was healing.
Don't worry. This is all temporary. Kids are great healers,
so you'll be back to normal soon. In some cases, your doctor might suggest you do special exercises to improve your strength
and flexibility. You'll want to go slow and ask the doctor if there are any activities you should avoid, such as hanging from
the monkey bars. If you want to return to a sport, ask the doctor how soon you'll be able to do it.
How can you be sure
you don't break any more bones? Accidents happen, but you often can prevent injuries by wearing safety helmets, pads, and
the right protective gear for your activity or sport.
It's also a smart idea to do what you can to build strong bones.
How do you do that?
Get a lot of physical activity, especially stuff like jumping and
running.
Feed your bones the calcium and vitamin D they need to stay strong. That means getting your share of milk
and other calcium-rich foods and drinks, such as broccoli and calcium-fortified orange juice.
When bone breaks, it bleeds from its torn ends due to disruption of its supplying vessels. Quite naturally the periosteum
also is torn as shown in the figure. This periosteum may be completely torn or partially damaged depending upon the force
of injury. The collected blood is called fracture hematoma.
Due to loss of vascularity or blood supply
adjacent portion of broken ends die. Inflammation changes occur in the haematoma over next few hours ( A reaction by the body
which occurs whenever there is an insult to a part or structure. The basic purpose of the inflammation is to contain the damage
and facilitate the healing and regeneration. Inflammation is responsible for redness, pain, warmth and tenderness of the wounds
and abcesses) .
This inflammation brings in many cells that would help in regeneration of the broken bone. Periosteum
plays a vital role in fracture healing. The periosteum is the primary source of precursor cells which develop into chondroblasts(
cartilage cells) and osteoblasts ( bone cells) that are essential to the healing of bone. as the time progresses, the fibroblasts
( A kind of cells which produce fibrous tissue in the body) get interspersed with small vesels and form a loose mesh like
structure uniting the broken ends of the bone and on which the future layers of bone tissue would be added. this structue
is called granulation tissue.
Over the next few days, the cells of the periosteum replicate and transform. The periosteal
cells proximal to the fracture gap develop into chondroblasts and form hyaline cartilage. The periosteal cells distal to the
fracture gap develop into osteoblasts and form woven bone a kind of bone which is structurally different from the lamellar
bone oound in the body.
These two new tissues grow in size until they unite with their counterparts from other pieces of the fracture. This process
forms the fracture callus. the callus is the first sign of union visible in x-ray and generally appears around two weeks after
fracture. Eventually, the fracture gap is bridged by the cartilage and woven bone, restoring some of its original strength.
A picture like this is produced
From here on slowly and steadily bone is restructured by a process called remodeling.
Fractures are classified according to the pattern in which bone breaks.
Transverse Fracture:
A fracture in which the break is across the bone, at a right angle to the long
axis of the bone. Adjoining figure would illustrate.
Oblique Fracture:
Instead of break being at right angle, it goes in oblique direction to the long axis
of the bone.The fracture is confined to one plane. In other words the bone has broken at an angle.
Spiral Fracture :
This fracture is easily confused with the oblique fracture. Instead of a straight
break as in oblique fracture that is only in one plane, the break in this case traverses both the planes. To understand this
you need to imagine a three dimensional view of the bone.
If you take a stick and slice it at an angle so that it is
divided in two, it is similar to oblique fracture. But if you twist and break that stick it would result in a break pattern
that would start from one point, move obliquely in on direction, reach the other end and then continue in other side of the
stick in a spiral fashion to meet the original point.
Adjoining diagram would give you rough idea of what I am trying
to say. Compare it with the oblique fracture diagram and you would be able to appreciate the difference.
Comminuted Fracture :
If the injury results in multiple breaks in the bone, they are visible as different
fragments. These kind of fractures are called comminuted fractures.
Apart from this, fracture can be displaced or undisplaced. If bone fragments stay together maintaining structural alignment
of the bone , it is called an undisplaced fracture. A hairline fracture is an example of an undisplaced fracture.
But
fragment of the bone may move from their original position resulting separation of the fragments. Such a fracture is called
a displaced fracture. (See the figure)
Interfragmentary screw or lag screw is used in fixation of spiral or oblique fractures of the shaft
of a bone. Interfragmentary screw or lag screw is used as an adjunct to plating and often as initial fixation holder
so as to safe and secure application of plate in neutral mode in reduced fracture.
The procedure involves placement
of one or more screws across a fracture site so that fractured fragments are apposed and compressed to each other, called
interfragmentary compression ( See image below). The interfragmentary screw can also be used for fixation after osteotomies.
Interfragmentary
screw is put in a direction perpendicular to the fracture. Therefore in case of a spiral fracture, the screw direction may
vary as the fracture plane changes.
Interfragmentary screw fixation of a spiral fracture
Image Credit:Muller ME, Allgower M. Schneider RW, 30. et al: Manual of Internal Fixation. New
York. Springer- Verlag, 1979.
Technique
Fracture is reduced and held temporarily with reduction
forceps and or Kwires-
A hole is drilled in the near cortex called gliding hole. This drill bit needs to be oversized
(equal ot outer diameter of screw) than the drill in far cortex so that screw just glides and compresses two surfaces of fracture.
Far cortex should not be drilled with this drill bit.
[The bone is like a hollow cylinder.The
shell of the cyllinder is cortex and empty hollow is medulla. When drilling one would encounter bone [or near cortex)followed
by relatively empty feeling of medulla followed by striking the bony surface from within on the other side {far cortex} in
the path of the drilling.
Insert a drill sleeve into the overdrilled cortex. Use appropriately
sized drill bit to drill the far cortex
Tap the bone using appropriately sized tapper.
Use a screw length
so as to allow screw to protrude 2 mm beyond far cortex a
Lag screw fixation of an oblique or spiral fracture
requires neutralization by a plate if sufficient stability is to be achieved to allow immediate rehabilitation without external
protection.
Non union is a delayed complication of fracture. Literally it means absence of union.
But
by definition a bone can be labeled as in non union only when the union has not occured in the bone even after passage of
sufficient time [in which the bone normally would have united]. Fractures of shaft of long bone should not be considered nonunion
until at least 6 months post injury but in contrast, a central fracture of the femoral neck can sometimes be defined as a
non union after only 3 months
Causes of Non Union
There is a long list of causes of non union.
These are patient related like age, injury related like open fractures and treatment related. Few of them are modifiable and
others are not.
Patient Related Factors
Older age
Poor nutrition
Steroid
therapy
Radiation therapy
Anticoagulant therapy
Smoking
High alcohol intake
Injury
Related Factors
Open injuries
Soft tissue interposition
Bone loss resulting in gap
Compromised
blood supply following injury to nutrient artery
Stripping injury to muscle and periosteum
Severe comminution
Infection
Treatment
Related Factors
Inadeuqate immobilisation
Distraction of fragments from traction or internal
fixation
Malposition of fragments
Implant failure
Types
Hypertrophic
non-union
Callus is formed, but the bone fractures have not joined. This can be due to inadequate fixation of the
fracture or inadequate mobilisation. Fracture is capable of a healing response to injury.There is increased uptake on radionuclide
scans.
Oligotrophic non unions
The callus is absent and occur after major displacement of fractures,
distraction of fragments, or internal fixation without accurate apposition of fragments. Blood supply is usually good. They
demonstrates uptake on radionuclide scans but the healing response is inadequate.
Atrophic non-union
No callus is
formed. This is often doe to impaired bony healing due to decreases blood supply. They show radionuclide uptake failure.
Gap
non union
There is a loss of a fragment of the diaphysis of a bone. The ends of the fragments are viable
but as time passes the ends of the fragments become atrophic. Occur after open fractures, sequestration in osteomyelitis,
and resection of tumors;
Diagnosis
Diagnosis is made on clinical examination and xrays. On clinical
examination, the fracture fragments would show relative mobilitya and there would be absence of tenderness on the fracture
site. Absense of tenderness differentiates non union from delayed union and denotes absence of any biological activity.
Xrays
would show
Absence of bone crossing the fracture site (bridging trabeculae)
Sclerotic fracture edges
Persistent
fracture lines
No changes toward union on serial xray
Presence or absence of callus is not a very reliable
finding especially in cases of rigid fixation.
Treatment
Nonunion is a failure of healing process.
The treatment principle is to augment the healing process by freshening the ends of bone and one grafting and
provide adequate immobilisation.
Typical treatment of non union is surgical. Following are the essential steps
Exposure
of fracture site
Freshening of sclerotic edges to get a bleeding surface.
Opening of intramedullary cavities
of fragments to facilitate flow of blood circulation
Rigid fixation
Bone grafting to augment bone healing
External
splinatge if required.
According
to Shé D'Montford, Shambhallah, from Australia ‘The human body "WILL HEAL"... If we get out of our
own way and allow it, it heals itself. It is our basic nature. Anybody who tells you other than that is trying to sell you
something. No matter what you have been told. Don't give up on yourself and don't buy into the lines like ... ‘oh well
you've had a good life'... 'at your age'... and the worst of all ...'there's nothing further I can do, I suggest you finalize
your affairs'... How dare anyone tell you to give up! So much in society combines to convince us of the propaganda that some
things never get better. It's up to you ... do you want to get better? Make things better? It is human nature to make things
better, evolve and grow.”
This site is intended to provide general information only and is not a substitute
for medical evaluation or treatment. All matters regarding health or a particular health situation should be supervised by
a licensed health care professional.The author and the publisher shall not be held responsible or liable for any harm or loss
allegedly arising, directly or indirectly from any information in this site
Transverse Fracture:
Oblique Fracture:
Spiral Fracture : 
Comminuted Fracture :
Apart from this, fracture can be displaced or undisplaced. If bone fragments stay together maintaining structural alignment
of the bone , it is called an undisplaced fracture. A hairline fracture is an example of an undisplaced fracture.
