Bone healing

Bone healing or fracture healing is a proliferative physiological process, in which the body facilitates repair of bone fractures.

Physiology and process of healing

In the process of fracture healing, several phases of recovery facilitate the proliferation and protection of the areas surrounding fractures and dislocations. The length of the process is relevant to the extent of the injury, and usual margins of two to three weeks are given for the reparation of the majority of upper bodily fractures; anywhere above four weeks given for lower bodily injury.

The process of the entire regeneration of the bone can depend upon the angle of dislocation or fracture, and dislocated bones are generally pushed back into place via relocation with or without anaesthetic. While the bone formation usually spans the entire duration of the healing process, in some instances, bone marrow within the fracture having healed two or fewer weeks before the final remodeling phase.

While immobilization and surgery may facilitate healing, a fracture ultimately heals through physiological processes. The healing process is mainly determined by the periosteum (the connective tissue membrane covering the bone). The periosteum is the primary source of precursor cells which develop into chondroblasts and osteoblasts that are essential to the healing of bone. The bone marrow (when present), endosteum, small blood vessels, and fibroblasts are secondary sources of precursor cells.

Phases of fracture healing

There are three major phases of fracture healing, two of which can be further sub-divided to make a total of five phases;

*1. Reactive Phase
**i. Fracture and inflammatory phase
**ii. Granulation tissue formation
*2. Reparative Phase
**iii. Callus formation
**iv. Lamellar bone deposition
*3. Remodeling Phase
**v. Remodeling to original bone contour

Reactive

After fracture, the first change seen by light and electron microscopy is the presence of blood cells within the tissues which are adjacent to the injury site. Soon after fracture, the blood vessels constrict, stopping any further bleeding. [Brighton and Hunt (1997), p. 248: The extravascular blood cells are identified as erythrocytes, platelets and neutrophils.] Within a few hours after fracture, the extravascular blood cells, known as a "hematoma", form a blood clot. All of the cells within the blood clot degenerate and die. [Brighton and Hunt (1991), p. 837: The cells within the clot are identified.] Some of the cells outside of the blood clot, but adjacent to the injury site, also degenerate and die. [Brighton and Hunt (1997)] Within this same area, the fibroblasts survive and replicate. They form a loose aggregate of cells, interspersed with small blood vessels, known as granulation tissue. [Ham and Harris]

Reparative

Days after fracture, 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. The fibroblasts within the granulation tissue also develop into chondroblasts and form hyaline cartilage. [Brighton and Hunt (1997), p. 248: Two light micrographs showing the cells of the woven bone and hyaline cartilage.] 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". [Brighton and Hunt (1986), p. 704: Two light micrographs of a typical fracture callus: one showing the tissues and the other showing the cells.] Rarely, if the callus formation is "hyperplastic" (or "exuberant"), there may be entrapment of adjacent tissues. Eventually, the fracture gap is bridged by the hyaline cartilage and woven bone, restoring some of its original strength.

The next phase is the replacement of the hyaline cartilage and woven bone with lamellar bone. The replacement process is known as endochondral ossification with respect to the hyaline cartilage and "bony substitution" with respect to the woven bone. Substitution of the woven bone with lamellar bone precedes the substitution of the hyaline cartilage with lamellar bone. The lamellar bone begins forming soon after the collagen matrix of either tissue becomes mineralized. At this point, "vascular channels" with many accompanying osteoblasts penetrate the mineralized matrix. The osteoblasts form new lamellar bone upon the recently exposed surface of the mineralized matrix. This new lamellar bone is in the form of trabecular bone. [Brighton and Hunt (1986); Brighton and Hunt (1997); Ham and Harris] Eventually, all of the woven bone and cartilage of the original fracture callus is replaced by trabecular bone, restoring much, if not all, of the bone's original strength.

Remodeling

The remodeling process substitutes the trabecular bone with compact bone. The trabecular bone is first resorbed by osteoclasts, creating a shallow resorption pit known as a "Howship's lacuna". Then osteoblasts deposit compact bone within the resorption pit. Eventually, the fracture callus is remodelled into a new shape which closely duplicates the bone's original shape and strength. [Ham and Harris]

References

*Brighton, Carl T. and Robert M. Hunt (1986), "Histochemical localization of calcium in the fracture callus with potassium pyroantimonate: possible role of chondrocyte mitochondrial calcium in callus calcification", "Journal of Bone and Joint Surgery", 68-A (5): 703-715

*Brighton, Carl T. and Robert M. Hunt (1991), "Early histologic and ultrastructural changes in medullary fracture callus", "Journal of Bone and Joint Surgery", 73-A (6): 832-847

*Brighton, Carl T. and Robert M. Hunt (1997), "Early histologic and ultrastructural changes in microvessels of periosteal callus", "Journal of Orthopaedic Trauma", 11 (4): 244-253

*Ham, Arthur W. and William R. Harris (1972), "Repair and transplantation of bone", The biochemistry and physiology of bone, New York: Academic Press, p. 337-399

Notes

External links

* [http://www.bonefixator.com/bone_fracture/fractures_and_healing_1.html Long bone fracture and healing]


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