PATHOPHYSIOLOGY OF FRACTURE HEALING
Speaker-Raghavendra MSModerator-Dr Marulasiddappa G
INTRODUCTION
Fracture is a break in the continuity of bone or periosteum
The healing of fracture is in many ways similar to soft tissue healing except that the end result is mineralized mesenchymal tissue i.e BONE
Fracture healing starts as soon as bone breaks and continues for many months
HYSTORY In 17th century Albrecht Haller, observed invading
capillary buds in fracture callus and thought that blood vessels are responsible for callus formation
John Hunter, a pupil of Haller, described the morphologic sequence of fracture healing.
In 1873, Kolliker observed the role of multinucleated giant cells, osteoclast to be responsible for bone resorption.
In1939, Gluksman suggested pressure and shearing stresses are possible stimuli for fracture healing.
In 1961, Tonna and Cronkie demonstrated the role of local mesenchymal cells in fracture repair.
Components of bone formation
Bone marrow Periosteum Cortex Soft tissue
PERIOSTEUM
Is a membrane that lines the outer surface of all bones except at the joints of long
bones.Is made up of : Outer FIBROUS layer : made up of white
connective and elastic tissue. Inner CAMBIUM layer : which has a looser
composition, is more vascular and contains cells with osteogenic potency.
FUNCTIONS OF PERIOSTEUM
1. Anchors tendons and ligaments to bone.2. Acts as a limiting membrane.3. Participates in growth (appositional) and
repair through the activities of the osteoprogenitor cells .
4. Periosteum helps in fracture healing by forming periosteal callus.
5. It also lessen the displacement of the # and helps in reduction.
6. Allows passage of blood vessels, lymphatics and nerves into and out of the bone.
OSTEO PROGENITOR CELLS
OSTEOBLASTS Are basophilic, cuboidal to pyramidal in shape ,
associated with bone formation, these cells are located where new bone is forming, eg: in the periosteum.
Osteoblasts often appear stratified as in an epithelium.
The nucleus is large with a single prominent nucleolus.
Osteoblasts contain the enzyme alkaline phosphatase used to calcify the osseous matrix.
They synthesize type 1 collagen, osteocalcin (bone Gla protein) and osteonectin
OSTEOCLASTS
Giant, multinuclear cells which vary greatly in shape.
They are found on the surfaces of osseous tissue usually in shallow depressions called Howship’s lacunae.
The cytoplasm is slightly basophilic and contains lysosomal vacuoles.
Under E.M. the cell surface facing the osseous matrix shows numerous cytoplasmic projections and microvilli described as a ruffled border.
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RUFFLED BORDER
MICROSCOPIC PICTURE ELECTRON MICROSCOPY
OSTEOCLASTS
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Basically, an osteoblast that has been enclosed within the bony matrix in a space called the lacuna.
The cytoplasm of the osteocyte is faintly basophilic containing fat droplets and granules of glycogen with single dark stained nucleus.
In developing bone, the cytoplasmic processes from one osteocyte make contact with the processes (i.e.: cannaliculi) from adjoining osteocytes. In mature bone, the processes are withdrawn almost completely.
In mature bone the empty canaliculi remain as passage ways for the diffusion of nutrients and wastes between bone and blood.
4.OSTEOCYTES
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Are flattened epithelium in adult skeleton found on resting surfaces.
Plays active role in differentiation of progenitor cells
Controls osteoclasts, mineral hemostasis and may secrete collagenase.
Lines – endosteal surface of marrow cavity - periosteal surface
- vascular channels within osteons.
5.BONE LINING CELLS
Modes of bone formation
Endoochondral Intramembranous ossification Oppositional new bone formation Osteonal migration (creeping substitution)
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Mechanism by which a long bone grows in width.
Osteoblasts differentiate directly from pre osteoblasts and lay down seams of osteoid.
Does NOT involve cartilage anlage.
INTRAMEMBRANOUS BONE FORMATION(PERIOSTEAL)
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INTRAMEMBRANOUS BONE FORMATION
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Mechanism by which a long bone grows in length.
Osteoblasts line a cartilage precursor.
The chondrocytes hypertrophy, degenerate and calcify (area of low oxygen tension).
Vascular invasion of the cartilage occurs followed by ossification (increasing oxygen tension).
ENDOCHONDRAL BONE FORMATION
Endochondral Bone Formation
Picture courtesy Gwen Childs, PhD.
Creeping substitution
The process of bone remodelling by osteoclastic resorption and creation of new vascular channals with osteoblastic bone formation resulting in new haversian systems
Seen in bone healing after bone grafting
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Primarily a
mechanism to
remodel bone.
Osteoclasts at the
front of the cutting
cone remove bone.
Trailing osteoblasts
lay down new bone.
CUTTING CONES
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Stages of fracture healing
•Stage of hematoma formation•Stage of inflammation and cellular proliferation
Reactive phase
•Stage of callus formation•stage of consolidation
Reparative phase
•Stage of remodelingRemodeling phase
1975, Cruess and Dumont
1989, FROST
Stage of hematoma formation
Torn vessels will bleed and form hematoma
A mass of clotted blood(hematoma) formed around the fracture site
Stage of inflammation and cellular proliferation(0-7 days)
Hematoma is invaded inflammatory cells & they degrade necrotic tissue
Release of TGF-β,PDGF by macrophages
Procuring osteoprogenitor cells
Stage of callus formation
new capillaries organize fracture hematoma into granulation tissue – procallus
Fibroblasts and osteogenic cells invade procallus.
Make collagen fibers which connect ends together
Chondroblasts begin to produce fibrocatilage
This is called soft callus(7days-6wks)
Stage of consolidation
Osteoblasts lay more boney trabacule
Fibrocartilagenous frame work is calcified to form boney callus(6-12wks)
Now fracture is painless and allows weight bearing
Stage of remodeling
Globular callus is slowly remodeled over years
More trabacule are layed in the line of stress and non stressed area is resorbed
Hence bone will take original shape
Woolfs law
A bone will adapt to mechanical stress and strain by changing size, shape and structure
Types for Bone Healing
Direct (primary) bone healing Indirect (secondary) bone
healing
Direct Bone Healing
Mechanism of bone healing seen when there is no motion at the fracture site (i.e. absolute stability)
Does not involve formation of fracture callus
Osteoblasts originate from endothelial and perivascular cells
Components of Direct Bone Healing
Contact Healing Direct contact between the fracture ends allows
healing to be with lamellar bone immediately Gap Healing
Gaps less than 200-500 microns are primarily filled with woven bone that is subsequently remodeled into lamellar bone
Larger gaps are healed by indirect bone healing (partially filled with fibrous tissue that undergoes secondary ossification)
Direct Bone Healing
Indirect Bone Healing Mechanism for healing in
fractures that have some motion, but not enough to disrupt the healing process.
Bridging periosteal (soft) callus and medullary (hard) callus re-establish structural continuity
Callus subsequently undergoes endochondral ossification
Process fairly rapid - weeks
Local Regulation of Bone Healing
Growth factors Transforming growth factor Bone morphogenetic proteins Fibroblast growth factors Platelet-derived growth factors Insulin-like growth factors Cytokines Interleukin-1,-4,-6,-11, macrophage and
granulocyte/macrophage (GM) colony-stimulating factors (CSFs) and Tumor Necrosis Factor
Prostaglandins/Leukotrienes Hormones Growth factor antagonists
Transforming Growth Factor
Super-family of growth factors (~34 members)
Acts on serine/threonine kinase cell wall receptors
Promotes proliferation and differentiation of mesenchymal precursors for osteoblasts, osteoclasts and chondrocytes
Stimulates both enchondral and intramembranous bone formation Induces synthesis of cartilage-specific
proteoglycans and type II collagen Stimulates collagen synthesis by osteoblasts
Bone Morphogenetic Proteins
These are included in the TGF-β family Except BMP-1
Sixteen different BMP’s have been identified
BMP2-7,9 are osteoinductive BMP2,6, & 9 may be the most potent in
osteoblastic differentiation Involved in progenitor cell transformation to
pre-osteoblasts Work through the intracellular Smad
pathway Follow a dose/response ratio
Bone Morphogenetic Proteins Osteoinductive proteins initially isolated from
demineralized bone matrix Induce cell differentiation
BMP-3 (osteogenin) is an extremely potent inducer of mesenchymal tissue differentiation into bone
Promote endochondral ossification BMP-2 and BMP-7 induce endochondral bone
formation in segmental defects Regulate extracellular matrix production
BMP-1 is an enzyme that cleaves the carboxy termini of procollagens I, II and III
Timing and Function of Growth Factors
Table from Dimitriou, et al., Injury, 2005
Clinical Use of BMP’s Used at doses between 10x & 1000x
native levels Negligible risk of excessive bone
formation rhBMP-2 used in “fresh” open fractures to
enhance healing and reduce need for secondary procedures after unreamed IM nailing
It is found that application of rhBMP-2 decreases infection rate in Type IIIA & B open fractures.
BMP-7 approved for use in recalcitrant nonunions in patients for whom autografting is not a good option (i.e. medically unstable, previous harvesting of all iliac crest sites, etc.)
BMP Future Directions BMP-2
Increased fusion rate in spinal fusion BMP-7 equally effective as ICBG in
nonunions (small series: need larger studies)
Must be applied locally because of rapid systemic clearance
BMP Antagonists May have important role in bone
formation Noggin
Extra-cellular inhibitor Competes with BMP-2 for receptors
BMP-13 found to limit differentiation of mesenchymal stromal cells Inhibits osteogenic differentiation
Fibroblast Growth Factors
Both acidic (FGF-1) and basic (FGF-2) forms
Increase proliferation of chondrocytes and osteoblasts
Enhance callus formation FGF-2 stimulates angiogenesis
Platelet-Derived Growth Factor
A dimer of the products of two genes, PDGF-A and PDGF-B PDGF-BB and PDGF-AB are the predominant
forms found in the circulation Stimulates bone cell growth Mitogen for cells of mesenchymal origin Increases type I collagen synthesis by
increasing the number of osteoblasts PDGF-BB stimulates bone resorption by
increasing the number of osteoclasts
Insulin-like Growth Factor Two types: IGF-I and IGF-II
Synthesized by multiple tissues IGF-I production in the liver is
stimulated by Growth Hormone Stimulates bone collagen and matrix
synthesis Stimulates replication of osteoblasts Inhibits bone collagen degradation
Cytokines Interleukin-1,-4,-6,-11, macrophage and
granulocyte/macrophage (GM) colony-stimulating factors (CSFs) and Tumor Necrosis Factor
Stimulate bone resorption IL-1 is the most potent
IL-1 and IL-6 synthesis is decreased by estrogen May be mechanism for post-menopausal bone
resorption Peak during 1st 24 hours then again during
remodeling Regulate endochondral bone formation
Specific Factor Stimulation of Osteoblasts and Osteoclasts
Cytokine Bone Formation Bone ResorptionIL-1 + +++TNF-α + +++TNF-β + +++TGF-α -- +++TGF-β ++ ++PDGF ++ ++IGF-1 +++ 0IGF-2 +++ 0FGF +++ 0
Prostaglandins / Leukotrienes
Effect on bone resorption is species dependent and their overall effects in humans unknown
Prostaglandins of the E series Stimulate osteoblastic bone formation Inhibit activity of isolated osteoclasts
Leukotrienes Stimulate osteoblastic bone formation Enhance the capacity of isolated osteoclasts to
form resorption pits
Hormones Estrogen
Stimulates fracture healing through receptor mediated mechanism
Modulates release of a specific inhibitor of IL-1 Thyroid hormones
Thyroxine and triiodothyronine stimulate osteoclastic bone resorption
Glucocorticoids Inhibit calcium absorption from the gut
causing increased PTH and therefore increased osteoclastic bone resorption
Hormones (cont.) Parathyroid Hormone
Intermittent exposure stimulates Osteoblasts Increased bone formation
Growth Hormone Mediated through IGF-1 (Somatomedin-
C) Increases callus formation and fracture
strength
Vascular Factors Metalloproteinases
Degrade cartilage and bones to allow invasion of vessels
Angiogenic factors Vascular-endothelial growth factors
Mediate neo-angiogenesis & endothelial-cell specific mitogens
Angiopoietin (1&2) Regulate formation of larger vessels
and branches
Factors affecting fracture healing
Systemic Factors A. Age B. Activity level including 1. General immobilization 2. Space flight C. Nutritional status D. Hormonal factors 1. Growth hormone 2. Corticosteroids
(microvascular osteonecrosis)
3. Others (thyroid, estrogen, androgen, calcitonin,
parathyroid hormone, prostaglandins)
E. Diseases: diabetes, anemia, neuropathies, tabes
F. Vitamin deficiencies, A, C, D, K G. Drugs: nonsteroidal
antiinflammatory drugs (NSAIDs), anticoagulants, factor XIII,
calcium channel blockers (verapamil), cytotoxins,
diphosphonates, phenytoin, sodium fluoride, tetracycline H. Other substances (nicotine,
alcohol) I. Hyperoxia J. Systemic growth factors K. Environmental temperature L. Central nervous system trauma
Local FactorsA. Factors independent of injury, treatment, or complications 1. Type of bone 2. Abnormal bone a. Radiation necrosis b. Infection c. Tumors and other pathological conditions 3. DenervationB. Factors depending on injury 1. Degree of local damage a. Compound fracture b. Comminution of fracture c. Velocity of injury d. Low circulatory levels of vitamin K1 2. Extent of disruption of vascular supply to bone, its fragments (macrovascular osteonecrosis), or soft tissues; severity of injury 3. Type and location of fracture (one or two bones, e.g., tibia and fibula or tibia alone) 4. Loss of bone 5. Soft tissue interposition 6. Local growth factors
C. Factors depending on treatment 1. Extent of surgical trauma (blood supply, heat) 2. Implant-induced altered blood flow 3. Degree and kind of rigidity of internal or external fixation and the influence of timing 4. Degree, duration, and direction of load-induced deformation of bone and soft tissues 5. Extent of contact between fragments (gap, displacement, overdistraction) 6. Factors stimulating posttraumatic osteogenesis (bone grafts, bone morphogenetic protein, electrical stimulation, surgical technique, intermittent venous stasis [Bier]) D. Factors associated with complications 1. Infection 2. Venous stasis 3. Metal allergy
Electromagnetic Field Electromagnetic (EM) devices are based
on Wolff’s Law that bone responds to mechanical stress: In vitro bone deformation produces piezoelectric currents and streaming potentials.
Exogenous EM fields may stimulate bone growth and repair by the same mechanism
Clinical efficacy very controversial No studies have shown PEMF to be effective in
“gap healing” or pseudarthrosis
Types of EM Devices
Microamperes Direct electrical current Capacitively coupled electric fields Pulsed electromagnetic fields (PEMF)
PEMF Approved by the FDA for the treatment of
non-unions Efficacy of bone stimulation appears to
be frequency dependant Extremely low frequency (ELF) sinusoidal
electric fields in the physiologic range are most effective (15 to 30 Hz range)
Specifically, PEMF signals in the 20 to 30 Hz range (postural muscle activity) appear more effective than those below 10 Hz (walking)
Ultrasound
Low-intensity ultrasound is approved by the FDA for stimulating healing of fresh fractures
Modulates signal transduction, increases gene expression, increases blood flow, enhances bone remodeling and increases callus torsional strength in animal models
Ultrasound
Human clinical trials show a decreased time of healing in fresh fractures treated nonoperatively Four level 1 studies show a decrease in
healing time up to 38% Has also been shown to decrease the
healing time in smokers potentially reversing the ill effects of smoking