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PERSONAL DATAPERSONAL DATAName Name : Prof. Dr. H. Errol U. : Prof. Dr. H. Errol U. HutagalungHutagalung, , SpBSpB, , SpOTSpOTPlace/Date of Birth Place/Date of Birth : : TanjungTanjung KarangKarang, May 15, 1942, May 15, 1942Married to Married to : Anita Errol : Anita Errol HutagalungHutagalungChildren Children : 4 : 4 childrenschildrensOffice/Institution Office/Institution : Div. of : Div. of OrthopaedicOrthopaedic & & TraumatologyTraumatology, Faculty of Medicine, Faculty of Medicine
University of Indonesia/Dr. University of Indonesia/Dr. CiptoCipto MangunkusumoMangunkusumoJlJl. . DiponegoroDiponegoro 71, Jakarta 1043071, Jakarta 10430
Telephone : (62Telephone : (62--21) 392 9655 Fax : (6221) 392 9655 Fax : (62--21) 390 5894 HP : 0816 808054 Email : 21) 390 5894 HP : 0816 808054 Email : [email protected]@dnet.net.idHome Address : Home Address : JlJl. H. . H. BuangBuang No. 27, No. 27, UlujamiUlujami, , KebayoranKebayoran Lama, Jakarta Lama, Jakarta SelatanSelatanEducationEducation : : -- Medical DoctorMedical Doctor : FKUI : FKUI –– 19671967
-- SurgeonSurgeon : FKUI : FKUI –– 19731973-- OrthopaedicOrthopaedic Surgeon : FKUI Surgeon : FKUI –– 19751975
Current Position : Chairman of Division of Current Position : Chairman of Division of OrthopaedicOrthopaedic & & TraumatologyTraumatology FKUI/RSCMFKUI/RSCMAcademic Appointment and Activities :Academic Appointment and Activities :
-- Chairman of Division of Chairman of Division of OrthopaedicOrthopaedic & & TraumatologyTraumatology FKUI/RSCM, since 1990 FKUI/RSCM, since 1990 –– nownow-- Chairman of Advisory Board, Dept. of Surgery, FKUI/RSCMChairman of Advisory Board, Dept. of Surgery, FKUI/RSCM-- Chairman of Education Committee, Academic Senate FKUIChairman of Education Committee, Academic Senate FKUI
Professional Activities :Professional Activities :-- Chairman of the Indonesian College of Chairman of the Indonesian College of OrthopaedicOrthopaedic & & TraumatologyTraumatology,,
PABOI (2006 PABOI (2006 –– now)now)-- Chairman of Steering Committee, PERTUMSIChairman of Steering Committee, PERTUMSI-- Chairman of Elect of PEROSIChairman of Elect of PEROSI
Awards and Qualifications :Awards and Qualifications :Society Memberships : PABOI, IKABI, POI, PERTUMSI, IRA, PEROSISociety Memberships : PABOI, IKABI, POI, PERTUMSI, IRA, PEROSI
FRACTURE HEALING :FRACTURE HEALING :--BIOLOGYBIOLOGY--INHIBITION FACTORS.INHIBITION FACTORS.
ERROL U. HUTAGALUNGERROL U. HUTAGALUNG
Div. of Div. of OrthopaedicOrthopaedic & & TraumatologyTraumatologyFaculty of Medicine, Univ. of IndonesiaFaculty of Medicine, Univ. of Indonesia
Dr. Dr. CiptoCipto MangunkusumoMangunkusumo Hospital Hospital -- JakartaJakarta
COE-54, Pontianak1-3 Mei 2008
Healing of a fracture Healing of a fracture –– most remarkable of all repairmost remarkable of all repairprocesses in the body since the result NOT in scar processes in the body since the result NOT in scar actual reconstitution of the injured tissueactual reconstitution of the injured tissue
Fractures unite by :Fractures unite by :1. Primary bone healing1. Primary bone healing2. Secondary bone healing2. Secondary bone healing
Primary occur when there is Primary occur when there is rigidrigid int. fixation,int. fixation,while secondary bone healing occur when there iswhile secondary bone healing occur when there isNON RIGID internal fixationNON RIGID internal fixation
Majority of fractures unite by secondary bone healingMajority of fractures unite by secondary bone healingwhich progress in five stageswhich progress in five stages
5 Stages as describe by Mc 5 Stages as describe by Mc KibbinKibbin (1978) :(1978) :
1. 1. HaematomaHaematoma
2. Inflammation 2. Inflammation
3. Formation of Soft Callus3. Formation of Soft Callus
4. Formation of Hard Callus4. Formation of Hard Callus
5. Remodeling
} Phase 1 : inflammation} Phase 1 : inflammation
} Phase 2 : reparation } Phase 2 : reparation
5. Remodeling } Phase 3} Phase 3
Phase 1 / Inflammation consist of :Phase 1 / Inflammation consist of :
-- Bleeding of fractureBleeding of fracture haematomahaematoma formform
ee-- Inflammation Inflammation
-- Next 2 Next 2 –– 3 days granulation tissue formation3 days granulation tissue formation
-- OsteogenicOsteogenic cells invade tissue and cells invade tissue and laydownlaydown osteoidosteoid
Phase 2 / Reparation Phase 2 / Reparation
-- At 3 weeks soft callus form consist of At 3 weeks soft callus form consist of osteoidosteoid
and cartilageand cartilage
-- In 6 In 6 –– 12 weeks hard callus is formed 12 weeks hard callus is formed
-- In 12 In 12 –– 16 weeks clinical union (+)16 weeks clinical union (+)
Phase 3 / Remodeling of united fracturePhase 3 / Remodeling of united fracture
From the stand point of biomechanics From the stand point of biomechanics 4 stages of fracture repair (White 1977)4 stages of fracture repair (White 1977)
St 1 : Bone stiffness similar to soft tissue stiffness; St 1 : Bone stiffness similar to soft tissue stiffness; fracture site has low stiffness & low strength fracture site has low stiffness & low strength due to formation fibrous granulation tissuedue to formation fibrous granulation tissue
St 2 : Bone stiffness more similar to mineralized tissue;St 2 : Bone stiffness more similar to mineralized tissue;fracture site has normal bone stiffness but low fracture site has normal bone stiffness but low strength strength due to formation of woven bonedue to formation of woven bone
From the stand point of biomechanics From the stand point of biomechanics 4 stages of fracture repair (White 1977)4 stages of fracture repair (White 1977)
St 3 : Fracture site has normal bone stiffness & medium St 3 : Fracture site has normal bone stiffness & medium strength strength –– due mixture of woven bone and due mixture of woven bone and lamellar bone that increases over all strength lamellar bone that increases over all strength
St 4 : Fracture site has normal bone stiffness & normal boneSt 4 : Fracture site has normal bone stiffness & normal bonestrength due completely remodeled bonestrength due completely remodeled bone(all lamellar) (all lamellar)
Three form of bone repair bring about fracture union :Three form of bone repair bring about fracture union :endochondralendochondral ossification, ossification, intramembraneintramembrane ossificationossification& appositional bone formation& appositional bone formation-- Closed to fracture site Closed to fracture site production of cartilage tissue production of cartilage tissue
undergo undergo endochondralendochondral ossification ossification -- Peripheral site Peripheral site direct direct intramembraneintramembrane ossification &ossification &
areas of appositional bone formation to reinforce theareas of appositional bone formation to reinforce theentire callusentire callus
-- These mechanism primarily produce These mechanism primarily produce WOVENWOVEN bone whichbone whichis later remodeled into is later remodeled into LAMELLARLAMELLAR bone bone
Role of Role of PeriosteumPeriosteum
PeriosteumPeriosteum : 2 layers : 2 layers –– outer fibrous layer & innerouter fibrous layer & innercambial layercambial layer
Inner cambial layer contain cells responsible for Inner cambial layer contain cells responsible for production of new bone production of new bone –– osteoprogenitorosteoprogenitor cells cells
OsteoprogenitorOsteoprogenitor cells in fact can be found oncells in fact can be found on
all free bone surfaces: all free bone surfaces: endostealendosteal & & periostealperiosteal
if if periosteumperiosteum is removed is removed osteogenicosteogenic potentialpotential
of bone is NOT deprived of bone is NOT deprived
Source of Source of OsteogenicOsteogenic Cells : 2 theory Cells : 2 theory
1. Arise from 1. Arise from specialisedspecialised cell cell osteoprogenitorosteoprogenitor cellscells
2. Arise from surrounding soft tissue (fibroblast) 2. Arise from surrounding soft tissue (fibroblast) if given the appropriate environmental stimulus if given the appropriate environmental stimulus
known as known as osteogenicosteogenic inductioninduction
Cells with Cells with osteogenicosteogenic potential in marrow my have potential in marrow my have access to the circulation access to the circulation
EXTRA Skeletal Bone FormationEXTRA Skeletal Bone FormationThis NOT quite the same as This NOT quite the same as METAPLASIAMETAPLASIA of cells of the of cells of the
soft tissuesoft tissue
Effect is the same Effect is the same
Normal Skeleton : Continuous process of replacement Normal Skeleton : Continuous process of replacement ((osteoblasticosteoblastic activity) & repair activity) & repair ((osteoclasticosteoclastic activity)activity)
Fracture repair : same processFracture repair : same process
Differences of process depend on type of boneDifferences of process depend on type of bonecancellouscancellous or compact boneor compact bone
CancellousCancellous : whole process of bone apposition or : whole process of bone apposition or replacement take place in the surface replacement take place in the surface
““creeping substitutioncreeping substitution””
Compact bone : process take place in deeply placed Compact bone : process take place in deeply placed
cells cells which require the presence ofwhich require the presence of
HaversianHaversian system which must be system which must be
replaced replaced ““Primary Bone UnionPrimary Bone Union””
since no intermediate / precursor since no intermediate / precursor
cells are involvedcells are involved
Fate of dead bone at the fracture site :Fate of dead bone at the fracture site :-- ResorbedResorbed not always; depend on not always; depend on
mechanical factors mechanical factors
Normal alignment preserved Normal alignment preserved dead bone will form dead bone will form an important mechanical link in restoration of an important mechanical link in restoration of continuity continuity will be preserved in accordancewill be preserved in accordanceof Wolffof Wolff’’s law s law the whole dead bone may bethe whole dead bone may be
converted into converted into livingliving cancellouscancellous bone bone
Alternatively if the presence of compact bone is more
appropriate then it will be revitalised by penetration
of new Haversian systems
If there is If there is MalunionMalunion, when incorporation of the bones, when incorporation of the bones
ends would serve no useful purpose ends would serve no useful purpose completely completely
removed / removed / resorbedresorbed
Union of fracture need a critical step Union of fracture need a critical step establishment establishment
of intact bone contact/bony bridge between of intact bone contact/bony bridge between
the fragment the fragment joining of hard tissue and the wholejoining of hard tissue and the whole
system MUST become IMMOBILE at least momentarilysystem MUST become IMMOBILE at least momentarily
Union / Healing of fracture develop by 3 mechanism Union / Healing of fracture develop by 3 mechanism
1. Healing by external callus1. Healing by external callus
2. Healing by 2. Healing by medullarymedullary calluscallus
3. Healing by primary bone union3. Healing by primary bone union
Healing by External CallusHealing by External CallusExplained by 3 hypotheses / theoryExplained by 3 hypotheses / theory
1. Cellular contact theory1. Cellular contact theory
2. Mechanical influences/bio electrical phenomena 2. Mechanical influences/bio electrical phenomena
3. 3. HumoralHumoral theory theory
Cellular Contact TheoryCellular Contact Theory
If the two fragment remain connected by If the two fragment remain connected by periosteumperiosteum ororrelated material related material callus bridge (callus bridge (CharnleyCharnley))
If fragments are excessively separated either by If fragments are excessively separated either by distraction or by interposition of soft tissue or held distraction or by interposition of soft tissue or held apart by long segment of terminal dead bone apart by long segment of terminal dead bone contact can not occur contact can not occur non unionnon union
Bioelectrical Phenomenon Bioelectrical Phenomenon
In the process of fracture healing In the process of fracture healing role of fibroblastrole of fibroblastof soft tissue which by induction mechanism becomeof soft tissue which by induction mechanism becomeosteogenicosteogenic cells cells possible through medium of bioelectricalpossible through medium of bioelectricalforcesforces
FukadaFukada (1957) (1957) mechanical deformities of bone gave mechanical deformities of bone gave rise to electric potentials rise to electric potentials as a result of as a result of piezopiezo electricelectriceffecteffect
Electro negativity Electro negativity favoursfavours bone formation and vicebone formation and vice
versa versa explained explained WolffWolff’’tt Law Law self regulating self regulating
feed back mechanism feed back mechanism stresses & strain in thestresses & strain in the
bone modifies the electrical environment of the bonebone modifies the electrical environment of the bone
Promising field, but electrical environment of bonePromising field, but electrical environment of bone
is extremely complex is extremely complex piezopiezo electric potential areelectric potential are
only a part of itonly a part of it
Clinical application :Treat human fracture by Clinical application :Treat human fracture by
applying electrical stimuli eitherapplying electrical stimuli either with direct with direct
current or non invasive use of electro magnetic current or non invasive use of electro magnetic
fields fields
HumoralHumoral theory :theory :
Fracture bone end liberate Fracture bone end liberate agent which influenceagent which influence
the healing process the healing process ““wound hormonewound hormone”” especiallyespecially
in the fracture in the fracture haematomahaematoma –– present only forpresent only for
limited period limited period search without success search without success
HeterotopicHeterotopic bone formation can be induced by bone formation can be induced by
dead tissue or by bone transplant dead tissue or by bone transplant humoralhumoral
inducing agent inducing agent mustmust exist exist
Several hypothesis Several hypothesis none of these are mutually none of these are mutually
exclusive exclusive reasonable to join the togetherreasonable to join the together
Healing by Healing by MedullaryMedullary Callus Callus
-- Distinguished for external callus only by its Distinguished for external callus only by its locationlocation
-- Cartilage formation is much less prominent in Cartilage formation is much less prominent in
medullarymedullary calluscallus
Obvious difference is the effect of mechanical stability Obvious difference is the effect of mechanical stability
Inhibitory effect in external callus while Inhibitory effect in external callus while medullarymedullary
callus flourishes callus flourishes
In the process may be involvedIn the process may be involved
-- Electrical phenomenon Electrical phenomenon -- Biochemical phenomenonBiochemical phenomenon-- Even neurological mechanism Even neurological mechanism
Part of fracture healing process which is still Part of fracture healing process which is still inadequately studied inadequately studied
Study by Study by OlerudOlerud (1971) in more realistic mode : (1971) in more realistic mode : in in segmentalsegmental fracture fracture
After ensuring the middle fragment was entirely After ensuring the middle fragment was entirely
devoid of vascular connection & fixed the wholedevoid of vascular connection & fixed the whole
with a with a compressioncompression plate as rigidly as plate as rigidly as possibilepossibile
the dead bone the dead bone did NOTdid NOT disappear but was disappear but was
invaded by new invaded by new osteonsosteons for the neighboring live bone for the neighboring live bone
Primary Bone HealingPrimary Bone Healing
Study of Study of WilleneggerWillenegger (1967) (1967) –– Apply rigidApply rigid
compression plates to dogcompression plates to dog’’s radius s radius dead endsdead ends
of cortical bone were not of cortical bone were not resorbedresorbed but werebut were
recanalisedrecanalised by new by new HaversianHaversian systemssystems
This process is different from the other twoThis process is different from the other two
that is NOT inhibited by stability as in externalthat is NOT inhibited by stability as in external
callus (method 1) and indeed even small degreescallus (method 1) and indeed even small degrees
of movement is harmful to the process, unlikeof movement is harmful to the process, unlike
medullarymedullary callus (second method)callus (second method)
However due to large amount of dead tissue However due to large amount of dead tissue
the process was the process was extremely slowextremely slow patient willpatient will
be dependent in the implant for a very long be dependent in the implant for a very long
time, and most of the time, and most of the revascularisationrevascularisation occurred occurred
from vessels from vessels lynglyng in the in the medullarymedullary canalcanal
The XThe X--ray obliteration of the fracture gap ray obliteration of the fracture gap
does does NOTNOT necessarily mean that the bone necessarily mean that the bone
has returned to its pre injury strengthhas returned to its pre injury strength
In practice to achieve direct bone union useIn practice to achieve direct bone union use
the Swiss School (AO, Muller 1965) the Swiss School (AO, Muller 1965)
with compression methodwith compression method
Clinical implication :Clinical implication :
Three main ways in which essential bridging Three main ways in which essential bridging
process of fracture healing can came aboutprocess of fracture healing can came about
and each of these is differently affected by and each of these is differently affected by
environmental circumstances environmental circumstances
External Callus :External Callus :The most rapid of all the process, normally predominates The most rapid of all the process, normally predominates in in fxfx treated by External Fixationtreated by External Fixation
The quickest way to restore the strength of a fractured The quickest way to restore the strength of a fractured diaphysisdiaphysis to its former levelto its former level
The process will not continue indefinitely / short lived The process will not continue indefinitely / short lived unless fracture is Bridged unless fracture is Bridged
Primary purpose is the arrest of movement between Primary purpose is the arrest of movement between fragment fragment
This process is This process is NOT incompatibleNOT incompatible with internal with internal
Fixation; provided does Fixation; provided does NOTNOT impose condition impose condition
of of total rigiditytotal rigidity
If consider ORIF If consider ORIF careful consideration must becareful consideration must be
given to given to soft tissuesoft tissue from which much of the repairfrom which much of the repair
tissue will come, in particular blood vessels whichtissue will come, in particular blood vessels which
pass from the muscle and fascia to the pass from the muscle and fascia to the periosteumperiosteum
With With extra extra periostealperiosteal dissection dissection formationformationof callus may be inhibited (of callus may be inhibited (TruetaTrueta 1968)1968)
WithWith subperiosteasubperiosteall dissection dissection these blood vesselsthese blood vesselsare preserved are preserved facilitating production of cufffacilitating production of cuffof of subperiostealsubperiosteal callus.callus.
If rigid plating in considered If rigid plating in considered formation formation
of external callus is deliberately abandoned of external callus is deliberately abandoned
preservation of blood supply of the bone is preservation of blood supply of the bone is VERYVERY
important important
If IM nailing as to be used If IM nailing as to be used even more care is even more care is
required with the required with the soft tissuesoft tissue, because , because medullarymedullary
circulation will be interrupted at least temporarily circulation will be interrupted at least temporarily
and depend solely on the supply from soft tissue and depend solely on the supply from soft tissue
MedullaryMedullary Callus :Callus :
This method predominate when extra callus response This method predominate when extra callus response
has failedhas failed
It arises principally from the It arises principally from the medullarymedullary cavitycavity
It has 2 special properties It has 2 special properties relatively independent relatively independent
of mechanical influences and can replace fibrous of mechanical influences and can replace fibrous
tissue by new bonetissue by new bone
The factors that govern this uncertain process areThe factors that govern this uncertain process arestill unknown still unknown
This process assisted by immobilization This process assisted by immobilization need need SECURE internal fixation. SECURE internal fixation.
Primary Bone Union :Primary Bone Union :
If RIGID fixation is applied If RIGID fixation is applied process of healing is process of healing is
altered altered ext. bridging callus is suppressed andext. bridging callus is suppressed and
the healing is dependent in the activity of the healing is dependent in the activity of medullarymedullary
callus and direct callus and direct osteonalosteonal penetration penetration
Disadvantage : great slowness especially if Disadvantage : great slowness especially if there is a large amount of dead bonethere is a large amount of dead bone
It is It is NOTNOT really method of union at all but really method of union at all but a remodeling process which normally occurs a remodeling process which normally occurs very late in the normal healing process very late in the normal healing process artificial stability must be maintained forartificial stability must be maintained formany months and even many months and even yearsyears
In rigid / compressed fixation In rigid / compressed fixation NOTNOT logicallogical
to supply bone graft external to boneto supply bone graft external to bone
Bone graft is to facilitate formation ofBone graft is to facilitate formation of
Ext. CallusExt. Callus which is deliberately inhibitedwhich is deliberately inhibited
Ideal Fixation Ideal Fixation preserved security without preserved security without
imposing total imposing total rigidityrigidity
Inhibition of Fracture HealingInhibition of Fracture HealingFactors that playing in these occasion :Factors that playing in these occasion :
1. Age1. Age
2. Co Morbidities2. Co Morbidities
3. Medication 3. Medication
Age : Children faster rate of healing due to Age : Children faster rate of healing due to thicker thicker periosteumperiosteum & larger & larger subperiostealsubperiostealhaematomahaematoma
Age related change : delay in onset of Age related change : delay in onset of periostealperiostealreaction cell differentiation and reaction cell differentiation and angiogenicangiogenicinvasion ; decreased bone formation and impairedinvasion ; decreased bone formation and impairedremodeling of boneremodeling of bone
Parker (1994): Age was predictive of non union afterParker (1994): Age was predictive of non union afterORIF of ORIF of intracapintracap fxfx. Of neck of femur. Of neck of femur
Over all Over all –– increasing age is a factor in the inhibition increasing age is a factor in the inhibition of of fxfx repair in the humanrepair in the human
CO Morbidities CO Morbidities
a/ Diabetes Mellitus (DM)a/ Diabetes Mellitus (DM)
Animal experiment Animal experiment fxfx callus 29% decreasecallus 29% decreasein tensile strength and 50% decrease is stiffnessin tensile strength and 50% decrease is stiffness
Between 4 Between 4 –– 1111thth day of healing : 50% decreaseday of healing : 50% decreasein collagen content & 40% decrease of DNA content ofin collagen content & 40% decrease of DNA content ofthe callus the callus
Clinical Studies :Clinical Studies :Significant higher incidence of delayed union, Significant higher incidence of delayed union, non union and doubling time to heal non union and doubling time to heal
Key treatment of fracture with DM : proper controlKey treatment of fracture with DM : proper controlof blood sugar level, which will minimize the of blood sugar level, which will minimize the complications of delayed fracture healing complications of delayed fracture healing
CO Morbidities :CO Morbidities :
b/ Anemia b/ Anemia
Animal studies : poor mineralization of callus dueAnimal studies : poor mineralization of callus due
to decrease in oxygen tension and deficiency of ironto decrease in oxygen tension and deficiency of iron
which is required for function of electron transportwhich is required for function of electron transport
system within the cell & hydroxylation of system within the cell & hydroxylation of prolineproline
in collagen formation in collagen formation
Secondary anemia due acute blood lossSecondary anemia due acute blood loss withoutwithoutmaintenance of blood maintenance of blood VOLUMEVOLUME may affect may affect wound healingwound healing
NormovolemicNormovolemic anemia had anemia had NONO adverse affect adverse affect following trauma following trauma fluidfluid RehydrationRehydration very importantvery important(not blood transfusion) to maintain fracture healing(not blood transfusion) to maintain fracture healing
c/ Mal nutrition c/ Mal nutrition
Animal study : deficiency Animal study : deficiency vitvit B6 B6 delay maturation ofdelay maturation ofcalluscallus-- VitVit C need in maintenance of function of C need in maintenance of function of osteoblastosteoblast& supplementary & supplementary vitvit. C . C accelerates accelerates fxfx healinghealing
-- Importance of dietary protein, CaImportance of dietary protein, Ca++, PO4, , PO4, VitVit D D in in fxfx healing healing
Human Study : Albumin level < 3,5 Human Study : Albumin level < 3,5 grgr % was predictive% was predictiveof increase length of stay and in hospital mortality of increase length of stay and in hospital mortality following a fracturefollowing a fracture
Low albumin level : 4,6 times less likely to recover toLow albumin level : 4,6 times less likely to recover toprefractureprefracture level of independence in basic activities level of independence in basic activities of daily livingof daily living
Post menopausal women with hip fracture had occultPost menopausal women with hip fracture had occultvitvit D deficiency D deficiency easily treated with supplementationeasily treated with supplementation
HypothyroidismHypothyroidism
Animal Study : Inhibit Animal Study : Inhibit endochondralendochondral ossifciationossifciation
Inhibit secondary bone healing, although primary Inhibit secondary bone healing, although primary bone healing appear to be unaffected bone healing appear to be unaffected
Prescribed Medication :Prescribed Medication :
NSAID : MOA inhibit synthesis of prostaglandinNSAID : MOA inhibit synthesis of prostaglandin
Result : Animal study : conflicting evidence as Result : Animal study : conflicting evidence as their affect on fracture repairtheir affect on fracture repair
NSAID :NSAID :
Clinical terms : NSAID prevent Clinical terms : NSAID prevent heterotropicheterotropic bone formationbone formationfollowing THRfollowing THR
Balanced information : Suggest it is prudent to avoidBalanced information : Suggest it is prudent to avoiduse of NSAID during fracture repairuse of NSAID during fracture repair
Corticosteroid, long term steroid therapy is detrimentalCorticosteroid, long term steroid therapy is detrimentalto fracture repairto fracture repair
StatinsStatins ::
Animal Study : anabolic effect on bone Animal Study : anabolic effect on bone –– enhancement enhancement
of fracture healing of fracture healing 63% greater 63% greater strenghtstrenght
than control at 14 daysthan control at 14 days
Antibiotics :Antibiotics :
Remain an important part of trauma care in Remain an important part of trauma care in
preventing infection but we should be aware of preventing infection but we should be aware of
studies which indicate it is prudent to avoid studies which indicate it is prudent to avoid high doseshigh doses
of ciprofloxacin, of ciprofloxacin, rifampicinrifampicin and topical and topical gentamicingentamicin
to minimize risk of non unionto minimize risk of non union
AnticoagulantAnticoagulant
LMWH used to prevent LMWH used to prevent thromboembolismthromboembolism
Animal study : significant negative effect in Animal study : significant negative effect in
fracture healing both fracture healing both biomechanicallybiomechanically
& & histologicallyhistologically
Fracture Treatment :Fracture Treatment :
Animal Studies : gap > 2 mm inhibit fracture healingAnimal Studies : gap > 2 mm inhibit fracture healing
Majority of fracture heal by secondary union Majority of fracture heal by secondary union a degree of motion at fracture site assist the process a degree of motion at fracture site assist the process early early w.bw.b. is encourage. is encourage
However excess motion and instability leads to NON union However excess motion and instability leads to NON union hypertrophichypertrophic union union gross callus formation but NOgross callus formation but NObridging of bone endsbridging of bone ends
Type of motion : Type of motion : -- axial movement axial movement –– beneficial beneficial -- shear; rotational movement inhibitshear; rotational movement inhibit
repairrepair
Lifestyle Lifestyle Smoking : Balance of evidence indicates a clear Smoking : Balance of evidence indicates a clear
inhibition of healing of fracture inhibition of healing of fracture complicate fracture healing complicate fracture healing –– develop develop non union non union –– infection infection –– flap failureflap failure
Causes by nicotine or other component of cigarette Causes by nicotine or other component of cigarette is not yet determined.is not yet determined.
Alcohol :
Dose dependent; toxic effect on activity of Dose dependent; toxic effect on activity of osteoblastosteoblast
References References 1. 1978; Mc 1. 1978; Mc KibinKibin: The Biology of Fracture healing in Long Bones;: The Biology of Fracture healing in Long Bones;
JBJS 60B : 150 JBJS 60B : 150 –– 6262
2. 2007; Little D et al : Review 2. 2007; Little D et al : Review articles.Thearticles.The anabolic and catabolicanabolic and catabolicresponses in bone repair; JBJS 89B: 425responses in bone repair; JBJS 89B: 425--3333
3. 2007; Gaston MS et al: Inhibition of fracture healing; JBJS3. 2007; Gaston MS et al: Inhibition of fracture healing; JBJS89B: 1553 89B: 1553 –– 6060
4. 2007; Biomechanics of Fracture Healing, 4. 2007; Biomechanics of Fracture Healing, diaksesdiakses daridari ::www.enginwww.engin.unich.edu/class/bone456/.bonefracture:htm.unich.edu/class/bone456/.bonefracture:htm
