Bone Healing and Fracture Repair Quiz
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Questions and Answers

Which of the following is a characteristic of indirect (secondary) bone healing?

  • Requires rigid stabilization of the fracture fragments.
  • Only possible with simple fractures.
  • Inhibited by motion at the fracture site.
  • Enhanced by motion at the fracture site. (correct)
  • What is the primary role of Bone Morphogenetic Protein (BMP) in indirect bone healing?

  • Stimulation of direct bone formation from the periosteum.
  • Inhibition of callus formation.
  • Promotion of osteoclast activity during the remodeling phase.
  • Release of inflammatory cells and mediators during the inflammation stage. (correct)
  • In indirect (secondary) bone healing, in which stage does chondrogenesis occur?

  • Chondrogenesis (correct)
  • Remodeling
  • Intramembranous bone formation
  • Hematoma formation/inflammation
  • Which type of fracture is most likely to be treated with rigid fixation techniques?

    <p>Simple fractures (B)</p> Signup and view all the answers

    What is the correct order of the general phases of fracture healing?

    <p>Hematoma formation, soft callus formation, hard callus formation, remodeling phase. (C)</p> Signup and view all the answers

    Which of the following is required for primary (contact) bone healing to occur?

    <p>Complete immobility and close apposition of bone fragments. (A)</p> Signup and view all the answers

    What is the main difference between intramembranous and endochondral ossification?

    <p>Endochondral ossification involves cartilage as an intermediate, while intramembranous ossification does not. (D)</p> Signup and view all the answers

    Which type of bone healing is characterized by the formation of a callus?

    <p>Secondary (indirect) bone healing (D)</p> Signup and view all the answers

    A fracture that has not healed within the expected timeframe is best described as what?

    <p>Delayed union (B)</p> Signup and view all the answers

    Which of the following is NOT a goal of using bone grafts?

    <p>Inhibiting angiogenesis to reduce inflammation. (B)</p> Signup and view all the answers

    Which cell type is directly derived from mesenchymal stem cells (MSCs)?

    <p>Osteoprogenitor cell (B)</p> Signup and view all the answers

    What percentage of bone's extracellular matrix (ECM) is composed of organic material and water?

    <p>35% (C)</p> Signup and view all the answers

    Which type of collagen makes up the majority of the organic component of bone's extracellular matrix?

    <p>Type I collagen (A)</p> Signup and view all the answers

    What is the maximum strain that bone (osteoblasts) can withstand during fracture healing?

    <p>2% (D)</p> Signup and view all the answers

    In direct (primary) bone healing, what size gap is typically associated with contact healing?

    <p>Gaps less than 300 microns (C)</p> Signup and view all the answers

    What process occurs during direct (primary) bone healing when gaps are less than 1 mm?

    <p>Blood vessels and connective tissue form before bone deposition (B)</p> Signup and view all the answers

    What is the function of ‘cutting cones’ in intra-cortical remodeling?

    <p>To stimulate osteoclast activity (B)</p> Signup and view all the answers

    What type of fracture healing requires rigid internal fixation to minimize strain?

    <p>Direct (primary) healing (B)</p> Signup and view all the answers

    Which type of fracture healing is associated with less rigid fixation, callus formation, and the use of fixation methods such as pins, wires, or external fixators?

    <p>Indirect fracture healing (D)</p> Signup and view all the answers

    What is a key characteristic of a fracture nonunion?

    <p>Complete cessation of osteogenic activity at the fracture site. (C)</p> Signup and view all the answers

    According to the Weber-Cech classification, what are the two main categories of nonunion?

    <p>Viable (Vascular) and Nonviable (Avascular) (D)</p> Signup and view all the answers

    What is commonly observed in oligotrophic nonunion?

    <p>Rounding of fracture edges and resorption of bone. (C)</p> Signup and view all the answers

    What is the primary cause of hypertrophic nonunion?

    <p>Inadequate stabilization of the fracture. (D)</p> Signup and view all the answers

    Which of the following is NOT a factor that increases the likelihood of fracture complications?

    <p>Adherence to proper fracture fixation techniques. (B)</p> Signup and view all the answers

    In what type of nonunion would you most likely see a broken plate or screws that have pulled out?

    <p>Mildly Hypertrophic nonunion (C)</p> Signup and view all the answers

    What can direct fracture healing be achieved with?

    <p>Bone plate (B)</p> Signup and view all the answers

    What is a characteristic of a dystrophic nonunion?

    <p>Intermediate fracture fragments healing exclusively to one main fragment. (A)</p> Signup and view all the answers

    Which of the following best describes a necrotic nonunion?

    <p>The fracture fragments have no blood supply and cannot heal to any main fragment. (A)</p> Signup and view all the answers

    What is the primary cause of a defect nonunion?

    <p>Large loss of bone at the fracture site. (B)</p> Signup and view all the answers

    Which statement best describes an atrophic nonunion?

    <p>It is the end result of other nonviable nonunions. (C)</p> Signup and view all the answers

    Which of the following factors is LEAST likely to cause a nonunion?

    <p>Appropriate and rigid implant fixation. (B)</p> Signup and view all the answers

    Which of these systemic factors can contribute to nonunion formation?

    <p>Diabetes Mellitus (D)</p> Signup and view all the answers

    Which clinical sign is MOST indicative of a nonunion?

    <p>Movement felt at the fracture site. (A)</p> Signup and view all the answers

    What radiographic finding suggests a nonunion?

    <p>A visible fracture gap with no activity at the fracture ends. (A)</p> Signup and view all the answers

    What is the primary goal when treating nonunions?

    <p>Rigidly stabilizing the fracture and enhancing blood supply. (A)</p> Signup and view all the answers

    Contaminated wounds in open fractures increase the likelihood of complications by approximately how much?

    <p>Five times (A)</p> Signup and view all the answers

    What is a malunion?

    <p>A fracture that heals in a non-anatomic position. (C)</p> Signup and view all the answers

    Which of the following is least likely to cause a malunion?

    <p>Limited range of motion during healing (A)</p> Signup and view all the answers

    What is a delayed union?

    <p>A fracture that has not healed in the expected timeframe. (C)</p> Signup and view all the answers

    What percentage of blood supply is provided by the nutrient artery to the bone marrow in normal bone?

    <p>80-85% (D)</p> Signup and view all the answers

    Which of the following describes an autogenous bone graft?

    <p>Graft within the same individual (D)</p> Signup and view all the answers

    Which characteristic of bone grafting involves the graft acting as a scaffold for new bone formation?

    <p>Osteoconduction (D)</p> Signup and view all the answers

    Which is the primary function of osteoinductive proteins like Bone Morphogenetic Proteins (BMPs) in bone grafting?

    <p>Inducing cells to promote new bone formation. (D)</p> Signup and view all the answers

    Which of the following is least important when harvesting a cancellous bone graft?

    <p>Ensuring the graft is completely dry before implantation. (C)</p> Signup and view all the answers

    Flashcards

    Primary Bone Healing

    Healing that occurs directly at the fracture site with contact or gap between bone ends.

    Secondary Bone Healing

    Healing characterized by the formation of a callus and is a more indirect process.

    Intramembranous Ossification

    The process by which bone forms directly from mesenchyme without a cartilage model.

    Endochondral Ossification

    The process where bone forms by replacing a cartilage template.

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    Fracture Healing Failures

    Conditions like delayed union, nonunion, and malunion where normal healing does not occur.

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    Indirect (Secondary) Healing

    A common type of fracture healing involving callus formation rather than direct union.

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    Hematoma Formation Phase

    The initial phase of fracture healing where blood collects around the fracture site, causing inflammation.

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    Soft Callus Formation Phase

    The phase of fracture healing characterized by the formation of a temporary soft tissue bridge across the fracture.

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    Hard Callus Formation Phase

    The stage in fracture healing where a hard bony callus is formed, replacing the soft callus.

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    Remodeling Phase

    The final phase of fracture healing where bone is reshaped and strengthened over time after healing.

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    Cancellous Bone Grafts

    Sources for bone grafts primarily found in specific locations.

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    Osteoblasts

    Cells responsible for producing new bone.

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    Direct Healing

    A type of bone healing requiring small fracture gaps and rigid fixation.

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    Strain in Bone Healing

    The change in length of a fracture gap expressed as a percentage.

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    Contact Healing

    Healing method for gaps less than 300 microns using cutting cones.

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    Gap Healing

    Type of healing occurring in gaps less than 1 mm with new tissue formation.

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    Granulation Tissue

    Tissue that can withstand 100% strain during the healing process.

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    Intra-cortical Remodeling

    The process of forming new osteons through osteoclast activity followed by osteoblast deposition.

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    Indirect Fracture Healing

    A healing process involving callus formation and less rigid fixation compared to direct healing.

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    Soft Callus

    The early stage of indirect fracture healing where a soft tissue callus forms around the fracture site.

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    Hard Callus

    The stage in indirect fracture healing where a hard tissue callus replaces the soft callus.

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    Fracture Nonunion

    A condition where the fracture site shows no evidence of osteogenic activity, requiring surgical intervention.

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    Viable Hypertrophic Nonunion

    A type of nonunion with abundant callus but no bridging across the fracture site, often called 'the elephant foot'.

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    Mildly Hypertrophic Nonunion

    A type of nonunion with mild callus and no bridging, referred to as 'the horses foot'.

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    Oligotrophic Nonunion

    A type of nonunion where no callus is formed, just fibrous tissue at the fracture ends.

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    Fracture Healing Summary

    Healing is a continuum; indirect healing is faster than direct, involving different fixation methods.

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    Dystrophic Nonunion

    Fracture fragments heal to one main fragment, not the other, often due to poor blood supply.

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    Necrotic Nonunion

    Fragments lack blood supply and cannot heal to main fragments; often leads to sequestrum requiring surgery.

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    Defect Nonunion

    Large bone defect where ends cannot bridge despite having blood supply.

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    Atrophic Nonunion

    Final stage of nonviable nonunions; most challenging to treat and uncommon.

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    Causes of Nonunion

    Various factors like infection, ischemia, and improper fixation that prevent fracture healing.

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    Clinical Signs of Nonunion

    Symptoms such as pain, lameness, disuse atrophy, and movement at fracture site.

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    Radiographic Signs of Nonunion

    X-ray findings like fracture gap, no activity at fracture ends, and osteopenia.

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    Sequestrum

    Segment of necrotic bone that must be surgically removed due to nonunion.

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    Nonunion

    A fracture that fails to heal properly after an appropriate time.

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    Malunion

    A fracture that heals in a non-anatomic position.

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    Delayed union

    A fracture that has not healed in the expected time frame.

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    Fracture gap

    The space between fractured bone ends that may hinder healing.

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    Blood supply to bone

    Nutrient arteries and other vessels that provide essential blood flow to bones.

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    Autogenous graft

    A bone graft taken from the same individual.

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    Osteogenesis

    The process of new bone formation from grafts.

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    Osteoconduction

    Graft acts as a scaffold for bone growth.

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    Indications for bone grafts

    Situations where bone grafting is necessary, like nonunions and fractures.

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    Platelet-Rich Plasma

    Material that enhances bone regeneration during grafting.

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    Study Notes

    Introduction to Surgery - Mechanisms of Bone Healing

    • Course: CVM 737A, Introduction to Surgery
    • Topic: Mechanisms of Bone Healing
    • Instructor: Robert S. Gilley, DVM, PhD, DACVS, Professor and Chief of Small Animal Surgery
    • Institution: LMU College of Veterinary Medicine, Lincoln Memorial University

    Learning Objectives

    • Describe primary (contact & gap) versus secondary (indirect) bone healing requirements.
    • Detail the phases of primary (direct) gap bone healing.
    • Detail the phases of secondary (indirect) bone healing.
    • Explain the difference between intramembranous and endochondral ossification.
    • List and describe types of fracture healing failures (delayed union, nonunion, malunion).
    • Characterize different types of bone grafts.
    • Describe the common locations for cancellous bone graft collection.

    Bone Composition

    • Cells:
      • Osteoprogenitor cells (directly from MSCs)
      • Osteoblasts (produce bone)
      • Osteoclasts (remove bone)
      • Osteocytes (resident support)
      • Bone lining (control & differentiation)
    • Extracellular Matrix (ECM):
      • Organic & Water: 35% (Type I collagen: 90%, osteocalcin, osteonectin, proteoglycans, glycosaminoglycans, lipids)
      • Inorganic: 65% (Mostly hydroxyapatite)

    Anatomy of Bone

    • The diagram illustrates the parts of a long bone, including the:
      • Epiphysis
      • Metaphysis
      • Diaphysis
      • Articular cartilage
      • Spongy bone
      • Epiphyseal plate
      • Medullary cavity
      • Endosteum
      • Periosteum

    Fracture Healing

    • Direct (Primary):
      • Osteonal reconstruction
      • Requires rigid internal fixation
      • Less than 2% strain
      • Minimal or no fracture gap
    • Indirect (Secondary):
      • Intermediate callus formation
      • Direct bone formation (intramembranous)
      • Endochondral ossification (transformation into bone within cartilage)

    Strain in Fracture Healing

    • Strain is defined as fracture gap length, change in length / original length, described as a percentage.
    • Tissues withstand various strains:
      • Granulation tissue (100% strain)
      • Cartilage (10% strain)
      • Bone (osteoblasts) (2% strain)

    Direct Healing

    • Contact healing: Gaps less than 300 microns, osteons (cutting cones), fracture plane across one fragment. (50-80 microns/day)
    • Gap healing: Gaps less than 1 mm, blood vessels & connective tissue formation, osteoblasts deposit perpendicular lamellar bone, cutting cones traverse the fracture plane, lamellar bone becomes longitudinally oriented.

    Intra-cortical Remodeling

    • Formation of new osteons ("cutting cones")

    Direct (Primary) Healing - Gap Healing

    • Detailed graphic depictions of this method

    Direct (Primary) Healing - Requirements

    • Rigid fixation to reduce inter-fragmentary strain.
    • Adequate reduction of fracture fragments to proper anatomical alignment.
    • Sufficient blood supply to facilitate healing.

    Indirect (Secondary) Healing

    • Most common fracture healing type (even in repaired fractures).
    • Enhanced by motion; more motion = more callus.
    • Inhibited by rigid stabilization.
    • Requires callus formation.

    Pinned Fracture Callus Formation

    • Diagrams illustrating ideal callus formation in pinned fractures.

    Pin Removed

    • X-ray images showing post-pin removal.

    Indirect (Secondary) Healing - General Phases

    • Hematoma formation (inflammation)
    • Soft callus formation (proliferative)
    • Hard callus formation (maturing/modeling)
    • Remodeling

    Indirect (Secondary) Healing - Specific Stages (Dr. Tom Einhorn)

    • Hematoma formation/inflammation (release of inflammatory cells/mediators, bone morphogenetic protein (BMP), other TGF-β proteins)
    • Intramembranous bone formation (direct bone formation from periosteum)
    • Chondrogenesis
    • Endochondral ossification (very similar to metaphyseal growth plate; Transforming Growth Factor β)

    Indirect Fracture Healing - Soft Callus

    • Diagram demonstrating the stages involved in soft callus formation.

    Indirect Fracture Healing - Hard Callus

    • Diagram illustrating the stages of hard callus formation.

    Summary of 4 Phases

    • Chronological diagrams/illustrations of the four phases of fracture healing, labeled with A, B, C, and D. 

    Fracture Healing Summary

    • Fracture healing is a continuum.
    • Indirect bone healing is faster than direct bone healing.
    • Direct fracture healing involves rigid stabilization (bone plate).
    • Indirect fracture healing involves less rigid fixation, callus formation (pins/wires, interlocking nails, external fixators, LCPs).

    Fracture Complications

    • Can occur even if repair principles are followed.
    • Less likely if rules are followed.
    • Factors to consider:
      • Bone healing
      • Bone blood supply
      • Growth factors
      • Surgical principles

    Fracture Nonunion

    • All evidence of osteogenic activity at fracture site has ceased.
    • Fracture union not possible without surgical intervention.
    • Various types/classifications (e.g., Weber-Cech classification: viable [vascular], nonviable [avascular]).

    Viable- Hypertrophic Nonunion

    • Abundant callus, but callus does not bridge fracture site.
    • Causes:
      • Inadequate stabilization
      • Premature weight-bearing
      • Excessive patient activity.

    Viable- Mildly Hypertrophic Nonunion

    • Mild callus, does not bridge fracture site.
    • Called "horse's foot."
    • Causes:
      • Inadequate stabilization
      • Implant failure (plate breaks/screw pulls out).

    Nonviable- Oligotrophic

    • No callus. Just fibrous tissue & blood vessels joining fracture edges..
    • Resorption of bone and shortening of fragments.
    • Causes:
      • Displacement of fracture fragments or inadequate apposition.

    Nonviable - Dystrophic Nonunion

    • Intermediate fragments heal to only one main fragment.
    • Causes:
      • Poor blood supply on non-healing side.
      • Instability on avascular side
      • More common in older animals

    Nonviable - Necrotic Nonunion

    • Fragments lack blood supply; cannot heal to main fragment.
    • Classical "sequestrum."
    • Avascularity of fragment leads to implant loosening.
    • Cause:
      • Poor blood supply
      • Infection (but does not always have to be infection related)

    Nonviable - Defect Nonunion

    • Large bone defect.
    • Ends have blood supply, but cannot bridge bone.
    • Causes:
      • Massive loss of bone at fracture site.

    Nonviable - Atrophic Nonunion

    • End result of other three nonviable forms.
    • Uncommon.
    • Most difficult cases to treat.

    Nonunion Causes

    • Infection
    • Ischemia (poor blood supply)
    • Distraction of bone ends
    • Excessive bone end compression
    • Interposition of soft tissue at fracture site
    • Improper surgical implant fixation
    • Systemic factors (e.g., diabetes, Cushing's)

    Clinical Signs of Nonunion

    • Pain at fracture site
    • Lameness (usually non-weight-bearing)
    • Atrophy of limb/Muscle wasting
    • Movement at fracture site

    Radiographic Signs of Nonunion

    • Fracture gap
    • Lack of activity at fracture ends
    • Obliteration of marrow cavity
    • Osteopenia (thinning) of surrounding bone.
    • Callus present, but does not bridge the gap.

    Treatment of Nonunions

    • Rigid stabilization of fracture.
    • Enhance blood supply (bone grafting).
    • Address underlying cause of nonunion (infection).
    • Contaminated wounds in open fractures are more likely to develop complications.
    • Ensure fracture gaps are not metabolically compromised.

    Malunions

    • Fracture heals in non-anatomic position.
    • Causes:
      • Untreated fracture
      • Improperly treated fracture
      • Premature excessive weight-bearing.

    Clinical Results - Malunion

    • Angular limb deformities
    • Limb shortening
    • Gait abnormalities
    • Degenerative joint disease

    Delayed Union

    • Fracture does not heal in expected time
    • Factors to consider:
      • Patient characteristics
      • Fracture environment

    Final outcome after grafting

    • X-ray images showing changes in fracture.

    Blood Supply to Normal Bone

    • Nutrient artery to bone marrow (80-85% supply)
    • Periosteal vessels
    • Epiphyseal & Metaphyseal vessels.
    • Differences exist based on growth vs. maturity phase.

    Blood Supply After Injury

    • Extraosseous blood supply (supplies early periosteal callus)
    • Medullary supply eventually takes over.

    Principles of Bone Grafts

    • Very important tool for fracture complications.
    • Types of grafts:
      • Autogenous (within same individual.
      • Allograft (different individuals, same species).
      • Xenograft (different individuals/species).

    Bone Graft Characteristics

    • Osteogenesis (osteoblasts surviving transfer)
    • Osteoconduction (graft acting as a scaffold for new bone)
    • Osteoinduction (inducing cells to form new bone)
    • Bone Morphogenetic Protein (BMP)
    • Osteopromotion

    Types of Bone Grafts- Cancellous

    • From trabecular bone.
    • Works due to "O's" of grafting.

    Bone Graft Physiology- Cancellous

    • Bone graft separated from blood supply results in few osteogenic cells surviving.
    • Mesenchymal stem cells form new bone cell lines.
    • Deposition of new bone from osteoprogenitor cells.
    • Resorption of necrotic bone

    Indications for Bone Grafts

    • Orthopedic fractures/arthrodesis
    • Infected fractures
    • Delayed/nonunions
    • Bone loss (cysts/fractures)
    • Limb-sparing for tumors

    Harvesting a Cancellous Bone Graft

    • Aseptic technique is critical
    • Preparation of donor site in advance.
    • Common donor sites: Ilial wing, proximal tibia, humerus, distal femur.
    • Separate surgical instruments.
    • Minimize exposure to air.
    • Graft storage in blood-soaked sponges.
    • Debridement of graft area is crucial..
    • Careful not to create additional fracture.

    Sites for Cancellous Bone Grafts

    • Diagrams/illustrations showing donor sites for grafts.

    Course Information

    • Small Animal Surgery, 5th Edition
    • Chapter 32; pages 991-995 & 1025-1032
    • Theresa Welch Fossum, DVM, MS, PhD, et al.
    • Copyright © 2018 by Mosby, Inc., an affiliate of Elsevier.

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