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Questions and Answers
Which of the following is a characteristic of indirect (secondary) bone healing?
Which of the following is a characteristic of indirect (secondary) bone healing?
What is the primary role of Bone Morphogenetic Protein (BMP) in indirect bone healing?
What is the primary role of Bone Morphogenetic Protein (BMP) in indirect bone healing?
In indirect (secondary) bone healing, in which stage does chondrogenesis occur?
In indirect (secondary) bone healing, in which stage does chondrogenesis occur?
Which type of fracture is most likely to be treated with rigid fixation techniques?
Which type of fracture is most likely to be treated with rigid fixation techniques?
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What is the correct order of the general phases of fracture healing?
What is the correct order of the general phases of fracture healing?
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Which of the following is required for primary (contact) bone healing to occur?
Which of the following is required for primary (contact) bone healing to occur?
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What is the main difference between intramembranous and endochondral ossification?
What is the main difference between intramembranous and endochondral ossification?
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Which type of bone healing is characterized by the formation of a callus?
Which type of bone healing is characterized by the formation of a callus?
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A fracture that has not healed within the expected timeframe is best described as what?
A fracture that has not healed within the expected timeframe is best described as what?
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Which of the following is NOT a goal of using bone grafts?
Which of the following is NOT a goal of using bone grafts?
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Which cell type is directly derived from mesenchymal stem cells (MSCs)?
Which cell type is directly derived from mesenchymal stem cells (MSCs)?
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What percentage of bone's extracellular matrix (ECM) is composed of organic material and water?
What percentage of bone's extracellular matrix (ECM) is composed of organic material and water?
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Which type of collagen makes up the majority of the organic component of bone's extracellular matrix?
Which type of collagen makes up the majority of the organic component of bone's extracellular matrix?
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What is the maximum strain that bone (osteoblasts) can withstand during fracture healing?
What is the maximum strain that bone (osteoblasts) can withstand during fracture healing?
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In direct (primary) bone healing, what size gap is typically associated with contact healing?
In direct (primary) bone healing, what size gap is typically associated with contact healing?
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What process occurs during direct (primary) bone healing when gaps are less than 1 mm?
What process occurs during direct (primary) bone healing when gaps are less than 1 mm?
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What is the function of ‘cutting cones’ in intra-cortical remodeling?
What is the function of ‘cutting cones’ in intra-cortical remodeling?
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What type of fracture healing requires rigid internal fixation to minimize strain?
What type of fracture healing requires rigid internal fixation to minimize strain?
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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?
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?
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What is a key characteristic of a fracture nonunion?
What is a key characteristic of a fracture nonunion?
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According to the Weber-Cech classification, what are the two main categories of nonunion?
According to the Weber-Cech classification, what are the two main categories of nonunion?
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What is commonly observed in oligotrophic nonunion?
What is commonly observed in oligotrophic nonunion?
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What is the primary cause of hypertrophic nonunion?
What is the primary cause of hypertrophic nonunion?
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Which of the following is NOT a factor that increases the likelihood of fracture complications?
Which of the following is NOT a factor that increases the likelihood of fracture complications?
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In what type of nonunion would you most likely see a broken plate or screws that have pulled out?
In what type of nonunion would you most likely see a broken plate or screws that have pulled out?
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What can direct fracture healing be achieved with?
What can direct fracture healing be achieved with?
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What is a characteristic of a dystrophic nonunion?
What is a characteristic of a dystrophic nonunion?
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Which of the following best describes a necrotic nonunion?
Which of the following best describes a necrotic nonunion?
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What is the primary cause of a defect nonunion?
What is the primary cause of a defect nonunion?
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Which statement best describes an atrophic nonunion?
Which statement best describes an atrophic nonunion?
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Which of the following factors is LEAST likely to cause a nonunion?
Which of the following factors is LEAST likely to cause a nonunion?
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Which of these systemic factors can contribute to nonunion formation?
Which of these systemic factors can contribute to nonunion formation?
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Which clinical sign is MOST indicative of a nonunion?
Which clinical sign is MOST indicative of a nonunion?
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What radiographic finding suggests a nonunion?
What radiographic finding suggests a nonunion?
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What is the primary goal when treating nonunions?
What is the primary goal when treating nonunions?
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Contaminated wounds in open fractures increase the likelihood of complications by approximately how much?
Contaminated wounds in open fractures increase the likelihood of complications by approximately how much?
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What is a malunion?
What is a malunion?
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Which of the following is least likely to cause a malunion?
Which of the following is least likely to cause a malunion?
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What is a delayed union?
What is a delayed union?
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What percentage of blood supply is provided by the nutrient artery to the bone marrow in normal bone?
What percentage of blood supply is provided by the nutrient artery to the bone marrow in normal bone?
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Which of the following describes an autogenous bone graft?
Which of the following describes an autogenous bone graft?
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Which characteristic of bone grafting involves the graft acting as a scaffold for new bone formation?
Which characteristic of bone grafting involves the graft acting as a scaffold for new bone formation?
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Which is the primary function of osteoinductive proteins like Bone Morphogenetic Proteins (BMPs) in bone grafting?
Which is the primary function of osteoinductive proteins like Bone Morphogenetic Proteins (BMPs) in bone grafting?
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Which of the following is least important when harvesting a cancellous bone graft?
Which of the following is least important when harvesting a cancellous bone graft?
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Flashcards
Primary Bone Healing
Primary Bone Healing
Healing that occurs directly at the fracture site with contact or gap between bone ends.
Secondary Bone Healing
Secondary Bone Healing
Healing characterized by the formation of a callus and is a more indirect process.
Intramembranous Ossification
Intramembranous Ossification
The process by which bone forms directly from mesenchyme without a cartilage model.
Endochondral Ossification
Endochondral Ossification
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Fracture Healing Failures
Fracture Healing Failures
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Indirect (Secondary) Healing
Indirect (Secondary) Healing
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Hematoma Formation Phase
Hematoma Formation Phase
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Soft Callus Formation Phase
Soft Callus Formation Phase
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Hard Callus Formation Phase
Hard Callus Formation Phase
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Remodeling Phase
Remodeling Phase
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Cancellous Bone Grafts
Cancellous Bone Grafts
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Osteoblasts
Osteoblasts
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Direct Healing
Direct Healing
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Strain in Bone Healing
Strain in Bone Healing
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Contact Healing
Contact Healing
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Gap Healing
Gap Healing
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Granulation Tissue
Granulation Tissue
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Intra-cortical Remodeling
Intra-cortical Remodeling
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Indirect Fracture Healing
Indirect Fracture Healing
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Soft Callus
Soft Callus
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Hard Callus
Hard Callus
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Fracture Nonunion
Fracture Nonunion
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Viable Hypertrophic Nonunion
Viable Hypertrophic Nonunion
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Mildly Hypertrophic Nonunion
Mildly Hypertrophic Nonunion
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Oligotrophic Nonunion
Oligotrophic Nonunion
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Fracture Healing Summary
Fracture Healing Summary
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Dystrophic Nonunion
Dystrophic Nonunion
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Necrotic Nonunion
Necrotic Nonunion
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Defect Nonunion
Defect Nonunion
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Atrophic Nonunion
Atrophic Nonunion
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Causes of Nonunion
Causes of Nonunion
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Clinical Signs of Nonunion
Clinical Signs of Nonunion
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Radiographic Signs of Nonunion
Radiographic Signs of Nonunion
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Sequestrum
Sequestrum
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Nonunion
Nonunion
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Malunion
Malunion
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Delayed union
Delayed union
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Fracture gap
Fracture gap
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Blood supply to bone
Blood supply to bone
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Autogenous graft
Autogenous graft
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Osteogenesis
Osteogenesis
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Osteoconduction
Osteoconduction
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Indications for bone grafts
Indications for bone grafts
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Platelet-Rich Plasma
Platelet-Rich Plasma
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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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Description
Test your knowledge on the intricacies of bone healing, including indirect (secondary) bone healing characteristics, roles of Bone Morphogenetic Protein (BMP), and the various types of ossification. This quiz covers key concepts related to fracture healing phases and the use of bone grafts.