Fracture Healing - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim's animated educational video describing fracture healing.
The stability of the fracture decides what type of healing will occur. If there is a small amount of strain (below 2%), the primary bone healing will occur. The primary bone healing will occur like when you are using a compression plate. If the strain is between 2-10%, then secondary bone healing will occur such as when using a cast, rod or external fixator. In primary bone healing, you will need absolute stability, called Haversian remodeling cutting cone remodeling, or sometimes called intramembranous healing.
Secondary bone healing will occur when the fixation is not rigid, such as with a cast, and there will be endochondral ossification. With an IM rod, there will be secondary bone healing, early on, there will be periosteal callus. Later on, there will be a medullary callus.
The external fixator is predominantly periosteal callus with endochondral ossification, because most of the time the external fixator is not very rigid. When endochondral ossification fails, because the fixation is inadequate, you get hypertrophic nonunion and you will have predominantly type II collagen. The endochondral ossification at this point has failed and stability is needed in order to change the cartilage to bone.
What are the stages of fracture healing?
1-Hematoma
2-Inflammation
3-Soft callus
4-Hard callus
5-Remodeling
When the fracture occurs, there will be bleeding at the fracture site. It will make a fibrin blood clot.
1-Stage of inflammation
Cells
•Macrophages
•Mesenchymal cells
•Stem cells migrate to the fracture and form the granulation tissue and will release the growth factors. Granulation tissue tolerates the greatest strain before failure.
COX-2 inhibitor and nonsteroidal depresses Runx2. Important for the differentiation of osteoblasts.
2-Stage of soft callus
•Will occur within two weeks.
•The amount of callus correlates with the immobilization.
•The stiffer the immobilization, the less amount of callus.
•Flexible fixation will result in endochondral ossification (abundant callus).
•Secondary bone healing: healing through cartilage formation. The stability helps direct bone formation. Lack of stability helps the formation of cartilage, which later on can change to endochondral ossification.
3-Stage of hard callus
•The collagen changes from predominantly type II, to be followed by type I.
•Type I= bone
•Type II =cartilage
4-Stage of remodeling
•The stage of remodeling will begin at 2 weeks and continue many years after the fracture has healed.
•The woven bone will be replaced by stronger, laminar bone and the fracture healing will be complete with the continuation of the medullary cavity.
•The remodeling of the bone is influenced by the Wolff’s law (means that the bone is affected by stress).
You need to be aware of this order of bone healing because sometimes it comes on the exam.
Blood flow at the fracture site is very important for fracture healing. The blood will supply the fracture with nutrients and cells. Initially there Is decreased blood flow at the fracture site which will increase later on and the blood flow will peak at two weeks and return to normal after about three months.
Distraction osteogenesis
Can get type I and type II cartilage (predominantly type I) because there is more intramembranous ossification.
How does the endochondral bone formation occur?
•Chondrocyte proliferation then hypertrophy
•Matrix mineralization
•The chondrocytes die
•Vascular invasion, ossification, and remodeling to lamellar bone.
What are the growth factors involved in fracture healing?
Bone morphogenic protein: osteoinductive causing the undifferentiated mesenchymal cells to differentiate into osteoblasts.
Transforming growth factor beta (TGF-B1): will make the mesenchymal cells produce type II collagen and proteoglycans (trying to produce endochondral ossification)
Insulin-like growth factor 2 (IGF-2): will stimulate type I collagen
Platelet derived growth factor (PDGF): will be released from the platelets. Attracts inflammatory cells to the fracture site (chemotactic).

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[GodfreyTempleton]

I had bone lengthening on my femur following a previous mal union of a fracture. It was frightening, but believe in your bones to fix themselves, it will come good, it did for me.

[qfourr]

Come here with a broken foot and left ready for the exam

[OlmiJonathanKaupaOJay]

Very helpful to my presentation on fracture healing. It's really educational, so thank you very much.

[Serika]

Types of collagen:
Type 1 : bOne
Type 2: Car2lage
Type 3: re3cular fibers
Type 4: 4 on the floor (found in the basement membrane)

[sitinazliayazid]

“The stiffer the immobilization, the kess amount of callus” what does this mean?? Is it due to immobilisation that caused poor blood flow?

[saludvitalvertebralluisehe]

I use your videos with my patients, Great material, thanks for shear your knowledge and values.

[brittalbach]

thank you so much, Dr. Ebraheim, this video was very helpful to me, very well explained
God bess you and keep up your great work

[steveflor]

Hope my rt. Collar bone remembers how to do that stuff. It's been 18 days since I broke it - bicycle accident.... It' s nearly 70yrs old!!

[joannecampbell]

Well, I know that the body is an amazing thing. I was one of very few who decided not to have surgery on my hip fracture.

I’m amazed, at how after nearly one month I can almost walk normally indoors. I will use crutches outside for the 6 weeks recommended (another three weeeks or so), but x-rays show I’ve been healing well..I’ve not exactly lead a healthy lifestyle, but this has really made me think how prescious our bodies are, and I took my health for granted the rreason for this fracture and both my wrists in April was abuse of strong sedatives).

I know the pain was worst during the inflammation stage, but after a week I was better. I’d get flare ups, but now I feel no pain at all and have good movement.

I know in these last three weeks I’ve been pretty dumb and pushing my body to limits - travelling, and too much weight bearing etc.. I’m just very thankful I did no damage. I had times of horrific anxiety about never being able to walk properly or dance again.

I know that in just one week I shouldn’t have travelled, and it was pretty humiliating to have to travel as a disabled person, sit in a wheelchair and be ported by lift into the aircraft. But I just kept my head up and *Positive thinking*. ❤️

I’m just thankful for having the strength in me to somehow get through this tough time. I would have hated to have had to go through more surgery, as I’ve already had a back operation as a kid, and two wrist fractures 7 months ago, which were secured with metal pins and plates. I had no say at the time, it was very rushed, and I was barely conscious. The surgeon just decided they needed operating.

This time I know I took a big risk, because apart from the spinal cord or pelvis, the hip is the most serious fracture.

Although it was considered an ‘unstable feacture’, it seems to have healed very well (not without initial intense pain and mobility issues). I had what they call a ‘femoral stress’ or ‘hairline’ fracture.

Yeah....nature is an amazing thing. I just can’t wait to be fully mobile, because if you love music, and also ballet, this sort of thing can be absolutely devastating. I was terrified I’d never heal. When I signed that disclaimer form in hospital, I knew I was gonna be out there - me, the big world, and my mangled body. But nature truly has been goood to me; I often don’t think I deserve it, for the way I treat my body...

I thank God every day for forgiving me for not looking after my body (and, like, racing round shops with a shopping cart, holding onto it with my weight, in heels, with my crutches in the cart, just a few days after I fell).
I could make a comedy of the stares I got from people... well at least I’m being good now, and wearing hospital socks and compression stockings, lol.

Think I’ve gottwn into my typical essay mode. It’s just been such a worrying time, but as I say, nature is amazing. But I know not to take it for granted. That was my lesson...


Thanks for the info. X

[mohammedholba]

Thank you very much for such a good educational video.

[shahbazkhan-brfj]

thank you, the video was very informative and helpful ……… plz make more of such videos on other topics as well

[shado-ops]

After a year and few months… once I’m fully healed. Does it take a lot more force to break my arm again? Or does it take less?

[JohnVessely]

Coral calcium complex capsule of planet ayurveda is a food supplement that contains high quality calcium and vitamins in it which helps in calcium absorption.

[faisalejaz]

In accident I have broken my leg tibia and fibula, but surgeon only treated tibia by insertion of IM rod in tibia through operation, and he didn't repaired fibula, according to him there is no need to repair fibula, it will heal by itself, it is not weight bearing bone, so no need to worry, is that so?

[na]

Can you please explain for me the deformities of the wrist, hands and fingers seen in rheumatoid arthritis ?!

[shamakuma]

What factors are taken into consideration while an implant is removed or retained within the bone.

[liammulligan]

Thats great .i have a break on my fibula .its about 3" below my knee .
It happened almost weeks ago .
Im wearing a boot however im not sure how much the boot helps with stabilisation.
The bone has not knitted yet.
Is this ok ?

[RaaTkRahi]

I have a proximal tibia schadzker 04 fracture and distal femur medial condyle, i am recovering from 4 months, pls give some tips for exercise, my knee is not bending

[shamakuma]

If you pass an IM nail and it causes an intramedullary callus will this callus affect hematopoesis and blood flow.

[joannaaligsao]

My husband has a non union tibia fracture. Its 6 months now since the fracture bone occur.. What is the best we can do?