Callus after fracture, rhinoplasty

If your car breaks down, you take it to a service center, if your pipes are leaking, you call a plumber, and if you have a broken bone, you visit a surgeon. But unlike other things, bones begin to repair themselves. The human body has amazing healing powers that allow it to cope with a number of diseases. Of course, doctors play a vital role in the healing process, but in most cases they simply help the body heal itself. Doctors provide optimal conditions for bone healing, and the rest is up to your cells. But how exactly do bones recover after a fracture? To answer this question, we must study in more detail what bones are made of.

At first glance, the bone looks like an inanimate, immobilized part of our musculoskeletal system. But our entire skeleton is as alive as any part of the body. The body stores minerals in the tough part of the bone. The inner red bone marrow produces red blood cells, and the yellow bone marrow produces fats. It is important to remember that bones are constantly changing. Old bone tissue is replaced with new bone, a process called bone remodeling. Bone tissue consists of osteoclasts, osteoblasts and chondroblasts. The latter are responsible for the formation of cartilage, and all of them together form all bone tissue.

General information

A callus is a multilayer structure formed during the regeneration of bone tissue, which is caused by a violation of the integrity of the bone (as a result of mechanical trauma or other external or internal influences) during the normal course of healing of fractures.
As a result, connective (provisional callus) or cartilaginous tissue is formed to replace other heterogeneous structures at the fracture site, which then undergoes metaplasia to form the final callus. Bone callus is a unique pathological and anatomical substrate for bone regeneration. Most typical for tubular bones. Histologically, it is a formation with all the specific elements and structures of bone tissue, but more calcified and phosphorylated.

Surgical treatment of patients with pseudarthrosis

Surgical treatment of patients with pseudarthrosis has been used for a long time, and its methods are being improved as science develops. For pseudarthrosis that formed after a closed fracture, at one time the method of choice was metal osteosynthesis with bone grafting.

After exposing the area, the pseudarthrosis is freed from scars and the bone fragments are refreshed, which, after reposition, are firmly fixed with a metal rod killed by the intramedullary. Then the area of pseudarthrosis is covered with a bone autograft, which is taken from the proximal metaepiphysis of the tibia or iliac wing; allografts (preserved cadaveric bones) or xenografts (bovine bone) are used. The graft is closely fitted with a spongy surface to the exposed layer of the pseudarthrosis area and firmly fixed with wire or bolts. The operation is completed by applying a plaster cast, which immobilizes the limb until the bone heals.

With tight pseudarthrosis without displacement of fragments, good results are achieved using a less traumatic operation - bone grafting with Khakhutov. After exposing the area of pseudarthrosis from the side of the subperiosteal wound, grafts of the same width are cut out from both fragments. Their length in one of the fragments should be 2/s, and in the second - 1/s of the total length of the graft. The grafts are moved so that the longer part covers the pseudarthrosis gap, and the shorter part fills the resulting defect after movement. After surgery, the limb is fixed with a plaster cast until the bone heals.

decortication surgery , has proven its worth . After opening all the soft tissues in the area of pseudarthrosis, thin plates of the cortex are knocked down with a subperiosteal chisel so that they are contained on the periosteum with the adjacent soft tissues. After performing circular decortication, the wound is sutured and a plaster cast is applied.

To stimulate reparative osteogenesis and improve blood supply to the pseudarthrosis area, some surgeons use a chisel to make incisions into the callus and bone to a depth of 2-3 mm in the form of a fir cone. The treatment of patients with infected pseudarthrosis complicated by osteomyelitis and after open fractures was very problematic. Treatment was delayed for many months and even years, since open surgical treatment can be carried out no earlier than 6 months after the healing of the festering wound or closure of the fistula.

To accelerate the healing of infected pseudarthrosis, the Steward-Bogdanov operation, or extrafocal bypass polysynostosis, was used, and for defects of the tibia, the Hahn operation was used - moving the fibula under the tibia.

Ilizarov apparatus into traumatological practice opened a new era, which radically changed the treatment tactics for pseudarthrosis, including those complicated by osteomyelitis and bone defects.

The use of hardware osteosynthesis eliminates deformation, creates stable fixation of the damaged segment, provides movement in adjacent joints, and allows loading the limb. However, with hypovascular pseudarthrosis, the process of bone fusion even in the apparatus remains slow, and therefore it is necessary to additionally apply bone grafting.

Patients with suppurative processes in the area of pseudarthrosis are treated according to the general rules of purulent surgery under conditions of hardware osteosynthesis.

For pseudarthrosis complicated by osteomyelitis , even when there is a fistula, the use of the device and the creation of stable fixation leads to increased regeneration, attenuation of the inflammatory process, closure of the fistula and bone fusion. If there is a formed sequestration, sequestrectomy is performed in the device or before its application. With the help of hardware osteosynthesis, it is possible to shorten the treatment period for patients and achieve bone fusion.

For bone defects, a 4-ring (or more) compression-distraction device is applied, a unipolar, and for large defects, a bipolar osteotomy (compactotomy) is performed in the metaphyseal (cancellous) area of the bone. After the formation of the primary cellular regenerate (7-10 days), the middle bone fragment begins to be lowered towards the defect. Lowering is carried out very slowly, 1 mm per day (in one or two steps of 0.5 mm), bringing the middle rings of the device closer together. As the space in the osteotomy area expands, it is filled with new regenerate and gradually grows.

When the ends of bone fragments approach each other at the site of the former defect, some compression is created to cause necrobiosis and stimulate the local reparative process and fusion of the fragments. For complete bone fusion, the device should be kept in a neutral position for 2.5-4 months. This treatment method allows you to eliminate bone defects over a significant area (15 cm or more).

Pathogenesis

of connective tissue occurs . After about a week, osteoid tissue begins to form, undergoing transformation either into bone itself, or initially into cartilage, and later into bone. This is usually caused by the mobility of bone fragments, which leads to trauma and disruption of the microcirculation of the resulting regenerate. The formation of initially cartilage tissue is due to the fact that this process requires less oxygenation and fewer biologically active compounds.

The formation of periosteal callus occurs as a result of processes in the bone-forming cells of the periosteum (periosteum) and endosteum. These mechanisms play a critical role in the process of healing of injured bone. The periosteum plays a fundamental role in the fusion process, from which the periosteal callus is formed.

Stages of callus formation

The formation of callus during a fracture is a complex regeneration process that occurs in several stages, although there may be variations in different locations; let’s look at the example of ribs:

The formation of a primary connective tissue callus takes approximately 10-14 days - first, blood accumulates at the fracture site and a hematoma , hyperemia and serous impregnation are formed, initiating the influx of leukocytes that cause swelling, as well as fibroblasts - cells capable of producing connective tissue structures, against the background of which the the process of alteration - osteoclastosis, designed with the help of osteoclasts to destroy necrotic and damaged cells of the bone and adjacent soft tissues, while the process of formation of vessels (granulating tissue) occurs.
The formation of young mesenchial tissue plays a critical role in filling bone defects and hematomas; hyaline or fibrocartilage grows between and around fragments.
The formation of osteoid callus - the process of transformation of connective tissue into osteoid within 3-4 months is caused by decalcification - processes of deposition of inorganic compounds present in normal bone, sometimes it is mistakenly mistaken for a “cartilaginous callus” and it resembles a soft (primary) callus, forming approximately after 5 weeks, during which time reverse processes occur at the fracture site - reduction of blood vessels, elimination of edema and normalization of blood flow against the background of disappearance of signs of inflammation.
The bone callus itself is a neoplasm enriched with apatites (hydroxyapatites) in the form of a conglomeration of amorphous osteoid tissue turning into bone, which is first distinguished by a loose structure, and then, decreasing in size, acquires the features of normal architectonics in the phase of reverse development of bone tissue structures (formation of trabeculae, restoration of the bone marrow canal), the process can last for years.

Callus does not form when bone fragments are tightly juxtaposed, when the size of the gap is fixed to 500 microns, there is good blood supply, there is no periosteum, as well as in fractures of the flat bones of the skull, sternum, pelvis and scapula, since fusion occurs due to connective tissue due to the peculiarities bone embryogenesis.

In the layers of skeletogenic cells of the periosteum and endosteum, bone beams can immediately, initially form, bypassing the fibrocartilaginous stage of bone formation, so the callus can be small in size or not expressed at all.

Layers of callus

Callus can have a different layered structure depending on the tissue source of its formation and usually differs in:

periosteal layer;
endosteal layer;
intermediary layer or otherwise called intermediate, which can develop from elements of the Haversian canals and occupies the space between the endo and periosteal layers;
the final - paraosseous layer covers from the outside all of the above layers, the source of its formation is the surrounding soft tissue;
At the base of the entire layered structure is osteoid tissue.

Pseudoarthrosis

Often there is pseudarthrosis of the tibia, less often - the bones of the forearm, shoulder and thigh.

With prolonged pseudarthrosis, the gap is temporarily filled with mucus-like liquid, and the ends of the fragments from friction are covered with coarse fibrous cartilage, polished, the area is covered with a fibrous capsule, and thus a new joint appears (neoarthrosis).

Treatment for bone fractures with impaired reparative osteogenesis includes general and local remedies.

General means of treatment are to increase the immune response of the body, muscle tone, improve hemodynamics, metabolic processes, etc. For this purpose, complete nutrition rich in proteins and vitamins, anabolic steroids (nebol, corticotropin), mumiyo, exogenous DNA, etc. are used. Exercise therapy, massage, physiotherapeutic procedures (general quartz treatment, warm wraps, etc.) are prescribed.

Local treatment consists of creating optimal conditions for bone fusion by repositioning and immobilizing fragments, normalizing local blood and lymph circulation and tissue trophism, and in the prevention and rational treatment of purulent complications.

With delayed consolidation, bone fusion is achieved using conservative methods - reliable fixation and stimulation of reparative processes.

If the fracture does not heal in a normal time frame and is accompanied by a hypertrophic callus, then it is advisable to continue fixing the segment with a plaster cast, an orthosis, or better yet, an Ilizarov apparatus or another apparatus with a functional load on the limb. At the same time, a complex of general and local treatment agents should be used to stimulate bone fusion.

In cases where, after the injury, two average periods necessary for fusion of the bone of a particular segment (localization) have passed, but there is no fusion, then one cannot count on the success of conservative treatment.

Classification

Depending on the functional characteristics, there are 4 types of callus, which develop on each bone fragment and form a common “coupling” of consolidation:

periosteal (external) – characterized by the fastest rate of formation, necessary for fixation of bone fragments, formed by the periosteum;
endosteal (internal) - like the external one, plays an adaptive function, is formed from the endosteum and is a temporary basis for future fusion and growth of bone regenerate, the first two types of callus ultimately undergo resorption;
intermediary – formed at the junction of a compact layer of fragments and ensures true bone fusion;
paraosseous - formed from connective tissue during the rapid development and proliferation of scar structures in cases of significant damage to surrounding tissues; such a callus subsequently undergoes transformation due to metaplasia into bone tissue, but can form a large protrusion on the bone.

Medical educational literature

X-rays are also of great practical importance in the study of pathological healing of fractures. These include the so-called malunion fracture, post-traumatic synostosis, excessive bone callus, aseptic traumatic necrosis, pseudarthrosis, complete resorption of bone tissue, etc.

When diagnosing a malunited fracture, the radiologist must be extremely careful. In general, you need to clearly understand the principles of modern treatment of fractures and the specific tasks that traumatology sets for itself in this regard.

The main thing that a trauma surgeon achieves is the complete restoration of the functional activity of the injured limb. It is achieved by strong fusion of bone fragments, but not necessarily by an absolute return to the normal shape of the bone. Restoring normal form is desirable and even very desirable, but is by no means necessary. In other words, anatomical cure and functional results are far from parallel to each other. Significant displacement, such as lateral displacement, is quite compatible with ideal restoration of function of the fused bone.

Most practically important is the restoration of the axes above and below the fracture. It would be better if there was no full contact between both fragments during lateral displacement, as long as there was no angle left between them. At worst, the lack of complete contact between the fragments will only slow down the healing of the fracture, but the functional outcome will be better. This means that we emphasize that it is precisely axial displacement of even a small degree that should not be tolerated; it is this so-called angulation that requires careful correction; axial deviations are most responsible for the further development of post-traumatic disfiguring osteoarthritis in the nearest joints. For the lower extremities, it goes without saying that correction of displacements along the length requires special attention.

Thus, the image often unexpectedly reveals a relatively large displacement of fragments, while the most demanding clinician has no reason to be dissatisfied with the results of the reposition. Strictly speaking, we only rarely see ideal adaptation of fragments; As a rule, debris only stands well where it was to begin with and has not been greatly displaced. With sharp displacements, even the most experienced surgeon rarely manages to achieve a position of the fragments that could be characterized as ideal from a radiological point of view. Therefore, inexperienced researchers and patients often make an unfavorable impression of radiographs of existing fractures, and in order to avoid additional iatrogenic mental trauma, such images should not be shown to patients, at least without explanation.

One must be very careful with repeating the reduction. Experience shows that in cases where non-bloody reposition fails the first time, it usually does not lead to success with repeated attempts: the fault most often lies not with the surgeon, but with the interposition of soft tissues or fragments between the main fragments or other obstacles surmountable only with surgical intervention. A strictly transverse smooth fracture of the diaphysis, which is “beautiful” to a radiologist’s eye, is most unfavorable for conservative treatment, for comparison and retention of fragments.

With large displacements of fragments, one can see on radiographs how the architecture of the bone changes in accordance with the laws of transformation. When the angular displacement of the fragments is not corrected, the bone callus appears earlier inside the angle itself and here most of all binds the fragments. Those parts of the callus that directly connect the cortical layer of the fragments and constitute their continuations become more and more compact and take the form of compact bone: the peripheral parts of the callus, outward from the line connecting the cortical layer, as well as the central ones, in place of the medullary cavity, dissolve. Those longitudinal stripes of the cortical layer, along which the main lines of force pass, thicken and appear more sharply in the photographs. Thus, the bone takes the form of an irregularly bent, twisted or compressed, or bayonet-shaped cylinder (Fig. 28).

A true idea of all the anatomical details of a poorly healed fracture, the nature and degree of unreduced displacement, shortening, and secondary changes in the bone is given, of course, only by X-ray examination; its significance for taking into account indications for active intervention and for choosing the method of operation is clear without further ado.

In case of fractures of adjacent bones, which are accompanied by significant displacement of the fragments, the callus often welds four or more fragments together: so-called post-traumatic synostoses are formed. Most often this happens with fractures of the forearm, tibia, ribs, and less often - metacarpal and metatarsal bones. Synostosis can cause limited function, such as the forearm, severe pain, etc. Clinical diagnosis of synostosis is not always easy; and here X-ray examination is crucial, providing the surgeon with all the necessary information about the shape, size, position of the callus, access to it, etc.

Excess callus (Fig. 29) is an overgrown lush callus in the form of an irregular spindle with bizarre projections, ridges and spines surrounding the fragments. This callus occurs most often on the metaphyseal ends of long bones, especially in the area of the femoral neck, less commonly the surgical neck of the humerus and in the area of the elbow joint. The main significance for the formation of lush calluses is the large number of widely spaced fragments and the detachment of the epithelium over a large area; Large hemorrhages and infection associated with open fractures are also important. A large, non-absorbable callus usually causes severe pain and serves as a mechanical obstruction that limits mobility in the nearby joint.

Rice. 28. Lateral callus with bayonet-shaped bone deformation after a fracture of the femoral diaphysis. The lateral displacement of the fragments could be tolerated; significant angular displacement and especially longitudinal displacement with shortening are unsatisfactory. Rice. 29. Excessive callus after an open fracture of the femoral shaft.

Patients with excess callus (callus luxurians) often see a radiologist with a diagnosis of osteoma or even a malignant neoplasm caused by bone trauma (Fig. 30). Therefore, X-ray examination plays a big role here. Differential diagnosis is based on the considerations that osteoma, in contrast to excess callus, has a regular configuration, sharply limited smooth contours and a uniform, regular pattern. Sarcoma or metastatic malignant tumor is characterized by large destruction of the bone, the formation of a defect, while the callus in its mass is well calcified. In addition, with excess callus there are usually many fragments with sharply defined contours, in contrast to a simple transverse pathological fracture of a neoplasm passing through a thinned cortical layer eaten by the tumor. Very big difficulties can be presented by those rare cases of true sarcoma that develop due to excess callus. Sometimes excess callus retains a shell-like structure for a long time, for many years, and thereby simulates one or another cyst.

The significance of aseptic traumatic necrosis has only been fully appreciated in recent years thanks to radiology.

Necrosis of a bone section or a fragment isolated by trauma in the area of damage becomes apparent after a fracture only relatively late, at the earliest after several months, only during the recovery period, which is thereby complicated or even disrupted.

Under normal conditions, quite large sections of bone and a certain number of bone fragments remain at the fracture site, completely cut off from the usual sources of arterial supply and innervation connections; they, as is not very well put, are devitalized. In the process of callus formation, all these elements are usually drawn into the general process of restoration, the interrupted innervation is resumed, recreated through developing new vessels and anastomoses and blood circulation; Partially deprived of nutrition, small areas of bone tissue are gradually resorbed and slowed down by active, viable tissue.

Rice. 30. Excessive callus after healing of a subtrochanteric fracture of the femur with varus deformity of the femur, i.e. high standing of the greater trochanter. From the clinical side, a suspicion of a tumor process was expressed.

However, it is not so rare that dead bone elements remain avascular, avascular, cut off from supply, and thereby become likened to a kind of local foreign bodies, so to speak, foreign bodies of internal, organic origin. For reasons that have not yet been specified, some parts of the skeleton have a certain predisposition to the formation of necrosis due to injury. Most often, the femoral head becomes dead in case of a fracture of the femoral neck, in case of a transverse fracture of the neck of the talus, its body, and the anteriorly located head remains alive, the medial part of the scaphoid bone of the wrist in case of a transverse fracture, etc. It is easy to see that avascular aseptic necrosis involves spongy elements bones located inside the joints, covered over a large surface with cartilage. As a result, long-term, progressive, disfiguring osteoarthritis inevitably develops. The name “traumatic malacia”, which is used by a number of foreign authors, must be considered unfortunate, vague, and it is not recommended to use it.

Of fundamental importance are the completely similar aseptic traumatic necrosis of large fragments described in 1949 by Compere in fractures of the diaphysis of tubular bones, moreover, in closed fractures, not of gunshot origin and not infected. This is observed with fractures of the femur, tibia, humerus, forearm bones and other large tubular bones.

Rice. 31. Aseptic necrosis of the head of the left femur and incipient secondary disfiguring osteoarthritis of the hip joint, which developed in a 40-year-old pilot after hip reduction for a traumatic dislocation of the hip joint. Clinically - severe pain and limited function, only recently appearing and gradually increasing.

Rice. 32. Partial aseptic necrosis of the head of the right femur in a 50-year-old blacksmith 2 years after a severe injury, gradually increasing, now severe pain. Free flexion and extension, but sharply limited abduction and rotation of the hip.

Usually, in this case, the structural trabecular pattern of the affected part is blurred, not differentiated, the compact substance merges with the spongy substance, the entire bone within the necrosis becomes uniformly dark, sometimes even strikingly intense, reminiscent of metal.

It should be considered a gross radiological mistake to interpret this picture as osteosclerosis, since under a microscope there is no true neoplasm and compaction of bone substance, i.e., an increase in the amount of bone substance per unit volume. In fact, the main reason for the increasing contrast between the dead bone and its living environment is the fact that vital activity continues in the neighboring bones, and due to hyperemia and innervation disorders, significant osteoporosis develops. But it’s unlikely that the matter comes down to just this factor - the difference in the intensity of the shadows in the dead and living zones is too sharp and the necrotic tissue is completely darkened. One might think that some other physicochemical local changes in the salt composition of the bone substance are to blame for the increase in the density of the shadow in the area of necrosis.

From a clinical and radiological point of view, aseptic traumatic osteonecrosis is a serious complication. After a fracture, both intra- and extra-articular, there does not occur the usual gradual progressive improvement and healing, but, on the contrary, increasing deterioration. Moreover, the greater the volume of necrosis, the worse the course and prognosis, and the more unsuccessful the commonly used treatment methods. By itself, a large necrotic lesion is not capable of resolving; just like an aseptic, non-inflammatory one, it is not rejected from the maternal soil and is not sequestered. This raises the question of indications for special treatment methods, first of all, early surgical removal of the necrotic lesion, if only the risk is technically justified. However, with necrosis of diaphyseal fragments, at the cost of a significant delay in the recovery period, assimilation of necrosis may still occur. We also observed the restoration of living bone after traumatic necrosis of almost the entire femoral head, which, however, required almost 5 years of diligent treatment. Of considerable interest is the issue of preventing necrosis in connection with skeletal trauma. The role of radiographic examination for the early and distinctive recognition of this complication of fractures, as well as for its follow-up and overall clinical understanding of it, is clear without further comment.

False arthrosis, or pseudarthrosis, occurs mainly in cases where, due to a violation of the integrity of the vessels, the nutrition of the ends of the fragments is interrupted and bone necrosis occurs at the fracture site. Probably, the innervation factor is very important here. Wide separation of fragments during muscle interposition, improper treatment, secondary infection, some common diseases, etc. also play a major role. Pseudarthrosis is also a common complication in a number of pathological fractures. With ordinary traumatic fractures, the most common complication is nonunion with the formation of a false joint in the scaphoid bone of the hand, and then in the femoral neck. We emphasize that false joints are extremely rare in childhood and adolescence.

Diagnosis of a pseudarthrosis is of great practical importance, since its presence shows that a usual cure is excluded - whoever makes a diagnosis of pseucarthrosis for ordinary traumatic fractures of long tubular bones, at the same time sets, in principle, indications for surgical intervention. For a clinician, recognition of this complication of a fracture is not always easy, especially shaky clinical diagnosis with pseudarthrosis near the true joints, with pseudarthrosis of small bones, as well as with damage to one of the bones of the leg or forearm, when the other bone remains intact.

We had to x-ray examine the area of the left elbow joint in one 70-year-old retired military man in connection with a recent contusion in this area, and unexpectedly a magnificent pseudarthrosis of the humerus was discovered at a level of 4-5 cm proximal to the joint, which developed after being wounded 48 years ago.

Rice. 33. Pseudarthrosis of the ulna with deformation of the radius after a poorly treated fracture of the forearm.

X-ray diagnosis of the pseudarthrosis (Fig. 33, 118 and 119) is critical. The main and most reliable symptom of pseudarthrosis in the photographs is the closure of the end of the medullary canal by a plate of compact substance - a product of endosteal callus.

The homogeneous shadow of the cortical layer on one side of the medullary canal, from one half-cylinder of the bone, passes in a continuous line at the end of the fragment to the other side of the canal, to the adjacent other half-cylinder, closing the opening of the canal. At the level of the pseudarthrosis, therefore, the medullary cavity on the side of each fragment is blocked. In fresh cases of the most common so-called interpositional pseudarthrosis, when the ends of the fragments are still connected by fibrous tissue, they become slightly sharpened, their contours are smoothed out, all irregularities and jagged edges of the fracture line disappear; slight osteoporosis is detected, there are no traces of callus.

In old cases of pseudarthrosis, which last at least 6-8 months, especially with diaphyseal fractures, something resembling a “new joint” develops with all the elements of a regular joint - smooth polished cartilaginous surfaces of the bone ends, a bursa and even synovial-like fluid. The fragments are shortened and rounded, their surface parts are compacted and take the form of a thick compact layer.

One of the ends expands saucer-shaped and becomes, as it were, a glenoid cavity, the other end takes the shape of a regular articular head, the “articular cleft,” i.e., the connective tissue or cartilaginous lining and the cleft between them, gapes wide in the photographs. Osteoporosis of bones is usually absent.

There are differences of opinion and inconsistency in the literature regarding the distinctive understanding of pseudarthrosis and neoarthrosis. The name of a new joint - neoarthrosis - should only mean a pathological articulation formed in an unusual place near a normal joint, one of the elements of which is a normally preformed epiphysis, for example the articular head. Neoarthrosis most often occurs as a result of long-term and persistent displacement of the articular head from the normal cavity into a secondary cavity as a result of any congenital, traumatic, inflammatory and destructive damage to the joint. Thus, the joint at the site of an ununited diaphyseal fracture, no matter how similar it is to normal, should not be called neoarthrosis, but remains only pseudarthrosis, albeit highly differentiated. Neoarthrosis is always a functionally inferior bone connection compared to a normal joint.

The so-called dangling false joint is characterized by a very significant distance between the fragments, which have an irregularly pointed shape, sometimes with spikes at the ends, and are usually sharply atrophied. It would be more correct to designate here a flaw, a bone defect, and not a “false joint.” Thus, differential diagnosis between a fresh fracture and a pseudarthrosis based on these radiological symptoms, and the entire clinical picture, does not present any difficulties (Fig. 34).

Rice. 34. Towards the differential diagnosis of pseudarthrosis. A significant defect of bone tissue in the middle third of the tibia in a 24-year-old woman after osteomyelitis of the tibia at the age of five. Severe deformation of the lower leg. Powerful hypertrophy of the fibula with its high standing.

A rare complication of a fracture is the so-called traumatic massive osteolysis - complete resorption of bone tissue in the affected area (“vanishing bones”, “phantom bone”). In otherwise completely healthy people, mainly in childhood, adolescence and young adulthood, after an unremarkable fracture, complete progressive resorption of large sections of the bone can unexpectedly occur. This is most often observed in the flat bones of the cranial vault and facial bones, in the area of the shoulder girdle (clavicle, scapula, proximal end of the shoulder) or pelvis (ilium and ischium, one half of the sacrum, proximal end of the femur). Conventional methods of clinical, laboratory and biochemical research cannot detect any deviations from the norm. In particular, there are no neurological, neurotrophic symptoms. This resorption of the bone after a fracture is not in itself accompanied by any pain. As a result, a large persistent bone defect remains with corresponding deformation, pathological mobility, looseness and loss of musculoskeletal function. The skin and soft tissues do not present any special changes.

Histologically, a picture of complete resorption of bone tissue without its replacement or in combination with the formation of fibrous tissue and many thin-walled cavities filled with lymph, undoubtedly of a non-tumor benign nature, is determined.

This amazing process of traumatic massive osteolysis gives a clear x-ray picture of the complete, complete disappearance of the bone. In the integumentary bones of the brain skull, extensive regular rounded defects are bordered by clear contours. We observed a similar case (published by E. F. Rothermel) of the disappearance of the entire central part of the clavicle, with its pointed epiphyseal ends, after the most banal fracture, without subsequent restoration of the bone substance. In our other case, there was massive osteolysis of the lower jaw in a young woman - first one and then the other half of the bone body completely resolved, followed by the disappearance of the chin, without pain, without biochemical changes, and the process of progressive non-inflammatory destruction occurred very quickly during pregnancy .

Differential diagnosis is not so difficult; it is easy to practically exclude neurogenic osteopathy with syringomyelia and tabes of the spinal cord, xanthomagosis, eosinophilic granuloma, as well as a malignant tumor.

The cause of this complication of bone injury remains a mystery. Apparently, massive osteolysis can occur without previous trauma. Such a convincing case of spontaneous progressive osteolysis of the bones of the lower leg without obvious neurological disorders was described in 1957 by 3. V. Bazilevskaya.

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Causes

Diseases that contribute to the development of bone calluses, disruption or slowdown of the processes of true fusion:

old age;
endocrine pathologies, for example, hyperparathyroidism and diabetes;
osteoporosis;
obesity;
pregnancy;
radiation sickness;
tuberculosis;
syphilis;
amyloidosis and chronic inflammatory diseases;
general exhaustion;
severe anemia ;
hypoproteinemia;
avitaminosis.

Factors influencing the regeneration process

The process of bone recovery after a fracture is influenced by many factors.

These include:

type and complexity of the fracture;
location of damage;
type of damaged bone;
degree of blood supply;
degree of displacement of fragments;
patient's age;
balanced diet;
the degree of functional load on the damaged bone;
degree of infection by pathogenic microorganisms;
quality of fracture immobilization;
speed of metabolic processes;
the presence of somatic pathologies.

The presence or absence of damage to nearby structures, ligaments and muscles plays a big role.

Symptoms

Signs of a fracture and secondary fusion with the formation of periosteal callus are:

local pain that subsides;
crepitus – a characteristic crunching sound, especially when trying to move a limb;
disappearance of pathological mobility;
distortion of the shape and structure of the bone during the formation of a paraosseous callus, which may look like a large protrusion.

Callus after a clavicle fracture

After a clavicle fracture, a natural process of formation, first of osteodin, then of callus, also occurs, which usually takes up to 2 months. The causes of fractures are most often falls, sports injuries, road accidents, and are also possible in newborns during birth.

Callus after a clavicle fracture

After the collarbone has completely fused, the callus should resolve, but in some cases this does not happen, as in the photo of the callus presented above.

Education mechanism

The formation of callus during a fracture is triggered by tissue irritation caused by injury. First, aseptic traumatic inflammation occurs in the damaged area. Leukocytes migrate to the location of the hematoma and immobile tissue cells form. Their formation triggers the regeneration process. Then, periosteal, endosteal and reticular cell elements of the bone marrow participate in the development of callus. When damaged, poorly differentiated cells are activated. They begin to actively reproduce at the site of damage. First, a cartilaginous structure is formed before callus is formed. Then, through active mineralization, it ossifies and a callus is formed. If the fracture is treated correctly, then the calluses will resolve in due time.

Tests and diagnostics

The main way to identify callus is x-ray examination. When collecting data, the patient’s complaints, medical history and the nature of the dysfunction of the limb are taken into account. In this case, it is necessary to trace the fracture line.

In severe diagnostic cases, radiographs are additionally repeated in various positions, as well as CT and MRI.

The speed and quality of callus formation become quite important for the prognostic picture. Osteodic calluses that form on the 10-20th day after a fracture are X-ray negative. Radiographically, callus becomes visible from about 4 weeks due to the fact that the tissue in it calcifies. Severe callus can be detected 3 months after injury.

Bone fusion options

There are two types of bone tissue restoration.

They are as follows:

Primary fusion occurs when the fragments are tightly and well matched. It goes on without callus formation. To do this, the fragments must be motionless and blood circulation must be maintained. Damaged bones heal easily and quickly.
Secondary fusion occurs with the formation of a callus. This occurs when bone fragments are not completely aligned and are not firmly fixed. Bone regeneration is slow.

There are several types of splicing.

These include:

contact splicing without load;
contact recovery with load;
indirect recovery with callus formation;
slow consolidation.

The type of fusion of the damaged bone depends on the type and complexity of the fracture.

In women after rhinoplasty

There are known cases where in women, in approximately 12% of cases after rhinoplasty, callus and hyperplasia formed during the rehabilitation process. It does not pose a threat to health, but is a fairly noticeable and unattractive cosmetic defect. Externally, the organ of smell looks excessively large and has a hump, so patients have to turn to a plastic surgeon again. The size of the formation, due to circumstances, can vary significantly, as well as the time of its manifestation; most often the growth appears after a few weeks, but there have been cases when it appeared after a year. This is facilitated by the reactivity of the body, state of health, skill of the surgeon and the age of the patient. By the way, persons under 18 years of age are not recommended to carry out such manipulations, since due to active processes of bone formation there is a high risk of developing calluses.

Callus after rhinoplasty

The cause of callus after rhinoplasty is the improper fusion of connective tissue damaged during surgery to correct the nose as a complex anatomical structure that does not have much strength. The main symptoms of callus formation in the nose are:

changing the shape of the nose;
pain;
swelling and a pronounced hump.

Treatment.

When bone healing is slow, there are two treatment options – conservative and surgical.

Conservative treatment is an extension of the period of immobilization of the fracture sufficient for its healing. A non-union fracture is treated by administering drugs that stimulate the process of bone formation; it is possible to inject the patient’s blood into the gap between the fragments, as well as strengthening and tonic injections.
If the consolidation time increases by more than 1.5-2 months, then the patient is prescribed surgical treatment. In the traumatology department, the patient will undergo one of the necessary operations according to indications: extrafocal compression osteosynthesis, bone grafting, Beck tunneling or sliding graft surgery according to Khakhutov.

Diet for callus

Diet for fractures

Efficacy: therapeutic effect after a month
Timeframe: 2 months
Cost of food: 1600-1800 rubles per week

The diet after a fracture and during the formation of callus should be complete and balanced. It is extremely important that every day your body receives:

a sufficient amount of proteins, the source of which should be veal, poultry, rabbit, legumes, cottage cheese and cheeses, as well as bone decoctions;
mineral compounds essential for osteogenesis are found in fish, seafood, eggs, dairy products and yoghurts such as “Rastishki”;
antioxidants and vitamins - can be taken in the form of additional complexes, but it is better to enrich the diet with fruits, berries, vegetables and herbs, drink green tea with ginger, smoothies and fruit drinks;
healthy fats - we must not forget about their benefits, so unrefined oil, nuts, seeds and seeds should be added to vegetables and other dishes;
carbohydrates - porridge and whole grain baked goods - are essential components of a complete diet.

If the callus has not formed

There are situations where insufficient callus formation occurs. It does not form at all, the formation process is slow, or the growth of the callus occurs with a defect.

High-quality and timely education depends on several factors:

maintaining the integrity of the skin and the absence of penetration of pathogenic microorganisms into the fracture site;
ability to completely compare bone fragments;
immobilization of the injury site during recovery;
maintaining blood circulation in the fracture area;
ensuring adequate dosed load on the damaged bone for the entire period of fusion.

In the absence of these disorders, physiological callus formation occurs.

Callus appears at the fracture site in the following situations:

incomplete comparison of bone fragments;
multiple attempts to eliminate the bias;
insufficient time for fracture immobilization;
frequent and unjustified changes in treatment methods;
incorrectly selected exercise therapy complexes;
large distance between fragments;
damage to regional vessels and nerve trunks;
a large number of small fragments;
instability of osteosynthesis;
earlier removal of structures for osteosynthesis;
suppuration in the fracture zone.

Disorders of bone fusion include: delayed consolidation, formation of a false joint, and nonunion of a fracture.

Slow consolidation

Slow consolidation of the fracture - with this disorder, timely fusion of fragments does not occur within the time limits specified for this type of bone. Instability at the site of injury persists and pain is noted. An x-ray image reveals a callus with a degree of maturity that does not correspond to its age. This anomaly also occurs in people who are overweight, diabetic, pregnant, or anemic.

Non-united fracture

A non-union fracture is understood as a type of bone fusion disorder in which the damage has not healed within the double time period characteristic for the restoration of this bone. Pathological mobility of fragments and pain are detected. The photographs reveal the space between the fragments with the absence of fusion of the bone cavity.

False joint

False joint (pseudoarthrosis) - develops when bone fragments do not fuse together. Between them a mobile formation consisting of cartilage is formed. Its structure resembles a joint capsule. The bone fragments are covered with cartilage tissue, and there is a cavity between them. This pathology is a common complication.

It develops for the following reasons:

weak fixation of elements during osteosynthesis;
defects in the reposition of fragments;
post-immobilization displacement of fragments;
increased loads during the rehabilitation period;
metabolic disorders in bone tissue;
endocrine diseases;
long-term treatment with glucocorticoids;
suppuration at the fracture site;
oncological diseases;
various diseases of the musculoskeletal system.

A false joint impairs bone function. It manifests itself as pathological mobility and pain.

Content

Mechanism of bone repair
Useful products for fractures
General principles of nutrition for fractures
Nutrition for a broken leg or spine
Nutrition for rib fractures
Nutrition for broken arm bones
Foods that slow down bone healing
Specialist help

A fracture is a complete or partial destruction of a bone. It becomes the result of excessive stress or a consequence of a decrease in bone strength due to certain diseases and age-related changes, leading to a decrease in bone density - osteoporosis.

Proper nutrition and physical activity

For the fastest healing of a broken bone and a return to normal life, it is necessary to follow a daily routine, eat right, do not neglect physical activity, and eliminate bad habits.

Avoid stress, get enough sleep. Your body works in a forced mode during recovery, do not overload it.
Eat a balanced diet to provide your body with the necessary energy balance. Proteins, vitamins, and microelements should be present in your diet in large quantities. Pay special attention to dairy products that contain calcium, which is necessary for bone healing. The doctor may additionally prescribe calcium-containing medications.
Do not smoke. Smoking promotes vasospasm and metabolic disorders. This slows down the recovery processes.
Painkillers and anti-inflammatory drugs should be taken only as prescribed by a doctor.
Do not neglect physical therapy, which will allow you to restore muscle tone. Don't overdo it with physical activity, but don't give in to the desire to feel sorry for yourself once again. Approach physical activity wisely.

If you want to speed up bone healing and return to your normal lifestyle as soon as possible, you should follow all the doctor’s recommendations and carefully monitor your condition. A course of shock wave therapy is available in the diagnostic and treatment center.

Installation

Installation of plates for a jaw fracture using the open method is carried out in 4 stages:

a soft tissue incision is made to visualize and connect the fragments;
connecting bone fragments using a plate;
fixation of bone elements with glue, staples, quick-hardening plastics used in modern surgery;
suturing.

The main difficulty of open surgery is trauma. The doctor works with the area in which the nerve endings and salivary glands are located, which creates the risk of damage to them, and therefore determines high requirements for the qualifications of the specialist.

A safer and less traumatic method is ultrasonic osteosynthesis of the jaw. It not only reduces the risk of complications during fixation, but also reduces the time for fracture healing.

Healing of bones after a fracture

Symptoms of a bone fracture are acute pain, tissue swelling, and unusual mobility of the broken bone. With multiple fractures, traumatic shock is possible. The fracture area is usually deformed. If bone fragments are not set correctly, the bone may heal crookedly. Such consequences always have to be corrected, especially when it comes to broken limbs. Incorrectly fused nasal bones are often left unattended, leading to facial asymmetry and subsequent breathing problems.

In diagnosing bone fractures and monitoring their proper healing, radiography plays a major role; all main appointments are made only after X-rays.

Conditions for fracture healing

For correct and rapid healing of a fracture, the patient’s bone fragments must be correctly aligned. With an ideal comparison, the distance between them is no more than five millimeters. The fracture site must be reliably fixed, the fragments are completely motionless. The damaged area should be well supplied with blood. The fracture site is not overheated or overcooled. Treatment should be carried out under the supervision of an orthopedic traumatologist. Loads on the damaged bone are limited.

Nutrition

The diet for a fracture should contain a large amount of protein, which is easily digestible.

It is found in the following products:

veal;
chicken meat;
turkey fillet;
rabbit meat;
fish;
dairy products;
cottage cheese.

You need to eat right from the next day after the injury. You can additionally introduce gelatin into the diet. From the second week after the fracture, it is necessary to include calcium-rich foods in the diet: hard cheese, leafy greens, nuts, legumes.

Medicines

In the treatment of fracture healing pathologies, several groups of drugs are used.

The following medications are recommended for the patient:

vitamin and mineral complexes with a high calcium content (Katsemin, Calcium D3 Nycomed);
immunostimulants (Pyrogenal, Timalin) – drugs strengthen the body’s defenses;
Kenalog – suppresses the activity of macrophages and leukocytes, reduces inflammation;
Diprospan - refers to glucocorticoids, reduces swelling and inflammation at the site of injury;
biostimulants (Aloe extract, Plasmol) - improve cell nutrition at the fracture site.

The use of these agents accelerates the formation of bone tissue, reduces swelling and pain at the fracture site.

Physiotherapy

Physiotherapy is considered the most effective method for treating pathological growth of callus.

The following procedures apply:

Electrophoresis is used to improve the processes of callus ossification in the final stages of fracture healing. If it is necessary to reduce pathological growth, electrophoresis with Lidase is used.
Magnetotherapy – magnetic polarization promotes the activation of regenerative processes at the fracture site.
Thermotherapy is the effect of infrared radiation on the damaged bone. Improves blood flow, helps inhibit the pathological growth of callus at the fracture site.
Phonophoresis with hydrocortisone reduces inflammation and swelling.

Procedures are prescribed ten per course. Exercise therapy is prescribed together with physiotherapy. A dosed load helps strengthen the bone structure and correct orientation of young bone beams.

IMPORTANT When exercising, you must be careful; damage to the callus contributes to the development of pathological growth.

Nutrition for a broken leg or spine

With fractures of the lower extremities, and even more so with fractures of the spine, physical activity, and therefore the energy consumption of the body, sharply decreases.

In this case, it is important to ensure that the food is complete in composition, and its energy value corresponds to energy costs. The calorie content of the diet is reduced by reducing the consumption of fast carbohydrates and fats.

On a note

When on bed rest, you should be careful with salty, smoked, and pickled foods. It contains a lot of salt, which causes fluid retention in the body and swelling.