The mechanics of fracture healing
The mechanics applied to healing fractures vary widely. At one extreme rigid internal fixation is advocated, while at the other early mobilisation is recommended using external splints. Kuhn's method of paradigm orientated research was used to define the historical context of current assumptions regarding fracture healing. Conflict between the various schools of thought is the main evidence for failure of these assumptions and the need to evolve a new perspective on fracture healing. A paradigm is presented which proposes healing by external callus as an early stage and 'primary healing' as the later stage as of one continuous but changing process. A fundamental hypothesis was tested: that mechanics is the major control of fracture healing in man. A multicentre study of 102 patients with serious fractures were treated with external skeletal fixation. In 60 patients rigid external fixation was applied. In the remaining 42 the same fixation device was used, but adapted to apply 1 to 2mm of cyclic axial micromovement across the fracture. A piston applied 500 cycles of movement over a 30 minute period each day until this could be achieved by the patient on weight-bearing. Objective assessment required development of new techniques of measuring fracture stiffness and defining the point of healing. This objective measure, and clinically defined healing, were significantly faster in the group treated with micromovement (two-way analysis of variance, p = 0.005 and 0.03, respectively). Repeated injury by plastic deformation is proposed to maintain callus growth in the first phase of healing. Evidence for the required parameters of movement was gathered from the trial of micromovement, from measurements in 4 cases of epiphyseolysis and also 8 patients undergoing arthrodesis. It would appear appropriate to apply cyclic axial displacement of 2mm within the first two weeks from injury and of consistent direction until sufficient bulk of callus is formed. Thereafter axial compaction is appropriate in a second phase where callus matures. The mechanics that govern remodelling were considered to apply to the final phase. Failure of a cell culture model to display obvious results from cyclic loading may indicate that the response to mechanical loading is indirect. Intermediate and mechanically dependent biochemical and bioelectrical factors are discussed.