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Fracture Fixation Internal & External. Fracture Types

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Presentation on theme: "Fracture Fixation Internal & External. Fracture Types"— Presentation transcript:

1 Fracture Fixation Internal & External

2 Fracture Types

3 Influencing Healing Systemic Factors Systemic Factors Age Age Hormones Hormones Functional activity Functional activity Nerve function Nerve function Nutrition Nutrition Drugs (NSAID) Drugs (NSAID) Local Factors Energy of trauma Degree of bone loss Vascular injury Infection Type of bone fractured Degree of immobilization Pathological condition

4 Stages of Fracture Healing 1. Inflammation & Hematoma Inflammation & Hematoma Inflammation & Hematoma Osteoprogenitor cells, Fibroblasts 2. Callus Formation Callus Formation Callus Formation Periosteal and Endosteal Fibro-cartilage differentiation 3. Woven Bone Woven Bone Woven Bone Substitution of avascular and necrotic tissue Haversian remodeling 4. Remodeling Remodeling Lamellar or trabecular bone Restoration of continuity and ossification Bone union **When compression is applied via implant, these stages are minimized**

5 Healing Complications Most often due to severe injury Most often due to severe injury Energy dissipation to bone and soft tissue results in damage to blood supply Energy dissipation to bone and soft tissue results in damage to blood supply Compartment syndrome Compartment syndrome Severe swelling resulting in decreased blood supply can cause the muscles around the fracture to die Severe swelling resulting in decreased blood supply can cause the muscles around the fracture to die Bad osmotic pressure lets blood out instead of across damaged muscle Bad osmotic pressure lets blood out instead of across damaged muscle As pressure remains high, blood cannot get to damaged muscle As pressure remains high, blood cannot get to damaged muscle Neurovascular injury Neurovascular injury Arteries and nerves around the injury site are damaged Arteries and nerves around the injury site are damaged Infection Infection Imbalance of bacteria and body’s ability to cope with it when amount of necrotic tissue and contraction of bacteria are not being cleared (by surgeon or patient) Imbalance of bacteria and body’s ability to cope with it when amount of necrotic tissue and contraction of bacteria are not being cleared (by surgeon or patient)

6 Healing Complications (Cont’d) Delayed union Delayed union Extended healing time Extended healing time Nonunion Nonunion Failure to heal Failure to heal Malunion Malunion Abnormal alignment Abnormal alignment Post-traumatic arthritis Post-traumatic arthritis Fractures that extend into the joints can cause premature arthritis of a joint Fractures that extend into the joints can cause premature arthritis of a joint Growth abnormalities Growth abnormalities A fracture through an open physis, or growth plate, could result in premature partial or complete closure of the physis; Part or all of a bone will stop growing unnaturally early A fracture through an open physis, or growth plate, could result in premature partial or complete closure of the physis; Part or all of a bone will stop growing unnaturally early

7 Treatment When will a cast suffice? When will a cast suffice? Fracture is stable Fracture is stablestable Patient preference Patient preference No complications (Ex.-infection, burn) No complications (Ex.-infection, burn) When is fixation necessary? When is fixation necessary? Fracture is unstable Fracture is unstableunstable Quick Mobilization Quick Mobilization Occupation Occupation Athletes Athletes

8 Principles of fracture fixation Obtain and maintain alignment Obtain and maintain alignment Reduction Reduction Transmission of compressive forces Transmission of compressive forces Minimum motion across fracture site Minimum motion across fracture site Achieve stability Achieve stability Avoid tensile/ shear/torsion forces Avoid tensile/ shear/torsion forces Across fracture site Across fracture site Prevent motion in most crucial plane Prevent motion in most crucial plane

9 Fixation: Internal vs. External Internal Internal Plates, screws, etc. completely within the body Plates, screws, etc. completely within the body Less expensive Less expensive Types Types Comminuted – nail with interlocking screw Comminuted – nail with interlocking screw Transverse or Oblique –plates or screws Transverse or Oblique –plates or screws External External Pins coming through skin interconnected by external frame Pins coming through skin interconnected by external frame Has complications Has complications

10 Internal Fixation

11 Internal Fixation Priciples Rigid, anatomic fixation Rigid, anatomic fixation Allows an early return to function Allows an early return to function Reserved for those cases that cannot be reduced and immobilized by external means Reserved for those cases that cannot be reduced and immobilized by external means Open reduction of a fracture Open reduction of a fracture Good blood supply to undisturbed tissues Good blood supply to undisturbed tissues

12 Physiological Response to IF Primary healing Primary healing Minimal extramedullary callus Minimal extramedullary callus Minimal intra-medullary callus Minimal intra-medullary callus Sub-periosteal Sub-periosteal Rapid Rapid Related to motion Related to motion Crosses miniature gaps Crosses miniature gaps Depends on soft tissue viability Depends on soft tissue viability

13 Stress Concentrations Geometric discontinuities (hole, base of threaded screw, corner) Geometric discontinuities (hole, base of threaded screw, corner) Local disturbance in stress pattern Local disturbance in stress pattern High stresses at site of discontinuity High stresses at site of discontinuity Drilling a hole reduces the bone strength by 10 – 40 % Drilling a hole reduces the bone strength by 10 – 40 %

14 Types of IF Devices Lag screws Lag screws Lag screws Lag screws Kirschner wire Kirschner wire Kirschner wire Kirschner wire Wire loop Wire loop Tension band wiring Tension band wiring Tension band wiring Tension band wiring Combination of wire loop and screw Combination of wire loop and screw Combination of wire loop and screw Combination of wire loop and screw Combination of Kirschner and wire loop Combination of Kirschner and wire loop Plate Plate Plate Intramedullary rods and nails Intramedullary rods and nails Intramedullary rods and nails Intramedullary rods and nails Interlocking screws Interlocking screws

15 Hemi-Arthroplasty In the hip, used for femoral neck fractures In the hip, used for femoral neck fractures Avascular necrosis Avascular necrosis Fractures of the proximal humerus Fractures of the proximal humerus Early mobilization is facilitated Early mobilization is facilitated

16 Bilboquet Device

17 Problems in IF Infection Infection Delayed union Delayed union Non-union Non-union

18 External Fixation

19 External Fixation Method of immobilizing fractures Method of immobilizing fractures Employing percutaneous pins in bone attached to Employing percutaneous pins in bone attached to Rigid external metal Rigid external metal Plastic frame Plastic frame For treatment of open and infected fractures For treatment of open and infected fracturesopen

20 Indications for EF Open grade III fractures Open grade III fractures Compound tibia fractures Compound tibia fractures Generally from motorcycle injuries Generally from motorcycle injuries Gunshot wounds Gunshot wounds Major thermal injuries Major thermal injuries Open fractures associated with polytrauma Open fractures associated with polytrauma Management of infected nonunions Management of infected nonunions

21 Forces in an External Fixator Compression Compression Neutralization Neutralization Distraction Distraction Angulation Angulation Rotation Rotation Translation or displacement Translation or displacement

22 Compression For transverse fractures For transverse fractures Adds stability at nonunion site Adds stability at nonunion site

23 Neutralization For comminuted fracture For comminuted fracture Compression may lead to excessive shortening Compression may lead to excessive shortening Used to maintain: Used to maintain: Length Length Alignment Alignment Stability Stability

24 Distraction For distal metaphyseal or intra-articular injuries For distal metaphyseal or intra-articular injuries Same principle of traction Same principle of traction Distraction of fragments Distraction of fragments Alignment of injury Alignment of injury

25 Angulation A – unacceptable alignment B – loosening clamps; loss of distr. and compr. force C – after frames completely loosened; angulation is corrected D - compression on distraction forces are reapplied

26 Rotation Exert rotational force Exert rotational force Along longitudinal axis Along longitudinal axis Release of forces first Release of forces first Can be done with repositioning pins Can be done with repositioning pins Most of present frames cannot apply rotational forces Most of present frames cannot apply rotational forces

27 Translation or Displacement Volkov apparatus Volkov apparatus Double ring unit Double ring unit Moves one ring in parallel to other Moves one ring in parallel to other For translation For translation

28 Types of EF Devices Unilateral Unilateral Bilateral Bilateral Triangular Triangular Quadrilateral Quadrilateral Semicircular & Circular ring Semicircular & Circular ring Ilizarov Ilizarov

29 Unilateral EF

30 Bilateral EF

31 Triangular EF

32 Quadrilateral EF

33 Semicircular and Circular EF

34 Advantages of EF Easy application Easy application Good stability Good stability Excellent pain relief Excellent pain relief Adjustable Adjustable Alignment, Angulation, Rotation Alignment, Angulation, Rotation Access to open wounds Access to open wounds Frequent dressing change Frequent dressing change Monitoring of damaged tissue Monitoring of damaged tissue

35 Disadvantages of EF Application may cause soft tissue damage Application may cause soft tissue damage Lacks advantages of cyclic loadings as seen in casts Lacks advantages of cyclic loadings as seen in casts Constrained in time Constrained in time Pins may drain Pins may drain Infection Infection

36 The End

37 Granulation Tissue damage repair begins with growth of new capillaries Tissue damage repair begins with growth of new capillaries Red dots are new clusters of capillaries Red dots are new clusters of capillaries Bleed easily Bleed easily Bright red tissue of a healing burn is granulation tissue Bright red tissue of a healing burn is granulation tissue

38 Hematoma Blood collection localized to an organ or tissue Blood collection localized to an organ or tissue Usually clotted Usually clotted Example: Contusions (bruises), black eye, blood collection beneath finger or toenail Example: Contusions (bruises), black eye, blood collection beneath finger or toenail Almost always present with a fracture Almost always present with a fracture

39 Fibrocartilage Cartilage with a fibrous matrix and approaching fibrous connective tissue in structure Cartilage with a fibrous matrix and approaching fibrous connective tissue in structure Produced by fibroblasts Produced by fibroblasts Forms in areas where size of the fracture gap is 1mm or greater Forms in areas where size of the fracture gap is 1mm or greater Subsequently replaced by bone Subsequently replaced by bone Mechanical properties inferior to other types of cartilage Mechanical properties inferior to other types of cartilage Contains: Contains: Large amounts of collagen type I Large amounts of collagen type I Reduced amounts of proteoglycans Reduced amounts of proteoglycans Collagen type II, found only in cartilage Collagen type II, found only in cartilage

40 Inflammation & Hematoma

41 Inflammation & Hematoma Inflammation begins immediately after a fracture Inflammation begins immediately after a fracture Initially consists of hematoma and fibrin clot Initially consists of hematoma and fibrin clothematoma Hemorrhage and cell death at location of fracture damage Hemorrhage and cell death at location of fracture damage Fibroblasts, mesenchymal cells, osteoprogenitor cells appear next Fibroblasts, mesenchymal cells, osteoprogenitor cells appear nextmesenchymal cellsmesenchymal cells Formation of granulation tissue Formation of granulation tissue Ingrowth of vascular tissue Ingrowth of vascular tissue Migration of mesenchymal cells Migration of mesenchymal cells Simon, SR. Orthopaedic Basic Science. Ohio: American Academy of Orthopaedic Surgeons; 1994.

42 Inflammation & Hematoma (Cont’d) Primary nutrient and oxygen supply provided by exposed cancellous bone and muscle Primary nutrient and oxygen supply provided by exposed cancellous bone and muscle Use of anti-inflammatory or cytotoxic medication during first week may alter the inflammatory response and inhibit bone healing Use of anti-inflammatory or cytotoxic medication during first week may alter the inflammatory response and inhibit bone healing

43 Callus Formation

44 Callus Formation Begins when pain and swelling subside Begins when pain and swelling subside Size inversely dependent on immobilization of fracture Size inversely dependent on immobilization of fracture Mesenchymal cells form cells which become cartilage, bone, or fibrous tissue Mesenchymal cells form cells which become cartilage, bone, or fibrous tissue Increase in vascularity Increase in vascularity Ends when bone fragments are immobilized by tissue Ends when bone fragments are immobilized by tissue Stable enough to prevent deformity Stable enough to prevent deformity Callus does not appear on x-ray images Callus does not appear on x-ray images Simon, SR. Orthopaedic Basic Science. Ohio: American Academy of Orthopaedic Surgeons; 1994.

45 Mechanical Role  Enlarge diameter at fracture site Reduces mobility Reduces mobility Reduces resulting strain Reduces resulting strain Granulation Replaces Hematoma Granulation Replaces Hematoma Granulation Granulation differentiates into Granulation differentiates into Connective tissue Connective tissue Random orientation of collagen fibrils Random orientation of collagen fibrils Their direction reflects the direction of tensile forces Their direction reflects the direction of tensile forces Fibrocartilage FibrocartilageFibrocartilage

46 Deformation of Callus Strength of initial reparative tissue is low Strength of initial reparative tissue is low If forces surpass the strength of callus If forces surpass the strength of callus Unstable fracture Unstable fracture Functional load deforms fracture Functional load deforms fracture Fracture fixation is recommended Fracture fixation is recommended

47 Woven Bone

48 Callus changes from cartilaginous tissue to woven bone Callus changes from cartilaginous tissue to woven bone Callus mineralized but internal architecture is not fully matured/arranged Callus mineralized but internal architecture is not fully matured/arranged Osteon organization is not complete Osteon organization is not complete Connective tissues and fibrocartilage thickens Connective tissues and fibrocartilage thickens Fracture becomes increasingly stable Fracture becomes increasingly stable Mineralization is sensitive to strain Mineralization is sensitive to strain Mechanically stable scaffold Mechanically stable scaffold Increased strength and stiffness with increase of new bone joining fragments Increased strength and stiffness with increase of new bone joining fragments Simon, SR. Orthopaedic Basic Science. Ohio: American Academy of Orthopaedic Surgeons; 1994.

49 Bone Remodeling Woven bone becomes lamellar bone Woven bone becomes lamellar bone Bone union occurs at fracture gap Bone union occurs at fracture gap Callus gradually reabsorbed by osteoclasts Callus gradually reabsorbed by osteoclasts Replaced by bone Replaced by bone Medullary canal reconstitutes Medullary canal reconstitutes Begins within 12 weeks after injury Begins within 12 weeks after injury May last several years May last several years Simon, SR. Orthopaedic Basic Science. Ohio: American Academy of Orthopaedic Surgeons; 1994.

50 Mesenchymal Cells Source of cells for new bone production Source of cells for new bone production Derived from bone marrow cells Derived from bone marrow cells Intramembranous bone formation Intramembranous bone formation Formation of bone directly from mesenchymal cells Formation of bone directly from mesenchymal cells Cells become osteoprogenitor cells then osteoblasts. Cells become osteoprogenitor cells then osteoblasts. Development of Cartilage model Development of Cartilage model Mesenchymal cells form a cartilage model of the bone during development Mesenchymal cells form a cartilage model of the bone during development

51 Fracture Stability Direction of fracture & material (type of bone) define stability Direction of fracture & material (type of bone) define stability Definition of direction of force important Definition of direction of force important Stable Stable Fissure (Hairline) – not complete break, minimal trauma Fissure (Hairline) – not complete break, minimal trauma Greenstick – crack on outside of “bend” Greenstick – crack on outside of “bend” Unstable Unstable Comminuted – many bone fragments Comminuted – many bone fragments Oblique – break at an angle Oblique – break at an angle Spiral – corkscrew-like crack pattern Spiral – corkscrew-like crack pattern

52 Lag Screw

53 Stability Stability Exerts inter-fragmentary compression Exerts inter-fragmentary compression Static compression Static compression Distal head must be engaged Distal head must be engaged

54 Screw Holding Force Increase in area of bone within screw threads Increase in area of bone within screw threads Decrease in pilot hole size Decrease in pilot hole size Increase in length of engaged threaded portion Increase in length of engaged threaded portion Area available to resist shear Area available to resist shear

55 Kirschner Wire

56 Kirschner Wire (Cont’d) Rotational stability Rotational stability May be a problem May be a problem Anchorage to tension band Anchorage to tension band Twisting of wires on both sides Twisting of wires on both sides Almost equally distributed compression Almost equally distributed compression

57 Tension Band

58 Tension Band (Cont’d) Dynamic compression Dynamic compression When tension applied When tension applied Compressive forces are at the fracture site Compressive forces are at the fracture site Used Used Substitutes torn ligaments & tendons Substitutes torn ligaments & tendons Allows injured ligaments to heal Allows injured ligaments to heal When fragments too small to be screwed When fragments too small to be screwed

59 Tension band & Screw

60 Tension Band & Screw

61 Plating of Vertebral Column

62 Vertebral Column

63 Intramedullary Pin Types Types Open Open Closed Closed 3-point fixation 3-point fixation End fixed in epiphyses End fixed in epiphyses

64 Intramedullary Pin (Cont’d) Stability is dependant on Stability is dependant on Friction / pressure between Friction / pressure between Deformable nail (elastic recoil) Deformable nail (elastic recoil) Endosteal surface of medullary canal Endosteal surface of medullary canal Fracture “personality” Fracture “personality”

65 Intramedullary Pin (Cont’d) Blood supply is from the medullary canal Blood supply is from the medullary canal Compromised by intramedullary fixation Compromised by intramedullary fixation More care has to be taken More care has to be taken

66 Open Fracture Bone ends have penetrated through and outside skin Bone ends have penetrated through and outside skin Important features Important features Polytrauma victims Polytrauma victims Varying soft tissue damage Varying soft tissue damage Contaminated wound Contaminated wound Requires emergency treatment Requires emergency treatment

67 Types of Open Fracture Type I – Low Energy Type I – Low Energy Puncture wound (1 cm dia. or lesser) Puncture wound (1 cm dia. or lesser) Not much soft tissue contusion Not much soft tissue contusion Usually simple transverse, short oblique fracture Usually simple transverse, short oblique fracture No crushing component No crushing component Type II Type II Laceration (more than 1 cm long ) Laceration (more than 1 cm long ) Not extensive soft tissue damage Not extensive soft tissue damage Not severe crushing component Not severe crushing component Type III – High Energy Type III – High Energy Extensive damage to soft tissue Extensive damage to soft tissue High velocity injury or severe crushing component High velocity injury or severe crushing component

68 Type I

69 Type II

70 Type III


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