Fracture Fixation Fracture Fixation Internal & External Internal & External
Jan 15, 2016
Fracture FixationFracture Fixation Internal & ExternalInternal & External
Fracture TypesFracture Types
http://health.allrefer.com/health/bone-fracture-repair-fracture-types-1.html
Influencing HealingInfluencing Healing
Systemic FactorsSystemic Factors AgeAge HormonesHormones Functional activityFunctional activity Nerve functionNerve function NutritionNutrition Drugs (NSAID)Drugs (NSAID)
Local FactorsLocal Factors Energy of traumaEnergy of trauma
Degree of bone lossDegree of bone loss Vascular injuryVascular injury InfectionInfection
Type of bone fracturedType of bone fractured Degree of immobilizationDegree of immobilization Pathological conditionPathological condition
http://www.orthoteers.co.uk/Nrujp~ij33lm/Orthbonefracheal.htm
Stages of Fracture HealingStages of Fracture Healing
1.1. Inflammation & Inflammation & HematomaHematoma Osteoprogenitor cells, FibroblastsOsteoprogenitor cells, Fibroblasts
2.2. Callus FormationCallus FormationPeriosteal and EndostealPeriosteal and Endosteal
Fibro-cartilage differentiationFibro-cartilage differentiation
3.3. Woven BoneWoven BoneSubstitution of avascular and necrotic tissue Substitution of avascular and necrotic tissue
Haversian remodelingHaversian remodeling
4.4. RemodelingRemodeling Lamellar or trabecular boneLamellar or trabecular bone
Restoration of continuity and ossificationRestoration of continuity and ossification
Bone unionBone union
**When compression is applied via implant, these stages are minimized****When compression is applied via implant, these stages are minimized**
http://www.orthoteers.co.uk/Nrujp~ij33lm/Orthbonefracheal.htm http://www.ivis.org/special_books/ortho/chapter_03/03mast.asp?Type=IPRP&LA=1
Healing ComplicationsHealing Complications Most often due to severe injuryMost often due to severe injury
Energy dissipation to bone and soft tissue results in Energy dissipation to bone and soft tissue results in damage to blood supplydamage to blood supply
Compartment syndromeCompartment syndrome Severe swelling resulting in decreased blood supply can cause the Severe swelling resulting in decreased blood supply can cause the
muscles around the fracture to diemuscles around the fracture to die Bad osmotic pressure lets blood out instead of across damaged muscleBad osmotic pressure lets blood out instead of across damaged muscle
As pressure remains high, blood cannot get to damaged muscleAs pressure remains high, blood cannot get to damaged muscle
Neurovascular injuryNeurovascular injury Arteries and nerves around the injury site are damagedArteries and nerves around the injury site are damaged
InfectionInfection Imbalance of bacteria and body’s ability to cope with it when amount of 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 necrotic tissue and contraction of bacteria are not being cleared (by surgeon or patient) surgeon or patient)
http://www.hughston.com/hha/a.fracture.htm
Healing Complications (Cont’d)Healing Complications (Cont’d) Delayed unionDelayed union
Extended healing timeExtended healing time
NonunionNonunion Failure to healFailure to heal
MalunionMalunion Abnormal alignmentAbnormal alignment
Post-traumatic arthritisPost-traumatic arthritis Fractures that extend into the joints can cause premature arthritis of a Fractures that extend into the joints can cause premature arthritis of a
jointjoint
Growth abnormalitiesGrowth abnormalities A fracture through an open physis, or growth plate, could result in 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 premature partial or complete closure of the physis; Part or all of a bone will stop growing unnaturally earlybone will stop growing unnaturally early
http://www.hughston.com/hha/a.fracture.htm
TreatmentTreatment When will a cast suffice?When will a cast suffice?
Fracture is stableFracture is stable Patient preferencePatient preference No complications (Ex.-infection, burn)No complications (Ex.-infection, burn)
When is fixation necessary?When is fixation necessary? Fracture is unstableFracture is unstable Quick MobilizationQuick Mobilization OccupationOccupation
AthletesAthletes
http://www.defence.gov.au/dpe/dhs/infocentre/publications/journals/NoIDs/ADFHealthApr01/adfhealthapr01_2_1_24-28.pdf
Principles of fracture fixationPrinciples of fracture fixation
Obtain and maintain alignmentObtain and maintain alignment Reduction Reduction
Transmission of compressive forces Transmission of compressive forces Minimum motion across fracture siteMinimum motion across fracture site Achieve stabilityAchieve stability
Avoid tensile/ shear/torsion forcesAvoid tensile/ shear/torsion forces Across fracture siteAcross fracture site
Prevent motion in most crucial planePrevent motion in most crucial plane
Fixation: Internal vs. ExternalFixation: Internal vs. External
InternalInternal Plates, screws, etc. completely within the bodyPlates, screws, etc. completely within the body Less expensiveLess expensive TypesTypes
Comminuted – nail with interlocking screwComminuted – nail with interlocking screw Transverse or Oblique –plates or screws Transverse or Oblique –plates or screws
ExternalExternal Pins coming through skin interconnected by external Pins coming through skin interconnected by external
frameframe Has complications Has complications
http://www.defence.gov.au/dpe/dhs/infocentre/publications/journals/NoIDs/ADFHealthApr01/adfhealthapr01_2_1_24-28.pdf
Internal Fixation Internal Fixation
http://www.nlm.nih.gov/medlineplus/ency/imagepages/18023.htm
Internal Fixation PriciplesInternal Fixation Priciples
Rigid, anatomic fixationRigid, anatomic fixation Allows an early return to functionAllows an early return to function
Reserved for those cases that cannot be Reserved for those cases that cannot be reduced and immobilized by external reduced and immobilized by external meansmeans
Open reduction of a fracture Open reduction of a fracture Good blood supply to undisturbed tissuesGood blood supply to undisturbed tissues
http://www.umm.edu/ency/article/002966.htm
Physiological Response to IFPhysiological Response to IF
Primary healingPrimary healing Minimal extramedullary callusMinimal extramedullary callus Minimal intra-medullary callusMinimal intra-medullary callus Sub-periostealSub-periosteal RapidRapid
Related to motionRelated to motion Crosses miniature gapsCrosses miniature gaps Depends on soft tissue viability Depends on soft tissue viability
Stress ConcentrationsStress Concentrations
Geometric discontinuities (hole, base of Geometric discontinuities (hole, base of threaded screw, corner)threaded screw, corner) Local disturbance in stress patternLocal disturbance in stress pattern High stresses at site of discontinuityHigh stresses at site of discontinuity
Drilling a hole reduces the bone strength Drilling a hole reduces the bone strength by 10 – 40 %by 10 – 40 %
Types of IF DevicesTypes of IF Devices
Lag screwsLag screws Kirschner wireKirschner wire Wire loopWire loop
Tension band wiringTension band wiring Combination of wire loop and screwCombination of wire loop and screw Combination of Kirschner and wire loopCombination of Kirschner and wire loop
PlatePlate Intramedullary rods and nailsIntramedullary rods and nails
Interlocking screwsInterlocking screws
Hemi-ArthroplastyHemi-Arthroplasty
In the hip, used for In the hip, used for femoral neck fracturesfemoral neck fractures
Avascular necrosisAvascular necrosis Fractures of the proximal Fractures of the proximal
humerushumerus Early mobilization is Early mobilization is
facilitatedfacilitated
http://www.orthogastonia.com/patient_ed/html_pages/hip/hip_hemiarthrooplasty.html
Bilboquet DeviceBilboquet Device
http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/100_bilboquet/bilboquet_us.shtml
Problems in IFProblems in IF
InfectionInfection
Delayed unionDelayed union
Non-unionNon-union
External Fixation External Fixation
http://www.nlm.nih.gov/medlineplus/ency/imagepages/18021.htm
External FixationExternal Fixation
Method of immobilizing fracturesMethod of immobilizing fractures Employing percutaneous pins in bone Employing percutaneous pins in bone
attached toattached to Rigid external metalRigid external metal Plastic framePlastic frame
For treatment of For treatment of openopen and infected and infected fracturesfractures
Indications for EFIndications for EF
Open grade III fracturesOpen grade III fractures Compound tibia fracturesCompound tibia fractures
Generally from motorcycle injuries Generally from motorcycle injuries
Gunshot woundsGunshot wounds Major thermal injuriesMajor thermal injuries Open fractures associated with polytraumaOpen fractures associated with polytrauma Management of infected nonunionsManagement of infected nonunions
Forces in an External FixatorForces in an External Fixator
CompressionCompression NeutralizationNeutralization DistractionDistraction AngulationAngulation RotationRotation Translation or displacementTranslation or displacement
CompressionCompression
For transverse For transverse fracturesfractures
Adds stability Adds stability at nonunion at nonunion sitesite
NeutralizationNeutralization
For comminuted For comminuted fracturefracture
Compression may Compression may lead to excessive lead to excessive shorteningshortening
Used to maintain:Used to maintain: LengthLength AlignmentAlignment StabilityStability
DistractionDistraction
For distal For distal metaphyseal or metaphyseal or intra-articular intra-articular injuriesinjuries
Same principle of Same principle of tractiontraction Distraction of Distraction of
fragmentsfragments Alignment of injuryAlignment of injury
AngulationAngulation
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
RotationRotation
Exert rotational Exert rotational forceforce Along longitudinal axisAlong longitudinal axis
Release of forces Release of forces first first
Can be done with Can be done with repositioning pinsrepositioning pins
Most of present Most of present frames cannot apply frames cannot apply rotational forcesrotational forces
Translation or DisplacementTranslation or Displacement
Volkov apparatusVolkov apparatus Double ring unitDouble ring unit Moves one ring in Moves one ring in
parallel to otherparallel to other For translationFor translation
Types of EF DevicesTypes of EF Devices
UnilateralUnilateral BilateralBilateral TriangularTriangular QuadrilateralQuadrilateral Semicircular & Circular ringSemicircular & Circular ring
IlizarovIlizarov
http://www.ilizarov.org.uk/content.htmhttp://www.ilizarov.org.uk/content.htm
Unilateral EFUnilateral EF
Bilateral EFBilateral EF
Triangular EFTriangular EF
Quadrilateral EFQuadrilateral EF
Semicircular and Circular EFSemicircular and Circular EF
Advantages of EFAdvantages of EF
Easy applicationEasy application Good stabilityGood stability Excellent pain reliefExcellent pain relief AdjustableAdjustable
Alignment, Angulation, RotationAlignment, Angulation, Rotation Access to open woundsAccess to open wounds
Frequent dressing changeFrequent dressing change Monitoring of damaged tissueMonitoring of damaged tissue
Disadvantages of EFDisadvantages of EF
Application may cause soft tissue damageApplication may cause soft tissue damage Lacks advantages of cyclic loadings as Lacks advantages of cyclic loadings as
seen in castsseen in casts Constrained in timeConstrained in time Pins may drainPins may drain
InfectionInfection
The EndThe End
GranulationGranulation
Tissue damage repair Tissue damage repair begins with growth of begins with growth of new capillariesnew capillaries Red dots are new Red dots are new
clusters of capillariesclusters of capillaries Bleed easilyBleed easily
Bright red tissue of a Bright red tissue of a healing burn is healing burn is granulation tissuegranulation tissue
http://medweb.bham.ac.uk/http/depts/path/Teaching/FOUNDAT/repair/grantiss.html
HematomaHematoma
Blood collection localized to an organ or tissueBlood collection localized to an organ or tissue Usually clottedUsually clotted Example: Contusions (bruises), black eye, blood Example: Contusions (bruises), black eye, blood
collection beneath finger or toenailcollection beneath finger or toenail Almost always present with a fractureAlmost always present with a fracture
http://www.healthscout.com/ency/68/677/main.html
FibrocartilageFibrocartilage Cartilage with a fibrous matrix and approaching Cartilage with a fibrous matrix and approaching
fibrous connective tissue in structurefibrous connective tissue in structure Produced by fibroblastsProduced by fibroblasts
Forms in areas where size of the fracture gap is 1mm Forms in areas where size of the fracture gap is 1mm or greater or greater
Subsequently replaced by boneSubsequently replaced by bone Mechanical properties inferior to other types of Mechanical properties inferior to other types of
cartilagecartilage Contains:Contains:
Large amounts of collagen type ILarge amounts of collagen type I Reduced amounts of proteoglycansReduced amounts of proteoglycans Collagen type II, found only in cartilageCollagen type II, found only in cartilage
http://www.vetmed.ufl.edu/sacs/notes/Cross-Healing/page9.html http://wberesford.hsc.wvu.edu/histolch6.htm http://www.nuigalway.ie/anatomy/wilkins/practicals/bone/html/bone_1.htmlhttp://www.bm.technion.ac.il/courses/336529/web/Cartilage/major%20types.htm
Inflammation & HematomaInflammation & Hematoma
http://www.ivis.org/special_books/ortho/chapter_03/03F2.jpg
Inflammation & HematomaInflammation & Hematoma
Inflammation begins immediately after a fractureInflammation begins immediately after a fracture Initially consists of Initially consists of hematomahematoma and fibrin clot and fibrin clot
Hemorrhage and cell death at location of Hemorrhage and cell death at location of fracture damagefracture damage
Fibroblasts, mesenchymal cells, osteoprogenitor Fibroblasts, mesenchymal cells, osteoprogenitor cells appear nextcells appear next Formation of granulation tissueFormation of granulation tissue Ingrowth of vascular tissueIngrowth of vascular tissue Migration of mesenchymal cellsMigration of mesenchymal cells
http://www.aans.org/education/journal/neurosurgical/apr01/10-4-1.pdf Simon, SR. Simon, SR. Orthopaedic Basic ScienceOrthopaedic Basic Science. Ohio: American Academy of Orthopaedic Surgeons; 1994.. Ohio: American Academy of Orthopaedic Surgeons; 1994.
Inflammation & Hematoma (Cont’d)Inflammation & Hematoma (Cont’d)
http://www.healthscout.com/ency/68/677/main.html
Primary nutrient and oxygen supply provided by Primary nutrient and oxygen supply provided by exposed cancellous bone and muscleexposed cancellous bone and muscle
Use of anti-inflammatory or cytotoxic medication Use of anti-inflammatory or cytotoxic medication during first week may alter the inflammatory during first week may alter the inflammatory response and inhibit bone healingresponse and inhibit bone healing
Callus FormationCallus Formation
http://www.ivis.org/special_books/ortho/chapter_03/03mast.asp?Type=IPRP&LA=1
Callus FormationCallus Formation
Begins when pain and swelling subsideBegins when pain and swelling subside Size inversely dependent on immobilization of Size inversely dependent on immobilization of
fracturefracture Mesenchymal cells form cells which become Mesenchymal cells form cells which become
cartilage, bone, or fibrous tissuecartilage, bone, or fibrous tissue Increase in vascularityIncrease in vascularity
Ends when bone fragments are immobilized by Ends when bone fragments are immobilized by tissuetissue Stable enough to prevent deformityStable enough to prevent deformity
Callus does not appear on x-ray imagesCallus does not appear on x-ray images
http://www.orthoteers.co.uk/Nrujp~ij33lm/Orthbonefracheal.htmSimon, SR. Simon, SR. Orthopaedic Basic ScienceOrthopaedic Basic Science. Ohio: American Academy of Orthopaedic Surgeons; 1994.. Ohio: American Academy of Orthopaedic Surgeons; 1994.
Mechanical RoleMechanical Role
Enlarge diameter at fracture siteEnlarge diameter at fracture site Reduces mobilityReduces mobility Reduces resulting strain Reduces resulting strain
GranulationGranulation Replaces Hematoma Replaces Hematoma Granulation differentiates intoGranulation differentiates into
Connective tissueConnective tissue Random orientation of collagen fibrilsRandom orientation of collagen fibrils
Their direction reflects the direction of tensile forcesTheir direction reflects the direction of tensile forces
FibrocartilageFibrocartilage
Deformation of CallusDeformation of Callus
Strength of initial Strength of initial reparative tissue is lowreparative tissue is low
If forces surpass the If forces surpass the strength of callusstrength of callus Unstable fractureUnstable fracture Functional load deforms Functional load deforms
fracturefracture Fracture fixation is Fracture fixation is
recommendedrecommended
Woven BoneWoven Bone
Woven BoneWoven Bone Callus changes from cartilaginous tissue to Callus changes from cartilaginous tissue to
woven bonewoven bone Callus mineralized but internal architecture is not Callus mineralized but internal architecture is not
fully matured/arrangedfully matured/arranged Osteon organization is not completeOsteon organization is not complete
Connective tissues and fibrocartilage thickensConnective tissues and fibrocartilage thickens Fracture becomes increasingly stableFracture becomes increasingly stable Mineralization is sensitive to strainMineralization is sensitive to strain Mechanically stable scaffoldMechanically stable scaffold
Increased strength and stiffness with increase of Increased strength and stiffness with increase of new bone joining fragmentsnew bone joining fragments
Simon, SR. Simon, SR. Orthopaedic Basic ScienceOrthopaedic Basic Science. Ohio: American Academy of Orthopaedic Surgeons; 1994.. Ohio: American Academy of Orthopaedic Surgeons; 1994.
Bone RemodelingBone Remodeling
Woven bone becomes lamellar boneWoven bone becomes lamellar bone Bone union occurs at fracture gapBone union occurs at fracture gap
Callus gradually reabsorbed by osteoclasts Callus gradually reabsorbed by osteoclasts Replaced by boneReplaced by bone
Medullary canal reconstitutesMedullary canal reconstitutes Begins within 12 weeks after injuryBegins within 12 weeks after injury May last several yearsMay last several years
http://www.glaciermedicaled.com/bone/bonesc3p2.htmlSimon, SR. Simon, SR. Orthopaedic Basic ScienceOrthopaedic Basic Science. Ohio: American Academy of Orthopaedic Surgeons; 1994.. Ohio: American Academy of Orthopaedic Surgeons; 1994.
Mesenchymal CellsMesenchymal Cells Source of cells for new bone productionSource of cells for new bone production
Derived from bone marrow cellsDerived from bone marrow cells
Intramembranous bone formation Intramembranous bone formation Formation of bone directly from mesenchymal cellsFormation of bone directly from mesenchymal cells
Cells become osteoprogenitor cells then osteoblasts.Cells become osteoprogenitor cells then osteoblasts.
Development of Cartilage modelDevelopment of Cartilage model Mesenchymal cells form a cartilage model of the bone Mesenchymal cells form a cartilage model of the bone
during developmentduring development
http://www.grossmont.edu/shina.alagia/lectures/144/Bone%20physiology.ppthttp://www.ecmjournal.org/journal/supplements/vol005supp02/pdf/vol005supp02a07.pdf
Fracture StabilityFracture Stability Direction of fracture & material (type of bone) Direction of fracture & material (type of bone)
define stabilitydefine stability Definition of direction of force importantDefinition of direction of force important
StableStable Fissure (Hairline) – not complete break, minimal Fissure (Hairline) – not complete break, minimal
traumatrauma Greenstick – crack on outside of “bend”Greenstick – crack on outside of “bend”
UnstableUnstable Comminuted – many bone fragmentsComminuted – many bone fragments Oblique – break at an angleOblique – break at an angle Spiral – corkscrew-like crack patternSpiral – corkscrew-like crack pattern
http://pain.health-info.org/Pain%20Pages/fractures.htm
Lag ScrewLag Screw
Lag ScrewLag Screw
Stability Stability Exerts inter-fragmentary Exerts inter-fragmentary
compressioncompression Static compressionStatic compression
Distal head must be Distal head must be engagedengaged
Screw Holding ForceScrew Holding Force
Increase in area of bone Increase in area of bone within screw threadswithin screw threads
Decrease in pilot hole Decrease in pilot hole sizesize
Increase in length of Increase in length of engaged threaded engaged threaded portionportion Area available to resist Area available to resist
shearshear
Kirschner WireKirschner Wire
Kirschner Wire (Cont’d)Kirschner Wire (Cont’d)
Rotational stabilityRotational stability May be a problemMay be a problem
Anchorage to tension bandAnchorage to tension band Twisting of wires on both sides Twisting of wires on both sides
Almost equally distributed compressionAlmost equally distributed compression
Tension BandTension Band
Tension Band (Cont’d)Tension Band (Cont’d) Dynamic compressionDynamic compression
When tension appliedWhen tension applied Compressive forces are at the fracture siteCompressive forces are at the fracture site
UsedUsed Substitutes torn ligaments & tendonsSubstitutes torn ligaments & tendons Allows injured ligaments to healAllows injured ligaments to heal When fragments too small to be screwedWhen fragments too small to be screwed
http://www.wheelessonline.com/o2/1536.htm
Tension band & ScrewTension band & Screw
Tension Band & ScrewTension Band & Screw
Plating of Vertebral ColumnPlating of Vertebral Column
Vertebral ColumnVertebral Column
Intramedullary PinIntramedullary Pin
TypesTypes Open Open ClosedClosed
3-point fixation3-point fixation End fixed in epiphysesEnd fixed in epiphyses
Intramedullary Pin (Cont’d)Intramedullary Pin (Cont’d)
Stability is dependant Stability is dependant onon Friction / pressure Friction / pressure
between between Deformable nail (elastic Deformable nail (elastic
recoil)recoil) Endosteal surface of Endosteal surface of
medullary canalmedullary canal Fracture “personality”Fracture “personality”
Intramedullary Pin (Cont’d)Intramedullary Pin (Cont’d)
Blood supply is from the medullary canalBlood supply is from the medullary canalCompromised by intramedullary fixationCompromised by intramedullary fixation
More care has to be takenMore care has to be taken
Open FractureOpen Fracture
Bone ends have penetrated through and Bone ends have penetrated through and outside skinoutside skin
Important featuresImportant features Polytrauma victimsPolytrauma victims Varying soft tissue damageVarying soft tissue damage Contaminated woundContaminated wound Requires emergency treatmentRequires emergency treatment
Types of Open FractureTypes of Open Fracture Type I – Low EnergyType I – Low Energy
Puncture wound (1 cm dia. or lesser)Puncture wound (1 cm dia. or lesser) Not much soft tissue contusionNot much soft tissue contusion Usually simple transverse, short oblique fractureUsually simple transverse, short oblique fracture No crushing componentNo crushing component
Type II Type II Laceration (more than 1 cm long )Laceration (more than 1 cm long ) Not extensive soft tissue damageNot extensive soft tissue damage Not severe crushing componentNot severe crushing component
Type III – High EnergyType III – High Energy Extensive damage to soft tissueExtensive damage to soft tissue High velocity injury or severe crushing componentHigh velocity injury or severe crushing component
Type IType I
Type IIType II
Type IIIType III