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Fracture Fixation Internal & External

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Title: Fracture Fixation Internal & External


1
Fracture Fixation Internal External
2
Fracture Types
3
Influencing Healing
  • Systemic Factors
  • Age
  • Hormones
  • Functional activity
  • Nerve function
  • Nutrition
  • Drugs (NSAID)
  • Local Factors
  • Energy of trauma
  • Degree of bone loss
  • Vascular injury
  • Infection
  • Type of bone fractured
  • Degree of immobilization
  • Pathological condition

http//www.orthoteers.co.uk/Nrujpij33lm/Orthbonef
racheal.htm
4
Stages of Fracture Healing
  • Inflammation Hematoma
  • Osteoprogenitor cells, Fibroblasts
  • Callus Formation
  • Periosteal and Endosteal
  • Fibro-cartilage differentiation
  • Woven Bone
  • Substitution of avascular and necrotic tissue
  • Haversian remodeling
  • Remodeling
  • Lamellar or trabecular bone
  • Restoration of continuity and ossification
  • Bone union
  • When compression is applied via implant, these
    stages are minimized

http//www.orthoteers.co.uk/Nrujpij33lm/Orthbonef
racheal.htm http//www.ivis.org/special_books/ort
ho/chapter_03/03mast.asp?TypeIPRPLA1
5
Healing Complications
  • Most often due to severe injury
  • Energy dissipation to bone and soft tissue
    results in damage to blood supply
  • Compartment syndrome
  • 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
  • As pressure remains high, blood cannot get to
    damaged muscle
  • Neurovascular injury
  • Arteries and nerves around the injury site are
    damaged
  • Infection
  • Imbalance of bacteria and bodys 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 (Contd)
  • Delayed union
  • Extended healing time
  • Nonunion
  • Failure to heal
  • Malunion
  • Abnormal alignment
  • Post-traumatic arthritis
  • Fractures that extend into the joints can cause
    premature arthritis of a joint
  • 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

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

http//www.defence.gov.au/dpe/dhs/infocentre/publi
cations/journals/NoIDs/ADFHealthApr01/adfhealthapr
01_2_1_24-28.pdf
8
Principles of fracture fixation
  • Obtain and maintain alignment
  • Reduction
  • Transmission of compressive forces
  • Minimum motion across fracture site
  • Achieve stability
  • Avoid tensile/ shear/torsion forces
  • Across fracture site
  • Prevent motion in most crucial plane

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

http//www.defence.gov.au/dpe/dhs/infocentre/publi
cations/journals/NoIDs/ADFHealthApr01/adfhealthapr
01_2_1_24-28.pdf
10
Internal Fixation
http//www.nlm.nih.gov/medlineplus/ency/imagepages
/18023.htm
11
Internal Fixation Priciples
  • Rigid, anatomic fixation
  • Allows an early return to function
  • Reserved for those cases that cannot be reduced
    and immobilized by external means
  • Open reduction of a fracture
  • Good blood supply to undisturbed tissues

http//www.umm.edu/ency/article/002966.htm
12
Physiological Response to IF
  • Primary healing
  • Minimal extramedullary callus
  • Minimal intra-medullary callus
  • Sub-periosteal
  • Rapid
  • Related to motion
  • Crosses miniature gaps
  • Depends on soft tissue viability

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

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

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

http//www.orthogastonia.com/patient_ed/html_pages
/hip/hip_hemiarthrooplasty.html
16
Bilboquet Device
http//www.maitrise-orthop.com/corpusmaitri/orthop
aedic/100_bilboquet/bilboquet_us.shtml
17
Problems in IF
  • Infection
  • Delayed union
  • Non-union

18
External Fixation
http//www.nlm.nih.gov/medlineplus/ency/imagepages
/18021.htm
19
External Fixation
  • Method of immobilizing fractures
  • Employing percutaneous pins in bone attached to
  • Rigid external metal
  • Plastic frame
  • For treatment of open and infected fractures

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

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

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

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

24
Distraction
  • For distal metaphyseal or intra-articular
    injuries
  • Same principle of traction
  • Distraction of fragments
  • 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
  • Along longitudinal axis
  • Release of forces first
  • Can be done with repositioning pins
  • Most of present frames cannot apply rotational
    forces

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

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

http//www.ilizarov.org.uk/content.htm
29
Unilateral EF
30
Bilateral EF
31
Triangular EF
32
Quadrilateral EF
33
Semicircular and Circular EF
34
Advantages of EF
  • Easy application
  • Good stability
  • Excellent pain relief
  • Adjustable
  • Alignment, Angulation, Rotation
  • Access to open wounds
  • Frequent dressing change
  • Monitoring of damaged tissue

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

36
The End
37
Granulation
  • Tissue damage repair begins with growth of new
    capillaries
  • Red dots are new clusters of capillaries
  • Bleed easily
  • Bright red tissue of a healing burn is
    granulation tissue

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

http//www.healthscout.com/ency/68/677/main.html
39
Fibrocartilage
  • Cartilage with a fibrous matrix and approaching
    fibrous connective tissue in structure
  • Produced by fibroblasts
  • Forms in areas where size of the fracture gap is
    1mm or greater
  • Subsequently replaced by bone
  • Mechanical properties inferior to other types of
    cartilage
  • Contains
  • Large amounts of collagen type I
  • Reduced amounts of proteoglycans
  • Collagen type II, found only in cartilage

http//www.vetmed.ufl.edu/sacs/notes/Cross-Healing
/page9.html http//wberesford.hsc.wvu.edu/histo
lch6.htm http//www.nuigalway.ie/anatomy/wilkins/
practicals/bone/html/bone_1.html http//www.bm.tec
hnion.ac.il/courses/336529/web/Cartilage/major20t
ypes.htm
40
Inflammation Hematoma
http//www.ivis.org/special_books/ortho/chapter_03
/03F2.jpg
41
Inflammation Hematoma
  • Inflammation begins immediately after a fracture
  • Initially consists of hematoma and fibrin clot
  • Hemorrhage and cell death at location of fracture
    damage
  • Fibroblasts, mesenchymal cells, osteoprogenitor
    cells appear next
  • Formation of granulation tissue
  • Ingrowth of vascular tissue
  • Migration of mesenchymal cells

http//www.aans.org/education/journal/neurosurgica
l/apr01/10-4-1.pdf Simon, SR. Orthopaedic Basic
Science. Ohio American Academy of Orthopaedic
Surgeons 1994.
42
Inflammation Hematoma (Contd)
  • 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

http//www.healthscout.com/ency/68/677/main.html
43
Callus Formation
http//www.ivis.org/special_books/ortho/chapter_03
/03mast.asp?TypeIPRPLA1
44
Callus Formation
  • Begins when pain and swelling subside
  • Size inversely dependent on immobilization of
    fracture
  • Mesenchymal cells form cells which become
    cartilage, bone, or fibrous tissue
  • Increase in vascularity
  • Ends when bone fragments are immobilized by
    tissue
  • Stable enough to prevent deformity
  • Callus does not appear on x-ray images
  • http//www.orthoteers.co.uk/Nrujpij33lm/Orthbonef
    racheal.htm
  • Simon, SR. Orthopaedic Basic Science. Ohio
    American Academy of Orthopaedic Surgeons 1994.

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

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

47
Woven Bone
48
Woven Bone
  • Callus changes from cartilaginous tissue to woven
    bone
  • Callus mineralized but internal architecture is
    not fully matured/arranged
  • Osteon organization is not complete
  • Connective tissues and fibrocartilage thickens
  • Fracture becomes increasingly stable
  • Mineralization is sensitive to strain
  • Mechanically stable scaffold
  • 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
  • Bone union occurs at fracture gap
  • Callus gradually reabsorbed by osteoclasts
  • Replaced by bone
  • Medullary canal reconstitutes
  • Begins within 12 weeks after injury
  • May last several years

http//www.glaciermedicaled.com/bone/bonesc3p2.htm
l Simon, SR. Orthopaedic Basic Science. Ohio
American Academy of Orthopaedic Surgeons 1994.
50
Mesenchymal Cells
  • Source of cells for new bone production
  • Derived from bone marrow cells
  • Intramembranous bone formation
  • Formation of bone directly from mesenchymal cells
  • Cells become osteoprogenitor cells then
    osteoblasts.
  • Development of Cartilage model
  • Mesenchymal cells form a cartilage model of the
    bone during development

http//www.grossmont.edu/shina.alagia/lectures/144
/Bone20physiology.ppt http//www.ecmjournal.org/j
ournal/supplements/vol005supp02/pdf/vol005supp02a0
7.pdf
51
Fracture Stability
  • Direction of fracture material (type of bone)
    define stability
  • Definition of direction of force important
  • Stable
  • Fissure (Hairline) not complete break, minimal
    trauma
  • Greenstick crack on outside of bend
  • Unstable
  • Comminuted many bone fragments
  • Oblique break at an angle
  • Spiral corkscrew-like crack pattern

52
Lag Screw
53
Lag Screw
  • Stability
  • Exerts inter-fragmentary compression
  • Static compression
  • Distal head must be engaged

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

55
Kirschner Wire
56
Kirschner Wire (Contd)
  • Rotational stability
  • May be a problem
  • Anchorage to tension band
  • Twisting of wires on both sides
  • Almost equally distributed compression

57
Tension Band
58
Tension Band (Contd)
  • Dynamic compression
  • When tension applied
  • Compressive forces are at the fracture site
  • Used
  • Substitutes torn ligaments tendons
  • Allows injured ligaments to heal
  • When fragments too small to be screwed

http//www.wheelessonline.com/o2/1536.htm
59
Tension band Screw
60
Tension Band Screw
61
Plating of Vertebral Column
62
Vertebral Column
63
Intramedullary Pin
  • Types
  • Open
  • Closed
  • 3-point fixation
  • End fixed in epiphyses

64
Intramedullary Pin (Contd)
  • Stability is dependant on
  • Friction / pressure between
  • Deformable nail (elastic recoil)
  • Endosteal surface of medullary canal
  • Fracture personality

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

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

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

68
Type I
69
Type II
70
Type III
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