traumatology fractures and dislocations l.yu.ivashchuk lecture:

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  • TRAUMATOLOGYFRACTURES AND DISLOCATIONSL.Yu.IvashchukLecture:

  • TraumaTrauma is influence on the organism of outward agents (mechanic, thermal, electric, ray, psychical and oth.), which provoked the anatomical and functional breaches in the organs and tissues, which are accompanied by local and general reaction of organism.

  • Types of traumatismTraumas of unindustrial character:a) transport traumas (railway, car, tram);b) everyday;c) sporting;d) others (traumas, which received as a result of natural catastrophes).Traumas of industrial character (manufactural and agricultural).Intentional traumas (battle traumas, ill-intentioned attacks, attempt of suicide).

  • Traumas are divided on:mechanic;chemical;electric;x-ray;psychical;operational;and others by a type provoked the damage agent.

  • The dividing of traumas by character of damage is very important - there are distinguished the open and closed traumas.

  • Peculiarities of examinations of traumatological patientsthe outward look of damaged place not always corresponds to the seriousness of damage;not always the trauma, symptoms of which are obvious, is threating for human life, the diagnostic of plurality traumas is especially hard in patients, which are unconscious, in a state of serious shock or alcoholic intoxication;the serious general phenomena (shock, acute anemia, traumatic toxicosis) can to conceal traumas. It is necessary to estimate them rightly and render the proper help.

  • FracturesA fracture is a structural break in the normal continuity of bone. This structural break, and hence fracture, may also occur through cartilage, epiphysis and epiphysal plate.

  • Classification of fracturesopen and closed;traumatic and pathological;

  • Classification of fracturesBy the direct blow - is transversal fracture, fracture with a dislocation of peripheral osseous piece;

  • Classification of fracturesBy localization the damages are divided:epiphysial fractures are unfavourable for the processes of consolidation and quite often accompanied by dislocation of osseous piece of a joint, which is hamper the comparison and fixation of osseous parts.metaphyseal - are the damages of a spongy part of bone. The important symptoms of a fracture (crepitation, abnormal mobility and others) are absent quite often by such fractures.diaphyseal - the important symptoms of a fracture (crepitation, abnormal mobility and others) are present quite often.

  • Classification of fracturesThe fractures are divided on transversal, oblique, longitudinal, spiral, splintered.There are total and incomplete fractures.There are simple, complex and combined fractures.There are single and plural fractures.

  • Clinical symptoms of fracture

  • Fractures of the bones

  • Fractures of the bones

  • Biology Versus MechanicsThe Balance

  • Biology and Mechanics:The BalanceBalance of osteosynthetic construct

  • Balance IS Important

  • Balance:A counterbalancing force or influenceStability produced by even distribution of active forcesEquality between interacting elements

  • Biology:Deals with living organisms and vital processes

  • Mechanics:Deals with energy and forces - effect on bodies

  • Mechanical responsibility:

  • Mechanic - Surgeon:UnderstandsRelative and absolute stabilityRigidityImplant/bone relationship spectrumHow spectrum of stability affects healing

  • Biological responsibility:

  • Biologist = patient:Life styleAge - osteoporosisHealth - diabeticMedicines - steroidsVascularity - atherosclerosisNeurological state - sensation , spastic

  • Bone HealingRestoration of structural integrity

    responsibilities surgeon, patientpatient provides the biological environmentsurgeon controls the mechanical environmentbalance of mechanical versus biology

  • Where have we come from?History of internal fixation

    1862 - first report by Gurlt using wire, screws, nails1870 - Berenger-Feraud Traite de l'mmobilisation dans les fractures predicted a new era

  • The Beginning of the Concept1950

    Muller understood Lambotte`s principlesvisited Danis in Brusselsas senior registrar performed 75 ORIFs + immediate motionsuccessful- starting a new era

  • The Concept

    an integrated system: principles, techniques, implantssupported by researchsupported by documentationsupported by education

  • The Integrated AO ConceptBased on biological and mechanical principlesatraumatic handling of the soft tissuesblood supply to bone and muscle importantfunction, union, asepsisanatomical reductionrigid fixation

  • A ProblemBlood supply to fracture site

    desire for a perfect anatomical reduction resulted in 1. direct reduction 2. disruption of blood supply to bone 3. damage to soft tissueslead to nonunions, infection and failures

  • BoneSoft tissue effects of fracturedisplacement disrupts tissueimplosion effect --> cavitation about fracture siteenergy dependent

  • Bone Blood SupplyEffect of fracture

    disrupts nutrient artery --> cell death at fracture sitesoft tissue stripping disrupts periosteal supplyvariable degree depending on amount and levelimplant contact also leads to necrosis

  • Fracture:Haversian system disruptedSoft tissue torn - BSImplant added - BS

  • Balance assisted by research:

  • Balance assisted by research:

  • Evolution ContinuedResearch

    bone

    understood healing in different mechanical situationsstrain theory of Perrenblood supplyeffect of stabilityimplant and technique modifications

  • Multi-fragmentary fracture best for splintage re small amounts of strain across a large gap.

  • Bone fractures: Mechanical overloadPattern depends onEnergy appliedDuration of force

  • Bone:Strong in compressionStiff spring absorbs force

  • Bone:Weak in tensionCollagen breaksFORCEFORCEBreak

  • Fragmentation:Amount of stored energy orSpeed at which applied

  • Direction:Torsional spiralAvulsion transverseBending short oblique or transverseCompression impact

  • Evolution ContinuedClinical

    locked nailing

    relative stability lead to indirect healingneeds only axial alignment in diaphyseal fractures biological platingreduction techniques to spare soft tissue - Ganz, Mastbridge plate, LCDC plate

  • The Evolved ConceptPrinciple: blood supply to soft tissue and bone is N.B.

    stable fixation

    absolute for articular fracturesabsolute for simple fractures reduced anatomically relative for diaphyseal fractures axially reducedrelative for metaphyseal or periarticular

  • Bone HealingBasic requirements

    living pluripotential cellsvascular environment to sustain cellscells available locally - haematoma, periosteumstimulus to healingappropriate mechanical setting

  • Bone HealingTypes: indirect healing

    callusfracture site resorptionfilled with callusbridges gapsmatures to cortical bone

  • Bone HealingTypes: indirect (secondary) healing - fixation

    achieved by splinting a fracturecasts, nails, ex fix and bridge platesimplant stiffness and fracture site stabilityenough stability to move and heal

  • Bone HealingTypes: direct (primary) healing - soudure autogene of Danis

    Internal remodelling of bonerequires bone to bone contact, blood supply and no motionsmall gap heals with bone: lamellar --> corticalachieved by anatomical reduction, absolute stability

  • Requisites for ReductionDiaphysis

    anatomical reduction not necessaryanatomical axial alignment necessaryrarely need open reduction except forearm

  • No motion: absolute stability

    Some motion: relative stability

  • Stability:Lack of Motion between fragmentsSpectrum none to absolute

  • Stability influencesbone healingTime dependent Contact dependent

  • Rigidity: Ability of implant to withstand deformation

  • Rigidity and Stability

    Rigidity: implant physical property, ability withstand deformationStability: motion between fracture fragments

  • Can have rigid construct and instability

  • Stability Between fracture segments

    achieved by the impaction of fracture fragmentsintimate contact restores structural continuityrestores load bearing capacity of bonebone - implant construct share stressesis a spectrum - varies in amount

  • Absolute StabilityCompressed fracture surfaces do not displace under load

    Requires: 1. anatomical reduction 2. interfragmental compressioncompression stabilizes by preload and frictionhealing is direct bone union (primary healing)

  • Tension band and Compression plate require intact opposite cortex

  • Absolute StabilityEffect of compression

    produces preloading contact maintained if compression > physiological loadproduces friction shear resisted if friction > physiological shear appliedmany methods: differ in implant, mechanism, efficiency

  • Absolute StabilityMethods

    lag screw - superior for large and/or dense bonescompression plate - fragments must be in contactprebending of a plate - best for small and/or porous bonestension band fixation - dynamic functional load needed

  • Importance of Fracture Fixation StabilityAssuming an adequate blood supply to fragments

    Stability of the fixation construct will determine:1. type of bone healing2. success of healing3. ability for early active muscle and joint rehabilitation

  • StabilityTwo situations

    1. No motion between fragments Absolute stability2. Motion between fragments Relative stability

  • Splint

    To keep in placeProtect an injured part

  • Relative Motion Depends on splintage coupleforsplint less stiff than boneand bridges a defect

  • Splint - relative stability:

    Motion between fragmentsCompatible with fracture healing

  • Relative StabilityMethods of coupling

    plaster cast - allows angulationfriction fit nail - bending is goodfriction fit nail - torsion is poorfriction fit nail - axial stability - fracture pattern

  • Relative StabilityTypes of splints

    Intramedullary: reamed/unreamed nailsextramedullary: plate-bridgetranscutaneous: external fixatorsspecial: buttressall bridge defect not able to carry load

  • All splints bridge a defect in the bone that is unable to carry a load.

  • Types of splintage:IM rodsReamed or unreamedLocked or unlockedButtress platesExternal fixation

  • Relative StabilityTypes of splint

    gliding: unlocked nailnongliding: plate, static locked nail

  • Nongliding (locked) SplintsPlates or locked nails

    plate need anatomical reduction + I.F. compressionany displacement leads to resorptionplate construct can`t adapt fragments & failslocked nail dynamizes (gliding splint) fragments coadaptgliding splint stabilizes fracture and heals

  • Non-gliding - Plate coupled by screws to bone - Locked rod

    Gliding - unlocked rod

  • Non-gliding - Plate coupled by screws to bone - Locked rod

    Gliding - unlocked rod

  • Gliding Splint

  • Relative Stability

    fixation that allows fragment motionmotion is within level to allow healingcallus is good - spontaneous healingaxial alignment is NOT anatomical reductionmany techniques to achieve it: nail, plate, ex fix

  • Splint stability determined by:Size of implantPosition of implant with bonePosition of its coupleFracture pattern

  • Splint stability determined by:Size of implantPosition of implant with bonePosition of its coupleFracture pattern

  • Judgment:

    The process of forming an opinionthrough knowledge and experience

  • Summary of BalanceRespect soft tissue blood supplyReduction of fractureApply proper technique properly

  • ConclusionsOverviewbiology > mechanics > implantsprinciple based and must be understoodeach fracture requires thoughtful assessmentinjury - biologyplan: reduction, stabilityimplementation: incision, implant

  • Given an adequate blood supply to bone: stability of fixation determines type of healing absolute = no motion, anatomical reduction, 1 union relative = motion, axial alignment, 2 union

  • Conclusion:BiologyMechanics

  • Conclusion:BiologyMechanics

  • Conclusion:BiologyMechanics

  • Conclusion:BiologyMechanics

  • Conclusion:BiologyMechanics

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