traumatology fractures and dislocations l.yu.ivashchuk lecture:

TRAUMATOLOGYTRAUMATOLOGYFRACTURES AND FRACTURES AND DISLOCATIONSDISLOCATIONS

L.Yu.IvashchukL.Yu.Ivashchuk

Lecture:Lecture:

TraumaTrauma

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

Types of traumatismTypes of traumatism Traumas of unindustrial character:Traumas of unindustrial character:

a) transport traumas (railway, car, tram);a) transport traumas (railway, car, tram);b) everyday;b) everyday;c) sporting;c) sporting;d) others (traumas, which received as a d) others (traumas, which received as a result of natural catastrophes).result of natural catastrophes).

Traumas of industrial character Traumas of industrial character (manufactural and agricultural).(manufactural and agricultural).

Intentional traumas (battle traumas, ill-Intentional traumas (battle traumas, ill-intentioned attacks, attempt of suicide).intentioned attacks, attempt of suicide).

Traumas are divided on:Traumas are divided on:

mechanic;mechanic; chemical;chemical; electric;electric; x-ray;x-ray; psychical;psychical; operational;operational; and others by a type provoked the and others by a type provoked the

damage agent.damage agent.

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

Peculiarities of Peculiarities of examinations of examinations of

traumatological patientstraumatological patients the outward look of damaged place not always the outward look of damaged place not always

corresponds to the seriousness of damage;corresponds to the seriousness of damage; not always the trauma, symptoms of which are not always the trauma, symptoms of which are

obvious, is threating for human life, the obvious, is threating for human life, the diagnostic of plurality traumas is especially diagnostic of plurality traumas is especially hard in patients, which are unconscious, in a hard in patients, which are unconscious, in a state of serious shock or alcoholic intoxication;state of serious shock or alcoholic intoxication;

the serious general phenomena (shock, acute the serious general phenomena (shock, acute anemia, traumatic toxicosis) can to conceal anemia, traumatic toxicosis) can to conceal traumas. It is necessary to estimate them traumas. It is necessary to estimate them rightly and render the proper help.rightly and render the proper help.

FracturesFractures

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

Classification of Classification of fracturesfractures

open and closed;open and closed; traumatic and pathological;traumatic and pathological;


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


By localization the damages are divided:By localization the damages are divided: epiphysial fractures are unfavourable for epiphysial fractures are unfavourable for

the processes of consolidation and quite the processes of consolidation and quite often accompanied by dislocation of often accompanied by dislocation of osseous piece of a joint, which is hamper osseous piece of a joint, which is hamper the comparison and fixation of osseous the comparison and fixation of osseous parts.parts.

metaphyseal - are the damages of a spongy metaphyseal - are the damages of a spongy part of bone. The important symptoms of a part of bone. The important symptoms of a fracture (crepitation, abnormal mobility fracture (crepitation, abnormal mobility and others) are absent quite often by such and others) are absent quite often by such fractures.fractures.

diaphyseal - the important symptoms of a diaphyseal - the important symptoms of a fracture (crepitation, abnormal mobility fracture (crepitation, abnormal mobility and others) are present quite often.and others) are present quite often.


The fractures are divided on The fractures are divided on transversal, oblique, longitudinal, transversal, oblique, longitudinal, spiral, splintered.spiral, splintered.

There are total and incomplete There are total and incomplete fractures.fractures.

There are simple, complex and There are simple, complex and combined fractures.combined fractures.

There are single and plural fractures.There are single and plural fractures.

Clinical symptoms of Clinical symptoms of fracturefracture

Fractures of the bonesFractures of the bones

Biology Versus Biology Versus MechanicsMechanics

The Balance The Balance

Biology and Mechanics:Biology and Mechanics:The BalanceThe Balance

““Balance” of osteosynthetic constructBalance” of osteosynthetic construct

Balance Balance ISIS Important Important

Balance:Balance: A counterbalancing force or A counterbalancing force or

influenceinfluence Stability produced by even Stability produced by even

distribution of active forcesdistribution of active forces Equality between interacting Equality between interacting

elementselements

Biology:Biology:

Deals with living organisms Deals with living organisms and vital processesand vital processes

Mechanics:Mechanics:

Deals with energy and forces -Deals with energy and forces -

effect on bodieseffect on bodies

Mechanical responsibility:Mechanical responsibility:

““Mechanic” - Surgeon:Mechanic” - Surgeon:

““Understands”Understands” Relative and Relative and

absolute stabilityabsolute stability RigidityRigidity Implant/bone Implant/bone

relationship relationship spectrumspectrum

How spectrum of How spectrum of stability affects stability affects healinghealing

Biological responsibility:Biological responsibility:

Biologist = patient:Biologist = patient:

Life styleLife style Age - osteoporosisAge - osteoporosis Health - diabeticHealth - diabetic Medicines - steroidsMedicines - steroids Vascularity - Vascularity -

atherosclerosisatherosclerosis Neurological state -Neurological state -

sensation , spasticsensation , spastic

Bone HealingBone HealingRestoration of structural integrityRestoration of structural integrity

responsibilities surgeon, patientresponsibilities surgeon, patient patient provides the biological patient provides the biological

environmentenvironment surgeon controls the mechanical surgeon controls the mechanical

environmentenvironment balance of mechanical versus balance of mechanical versus

biologybiology

Where have we come Where have we come from?from?

History of internal fixationHistory of internal fixation 1862 - first report by Gurlt using 1862 - first report by Gurlt using wire, screws, nailswire, screws, nails

1870 - Berenger-Feraud Traite de 1870 - Berenger-Feraud Traite de l'ìmmobilisation dans les fracturesl'ìmmobilisation dans les fracturespredicted a new erapredicted a new era

The Beginning of the The Beginning of the ConceptConcept

19501950 Muller understood Lambotte`s Muller understood Lambotte`s

principlesprinciples visited Danis in Brusselsvisited Danis in Brussels as senior registrar performed 75 as senior registrar performed 75

ORIFs + immediate motionORIFs + immediate motion successful- starting a new erasuccessful- starting a new era

The ConceptThe Concept

an integrated system: principles, an integrated system: principles, techniques, implantstechniques, implants

supported by researchsupported by research supported by documentationsupported by documentation supported by educationsupported by education

The Integrated AO The Integrated AO ConceptConcept

Based on biological and mechanical Based on biological and mechanical principlesprinciples

atraumatic handling of the soft atraumatic handling of the soft tissuestissues blood supply to bone and muscle blood supply to bone and muscle

importantimportant function, union, asepsisfunction, union, asepsis

anatomical reductionanatomical reduction ‘‘rigid’ fixationrigid’ fixation

A ProblemA ProblemBlood supply to fracture siteBlood supply to fracture site

desire for a perfect anatomical desire for a perfect anatomical reduction resulted inreduction resulted in1. direct reduction1. direct reduction2. disruption of blood supply to bone2. disruption of blood supply to bone3. damage to soft tissues3. damage to soft tissues

lead to nonunions, infection and lead to nonunions, infection and failuresfailures

BoneBoneSoft tissue effects of Soft tissue effects of

fracturefracture

displacement disrupts tissuedisplacement disrupts tissue implosion effect --> cavitation implosion effect --> cavitation

about fracture siteabout fracture site energy dependentenergy dependent

Bone Blood SupplyBone Blood SupplyEffect of fractureEffect of fracture

disrupts nutrient artery --> cell disrupts nutrient artery --> cell death at fracture sitedeath at fracture site

soft tissue stripping disrupts soft tissue stripping disrupts periosteal supplyperiosteal supply

variable degree depending on variable degree depending on amount and levelamount and level

implant contact also leads to implant contact also leads to necrosisnecrosis

Fracture:Fracture:

Haversian Haversian system disruptedsystem disrupted

Soft tissue torn - Soft tissue torn - BS BS

Implant added - Implant added - BSBS

Balance assisted by research:Balance assisted by research:

Evolution ContinuedEvolution ContinuedResearchResearch

bonebone

understood healing in different understood healing in different mechanical situationsmechanical situations

strain theory of Perrenstrain theory of Perren

blood supplyblood supply effect of stabilityeffect of stability implant and technique implant and technique

modificationsmodifications

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

1010mm 55mm

2020mm

Bone fractures: Mechanical Bone fractures: Mechanical overloadoverload Pattern Pattern

depends ondepends on Energy Energy

appliedapplied Duration of Duration of

forceforce

Bone:Bone:

Strong in Strong in compressioncompression

““Stiff spring” Stiff spring” absorbs forceabsorbs force

Bone:Bone:

Weak in Weak in tensiontension

““Collagen Collagen breaks”breaks”

FORCE

FORCE

Break

Fragmentation:Fragmentation:

Amount of Amount of stored energy stored energy oror

Speed at Speed at which appliedwhich applied

Direction:Direction:

Torsional spiralTorsional spiral

Avulsion Avulsion transversetransverse

Bending short Bending short oblique or oblique or transversetransverse

Compression Compression impactimpact

Evolution ContinuedEvolution ContinuedClinicalClinical

locked nailinglocked nailing relative stability lead to indirect relative stability lead to indirect

healinghealing needs only axial alignment in needs only axial alignment in

diaphyseal fracturesdiaphyseal fractures biological plating biological plating

reduction techniques to spare soft reduction techniques to spare soft tissue - Ganz, Masttissue - Ganz, Mast

bridge plate, LCDC platebridge plate, LCDC plate

The Evolved ConceptThe Evolved ConceptPrinciple: blood supply to soft tissue Principle: blood supply to soft tissue

and bone is N.B.and bone is N.B.

stable fixationstable fixation absolute for articular fracturesabsolute for articular fractures absolute for simple fractures reduced absolute for simple fractures reduced

anatomicallyanatomically

relative for diaphyseal fractures axially relative for diaphyseal fractures axially reducedreduced

relative for metaphyseal or relative for metaphyseal or periarticularperiarticular

Bone HealingBone HealingBasic requirementsBasic requirements

living pluripotential cellsliving pluripotential cells vascular environment to sustain cellsvascular environment to sustain cells cells available locally - haematoma, cells available locally - haematoma,

periosteumperiosteum stimulus to healingstimulus to healing appropriate mechanical settingappropriate mechanical setting

Bone HealingBone HealingTypes: indirect healing Types: indirect healing

calluscallus fracture site resorptionfracture site resorption filled with callusfilled with callus bridges gapsbridges gaps matures to cortical bonematures to cortical bone

Bone HealingBone HealingTypes: indirect (secondary) healing - Types: indirect (secondary) healing -

fixationfixation

achieved by splinting a fractureachieved by splinting a fracture casts, nails, ex fix and bridge platescasts, nails, ex fix and bridge plates implant stiffness and fracture site implant stiffness and fracture site

stabilitystability enough stability to move and healenough stability to move and heal

Bone HealingBone HealingTypes: direct (primary) healing - Types: direct (primary) healing -

soudure autogene of Danissoudure autogene of Danis

Internal remodelling of boneInternal remodelling of bone requires bone to bone contact, blood requires bone to bone contact, blood

supply and no motionsupply and no motion small gap heals with bone: lamellar small gap heals with bone: lamellar

--> cortical--> cortical achieved by anatomical reduction, achieved by anatomical reduction,

absolute stabilityabsolute stability

Requisites for ReductionRequisites for ReductionDiaphysisDiaphysis

anatomical reduction not necessaryanatomical reduction not necessary anatomical axial alignment anatomical axial alignment

necessarynecessary rarely need open reduction except rarely need open reduction except

forearmforearm

No motionNo motion: absolute : absolute stabilitystability

Some motionSome motion: relative : relative stabilitystability

Stability:Stability:

Lack of Motion Lack of Motion between fragmentsbetween fragments

Spectrum none to Spectrum none to absoluteabsolute

Stability influencesStability influencesbone healingbone healing

Time dependent Time dependent Contact dependentContact dependent

Rigidity:Rigidity:

Ability of implant to Ability of implant to

withstand withstand deformationdeformation

Rigidity and StabilityRigidity and Stability

Rigidity:Rigidity:implant physical property, ability implant physical property, ability withstand deformationwithstand deformation

Stability:Stability:motion between fracture fragmentsmotion between fracture fragments

Can have “rigid construct” and instabilityCan have “rigid construct” and instability

Stability Stability Between fracture segmentsBetween fracture segments

achieved by the impaction of fracture achieved by the impaction of fracture fragmentsfragments

intimate contact restores structural intimate contact restores structural continuitycontinuity

restores load bearing capacity of bonerestores load bearing capacity of bone bone - implant construct share bone - implant construct share

stressesstresses is a spectrum - varies in amountis a spectrum - varies in amount

Absolute StabilityAbsolute StabilityCompressed fracture surfaces do Compressed fracture surfaces do

not displace under loadnot displace under load

Requires:Requires:1. anatomical reduction1. anatomical reduction2. interfragmental compression2. interfragmental compression

compression stabilizes by preload compression stabilizes by preload and frictionand friction

healing is direct bone union healing is direct bone union (primary healing)(primary healing)

Tension band and Compression Tension band and Compression plate plate

require intact opposite cortexrequire intact opposite cortex

Absolute StabilityAbsolute StabilityEffect of compressionEffect of compression

produces preloadingproduces preloadingcontact maintained if compression > contact maintained if compression > physiological loadphysiological load

produces frictionproduces frictionshear resisted if friction > shear resisted if friction > physiological shear appliedphysiological shear applied

many methods: differ in implant, many methods: differ in implant, mechanism, efficiencymechanism, efficiency

Absolute StabilityAbsolute StabilityMethodsMethods

lag screw - superior for large and/or lag screw - superior for large and/or dense bonesdense bones

compression plate - fragments must compression plate - fragments must be in contactbe in contact

prebending of a plate - best for small prebending of a plate - best for small and/or porous bonesand/or porous bones

tension band fixation - dynamic tension band fixation - dynamic functional load neededfunctional load needed

Importance of Fracture Importance of Fracture Fixation StabilityFixation Stability

Assuming an adequate blood supply Assuming an adequate blood supply to fragmentsto fragments

Stability of the fixation construct Stability of the fixation construct will determine:will determine:

1. type of bone healing1. type of bone healing 2. success of healing2. success of healing 3. ability for early active muscle 3. ability for early active muscle

and joint rehabilitationand joint rehabilitation

StabilityStabilityTwo situationsTwo situations

1. No motion between fragments1. No motion between fragmentsAbsolute stabilityAbsolute stability

2. Motion between fragments2. Motion between fragmentsRelative stabilityRelative stability

SplintSplint•To keep in placeTo keep in place•Protect an injured partProtect an injured part

Relative Motion Relative Motion DependsDepends

on on splintage couplesplintage coupleforforsplint less stiff than bonesplint less stiff than boneand and bridges a defectbridges a defect

Splint - relative stability:Splint - relative stability:

Motion Motion between between fragmentsfragments

Compatible Compatible with fracture with fracture healinghealing

Relative StabilityRelative StabilityMethods of couplingMethods of coupling

plaster cast - allows angulationplaster cast - allows angulation friction fit nail - bending is goodfriction fit nail - bending is good friction fit nail - torsion is poorfriction fit nail - torsion is poor friction fit nail - axial stability - friction fit nail - axial stability -

fracture patternfracture pattern

Relative StabilityRelative StabilityTypes of splintsTypes of splints

Intramedullary: reamed/unreamed Intramedullary: reamed/unreamed nailsnails

extramedullary: plate-bridgeextramedullary: plate-bridge transcutaneous: external fixatorstranscutaneous: external fixators special: buttressspecial: buttress all bridge defect not able to carry all bridge defect not able to carry

loadload

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

Types of splintage:Types of splintage:

IM rodsIM rods Reamed or unreamedReamed or unreamed Locked or unlockedLocked or unlocked

Buttress platesButtress plates External fixationExternal fixation

Relative StabilityRelative StabilityTypes of splintTypes of splint

gliding: unlocked nailgliding: unlocked nail nongliding: plate, static locked nailnongliding: plate, static locked nail

Nongliding (locked) Nongliding (locked) SplintsSplints

Plates or locked nailsPlates or locked nails plate need anatomical reduction + I.F. plate need anatomical reduction + I.F.

compressioncompression any displacement leads to resorptionany displacement leads to resorption plate construct can`t adapt fragments plate construct can`t adapt fragments

& fails& fails locked nail dynamizes (gliding splint) locked nail dynamizes (gliding splint)

fragments coadaptfragments coadapt gliding splint stabilizes fracture and gliding splint stabilizes fracture and

healsheals

Non-glidingNon-gliding

- Plate coupled - Plate coupled by by screws to screws to bone bone

- Locked rod - Locked rod

GlidingGliding

- unlocked rod- unlocked rod

Non-glidingNon-gliding

- Plate coupled - Plate coupled by by screws to screws to bone bone

- Locked rod- Locked rod

GlidingGliding

- unlocked rod- unlocked rod

Gliding Splint

Relative StabilityRelative Stability

fixation that allows fragment motionfixation that allows fragment motion motion is within level to allow motion is within level to allow

healinghealing callus is good - spontaneous healingcallus is good - spontaneous healing axial alignment is NOT anatomical axial alignment is NOT anatomical

reductionreduction many techniques to achieve it: nail, many techniques to achieve it: nail,

plate, ex fixplate, ex fix

Splint stability Splint stability determined by:determined by:

Size of implantSize of implant Position of implant Position of implant

with bonewith bone Position of its couplePosition of its couple Fracture patternFracture pattern

Splint stability determined by:Splint stability determined by:

Size of Size of implantimplant

Position of Position of implant with implant with bonebone

Position of its Position of its couplecouple

Fracture Fracture patternpattern

Judgment:Judgment:

The process of forming an opinionThe process of forming an opinionthrough knowledge and experiencethrough knowledge and experience

Summary of Summary of “Balance”“Balance” Respect soft tissue blood Respect soft tissue blood

supplysupply Reduction of fractureReduction of fracture Apply proper technique Apply proper technique

properlyproperly

ConclusionsConclusions

OverviewOverview biology > mechanics > implantsbiology > mechanics > implants principle based and must be principle based and must be

understoodunderstood each fracture requires thoughtful each fracture requires thoughtful

assessmentassessment injury - biologyinjury - biology plan: reduction, stabilityplan: reduction, stability implementation: incision, implantimplementation: incision, implant

Given an adequate blood supply to Given an adequate blood supply to bone:bone:stability of fixation determines type stability of fixation determines type of healingof healingabsolute = no motion, anatomical absolute = no motion, anatomical reduction, 1° unionreduction, 1° unionrelative = motion, axial alignment, relative = motion, axial alignment, 2° union2° union

Conclusion:Conclusion:

BiologyBiology MechanicsMechanics

traumatology fractures and dislocations l.yu.ivashchuk lecture:

Documents