TRAUMATOLOGY FRACTURES AND DISLOCATIONS Lecture: TRAUMATOLOGY FRACTURES AND DISLOCATIONS L.Yu.Ivashchuk

Trauma Trauma 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 traumatism Traumas 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 patients the 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.

Fractures A 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 fractures open and closed; traumatic and pathological;

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

Classification of fractures By 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 fractures The 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 Mechanics The Balance

Biology and Mechanics: The Balance “Balance” of osteosynthetic construct

Balance IS Important

Balance: A counterbalancing force or influence Stability produced by even distribution of active forces Equality between interacting elements

Biology: Deals with living organisms and vital processes

Mechanics: Deals with energy and forces - effect on bodies

Mechanical responsibility:

“Mechanic” - Surgeon: “Understands” Relative and absolute stability Rigidity Implant/bone relationship spectrum How spectrum of stability affects healing

Biological responsibility:

Biologist = patient: Life style Age - osteoporosis Health - diabetic Medicines - steroids Vascularity - atherosclerosis Neurological state - sensation , spastic

Bone Healing Restoration of structural integrity responsibilities surgeon, patient patient provides the biological environment surgeon controls the mechanical environment balance of mechanical versus biology

Where have we come from? History of internal fixation 1862 - first report by Gurlt using wire, screws, nails 1870 - Berenger-Feraud Traite de l'ìmmobilisation dans les fractures predicted a new era

The Beginning of the Concept 1950 Muller understood Lambotte`s principles visited Danis in Brussels as senior registrar performed 75 ORIFs + immediate motion successful- starting a new era

The Concept an integrated system: principles, techniques, implants supported by research supported by documentation supported by education

The Integrated AO Concept Based on biological and mechanical principles atraumatic handling of the soft tissues blood supply to bone and muscle important function, union, asepsis anatomical reduction ‘rigid’ fixation

A Problem Blood 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 tissues lead to nonunions, infection and failures

Bone Soft tissue effects of fracture displacement disrupts tissue implosion effect --> cavitation about fracture site energy dependent

Bone Blood Supply Effect of fracture disrupts nutrient artery --> cell death at fracture site soft tissue stripping disrupts periosteal supply variable degree depending on amount and level implant contact also leads to necrosis

Fracture: Haversian system disrupted Soft tissue torn - BS Implant added - BS

Balance assisted by research:

Balance assisted by research:

Evolution Continued Research bone understood healing in different mechanical situations strain theory of Perren blood supply effect of stability implant and technique modifications

10mm 5mm Multi-fragmentary fracture best for splintage re small amounts of strain across a large gap. 20mm

Bone fractures: Mechanical overload Pattern depends on Energy applied Duration of force

Bone: Strong in compression “Stiff spring” absorbs force

Bone: FORCE Weak in tension “Collagen breaks” Break FORCE

Fragmentation: Amount of stored energy or Speed at which applied

Direction: Torsional spiral Avulsion transverse Bending short oblique or transverse Compression impact

Evolution Continued Clinical locked nailing relative stability lead to indirect healing needs only axial alignment in diaphyseal fractures biological plating reduction techniques to spare soft tissue - Ganz, Mast bridge plate, LCDC plate

The Evolved Concept Principle: blood supply to soft tissue and bone is N.B. stable fixation absolute for articular fractures absolute for simple fractures reduced anatomically relative for diaphyseal fractures axially reduced relative for metaphyseal or periarticular

Bone Healing Basic requirements living pluripotential cells vascular environment to sustain cells cells available locally - haematoma, periosteum stimulus to healing appropriate mechanical setting

Bone Healing Types: indirect healing callus fracture site resorption filled with callus bridges gaps matures to cortical bone

Bone Healing Types: indirect (secondary) healing - fixation achieved by splinting a fracture casts, nails, ex fix and bridge plates implant stiffness and fracture site stability enough stability to move and heal

Bone Healing Types: direct (primary) healing - soudure autogene of Danis Internal remodelling of bone requires bone to bone contact, blood supply and no motion small gap heals with bone: lamellar --> cortical achieved by anatomical reduction, absolute stability

Requisites for Reduction Diaphysis anatomical reduction not necessary anatomical axial alignment necessary rarely need open reduction except forearm

No motion: absolute stability Some motion: relative stability

Stability: Lack of Motion between fragments Spectrum none to absolute

Stability influences bone healing Time dependent Contact dependent

withstand deformation Rigidity: Ability of implant to withstand deformation

Rigidity and Stability Rigidity: implant physical property, ability withstand deformation Stability: motion between fracture fragments

Can have “rigid construct” and instability

Stability Between fracture segments achieved by the impaction of fracture fragments intimate contact restores structural continuity restores load bearing capacity of bone bone - implant construct share stresses is a spectrum - varies in amount

Absolute Stability Compressed fracture surfaces do not displace under load Requires: 1. anatomical reduction 2. interfragmental compression compression stabilizes by preload and friction healing is direct bone union (primary healing)

Tension band and Compression plate require intact opposite cortex

Absolute Stability Effect of compression produces preloading contact maintained if compression > physiological load produces friction shear resisted if friction > physiological shear applied many methods: differ in implant, mechanism, efficiency

Absolute Stability Methods lag screw - superior for large and/or dense bones compression plate - fragments must be in contact prebending of a plate - best for small and/or porous bones tension band fixation - dynamic functional load needed

Importance of Fracture Fixation Stability Assuming an adequate blood supply to fragments Stability of the fixation construct will determine: 1. type of bone healing 2. success of healing 3. ability for early active muscle and joint rehabilitation

Stability Two situations 1. No motion between fragments Absolute stability 2. Motion between fragments Relative stability

Splint To keep in place Protect an injured part

Relative Motion Depends splintage couple for splint less stiff than bone and bridges a defect

Splint - relative stability: Motion between fragments Compatible with fracture healing

Relative Stability Methods of coupling plaster cast - allows angulation friction fit nail - bending is good friction fit nail - torsion is poor friction fit nail - axial stability - fracture pattern

Relative Stability Types of splints Intramedullary: reamed/unreamed nails extramedullary: plate-bridge transcutaneous: external fixators special: buttress all 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 rods Buttress plates External fixation Reamed or unreamed Locked or unlocked Buttress plates External fixation

Relative Stability Types of splint gliding: unlocked nail nongliding: plate, static locked nail

Nongliding (locked) Splints Plates or locked nails plate need anatomical reduction + I.F. compression any displacement leads to resorption plate construct can`t adapt fragments & fails locked nail dynamizes (gliding splint) fragments coadapt gliding splint stabilizes fracture and heals

Non-gliding Gliding - Plate coupled by screws to bone - Locked rod - unlocked rod

Non-gliding Gliding - Plate coupled by screws to bone - Locked rod - unlocked rod

Gliding Splint

Relative Stability fixation that allows fragment motion motion is within level to allow healing callus is good - spontaneous healing axial alignment is NOT anatomical reduction many techniques to achieve it: nail, plate, ex fix

Splint stability determined by: Size of implant Position of implant with bone Position of its couple Fracture pattern

Splint stability determined by: Size of implant Position of implant with bone Position of its couple Fracture pattern

Judgment: The process of forming an opinion through knowledge and experience

Summary of “Balance” Respect soft tissue blood supply Reduction of fracture Apply proper technique properly

Conclusions Overview biology > mechanics > implants principle based and must be understood each fracture requires thoughtful assessment injury - biology plan: reduction, stability implementation: 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: Biology Mechanics

Conclusion: Biology Mechanics

Conclusion: Biology Mechanics

Conclusion: Biology Mechanics

Conclusion: Biology Mechanics