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

2. 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.

3. 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).

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

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

6. 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.

7. 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.

8. Classification of fractures
open and closed;
traumatic and pathological;

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

10. 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.

11. 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.

12. Clinical symptoms of fracture

13. Fractures of the bones

14. Fractures of the bones

15. Biology Versus Mechanics The Balance

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

17. Balance IS Important

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

19. Biology:
Deals with living organisms and vital processes

20. Mechanics:
Deals with energy and forces -
effect on bodies

21. Mechanical responsibility:

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

23. Biological responsibility:

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

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

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

28. 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

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

30. 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

31. 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

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

33. 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

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

36. Balance assisted by research:

37. Balance assisted by research:

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

39. 10mm
5mm
Multi-fragmentary fracture best for splintage re small amounts of strain across a large gap.
20mm

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

41. Bone:
Strong in compression
“Stiff spring” absorbs force

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

43. Fragmentation:
Amount of stored energy or
Speed at which applied

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

45. 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

46. 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

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

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

49. 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

50. 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

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

53. No motion: absolute stability
Some motion: relative stability

54. Stability:
Lack of Motion between fragments
Spectrum none to absolute

55. Stability influences bone healing
Time dependent
Contact dependent

56. withstand deformation
Rigidity:
Ability of implant to
withstand deformation

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

59. Can have “rigid construct” and instability

60. 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

61. 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)

62. Tension band and Compression plate require intact opposite cortex

63. 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

64. 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

66. 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

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

68. Splint
To keep in place
Protect an injured part

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

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

71. 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

72. 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

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

74. Types of splintage: IM rods Buttress plates External fixation
Reamed or unreamed
Locked or unlocked
Buttress plates
External fixation

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

76. 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

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

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

79. Gliding Splint

80. 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

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

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

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

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

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

89. 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

90. Conclusion:
Biology
Mechanics

91. Conclusion:
Biology
Mechanics

92. Conclusion:
Biology
Mechanics

93. Conclusion:
Biology
Mechanics

94. Conclusion:
Biology
Mechanics