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

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. 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: 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). Traumas of industrial character (manufactural and agricultural). Intentional traumas (battle traumas, ill-intentioned attacks, attempt of suicide). Intentional traumas (battle traumas, ill-intentioned attacks, attempt of suicide).

4. 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 damage agent. 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. 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; 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; 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. 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. 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; open and closed; traumatic and pathological; traumatic and pathological;

9. Classification of fractures By the direct blow - is transversal fracture, fracture with a dislocation of peripheral osseous piece; 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. 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. 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. 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. The fractures are divided on transversal, oblique, longitudinal, spiral, splintered. There are total and incomplete fractures. There are total and incomplete fractures. There are simple, complex and combined fractures. There are simple, complex and combined fractures. There are single and plural fractures. There are single and plural fractures.

12. Clinical symptoms of fracture

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

19. Biology: Deals with living organisms and vital processes Deals with living organisms and vital processes

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

21. Mechanical responsibility:

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

23. Biological responsibility:

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

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

26. Where have we come from? History of internal fixation 1862 - first report by Gurlt using wire, screws, nails 1862 - first report by Gurlt using wire, screws, nails 1870 - Berenger-Feraud Traite de l'ìmmobilisation dans les fractures predicted a new era 1870 - 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 Muller understood Lambotte`s principles visited Danis in Brussels visited Danis in Brussels as senior registrar performed 75 ORIFs + immediate motion as senior registrar performed 75 ORIFs + immediate motion successful- starting a new era successful- starting a new era

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

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

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

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

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

36. Balance assisted by research:

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

39. Multi-fragmentary fracture best for splintage re small amounts of strain across a large gap. 10  m 5m5m5m5m 20  m

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

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

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

43. Fragmentation: Amount of stored energy or Amount of stored energy or Speed at which applied 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 relative stability lead to indirect healing needs only axial alignment in diaphyseal fractures biological plating needs only axial alignment in diaphyseal fractures biological plating reduction techniques to spare soft tissue - Ganz, Mast reduction techniques to spare soft tissue - Ganz, Mast bridge plate, LCDC plate 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 articular fractures absolute for simple fractures reduced anatomically absolute for simple fractures reduced anatomically relative for diaphyseal fractures axially reduced relative for diaphyseal fractures axially reduced relative for metaphyseal or periarticular relative for metaphyseal or periarticular

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

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

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

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

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

56. Rigidity: Ability of implant to withstand deformation

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

59. Can have “rigid construct” and instability

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

61. Absolute Stability Compressed fracture surfaces do not displace under load Requires: 1. anatomical reduction 2. interfragmental compression Requires: 1. anatomical reduction 2. interfragmental compression compression stabilizes by preload and friction compression stabilizes by preload and friction healing is direct bone union (primary healing) 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 preloading contact maintained if compression > physiological load produces friction shear resisted if friction > physiological shear applied produces friction shear resisted if friction > physiological shear applied many methods: differ in implant, mechanism, efficiency many methods: differ in implant, mechanism, efficiency

64. Absolute Stability Methods lag screw - superior for large and/or dense bones lag screw - superior for large and/or dense bones compression plate - fragments must be in contact compression plate - fragments must be in contact prebending of a plate - best for small and/or porous bones prebending of a plate - best for small and/or porous bones tension band fixation - dynamic functional load needed 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: Stability of the fixation construct will determine: 1. type of bone healing 1. type of bone healing 2. success of healing 2. success of healing 3. ability for early active muscle and joint rehabilitation 3. ability for early active muscle and joint rehabilitation

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

68. Splint To keep in place To keep in place Protect an injured part Protect an injured part

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

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

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

72. Relative Stability Types of splints Intramedullary: reamed/unreamed nails Intramedullary: reamed/unreamed nails extramedullary: plate-bridge extramedullary: plate-bridge transcutaneous: external fixators transcutaneous: external fixators special: buttress special: buttress all bridge defect not able to carry load 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 IM rods Reamed or unreamed Reamed or unreamed Locked or unlocked Locked or unlocked Buttress plates Buttress plates External fixation External fixation

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

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

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

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

79. Gliding Splint

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

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

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

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

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

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