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Table of Contents
Section I: History of Orthopaedic Trauma Section II: Evolution of Current Orthopaedic Trauma Treatment Section III: Biomechanics and Fractures Section IV: Open Fracture Classification System Section V: Evaluating Fracture Severity Section VI: Fracture Repair Biology 1 8 14 17 21 36
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Plaster of Paris
Antonius Mathijsen (18051878) of Holland popularized the use of plaster of Paris in external splinting. He was a military surgeon who described the use of plaster of Paris bandages to allow transport of patients following injury in 1852. Over the coming decades, the use of plaster of Paris became widespread.
Hippocrates 460370 BC
Thomas Splint
Hugh Owen Thomas (18341891) was a British physician who developed an ischial weight bearing splint for the management of tuberculosis of the knee. Subsequently, it was widely used for the management of femur fractures, and is still used today for temporary stabilization and traction of the femur. The use of the Thomas splint (Figure 1-1) during World War I dramatically reduced the mortality of soldiers sustaining femoral fractures due to gun shot wounds. In 1916, the death rate in the British Army following a gun shot wound to the femur was 80%, and was reduced to 20% by 1918 after the institution of systematic use of the Thomas splint. Until development and refinement in intramedullary nailing, many femur fractures were treated with prolonged traction in bed. This often required several months of hospitalization and was plagued by problems of bed sores, pulmonary issues, and less than perfect alignment and length. Figure 1-1. Thomas Splint, now widely used for temporary stabilization of femur fractures.
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Functional Bracing
The early concepts of external splinting are continued today in functional bracing, most commonly used in the humerus (Figure 1-2) and in certain tibial shaft fractures. August Sarmiento, former chairman of Orthopaedics at the University of Southern California, has been a strong proponent of functional bracing.
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the metallurgists he worked with, he developed various plates and screws with improved mechanical properties. He described the superior holding power of fine pitch, parallel threaded, self-tapping screws. George Eggers, from Galveston Texas, experimented with a slotted plate that permitted axial compression of the fracture (Figure 1-4). In 1948, he reported on experimental work in dogs and the plate was subsequently used clinically in the U.S. Robert Danis (18901962) was a surgeon at the University of Brussels who is considered the modern father of osteosynthesis. He developed a plate (Figure 1-5) with a set screw that provided compression across the fracture site. This device, called a coapteur, was available in various lengths. In 1949, Danis published a textbook, Theorie et Pratique de losteosynthese, which would ultimately interest a young swiss surgeon, Maurice Mueller. Danis described three principle objectives of osteosynthesis: 1. The possibility of immediate and active mobilization of the muscles of the region and the neighboring joints. 2. Complete restoration of the bone to its original form. 3. Soudere per primum (primary bone healing) of bone fragments without the formation of callus. Further advances and popularization of plate fixation occurred by the AO group in the late 1950s and 1960s. They developed a dynamic compression plate (Figure 1-6) with sloped plate holes that provided axial fracture compression when a screw was inserted eccentrically in the plate. While the AO dynamic compression plate provided a significant improvement in the fixation methods, some problems with plate fixation continued. Stability of the fixation requires friction between the plate and bone (maintained by the screws). As long as the forces acting on the implant are less than the friction, the fixation remains stable. However, when the forces exceed the friction, there is loosening of the screws and eventual failure. This can easily occur in osteoporotic bone in which the screw purchase (holding power) is decreased. In addition, the compression of the plate to the bone surface leads to damage to the periosteum beneath the plate and subsequent necrosis of the underlying cortical bone.
Figure 1-4. Slotted plate designed by Eggers to allow axial compression across the fracture.
Figure 1-5. Coapteur developed by Robert Danis. The set screw seen on the left end of the plate was used to provide compression at the fracture site.
Figure 1-6. Sloped plate hole of the AO dynamic compression plate. As the eccentrically placed screw is inserted, the screw head shifts the plate producing axial compression at the fracture site.
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Further advances in plate design occurred over subsequent decades culminating in the development of locked plate technology (Figure 1-7). In these implants, the head of the screw is threaded and can be engaged in the threaded plate hole. This type of implant does not require friction between the plate and bone to maintain stability. Locked plates are particularly useful in osteoporotic bone.
External Fixation
The first use of an external fixator was reported in 1840 by Joseph Francois Malgaigne (1806 1865), a surgeon in Paris. He developed a Pointe metallique (Figure 1-8), which was used in conjunction with plaster immobilization to assist fracture reduction. Part of the device was incorporated into the cast, while the point of the reduction clamp was inserted through the skin to apply a reduction force to the bone. In 1893, C.B. Keetley, from London, described the first external fixator that was secured fully in bone. This device was designed to hold oblique femoral shaft fractures out to length. In 1894, Clayton Parkhill (1860 1902), a surgeon from Denver, Colorado, first reported on the use of an external fixator for treatment of a nonunion. In 1898, he reported on the use of his external fixator in 14 patients (Figure 1-9). Figure 1-8. Pointe metallique external fixation reduction device developed by Malgaigne, circa 1840.
Figure 1-7. Locked plate fixation uses threads of the screw heads inserted into threaded plate holes to provide mechanical stabilization of the fracture.
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In 1902, Lambotte reported on the use of his Fixateur de lauteur, which was an external fixator that placed two pins on each side of a fracture and clamped them together with a metal plate (Figure 1-10). He later developed a more sophisticated fixator using pins connected to a bar with adjustable clamps
Intramedullary Fixation
The earliest form of intramedullary fixation included the use of short bone or ivory pegs that were inserted through the fracture site. Various techniques were used to push or pull the peg into the opposite side of the fracture. Ernest Hey-Groves (18721944), from Bristol, England, performed many pioneering experimental studies in fracture healing, including the use of intramedullary fixation. Initially he used ivory pegs but later advocated the use of metallic implants (Figure 1-11A and B). Figure 1-10. External fixation device designed by Lambotte, circa 1902.
Figure 1-11A. Ivory peg inserted into the intramedullary canal. The fracture would be manually distracted to insert the other end of the peg into the opposite intramedullary canal. Figure 1-11B. Ivory pegs used for intramedullary fixation by Hey-Groves, circa 1900.
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During that era (prior to the advent of x-ray), the femoral intramedullary nail was inserted through an incision made to expose the fracture site, advanced proximally out the upper end of the femur, and then advanced back distally across the fracture (Figure 1-12). Gerhard Kntscher (19001972), from Kiel Germany, is credited with advancing the use of intramedullary nailing. He completed experimental work that convinced him that disruption of the endosteum would not impair fracture healing. During the 1930s, while working with engineer Ernest Pohl, he developed a cloverleaf cross-section nail for long bone fracture fixation (Figure 1-13). Kntscher pioneered many aspects of intramedullary nailing techniques that are used today. American prisoners of war in World War II were found to have been treated by his method. When these patients returned to America and were x-rayed, surgeons discovered the innovative treatment, which was not initially accepted as good practice. It was not until several decades later that the benefits of intramedullary nailing were accepted around the world. Prior to the widespread use of intramedullary femoral nailing, many patients with femur fractures were treated nonoperatively with at least 6 weeks of hospitalized bed traction (Figure 1-14). Meanwhile, in the United States, two brothers, H. Lowery and Leslie V. Rush, developed their own intramedullary fixation method with smaller diameter semi-flexible devices called Rush Pins (Figure 1-15). These pins were slightly bent to provide some rotational control, but usually required some form of supplemental cast or splint.
Figure 1-12. Technique for open insertion of an intramedullary nail. Currently, most nails are inserted in a closed manner using fluoroscopic guidance.
Figure 1-14. Skeletal traction for treatment of a femoral shaft fracture, now rarely used.
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The AO Foundation
Robert Danis, a surgeon in Belgium who is considered to be the father of osteosynthesis, published a textbook in 1949 on the theory and practice of osteosynthesis. Dissatisfied with the clinical outcomes of his fracture patients, Maurice Muller, a young swiss surgeon visited Robert Danis in 1950. In 1958, Muller and a small group of colleagues met in Chur, Switzerland and formed the arbeitsgemeinschaft fur osteosynthesefragen (AO), which roughly translates to the working group for the study of fracture fixation. This group established four primary goals: (1) Develop a comprehensive technical armamentarium; (2) clinical and experimental research; (3) documentation of research; and (4) continuing education. Their management of fractures was based on four objectives: Restoration of anatomy Stable fracture fixation Preservation of blood supply Early mobilization of the limb and patient The influence of the AO slowly spread around the world as surgeons were trained in their philosophy. The organization developed cutting edge instructional methods using hands-on methods, initially with cadaver bone and subsequently with plastic bone models. Currently, some 20,000 surgeons participate in AO courses presented throughout the world. In the United States, AO was a registered trademark for American Optical, so in the U.S. the organization initially used the name Association for the Study of Internal Fixation (ASIF). More recently, the organization has purchased the trademark rights to AO, so it is no longer necessary to refer to the organization as AO-ASIF in the United States. The organization developed many different implants, and initially licensed the rights to produce and sell the implants to three different companies. One of these companies was Synthes USA, which has since acquired the other two manufacturing companies. Royalties for product sales were used to fund the various educational and research activities of the AO foundation.
Helpful Hint
Fracture Mangement Principles Today:
1. Fracture reduction and fixation to restore anatomical relationships. 2. Stability by fixation or splitage, as the personality of the fracture and the injury requires. 3. Preservation of the blood supply to soft tissues and bone by careful handling and gentle reduction techniques. 4. Early and safe mobilzation of the part and the patient. The 4 objectives or principles of fracture management as expressed today have remained largely unchanged from the original. Source: 2001. Redi TP, Buckley RE, Moran CG. AO Principles of Fracture Management, 2nd ed. New York, NY: Thieme Medical Publishers; 2007.
In 2006, the AO organization sold all intellectual property rights to Synthes, Inc. The proceeds of this one billion Swiss francs transaction are used by the AO Foundation to provide continued support of the AO Mission. Synthes, Inc., still maintains a strong relationship with the AO organization. Synthes implants are used exclusively in AO courses, at least for the next 10 years through a contract negotiated at the time of the 2006 restructuring. However, changes in the Continuing Medical Education regulations have lead to involvement of additional corporate participation in AO courses, such as BrainLab and surgical table manufacturers. In addition to orthopaedic trauma, the AO group maintains specialized interest groups in spine, maxillofacial, and veterinary medicine.
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Figure 2-1. A spanning external fixator placed across the knee joint, that allows traction to be applied while injured and swollen soft tissues recover.
reattached at the local site to provide blood supply to the tissue. Common donor muscles for such free tissue transfers include the latisimus dorsi, rectus abdominis, and gracilis. In addition to complex microvascular free flaps, it may also be possible to perform a local rotation flap. In this procedure, a muscle's blood supply remains intact, but its attachment is released at one end and the muscle is rotated to a new position to cover a defect. An example of a local rotation flap would be a gastroc flap in which the distal end of part of the gastrocnemius (calf ) muscle is released and the muscle is rotated to cover a defect over the proximal one-third of the anterior tibia.
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Negative pressure wound therapy, commonly referred to as the V.A.C. Therapy System (vacuum assisted closure), has become a popular method for the management of many soft tissue injuries (Figure 2-2). Prior to the use of the V.A.C. Therapy System, many of these wounds were treated with a wet to dry dressing that was changed every 8 hours. The V.A.C. Therapy System consists of a layer of open cell foam that is applied to the wound and connected to either intermittent or continuous vacuum. A large sheet of adhesive plastic bandage provides an occlusive seal. The use of this device has several benefits. It removes fluid (edema) from the extravascular space, thereby improving local microvascular blood supply that can be impeded because of elevated tissue pressure. It stimulates the rapid formation of reparative granulation tissue, which is necessary to support subsequent split thickness skin grafting. It can serve to draw the wound edges closer together, making the size of the wound smaller. Finally, as a closed system, it decreases the potential risk of contamination and reduces the exposure of healthcare workers to potentially infectious body fluids. The V.A.C. Therapy System (marketed by KCI, Inc. and first introduced in 1995) is frequently used following debridement of traumatic wounds, including those associated with open fractures. It is also used for the management of fasciotomy wounds (incisions used to treat compartment syndrome). The device is typically changed every two days, and depending on the situation, may be changed in the operating room or in the patient's hospital room.
surgeons attempted to fix all fractures immediately on presentation. During this time, several landmark studies that compared early intramedullary nailing of femur fractures with treatment in traction showed that early surgical treatment improved patient survival, decreased the ICU stay, and decreased the time the patients were on a ventilator. In the early 1990s, surgeons at a large trauma center in Hannover Germany began reporting on their finding that some multiply injured patients (those with a severe pulmonary injury) did worse with early intramedullary nail fixation. Some thought the problem was related to intramedullary reaming, which results in embolization of fat and marrow to the lungs. Because of this concern in multiply injured patients, it was common for surgeons to use a smaller diameter femoral nail, which was placed without reaming. This was not found to be as effective as hoped, and centers began to rethink their operative management of the multiply injured patient. The concept of damage control surgery refers to temporarily stabilizing fractures soon after injury, minimizing the operative time, and preventing heat and blood loss in multiply injured patients. This usually consists of placing a quick external fixation device to stabilize fractures of the pelvis, femur, and/or tibia. The patient's condition is then optimized and definitive surgical treatment is delayed at least 5 days, and perhaps even longer, until the patient's condition improves.
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Figure 2-3. Early plate fixation techniques usually relied upon anatomic reduction of each fracture fragment with a lag screw. The improved mechanical strength came at the cost of damage to the local biology.
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Figure 2-5. Minimally invasive insertion of an implant through a small incision. An outrigger is attached to the plate to guide screw insertion.
Figure 2-7. Rolled bump (tan color) placed beneath the knee to provide indirect reduction assistance.
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Minimally invasive techniques may cause less local damage to the periosteum and soft tissues at the fracture site (Figure 2-8). Smaller incisions may also result in faster rehabilitation. The downside to a minimally invasive technique is that there is a higher learning curve. Some fractures are difficult to reduce, may be incompletely reduced, or the implant may not be appropriately positioned.
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developed, the use of hybrid external fixation has dramatically dropped. While external fixation is still used today, its use for definitive fracture treatment is far less common in the U.S. as other surgical techniques have been developed. The most common use of external fixation in the U.S. today is for temporary fracture stabilization. The two major reasons that temporary stabilization with an external fixator is used are:
Severe soft tissue injuries that require
time to recover (decreased swelling and inflammation), such as occurs around the tibial plateau and tibial pilon. In this case, an external fixator would be placed to span the knee or ankle, providing traction and reduction of the fracture until the soft tissues recover adequately to allow safe, open operative treatment. Severely and multiply injured patients whose condition does not safely permit immediate internal fixation. In this case, temporary external fixation is referred to as damage control orthopaedics, and would commonly consist of external fixation of the femoral shaft or pelvis.
Figure 2-10. An example of a hybrid external fixator that combines a ring with thin tensioned wires and a standard external fixator with pins and bars.
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Oblique
Transverse
Comminuted
Figure 3-1.
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bending force on the vertebral column may result in A a vertebral compression fracture in which the anterior part of the vertebral bone is crushed, while the posterior portion remains intact (Figure 3-3). The mechanical properties of bone are significantly different in children. In children, the bone is more elastic and can undergo plastic deformation without sustaining a complete break. This type of fracture is termed a greenstick fracture (Figure 3-4). This term is used because it is similar to what happens when you try to break a green or living tree branch and the break does not go all the way through the stick. In addition, because childrens' bone heals so rapidly and remodels with growth, treatment is often nonoperative cast fixation. Additional description of fracture patterns include the terms butterfly fragment, which refers to a separate wedge of bone which occurs adjacent to the primary fracture line.
Figure 3-5.
Bending
Compression
Torsion
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heals by primary bone healing, with osteonal remodeling. This is commonly performed for simple both-bone forearm fractures. Callus will not be visible on x-ray, but the fracture lines will disappear over the healing period. The downside to such fixation is that additional dissection and periosteal stripping is required, and this may impair fracture healing. Currently, many fractures are stabilized by a method that provides relative stability. There is still some motion at the fracture site, and the fracture heals with callus formation through a process termed "secondary bone healing." Intramedullary nails allow some residual motion at the fracture site (they are a smaller diameter than the intramedullary canal) and provide relative stability. Similarly, most minimally invasive plate fixation techniques provide relative stability.
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Figure 4-1.
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patient was returned to the operating room in 24 to 48 hours for a second look and repeat I & D. Today, many surgeons will primarily close some open fracture wounds, assuming that they feel they have done a thorough debridement. Other wounds require repeat or serial debridement. Extensively contaminated wounds (such as those with significant dirt or fecal contamination) may be returned to the operating room for repeat I & D in 24 hours, while less contaminated wounds may be returned to the operating room in 4872 hours for repeat I & D. Some tissue that was initially thought to be viable may have died over the ensuing period and will be removed during the subsequent debridement(s). Definitive soft tissue coverage or wound closure will only be performed when the surgeon is convinced the wound is clean and the tissues are no longer at risk for further deterioration. There are various devices that provide pulsatile irrigation. This can be a useful mechanical adjunct to break away adherent foreign debris. Disadvantages of pulsatile irrigation are that, at too high a pressure, it can cause tissue damage and can potentially push debris further into a wound. Some surgeons will add either antibiotics or soap solution to all or part of their irrigation fluid. Basic science studies have shown that soap solution works best for disrupting bacteria that may be attached to bone or soft tissues. However, some of these substances may also cause some detrimental inflammatory response or may even be toxic to the living tissue cells. Therefore, some surgeons will use only saline, or conclude their irrigation with pure saline.
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Helpful Hint
Type IIIA Open Fracture Adequate skin and soft tissue to allow primary closure over the fracture site.
Type IIIB Open Fracture Requires a rotation flap or free flap to cover the fracture site.
Type IIIC Open Fracture Associated with a vascular injury that requires repair. The higher type open fractures have a higher nonunion rate and a higher infection rate.
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A medium energy tibia fracture. There is a butterfly fragment and an open wound at the site of the fracture.
INJURY Fall from curb Spiral fracture from skiing High velocity gun shot Bumper strike 20mph
The energy of injury is important because it is an indicator of the associated soft tissue injury and risk for subsequent complications. It is usually safe to perform an open operation on a low energy injury immediately, while delayed fixation may be required for a high energy injury. The amount of energy involved in producing a fracture will have an impact on numerous factors, including infection risk, patients' functional outcome, risk of compartment syndrome, difficulty with soft tissue coverage, and the incidence of nonunion formation. Surgeons may also talk about the personality of a fracture. The description of fracture personality was coined by Nicoll in 1964. By personality is meant the extent to which each fracture contains in its make-up certain factors prejudicial to
This severely comminuted tibial shaft fracture is a result of an extremely high energy injury. Treatment will need to be modified and there is a higher risk for complications.
Figure 5-1.
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unionin other words, its inherited criminal tendencies. Factors that surgeons include in describing fracture personality include the energy absorbed, the soft tissue injury, and the radiographic fracture pattern.
Airway assess and secure an adequate airway. This may require insertion of a breathing tube (intubation). Breathing assess that the patient is breathing adequately, and if not, provide artifical breathing or place on a ventilator. Circulation assess patient pulses in the extremities. They should be the same on both sides. Cold extremities suggest the patient may be constricting blood flow to their limbs in order to maintain perfusion of their vital organs. This is commonly seen when a patient is in shock. Patients receive intravenous fluids, and occasionally emergent blood transfusions if blood loss is severe. Disability the patient's neurologic status is assessed. Are they awake? Can they respond appropriately to questions? Can they move their extremities? Expose the patients clothing is removed in order to fully examine them, and they are eventually rolled on to their side to inspect their backside for any hidden injuries.
Associated Injuries
Since many fractures are the result of high energy trauma, these patients often have associated injuries (both orthopaedic and non-orthopaedic). The initial evaluation of a patient that is involved in a high energy injury should follow a standard protocol that is designed to avoid missing life-threatening injuries. A series of guidelines, referred to as ATLS (Advanced Trauma Life Support), indicates how a trauma patient should be initially evaluated. This evaluation often includes an emergency medicine specialist and a general surgeon. Patients may be unconscious or have an altered level of consciousness due to head trauma. In addition, severe pain from one injury, referred to as a distracting injury, may prevent a patient from being able to notice additional sites of injury. The initial evaluation and resuscitation follows an easily remembered alphabetical guideline (Figure 5-2). X-rays of the chest, pelvis, and cervical spine are obtained. The chest x-ray can identify rib fractures (a sign of associated pulmonary injury), a pneumothorax (air in the pleural space around the lung), or even injury to the heart or great vessels (a widened heart silhouette may indicate that there is a tear in the aorta as it leaves the heart). The cervical spine x-ray can indicate fractures or dislocation of the cervical spine. In the presence of such an injury, manipulation of the neck, as is commonly done during insertion of a breathing tube, may result in damage to the spinal cord. Finally, severe pelvic fractures can result in life threatening bleeding. Assessment of the x-ray can provide a guide to the risk of such an injury.
Airway
Breathing
Circulation
Disability
Expose
Figure 5-2.
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From an orthopaedic standpoint, in addition to reviewing the x-rays, the patient is carefully examined. All extremities are palpated to feel for deformity, crepitance (crunching sound or sensation), and tenderness. If the patient is awake, motor function and sensation is examined.
Usually a splint is placed first, which allows for soft tissue swelling, then at around one to two weeks the splint is removed and a cast applied. A cast provides an external force to resist deforming muscle forces. Distal radius (wrist fractures) that can be maintained in an acceptable position can often be treated with a cast. However, locked plate fixation is being increasingly used to allow the patient to begin earlier function. One type of plate commonly used for these fractures is called the volar plate. Most humeral shaft fractures are treated nonoperatively using a brace that provides circumferential pressure. Most fractures in children are also treated nonoperatively. Children tend to heal rapidly, and as they grow, they can correct angular deformities that may occur following a fracture. Many fractures are not ideally treated nonoperatively. Displaced fractures involving the joint surface (articular fractures) should be treated operatively to reduce the joint surface in order to minimize the risk of arthritis. Sometimes the deforming muscle forces are too severe to be adequately controlled by cast immobilization and require operative treatment. Similarly, comminuted fractures may not have the bony stability necessary to permit nonoperative cast treatment.
Figure 5-3.
PATIENT AGE
TREATMENT PLAN
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Sometimes a fracture can be treated successfully by either nonoperative or operative methods. In this situation, surgeons will discuss the pros and cons of all treatment options with the patient in order to provide the information necessary for an informed decision. Tibial shaft fractures sometimes fall into this category (Figure 5-4 ). If the fracture is a relatively simple fracture that can be adequately reduced and held in position with a cast, nonopertive treatment can be considered. However, such treatment may require 4 weeks in a long leg cast, which makes it difficult for patients to get around. Following that, patients usually require a short leg cast for several months since the fracture may take up to 6 months to fully heal. Given the long period of cast immobilization, some patients may prefer operative treatment with an intramedullary nail that will allow them to immediately begin weight-bearing. Other patient factors, such as pregnancy, may necessitate nonoperative treatment of the fracture.
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bacteria, and susceptibility testing is performed to identify which antibiotic(s) are optimal for treatment of the infection. This frequently requires treatment with intravenous antibiotics, commonly for 6 weeks duration. Laboratory blood tests can also be monitored to assess the response to treatment. The two tests that are common are the erythrocyte sedimentation rate (ESR or sed rate) and C-reactive protein (CRP). The patient's white blood cell count (WBC) is also evaluated.
Figure 5-5. Internal versus external fixation with intramedullary nail and external fixator.
Proximal 1/3
Middle 1/3
Distal 1/3
Figure 5-6. For diaphyseal fractures, anatomic reduction of each fragment is not necessary. What is important is to restore the relationship between the proximal and distal segment (length, rotation, alignment). What happens to individual fragments in the middle area is not critical.
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can be achieved by anatomic reduction and lag screw fixation or through the use of locked or compression plates (Figure 5-7). In contrast, relative stability allows some motion between the fracture fragments. This type of stability can be achieved by several methods, including external fixation, IM nailing, and casting (Figure 5-8). The fracture pattern and location may guide the type of fixation desired. In general, articular fractures require absolute stability (anatomic reduction and rigid lag screw fixation that prevent any motion). Some simple diaphyseal fractures, such as the forearm or humerus, may also be amenable to treatment that achieves absolute stability. Mutlifragmentary comminuted fractures usually are treated with a method that provides relative stability (e.g., a comminuted fracture of the tibial shaft that is treated with an IM nail). The type of fracture healing that occurs differs, depending on the type of stability. Fractures fixed with absolute stability heal by primary (or direct) fracture healing without callus. In contrast, fractures fixed with relative stability heal by secondary (or indirect) fracture healing in which a large callus is formed.
Figure 5-7. A forearm fracture that is treated with absolute stability heals without the formation of external callus. The fracture ends are compressed together with a compression plate eliminating any motion at the fracture site.
Figure 5-8. An IM nail provides relative stability and the fracture heals with callus formation.
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The pins are connected to each other using a combination of clamps and bars or rods. Several factors affect the stability of the external fixation. Larger diameter pins are stiffer. The stiffness of the pin is related to the radius of the pin. A 5 mm diameter pin is 144% stiffer than a 4mm pin. However, not all bones are large enough to use a 5mm diameter pin. For example, when external fixation pins are placed in the hand metacarpal for a wrist fracture, 2.5mm3.0mm diameter pins are usually used. External fixation stability can be increased by placing the bars closer to the skin. However, adequate space is needed to allow for soft tissue swelling and to allow for local wound care (Figure 5-10). In general, the distance between pins should be maximized to increase construct stability. Placing pins as close to the fracture and as far away as possible will be more stable than pins placed close together. However, placing a pin close to the fracture may increase the potential for a pin-site infection to track down to the fracture site (Figure 5-11). The addition of a second bar or rod will also increase the stiffness of an external fixator. This is sometimes referred to as a stacked frame" (Figure 5-12). While not as effective, the addition of a third external fixation pin on each side of the fracture will provide a slight increase in the stiffness of an external fixator (Figure 5-13). One of the most effective methods to increase stiffness of an external fixator is to place a second set of external fixation pins and bars in a different plane. When these two frames are connected they form a triangular shape. This is commonly referred to as a delta frame(Figure 5-14). Figure 5-12. The addition of a second bar or rod increases the stiffness of an external fixator. Figure 5-10. Placing the bar closer to the skin will increase the stiffness of an external fixator.
Figure 5-11. Maximizing the distance between pins will increase the stiffness of an external fixator.
Figure 5-14. The delta frame configuration of an external fixator refers to the triangular cross-sectional appearance (diagram above) when external fixation is applied in two planes, roughly at 90 degrees to each other.
Figure 5-13. The addition of a third pin will slightly increase the stiffness of an external fixator.
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The other main type of external fixation is known as a ring fixator. Instead of threaded pins, smooth wires are drilled through the bone and passed out the other side of the skin. The pins are connected to a circular ring and tensioned until they are stiff like the spokes of a bicycle wheel. This technique was popularized by Russian surgeon, Gabril Ilizarov (Figure 5-15). An infinite variety of configurations are possible as the rings are connected to each other with threaded rods. The device is extremely versatile. Hinges can be placed between rings to correct angular deformity. New bone can even be produced through a process known as distraction osteogenesis (Figure 5-16). If the bone is cut circumferentially and then the two fragments gradually pulled apart (1 mm of distraction per day), new bone will form between the two ends of the cut bone. This regeneration of bone can be used in cases where there is bone loss or infection that requires excision of a segment of infected bone. The use of thin wire ring fixators requires specialized training and careful patient monitoring. During distraction, osteogenesis patients may need to be monitored with x-rays on a weekly basis to gauge the correction and rate of bone formation. The larger the defect, the longer the time the fixator will be required. It is not uncommon for patients to remain in the external fixator for a year or longer. After the initial lengthening, the regenerated bone remains very weak and these patients may experience multiple pin track infections during the prolonged treatment period. The external fixator must remain in place for many months while the regenerated bone strengthens and remodels. Figure 5-15. A complex ring Ilizarov fixator used for correction of a deformed tibia fracture. Note the presence of hinges and distraction bars that will be used to gradually correct the deformity.
Figure 5-16. An open tibial shaft fracture with a large segmental bone defect treated by distraction osteogenesis with a ring fixator. An osteotomy is made in the proximal tibia and the middle segment gradually transported distally. Bone regenerates as the middle segment is pulled away from the proximal segment (arrow in right image shows region of regenerated bone. This is a slow process and after bone formation, the frame must remain in place for months while the regenerated bone remodels.
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Figure 5-19. Cannulated screws are hollow and are placed over a thin guidewire.
Fuse a joint (ankle, subtalar joint fusion) Fix a fracture of the posterior pelvic ring (sacroiliac screws SI screw) Both cortical and cancellous screws can function as a lag screw. Lag screws are used to compress a fracture. Two different methods can be used to achieve interfragmentary compression of a fracture. In cortical bone, a gliding hole is drilled in the near cortex (the hole size is as large as the outer diameter of the screw threads), and a smaller diameter hole is drilled in the far cortex. The screw threads only engage the far cortex and compression is achieved as the screw is tightened (Figure 5-20). In cancellous bone, partially threaded screws may be used. The threads only engage the bone on one side of the fracture (Figure 5-21).
Figure 5-20. Cortical lag screw (larger hole in upper cortex allows for compression).
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Locking Screws
Locking screws are used to anchor locking plates to bone. These specialized screws have two sets of threads. One set of threads engage the bone while the other set of threads engage the threaded hole of the plate, locking the screw to the plate (Figure 5-22).
Figure 5-22. Locking threads that engage the threaded plate hole.
Plate Fixation
Plates may be made of either stainless steel or titanium. Titanium is a softer, more flexible metal. The stiffness of the titanium is similar to the stiffness of bone, while stainless steel tends to be stiffer than bone. Titanium screws can cold-weld to the plate, making their later removal impossible. Removal of a cold-welded screw requires the use of a metal cutting bur to drill away the screw head. Plates vary in size depending on their intended area of use. Different sets of plates use different diameter screws. Mini-fragment plates are commonly used for fixation of small bones, such as during hand surgery. Small fragment plates are commonly used on the forearm, while large fragment plates are commonly used for larger bones, such as the femur or humerus. Various plate designs are available for use in different fractures and different locations. The function of a plate depends on how it is applied to bone. This may differ from the plates catalog name. For example, a dynamic compression plate (catalog name) can be applied to function in compression, neutralization, buttress, or bridging mode. Figure 5-23. Standard plate.
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Locking plates function through a different mechanism. Rather than relying on friction between the plate and bone, the locking screws engage the threaded plate holes (Figure 5-24). ocking plates are especially useful in osteoporotic bone L where the ability to obtain and maintain adequate friction between the plate and bone is limited. They are also useful in fractures where one fragment is very short, allowing only one or two screws to be placed in the short fragment.
Figure 5-25. A third tubular plate has been used to fix the fibula.
Figure 5-28. Periarticular plate used for fixation of tibial plateau fractures.
Figure 5-26. The indentations of a reconstruction plate permit it to be easily contoured to fit irregular bone surfaces, such as this distal humerus fracture.
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Intramedullary nailing is commonly performed for diaphyseal (shaft) fractures of the femur and tibia. Newer nail designs have allowed intramedullary nails to also be used in more distal fractures. IM nailing can also be performed for humeral shaft fractures, but some surgeons prefer plate fixation of the humerus. Insertion of a humeral nail usually requires an incision through the rotator cuff tendon of the shoulder joint. Shoulder pain and complications related to the rotator cuff are common following humeral IM nailing. Intramedullary nails can be inserted in a reamed or unreamed manner. Through the years, there has been concern about the potential detrimental effects of reaming, since it causes additional damage to the inner surface of the bone. However, most surgeons now feel that it is safe to ream even in the setting of an open tibia fracture. Reamers, which are available in halfmillimeter increments, are used to gradually enlarge the intramedullary canal (Figure 5-33). Enlarging the intramedullary canal allows placement of a larger diameter nail with a larger cortical contact length (Figure 5-34), which improves stability at the fracture. While generally beneficial, reaming may be disadvantageous in certain circumstances. Reaming can lead to extravasation of fat and other particles, which travels to the lungs and can lead to pulmonary complications. Interlocking screws are usually placed through holes near the end of an intramedullary nail. This is especially important in comminuted fractures that would shorten if interlocking screws were not placed. In addition to length, rotation and angulation can also be maintained by placement of interlocking screws (Figure 5-35). As the material properties of the nails have improved, the interlocking holes are now located closer to the ends of the nail, which allows treatment of more proximal and more distal fractures. In general, placing interlocking screws proximally and distally is performed for almost all fractures. An exception might be a transverse fracture that is not at risk for shortening. However, because of the potential for there to be a nondisplaced extension of the fracture that cannot be well visualized, most surgeons recommend routinely interlocking all fractures. One or more of the interlocking holes may be oblong or oval in shape. This allows placement of the interlocking screw in an eccentric manner, which provides for dynamic compression across the fracture (Figure 5-36).
Unreamed
Transverse Screws
Figure 5-35. Interlocking screws placed above and below a comminuted fracture prevents shortening of the fracture.
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Compression along a transverse fracture can be achieved using a dynamic compression plate. The screw hole is sloped, so that a screw placed eccentrically shifts the plate as the screw head is seating, producing compression at the fracture site (Figure 5-29).
Figure 5-29. Dynamic compression plates are designed to permit compression of transverse fractures.
Force
Intramedullary Nailing
Intramedullary nailing allows minimally invasive surgical stabilization of long bone shaft fractures. The central (intramedullary) location offers optimal mechanical properties. While weight-bearing may need to be limited following plate fixation, patients are often allowed full weight-bearing following intramedullary nailing.
Force
Figure 5-30. A plate placed along the medial or lateral tibia can function as a buttress. Buttress plates resist shear forces.
Figure 5-31. Lag screws have been placed to fix this tibial fracture. The plate placed along the medial tibia functions in neutralization mode.
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Removal of interlocking screws can be performed to dynamize a fracture. To maintain angular stability, the interlocking screws farthest from the fracture site are removed. This permits dynamic compression of the fracture site with weight-bearing and may stimulate bone healing. Dynamization, if performed, is typically done about 6 to 10 weeks after the initial fracture stabilization. It may be particularly useful if there is distraction (or a gap) at the fracture site (Figure 5-37). Tibial nails have a proximal bend, referred to as the Herzog bend. The location and degree of the bend varies slightly between manufacturers. Femoral nails are bowed when viewed from the side. This bow is designed to match the femur, which normally has a slight bow. Depending on the nail and the individual, there may be a mismatch of the bow, occasionally leading to protrusion of the distal end of the nail through the anterior femoral cortex.
Figure 5-36. The oblong hole in the proximal end of this tibial nail provides for dynamic interlocking. If the screw is placed at the top of the hole, compression can occur at the fracture. Only about 1 cm of displacement is allowed before the other end of the hole will block further displacement.
Figure 5-37. Interlocking screws have been removed from the end farthest from the fracture resulting in dynamization (dynamic compression) at the fracture site.
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Figure 6-1. Endochondral ossification during fetal development. Bone Collar Periosteum Blood vessels Medullary cavity Epiphyseal plate
Articular cartliage
Spongy bone
Compact Bone
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During development, growth in bone length occurs through the growth plate. Cells in the growth plate are arranged in a specific order: Undifferentiated or resting cartilage cells Zone of proliferation Hypertrophic zone Zone of provisional calcification Fracture healing occurs in phases or stages (Figure 6-2). One simple classification divides fracture healing into three main phases:
Figure 6-2.
Proliferation
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Types of Nonunions
Most nonunions are diagnosed by x-ray and can be classified according to their radiographic appearance. There are three major classifications of nonunions: hypertrophic oligotrophic atrophic Each of these nonunion types has a typical overlaying pathology that causes the fracture to progress to nonunion.
Helpful Hint
Reasons Why Fractures Dont Heal.
The cause of fracture nonunion can be due to a mechanical factor, biologic factor, or a combination of the two.
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Glossary
Absolute stability - an internal fixation construct that eliminates all
motion at the fracture site under normal loads. Usually achieved in a simple fracture fixed with a lag screw, or a transverse fracture fixed in compression using a dynamic compression plate.
Anatomic reduction - a process in which each fracture fragment is pieced back into its original position. Such a reduction is important for articular (joint surface) fractures. Articular fracture - a fracture that involves the joint surface. Autogenous bone graft (or autograft) - a bone graft that is
harvested from the patient. It is taken from one location and used at another location.
Compression plate fixation - fixation that results in pressing together fracture fragments. Compression fixation may be achieved by several different techniques.
Cortical bone - the dense outer portion of bone.
Damage control orthopaedics (DCO) - refers to the temporary stabilization of fractures soon after injury, to minimize the operative time and prevent heat and blood loss in multiply injured patients. This usually consists of placing a quick external fixation device to stabilize fractures of the pelvis, femur, and/or tibia. DCP - acronym for dynamic compression plate. Distraction osteogenesis - a technique used to regenerate a
missing segment of bone by gradual distraction of a corticotomy site. Commonly performed with a ring external fixator. Also referred to as an Illizarov technique.
Buttress plate fixation - fixation that is designed to resist compressive loads placed on a reduced fracture fragment. This is commonly performed in a fracture of the tibial plateau. Callus - tissue formed during the healing of fractures in which there
is motion present at the fracture site.
Delayed union - the failure of a fracture to heal within the expected timeframe. The expected timeframe for fracture healing varies depending on the patient age, the bone injured, and the severity of the injury. Diaphysis - the tubular middle portion of a bone, also referred to as
the shaft.
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GLOSSARY
Fracture - a broken bone. Functional bracing - a removable external splint that allows
patient to function during the healing process. Functional bracing is commonly used for the nonoperative treatment of humeral shaft fractures, and can also be used for the treatment of nondisplaced simple tibial shaft fractures and isolated ulnar shaft fractures.
Gliding hole - refers to the larger hole drilled when placing a lag
screw. The larger hole does not engage the screw threads. As the screw is tightened, the fracture is compressed with purchase achieved only in the far cortex.
Distal - refers to a location in a bone farthest away from the center of the body. Dynamic compression plate (DCP) - Synthes trademark name
for the original AO compression plate. Placement of a screw eccentrically in the specially designed holes produces compression in a tranverse fracture.
Hypertrophy - excessive growth; increase in mass without multiplication of parts. Indirect fracture healing - the type of fracture healing that occurs when there is motion present at a fracture. This type of healing is characterized by the presence of callus formation. Seen with nonoperative cast treatment and internal fixation with relative stability. Also called secondary fracture healing. Interfragmentary compression - compression between individual
fracture fragments. This may commonly be achieved with a lag screw, or the use of a plate in compression fixation technique.
Endosteal - refers to the inner surface of a bone. Epiphysis - the end of a long bone containing the articular surface. External fixation - a technique for fracture fixation in which pins are placed percutaneously through the skin into bone. The pins are connected to some type of bar or ring. Fascia - the non-distendable covering of a muscle. Fasciotomy - a surgical procedure used for the treatment of
compartment syndrome. The external covering of a muscle (fascia) is incised longitudinally to permit muscle swelling.
Flexible fixation - fixation of a fracture that allows some limited deformation under load. Motion at the fracture site leads to the fracture healing with callus. Flexible fixation includes external fixation and bridge plating techniques.
Fracture disease - the term used historically to describe the detrimental effects of nonoperative fracture treatment. It consists of disproportionate pain, soft-tissue swelling, osteoporosis, and joint stiffness.
LC-DCP - acronym for Limited Contact Dynamic Compression Plate. Limited Contact Dynamic Compression Plate (LC-DCP)Synthes trademark name for a compression plate with an undercut surface minimizing contact with (and damage to) the underlying periosteum. Locking plate - an internal fixation device in which threads on the
screw head can be engaged in threaded holes in the plate creating a fixed angle device.
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Percutaneous - effected or done through the skin. In orthopaedic trauma, refers to fracture reduction and fixation done through minimally disrupted skin and soft tissue. Periosteum - the tissue surrounding the external surface of bone. This tissue is rich in small blood vessels and plays an important role in fracture healing. Protection plate fixation - see neutralization plate fixation. Proximal - refers to a location in a bone closest to the center of the
body.
Malunion - healing of a fracture in a deformed position. Metaphyseal - the region of bone between the epiphysis (articular
end) and the diaphysis (shaft).
Primary fracture healing - see direct fracture healing. Relative stability - an internal fixation construct that allows a small amount of motion at the fracture site. Resorption - the destruction, disappearance, or dissolution of a
tissue or part by biochemical activity, such as the loss of bone or of tooth dentin.
ORIF - acronymn for Open Reduction and Internal Fixation. Osteoblast - bone cells that are capable of forming new bone. Osteonecrosis - death of bone tissue. Osetoclast - bone cells that are capable of removing bone. These cells live
within small wells known as Howship lacunae. They are found at the tips of remodelling osteons and can remove either dead or living bone, setting the stage for osteoblasts to lay down new bone.
Secondary fracture healing - see indirect fracture healing. Simple fracture - a fracture consisting of a single fracture line without comminution. Subluxation - the displacement of a joint such that there is partial
contact between the two surfaces, but the two surfaces are not in proper position.
Osteomyelitis - an infection in bone. Osteon - small channels containing a blood vessel that comprise
part of the internal Haversian system in cortical bone.
Spanning external fixation - a temporary external fixator that is placed across a joint (external fixation pins placed above and below the joint). Used for staged fixation of an injury with significant associated soft tissue injury in which it would be risky to perform immediate internal fixation.
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GLOSSARY
Tensile force - a force that elongates an object, or pulls two fragments apart. Tension band fixation - a fixation technique that is designed to convert distractive forces into compressive forces at the cortex opposite the fixation. Tension band wire fixation of the olecranon and patella are common examples of tension band fixation. Torsion - a rotational or twisting force.
Trabecula (plural, trabeculae) - the individual struts that make up cancellous bone.
Transverse fracture - a fracture that is oriented perpendicular to the long axis of a bone. Wedge fracture - a fracture that is composed of three pieces, one of which is triangular in shape.
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Section III: Biomechanics and Fractures 1. 2. 3. 4. 5. Absolute stability, primary or osteonal Relative stability, secondary or callus spiral transverse or short oblique greenstick
Secton IV: Open Fracture Classification System 1. 2. 3. 4. 5. 6. Gustillo Anderson three three soft tissue coverage such as a free flap or rotation flap vascular injury requiring repair injury energy, fracture comminution, soft tissue injury
Section V: Evaluating Fracture Severity 1. 2. 3. 4. lag Compression, buttress, neutralization, bridging friction osteoporotic
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This module was developed by David J. Hak, MD/MBA, Associate Professor - University Colorado School of Medicine and Denver Health of Denver, CO, in conjunction with the Medtronic Spinal and Biologics Global Sales Training and Biologics Trauma Marketing departments. All rights reserved.
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