Orthopaedic Trauma Foundation Module 10789-3 0-02 642351

Orthopaedic Trauma Foundation Module
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orthopaedic trauma foundation MODULE
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
Glossary 41 Test Your Knowledge Answer Key 45
section i : history of orthopaedic trauma
Section I - History of Orthopaedic Trauma

Man has always been subject to trauma, and bone setting with external splinting was the earliest form of treatment. Early external splints were likely composed of wood or sticks, bound together with cloth or leather. Some of the earliest known fossil examples were found in Egypt dating back to 300 BC. The Greek physician Hippocrates (460 BC370 BC) described the use of wooden splints and even a fracture reduction table. Hippocrates is often referred to as the father of medicine." He is credited as the first physician to reject superstitions and beliefs that supernatural or divine forces caused illness. He has been credited with advancing the systematic study of medicine, summarizing known medical knowledge, and prescribing an ethical code of conduct for physicians known as the Hippocratic Oath, which is still used today during medical school graduations.
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.
orthopaedic trauma foundation M ODULE
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.
Early Surgical Techniques

Advancements in surgical treatment have followed improved understanding and advances in sterility and anesthesia. The earliest form of surgical treatment is believed to be the use of a wire ligature, with the first recorded use dating back to the 1770s. It was not until 1867 that Joseph Lister developed the tenets of antisepsis. Subsequent understanding and development of sterilization techniques reduced the risk of bacterial infection with surgical treatment. Further advances came with the development of antibiotics. In 1895, Wilhelm Conrad Roentgen (18451923) from the University of Wurtzberg, Germany, reported on the first use of x-ray to image bones. The use of screws for bone fixation likely started around 1850, with the use of plate fixation first reported in 1886. Hannsman, a surgeon from Hamburg Germany, reported on the treatment of 20 patients with a malleable plate and screws. The shaft of the screw, along with one end of the plate, were left protruding outside the skin for later removal at 4 to 6 weeks. Creative surgeons and advances in metallurgy lead to further refinements in fracture reduction and plate fixation. Albin Lambotte (18661955) was a Belgian surgeon who coined the term osteosynthesis. He was a skilled craftsman who made both violins and surgical tools in his workshop. He developed various plate and external fixation devices. In 1907, he published a textbook on the operative treatment of fractures. illiam ONeil Sherman (18901979) was a surgeon for W the Carnegie Steel Company in Pittsburgh Pennsylvania who first popularized the use of plate fixation in the United States (Figure 1-3). In conjunction with Figure 1-3. Examples of plates, and instruments developed by Sherman. Figure 1-2. Humeral fracture brace and x-ray showing callus formation. The brace allows for functional use of the elbow and shoulder.
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.
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.
Figure 1-9. External fixation device developed by Parkhill, circa 1898.
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.
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 1-13. Cloverleaf cross-section nail developed by Knstcher.
Figure 1-15. Slightly bent Rush Medullary Pin after insertion.
Figure 1-14. Skeletal traction for treatment of a femoral shaft fracture, now rarely used.
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.
Section II - Evolution of Current Orthopaedic Trauma Treatment

Soft Tissue Management
During the past two decades, the importance of the associated soft tissue in fracture healing has received increased emphasis. The Swiss initially reported on their successful operative treatment of tibial pilon fractures (also known as distal tibia fractures). Because the majority of their patients sustained these from relatively low energy skiing injuries, early operative fixation was not problematic. When others began similar early operative treatment of higher energy tibial pilon fractures (for example, from motor vehicle collisions), there was a high rate of wound complications (up to 50 %) and some disastrous problems resulting in below knee amputation. It was found that the extensive soft tissue damage associated with these high energy fractures necessitated a different treatment method than that used for low energy fractures that have less soft tissue damage. A better understanding of the importance of a healthy soft tissue envelope has lead to the staged fixation of fractures of the tibial pilon and tibial plateau. Patients are initially stabilized in a spanning external fixator (e.g., fix pin placed above and below the fracture/joint [Figure 2-1]) to allow recovery of the soft tissue injury. Excess interstitial fluid associated with the response to the trauma may result in the formation of fluid filled blisters in the region of the fracture. The soft tissues are allowed to recover. The patient is returned to the operating room for definitive internal fixation when there is adequate soft tissue healing and resolution of swelling. This usually occurs within two weeks, but occasionally may take longer. Improvements in surgical techniques to salvage problematic soft tissue wounds has also occurred. Both plastic surgeons and orthopaedic hand specialists (microvascular surgeons) perform free flaps, which may be required for a severe open wound or a wound that has failed to heal. A free flap transfers healthy muscle from one body site to the wound site. The blood vessels (arteries and veins) of the transferred tissue are
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.
SECTION II - EVOLUTION OF CURRENT ORTHOPAEDIC TRAUMA TREATMENT
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.
adhesive plastic dressing vacuum pad and tubing

foam pad
Figure 2-2. Example drawing of the V.A.C. Therapy System.
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.
Damage Control Orthopaedics (DCO)

Some multiply injured patients are at risk for further decompensation if they undergo prolonged operative procedures immediately after their injury. Several detrimental things can occur during a prolonged operative procedure. The patient may continue to lose blood, their blood pressure may drop, and they may become cold (which can lead to increased bleeding due to its effect on the coagulation system). Early on after injury, the patient's immune system is primed for an exaggerated response to additional insults. In the 1970s and 1980s, many surgeons practiced the concept of early total care. It was felt that the patient was healthiest at the time of hospital presentation, and that their condition would deteriorate with time. Therefore,
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Evolution of Plate Fixation

Plate fixation, as initially described by the AO group, relied primarily on rigid fixation. Ideally a lag screw was placed between each fracture fragment, increasing the mechanical strength of the fixation construct. In this era, plate fixation emphasized mechanics over biology. Implants used during this era tended to be heavier (thicker and larger diameter) than those used currently (Figure 2-3). The heavier implants were necessary because the healing process was slowed by the damage caused to achieve perfect reduction of each fragment. There were several detrimental effects of these reduction and fixation methods. Devascularization of the individual fracture fragments both slowed fracture healing and created a potential for infection. Bacteria can infiltrate a dead bone fragment and provide a region that the body's defense mechanisms and antibiotics can not reach. Such infected, devitalized bone fragments are termed sequestra. The large plates had a large surface area that maintained their mechanical stability by compression against the bone cortex. This lead to damage to the underlying periosteum, necrosis (death) of a layer of bone beneath the plate, and osteoporosis (diminished bone density) in the area beneath the plate. During the 1980s, improvements in plate design were made by the AO group to counteract some of the known disadvantages of early plate fixation. The first important change was to develop a plate with a smaller foot-print" by creating undercuts on the undersurface of the plate so there was less damage to the underlying periosteum (Figure 2-4). The most recent advancement in plate fixation was the development of locked plates in which the threaded screw heads lock into the threaded plate holes. Because this implant does not require compression of the plate to the bone cortex, it minimizes any damage to the underlying periosteum and bone. Figure 2-4. Evolution of plate design in the 1990s included undercutting the surface of the plate to minimize damage to the underlying periosteum and cortical bone.
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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Minimally Invasive Surgical Techniques

The importance of minimizing damage to the local biology that occurs with extensive open approaches and periosteal stripping became apparent in the 1990s. This concept lead to the development of minimally invasive methods of fracture reduction and implant insertion (Figure 2-5). Surgeons in Hannover Germany were at the forefront of this emerging trend. Christian Krettak first reported on the insertion of a two-piece dynamic condylar implant for distal femur fractures in 1997. The AO group subsequently developed an implant that allowed minimally invasive insertion for treatment of distal femur and proximal tibia fractures. This implant, which is still used today, is named LISS, which is an acronymn for less invasive stabilization system. In addition to allowing minimally invasive insertion, this implant provided the first opportunity to use locking screws (screws with threads that lock into the plate [Figure 2-6]). Now many companies offer implants that provide for minimally invasive insertion through a small incision and for percutaneous insertion of screws. These techniques avoid open exposure of the fracture and minimize periosteal disruption, potentially leading to faster healing with fewer complications. Minimally invasive techniques use intraoperative fluoroscopy to visualize the fracture reduction, implant position, and screw location. Various techniques are used to achieve reduction of the fracture, including the placement of different sized bumps, external fixators, and joy-sticks (threaded pins inserted in the bone to allow direct manipulation of the bone [Figure 2-7]).
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 2-6. Locking screws used in the LISS implant.
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.
Evolution in Intramedullary Nail Fixation

Early intramedullary nails (IM nails) were composed of relatively flexible stainless steel. In cross section, they were open section cloverleaf designs (Figure 2-9). Development of interlocking screw holes allowed surgeons to extend the use of intramedullary nails to fix fractures located closer to the end of the bone. Some surgeons initially had problems inserting interlocking screws, which required accurate aiming to drill directly through the IM nail interlocking hole. Fatigue failure of the original intramedullary nails, along with advances in metallurgy and implant fabrication, led to the development of closed section nails composed of titanium alloys. These nails are significantly stronger than earlier nails and fatigue failure is far less common. While IM nails can still break if the fracture does not heal, the interlocking screws most commonly suffer fatigue failure. Figure 2-8 Upper image simulates intact periosteal vasculature following minimally invasive plate insertion. Bottom image shows markedly diminished periosteal circulation following standard open-plate fixation.
Figure 2-9. Cloverleaf cross sectional design of early intramedullary nails.
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Evolution in External Fixation

Through the 1980s, external fixation was frequently used for the definitive treatment of certain fractures, especially fractures of the tibia that were not amenable to closed (cast) treatment. Because of the slow healing rate, it was necessary for the external fixator to remain in place for a prolonged time. With prolonged treatment, localized superficial infection of the pins is a common complication. This may require treatment with increased local wound care, a course of antibiotics, or occasionally removal and repositioning of the infected pin. Most pin-site infections resolve when the external fixation pin is removed. During the 1990s, a combination of ring and standard pin/bar external fixation was popular, referred to as a hybrid external fixator (Figure 2-10). These were frequently used for tibial plateau and tibial pilon fractures. They offered the benefit of easier and quicker application than a complete ring external fixator. Stability of the hybrid external fixator is not nearly as good as the complete ring fixator, and as other techniques have
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.
Test Your Knowledge - Section II - Evolution of Current Orthopaedic Trauma Treatment

1. The transfer of a portion of muscle from one part of the body to a open wound using a microvascular anastomis is referred to as a______ __________. 2. Repositioning the gastrocnemius muscle to cover the anterior one third of the proximal tibia while maintaining its normal blood supply is one example of a _______ __________ flap. 3. The use of a temporary stabilizing external fixator for bilateral femoral shaft fractures in a multiply injured patient in referred to as _________ _________ orthopaedics. 4. Staged fixation of high energy fractures of the tibial pilon is necessary to avoid ________ complications. 5. Plate designs have changed to decrease the surface area that is in contact with bone. This decrease in contact is beneficial because it decreases damage to the underlying bone _____________.
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Section III - Biomechanics and Fractures

Bone has a mechanical function that supports load and allows muscle action. In addition, it protects vital organs (skull, rib cage). It also has a biologic role in calcium hemostasis and blood production. Cortical bone is thickest at the diaphysis. Cortical bone is dense, with a porosity of 59%. Cancellous bone has higher porosity (3090%) and has about 10% of the strength of cortical bone. One important component of the porosity is small vascular channels that connect blood vessels from the inside to the outside of the bone. Cortical bone is very strong and resists deformity. While bone is strong, it is also very stiff, which means it can only deform a little before it breaks. In comparison, a rubber band can tolerate a great amount of deformation before breaking. Bone is strongest in compression but weak in tension. Therefore, when a fracture starts, it usually begins at the site where the tension is the greatest. Bone remodels based on the stress placed upon it (Wolffs law). Increased stress leads to hypertrophy, while decreased stress leads to resorption. Bone is both strong (tolerates high load without failure) and stiff (deforms only a little under load). While bone is a strong material, it is also brittle (breaks under very small deformation). Bone is subject to different stresses or mechanical forces. When these forces exceed the limit that bone can withstand, a fracture is produced. Different forces will produce different fracture patterns (Figure 3-1). A torsional force will produce a spiral fracture. This type of fracture can occur when the foot or leg gets caught while the body continues to rotate during a fall. A spiral fracture pattern in the tibia due to a torsional force is shown. Note the fracture begins in the distal tibia, then the force travels across the interosseus membrane (between tibia and fibula) and, finally, produces a spiral fracture in the middle of the fibula (Figure 3-2). In contrast, a bending force will produce a transverse or short oblique fracture. In general, higher energy injuries will produce multiple fractures with comminution (multiple fragments) as the bone literally explodes at the time of impact. Figure 3-2. Spiral fracture pattern in the tibia.
Oblique
Transverse
Comminuted
Figure 3-1.
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SECTION III - BIOMECHANICS AND FRACTURES
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 3-3. Vertebral Compression.
iomechanical Properties of Internal B Fixation Implants

Internal fixation devices used to stabilize a fractured bone are also subject to different mechanical forces. The forces involved in a specific situation may influence the type of implant that is selected for fracture fixation. Similarly, the implant chosen, and its method of application, will influence the pattern of fracture healing. Intramedullary nails, being centrally located within the intramedullary canal, offer optimal mechanical properties. They are considered load sharing and often permit full weight bearing. When interlocking screws are placed above and below the fracture, an intramedullary nail offers good resistance to bending, compression, and torsional forces. Compressive forces can result in shortening while torsion can cause a malrotation of the bone (Figure 3-5). Plate fixation, on the other hand, is located more eccentric to the axis of the bone and is usually subjected to greater bending loads. Because of its weaker mechanical properties, plate fixation of the tibia and femur is not usually sufficiently strong to permit full weight-bearing. A fracture may be stabilized in one of two main methods. A simple fracture (single fracture line) can sometimes be anatomically reduced and rigidly fixed with compression applied across the fracture site. This method provides absolute stability of the fracture. The fixation is designed to eliminate all motion at the fracture site. The fracture
Figure 3-4. Greenstick fracture.
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.
Risk Factors for Fractures

Osteoporosis (weakening of bone) that occurs with aging, especially in women after menopause, is the greatest risk factor for fracture healing. As life span has increased, the incidence of fractures has increased dramatically in some instances. Certain genetic factors also play a role, since they influence bone size, bone mass, and bone density. Nutritional factors, namely a lack of calcium and vitamin D during early development (childhood and adolescence), plays an important role in a patient's bone mineral density. Weight-bearing activity also helps to strengthen bones. Certain medications can accelerate bone loss, such a corticosteroids (prednisone), anticonvulsants, thyroid medications, and certain diuretic blood pressure medications.
Test Your Knowledge - Section III - Biomechanics and Fractures

1. The term _________ ___________ refers to a fracture that is rigidly fixed in compression with a lag screw. This type of fixation will lead to _________ bone healing. 2. The term __________ __________ refers to a fracture stabilized in a manner that allows slight residual motion at the fracture site. This type of fixation will lead to __________ bone healing. 3. A torsional force will produce a _______ fracture pattern. 4. A bending force will produce a __________ fracture pattern. 5. In children, the plasticity of their bone can result in an incomplete fracture, called a _________ fracture.
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SECTION IV - OPEN FRACTURE CLASSIFICATION SYSTEM
Section IV - Open Fracture Classification System

Open fractures are commonly classified using the GustiloAnderson classification system. Dr. Ramon Gustilo, an orthopaedic surgeon practicing at the Hennepin County Medical Center in Minneapolis Minnesota, published his landmark paper describing the classification and recommended treatment of open fractures in 1976. (Gustillo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976 Jun;58(4): 453458. The fractures are classified into three categories or types (type I, II, and III [Figure 4-1]). While many factors are considered in the categorization, the energy that produced the injury is considered one of the key factors. With higher energy injuries, there is greater soft tissue injury, more comminution of the bone, more periosteal disruption (stripping), and higher risk of infection and nonunion. Additional factors that are considered are the degree of contamination. Historically, it was recommended not to primarily close the skin in association with type III injuries. However, current practice now includes primary wound closure as long as a thorough debridement is performed. Debridement of an open fracture wound is critical to decrease the risk of infection. Because of the exponential bacterial growth, most surgeons recommend debridement of open fractures within 68 hours of injury. During the debridement procedure, the surgeon methodically explores the wound and cuts away any dead or damaged tissue and removes any foreign debris (dirt, gravel, sticks, pieces of clothing, glass, and other material may be encountered). The ends of the fracture are typically exposed and a curette is used to scrap the exposed bone. A thorough debridement includes inspection and removal of any devitalized bone, muscle, subcutaneous tissue, and skin. In addition to sharp debridement, the wound is copiously irrigated, often with at least 9 liters of fluid. The combination of these two tasks is referred to as irrigation and debridement, or I & D. Bone fragments that do not have any soft tissue/periosteal attachments are removed. This commonly occurs in comminuted fractures in which small and large bone fragments are completely stripped of their periosteum and floating freely in the wound. If these devitalized bone fragments were left in the wound, they would become a potential source of infection. Traditionally, most open wounds were debrided and the skin was left open (covered with a sterile dressing). The Open Fracture Type II.
Open Fracture Type I.
Open Fracture Type III.
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.
Figure 4-2. Open Fracture Type I.
Type I Open Fracture

Type I open fractures usually result from a low energy injury and are produced by the bone poking out through the skin (inside-out mechanism). The size of the soft tissue laceration is usually small, often less than 1 cm (Figure 4-2). Figure 4-3. Open Fracture Type II.
Type II Open Fracture

Type II open fractures involve a higher energy mechanism, with greater skin laceration and soft tissue injury. There is some periosteal stripping (Figure 4-3).
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SECTION IV - OPEN FRACTURE CLASSIFICATION SYSTEM
Type III Open Fracture

Type III open fractures are further subdivided into three groups. In type IIIA open fractures, the skin and soft tissues are able to be closed. In type IIIB open fractures, there is significant skin or muscle loss at the fracture site. In this case, a local rotation flap or vascularized free tissue transfer (free flap) is required. Type IIIC open fractures are defined as those which are associated with a vascular injury that requires repair. These are usually the result of a high energy mechanism such as a high speed motor vehicle accident. They are associated with severe soft tissue injury and significant periosteal stripping (Figure 4-4). Like many classification systems, the degree of interobserver reliability is poor (if you ask two surgeons whether an open fracture is a type II or a type III, there is little agreement).
Figure 4-4. Open Fracture Type III.
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.
LEAP Study Summary

The Lower Extremity Assessment Project (LEAP) was a large multicenter, prospective, observational study of 545 patients with severe open tibia fractures funded by the National Institute of Health (NIH). Its goal was to compare the longterm outcomes of limb reconstruction/repair or amputation in these patients, with the hope that the study data could help surgeons decide which patients were better candidates for each treatment. Patients were not randomized; the choice of treatment was left up to the individual surgeon. Results were first published in 2002 and showed that the two-year outcomes were equal between amputation and reconstruction.* From that publication, we can see just how challenging open tibia fractures can be to treat. Of the 135 patients with a Type IIIB open tibia fracture, 57% of them had to be rehospitalized (at least one time) in the 2-year period after reconstruction, 29% experienced a nonunion, and 25% had either a deep or superficial infection. Most striking was the fact that 13% of those tibia fractures were still not considered healed at the 2-year time point. Clearly, patients with Type IIIB open tibia fractures have a high risk of experiencing a nonunion and/or a complication during treatment. This suggests the need for a biologic agent that can induce new bone formation and improve healing of open tibia fractures.
* Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, McCarthy ML, Travison TG, Castillo RC. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002 Dec 12;347(24):1924-1931.
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Test Your Knowledge - Section IV - Open Fracture Classification System

1. Open fractures are commonly classified using the ___________ _____________ system. 2. Open fractures are classified into ______ types. 3. Type III open fractures are subdivided into _____ subtypes. 4. A type IIIB open fracture requires ___________ _____________ to achieve wound closure. 5. A ________ ________ _______ ________ defines a type IIIC open fracture. 6. Factors that contribute to the open fracture classification system include the degree of ____________, _____________, and ______________.
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SECTION V - EVALUATING FRACTURE SEVERITY
Section V - Evaluating Fracture Severity

The severity of the injury is directly related to the amount of force involved in producing the fracture. Surgeons will often classify an injury in one of two categories; low energy or high energy. A simple twisting fall while walking, resulting in an ankle fracture, would be termed a low energy injury, while someone struck by a car sustaining a comminuted open tibial shaft fracture would be classified as a high energy injury (Figure 5-1). Though surgeons may sometimes use a binary classification for the energy of injury, it really falls along a spectrum from low to high. The history of how the injury occurred, the clinical examination (swelling, contusions, open lacerations), and radiographic findings (amount of comminution) can all provide clues to the amount of energy that produced the fracture. From physics, we know that the kinetic energy is related to both mass and even more so to velocity (kinetic energy = mass x velocity2). The amount of energy involved from some common mechanisms of injury has been estimated as follows: A spiral tibia fracture is an example of a lower energy injury.
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
ENERGY 100 ft/lb 300-500 ft/lbs 2000 ft/lbs 100,000 ft/lbs
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.
Treatment Decision Making

It is important to treat the patient and not just the x-ray (Figure 5-3). There are several factors that may influence the treatment decision. The importance of the surrounding soft tissues has already been discussed. This may require either a staged treatment (external fixation initially, then delayed internal fixation), or may even alter the final treatment selected (e.g., treat the injury definitively in an external fixator). In addition, patients have differing functional demands and associated health problems. The recommended treatment for a non-ambulatory patient with severe dementia may be different from that of a young, active patient.
Operative Versus Nonoperative Treatment

Many fractures can be treated nonoperatively with cast immobilization. Because of the potential risk of swelling, circumferential casts are not commonly placed initially.
Figure 5-3.
Treat the patient, not the x-ray.
HEALTH LIFESTYLE ADDITIONAL INJURIES
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.
Delayed Bone Grafting

Bone grafting of a segmental bone defect, or a severe open fracture, is often done in a delayed manner rather than acutely near the time of injury. Delaying bone grafting until six or more weeks after the injury offers two benefits. First, the successful healing of the initial injury suggests the wound is free of significant infection risk. Second, soft tissues surrounding the injury are healthier and potentially provide a soft tissue bed that is more conducive to bone regeneration. At the time of the initial injury, surgeons may place an antibiotic impregnated cement spacer or antibiotic impregnated beads in the defect. The polymethyl metacrylate cement used is the same used for total joint arthroplasty. Typically, tobramycin and/or vancomycin is added to the cement and are gradually released locally into the body fluids surrounding the cement. This treatment both maintains the space and decreases the infection risk. Some studies have shown that the reactive membrane that forms around such a cement spacer is actually conducive to bone regeneration when the delayed bone graft is performed. Bone grafting is never performed in the presence of active infection, since the infectious process will cause resorption of the bone graft. A known bone infection is treated by debridement. Cultures are obtained to identify the specific
Figure 5-4 .Tibial shaft 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.
Internal Versus External Fixation

While external fixation was previously used more commonly for definitive fixation, it is less frequently used today. There are a number of factors that have lead to the decreased use of external fixation, including complications associated with pin site infections, poor patient acceptance of the device, and a higher rate of reduction loss. Improvements in internal fixation devices, including the development of some minimally invasive insertion methods, has lead to a higher use of internal fixation (Figure 5-5).
Figure 5-5. Internal versus external fixation with intramedullary nail and external fixator.
Principles of Internal Fixation

Some fractures require precise (anatomic) reduction of each piece. For example, a fracture of the joint surface (articular fracture) should be anatomically reduced to minimize the risk of post-traumatic arthritis. Other simple fracture patterns, such as a both-bone forearm fracture (fracture of the radius and ulna shafts), are also commonly treated by anatomic reduction. In the forearm, it is important to restore the anatomic bow of the radius to allow full forearm rotation. While an anatomic reduction can allow you to put each fragment back in perfect position, doing so may cause damage to the vascularity of the fragments, which may impair or even prevent the fracture from healing. It may also lead to increased wound and infection complications. Other fractures require anatomic alignment (correct length, rotation, and angulation between the part above and below the fracture [Figure 5-6]) but may not require precise reduction of each individual fragment. A comminuted fracture of the shaft of a long bone would be an example of this type of fracture.
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.
Absolute Versus Relative Stability

The methods of internal fixation chosen will affect the mechanical stability and this will influence the way in which a fracture heals. Fixation can provide either absolute stability or relative stability. Absolute stability occurs when there is complete absence of motion between fracture fragments with physiologic load. This
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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.
Principles of External Fixation

External fixation is now most commonly used for temporary stabilization of certain fractures with severe soft tissue injuries and in severely injured patients. Once the soft tissue injury recovers or the patient's condition improves, the external fixation is removed and definitive internal fixation is performed. External fixation can be used for definitive fracture fixation. If soft tissues remain significantly damaged, they preclude safe internal fixation. In previously infected wounds, the risk of internal fixation becoming infected may lead a surgeon to choose external fixation. External fixation may also be used when there is a segmental defect that may be treated with a specialized method known as distraction osteogenesis, which can generate new bone formation. There are two main types of external fixation devices: standard and ring fixators. A standard external fixator consists of threaded pins, known as Schanz pins, which are passed through stab wounds in the skin and drilled into the bone. Insertion of pins must be performed in areas where nerves and vessels are not at risk for injury. The safe zone varies depending on the location (Figure 5-9). Figure 5-9. The safe zones for external fixation pin insertion in the tibia varies. Placing pins in these locations minimizes the risk of damage to nerves and vessels.
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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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Screw and Plate Fixation

Screws used in orthopaedic trauma surgery may have one of three purposes: To achieve compression of a fracture (lag screws) To compress a standard plate to bone To anchor a locking plate to bone There are different screw designs based on the screw's purpose and on the location where it is used. Screws are available in different diameters and varying lengths.
Figure 5-17. Cortical screw.
Figure 5-18. Partially threaded cancellous screw.
Cortical Versus Cancellous Screws

Cortical screws are used in dense cortical bone. In general, they have shallow threads (Figure 5-17). Cancellous screws are used in the spongy trabecular bone and usually have deeper threads than cortical screws. Cancellous screws may be fully threaded or partially threaded (Figure 5-18). Cannulated screws are hollow and are placed over a thin guidewire (Figure 5-19). Placing a guidewire first allows the surgeon to check its position and redirect if necessary, without drilling a large hole in the bone. Cannulated screws are often used during minimally invasive surgical procedures in which only a small incision is used. Cannulated screws may be used to:
Fix some tibial plateau fractures
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).
Figure 5-21. Partially threaded cancellous lag screw.
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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.
Standard Versus Locking Plates

Distinctly different mechanical properties are present in standard plates and locking plates. tandard plates require screws to compress the plate to S the bone, producing friction between the plate and bone. The plated fracture remains stable as long as the forces on the fracture are less than the friction produced between the plate and bone. With a standard plate, screws can loosen one by one, reducing the fixation slowly over time until the construct fails (Figure 5-23).
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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.
Specific Plate Designs

Third tubular plates are thin malleable plates that are commonly used for fixation of fibula fractures (Figure 5-25). Reconstruction plates can be easily contoured in multiple planes. They are commonly used for fixation of pelvic fractures, acetabular fractures, and the distal humerus (Figure 5-26). Blade plates are used less commonly now than in the past. Locking plates are now commonly used for situations where a blade plate might have previously been used. The blade is a U shaped channel that provides secure bone fixation. Blade plates might be used for surgery of the proximal femur, i.e., fractures or correction realignment osteotomy (Figure 5-27). Periarticular plates are precontoured to fit specific anatomic locations (Figure 5-28). These plates are commonly used to fix fractures of the: Tibial plateau Tibial pilon Supracondylar humerus Distal femur Compression plate function
Figure 5-24. Locking plate.
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 5-27. Two different blade plate designs.
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).
Figure 5-33. Intramedullary reamer over a guidewire.
Entrance Hole Reamed
Unreamed
Cortical Contact Length
Transverse Screws
Figure 5-34. A longer cortical contact length is achieved following reaming.
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).
Buttress Plate Function

A plate positioned to resist shear forces functions as a buttress. Different sizes and types of plates may be used in buttress mode depending on the mechanical need (Figure 5-30).
Neutralization Plate Function

Many oblique fractures are fixed with a lag screw. A single lag screw may not be sufficient to resist the forces put on the bone. A plate is often added to the lag screw in another plane to provide additional protection or neutralization" (Figure 5-31).
Figure 5-29. Dynamic compression plates are designed to permit compression of transverse fractures.
Force
Bridging Plate Function

A plate that is anchored on each side of a comminuted fracture is said to function in bridging mode (Figure 5-32).
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.
Figue 5-32. A plate placed in bridging mode spanning a comminuted fracture.
Figure 5-31. Lag screws have been placed to fix this tibial fracture. The plate placed along the medial tibia functions in neutralization mode.
34
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.
SPRINT Study Summary

The study to prospectively evaluate reamed intramedullary nails in patients with tibial fractures (SPRINT) was a large multicenter, prospective, randomized study of 1319 patients with tibia fractures (both open and closed).* The study took seven years to complete at 29 clinical sites in Canada, United States, and Netherlands. Patients were randomized to be treated with either a reamed or unreamed intramedullary nail, with the goal to compare these two fixation methods. Patients were followed for one year to determine the rates of reoperation and complication; investigators were not allowed to perform a reoperation within the first 6 months following surgery. In the patients with closed fractures, there were fewer reoperations in those treated with reamed nails when compared to unreamed nails. There was no difference found in the outcomes of the open tibia fracture patients. Results showed that 26.5% of patients with an open tibia fracture underwent a reoperation or autodynamization within the first year after surgery. Among the open tibia fracture patients, 37 (9%) required implant exchange or bone-grafting because of nonunion. This study further established the need for a biologic solution that can improve the healing in open tibia fractures.
* Bhandari M, Guyatt G, Tornetta P 3rd, Schemitsch EH, Swiontkowski M, Sanders D, Walter SD. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am. 2008 Dec;90(12):2567-78.
Figure 5-37. Interlocking screws have been removed from the end farthest from the fracture resulting in dynamization (dynamic compression) at the fracture site.
35
Test Your Knowledge - Section V - Evaluating Fracture Severity

1. A _____ screw functions to compress a fracture. 2. Plates may be applied to fulfill different mechanical funtions. Examples of plate functions include: _______________, ______________, ____________, and __________. 3. Standard, non-locking plates function by producing __________ between the plate and bone. 4. Locking plates are especially useful in ______________ bone where the ability to obtain and maintain adequate friction between the plate and bone is limited.
36
Section VI - Fracture Repair Biology

Fracture repair is a complex process that is similar to the manner in which bone is formed during fetal development. During fetal development, bone formation occurs by one of two methods: intramembranous or endochondraldepending on the location (Figure 6-1). Flat bones of the skull and the mandible form through the process of intramembranous bone formation. In this process, ossification occurs directly in undifferentiated mesenchymal tissue. This is similar to the primary bone healing observed when absolute stability of a fracture is provided by plate fixation. All other bones develop through the process of endochondral bone formation. In this process, a cartilage precursor (anlage) first develops. Primary and secondary ossification centers develop in the cartilage anlage. The articular cartilage and growth plate cartilage then develop and are later replaced by bone. This is similar to the callus formation or secondary bone healing that is seen with the relative stability provided by a cast or intramedullary nail.
Figure 6-1. Endochondral ossification during fetal development. Bone Collar Periosteum Blood vessels Medullary cavity Epiphyseal plate
Articular cartliage
Spongy bone
Hyaline cartilage "model"
Primary ossification center
Secondary ossification center
Compact Bone
37
SECTION VI - FRACTURE REPAIR BIOLOGY
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:
Reactive phase occurs immediately following fracture

as hematoma forms and is followed by migration of inflammatory cells. Ends with the presence of granulation tissue.
Reparative phase a soft callus of cartilage develops

surrounding the fracture. This is then converted to hard callus as bone mineral (calcium) is deposited.
Remodeling phase in the final phase the structure of

the bone is re-established.
Figure 6-2.
The Cascade of Bone Graft Incorporation

Mesynchymal Cells BMPs Chemotaxis
Stage I Reactive Phase
Proliferation
Cell Differentiation BMPs: Chondroblasts Chondrocytes Cartilaginous Matrix
Stage II Reparative Phase
Cell Differentiation BMPs: Osteooblasts Osteocytes Mineralized Bone Remodeling
Stage III Remodeling Phase
38
Delayed Unions and Nonunions

While most fractures heal, some fractures can be slow to heal (delayed unions) and some may fail to heal (nonunions) (Figure 6-3). The anticipated length of time required for a fracture to heal varies, depending on several factors. Young patients, especially children, heal more rapidly than older patients. Bones with healthy surrounding soft tissues (e.g., femur) heal more rapidly than bones that are predominantly subcutaneous (e.g., the tibia). Higher energy injuries and open fractures are slower to heal than lower energy injuries and closed fractures. Other factors believed to play a role in the rate of healing include smoking and diabetes. One accepted definition of nonunion is a fracture that fails to progress towards healing during a period of at least three consecutive months. Figure 6-3. Examples of nonunion fractures.
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.
Mechanical factors that may lead to nonunion:

Inadequate immobilization Fracture site distraction Unstable fixation Implant failure
Biologic factors that may lead to nonunion:

Lack of vascularity at the fracture site Infection
39
SECTION VI - FRACTURE REPAIR BIOLOGY
Hypertrophic nonunions have a distinctive

appearance on radiograph. There is a large callus that has clearly developed around the fracture site, but the initial fracture line is still clearly visible (Figure 6-4). Hypertrophic nonunions are sometimes subclassified as elephant foot or horse hoof nonunions, depending upon the amount of callus that is present. Regardless of the subclassification, the vast majority of hypertrophic nonunions are the result of mechanical instability. Whether it is a loosening plate or an undersized intramedullary nail, the motion at the fracture site is preventing the biologic activity from ultimately uniting the fracture ends. Hypertrophic nonunions occur when there is proper biologic activity but less than desirable mechanical stability. What would result if the two conditions were switched; that is, you had a mechanically stable fracture but less than desirable biologic activity? The result is an oligotrophic nonunion.
Figure 6-4. Hypertrophic nonunion.
Oligotrophic nonunions have a radiographic

appearance that shows little callus formation, but the bone ends appear to be unaffected. The fracture line is still clearly present, but little to no callus formation is observed (Figure 6-5). An arteriogram of the area would show an uncompromised blood supply. The hardware observed in early oligotrophic nonunions does not show signs of loosening, but as the nonunion progresses, the hardware may become progressively looser. Again, oligotrophic nonunions generally occur at sites with adequate internal fixation and good blood supply but inadequate cellular activity. Figure 6.-5. Oligotrophic nonunion.
Atrophic nonunions have a radiographic appearance

with little to no callus formation and resorption of the bone nearest the fracture site. The fracture line is still clearly evident and may appear to be expanding as bone resorbs away from the fracture site (Figure 6-6). An arteriogram of the site will usually show a decreased blood supply to the area. Atrophic nonunions generally occur in areas of good mechanical stability but poor cellular activity and reduced systemic viability. Atrophic nonunions are thought to be incapable of a biologic reaction without surgical intervention (e.g., bone grafting procedure). Atrophic nonunions may also result from fractures that create segmental bony defects that are too large to heal without the addition of a bone graft (e.g., defect lengths greater than 1.5 times the bone width).
Figure 6-6. Atrophic nonunion.
41
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.
Compartment syndrome - a pathologic condition in which

the pressure within a muscle compartment increases, and if left untreated, leads to death of the muscle cells. The most common cause is direct trauma leading to increasing inflammation in the muscle that is surrounded by a non-distendable covering called fascia.
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.
Compound fracture - a lay term for an open fracture in which the

skin is lacerated exposing the bone to the external environment. The term compound fracture is used in the United Kingdom, but in the U.S. surgeons use the term open fracture.
Biologic fixation (or biologically friendly fixation) - a term

surgeons use to describe a surgical approach and technique that minimizes additional damage to the periosteum and blood supply in the region of the fracture to maximize the healing potential of the fracture. This is most commonly done in multifragmentary fractures fixed with a bridging technique, rather than achieving anatomic reduction of each individual fracture fragment.
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.
Corticotomy - a specialized cut (osteotomy) of cortical bone that

minimizes damage to the periosteum and intramedullary vessels. It is used during distraction osteogenesis.
Bridge plate fixation - refers to plate fixation in which the plate is

secured proximal and distal to a zone of fracture comminution. May be achieved with either a standard or locking plate.
Butterfly fragment - a small wedge shaped fragment of bone

frequently seen in fractures composed of 3 pieces (the proximal segment, the distal segment, and the butterfly fragment). In contrast to a segmental fracture, the butterfly fragment encompasses less than the full cross section 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.
Debridement - a surgical procedure to remove nonviable tissue

and foreign material from a wound. In an open fracture, the wound is extended to adequately expose the ends of the bone and to inspect the wound for any foreign material or dead tissue.
Cancellous bone - the trabecular (spongy) bone present centrally

within the proximal and distal ends of bone.
Chondrocytes - living cartilage cells.

Comminution - a fracture that is fragmented; composed of numerous pieces.
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.
42
GLOSSARY
Direct fracture healing - the type of fracture healing that occurs

when a fracture is rigidly fixed with absolute stability. This type of healing is characterized by an absence of callus formation. Bony healing occurs directly without the formation of any intermediate repair tissue. Also called primary fracture healing.
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.
Dislocation - the displacement of a joint such that one surface no

longer articulates (is in contact with) the other surface.
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.
Greenstick fracture - an incomplete fracture that can be seen in

children.
Haversian system - a system of small channels which exists in

cortical bone.
Dynamization - refers to a situation where load is transferred

across a fracture: for example, removal of interlocking screws in an intramedullary nail to stimulate fracture healing.
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.
Inflammatory cells - cells that respond to injury (e.g., platelets, white

blood cells, etc.). They release factors that cause inflammation. Lag screw - a technique used to achieve interfragmentary compression. The near cortex is drilled with a larger gliding hole that does not engage the screw threads. The far cortex is frilled with a smaller hole that engages the screw threads. Tightening the screw compresses the two fragments together.
Fixed angle device - an internal fixation device in which a part is

fixed at right angles to the long axis of the plate. This term is used to refer to blade plates and to locked plates fixed with locked screws. In contrast, screws placed in standard plates can eventually loosen and angle when subjected to excessive load.
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.
43
Locking plate fixation - fixed angle fixation with a locked plate

that is commonly used in osteoporotic bone or in fractures near the ends of bone. The locking screws can not loosen from the plate. This fixation is mechanically stronger than standard plate fixation in which the screws can individually loosen.
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).
Neutralization plate fixation - refers to plate fixation that is used

in conjunction with lag screw fixation to neutralize functional loads. While a lag screw can provide compression across a fracture, other forces that act on the bone may lead to loosening of the lag screw. The neutralization plate helps resist these forces. Also referred to as protection plate fixation.
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.
Rigid fixation - fixation of a fracture that allows little or no

deformation under load.
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.
Osteopenia - a condition that results in a significant decrease in

bone density but not necessarily an increase in the risk or incidence of fracture. This is usually a precursor to osteoporosis. Defined more specifically as a bone mineral density (BMD) score from 1 to 2.5 standard deviations below the T-score (normal values based on patient age).
Segmental fracture - fractures occurring at two separate location

in the shaft of a bone, producing a middle segment of bone that comprises the full cross section of bone.
Sequestrum - a piece of dead bone whose blood supply and soft

tissue connections has been destroyed. In the absence of blood supply, the bone piece cannot participate in the healing process and is at risk for becoming infected, since antibiotics and the natural immune system cannot reach the interior surface of the dead bone.
Osteoporosis - a skeletal disease characterized by a decrease in

bone mass and bone density and an increased risk and/or incidence of fracture. Defined more specifically as a bone mineral density (BMD) score more than 2.5 standard deviations below the T-score (normal values based on patient age).
Shear force - a force that causes a bone segment to slide upon

another segment.
Osteosynthesis - a surgical procedure designed to encourage bone

healing. While this usually refers to internal fixation, it also applies to external fixation techniques.
Osteotomy - a surgical saw cut made in 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.
44
GLOSSARY
Spiral fracture - a fracture that is produced by a torsional force.

Resembles a candy cane or barber pole pattern.
Staged fixation - refers to a two stage treatment protocol in which

a fracture with significant soft tissue swelling is first stabilized with a spanning external fixator. Once the soft tissue injury recovers, usually after one to two weeks, the patient undergoes definitive internal fixation. This is commonly performed for high energy injuries to the tibial plateau and tibial pilon.
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.
45
Test Your Knowledge Answer Key

Section II: Evolution of Current Orthopaedic Trauma Treatment 1. 2. 3. 4. 5. free flap local rotation damage control wound healing periosteum
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
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.
www.sofamordanek.com
Medtronic Spinal and Biologics Business Worldwide Headquarters 2600 Sofamor Danek Drive Memphis, TN 38132 1800 Pyramid Place Memphis, TN 38132 (901) 396-3133 (800) 876-3133 Customer Service: (800) 933-2635 For more information visit www.myspinetools.com
2010 Medtronic Sofamor Danek USA, Inc. All Rights Reserved. 10789-3.0-02

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orthopaedic trauma foundation MODULE

Glossary 41 Test Your Knowledge Answer Key 45

section i : history of orthopaedic trauma

Section I - History of Orthopaedic Trauma

orthopaedic trauma foundation M ODULE

Early Surgical Techniques

section i : history of orthopaedic trauma

orthopaedic trauma foundation M ODULE

Figure 1-9. External fixation device developed by Parkhill, circa 1898.

section i : history of orthopaedic trauma

orthopaedic trauma foundation M ODULE

Figure 1-13. Cloverleaf cross-section nail developed by Knstcher.

Figure 1-15. Slightly bent Rush Medullary Pin after insertion.

section i : history of orthopaedic trauma

orthopaedic trauma foundation M ODULE

Section II - Evolution of Current Orthopaedic Trauma Treatment

SECTION II - EVOLUTION OF CURRENT ORTHOPAEDIC TRAUMA TREATMENT

adhesive plastic dressing vacuum pad and tubing

Figure 2-2. Example drawing of the V.A.C. Therapy System.

Damage Control Orthopaedics (DCO)

orthopaedic trauma foundation M ODULE

Evolution of Plate Fixation

SECTION II - EVOLUTION OF CURRENT ORTHOPAEDIC TRAUMA TREATMENT

Minimally Invasive Surgical Techniques

Figure 2-6. Locking screws used in the LISS implant.

orthopaedic trauma foundation M ODULE

Evolution in Intramedullary Nail Fixation

Figure 2-9. Cloverleaf cross sectional design of early intramedullary nails.

SECTION II - EVOLUTION OF CURRENT ORTHOPAEDIC TRAUMA TREATMENT

Evolution in External Fixation

Test Your Knowledge - Section II - Evolution of Current Orthopaedic Trauma Treatment 

orthopaedic trauma foundation M ODULE

Section III - Biomechanics and Fractures

SECTION III - BIOMECHANICS AND FRACTURES

Figure 3-3. Vertebral Compression.

 iomechanical Properties of Internal B Fixation Implants

Figure 3-4. Greenstick fracture.

orthopaedic trauma foundation M ODULE

Risk Factors for Fractures

Test Your Knowledge - Section III - Biomechanics and Fractures 

SECTION IV - OPEN FRACTURE CLASSIFICATION SYSTEM

Section IV - Open Fracture Classification System

Open Fracture Type I.

Open Fracture Type III.

orthopaedic trauma foundation M ODULE

Figure 4-2. Open Fracture Type I.

Type I Open Fracture

Type II Open Fracture

SECTION IV - OPEN FRACTURE CLASSIFICATION SYSTEM

Type III Open Fracture

Figure 4-4. Open Fracture Type III.

LEAP Study Summary

orthopaedic trauma foundation M ODULE

Test Your Knowledge - Section IV - Open Fracture Classification System 

SECTION V - EVALUATING FRACTURE SEVERITY

Section V - Evaluating Fracture Severity

ENERGY 100 ft/lb 300-500 ft/lbs 2000 ft/lbs 100,000 ft/lbs

orthopaedic trauma foundation M ODULE

SECTION V - EVALUATING FRACTURE SEVERITY

Treatment Decision Making 

Operative Versus Nonoperative Treatment

Treat the patient, not the x-ray.

Test Your Knowledge - Section II - Evolution of Current Orthopaedic Trauma Treatment

iomechanical Properties of Internal B Fixation Implants

Test Your Knowledge - Section III - Biomechanics and Fractures

Test Your Knowledge - Section IV - Open Fracture Classification System

Treatment Decision Making

Test Your Knowledge - Section V - Evaluating Fracture Severity