goals of fracture management

GOALS OF FRACTURE MANAGEMENT
•
Fracture reduction and fixation to restore anatomical relationships
•
Stability by fixation or splintage as the personality of the fracture and
the injury required
•
Preservation of the blood supply to soft tissues and bone by careful
handling and gentle reduction techniques
•
Early & safe mobilization of the part and the patient
1
IMPLANTS AND MATERIALS IN FRACTURE FIXATION
1.
General requirements
-
In internal fixation the implant material of choice is still metal,
which offers high stiffness and strength, good ductility and is
biologically well tolerated. Today's metal implants are made
either of stainless steel or titanium.
2.
Special requirements
Stiffness :
Stiffness characterizes the relation between load applied and resulting
deformation. Osteosynthesis restores bone stiffness temporarily while
fracture healing restores its permanently. Stiffness of an implant
depends not only the material but even more on the design and the
dimension of the device. Less stiff materials reduce but do not abolish
stress shielding.
Under similar bending conditions the titanium plate deforms nearly twice
as much as the steel plate. This is due to the lower modulous of
elasticity of titanium
2
a)
Strength
The strength defines the limit of stress that a material or structure can
withstand without rupture. In internal fixation the resistance to
repeated load, which may result in failure by fatigue is more important
than strength.
b)
Ductility
Ductility of an implant material characterizes its tolerance to plastic
deformation. Ductility of a material determines the degree to which a
plate can be contoured.
c)
Corrosion resistance
Corrosion determines how much metal is released into the
surrounding tissue.
Repassivation behavior of titanium in 0.9% NaCl solution
d)
Surface structure
Stable interface to the soft tissue of an implant prevents dead space
around because dead space promote growth of bacteria.
3
3
Biocompatibility
Better behaviour of an implant in respect to resisting infection may be
achieved by appropriate selection of the implant material.
(a)
Local toxic reaction
Titanium produces less local toxic reactions
(b)
Allergic reactions
Allergic reactions to stainless steel implants are rare and completely
unknown for titanium devices.
4
EVALUATION AND CLASSIFICATION OF CLOSE AND OPEN INJURIES
1.
Pathophysiology and biomechanics
Open Soft tissue injury
Condition of the wound after injury determined by following factors
-
Type of insult and area of contact
-
Force applied
-
Direction of force (Vertical or tangential)
-
Area of body affected
-
Contamination of wound
-
General physical condition of the patients
Types of wounds
Type of Force
Type of Injury
Sharp, pointed
Dash, Stab wound
Blunt
Contusion injury, cut
Extension, twist
Laceration
Shear
Degloving, wound defect, avulsions,
abrasion
Combination of forces
Wounds from blows, impaling, bites,
and gunshot
Crushing
Traumatic amputation, rupture, crush
injury
Thermal
Burns
2.
Pathophysiological responses in healing
Three Phases
-
Inflammatory or exudative
-
Proliferative
-
Reparative
5
(a)
Inflammatory phase
Excessive amount of necrotic tissue will decrease the antimicrobial activity of
mononuclear phagocytes which have a limited capacity to phagocytose the
necrotic tissue. Since there phagocytic activities are associated with higher
O2 consumption, areas of hypoxia and avascular areas are especially at risk
of infection. The pathophysiological rationale for performing radical surgical
debridement in areas of dead tissue lies, therefore, in helping or supporting
the phagocytic process of macrophages.
(b)
Proliferative and reparative phases
Proliferative phase begins with the migration of fibroblast and endothelial
cells into the areas of wound. At the end of the reparative phase, water
content is reduced and the collagen initially formed is replaced by cross
linked collagen type III. Fibrosis and scarring follow. The role of growth
factors in scar formation is as yet unclear but it seems that TGF-β plays a
decisive role.
3.
Diagnosis and treatment in closed soft-tissue injuries
(a)
Problems of diagnosis and assessment
In closed injury the principal diagnostic and therapeutic difficulties lie
in the inaccessibility of the subcutaneous soft tissues. As yet no clear
diagnostic criteria to allow definite preoperative differentiation
between reversible & irreversible damage tissue.
6
(b)
Damage Mechanisms
Prolonged breakdown of microvascular blood supply of marginal areas
characterized by increased microvascular permeability leading to massive
transendothelial leakage of plasma and consequently to interstitial oedema.
(c)
Compartment Syndrome
A compartment syndrome is defined as an increase within a facial or
osteofacial space of interstitial fluid pressure sufficient to compromise
microcirculation and neuromuscular function.
(i)
Mechanism and local pathology
Triggered by an increase intramuscular pressure either exogenous
(restrictive plaster casts) or endogenesis (ischaemia, hematoma) a within a
closed osteofascial space at a level above a critical microvascular perfusion
pressure in contrast to previous opinions it has been shown that for
compartment syndrome to become manifest it is the relationship (∆P,
muscle perfusion pressure) of the mean systemic BP to the intramuscular
compartment pressure which is critical rather than the constant threshold
value of 30 mmHg.
(ii)
Compartment
syndrome
clinical
manifestations
and
management
Severe pain specially on passive motion is often the first sign for a
compartment syndrome. Multiply injured patients with hypovolemia and
hypoxia are predisposed to compartment syndrome. Other injuries carrying a
high risk - vascular injuries with peripheral ischaemia, - high energy trauma,
severe soft tissue crush, - comminuted fractures of the tibia.
7
(iii)
Diagnosis
Tissue pressure measurements may help to diagnose compartment
syndrome especially in the unconscious patients.
(iv)
Management
Immediate release of compartment pressure by dematofasciotomy is
mandatory.
(d)
Systemic response to soft-tissue injury
Severe damage to soft tissue causes release of proinflammatory
cytokines (TNF α , IL 1 IL 6 IL 10) which can lead to multi organ dysfunction
syndrome.
Pathophysiology of the soft tissue injury
8
(e)
Emergency evaluation of soft tissue injury
(i)
History
The knowledge of the direction and the amount force or energy causing the
injury is essential.
(ii)
Vascular status
For the assessment of an injured limb it is mandatory to determine its
vascular status. The peripheral pulses as well as the temperature and the
capillary refill must be checked and compared with the uninjured side.
(iii)
Neurological status
Neurological assessment can be difficult in the multiply injured patient
because of unconsciousness with lack of response to tests for motor function
and sensation.
(iv)
Soft tissue conditions
Although less evident than in open fractures, concomitant soft tissue injuries
have an enormous importance also in closed fractures.
The definitive
assessment injury requires an experience surgeon as it determines the
treatment protocol as well as the choice of implant for fracture fixation.
4.
Classification of fractures with soft tissue injury
Soft tissue classification decreases complication by preventive
therapeutic errors and can have prognostic value.
(a)
Gustilo and Anderson classification
Gustilo and Anderson developed their classification initially describing three
types (I-III). Clinical practice led Gustilo to extend and subdivided his
classification of the type III injury into subgroups A,B and C.
9
Gustillo type I : Fractures of this type have a clean wound of less than 1 cm
in size with little or no contamination. The wound results from a perforation
from the inside out by one of the fracture ends. Type I fractures are simple
fractures, like spiral or short oblique fractures.
Gustilo type II : Injuries have a skin laceration larger than 1 cm, but the
surrounding tissues have minor or no signs of contusion. There is no dead
musculature present and the fracture instability is moderate to severe.
Gustilo type III : open fractures have extensive soft-tissue damage,
frequently with compromised vascularity with or without severe wound
contamination, and marked fracture instability due to comminution or
segmental defects. Because of the many different factors occurring in this
group.
Gustilo type III A usually from high energy trauma, but there is still
adequate soft-tissue coverage of the fractured bone, despite extensive soft tissue laceration or flaps.
Gustilo type III B in contrast to the type III A has an extensive soft-tissue
loss with periosteal stripping and bone exposure. These injuries are usually
associated with massive contamination.
Gustilo type III C includes any open fracture associated with arterial injury
requiring repair, independent of the fracture type.
10
Management algorithm for the treatment of fractures with a
concomitant soft-tissue injury
(b)
Tschene classification of soft-tissue injuries
Open fracture grade I : Fracture of this group are represented by skin
lacerated by a bone fragment from he inside. There is no or only little
contusion of the skin, and thus fractures are the results indirect trauma.
Open fracture grade II : Grade II open fractures are characterized by any
type of skin laceration with a circumferential skin or soft tissue contusion and
moderate contamination. This injury can be accompanied by any type of
fracture. Any severe soft - tissue damage without injury to a major vessel or
peripheral nerve is categorized in this group.
11
Open fracture grade III : To classify a fracture as grade III the fracture must
have an extensive soft-tissue damage, often with an additional major vessel
injury and/or nerve injury. Every open fracture that is accompanied by
ischemia and severe bone comminution belongs in this group. Furthermore,
farming
accidents,
high-velocity
gunshot
wounds,
and
manifest
compartments syndromes are graded as third degree open because of their
extremely high risk of infection
Open fracture grade IV : Grade IV open fractures represent the subtotal
and
total
amputations.
Subtotal
amputations
are
defined
by
the
"Replantation Committee of the International Society for Reconstructive
Surgery" as separation of all important anatomical structures, especially the
major vessels with total ischemia. The remaining soft tissue bridge may not
exceed 1/4 of the circumference of the limb. Any case of revascularization
can only be classified as grade three open.
(c)
Tscherne classification of closed fractures
Closed fracture grade 0 : No or minor soft-tissue injury. The fracture
0 includes simple fracture type with an in indirect fracture mechanism. A
typical example is the spiral fracture of the tibia in a skiing injury.
Closed fracture grade I : Superficial abrasion on contusion the
fragment pressure from the inside, simple or medium severe fracture types.
A typical injury is the unreduced pronation-dislocation fracture of the ankle
joint ; the soft-tissue damage occurs through fragment pressure at the
medial malleolus.
12
Closed fracture grade II : Deep contaminated abrasions and
localized skin or muscle contusions through an adequate direct trauma. The
imminent compartment syndrome also belongs into this group. Usually the
injury results from direct trauma with medium to severe fracture types. A
typical example is the segmental fracture of the tibia from a direct blow by a
car fender.
Closed fracture grade III : Extensive skin contusions, destruction of
musculature,
subcutaneous
tissue
avulsion.
Manifest
compartment
syndromes and vascular injuries are also graded III. The fracture types are
severe and mostly comminuted. The soft tissue treatment of the fracture
grade is usually much more difficult than a type III open fracture.
13
PATIENT AND THE INJURY
1.
Introduction
In fracture management and assessment decision making must
focused on the patient as a whole. Musculoskeletal injury frequently occur in
association with injuries to the other part of body and must be considered in
the context of polytrauma.
The personality of injury is determined by careful assessment of the patient,
the injury, and the environment
Priorities in surgical management of musculoskeletal injury
1.
Save life
2.
Save limb
3.
Save joints
4.
Restore function
The treating hospital must be looked at and the facilities available
weighed against the care and skills required to carry out optimum treatment.
By bringing these factors together, the treating surgeons is able to define the
"personality of the injury".
If is not only necessary to assess the fracture itself, but also to define
the degree of soft-tissue injury.
14
2.
Injury factors
Because kinetic energy increases with the square with the velocity,
high speed impacts produce significantly greater damage in living tissue than
due to low velocity impacts.
Injury Patterns
The magnitude of the injury also depend on the type of tissue and the
site of force application. There is zone of sift tissue injury which is larger than
a area of fracture site.
The zones of injury in a burn are analogues to the concept of a softtissue zone of injury
15
The assessment and management of polytrauma patients has been
said to comprise the "three Rs" of resuscitation, Reconstruction and
Rehabilitation.
Resuscitation
Based on the ATLS protocol, initial assessment and management of the
polytrauma patient is divided into four phases :
•
primary survey
•
resuscitation phase
•
secondary survey
•
definitive care
Summary of system of assessment / decision making in fracture
surgery
1.
History : Initially to define direction / magnitude of force.
2.
Examination : Estimate extent of zone of injury by assessment of
bruising / abrasions / degloving / wounds. Assess (if possible)
neurovascular status and muscle / tendon function.
3.
Radiology : Define site / type of fracture (Comprehensive
Classification of Fractures). Will give additional information on energy
dissipation (zone of injury).
4.
Patient : Further history to define pre existing conditions, occupation /
hobbies / psychological status and expectations.
5.
Needs : Define optimum treatment for individual patients (i.e. what
resources are required).
16
6.
Environment : Are all necessary resources available for providing
optimum treatment? If not, transfer patient to where resources are
available.
7.
Contract : What the patient expects and what the surgeon can
achieve must be same. The may require negotiation.
17
DIAPHYSEAL FRACTURES : PRINCIPLES
1.
Introduction
Exact anatomical reconstruction of the diaphysis is not necessary for
normal limb function.
Diagram of the mechanical axis of the lower limb showing correct alignment
of femur and tibia
2.
Functional consideration
In the leg the normal mechanical axis of the limb should be restored.
Radius and ulna demand anatomical reduction similar to a joint. Joints must
be in their original axial relationship.
3.
Mechanism
Pattern of injury : Fracture type and displacement are good predictors of
soft-tissue damage. The greater the anticipated soft-tissue damage the more
18
important the choice of implant, reduction technique and gentle overall
management.
4.
Initial evaluation :
Patient status : History is of foremost importance in assessing a diaphyseal
fracture, particularly to discover the mechanism and forces which caused the
fracture. Arterial injury dominates decision making. Most urgent condition
concerns the development of a compartment syndrome, which is seen
mostly in the lower leg, but can also occur in the thigh, forearm, buttock, and
foot. Bone quality influences the choice of fixation technique.
Radiographic evaluation : AP and lateral views that must include the
adjacent joint will serve in most cases, while oblique projections may be
helpful in the metaphysis. CT and MRI scanning have no role in assessment
of acute diaphyseal injuries, although they must be useful in planning
reconstructive surgery in cases of complex malunions.
Associated injuries : Soft-tissue injuries always influence and may
frequently dictate the management options of a diaphyseal fracture. The
presence of more than one fracture in the same limb may make it desirable
to fix all of them, particularly if the combination has produced a "floating"
joint.
19
5.
Indication for operative fracture fixation
Absolute indications
1.
Saving life
2.
Saving limb
Relative indications
Inability to reduce or hold a fracture by conservative means.
6.
General principles of operative treatment
Timing
: For direct open reduction, surgical intervention within 6 hours is
recommended. If as sometimes happen, significant swelling occurs sooner
than this, it is usually safer to establish provisional stabilization and wait 7-10
days for the swelling to subside.
Preoperative planning and approaches
Preoperative planning must include thinking ahead. Timing of surgery
depends on the patient, soft-tissue conditions, logistics, and facilities.
Reduction fixation techniques: Diaphyseal fractures can be reduced
directly or indirectly. Independent of the technique, any reduction maneuver
should be as gentle as possible to the soft parts and periosteum surrounding
the fracture, the aim being to preserve all existing blood supply.
Postoperative care
The most important single factor in deciding about mobilization and
functional loading is the surgeon's assessment of the stability of the fixation.
The fracture anatomy and the fixation technique must be considered
together. Good preoperative planning is the key.
20
ARTICULAR FRACTURES : PRINCIPLES
1.
Introduction
Perfect anatomical restoration and freedom of joint motion can only
be to obtained by internal fixation - (Sir John Charnley).
Review of the experimental and clinical studies led Schatzker in 1987
to enunciate the principles of intra-articular fracture treatment as follows :
•
Immobilizaiton of intra-articular fractures results in joint stiffness.
•
Immobilization of articular fractures treated by open reduction and
internal fixation results in much greater stiffness.
•
depressed articular fragments, which do not reduce as a result of closed
manipulation and traction, are impacted and will not reduce by closed
means.
•
Major articular depression do not fill with fibrocartilage, and instability,
which results from their displacement, is permanent.
•
Anatomical reduction and stable fixation of articular fragments is
necessary to restore joint congruity.
•
Metaphyseal defects must be bone grafted to prevent articular fragment
redisplacement.
•
Metaphyseal and diaphyseal displacement must be reduced to prevent
joint overload.
•
Immediate motion is necessary to prevent joint stiffness and to ensure
articular healing and recovery. This requires stable internal fixation.
21
2.
Mechanism of Injury
Indirect application of force, producing a bending moment through the
joint, which drives a part of the joint into its opposing articular surface.
Usually the ligaments are strong enough to resist this eccentric load,
converting the bending moment to direct axial overload, fracturing the joint
surface. Typically, this results in a partial articular fracture.
Direct crushing or axial application of force commonly causes an
explosion of the bone and a dissipation of force into the soft tissues.
Complete multifragmentary articular fractures, with associated severe softtissue injuries are the results.
The mechanism that commonly
cause an articular fracture : an
eccentric load or indirect force which
causes a pronation and supination,
varus or valgus mechanism to any
joint
The mechanism in axial loading
forces which allows one end to act
as a hammer on the other producing
and impaction of the articular
surface or it more severe an
impaction
with
fracture
fragmentation of the metaphysis or
diaphysis
22
3.
Evaluation of patient and injury
Knowing the mechanism of injury helps in predicting the amount of
soft-tissue
damage.
Articular
fracture
dislocations
have
associated
neurovascular injuries.
4.
Evaluation of the bone injury
In displaced articular fractures "traction views" help planning.
Impacted articular fragments require operative reduction.
5.
Scientific basis of treatment of articular fractures
Pauwels proposed that there exists an equilibrium between articular
cartilage regeneration and degeneration, depending on the biomechanical
environment of the joint.
Axial malalignment alters load transmission across a joint and has
been associated with accelerated joint degeneration. Repair of adult articular
cartilage depends on exact reconstruction, rigid fixation, and early motion.
Mitchell and Shepard demonstrated experimentally that anatomical
reduction and inter-fragmentary compression fixation of an intra-articular
fracture, followed by continuous motion, can lead to true hyaline cartilage
healing.
Salter et al demonstrated that immobilization of an injured joint leads
to stiffness and articular cartilage degeneration, due to lack of nutrition and
the formation of pannus. Further experiments revealed that the use of
23
continuous passive motion (CPM) facilitated the repair of full-thickness
articular cartilage defects in immature rabbits.
6.
Principles of treatment
(a)
Understanding of the injury
Exact history, clinical and x-ray assessment are mandatory for preoperative
planning.
(b)
Preoperative planning
A detailed plan and surgical tactics are mandatory prior to starting any
osteosynthesis of an intra-arcular fracture.
(c)
Timing of operation
If the soft-tissue envelope around the joint is swollen or traumatized
with abrasions or degloving injuries on presentation, early surgery within the
first few days may be contraindicated. Temporary joint bridging by external
fixation helps to resolve swelling.
(d)
Surgical approach
For most appendicular skeletal injuries, skin incision should be
longitudinal, perpendicular to the axis of the joint, and nor directly over any
boney prominence. The possibility of future procedure should be kept in
mind while planning the approach.
24
(e)
Articular reduction
Impacted fragment must be elevated
and fixed in reduce position
Impacted fragments must be elevated and fixed in the reduced
position. Metaphyseal bone defects must be filled with autogenous bone or a
substitute. Joint surface restoration must be checked intraoperatively.
(f)
Metaphyseal / diaphyseal reduction and fixation
The primary goal for reduction for fixation of the extra-articular
component is restoration of axial alignment with adequate stability to start
early motion. Comminution of the metaphysis or diaphysis may tempt a
surgeon to precisely reduce and internally fix all of the non-articular cortical
fragments. Such exact reductions may result in improved stability, however,
at the cost of possible devascularization of fragments. Exact reduction of
cortical fragments in the metaphysis is not necessary as long as axial
alignment of the limb is maintained.
Buttress of the metaphysis can be done by plate or external fixators.
25
(g)
Soft tissue reconstruction
Ligament injury occurs in 20-30% of intraarticular fractures around the
knee. Unless it appears that ligament repair will improve stability to facilitate
postoperative mobilization, it should be delayed. Skin closure without tension
is vital for uneventful healing.
(h)
Post operative care
If stable fixation has been achieved, early postoperative CPM or
active assisted and active range of motion exercises an be started under the
supervision of a therapist.
26
PREOPERATIVE PLANNING
1.
Introduction
The time which a surgeon devotes to a careful preoperative plan often
determines the success or failure of the procedure. The diagnosis alone is
not enough to guide the surgeon to the correct choice of a procedure. The
plan should contain also all the steps necessary for the procedure,
numbered in order.
2.
Planning in the acute situation
Planning of plating needs to be more detailed than for nailing.
Articular fractures present different challenges than diaphyseal fractures.
Planning techniques
Direct overlay
The
direct
overlay
technique is a quick
method for planning in a
straight bone. The various
components
of
the
segmental fracture should
be traced on individual
pieces of paper. A straight
line is drawn and the
fragments
are
then
assembled on this axis.
27
Overlay using the normal side
(a) Tracing of the normal side - rotated to serve as template (b) Tracing of
the fracture (c) The fracture fragments can be cut out or drawn separately (d)
These fragments are then re-assembled on the drawing of the intact side
which has been reversed to match the fractured side.
Drawing a fracture adjacent to a joint using the physiological axes.
b) An outline of
each physiological
axis is made using
a template (a) or a
drawing from the
opposite side.
(a) each major fracture fragment is
drawn on a separate sheet (b) The
bone is reassembled around the
physiological axes (c) by the use of
templates the appropriate implants
are drawn in.
28
PREVENTION OF INFECTION
Operating room environment
The sources of contamination
1.
Endogenous : By definition the patient is the sources of endogenous
bacterial contamination.
2.
Exogenous : Exogenous sources are operative room personal, (5000
to 55000 particles are shed per minute by each person in an
operating room) instrument, punctured gloves and air.
The term clean air can be defined only as a degree of air borne
particular matter present in a given volume of air. The air borne
particular matter is controlled basically by the use of filtration method.
Recommended standards of air delivery into the theater by ventilation
system should contain not more than one colony forming unit of C.
Welchii or S. aureus per 30m3 and not more than 35 bacteria carrying
particles per m3. Total air counts, measured over a 5 minutes period
in the theatre during surgical operations, should not exceed 180 per
m3.
Ventilation system in the operating room has three functions.
1.
To supply heated/cooled, humidified contamination free air to
be operating room.
2.
To introduce this air into the room so that it removes
contaminants liberated there, and
3.
To prevent the entry of air from adjacent contaminated areas.
29
Ventilation system in conventional operating rooms appear to be adequate
for dealing with first and third requirement but not for removing endogenous
contaminants.
Laminar flow system of ventilation in operating room evolved as an
alternate to conventional ventilated and enclosure type of operation areas
with the characteristics of low humidity, low velocity, low temperature, low
turbulence flow of air movement provides a particle free operation site.
The fundamental difference between existing system of ventilation
and laminar flow ventilation in the conventional approach, emphasis is
placed on limiting the amount of contamination liberation into the air by
controlling the number and movements of the people in the room.
Contamination is removed by cleaning and maintenance. The conventional
operating room uses 10-15 air changes per hour. By contrast the laminar
flow system utilized highly filtered and conditioned air brought into the room
towards the critical work and through a filter bank comprising an entire wall
or ceiling of a room and making only a single transit of any given area of the
room.
The laminar air flow system is useful in teaching institution where the
number of observers present are more.
There are three designs laminar / linear flow rooms
1.
Ceiling to floor (vertical flow room)
2.
Wall to wall (Horizontal flow room)
3.
Wall to floor (Whitfield original concept).
30
Laminar flow may be considered as a unidirectional air flow, made up
of their parallel layers i.e. molecules of air are all moving in the same
direction and are considered to be moving in the parallel to each other
at any given point of time or space.
HEPA : high efficiency particulate air filters in laminar flow rooms are
rated 99.9% efficient in removing particles 0.3 micro meter or large in
diameter.
Charnley's post operative infection rate of 8% was reduces to about
1% after he began using laminar flow rooms and hood and gowns
with body exhaust system.
Nelson and Philips reported an infection rate of 5.8% in a
conventional operative room without the use of antibiotics and 1.3%
with the use of antibiotics.
THE INFECTION CONTROL PROCESS
Designing and equipping hospital buildings
The help of local microbiologists in planning and designing a new
hospital building should be sort.
SAFE PROCEDURES
a. Sterilization and disinfection
The first task is to make comprehensive list of all objects and materials that
need to be treated in order to destroy potentially pathogenic microorganisms. Factors to be taken into consideration include
31
(1)
Whether absolute sterility is required or whether a disinfection
process in which only vegetative bacteria and viruses are destroyed,
is sufficient
(2)
Whether the object or material can be sterilized or disinfected by heat.
(3)
If that is not the case what chemical disinfection process is
acceptable.
b. Cleaning : Good "domestic" cleaning of hospital premise is best
monitored visually and bacteriological tests should seldom be needed.
c. Specific ward procedure
Written instruction sheets should be provided by the infection control
committee to the hospital staff for certain procedures.
1.
Aseptic technique for wound dressing
2.
Catheterization and closed bladder drainage
3.
Intra-venous injection or cannulation
4.
Lumbar puncture
5.
Pre-operative skin preparation and
6.
Collection of specimens for laboratory examination. Hand washing
procedures should also be outlined.
Operating theaters
Aspects of operating theatre practice relevant to the prevention of infection
include the following
1.
Design and ventilation
2.
Discipline
3.
Cleaning the theatre and
4.
Hand decontamination and use of gloves
5.
Preoperative skin preparation
32
SURGICAL REDUCTION
1.
Displacement of fragments, deformation of bone
The aim of reduction is correct alignment of adjacent joints.
2.
Fracture reduction
Fracture reduction the act of restoring the correct position of the
fragments including the process of reconstruction of cancellous bone by
disimpaction. Thus, it reverses the process which created the fracture
displacement during the injury.
(a) Distal radius fracture with shortening, posterior displacement and dorsal
angulation. The intact periosteum on the dorsal side may act as an
obstruction to reduction by traction, because the fragments are interlocked
(b) The first step to reduce this fracture consists in disengaging of the bone
ends by extension of the wrist and dorsally angulated traction to relax the
soft-tissue hinge (c) Under dorsal traction the distal fragment is pushed
(arrow) into its correct position, with the dorsal fragment ends reduced into
contact (d) With a flexion force and continuing push the distal fragment will
realign.
33
Aim of reduction
In the articular segment, to avoid post traumatic osteoarthrosis,
anatomical reduction of the joint surface, with elevation of the impacted
areas is mandatory. Fracture reduction requires a variety of techniques and
flexibility of approach.
Reduction techniques
Reduction techniques must be gentle and atraumatic.
Bone healing will be delayed if following factors are impaired
1.
Mechanical condition at the fracture (strain)
2.
The capacity of biological reaction
Two fundamentally different techniques
-
Direct
-
Indirect : the term indirect reduction implies that the fracture lines are
not directly exposed and seen, and that the fracture remains covered
by the surrounding soft tissues. It requires accurate assessment of
the soft tissue lesion, understanding of the fracture pattern, and
meticulous preoperative planning.
In simple shaft fractures direct reduction is acceptable. Repeated use of
bone clamps and other reduction tools or implants may completely devitalize
the fragments in the comminuted area which may have disastrous
consequences for the healing process; including delayed union, infection or
implant failure.
34
To achieve reduction, traction is normally applied in the long axis of
the limb. This works only when the fragments are still connected to some
soft tissues.
Instruments for reduction
Standard and pointed reduction forceps
The pointed reduction forceps tends to be more gentle to the periosteum.
Direct
reduction
with
standard reduction forceps.
One branch of the clamp is
positioned on each main
fragment.
With
some
pressure and simultaneous
rotation of the handles the
bone is lengthened and the
fragments are reduced.
In the tibia, the large pointed reduction forceps may be applied
percutaneously.
Other instruments useful for reduction
Implants used for reduction
Ideally an implant should contribute to the reduction as well as the
stabilization of a fracture. Reduction may be obtained with an implant
through interference with the bone.
Assessment of reduction
Intraoperative controlling of reduction and fixation is mandatory.
35
LAG SCREW
1.
General aspects
A single interfragmentary lag screw does not prevent rotation between
two fragments.
(A) the undersurface of the
screw
head
is
spherical,
allowing a congruent fit to be
maintained while tilting the
screw, e.g., within a plate hole.
The thread is asymmetrical. The
dimensions shown are designed
to offer a good relation between
axial force and torque applied
(B) and these dimensions result
in an inclination of the thread
which is self-locking (C) The
screw corresponds to the ISO
standard 5833
Types of bone screws : There are two basic types of bone screws within the
AO system: the cortex and the cancellous bone screws.
2.
Mode of application of a fully threaded lag screw
To act as a lag screw the cortex screw requires a gliding hole in the
near (cis) and a threaded hole in the far (trans) cortex.
The thread pulls the opposite
bone fragment towards the head
of the screw. The shaft of the
screw does not transmit any
great axial force between the
shaft and the surrounding bone.
The length of the screw shaft
must be chosen so that the
threaded part of the screw lies
fully within the opposite bone
fragment. To prevent the screw
head from sinking into the thin
cortex, a washer is used.
36
Lag screw effect using fully threaded screws
(a) By overdrilling the bone thread in the near
fragment to the size of the outer diameter of
the screw thread, the threaded part of the
bone screw is enabled to glide in relation to
the bone. When this technique is used for an
inclined screw whose head rests on a
surface parallel to the long axis of the bone
(e.g. in DCP or LC-DCP), then one
component of the axis screw force acts along
the long axis of the bone. It tends to shift the
screw head towards the fracture. The screw
thread within the gliding hole may then
engage and compression is lost to a varying
degree. This has led to the development of a
cortex screw with a shaft corresponding to
the outer diameter of the thread - the shaft
screw (b).
Amount and maintenance of compression
Loosening of screws is induced by micromotion.
Special considerations of screw insertion
A screw should not be tightened to the limits of its strength, but to only
about 2/3 of this, to allow additional functional loading.
3.
Clinical applications of lag screw
Positioning of the screw in respect to the fracture plane
Lag screws produce their best efficiency when the screw is
perpendicularly oriented in relation to the fracture surface.
Lag screws in metaphyseal and epiphyseal regions
To
obtain
anatomical
reduction
and
absolute
interfragmentary lag screws are mandatory in articular fractures.
37
stability,
Self tapping screws
Self-tapping screws are not recommended for sue as lag screw. A self
tapping screw may fail upon removal, when the cutting flutes are filled with
ingrown new born.
The lag screw, finds its application mainly in conventional fixation with
interfragmentary compression and may have limited application for, and in
certain situations even be incompatible with biological internal fixation.
New trends in screw application : internal fixator with locked screws
Conventional and locked screws (a) shows the design and force components
of a conventional screw as used for the DCP and LC-DCP. The screw acts
by producing friction between the plate undersurface and the bone surface
due to compression of the interface. (b) Locked screws as used in newer
implants like the PC-Fix and the LISS. These are usually unicortical and
work more like bolts than screws ; the axial force produced by the screw is
minimal. The screw provides fixation based on the fact that the screw head
is locked in a position perpendicular to the "plate" body. Such systems act
more like fixators than plates.
38
PLATES
1.
Introduction
The technique of absolute stability leading to direct bone healing is
being challenged by less invasive so called biological methods of fracture
fixation.
Rigid fixation with plates and screws has a firm place in fracture
treatment. Articular require anatomical reduction and stable fixation as callus
formation is not desired. The potential compromise of cortical blood supply
is a major draw back of conventional plating.
2.
Plate designs
Most plates can be used for rigid as well as biological fracture fixation.
Dynamic compression plate
Dynamic compression principle. The holes of the plate are shaped
like an inclined and traverse cylinder. Like a ball, the screw head slides down
the inclinated cylinder. Since the screw head is fixed to the bone via the
shaft, it can only move vertically relative to the bone. The horizontal
movement of the head, as it impact against the angled side of the hole,
results in movement of the bone fragment relative to the plate, and leads to
compression of the fracture.
39
Dynamic compression principle
After
insertion
of
one
compressing screw it is only
possible to insert one other
screw
with
compressing
function, otherwise the first
screw locks. When the second
screw is tightened, the first has
to be loosened to allow the
plate to slide on the bone, after
which it is retightened.
The shape of the holes of the
DCP allows inclination of the
screws in transverse direction of
±7º and in longitudinal direction
of 25º.
3.
Classical principles of rigid internal fixation with plates
Static compression between two fragments is maintained over several
weeks and does not enhance bone resorption or necrosis. Interfragmentary
40
compression leads to increased stability through friction, but has no direct
influence on bone biology or fracture healing.
In over the achieve absolute stability the compression over the whole
cross section of a fracture must be sufficiently high to neutralize all forces
(bending, distraction, shear and rotation).
-
Compression with the tension device.
-
Compression
with
the
dynamic
compression
principle
(DCP/LC-DCP).
4.
-
Compression by contouring (over bending) the plate.
-
Additional lag screws through plate holes
Rigid fixation by lag screw and neutralization (protection) plate
Lag screw osteosyntehsis with neutralization plate. Interfragmentary
compression is achieved by lag screws. The function of the plate is to
neutralize bending forces. Lag screws applied through the plate are
preferable and do not require additional exposure.
5.
Different functions of plate
The function assigned to a plate does not depend on its design.
Tension band plate
Four criteria for a plate to act as tension band.
1.
The fractured bone must be eccentrically loaded e.g. femur
2.
The plate must be placed on the tension side.
3.
The plate must be able to withstand the tensile forces.
41
4.
The bone must be able to withstand the compressive force which
results from the conversion of distraction forces by the plate. There
must be a bony buttress opposite to the plate to prevent cyclic
bending.
Tension band principle at the femur
A plate under tension is much stronger than under bending forces.
Bridge plate
Bridge plates are indicated in complex diaphyseal fracture patterns.
42
TENSION BAND PRINCIPLE
1.
Biomechanical principles
The tension band converts tensile forces into compression forces.
2.
Concepts of application
In the diaphysis angular deformity (convexity) indicates the tension
side.
Prerequisites essential for application for tension band principle.
1.
Bone or a fracture pattern that is able to withstand compression.
2.
An intact cortical buttress on the opposite side of the tension band
element.
3.
Solid fixation that withstands tensile forces.
(a) Illustration of tension band principle on a fracture of the patella. The
figure of eight wire loop lies anterior to the patella and fracture. Upon kneeflexion the distraction forces (between quadriceps and tibial tuberosity) are
converted to compression. (b) In the olecranon fracture the figure-of-eight
wire loop acts as a tension band upon flexion of the elbow. (c) Application of
the tension band principle at the proximal humerus with an avulsion of the
greater tubercle. The wire loop is anchored to the humerus via a 3.5 mm
cortex screw.
43
INTRAMEDULLARY NAILING
1.
Types of intramedullary nailing
(a)
Classical Kuntscher nail (tight fitting, unlocked)
Nailing of diaphyseal fractures is standard.
(b)
Universal nail (tight fitting, locked)
Interlocking increases stability of fixation and widens the indications
for nailing. Interlocking screws originally introduced by Grosse and Kempf
enhanced the mechanical properties of intramedullary implant and widened
the range of indications.
(c)
Nailing without reaming or locking :
Ender nail, Lottes nail Rush pins) major disadvantage was the
frequent need for additional external stabilizes, such as plaster casts, which
are undesirable.
(d)
Nailing without reaming with locking ("unreamed solid nail")
A solid nail is less susceptible to infection than a tubular nail.
Damage to cortical blood supply after reaming of reversible.
2.
Pathophysiology of intramedullary nailing
Nailing with reaming
Local changes
Reaming the medullary cavity causes damage to the internal cortical
blood supply, which in animal experiments, was shown to be reversible
within 8-12 weeks.
44
This reduced blood supply during early weeks after trauma and
reaming might account for the increased risk of infection, especially in open
tibial fractures.
General Changes
Pulmonary embolization, temperature related changes of the
coagulation system and humoral, neural and inflammatory reactions among
others. Post traumatic pulmonary failure including ARDS. IM nailing appeas
to be a particular insult to the patient's pulmonary system especially in cases
of polytrauma, since the lungs are very sensitive to any additional stress in
the period immediately following trauma. Wenda et al found IM pressures
intraoperatively to increase from 40-70 mmHg to 420-1510 mmHg since
device introduced into the medullary canal (guide wire, reamer, nail) acts as
a piston and forces the contents of the medullary cavity either through the
fracture gap into the adjacent tissue or into the venous system.
Nailing without reaming
Susceptibility of tubular nails to infection as compared to solid name is
more.
3.
General techniques
Preoperative planning and management
Patient positioning
The fracture table or a standard radiolucent operating table, with or
without the use of the femoral distractor, are alternatives for patient
positioning for femoral nailing.
45
Sequence of stabilization in multiple extremity fractures
The recommended order for he treatment of closed fractures is : 1)
femur 2) tibia 3) pelvis or spine 4) upper limb.
Correct implant selection
Preoperative selection of nail length
Intraoperative nail length selection with the use of radiolucent rulers or
by clinical means.
Nail diameter
4.
Insertion techniques
Technique for selection of
starting point by entering the
medullary cavity with the 3.2
mm guide wire and universal
chuck with T-handle. The
position of the guide wire is
assessed in two planes by the
image intensifier. If the position
is not accurate, it must be
corrected, as this may be
decisive for the entire nailing
procedure. The first wire is left
in place as a reference for the
second wire
(a)
Surgical approach and preparation of the starting point
(b)
Preparation of the staring point in antegrade femoral nailing
A correct starting point is crucial in intramedullary nailing.
(c)
Preparation of the staring point in retrograde femoral nailing
Retrograde nailing of the femur, the knee is flexed approximately 30º.
care must be taken that the origin of the posterior cruciate ligament is not
injured. The important landmark in the lateral view is the "Blumensaat's line",
46
a radiodense line representing the cortical bone of the roof of the
intercondylar notch of the femur
(d)
Technique of reaming
Design of reamers and reamer shaft influences intramedullary
pressure and temperature. Never ream with an inflated tourniquet as the
normal circulation is an effective "cooling system".
(e)
Reduction techniques
Considerations for the reduction maneuvers in antegrade femoral
nailing.
Femoral fractures are usually more difficult to reduce than tibial
fractures.
1.
A thicker soft-tissue envelope and less direct access to bone.
2.
A somewhat hidden starting point.
3.
The presence of the iliotibial tract, which tends to shorten the fracture
if the leg is adducted.
Positioning of leg in antegrade femoral nailing
Steps
Starting point and nail
insertion in proximal
main fragment
Passing the nail into the
distal main fragment
Problem
Solution
In neutral position, soft
tissues and iliac crest
prevent easy access
AD-duction and flexion
of the proximal femuror
entire leg.
In adducted position,
the iliotibial tract is
under tension and
shortens the fracture
AB-duction or neutral
position of the distal
main fragment with the
proximal main fragment
in neutral position
47
(f)
Reduction aids
Reduction for closed nailing in fresh fractures in rarely a problem ; for
delayed nailing additional tools may be needed.
Use of Schanz screws for reduction. Three principles
1.
Screw placement as close to the fracture as possible.
2.
Unicortical insertion in the proximal fragment
3.
Connection
with
universal
chuck
with
T-handle
for
easier
manipulation.
The use of Schanz screws for reduction. In the proximal fragment the
Schanz screws are placed unicortically, in the distal fragment bicortically.
With two universal chucks with T-handle the fragments are manipulated
under C-arm control (AP view). The orientation in the sagittal plane is
obtained by "feeling" the fragments touching each other
48
Poller
screws
can
be
used
for
1)
alignment
2)
stabilization
3) manipulation. Screw is placed perpendicular to the direction in which the
implant might displace.
Placement of poller screws in undesirable nail positions as well as
malalignments which can be prevented or correct while simultaneously
stabilization is increased
(g)
Reduction techniques for delayed cases and non-unions
In delayed cases, and depending on the time interval, we are faced
with the following problems :
1.
Axial deformation (shortening, angulation, and / or translation).
2.
Connective tissue in growth and early callus formation making
reduction difficult.
3.
Sclerosis at the fracture site.
In malunions and non-unions nailing may be difficult. Alternately
plates can be used.
49
(h)
Techniques for prevention of malalignment
Selection of the correct starting point in the proximal fragment and a
central nail position in the distal fragment are the most important points to
observe in order to avoid varus-valgus and antecurvatum deformities.
(i)
Fixation techniques / interlocking
In unreamed nailing the use of locking bolts is mandatory.
(j)
Dynamization
Dynamization is rarely necessary in the femur, while in the tibia it may
be recommended for certain fracture patterns.
50
BRIDGE PLATING
1.
Introduction
Biological or bridge plating uses the plate as an extramedullary splint
fixed to the two main fragments, while the complex fracture zone is virtually
left untouched, or rather bridged, by the plate. This concept combines
adequate mechanical stability offered by the plate with uncompromised
natural fracture biology to achieve rapid interfragmentary callus formation
and fracture consolidation. Misinterpretation of principles and misapplied
techniques are responsible for most failures.
The current plating concepts embrace the principle of placing biology
before mechanics.
Tissue strain within minimal ranges enhances callus formation.
2.
Indirect reduction techniques
Biological or bridge plating is usually applied following some form of
indirect reduction.
Ligamentotaxis coined by Vidal
Ligamentotaxis = traction via ligaments and capsule.
3.
Implant consideration
Most plates are suitable to be used either for conventional or bridge
plating.
51
The wave plates
The wave plate with its central curved segment provides three
theoretical advantages for the treatment of fractures :
1.
by reducing interference with the vascular supply to the fracture site
by avoiding bone contact.
2.
by providing excellent access for the application of a bone graft at the
fracture site
3.
by altering the load to pure tension forces on the plate
Wave plate allowing for
grafting of lateral defect
The bridging concept using plates has been supported by new
developments in plate design, such as the LC-DCP, PC Fix, and LISS.
These new implants are designed to minimize the area of contact
between plate and bone, and they also display an even distribution of
strength throughout the plate, thereby eliminating stress raisers at a screw
hole.
52
4.
Soft tissue considerations
Plating becomes a semi-closed technique thereby preserve the
vascularity around the fracture area, resulting in more rapid and abundant
callus formation.
If difficulties are anticipated, a conventional approach is advisable.
5.
Experimental verification
Biological techniques are supported by good clinical studies.
53
EXTERNAL FIXATION
1.
Introduction
An external fixation is a device placed out side the skin which
stabilizes the bone fragments through wires or pins connected to one or
more longitudinal bars / tubes.
2.
Stiffness of the frame
Stiffness of the frame depends upon the following factors :
-
Distance of pins / Schanz screws - the closer the better
-
Distance of longitudinal connecting tube / bar from bone : the
closer the better
-
Number of bars / tubes : two are better than one
-
Configuration
-
Combination of limited internal fixation with external fixation.
Fixation which is either too elastic or too rigid can delay
fracture healing.
Hybrid and pinless fixators are mostly used for temporary fracture
stabilization in case of critical soft-tissue conditions.
Mefisto
The Mefisto is a recently introduced external fixator. It was designed
mainly for limb lengthening and bone transport. Thanks to the modular
configuration it proved also to be a very useful tool for the management of
fractures.
54
3.
Surgical technique
Pin insertion technique
The surgeon must be familiar with the anatomy of the different crosssections of the lower leg and make use of the recommended pin placement
sites (safe zones).
Safe zones in different levels
of the tibia as described for
application of the external
fixation pins.
Frame Construction
(a)
Schema illustrating the "fixator first" protocol for a complex open
fracture.
(b)
In each main fragment two pins are inserted according to the softtissue conditions.
(c)
Fixed to a bar by universal clamps two "handles" are obtained for
reduction.
55
(d)
After reduction the two bars are united by a third tube and two tubeto-tube clamps.
(e)
The fibula has been plated adding stability.
Diaphyses
To avoid heat damage, the holes for Schanz screws and Steinmann
pins must be predrilled.
There is no way to build a solid frame over poorly inserted pin.
Metaphyses
Joint involvement of any pin must be avoided.
External fixation is the gold standard in open fractures, avoiding
additional damage to an already compromised limb.
The modular frame used in association with
lag screw employed : (a) to hold a large vital
butterfly bone fragment (b) to restore joint
surface
Children's fractures
Pediatrics fractures are good indications for external fixation.
56
4.
Special indications - articular fractures / joint bridging
As joint bridging external fixation is usually only a temporary measure,
careful planning of pin placement is essential.
A bridging frame used to protect a
potentially unstable elbow (a) Complex
proximal forearm fracture. (Note the
displaced radial head and the floating
coronoid process). (b) The ulna has
been plated and the still unstable
elbow is bridged with a temporary
external fixator
Timing of the procedure
Intramedullary nailing, preferably without reaming, is considered safe
if performed within the first 2 weeks after external fixation, provided the pin
sites are clean without signs of infection.
57
INTERNAL FIXATION : A NEW TECHNOLOGY
1.
Introduction
To prevent the pressure of a plate against bone a completely new
system was chosen : the internal fixator.
This new and quite different
technique of applying a plate has been termed the internal fixator system, as
the implant functions more like a fixator than a plate, while the whole
construct is covered by soft tissues and skin.
2.
PC-fix (point contact fixator)
The first implant designed to fulfill the new requirements was the
small PC-Fix of forearm bones. The PC fix consists of a narrow plate with a
specially designed undersurface having only small points that come into
contact with bone.
The screws are self tapping and unicortical and are available in one
length only. The screw head locks firmly in the plate hole with a fine thread.
PC fix has been tested in more than 1000 fractures with very promising
results.
3.
LISS (less invasive stabilization system)
LISS was designed for the distal femur and proximal tibia to be
inserted as minimal invasive plate osteosynthesis.
58
4.
In Summary the new internal fixator systems LISS and PC-Fix.
•
constitute a completely new, but promising alternative to
conventional plating.
•
preserve vascularity of bone in an optimal way
•
should have a better resistance to infection than conventional
plates.
•
are designed to be inserted in a minimally invasive fashion (LISS
only)
•
provide a fixed angle plate screw device consisting of two
components for easy application in complex fractures.
•
are, because of their self-tapping, unicortical screws, easily and
rapidly applied to a reduced fracture.
Locking plate technology
Internal fixation with locking plates creates a toggle-free fixed angle
construct. Early data on the biomechanical and clinical performance of these
implants are encouraging.
Biomechanics
To understand the comparison between locking screw plates and
existing devices it is important to understand the concepts of working length,
mechanics plate stability, and the effect of cantilever bending.
Current locking plate designs have used self-tapping unicortical
screws (PC-fixed and LISS) : this has eliminated the need to measure the
length for percutaneous screw
insertion has decreased inventory and
59
minimized surgical time. A locking plate construct might be considered the
ultimate external fixator with minimal soft tissue dissection, wide screw
spacing, locked screws and the plate functioning as the connecting bar,
placed extremely closed to the mechanical axis of the bone.
Indications
Current indications for locking plate fixation are complex periarticular
fractures, especially those with comminution of the metaphyseal region.
Comminuted distal femoral fractures with multiplanar articular involvement
are excellent indications.
Other potential indications
for locking plate technology include
periprosthetic fractures involving total knee arthroplasty
60
OPEN FRACTURES
1.
Introduction
Open fracture indicates a communication between fracture and
external environment. Most severe open tibial fractures associated
with
vascular injury show documented amputation rates in excess of 50%. Risk of
infection, delayed union and non-union are high.
2.
Etiology and mechanism of injury
The degree of trauma suffered is related to the impact velocity.
3.
Microbiology
Most open fractures are contaminated with bacteria, at or shortly after
the time of injury, 60-70% showing positive wound cultures before treatment
begins.
These bacteria are relatively innocuous skin and environmental
contaminants, which rarely cause infection. Most commonly infection follows
contamination after arrival at hospital, with pathogenic. Staphylococcus
aureus, enterococcus or pseudomonas.
4.
Classification
Most widely used the Gustilo and Anderson.
Classification of open fractures
Gustillo type I : Fractures of this type have a clean wound of less than 1 cm
in size with little or no contamination. The wound results from a perforation
from the inside out by one of the fracture ends. Type I fractures are simple
fractures, like spiral or short oblique fractures.
61
Gustilo type II : Injuries have a skin laceration larger than 1 cm, but the
surrounding tissues have minor or no signs of contusion. There is no dead
musculature present and the fracture instability is moderate to severe.
Gustilo type III : open fractures have extensive soft-tissue damage,
frequently with compromised vascularity with or without severe wound
contamination, and marked fracture instability due to comminution or
segmental defects. Because of the many different factors occurring in this
group.
Classification of type III open fractures
Type IIIa :
-
Adequate soft-tissue cover of bone despite extensive soft-tissue
damage.
Type IIIb :
-
Extensive soft-tissue injury with periosteal stripping and bone
exposure.
-
Major wound contamination
Type IIIc
-
Open fracture with arterial injury requiring repair.
62
5.
Principles of management
Ultimate goal in the management of the open fracture is the early
return to normal function of the injured limb.
Principles of management
6.
-
Prevention of infection
-
Soft-tissue healing and bone union
-
Restoration of anatomy
-
Functional recovery.
Antibiotics
The choice of antibiotic is dictated by the potential bacterial
contaminant. Prolonged antibiotic administration is not necessary.
7.
Definitive assessment
A tourniquet should be applied, but not inflated unless there is
excessive hemorrhage. The concept of "the zone of injury" is important. The
skin wound is merely the "window" through which the true wound
communicates with the exterior.
Evaluation of the wound demands a detailed assessment of the true
extent of the zone of injury.
63
Staged surgical debridement
Surgical debridement demands meticulous excision of all dead and
devitalized tissues. A "second look" should be routinely performed after 4872 hours.
Fracture stabilization
Type II and type III open fractures are almost inevitably displaced and
unstable. This usually dictates surgical fixation.
There is experimental evidence to suggest that bacterial proliferation
is influenced by fracture stability.
The benefits of stable fixation must be balanced against the pitfalls of
further damage to local blood supply and the risk of complications.
It is not essential to achieve definitive fixation at the first intervention.
External fixation
External fixators are the device of choice in severely soiled and
contaminated wounds.
8.
Skin cover and soft tissue reconstruction
Early fracture stabilization and soft tissue reconstruction promote
early movement. Delayed union and non-union occur more frequently after
open fracture than in closed fractures.
64
9.
Pitfalls and complications
The management of severe open fractures is time consuming and
difficult. Infection remains the major risk and follows poor surgical technique,
inadequate debridement or delay in skin cover.
Futile attempts at salvage in situations doomed to failure are illconceived.
65
1.
Introduction
Definition : The term polytrauma means a syndrome of multiple
injuries exceeding a defined severity (ISS>17) with sequential systemic
traumatic reactions which may lead to dysfunction or failure of remote
organs and vital systems which has not themselves been directly injured.
2.
Pathophysiological background
Systemic traumatic reactions produce a whole body inflammation or a
systemic inflammatory response syndrome (SIRS). SIRS is associated with
a general capillary leak syndrome and high energy consumption demanding
a hyperdynamic hemodynamic state (flow phase) and an increased
availability of oxygen. This flow phase generates an increase metabolic load
with significant muscle wasting, nitrogen loss, and accelerated protein
breakdown. This hypermetabolic state is accompanied by an increase in
core body temperature and by thermal dysregulation.
"Afferent
input"
in
trauma and resulting
reflex responses
66
3.
Timing and priorities of surgery
Algorithm for initial assessment, life support, and day-1 surgery
Within the locomotor system treat with high priority :
-
Limb-threatening and disabling injuries
-
Long bone fractures, unstable pelvic injuries, highly unstable
large joints, and spinal injuries i.e. they require at least
provisional reduction and fixation.
During this window of opportunity, scheduled definitive surgery
of long bone fractures shaft and articular - can be performed in
relative safety.
Early fracture fixation in polytrauma is beneficial in terms of mortality
and morbidity.
67
Endpoints of Resuscitation
-
Stable hemodynamics
-
No hypoxemia, no hypercapnia
-
Lactate < 2 mmol/L
-
Normal coagulation
-
Normothermia
-
Urinary output > 1 ml / kg / hour
-
No need for vasoactive or inotropic stimulation
Priorities and timing of surgery depending on physiological status
Surgical Intervention
Physiological Status
Response to
resuscitation
–
Life saving Surgery
?
Damage control
+
Delayed primary surgery
Timing
Day 1
Hyper-inflammation
"Second look",only!
Day 2-3
"Window of opportunity
Scheduled definitive surgery
Day 5-10
Immunosuppression
No Surgery!
Recovery
Secondary reconstructive surgery
4.
Week 3
General aims and scopes of fracture management inpolytrauma
Aims ad scopes for fracture management are :
-
Control of hemorrhage
-
Control of sources of contamination, removal of dead tissue,
prevention of ischemia reperfusion injury,
-
pain relief
-
Facilitation of intensive care
68
5.
Pros and cons of different fixation methods
Femoral nailing has an adverse effect due to pulmonary embolization.
Simple fracture types in a young patient with a narrow medullary canal are
more prone to pulmonary embolization.
External fixation minimizes additional surgical trauma. Rigid protocols
related to timing and choice of implant should be avoided.
6.
Fracture management under specific conditions
Massive hemorrhage due to a crushed or disrupted pelvis
Massive pelvic hemorrhage requires immediate reduction and fixation
of pelvic ring by external fixator or C-clamp.
7.
Early fixation of femoral shaft fractures in severe polytrauma or
polytrauma patients with chest injury
Primary intramedullary nailing only in patients with no significant chest
injury or ISS <25. If the ISS>40, primary stabilization is essential, but with
external fixators.
Advantages include facilitation of nursing care, early
mobilization with improved pulmonary function, shorter time on the ventilator,
and reduced morbidity and mortality.
Polytrauma must be considered as a systemic surgical disease.
69
PRE AND POST EVALUATION SHEET
1.
What are the goals of fracture fixation ?
a. Fracture reduction and fixation to restore anatomical relationships
b. Stability by fixation or splintage as the personality of the fracture
and the injury required
c. Preservation of the blood supply to soft tissues and bone by
careful handling and gentle reduction techniques
d. Early & safe mobilization of the part and the patient
e. All of the above
2.
Dipping a dry plaster roll into water causes which change in chemical
state?
3.
a.
2CaSO4. 2H2O → (CaSO4)2. H2O+3H2O
b.
(CaSO4)2. H2O+3H2O → 2CaSO4. 2H2O
c.
Ca(OH)2 2. H2O+3H2O → 2Ca (OH)2. 2H2O
d.
Ca(OH)2 2H2O → 2Ca3 (PO4)2. 2H2O
a.
Ca3 (PO4)2 + 4H2O → Ca3 (PO4)2. 4H2O.
Closed treatment of displaced fractures of both bones of the forearm
in adults may be expected to yield poor functional results in _______
of cases.
4.
a.
10%
b.
30%
c.
50%
d.
70%
e.
90%
A contaminated wound is usually considered to be infected after__
_____________ hours.
a.
3
b.
6
c.
12
d.
18
e.
24
70
5.
The earliest skeletal radiologic sign of infection of the hip joint after
internal fixation of the hip fracture is:
6.
a.
Increased size of the acetabulum
b.
Sequestration of a portion of the femoral head
c.
Bone absorption around the fixation device.
d.
Narrowing of the joint space.
In a patient with a supracondylar fracture of the humerus the most
important early signs of impending Volkmann's ischemic contracture
is:
7.
a.
Pallor
b.
Coolness.
c.
Swelling
d.
Numbness.
e.
Pain
Which of the following usually does not cause ligementous injury to
the knee?
8.
a.
Hyperextension.
b.
Hyperflexion.
c.
Valgus motion, flexion, and internal rotation.
d.
Varus motion, flexion, and external rotation.
e.
Anterior or posterior displacement of the tibia on the femur.
Separation of the proximal radial epiphysis generally results in a
decreased ability to ______________ the forearm, and fusion of the
epiphysis results in a _______________ deformity.
a.
Pronate
b.
Supinate
c.
Varus
d.
Valgus
e.
Flexion.
71
9.
Early active exercise without weight bearing after either open or
closed reduction of a traumatic hip dislocation or fracture dislocation
will cause ______________ incidence of myositis ossificans and will
yield a ___________ result than will immobilization.
10.
11.
a.
Increased
b.
No difference in the
c.
Decreased
d.
Better
e.
Worse
The most valid method of making a diagnosis of fat embolism is:
a.
EEG changes
b.
Fat droplets in the sputum
c.
Fat droplets in the urine
d.
Arterial Po2 of less than 70 mm Hg
e.
Clinical evaluation.
Which of the following are the criteria for a Plate to act as a tension
band.
a.
The fractured bone must be eccentrically loaded
b.
The plate must be placed on the tension side
c.
The plate must be able to withstand the tensile forces
d.
There must be a bony buttress opposite to the plate the plate
to prevent cyclic bending
12.
e.
None of the above
f.
All of the above
The recommended order for the treatment of closed multiple fractures is
a.
Upper limb → pelvis or spine → femur → tibia
b.
Femur → tibia → pelvis or spine → upper limb
c.
Pelvis or spine → Femur → Upper limb → tibia
d.
Tibia → Femur → Upper limb → Pelvis on spine
72
13.
14.
Which of the following can be used for Bridge plating
a.
LC-DCP
b.
PC-Fix
c.
LISS
d.
All of the above
e.
None of the above
Which of the following device functions as a subcutaneous or
submuscular external fixator
15.
a.
Narrow D.C.P.
b.
PC-Fix
c.
LISS
d.
b & c both
e.
None of the above
"Window of opportunity" The period post trauma during which there
exists an immunological window of opportunity when the phase of
higher inflammation is followed by a period of immunosuppression.
This period exists between day
a.
Day 2-3
b.
Day 5-10
c.
Beyond 3 weeks
d.
Day 1
Mark the following as true or false
16.
17.
18.
19.
20.
The zones of injury in a burn are analogous to the
concept of a soft tissue zone of injury
The presence of peripheral pulses and adequate
skin circulation excludes a compartment syndrome
Continuous passive motion after anatomical
reduction and rigid fixation of an articular fracture
can lead to hyaline cartilage healing
To act as a leg screw the cortex screw requires a
threaded hole in the near and a gliding hole in the
far.
A plate under tension is much stronger than under
bending forces.
73
True
False
True
False
True
False
True
False
True
False
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