Principles of Fracture Management for General Surgeons.pptx

Principles of Fracture Management for General Surgeons

1. Principles of Fracture Management Rohan Jayawardena Registrar in General Surgery NHSL 24/12/2020

2. What is a fracture ? An interruption in the continuity of the bone which may be a complete or partial break at one or multiple sites & at various angles Medscape

3. Biology of fracture healing 2 types Primary/ Direct – by internal remodeling Secondary/ Indirect – by callus formation AO Principles of Fracture Management, 3rd Edition

4. Primary/Direct healing Only with absolute stability Biological process of osteonal bone remodeling AO Principles of Fracture Management, 3rd Edition

5. Secondary/Indirect healing 4 stages 1) Inflammation 2) Soft callus formation 3) Hard callus formation 4) Remodeling AO Principles of Fracture Management, 3rd Edition

6. Inflammation AO Principles of Fracture Management, 3rd Edition Inflammatory exudate & haematoma formation Bone necrosis at the ends of the fracture fragments Injury to soft tissues & degranulation of PLT releases cytokines which produce inflammatory response Haematoma – network of fibrin & reticulin fibrils, collagen fibrils Replaced by granulation tissues Osteoclasts – remove necrotic bone fragments

7. Soft callus formation AO Principles of Fracture Management, 3rd Edition 2-3 weeks after the fracture Progenitor cells in the periosteum & endoseteum become osteoblasts & forms a cuff of woven bone periosteally & filling the intramedullary canal Closer to fracture gap mesenchymal progenitor cells differentiate in to fibroblasts/chondrocytes producing extracellular matrix Replaces the haematoma At the end stability is adequate to prevent shortening But angulation can occur at the fracture site

8. Hard callus formation AO Principles of Fracture Management, 3rd Edition Lasts 3 – 4 months Starts when the fracture ends are linked together by soft callus Hard callus formation begins at the periphery of the fracture & progressively moves toward the center Production of bone peripherally reduces the strain at the center When fracture gap narrows the strain increases Final gap bridged by osteoblasts line up in a spiral formation like a spring to reduce strain which allow bone formation Soft tissue in the gap is replaced by woven bone, eventually joins the original cortex

9. Remodeling AO Principles of Fracture Management, 3rd Edition This stage begins once the fracture has solidly united with woven bone Woven bone is slowly replaced by lamellar bone Lasts until the bone has completely returned to its original morphology including restoration of medullary canal Lasts few months to several years

10. Fracture & blood supply Fracture is a mechanical process It triggers biological reactions such as bone (callus) formation & bone resorption Depends on intact blood supply AO Principles of Fracture Management, 3rd Edition

11. Fracture & blood supply Determining factors 1) Mechanism of injury 2) Initial patient management 3) Patient resuscitation 4) Comorbidities 5) Surgical approach & technique 6) Implant 7) Consequences of trauma AO Principles of Fracture Management, 3rd Edition

12. Mechanism of injury Amount & direction of force Fracture type & site Soft tissue injuries Displacement of fragments can rupture periosteal & endosteal blood vessels. AO Principles of Fracture Management, 3rd Edition

13. Initial management Important to prevent further damage Eg :- Rescue & transportation without splinting of fractures can add to initial damage AO Principles of Fracture Management, 3rd Edition

14. Resuscitation Hypovolemia Hypoxia increase damage to injured bone & soft tissues Coagulopathy Must be corrected early in the management AO Principles of Fracture Management, 3rd Edition

15. Comorbidities PVD DM AO Principles of Fracture Management, 3rd Edition

16. Surgical approach & technique Surgical exposure will invariably result in additional damage Can be minimized by - thorough knowledge of anatomy - preoperative planning - meticulous surgical technique - minimal invasive procedures Not to strip any soft tissue – vascular supply to callus is from the surrounding soft tissue AO Principles of Fracture Management, 3rd Edition

17. Surgical approach & technique More flexible fixation – greater vascular response due to more callus formation High strain in tissues due to excessive instability reduces the blood supply especially in the fracture gap Intramedullary reaming – immediate reduction of endosteal blood flow - rapid hyperemic response if reaming is not excessive - does not affect blood supply to the callus (mainly from surrounding soft tissues) AO Principles of Fracture Management, 3rd Edition

18. Implant Contact between implant & bone – interferes the blood supply Plates with flat surface (DCP) – large area of contact Plates with undercut surface (LC-DCP) – reduce area of contact AO Principles of Fracture Management, 3rd Edition

19. Consequences of trauma Immediate reduction of cortical circulation by 50% after fracture/ osteotomy Elevated intraarticular pressure reduces the epiphyseal bone circulation Internal remodeling allows replacement of dead osteocytes but results in temporary weakening of the bone due to transient porosis This is often seen immediately beneath plates & can be lessened by reducing the contact area of the plate ( eg :- LC-DCP/ LCP) AO Principles of Fracture Management, 3rd Edition

20. Principles of fracture management Reduction Fixation Preservation of blood supply Early mobilization AO Principles of Fracture Management, 3rd Edition

21. Reduction Anatomical Functional Restore bony anatomy & morphology E g:- Articular # Restore relationship between proximal & distal fragment/ Length/ Alignment/ Rotation Eg:-Diaphysial # (Except forearm) AO Principles of Fracture Management, 3rd Edition

22. Fixation Goals Mainatin the reduction Create adequate stability Stability Absolute Relative AO Principles of Fracture Management, 3rd Edition

23. Absolute stability No movement at # site Achieved by interfragmentary compression No callus formation Iry bone healling Eg:- Lag screws/ Compression plate/ Tension band AO Principles of Fracture Management, 3rd Edition

24. Relative stability Movements at # site No interfragmentary compression at # Callus fromation I Iry bone healing Eg :- IM nails POP casts EF AO Principles of Fracture Management, 3rd Edition

25. Preservation of blood supply Care for soft tissues Evaluation of limb swelling Staged prcedures Eg:- External fixation Definitive fixation Careful reduction Minimal invasive surgery Good nursing care AO Principles of Fracture Management, 3rd Edition

26. Early mobilization Pain management Physiotheraphy Early joint motion Gradual weight bearing Early recognition & treatment of complications Proper followup AO Principles of Fracture Management, 3rd Edition

27. Internal Fixation

28. Indications for internal fixation Displaced intra-articular fractures Axial/ angular/ rotational instability that can not be controlled by closed methods Polytrauma patients Associated neurovascular injuries Patient’s demands Eg: Paraplegics, Elderly, Sportsmen AO Principles of Fracture Management, 3rd Edition http:// www.orthofracs.com /adult/trauma/principles/fracture-classification/internal- fixation.html

29. Benefits of internal fixation Early functional recovery More predictable fracture alignment Faster healing AO Principles of Fracture Management, 3rd Edition

30. Lag screws Compresses both sides of # together Absolute stability Load transfer occurs directly from fragment to fragment & not via the implant Lag screws must pass perpendicular to # to prevent loss of reduction Drilling & insertion of a lag screw stimulates bone formation around the threads Maximum strength is reached at 6-8 weeks AO Principles of Fracture Management, 3rd Edition http://www.orthofracs.com/adult/trauma/principles/fracture-classification/internal-fixation.html

31. Plates Neutralisation plate Compression plate Buttress plate Bridging plate/ wave plate Antiglide plate Tension-band plate Spring plate AO Principles of Fracture Management, 3rd Edition http:// www.orthofracs.com /adult/trauma/principles/fracture-classification/internal- fixation.html

32. Intramedullary Nails Fixation of diaphyseal fractures of long bones Relative stability Types Reamed vs Unreamed Cylindrical vs Slotted Locked vs Unlocked Anterograde vs Retrograde AO Principles of Fracture Management, 3rd Edition http:// www.orthofracs.com /adult/trauma/principles/fracture-classification/internal- fixation.html

33. Tension band wiring Conversion of tension forces to compression forces Absolute stability Allows some load-induced movement Eg :- Patella & olecranon fractures AO Principles of Fracture Management, 3rd Edition http:// www.orthofracs.com /adult/trauma/principles/fracture-classification/internal- fixation.html

34. Thank you