Ortopedick

1
Ortopedická klinika UK.2.LF a FN Motol- Detská
a dospelá ortopedie a traumatologie

2
Ostheosynthesis
3
Fracture healing

• Inflammatory response 
• Reparative response 
• Remodelling 

4
Inflammatory response 

• Time of injury to 24-72 hours
• Injured tissues and platelets release vasoactive
  mediators, growth factors and other cytokines.
• These cytokines influence cell migration,
  proliferation, differentiation and matrix
  synthesis.  
• Growth factors recruit fibroblasts, mesenchymal
  cells osteoprogenitor cells to the fracture
  site.
• Macrophages, PMNs mast cells (48hr) arrive at
  the fracture site to begin the process of
  removing the tissue debris.

5
Important cytokines in bone healing
BMPs Osteoinductive, induces metaplasia of mesenchymal cells into osteoblasts Target cell for BMP is the undifferentiated perivascular mesenchymal cell
TGF-? Induces mesenchymal cells to produce type II collagen and proteoglycans Induces osteoblasts to produce collagen
PDGF Attracts inflammatory cells to the fracture site
FGF Stimulates fibroblast proliferation
IGF II Stimulates type I collagen production, cartilage matrix synthesis and cellular proliferation
IL 1 Attracts inflammatory cells to the fracture site
IL 6 Attracts inflammatory cells to the fracture site
6
Reparative response

• 2 days to 2 weeks
• Vasoactive substances (Nitric Oxide Endothelial
  Stimulating Angiogenesis Factor) cause
  neovascularisation local vasodilation
• Undifferentiated mesenchymal cells migrate to the
  fracture site and have the ability to form cells
  which in turn form cartilage, bone or fibrous
  tissue.
• The fracture haematoma is organised and
  fibroblasts and chondroblasts appear between the
  bone ends and cartilage is formed (Type II
  collagen).
• The amount of callus formed is inversely
  proportional to the amount of immobilisation of
  the fracture.
• In fractures that are fixed with rigid
  compression plates there can be primary bone
  healing with little or no visible callus
  formation.

7
Types of callus
External (bridging) callus From the fracture haematoma Ossifies by endochondral ossification to form woven bone
Internal (medullary) callus Forms more slowly and occurs later
Periosteal callus Forms directly from the inner periosteal cell layer. Ossifies by intramembranous ossification to form woven bone
8
Remodelling 

• Middle of repair phase up to 7 years
• Remodelling of the woven bone is dependent on the
  mechanical forces applied to it (Wolffs Law -
  'form follows function')
• Fracture healing is complete when there is
  repopulation of the medullary canal
• Cortical bone
• Remodelling occurs by invasion of an osteoclast
  cutting cone which is then followed by
  osteoblasts which lay down new lamellar bone
  (osteon)
• Cancellous bone
• Remodelling occurs on the surface of the
  trabeculae which causes the trabeculae to become
  thicker

9
Factors influencing bone healing
Local Degree of local trauma Degree of bone loss Vascular injury Type of bone fractured Degree of immobilisation Infection Local pathological condition
Systemic Age, Hormones (Cortisone Calcitonin TH/PTH GH Androgens) Functional activity, Nerve function, Nutrition, Drugs (NSAID)  
10
Fracture managemet

• first aid - immobilisation
• conservative
• operative

11
Nonoperative

• immobilization with casting or splinting made
  from fiberglass or plaster of Paris (POP).
• Closed reduction is needed if the fracture is
  significant displaced or angulated -the
  nonoperative techniqueis achieved by applying
  traction to the long axis of the injured limb and
  then reversing the mechanism of injury/fracture
• Traction

12
Traction

• fractures and dislocations that are not able to
  be treated by casting
• skin traction,
  
  traction tapes attached
  to the skin of the limb segment below the
  fracture usually 10 of the patient's body
  weight is rarely
  used as definitive therapy in adults(the
  traction is maintained until the patient is taken
  to the operating room for ORIF or
  hemiarthroplasty in NOF fr.)
• skeletal traction, a pin (eg, Steinmann pin, KI
  wires) is placed through a bone distal to the
  fracture
  Weights applied to this pin
  and the patient is placed in an apparatus to
  facilitate traction and nursing care
  Skeletal
  traction is most commonly used in femur
  fractures A pin is placed in the distal femur or
  proximal tibia 1-2 cm posterior to the tibial
  tuberosity

13
Sceletal traction
14
Operative

• Failed nonoperative (closed) management
• Unstable fractures that cannot be adequately
  maintained in a reduced position
• Displaced intra-articular fractures (gt2 mm)
• Patients with fractures that are known to heal
  poorly following nonoperative management (eg,
  femoral neck fractures)
• Large avulsion fractures that disrupt the
  muscle-tendon or ligamentous function of an
  affected joint (eg, patella, olecranon fracture,
  )
• Impending pathologic fractures
• Multiple traumatic injuries with fractures
  involving the pelvis, femur, or vertebrae
• Unstable open fractures or complicated open
  fractures
• Fractures in individuals who are poor candidates
  for nonoperative management that requires
  prolonged immobilization (eg, elderly patients
  with proximal femur fractures)
• Fractures in growth areas in skeletally immature
  individuals that have increased risk for growth
  arrest (eg, Salter-Harris types III-V)
• Nonunions or malunions that have failed to
  respond to nonoperative treatment

15
Surgical therapy

• In 1958, the Association for the Study of
  Internal Fixation (ASIF) OA( Arbeitsgemeinschaft
  für Osteosynthesefragen)
  4 treatment goals
• Anatomic reduction of the fracture fragments
  diaphysis anatomical alignment
  assuring length, angulation, and rotation
  
  intra-articular fractures
  anatomic reduction of all fragments.
• Stable internal fixation to fulfill biomechanical
  demands
• Preservation of blood supply to the injured area
  of the extremity
• Active pain-free mobilization of adjacent muscles
  and joints

16
Surgical therapy

• ORIF - Open reduction and internal fixation
• Kirschner wires (K- wires)
  Plates and screws
• Intramedullary nailing
• External fixation

17
Open reduction and internal fixation

• exposing the fracture site and obtaining a
  reduction of the fracture
• must be stabilized and maintained

18
AO principles

• System
• Fixation elements
• Surgical technique
• Complications resolving
• Manual

19
New technique
20
Kirschner wires

• commonly used in fractures around joints.
• resist only changes in alignment, they do not
  resist rotation and have poor resistance to
  torque and bending forces
• used as adjunctive fixation for screws or plates
  and screws
• casting or splinting is used in conjunction.
• can be placed percutaneously
• adequate for small fragments in metaphyseal and
  epiphyseal regions, especially in fractures of
  the distal foot, wrist, and hand, ( Colles
  fractures, and in displaced metacarpal and
  phalangeal fractures after closed reduction )

21
(No Transcript)
22
Plates and screws

• designs vary depending on the anatomic region and
  size of the bone
• used in the management of articular fractures
• allows early ROM and the use of muscles and
  joints
• strength and stability, neutralize forces
• Buttress plates counteract compression and shear
  - metaphysis and epiphysis
  used around joints to support
  intra-articular fractures
• Compression plates (DCP Dinamic commpression
  plate, LC-DCP low contact dinamic commpression
  plate)
  counteract bending, shear, and torsion,
  eccentrically loaded holes
  in the plate
  
  used in long bones (fibula, radius, and ulna)
• Neutralization plates combination with
  interfragmentary screw fixation
  interfragmentary compression
  screws provide compression, plate neutralizes
  torsional, bending, and shear forces ( lag screws
  increases the stability of the construct)
  (fibula, radius and ulna, and humerus)
• Bridge plates - management of multifragmented
  diaphyseal and metaphyseal fractures.

23
(No Transcript)
24
(No Transcript)
25
(No Transcript)
26
Contraindications of ORIF

• Active infection (local or systemic) or
  osteomyelitis
• Osteoporotic bone that is too weak to sustain
  internal or external fixation
• Soft tissues overlying the fracture or surgical
  approach that are poor in quality due to burns,
  surgical scars, or infection (In such scenarios,
  soft tissue coverage is recommended.)
• Medical conditions that contraindicate surgery or
  anesthesia (eg, recent myocardial infarction)
• Cases in which amputation would better serve the
  limb and the patient

27
Intramedullary nailing

• widely accepted
• operate like an internal splint
• allows for compressive forces at the fracture
  site, which stimulates bone healing
• minimally invasive procedures
• femoral shaft fr. UFN,tibial shaft fr. UTN
  humeral shaft fr. UHN.
• ESIN Elastic stabilization intramedullary nailing
  TEN titanium elastic nail

• Intramedullary nails
• flexible or rigid,
• locked (maintain alignment and length, and limit
  rotation) or unlocked,
• reamed or unreamed,

28
(No Transcript)
29
(No Transcript)
30
Complications surgical management

• Neurologic and vascular injury
• Compartment syndrome
• Infection
• Thromboembolic events
• Avascular necrosis
• Posttraumatic arthritis

31
Neurologic and vascular injury

• nerve injury - patient experiences motor or
  sensory deficiencies
• Arterial injury - pulses are diminished or absent
  - immediate realignment, angiography is indicated
  - vascular surgeons (knee dislocations, proximal
  tibial fractures, and supracondylar humerus
  fractures)

32
Compartment syndrome

• reported by von Volkmann in 1872, potentially
  limb-threatening condition,
• tissue pressure exceeds perfusion pressure in a
  closed anatomic space ( hand, forearm, upper arm,
  most commonly occurs in the anterior compartment
  of the leg)
• involves tissue necrosis functional limb
  impairment renal failure secondary to
  rhabdomyolysis, which may lead to death
• occur after traumatic injury, after ischemia (eg,
  after hemorrhage or thromboembolic event) and in
  rare cases, with exercise
• Clinically pain out of proportion to the degree
  of injury, pain with passive stretch of the
  involved muscles, pallor, paresthesia,
  pulselessness is a late finding
• can be measured greater 30 mm Hg indicates
  surgical fasciotomy of the affected compartments.

33
Infection

• local infection cellulitis, osteomyelitis,
  systemic infection, sepsis
• Early recognition prevents the development of
  sepsis
• The most common pathogen is Staphylococcus
  aureus, group A streptococci, coagulase-negative
  staphylococci, enterococci
• ATB should be administered if an infection is
  suspected,
• lab C-reactive protein (CRP), erythrocyte
  sedimentation rate (ESR)
• If infection cannot be eradicated with
  antibiotics, ID of the surgical wound may be
  necessary, with removal of the hardware, but only
  if it is not performing its role.

34
Thromboembolic events

• may occur after trauma with prolonged
  immobilization
• immobile for 10 or more days have a 67 incidence
  of thrombosis (Canale, 1998)
• prophylaxis is effective in decreasing the
  incidence of deep vein thrombosis, but it has not
  been shown to be effective in decreasing the
  incidence of fatal pulmonary embolism.
• Prophylactic anticoagulation LMWH, Warfarin,
• early mobilization

35
Avascular necrosis

• disruption of blood supply to a region of bone
• can lead to nonunion, bone collapse, or
  degenerative changes
• associated with NOF and femoral head ,
  scaphoid, talar neck and body, and proximal
  humerus.

36
Posttraumatic arthritis

• common in intra-articular fractures
• fractures that are not adequately reduced
• management arthroscopic debridement, osteotomy,
  arthroplasty, or arthrodesis

37
External fixation

• In 1907 in Alvin Lambotte, 1952 Ilizarev
• provides stabilization at a distance from the
  fracture site without interfering with the soft
  tissue structures
• maintains length, alignment, and rotation without
  requiring casting
• allows inspection
• types Wagner, Orthofix, Unifix,

• Indications
• Open fractures with significant soft tissue
  disruption (eg, type II or III open fractures)
• Soft tissue injury (eg, burns)
• Pelvic fractures (temporarily)
• Severely comminuted and unstable fractures
• Fractures that are associated with bony deficits
• Limb-lengthening procedures
• Fractures associated with infection or nonunion
• arthrodesis

38
(No Transcript)
39
Complications of external fixation

• pin tract infection,
• pin loosening or breakage,
• interference with joint motion,
• neurovascular damage when placing pins,
• malalignment caused by poor placement of the
  fixator,
• delayed union and malunion

40
Spetial types of osteosynthesis

• LISS ( less invasive stabilisation system)
  implants for MIPPO (minimal invasive percutane
  plate osteosynthesis)
• -Herberts screw scafoid
• DHS NOF basicervical
• PFN NOF pertrochanteric
• Phillos prox. humerus
• DCS (dinamic condylar screw) and DFN (distal
  femoral nail) - dist. femur
• Pilon plate dist. tibia