Fractures Z. Rozkydal I.Orthopaedic department Medical faculty, Masaryk university Brno Fractures - etiology • •Traumatic (acute violence) •Pathological (pathological lesion) •Stress fractures Traumatic fracture Zl spiral Pathological fracture Zl Tumors Infections Osteopaties Congenital diseases Stress fracture Zl Fosa-skelet Zl Osteoporosis of vetebrae Fosa-páteř Zl násilí Fractures from direct violence Fractures from indirect violence Mechanism of injury traction angulation rotation vertical compression torsion Missile fractures Zl Zl násilí Mechanism of injury High energy trauma – large lesion of soft tissue Low energy trauma - small lesion of soft tissue Classification of fractures • • • • • • • • • • Zl Complete Zl Incomplete: - fissures - infractions - impressions - subperiostal Localisation of fractures • •Epiphyseal •Metaphyseal •Diaphyseal Zl epiphysis metaphysis diaphysis metaphysis epiphysis Zl interfragment transverse oblique spiral comminution Fracture lines Zl - dislokace Dislocatio ad axim Dislocatio ad latus Dislocatio ad longitudinem cum contractione Impactio Dislocatio ad longitudinem cum distractione Dislocatio ad peripheriam Dislocation Clinical symptoms of fractures •Pain and tenderness •Swelling, haematoma •Impaired function •Deformity •Crepitation •Pathological movements Healing of fractures •Osteoblasts: •Cambian layer of periosteum and • endosteum •Tratebulae in metaphyseal •and epiphyseal region • •Osteoprogenitor cells: •reticular, perivascular cells, monocyts • •Diaphysis – longer period of healing •Epi and metaphysis – shorter period • of healing Osteo- haverský systém Osteo- spongioza1 Zl hojení 1 Secondary healing 1. Haematoma 2. Granulation tissue 3. Osteoid ( since 5. day ) 4. Primary callus formation - primary woven bone - fibrous tissue, - cartilage tissue - mineral layers after 6 days Zl hojení 2 Secondary healing 5. Secondary callus formation - woven bone is replaced by cortical and trabecular bone 6. Remodelation of callus Zl hojení 3 Primary healing Prerequisity: stable fixation It is intercortical healing without callus formation 1. Contact 2. Gap Osteon: osteoclasts, vessels, osteoblasts Zl hojení 4 Functional unit: osteon Speed of osteons: 0,1 mm/day Primary healing Zl AO classification Davos, 1958. E. Műller M. Allgőver H. Willenegger Zl AO classification - diaphysis Type Zl AO classification - metaphysis, epiphysis Type Zl AO classifications Type Group Zl AO classification – proximal humerus Management of fractures •Conservative: • • 1. Reduction • 2. Retention (immobilisation) • 3. Physiotherapy • Zl Zl Zl Conservative management Operative treatment • In all cases, in which we get advantage against conservative treatment •Intraarticular fractures •Dislocated fr. – not redusable by closed reduction •Fr. of proximal femur •Diaphyseal fr. •Open fr. Osteosynthesis •Aim – anatomical reduction • •Absolute stability ( AO plate) • •Relative stability • + secondary healing with periosteal and endosteal callus (intramedullary nails) Zl OS K dráty Zl Zl Kirschner wires Osteosynthesis Tension band wiring AO screws cortical cancellous Zl K- wires Zlo- patela1 Zlo-patela 2 Tension band wiring of patella Zl Zl AO plates Compression AO plate Self- compression AO plates Zlo- AO dlaha na předloktí Osteosynthesis of radius and ulna AO plate of proximal femur Zl DHS Dynamic hip screw Zl DCS Dynamic condylar screw Zl Zl Gamma locking nail Zl Gamma locking nail Zlo - PFN Synthes Nail PFNA Rotation and angle stability Static and dynamic locking mechanism PFNA Synthes Sc LISS – less invasive stabilisation system Zl Zl Unicortical plates Zl Locking compression plate - LCP Zlo - schéma LCP otvoru Zlo- LCP radia Unicortical fixation – in diaphysis Bicortical fixation - in epiphysis Compression screws – oblique direction Limited contact Adjusted to every anatomical region Titanium Zlo- LCP lokte Zlo- LCP humeru Locking compression plate - LCP In epiphysis bicortical fixation In diaphysis unicortical fixation Zlo- Philos LCP - Philos Anatomical shape Zl Locking intramedullary nails Reamed Unreamed Zl Locking intramedullar nails Reamed: Stronger Flexible reamers Hollow Good stability Risk of fat embolism In type fx. A,B Zl Locking intramedullar nails Unreamed: Solid Proximal and distal locking Less stability For fx. type C Zl Intramedullar nail of femur Rotation stability Static - circle holes Dynamic - oval holes with compression of fragments Middle 3/5 of diaphysis PFN - proximal femoral nail Reconstructive nails Zl Zl Kűntscher intramedullar nail Zlo- hřeb v diafýze femuru Intramedullar nailing of the femur Zl Locked nail in humerus Zl Locked nail in tibia Zlo - tibiální hřeb Tibial nail - Synthes Steel Titan Anatomic curvature Zl External fixator - frame Zl External fixator Zlo- FE 1 Zl External fixator Zl External fixator - Ilizarev External fixator of the wrist • CIMG1083 Fractures in children •Fast healing • •Many fx. healed by conservative methods • •Few complications Zl Zl Remodelation (dislocation ad latus, ad axim, in antecurvation or recurvation) can heal properly. Depends on age and site to growth plate. Dislocations ad peripheriam should be reduced. Remodelation Zl Fractures in children - growth plate – lengthening of long bones - damage of growth plate – disturbance of growth Fractures in children •Strong periosteum, elasticity of bone (green stick fractures) •Subperiosteal haematoma. • Ossifications of haematoma •Ligaments are elastic • - epiphyseolysis is common • - fracture is less common Zl Epiphyseal injuries - Salter- Harris - in 15 % of cases 1. Epifyseolysis 2. Fx. of epiphysis- Holland triangle 3. Fx. of epiphysis 4. Fx. epiphyseometaphyseal 5. Contusion of epiphysis Zl Green stick fractures Bone is broken in a periosteal sleeve Periosteum is not disrupted Zl Physiotherapy • •Physiotherapy in chidren is easier than • in adults Componed (open) fractures Damage of skin Damage of soft tissues Bacterial contamination Classification of Gustilo and Anderson • •1 stage – puncture of skin from bone fragment • low energy trauma • •2 stage – open fracture without defect of skin and • soft tissue • •3 stage – wound with defect of skin and soft • tissue, high energy trauma B25 B25 Tscherne clasification Closed fr. G0 no damage to soft tissues GI superficial excoriations GII deep excoriations GIII contusion of the skin, decollement, damage of muscles Open fr. OI puncture wound from bone fragment, small wound OII wound without loss of skin OIII large wound with loss of skin OIV subtotal amputation Management •Surgery as soon as possible •1. Cleaning of skin •2. Debridement of wound (removal of foreign bodies, excision od dead parts, lavage •3. Open reduction, stabilisation with external fixator, suction drainage, suture of skin without tension Management B18 B18 B20 Conversion to the intramedullary nail Management •Musculocutaneous flap •Antibiotics •Tetanus prevention •Antigangrenous serum •Prevention of phlebotrombosis • B26 Disturbance of fracture healing •Malunion- fractura male sanata •Hypertrophic callus •Delayed union •Avascular necrosis of epiphysis •Nonunion: aseptic, septic • vital, nonvital •Refracture Olšová 15 Consequences of fractures Growth arrest Shortening of bone Paraarticular ossifications Osteoarthrosis Limites movements in joint Noha- zrůstková 2 Noha- zrůstková 1 Malunion Zl Zl Vital nonunion Zl Avascular nonunions Zl Pseudoarthrosis of the femur Zl Pseudoarthrosis of the tibia Complications of fractures - local •Soft tissue damage: • vessels, peripheral nerves, muscles, surrounding tissues •Infection •Compartment syndrom •Algoneurodystrophy Zl Compartment syndrom- CS Physiogical pressure in tissue: 0 - 6 mm Hg Patholocal pressure in CS -tissue : 30- 40 mm Hg Compartment syndrom Hematoma Swelling Tight bandage ,tight plaster of Paris Severe contusion Tight suture of fascia Compartment syndrom Pain Pallor Paresthesia Paralysis pulselessness Normal preasure 3-10 mm Hg Above 30 mm slow doen od circulation cirkulace Piesoelectric sensor Indication for fasciotomy mpre than 30-45 mm Hg D CS 1 Symptoms • •Pain – intensive and growing •Swelling- increasing •Cold periphery, cyanosis •Parestesia, hyperestesi, numbness of toes •Diminished motor function (from ischemia) •Diminished puls in periphery Management of CS Urgent fasciotomy D CS 2 D CS 2 D CS 3 D CS4 D CS 5 D CS4 Compartment syndrom - consequences After 6 hours – irreversible damage to muscles - Change to fibrous filaments - contracture of muscles - After 12 hours - Irreversible damage to nerves Noha Algoneurodystrophy Reaction of sympathetic nerves to the injury Zlo- Sudeck 2 Algoneurodystrophy •1. Stage - hyperemia, 0- 3 months • pain, swelling, hyperestesia • •2. Stage - dystrophy • plastic oedema, cold periphery, thin skin, limited movements, X-ray - osteoporosis • •3. Stage - atrophic • atrofic skin, muscles, limited movements Zlo- Sudeck 1 Zlo- Sudeck 3 Algoneurodystrophy -management Short immobilisation Drugs against swelling Analgetics, sedative drugs physiotherapy Sympaticolytics Regional blocks Corticoids Calcitonin, alendronate Physioterapy after removal of bandage Zlo- Sudeck 3 Complication of fractures - general Hypovolemic shock Cardiopulmonar arrest Fat embolism Haemoragic complications Disseminated intravascular coagulopathy Trombembolism Complication of fractures - general •Fracture disease: •- bronchopneumonia •- Phlebotrombosis, pulmonary embolism •- Preassure sores •- Urinary tract infection •- Weakness •- Muscle atrophy and contractures Garden classification Zl Head prosthesis Over 80 years Minimal blood loss Immidiate weightbearing Disadvantage: Erosion of the cartilage of the acetabulum THA výuka- CKP Sc Sc SC Sc SC