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