Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

principles of internal fixation

14,020 views

Published on

Historical Background
Preoperative Planning
Fracture Reduction
Techniques and Devices for Internal Fixation

Published in: Education
  • DOWNLOAD FULL BOOKS, INTO AVAILABLE FORMAT ......................................................................................................................... ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/yxufevpm } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/yxufevpm } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/yxufevpm } ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/yxufevpm } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/yxufevpm } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/yxufevpm } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

principles of internal fixation

  1. 1. PRINCIPLES OF INTERNAL FIXATION » DR MANU MATHEW » MODERATOR DR GAURAV SHARMA
  2. 2. • Historical Background • Preoperative Planning • Fracture Reduction • Techniques and Devices for Internal Fixation
  3. 3. Historical Background • First reports on modern techniques of internal fixation are only about 100 years old. • Elie and Albin Lambotte “osteosynthesis” of fractures with plates and screws, wire loops and external fixators
  4. 4. Robert Danis (1880 to 1962) introduced the term of “soudure autogéne
  5. 5. Maurice Müller was impressed by DANIS &founded the Arbeitsgemeinschaft für Osteosynthesefragen (AO)
  6. 6. Gerhard Küntscher (1900 to 1972) in Germany had developed the technique of IM nailing,
  7. 7. • GOAL OF OPERATIVE FRACTURE FIXATION • full restoration of function • faster return to his preinjury status • • minimizethe risk and incidence of complications. • Predictable alignment of fracture fragments
  8. 8. The purpose of implants to provide a temporary support to maintain alignment during the fracture healing to allow for a functional rehabilitation
  9. 9. Biology and Biomechanics on Fracture Healing fractured bone needs - a certain degree of immobilization -optimally preserved blood supply -biologic or hormonal stimuli in order to unite.
  10. 10. Soft Tissue Injury and Fracture Healing “every fracture is a soft tissue injury, where the bone happens to be broken,” The more extensive the zone of injury and the tissue destruction, the higher is the risk for a delay of the healing process or for other complications
  11. 11. mechanical stability, Absolute stability rigid fixation that does not allow any micro motion elastic fixation provided by internal or external splinting of the bone
  12. 12. High Rate of HealingHigh Rate of Healing Spectrum of Healing Absolute Stability = 10 Bone Healing Relative Stability = 20 Bone Healing Biology of Bone Healing THE SIMPLE VERSION... Fibrous Matrix > Cartilage > Calcified Cartilage > Woven Bone > Lamellar Bone Haversian Remodeling Minimal Callus Callus
  13. 13. Absolute (Rigid) – eg Lag screw/ plate – Compression plate Relative – (Flexible) – eg – IM nailing – - Bridge plating No callus Fixation Stability Callus Reality
  14. 14. Functions of Fixation • Interfragmentary Compression – Lag Screw • Plate Functions – Neutralization – Buttress – Bridge – Tension Band – Compression – Locking • Intramedullary Nails – Internal splint • Bridge plate fixation – Internal splint • External fixation – External splint • Cast – External splint *Not internal fixation
  15. 15. Indications for Internal Fixation • Displaced intra-articular fracture • Axial, angular, or rotational instability that cannot be controlled by closed methods • Open fracture • Polytrauma • Associated neurovascular injury
  16. 16. The components of a preoperative plan • Timing of surgery • Surgical approach • Reduction maneuvers • Fixation construct • Intraoperative imaging • Wound closure/coverage • Postoperative care • Rehabilitation
  17. 17. Prophylactic Antibiotics • In general a second generation cephalosporin with a broad spectrum is recommended, applied as single dose • 30 minutes before the start of surgery or for a period of a maximum • 24 to 48 hours postoperatively
  18. 18. Fracture Reduction • The goal of reduction is to restore the anatomical relationship
  19. 19. Direct Reduction • Direct reduction – fragments are manipulated directly by the application of different instruments or hands, via open exposure of the fracture •
  20. 20. joysticks
  21. 21. Collinear reduction clamp
  22. 22. Reduction Forceps provide an excellent purchase on the fragments without stripping or squeezing the periosteum EG WEBERS FORCEPS
  23. 23. ADVANTAGES precise restoration of anatomy; DISADVANTAGES 1 more interference with bone and soft tissue biology. 2 higher risk of infection and 3 possibly a delay in bony union
  24. 24. Open Reduction • Open reduction implies that the fracture site is exposed, allowing to watch and inspect the adequacy of reduction with our eyes.
  25. 25. Indications for open reduction 1 Displaced articular # with impaction of the joint surface 2 #which require exact axial alignment (e.g., forearm #, simple metaphyseal #) 3 failed closed reduction due to soft tissue interposition 4 Delayed surgery where granulation tissue or early callus has to be removed 5 high risk for neurovascular structures 6 no or limited access to perioperative imaging to check reduction
  26. 26. Indirect reduction • Indirect reduction means that the reduction and alignment of the # by applying reduction forces indirectly • via the soft tissue envelope—to the main fragments by manual Or skeletal traction, a distractor, or some other means.
  27. 27. • classical example of indirect reduction is the “closed” insertion • of an intramedullary nail on a fracture table
  28. 28. The distractor
  29. 29. Indirect reduction ADVANTAGES virtually NO exposure of the fracture site ; LESS damage to the vascularity of the tissue DISADVANAGES 1demanding technique and that 2the correct overall alignment of the fracture is more difficult to assess, especially in rotation
  30. 30. Closed Reduction • Closed reduction relies entirely on indirect fragment alignment by ligamentotaxis or the pull of the soft tissue envelope
  31. 31. • Traction is the most common means to reduce a fracture – D/A applied across a joint and that there are limited possibilities to move the limb. Eg The fracture table
  32. 32. The distractor offers many possibilities and more freedom of movement •D/Aquite demanding to manipulate and requires considerable practice
  33. 33. advantages of closed reduction • minimal damage to soft tissues • safer • more rapid fracture repair • lesser infection.
  34. 34. Indications for closed reduction • Most diaphyseal fractures • • Minimally displaced articular fractures. • Geriatric femoral neck fractures, trochanteric fractures, subcapital humerus fractures, and certain distal radius fractures
  35. 35. Techniques and Instruments for Fracture Reduction
  36. 36. Screws • The two basic principles of a conventional screw are • to compress a fracture plane (lag screw) and • to fix a plate to the bone (plate screw)
  37. 37. • Cortical screws: –Greater number of threads –smaller pitch –Outer thread diameter to core diameter ratio is less –Better hold in cortical bone –Usually fully threaded –Size1-4.5mm diameter –Self tapping ,cannulated etc Figure from: Rockwood and Green’s, 5th ed.
  38. 38. •Cancellous screws: – Larger thread to core diameter ratio –pitch is greater -Lag effect with partially-threaded screws - – Theoretically allows better fixation in cancellous bone - indicated for meta-epiphyseal , cancellous bone Tapping is recommend
  39. 39. LHS •The LHS have a head with a thread •that engages with the reciprocal thread of the plate hole. •a screw-plate device with angular stability variable angular stability, which allows angulating locking screws within the plate hole to address specific fracture configurations
  40. 40. LAG SCREW
  41. 41. Positioning Screw a fully threaded screw that joins two anatomical parts at a defined distance without compression. The thread is therefore tapped in both cortices. example is a screw placed between fibula and tibia in a malleolar fracture
  42. 42. Plates • Conventional non locked screws used to fix a plate to the bone plate is pressed against the bone which produces preload and friction between the two surfaces. • #forearm bones , • simple metaphyseal fractures of long bones, malunion and nonunions, D/A local cortical necrosis
  43. 43. HISTORY OF PLATES • Early modern plates - round holes the conical--firm fit the dynamic compression • plate (DCP) by Perren . spherical screw head and an inclined oval screw hole
  44. 44. •Angle blade plates tubular plates, •reconstruction plates, the sliding hip screw and dynamic condylar •LC-DCP (limited contact- •DCP)
  45. 45. THE FIVE FUNCTIONS OF PLATING • Neutralization or protection • Compression • Buttressing • Tension band function • Bridging
  46. 46. Neutralization Plates • Neutralizes/protects lag screws from shear, bending, and torsional forces across fx • “Protection Plate"
  47. 47. Buttress / Antiglide Plates • “Hold” the bone up • Resist shear forces during axial loading – Used in metaphyseal areas to support intra-articular fragments • Plate must match contour of bone to truly provide buttress effect • Buttress Plate – When applied to an intra- articular fractures • Antiglide Plate – When applied to diaphyseal fractures
  48. 48. • Order of fixation: • Articular surface compressed with bone forceps and provisionally fixed with k-wires 1. Bottom 3 cortical screws placed • Provide buttress effect 2. Top 2 partially-threaded cancellous screws placed • Lag articular surface together 3. Third screw placed either in lag or normal fashion since articular surface already compressed Buttress Concepts Figure from: Schatzker J, Tile M: The Rationale of Operative Fracture Care. Springer-Verlag, 1987.
  49. 49. Bridge Plates • “Bridge”/bypass comminution • Proximal & distal fixation • Goal: – Maintain length, rotation, & axial alignment • Avoids soft tissue disruption at # = maintain # blood supply
  50. 50. Tension Band Plates • Plate counteracts natural bending moment seen wih physiologic loading of bone – Applied to tension side to prevent “gapping” – Plate converts bending force to compression – Examples: Proximal Femur & Olecranon
  51. 51. Plate Pre-Bending Compression • Prebent plate – A small angle is bent into the plate centered at the # – The plate is applied – As the prebent plate compresses to the bone, the plate wants to straighten and forces opposite cortex into compression – Near cortex is compressed via standard methods • External devices as shown • Plate hole design
  52. 52. Screw Driven Compression Device • Requires a separate drill/screw hole beyond the plate • Currently, more commonly used with indirect fracture reduction techniques
  53. 53. Dynamic Compression Plates •
  54. 54. Dynamic Compression Plating • Compression applied via oval holes and eccentric drilling – Plate forces bone to move as screw tightened = compression
  55. 55. Lag screw placement through the plate • Compression + rigidity obtained a with one construct • Compression plate first • Then lag screw placed through plate Figure from: Rockwood and Green’s, 5th ed.
  56. 56. Locking Plates • Screw head has threads that lock into threaded hole in the plate • Creates a “fixed angle” at each hole • Theoretically eliminates individual screw failure • Plate-bone contact not critical Courtesy AO Archives
  57. 57. Locking Plates • Increased axial stability • It is much less likely that an individual screw will fail • But, plates can still breakIndications: – Osteopenic bone – Metaphyseal fractures with short articular block – Bridge plating
  58. 58. Intramedullary Nails • Relative stability • Intramedullary splint • Less likely to break with repetitive loading than plate • More likely to be load sharing . • Secondary bone healing • Diaphyseal and some metaphyseal fractures
  59. 59. Intramedullary Fixation • Generally utilizes closed/indirect or minimally open reduction techniques • Greater preservation of soft tissues as compared to ORIF • IM reaming has been shown to stimulate fracture healing • Expanded indications i.e. Reamed IM nail is acceptable in many open fractures
  60. 60. Intramedullary Fixation • Rotational and axial stability provided by interlocking bolts • Reduction can be technically difficult in segmental and comminuted fractures • Difficult to Maintain reduction of fractures in close proximity to metaphyseal flare
  61. 61. • Open segmental tibia fracture treated with a reamed, locked IM Nail. • Note the use of multiple proximal interlocks where angular control is more difficult to maintain due to the metaphyseal flare.
  62. 62. • Intertrochanteric/ Subtrochanteric fracture treated with closed IM Nail • The goal: • Restore length, alignment, and rotation • NOT anatomic reduction • Without extensive exposure this fracture formed abundant callus by 6 weeks Valgus is restored...
  63. 63. Percutaneous Plating • Plating through modified incisions – Indirect reduction techniques – Limited incision for: • Passing and positioning the plate • Individual screw placement – Soft tissue “friendly”
  64. 64. •Classic example of inadequate fixation & stability •Narrow, weak plate that is too short •Insufficient cortices engaged with screws through plate •Gaps left at the fx site Unavoidable result = Nonunion Failure to Apply Concepts
  65. 65. Summary • Respect soft tissues • Choose appropriate fixation method • Achieve length, alignment, and rotational control to permit motion as soon as possible • Understand the requirements and limitations of each method of internal fixation
  66. 66. Thankyou

×