conventional plates including different functions of screws, modes of plate application, Compression Mode.
Neutralization Mode.
Buttress plate.
Antiglide plate.
Bridge plating or span plating.
Tension band.
prebending precountouring
working length
lag screw
AO principles
biological fixation
MIPO
conventional plates including different functions of screws, modes of plate application, Compression Mode.
Neutralization Mode.
Buttress plate.
Antiglide plate.
Bridge plating or span plating.
Tension band.
prebending precountouring
working length
lag screw
AO principles
biological fixation
MIPO
Bone fractures are a very common orthopedic injury resulting from trauma and sudden loads or stresses applied to bones or a result from bones being weakened by certain diseases. More than 250,000 femur fracture patients are seen per year in the U.S. on average. Bone fractures are either a complete or partial break in a bone and in some cases a simple cast to immobilize the injury site is not enough to completely heal the fracture.
Immobilization from casts may not be enough to completely heal the fracture if a malunion (when both ends of the fractured bone misalign) occurs and/or if a non-union (when the fracture gap is too large and the fractured ends cannot re-attach to one another) occurs. In the case of a malunion or non-union, a possible solution to the problem is by surgically inserting an intramedullary rod into the center canal (diaphysial) region of the injured bone and fixating it into place with screws.
Screw and plates are most common used devices in orthopedics. However, sometimes we forget their principles, so this presentation hopes to review most their problems. Thank you for your attention!
This is a lecture presentation on applying external fixator on open fracture specially on tibia. This method is a classical method. Various new and dynamic fixators are there but the basics are the same.
Arthroscopic ACL Reconstruction By Dr Shekhar ShrivastavDelhiArthroscopy
Arthroscopic Acl Reconstruction By Dr Shekhar Shrivastav.
HOW NORMAL KNEE WORKS ?
The knee is the largest joint in the body, and one of the most easily injured. It is made up of the lower end of the thigh bone(femur), the upper end of the shin bone (tibia), and the knee cap (patella), which slides in a groove on the end of the femur. Four bands of tissue, the anterior and posterior cruciate ligaments, and the medial and lateral collateral ligaments connect the femur and the tibia and provide joint stability. The surfaces where the femur, tibia and patella touch are covered with articular cartilage, a smooth substance that cushions the bones and enables them to glide freely. Semicircular rings of tough fibrous-cartilage tissue called the lateral and medial menisci act as shock absorbers and stabilizers.
WHAT IS THE ROLE OF ACL ?
ACL along with other ligaments of the knee joint and meniscus provides stability to the knee joint.
WHAT IS LIGAMENT RECONSTRUCTION ( ACL ) ?
Ligament reconstruction involves replacing the torn ligament with a tendon (graft) from your knee and fixing the graft in place with screws. This procedure is performed with the use of the arthroscope. The anterior cruciate ligament (ACL) is the most common ligament requiring reconstruction procedures. The torn ligament is excised arthroscopically and new ligament is prepared by ligament grafts taken from your own body. Bony tunnels are prepared in femur and tibia using specialized instruments through which the new ligament is passed and fixed with special screws. This procedure requires relative rest or leave from your work or studies for about 2-3 weeks after which you will be allowed normal day to day activities.
WHEN CAN THE PATIENT BE AMBULATED AFTER SURGERY ?
The patient can walk from the same evening of the surgery. Initially the patient is advised to walk with a brace and a walking cane. Strengthening and range of motion exercises for the knee are started from the next day. The patient is discharged from the hospital 2nd or 3rd day after surgery. The patient can walk without support by 10-14 days depending on muscle strengthening. Slow Jogging and other strenuous activities are permitted after 3 months and the patient can return to active sports only 8-9 months after surgery.
Torn ACL Reconstructed ACL
For Further Queries contact your Orthopedic Surgeon at
+ 91 9971192233
Bone fractures are a very common orthopedic injury resulting from trauma and sudden loads or stresses applied to bones or a result from bones being weakened by certain diseases. More than 250,000 femur fracture patients are seen per year in the U.S. on average. Bone fractures are either a complete or partial break in a bone and in some cases a simple cast to immobilize the injury site is not enough to completely heal the fracture.
Immobilization from casts may not be enough to completely heal the fracture if a malunion (when both ends of the fractured bone misalign) occurs and/or if a non-union (when the fracture gap is too large and the fractured ends cannot re-attach to one another) occurs. In the case of a malunion or non-union, a possible solution to the problem is by surgically inserting an intramedullary rod into the center canal (diaphysial) region of the injured bone and fixating it into place with screws.
Screw and plates are most common used devices in orthopedics. However, sometimes we forget their principles, so this presentation hopes to review most their problems. Thank you for your attention!
This is a lecture presentation on applying external fixator on open fracture specially on tibia. This method is a classical method. Various new and dynamic fixators are there but the basics are the same.
Arthroscopic ACL Reconstruction By Dr Shekhar ShrivastavDelhiArthroscopy
Arthroscopic Acl Reconstruction By Dr Shekhar Shrivastav.
HOW NORMAL KNEE WORKS ?
The knee is the largest joint in the body, and one of the most easily injured. It is made up of the lower end of the thigh bone(femur), the upper end of the shin bone (tibia), and the knee cap (patella), which slides in a groove on the end of the femur. Four bands of tissue, the anterior and posterior cruciate ligaments, and the medial and lateral collateral ligaments connect the femur and the tibia and provide joint stability. The surfaces where the femur, tibia and patella touch are covered with articular cartilage, a smooth substance that cushions the bones and enables them to glide freely. Semicircular rings of tough fibrous-cartilage tissue called the lateral and medial menisci act as shock absorbers and stabilizers.
WHAT IS THE ROLE OF ACL ?
ACL along with other ligaments of the knee joint and meniscus provides stability to the knee joint.
WHAT IS LIGAMENT RECONSTRUCTION ( ACL ) ?
Ligament reconstruction involves replacing the torn ligament with a tendon (graft) from your knee and fixing the graft in place with screws. This procedure is performed with the use of the arthroscope. The anterior cruciate ligament (ACL) is the most common ligament requiring reconstruction procedures. The torn ligament is excised arthroscopically and new ligament is prepared by ligament grafts taken from your own body. Bony tunnels are prepared in femur and tibia using specialized instruments through which the new ligament is passed and fixed with special screws. This procedure requires relative rest or leave from your work or studies for about 2-3 weeks after which you will be allowed normal day to day activities.
WHEN CAN THE PATIENT BE AMBULATED AFTER SURGERY ?
The patient can walk from the same evening of the surgery. Initially the patient is advised to walk with a brace and a walking cane. Strengthening and range of motion exercises for the knee are started from the next day. The patient is discharged from the hospital 2nd or 3rd day after surgery. The patient can walk without support by 10-14 days depending on muscle strengthening. Slow Jogging and other strenuous activities are permitted after 3 months and the patient can return to active sports only 8-9 months after surgery.
Torn ACL Reconstructed ACL
For Further Queries contact your Orthopedic Surgeon at
+ 91 9971192233
Stacked Flexible Nailing for Radius Ulna Fractures: Revival of a lost Techniq...Inamdar Hospital
What to Learn from this Article? Stacked Flexible Nailing done for midshaft radius ulna fractures in adults seems a good minimally invasive surgical option
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
2. The intramedullary nail is commonly used for long-bone
fracture fixation and has become the standard treatment
of most long-bone diaphyseal and selected metaphyseal
fractures1
To understand the intramedullary nail, knowledge of
evolution and biomechanics are helpful 2
3. In 16 th Century In Mexico Aztec physicians have placed
wooden sticks into the medullary canals of patients with long
bone non-union.
In Mid 1800’s Ivory pegs were inserted into the medullary
canal for non-union. In1917 ‘s Hoglund of United States
reported the use of autogenous bone as a intramedulary
implant.
4. 1930’s In the United States, Rush and Rush described the
use of Steinman pins placed in the medullary canal to treat
fractures of the proximal ulna and proximal femur.
1940 ‘s : The Evolution of Kűntscher Nailing
Gerhard Kűntscher was born in Germany in 1900
1931 : Smith-Petersen reported the success of stainless
steel nails for the treatment of NOF #s
6. Harvey C. Hansen and Dana
M. Street developed a diamond
shaped nail which is relied on
the holding power of cancellous
bone at both ends. He termed
the word ‘Bolt
Lottes designed three flanged
femur and tibial nails. Both nails
employed a screw-on driver-
extractor
7. 1950’s:
Stryker designed a broach in
a cloverleaf and diamond
shaped pattern. It provided
maximum holding power to
resist torque and avoided
reaming the entire canal
circumference.
.
.
Schneider designed his nail
which incorporated a double-
ended stud, self broaching and
fluted with a square cross
section
8. 1950’s Interlocking Screws :
Modny and Bambara introduced
the transfixion intramedullary
nail in 1953
Nailing of tibia is introduced by
herzog in 1950.
Livingston bar,introduced a
short I-beam pattern pointed
nail at both ends,which had
short slots for cross-pinning with
screws
9. Today any fracture is stabilized by one of the two
systems of fracture fixation .
1. compression system
2. splinting system
Intramedullary fixation belongs to internal splinting
system.
Splintage may be defined as a construct in which
micromotion can occur between bone & implant,
providing only relative stability without interfragmentary
compression.
10. Depending on the anatomy the insertion can be ante
grade and retrograde.
The entry point depends on the anatomy of the bone but
is distant from the fracture site.
Intramedullary fixation techniques offer the advantages of
closed reduction and closed fixation.
11. A.CENTROMEDULLARY- K NAIL,FIRST GENERATION
IM NAIL
B.CEPHALOMEDULLARY- GAMMA NAIL, RUSSELL
TAYLOR NAIL,UNIFLEX, PFN
C.CONDYLOCEPHALIC NAIL-ENDER NAIL,LOTTES
ETC
12. •Also known as elastic stable intramedullary nailing
(ESIN), is a primary definitvie fracture care (PDFC) in
paediatric orthopaedic practice.
•This method works by 3 – point fixation or bundle
nailing.
•The elasticity of the construct allows for ideal
cirumstances of micro-motion for rapid fracture healing.
13. • Nonreamed nails are actually not nails but
pins. Their mechanical characteristics and
use are different from IM nails. They are of
smaller diameter and are more elastic.
• Their flexibility allows insertion through a
cortical window. There are many different
types of flexible nails, the best known are:-
Lottes nails - Tibia
Rush pins – for all the long bones of the body
Ender nails
Morote nails
Nancy nails
Prevot nails
Bundle nails
14. Intramedullary nails to be
used as single without
reaming.
A. Schneider nail [ solid,
four flutedcross section
and self broaching ends.
B. Harris condylocephalic
nail [curved in two
planes, and designed for
percutaneous, retrograde
fixation of extra capsular
hip fractures.
C. Lottes tibial nail
specially curved to fit the
tibia, and has triflanged
cross section.
15. RUSH NAILS
SOLID, CIRCULAR IN
CROSS SECTION,
STRAIGHT,WITH A
SHARP BEVELLED TIPS
AND A HOOK AT THE
DRIVING END.
16. Ender Nails, which are
solid pins with an
oblique tip and an eye in
flange at the other end,
were originally designed
for percutaneous, closed
treatment of extra
capsular hip fractures
17. •Each nail is precurved to achieve 3-point fixation where the
required precurve should be approximately 3 times the
diameter of a long bone at its narrowest point.
•Part of the biomechanical
stability is provided by the intact
muscle envelope surrounding
the long bone.
•All currently available nails
have beaked or hooked ends to
allow satisfactory sliding down
on insertion along inner surface
of the diaphysis without
impacting the opposite cortex.
18. •Insertion points that do not lie
opposite to one another produce
differing internal tension and
imbalance of the fracture stability
and fixation.
•The apex of the curvature should
be at the level of the fracture site.
•The nail diameter should be 40%
of the narrowest medullary space
diameter.
•.
19. •Two nails of the same diameter
and similarly prebent to be
used.
•Commonest biomechanical
error is lack of internal support.
20. There are two basic methods of IM pinning, they are:
1. Three point compression.
2. Bundle nailing.
Most pins stabilize fracture by three point
compression.
These pins are C- or S – Shaped, they act like a
spring.
The equilibrium between the tensioned pin and the
bone with its attached soft tissues will hold the
alignment.
21. The principle of bundle nailing was introduced by
Hackethal.
He inserted many pins into the bone until they jammed
within the medullary cavity to provide compression
between the nails and the bone.
Both techniques should be seen more as IM splinting
than rigid fixation.
Bending movements are neutralized, but telescoping and
rotational torsion are not prevented with this technique
22.
23. Flexible nail are usually simpler to use and can be
inserted more quickly.
If infection intervenes, the complication of likely less
severe. So can be used in tibia open fracture because of
its less blood supply and its subcutaneous location.
Because of small size of forearm bones reaming is
technically difficult, so unreamed nail have generally
been used.
24. •They are usually reamed nails in which interlocking is
its newer modification.
•The classic reamed nail is the hollow, open – section
nail of Küntscher.
•Most other reamed nails are variations of the
Küntscher nail such as the AO nail, and the various
interlocking nails, such as the Grosse – kempf, Klemm
Alta, Russell – Taylor, Uniflex, AO Universal and
others.
25. Consecutive advancements of nails over years Can be
grouped under three generations
1 st generation:
primarily act as splints ,rotational stability is minimal , primarly
relies on close fit
Eg –K nail , V nail
2 nd generation :
Improved rotational stability due to locking screw
Eg-Russel taylor nail
3 rd generation:
Nails with various designs to fit anatomocally as much as
possible ,to aid the insertion and stability
Eg -Nails with multiple curves ,multiple fixation systems
Tibial nail with malleolar fixation
26. A. Kuntscher nail, designed for open
nailing.
B. Kuntscher nail designed for closed
nailing which has a curved, tapered
tip, and is slotted throughout.
C.Grosse – Kempf nail
D.Alta intramedullary locking nail for
the femur. This is solid section,
cannulated nail with a hexagonal
cross section with smooth flutes to
enhance revascularization.
.
27. Russell – Taylor nail:
This is a second generation nail.
Proximal locking into the
femoral head enhances its
stability in hip fractures
28. Brooker – Wills nail fixing a
fracture of the femur, an AP
roentgenogram. This nail has
flanges deployed through
slots in the tip of the nail for
distal stability.
29. Except for the Brooker – Wills nail with its flanges and
the expandable tip of the Seidel nail, which is used
exclusively for the humerus, all current designs use two
distal transverse cross – locking screws, as in the Alta
intramedullary rod
Proximal fixation includes inclined screws as in the
Grosse Kempf nail, two transverse screws, as in the Alta,
and specialized screws though the nail designed to
secure fixation in the femoral head, as in the Russell –
Taylor
30. Gamma nail: This intramedullary
device is designed for proximal
intramedullary fixation of
intertrochanteric and some
subtrochanterc fractues.
31. When placed in a fractured long
bone, IM nails act as internal
splints with load-sharing
characteristics.
Various types of load act on an IM
nail: torsion, compression, tension
and bending
Physiologic loading is a
combination of all these forces
32. Bending moment = F x D
F = Force
D
F = Force
D
The bending moment for the plate
is greater due to the force being
applied over a larger distance.
IM Nail Plate
D = distance from force
to implant.
33. • Nail cross section
is round resisting
loads equally in all
directions.
• Plate cross-section
is rectangular
resisting greater
loads in one plane
versus the other.
34. The amount of load borne by the nail depends on the
stability of the fracture/implant construct.
This stability is determined by
1.Nail Characteristics
2.Number and orientation of locking screws
3.Distance of the locking screw from the fracture site
4.Reaming or non reaming
5.Quality of the bone
IM nails are assumed to bear most of the load initially, then
gradually transfer it to the bone as the fracture heals.
35. Several factors contribute to the overall biomechanical profile
and resulting structural stiffness of an IM nail.
Chief among them are
a)Material properties
b)Cross-sectional shape
c)Diameter Curves
d)Length and working length
e)Extreme ends of the nail
f) Supplementary fixation devices
36. • Metallurgy less important
than other parameters for
stiffness of an IM Nail.
Most of them are
fabricated from stainless
steel, with a small number
from titanium.
0
50
Cobalt
316L Stainless
steel
Titanium
Bone cortex
PMMA
* 10 ⁸ psi
37. Titanium alloy has a modulus of elasticity closely
approximates that of cortical bone ( Modulus is ability to
resist deformation in tension
The material must be stiff . Titanium are 1.6 times stiffer and
elastic modulus is 50% lower than steel nail
38. The cross-sectional shape of the nail ,Diameter
determines its bending and torsional strengths( Resistance
of a structure to torsion or twisting force is called polar
movement of inertia )
Circular nail has polar movement of inertia proportional to
its diameter, in square nail its proportional to the edge
length
Nails with Sharp corners or fluted edges has more polar
movement inertia
Cloverleaf design resist bending most effectively .Presence
of slot reduces the torsional strength . It is more rigid when
slot is placed in tensile side
40. Diameter :
Nail diameter affects bending rigidity of nail.
For a solid circular nail, the bending rigidity is proportional to
the third power of nail diameter
Torsional rigidity is proportional to the fourth power of
diameter .
Large diameter with same cross-section are both stiffer and
stronger than smaller ones.
•Some nails are designed in a such a way that stiffness
doesn’t vary with diameter.
41. •The diameter of a nail should always
be measured with a circular guage.
•In reamed nailing, the width of nail is
better determined by the feel of the
reamers than by radiographic
measurements, although the
approximate size to be used can be
determined from preoperative
radiographs.
Nail
Diamete
r (mm)
Stainles
s Steel
(X 106 )
Titaniu
m
(X 106 )
10 40.0 20.0
11 52.0 26.0
12 69.0 34.5
13 88.8 44.4
14 112.1 56.4
15 139.1 69.6
16 170.1 75.1
17 241.4 120.7
Flexural rigidity (EI) of slotted cloverleaf
IM Nails (1mm wall thickness) (Nmm2)
42. Obtain preoperative radiographs of the
fractured long bone, including the proximal
and distal joints.
If there is any question, obtain an
anteroposterior radiograph of the opposite
normal limb at a tube distance of 1meter. A
nail of the appropriate size should be taped to
the side of the limb for reference, or a
radiographic ruler can be used, alternatively a
Kuntscher measuring device – the ossimeter
may be used to measure length and width.
The ossimeter has two scales, one of which
takes into account the magnification caused
by the X-ray at a 1 – m tube distance.
-In most cases, a nail reaching to within 1 to 2
cm of the subchondral bone distally is
indicated.
Size – length
43. CURVES
Longitudinal (Anterior) bow
•Governs how easily a nail can be inserted as well as bone/
nail mismatch, in turn influences the stability of fixation of the
nail in the bone.
•Complete congruency minimizes normal forces and hence
little frictional component to nail’s fixation.
•Conversely, gross mismatch increases frictional component of
fixation and inadequate fracture reduction.
Femoral nail designs have considerably less curve, with
radius ranging from 186 to 300 cm
44. Herzog bend
Tibial nail also has a smooth 11
bend in the anterioposterior
direction at junction of upper one
third and lower two third .
Mismatch in the radius of
curvature between the nail and
the femur can lead to distal
anterior cortical perforation
45. When inserting nail , axial force is necessary as the nail
must bend to fit the curvature of the medularly canal .
The insertion force generates hoop stress in the bone (
Circumferential expansion stress )
Greater the insertion force higher the hoop stress. Larger
hoop stress can split the bone
46. Over reaming the entry hole by 0.5-
1mm ,selecting entry point
posterior to the central axis reduce
the hoop stress
Example :The ideal starting
point for insertion of an
antegrade femoral nail is in the
posterior portion of the piriformis
fossa . It reduces the hoop
stress
47. Length and working length
A-Total nail length- total anatomical length
B-Working length-
-Length of a nail spanning the fracture site
from its distal point of fixation in the proximal
fragment to proximal point of fixation in the
distal fragment
-Length between proximal and distal point of
firm fixation to the bone
-Un supported portion of the nail between
two major fragments
48. Working length is affected by various factors
Type of force (Bending ,Torsion )
Type of fracture
Interlocking
Reaming
49. The bending stiffness of anail is inversely proportinal to
the square of its working
Length
The torsional stiffness is inversely proportional to its
working length.
Shorter the working length stronger the fixation
Medullary reaming prepares a uniform canal and improves
nail- bone fixation
Towards the fracture,thus reducing the working length.
50. Interlocking screws are recommended for most cases of IM
nailing.
The number of interlocks used is based on fracture location,
amount of fracture comminution , and the fit of the nail
within the canal.
Placing screws in multiple planes may lead to a reduction
of minor movement
The principle of interlocking nailing is different. The nail is
locked to the bone by inserting screws through the bone and
the screw holes. The resistance to axial and torsional forces
is mainly dependent on the screw – bone interface, and the
length of the bone is maintained even if there is a bone
defect.
51. when screws placed proximal and
distal to the fracture site. This restrict
translation and rotation at the fracture
site.
Indications – communited ,
spiral,pathologicalfractures Fractures
with bone loss lengthning or shortening
osteotomies , Atropic non union
•It achieves BRIDGING FIXATION
through which fracture is often held in
distraction , a favourable environment for
periosteal callus formation exists and
healing rather than nonunion is rule.
52. It achieves additional rotational
control of a fragment with large
medullary canal or short epi-
metaphyseal fragment.
It is effective only when the contact
area between the major fragments is
atleast 50% of the cortical
circumference.
With axial loading, working length in
bending and torsion is reduced as
nail bends and abuts against the
cortex near the fracture, improving
the nail-bone contact
53. •No longer std. practice to dynamize an interlocked
nail by removing the locked screws .
•It is indicated when there is a risk of development of
nonunion or established pseudoarthrosis.
•The screws are then removed from the longer
fragments, maintaining adequate control of shorter
fragment. Premature removal may cause shortening,
instability and nonunion.
54. •when malalignment develops during
nailinsertion,placement of blocking
screw, and nail reinsertion improves
alignment.
•Most reliable in proximal and distal
shaft fractures of tibia.
•A posteriorly placed screw prevents
anterior angulation and laterally placed
screw prevents valgus angulation.
Poller screw
55. •Characterised by an outer
diameter, root diameter and
pitch.
•Shape of the threads at their
base determines stress
concentration (sharp v/s
rounded).
56. •Pullout strength is dependent on
the outer diameter.
•The largest diameter of the screw
which can be used is limited by the
diameter of the nail.
•Increasing the diameter of the
screws reduces the cross section
of the nail at its hole and their by
predisposes to failure.
57. Stability depends on the locking screw diameter for a given
nail diameter. In general, 4 to 5 mm for humeral nails and 5
to 6 mm for tibial and femoral nails.
Nail hole size should not exceed 50% of the nail diameter.
Interlocking screws undergo four-point bending loads, with
higher screw stresses seen at the most distal locking sites
The number of locking screws is determined based on
fracture location and stability.
In general, one proximal one distal screw is sufficient for
stable fractures.
58. The location of the distal locking screws
affects the biomechanics of the fracture .
The closer the fracture to the distal locking
screws, the nail has less cortical contact ,
which leads to increased stress on the
locking screws.
More distal the locking screw is from
fracture site, the fracture becomes more
rotationally stable
.
59. -
Orientation of the proximal femur locking screws has little
effect on fixation stability, with both oblique and transverse
proximal locking screws showing equal axial load to failure.
.
-
Oblique ( angled to nail axis, not 90°) proximal locking
screws appear to increase the stability of proximal tibia
fractures compared with transverse ( 90° to nail axis)
locking screws.
However, oblique or transverse orientation of the distal
screws in distal-third tibia fractures has minimal effect on
stability
60. K-nail has slot/eye in the either ends for attachment of
extraction hook .one end is tapered to facilitate the insertion .
Present version of cannulated locking screw contains
cylinderical proximal end with internally threaded core to
allow firm attachment of driver and extracter.
Holes for interlocking screws present either ends .
Some nails have slots near the distal end for placement of
anti rotation screw
61. Slot
- Anterior slot - improved
flexibility
- Posterior slot - increased
bending strength
Non-slotted - increased
torsional stiffness, increased
strength in smaller sizes.
Unknown if its of any clinical
advantage.
62. Closed nailing :
- Fluoroscopy is used to achieve fracture reduction .
- Medullary cavity is entered through one end of the bone “
antegrade .
eg-Piriformis fossa in femur .
Closed antegrade nailing is the method of choice .
Open nailing :
- Performed in lessthan ideal operation room conditions
- Antegrade nailing is prefered .
- In retrograde method nail is inserted in to the proximal
fragment through fracture site and brought out at one end of
the bone ,after reduction nail is driven in to the distal
fragment
- Infection and non union is six and ten times greater in open
nailing
63. F R A C T U R E R E D U C T I O N
The earlier a fracture is nailed,
easier is the reduction. Shortly
after injury, the hydraulic effects
of edematous fluid can cause
shortening and rigidity of the
limb segment, which may make
fracture reduction extremely
difficult. If nailing is not done
before this degree of edema,
gentle traction may be required
to regain length and alignment
gradually.
64. In femur, the reduction is most easily achieved by placing
the distal fragment in neutral position, avoiding tightness of
the iliotibial band, which could otherwise result in shortening
and a fixed valgus deformity.
65. As the tibia is subcutaneous, direct
manipulation results in reduction in
most cases.
- In upper extremity, reduction is
achieved by a combination of
manipulation of the proximal fragment
with the nail and direct manipulation
of the distal fragment and fracture site
.
- In open nailing, the key to reduction
is to angle the fracture. - The corners
of the cortices of the proximal and
distal fragments are approximated at
an acute angle, and the fracture is
then straightened into appropriate
alignment.
66. With reamed rods, which are generally fairly rigid, the
entry site must be directly above the intramedullary
canal. Eccentric entry sites, particularly in the femur
and tibia, can result in incarceration of the nail or
comminution.
For nonreamed, flexible nails, an eccentric entry site is
usually used to take advantage of three – point
fixation of the curved nail within the medullary canal.
Generally these nails are inserted distally through the
supracondylar flares of the long bones
68. The entry site for reamed
nails is in the thin cortex at
the base of the greater
trochanter at the site of its
junction with the superior
aspect of the femoral neck.
ANTEGRADE NAILING FOR FEMUR:
69.
70.
71. RETROGRADE IM
NAILING
3 cm longitudinal incision
approximately 1 cm from
the medial border of
patella, beginning about 2
cm proximal to distal pole
of the patella
72.
73. IM reaming can act to increase the contact area between the
nail and cortical bone by smoothing internal surfaces.
When the nail is the same size as the reamer, 1 mm of
reaming can increase the contact area by 38% .
Reaming reduces the working length and increase the
stability.
More reaming allows insertion of a larger-diameter nail,
which provides more rigidity in bending and torsion.
Biomechanically, reamed nails provide better fixation stability
than do unreamed nails
74. Medullary canal is more or less like an hour-glass than
a perfect cylinder. Reaming is an attempt to make the
canal of uniform size to adapt the bone to the nail. The
size of the canal limits the size of the nail.
75. Reamers must be sharp, and the
surgeon must consider the
relationship between the size of the
reamers and the nail.
A 12mm reamer is not necessary
equal in diameter to a 12mm nail.
Because flexible reamers follow a
curvilinear pathway, overreaming is
usually necessary for most nails.
Most nail require overreaming from
0.5 to 2mm over the size of the
nail, depending on the type of nail,
the configuration of the fracture,
and the canal of the bone.
76. Insert a ball-tipped reaming guide pin across the fracture
to the subchondral bone in the distal fragment begin with
an end – cutting reamer, generally 8.5 to 9.0 mm in
diameter.
On the first pass of the reamer past the fracture site,
visualize it on the fluoroscope to ensure that reaming is
progressing appropriately.
It is safest to ream progressively in 0.5 – 1mm
increments.
77.
78. Both reamed and unreamed nails cause damage to
the endosteal blood supply.
Experimental data suggest that reamed nailing
deleteriously affects nutrient artery blood flow, but
cortical blood supply is significantly reduced after
reamed nailing compared with unreamed nailing.
Reaming is also associated with the potential risk of
fat necrosis
Blunt reamers and the use of reamers larger in
diameter than the medullary canal Lead to increased
temperature , therefore it suggested that long bones
with very narrow canals should first be
reamed manually or an alternative treatment method
should be used.
79. Some surgeons believe that unreamed nailing is
advantageous in the treatment of Gustilo III B open
fractures, citing higher infection rates.
Clinical studies of both tibial and femoral fractures
show that reamed nailing of fractures with low – grade
soft tissue injuries significantly reduces the rates of
nonunion and implant failure in comparison with
unreamed nailing. In fractures with an intact soft
tissue envelope, reaming of the medullary cavity
increases significantly the circulation within the
surrounding muscles. This increased circulation may
improve fracture healing
Reaming does not increase the risk of compartment
syndrome.
80. Fat embolism due to IM reaming was described by
Kuntscher. Fat embolism due to passage of IM contents
into the bloodstream can occur only in the IM pressure
associated with instrumentation exceeds the physiologic
IM pressure and out weighs the effects of the normal
blood flow.
The incidence of fat embolism is more with femoral
reaming,. Reaming of the tibia does not lead to a
significant increase of IM pressure, and intraoperative
echocardiography does not show significant fat embolism
in reamed tibial fractures.
The use of a venting hole to reduce the IM pressure
increase during reaming is controversial.
81. Advantages
• Allows insertion of larger-sized implants which helps in weight
bearing and joint function during the healing process.
- Improves nail-bone cortical contact across the working length of
the implant and directs fracture fragments into a more anatomical
position.
- From a biologic standpoint, provides systemic factors to promote
mitosis of osteogenic stem cells and to stimulate osteogenesis.
Disadvantages
Eccentric reaming may lead to malreduction of the fracture.
- Destroys all medullary vessels, resulting in a initial decrease in
endosteal blood flow and in turn decreased immune response and
delay in early healing of the involved cortices.
- In open fractures, avascular and nonviable fragments causes
increased susceptibility to infections.
82. Side effects
- Heat: a rise in temperature upto 44.6⁰ C had
a negative effect on fracture healing.
•Cell enzymes get damaged and cannot fullfill
their function.
•The threshold value of heat induced
osteonecrosis is 47⁰C.
- Pressure: hydraulic pressure builds up in the
cavity which far exceeds that of blood
pressure and is independent of the size of the
reamer.
•It acts as a piston in sleeve which is filled
with a mixture of medullary fat, blood, blood
clots and bone debris.
•High intramedullary pressure forces contents
into the cortical bone and systemic circulation.
83. A long, very sharp awl, mounted on a T – handle, must
be used to pinpoint the area of penetration of the bone to
avoid exposing the surgeon’s hands to the direct beam of
the fluoroscope.
Bring the awl into the fluoroscope image, placing it
directly over the screw hole image. Mark the location for
the skin incisions.
Make a 1 cm longitudinal incision directly over the screw
hole. Insert the awl percutaneously to the cortex of the
bone.
84. Again, bring the tip of the awl into the fluoroscopic image
at an angle to the fluoroscope beam and locate the tip of
the awl directly in the middle of the screw hole, make a
hole in cortex.
Once this hole is made, insert the appropriately sized
drill point and, while maintaining alignment with
fluoroscope head, drill the hole through the rod and
medial cortex.
Verify its position on the anteroposterior view, and then
insert the appropriately sized screw.
85. Lateral fluoroscopic
view of the distal
screws in Grosse –
Kempf nail:
The hole, which is to
be cross – locked is
in the center of the
screen and is
perfectly
superimposed
86. Segmentally comminuted diaphyseal fracture without bony
contact and nails with a 12-mm diameter and two distal
locking bolts could with stand the typical biomechanical
forces of weight bearing.
In patients who retain diaphyseal bony contact after fracture
fixation, nails with a diameter <12 mm or nails with a single
distal interlock may provide adequate stability for weight
bearing because the bony contact reduces the load
encountered by the distal interlocking screws.
Weight bearing through a locked IM nail could be allowed in
fractures in which 50% cortical contact is present
87. It is not necessary to remove a nail in a weight bearing limb
unlike a plate.
If needed can be removed after 18 months.
Indications for removal-
- Patient request, pain swelling secondary to backing out of
the implant.
- Nail removal should not be undertaken lightly ,specialized
extraction equipment fitting the nail must be available.
- Full weight bearing can commence immediately after the
removal of nail
88. Z-Effect is an unfortunate by-product of most intramedually
nails that utilize two screws placed up into the femoral neck
and head. Typically, the superior screw is of smaller diameter
than the inferior and bears a disproportionate amount of load
during weight bearing. Excessive varus forces placed on the
smaller screw at the lateral cortex cause it to toggle and either
back out or migrate through the femoral head into the
acetabulum. The larger inferior screw is neither keyed in
rotation nor locked in place, and it too will either back out or
migrate medially. The resultant Z-Effect where the two screws
move in opposite directions is one mode of failure for the
conventional two screw reconstruction device.
89. With all metallic implants, there is a relative race between
bone healing and implant failure.
Occasionally, an implant will break when fracture healing is
delayed or when nonunion occurs.
IM nails usually fail in predictable patterns. Unlocked nails
typically fail either at the fracture site or through a screw hole
or slot.
Locked nails fail by screw breakage or fracturing of the nail at
locking hole sites, most commonly at the proximal hole of the
distal interlocks
90. applications of im nailing
Anatomic alignment, early weight bearing, early unrestricted joint &
muscle rehabilitation are of advantage to the patient.
ARDS can be prevented in multiple injuries by stabilizing and mobilizing
the patient immediately.
Floating hip, floating knee, floating elbow.
To protect the vascular repair following injuries by a fracture.
Aseptic and septic non-union.
Pathological fractures.
Malunions.
High proximal and low distal fractures of long bones
Open tibial and femoral grade I and II fractures
91. 40gms of bone cement is
taken and mixed with 2 to 4
gms of powder when dough
is semi solid.
It is wrapped around K nail
of size 6 to 7 mm and rolled
between two palms.The rod
is then passed through the
holes of the nail major
usually 8 to 9mm diameter
to maintain uniformity of
diameter.
92.
93. 1.CAMPBELL OPERATIVE ORTHOPAEDICS
11TH EDITION
2.The science and practice of Intramedullary
Nailing – Bruce D. Brown
3.ROCKWOOD AND GREENS
4.INTERLOCKING NAILING-DD.TANNA
5. The elements of fracture fixation – Anand J
Thakur
6.Prospective study of distal end radius fracture by an
intramedullary nailing JBJS aug3 2011