2/1/2018. Clinical Reasoning for Fracture Management

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1 Clinical Reasoning for Fracture Management AO: Arbeitsgemeinschaft für Osteosynthesefragen (German for "Association for the Study of Internal Fixation") Fracture is an event with immediate multi-tissue trauma 1

2 Potential Soft Tissue Injury with Fracture Ligament Volar Plate Tendons Skin Matrix Matrix % Collagen Cells % Ground Substance Cells Fibroblast, Myocyte, Chondroblast, Endothelial + Load Overuse Sprain/Strain Tear Fracture Disrupt Healing Kjaer2004, PhysiolRev: Mechanical Loading of Tissues: Counteract these extreme stresses by gradually adjusting the load towards normal, rather than the absence of loading (immobilization) - Load Atrophy Contracture Bone Density Healing 2

3 Grade C1 Simple Fx Grade C2 Complex Fx Grade C3 Complex Fx Grade C1 Simple Fx Grade C2 Complex Fx Grade C3 Complex Fx 3

4 Closed Injury Fracture Type Soft Tissue Complications Grade IC 1 Simple Fx No to minimal visible soft tissue injury Grade lc 2 Simple Fx Visiblecontusion, hematoma Grade IC 3 Complex Fx Deep contusion of skin Grade lc 4 Complex Fx Deep erosion/ necrosis of skin If you only measure what your expect, your miss None None R/O compartment syndrome Grade lc 5 Complex Fx Tissue necrosis All above High probabilityof infection;compartm ent syndrome The most common complication of hand fractures is not malunion or infection. Rather it is joint contracture and tendon adhesions. Baratz 1999 Hand Clinics 4

5 A method of documenting associated soft tissue injuries, and tying them to fracture classification, would be of benefit in reporting/comparing different outcome results The incidence of soft-tissue injury associated with (UE) fractures is not truly known and continues to evolve. Elbow Fractures 66% Soft Tissue Injuries Distal Radius Fracture 68% -81% Soft Tissue Injuries Meta/ Phalangeal Fractures? % Soft Tissue Injuries 13% -metacarpal fx stiffness 64% - phalangeal fxstiffness 19% -uninjured, neighboring digits Creighton 1994 Hand Clinics Page & Stern 1998 JHS Lutsky2016 HAND Von Kieseritzky2017 J Pl Surg& Hand Surg Neuro-inflammatory mechanism of fibrosis: Substance P stimulation Mast Cell signaling Myofibroblast contraction 5

6 Methods to fight the Axis of Fibrosis Pharmacology Motion best defense at present In the treatment of fractures, stabilizationof the injury and early motion remain the most effective methods we have available to prevent or minimize contractures Hildebrand 2013 Pain Infection See you in 6 weeks partner Hardware Failure Non-union Implant tolerance to stress Strength of Fixation Crossed K-wires K-wire Relative Stability External Fixator Interosseous wiring with K-wire Intermedullary Rods Tension band wiring wiring Screw Plate & screws 6

7 FRACTURE FIXATION AND HEALING METHODS CLOSED REDUCTION OPEN REDUCTION SECONDARY HEALING COMBINED HEALING PRIMARY HEALING Limited Relative Stability Absolute CRES CREF/CRIF Co-aptive Fixation Flexible Fixation Rigid Fixation Cast Percutaneous Pin K Wire Dynamic Plate & Screw: Compression Plate Splint Percutaneous K Wire Intramedullary Locking/Bridging Buttress Plate Fracture Bracing External Fixator Pin/Nail Tension Band Wiring Lag Screw Traction Splint Traction Splint (K wire) Interosseous Wiring (skin, nail) Wiring Limited Relative Mobility Full IFM InterfragmentaryMotion (IFM) micro-motion that occurs between the fracture fragments during early healing due to physiologic stress Mechanical stimuli provided by early IFM is essential for signaling cell recruitment and differentiation necessary for fracture healing Dose Dependent Animal model Fxwith Ext Fixator Controlled cyclical low compressive loads 17 min/day Results 1 wkdelay: fast increase in callus stiffness 4 wkdelay: delayed increase in callus stiffness 6 wkdelay: significant lower stiffness; predicted non-union 7

8 Feehan 2007 JHS: Effect of Early Controlled Passive Motion on the Quality and Rate of Early Fracture Healing in a Rabbit Model Closed Metacarpal Fracture Metacarpal Fracture Brace Group I: Immobilized Group 2: ECPM starting day 5 Effect of IM vs. ECPM on: 4-Point Bending Structural Properties Stiffness Fracture Dorsal Angulation Malunion Feehan 2007 JHS ECPM: x2 Daily, 15 Minute Sessions Pinch Stabilization Full Passive Digital Flexion and Extension Feehan 2007 JHS EPM 29% Stiffer EPM 33% Straighter Stiffness (N/mm*2) Initial Stiffness - Primary Outcome 200 IM 150 EPM Days 14 Days 28 Days 29% Fracture Angulation (Degrees) Fracture Dorsal Angulation - Secondary 50 Outcome IM EPM 5 Days 14 Days 28 Days 8

9 EZINE "We must appreciate the synergistic effect of soft tissue management on bone healing and vice versa." Jabaley2000 9

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