7/23/2018 DESCRIBING THE FRACTURE. Pattern Open vs closed Location BASIC PRINCIPLES OF FRACTURE MANAGEMENT. Anjan R. Shah MD July 21, 2018.
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1 BASIC PRINCIPLES OF FRACTURE MANAGEMENT Anjan R. Shah MD July 21, 2018 DESCRIBING THE FRACTURE Pattern Open vs closed Location POLL OPEN HOW WOULD YOU DESCRIBE THIS FRACTURE PATTERN? 1 Spiral 2 Transverse 3 What Fracute? 1
2 LANGUAGE OF FRACTURES How would you describe this fracture pattern? A. Spiral B. Transverse C. What fracture? LANGUAGE OF FRACTURES Fracture Pattern Spiral Transverse LANGUAGE OF FRACTURES Fracture Pattern Spiral Transverse Comminuted 2
3 LANGUAGE OF FRACTURES Fracture Pattern Spiral Transverse Comminuted Open Shaft LOCATION OF FRACTURE POLL OPEN WHERE IS THE LOCATION OF THIS FRACTURE? 1 Radial shaft 2 C spine 3 intra-articular distal radius 3
4 Where is the location of this fracture? A. Radial shaft B. C spine C. intra-articular distal radius LOCATION OF FRACTURE FRACTURES 101 Location and Pattern Depends on bone quality and mechanism of injury (i.e deforming forces) Dictates treatment options Directs rehabilitation plan Affects long term outcomes and expectations TYPES OF BONE HEALING Determined by mechanical stability Primary When strain is less than 2% : Rigid Fixation Direct or end to end healing To restore a smooth joint surface Plates/screws Secondary Strain 2-1 Non rigid fixation Callous formation Casts, Rods, Braces 4
5 TYPES OF BONE HEALING Determined by mechanical stability Primary When strain is less than 2% : Rigid Fixation Direct or end to end healing Plates/screws. Secondary Strain 2-1 Non rigid fixation Callous formation Casts, Rods, Braces TYPES OF BONE HEALING Determined by mechanical stability Primary When strain is less than 2% : Rigid Fixation Direct or end to end healing Plates/screws. Secondary Strain 2-1 Non rigid fixation Callous formation Casts, Rods, Braces INTRA-ARTICULAR FRACTURES Pose an unique set of challenges and goals! Injury to joint surface and cartilage Risk of post traumatic arthritis Requires primary bone healing Absolute stability Small fragments Limits fixation 5
6 CHOICE OF FIXATION FOR INTRA-ARTICULAR INJURIES Load bearing implants Load of force transfers to implant Plate(s) & screws Often around articular and peri-articular injuries 6
7 WOULD YOU ALLOW THIS PATIENT TO BE WBAT IMMEDIATELY POST OP? POLL OPEN 1 A. Yes 2 B. NO Would you allow this patient to be WBAT immediately post op? A. Yes B. NO INTRA-ARTICULAR FRACTURES Injury to cartilage Small fragments Limited fixation Absolute stability Primary bone healing Restoring and maintaining congruity is critical for limiting post traumatic arthritis. 7
8 as1 POST TRAUMATIC ARTHRITIS Osteoarthritis caused secondary to trauma Compromised bone health Inadequte reduction/stabilization Poor blood supply Tobacco DM Important to maintain a good joint Articular Fractures Distal Femur INTRA-ARTICULAR FRACTURES Articular Fractures INTRA-ARTICULAR FRACTURES Acetabular Fractures 8
9 Slide 22 as1 anjan shah, 7/18/2015
10 INTRA-ARTICULAR FRACTURES Articular Fractures Wrist fractures SUMMARY Intra-articular fractures represent significant trauma with both acute and potential long term issues for the joint and patient overall health Anatomic, rigid fixation Optimal joint reconstruction to achieve optimal outcomes LONG BONE FRACTURES 9
11 WHAT ARE THE LONG BONES? Humerus Femur Tibia + Fibula LONG BONE FRACTURE LOCATION MATTERS Shaft Surgical Goals Re-establish stable axial alignment Rehabilitation Goals Mobilization Strength Long Term Goals Restoration to preinjury state HUMERAL SHAFT FRACTURES 5% of all fractures Young patients (20s, male) High energy MVC, fall from height, GSW Older patients (60s, female) Low energy GLF 10
12 MECHANISM OF INJURY Torsional, bending, axial, combo Direct impact or blast (GSW) CLINICAL EVALUATION Pain Swelling Deformity Careful neurovascular examination Standard radiographic examination AP Lateral view Joints above and below Traction xrays may help CT for joint involvement MRI for pathologic process IMAGING 11
13 TREATMENT GOALS Maintain acceptable alignment of the fracture Provide enough stability to allow healing Preserve joint motion Avoid complications HUMERAL SHAFT FRACTURES- MOST SIMPLE HUMERAL SHAFT FRACTURES REQUIRE SURGERY? POLL OPEN 1 A. True 2 B. False 3 C. Depends on the day of the week? HUMERAL SHAFT FRACTURES Most Simple Humeral Shaft Fractures Require Surgery? A. True B. False C. Depends on the day of the week? 12
14 NON-SURGICAL TREATMENT Generally successful Rigid immobilization not required for successful healing Perfect alignment not essential for a good result NON-SURGICAL TREATMENT Requirements Cooperative, upright patient Absence of major soft tissue injury Ability to obtain and maintain an adequate reduction NON-SURGICAL TREATMENT Hanging Arm Cast Coaptation Splint Better support of proximal fragment Functional Orthosis 7-10 days Tighten as swelling decreases Flex/ext elbow helps align 13
15 NON-SURGICAL TREATMENT Zagorski et al: JBJS 1988 Good functional restoration Complications minimal More recent reports (JOT 06): Nonunion rates 10-2 Caution: simple olique pattern INDICATIONS FOR SURGICAL TREATMENT Absolute Failed closed treatment Open fracture Vascular injury Floating elbow Severe soft tissue injury Pathologic INDICATIONS FOR SURGICAL TREATMENT Relative Polytrauma Inability to maintain reduction with bracing Segmental Radial nerve dysfunction following manipulative closed reduction** 14
16 FEMUR FRACTURES Common injury due to major violent trauma 1 femur fracture/ 10,000 people More common in people < 25 yo or >65 yo Motor vehicle, motorcycle, auto-pedestrian, aircraft, and gunshot wound accidents are most frequent causes FEMUR FRACTURE MANAGEMENT Initial traction with portable traction splint Timing of surgery is dependent on: Resuscitation of patient Other injuries - abdomen, chest, brain Isolated femur fracture FEMUR FRACTURE MANAGEMENT Shaft fractures are managed by intramedullary nailing Proximal or distal 1/3 fractures MAY be managed best with a plate or an intramedullary nail depending on the location and morphology of the fracture 15
17 INTRAMEDULLARY NAILING OF FEMUR FRACTURES IMMEDIATE WEIGHT BEARING Axial Load to Failure 30 75% Stiffness in Bending 5 Stiffness in torsion Withstand 500,000 cycle at loads of 3X body FEMUR FRACTURE TECHNIQUE Retrograde Intramedullary Nailing 16
18 TIBIA FRACTURES Most common long bone fracture 492,000 fractures yearly Average 7.4 day hospital stay 100,000 non-unions per year HISTORY & PHYSICAL Low Energy Minimal soft-tissue injury Less complicated fracture pattern and management decisions 17
19 HISTORY & PHYSICAL High Energy High incidence of neurovascular energy and open injury Low threshold for compartment syndrome Complete soft-tissue injury may not declare itself for several days RADIOGRAPHIC EVALUATION Full length AP and Lateral Views Check joint above & below Oblique views may be helpful in followup to assess healing INJURIES ASSOCIATED 3 of patients will have multiple injuries Ipsilateral Fibula Fracture Foot & Ankle injury Syndesmotic Injury Ligamentous knee injuries 18
20 INJURIES ASSOCIATED Ipsilateral Femur Fx Floating Knee Neurovascular Injury More Common In: High Energy Proximal Fracture Floating Knee Knee Dislocation CLOSED TIBIAL SHAFT FRACTURE Broad Spectrum of Injures w/ many treatments Closed Management Intramedullary Nails Plates External Fixation POLL OPEN CLOSED TIBIAL SHAFT FRACTURE- MOST DISPLACED TIBIAL SHAFT FRACTURES CAN BE TREATED IN A CAST? 1 True 2 False 19
21 CLOSED TIBIAL SHAFT FRACTURE Most displaced tibial shaft fractures can be treated in a cast? A. true B. false NON-OPERATIVE TREATMENT INDICATIONS Minimal soft tissue damage Stable fracture pattern < 5 varus/valgus < 10 pro/recurvatum < 1 cm shortening Ability to bear weight in cast or fx brace Requires frequent follow-up Schmidt ICL 52, 2003 Surgical Options Intramedullary Nail ORIF with Plate External Fixation Combination of fixation 20
22 ADVANTAGE OF IM NAIL Less malunion Early weight-bearing Early motion Early WB (load sharing) Patient satisfaction L Bone, JBJS Cost Less expensive to society when compared to casting Busse Acta Ortho 05 SUMMARY LONG BONE FRACTURES Injury can occur at any location Shaft fractures unique to long bones IM nailing allows early WB Restoration of alignment and function Thank You! 21
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