FRACTURE TREATMENT
Transcript of FRACTURE TREATMENT
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FRACTURE TREATMENT
DEPARTMENT OF TRAUMATOLOGY AND HAND
SURGERYINSTITUTE OF MUSCULOSKELETAL SURGERY
Presenter:
Dr Tamás Szabó
ENGLISH PROGRAM LECTURES – EN_03 - 2019
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Fracture treatment
Böhler’s Rules
Reduction
Retention(Stabilization)
Rehabilitation
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CONSERVATIVE OR OPERATIVE TREATMENT?
Which of the methods I can select from… since there
are plenty of them ….
Non-operative treatment:
• closed reduction
• splint / cast (circular, open)
fixation
• alternatively: brace
• functional therapy
Operative treatment:
• minimal OS (K-wires)
• screw
• rigid fixation (reamed
intramedullary nails, plates)
• flexible / dynamic fixation
(unreamed intramedullary
nails, external fixation)So much information already at the beginning…
Let’s see some help how to make the right decision…
at the right time…!
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CONSERVATIVE OR OPERATIVE TREATMENT?
A) Biology:
• which method is the best (optimal, ideal) ?
• which of the methods results in the best function?
• time frame?
B) Hospitals:
• conditions: personal (knowledge, training, experience)
and instrumental (implants, fluoroscope, navigation,
OR) means
• capability to deal with the possible complications
If not: → request help
→ transfer the patient to higher level
trauma care center
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CONSERVATIVE OR OPERATIVE TREATMENT?
C) Patients:
• general condition
• age, activity, other diseases
• associated injuries: multiple injured patients, priorities
• informed consent: possible complications
• compliance
Summary:
• right indication
• fracture analysis - bone consistency
• patient’s condition
• consider the possible treatments and discuss with
the patient
• to achieve the best outcome in the shortest time
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NON-OPERATIVE (CONSERVATIVE) - TREATMENTS
• Early load and muscle contraction promote
fracture healing: patella fracture without
dislocation (extensor function intact), single rib
fracture, os pubis fracture, fracture of proximal-
end of the humerus in elderly: Pölchen-therapy,
isolated fibular fracture
• Immediate motion exercises, adequate NSAID-
therapy
Early physiotherapy (without fixation) – ‘functional treatment’
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• Indication: (mostly) temporary
• Direction of pulling force: (usually)
axial
• System: K-wire – line – pulley – weight
• Site of K (Kirschner)-wires: femur
condyles, tuberositas tibiae /
calcaneus
• Pulling force: acetabulum fracture: 1/7
of b.w., femur fracture: 1/10 of b.w.,
tibia fracture: 1/20 of b.w. – max: 3 Kg
• Length: until fracture healing and/or
the soft-callus appears
NON-OPERATIVE TREATMENTS – SKELETAL TRACTION
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NON-OPERATIVE TREATMENTS – SKELETAL TRACTION
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• conventional plaster, fiberglass cast fixation
• splint, circular cast (first: always splint or circular
cast with open up!)
• Böhler: immobilize the two neighboring joints in
functional position
• alternatively: braces
NON-OPERATIVE TREATMENT – CAST FIXATION
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Mistakes
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Combination fixation devices & cast / brace – compromises in solution
‘SEMI-CONSERVATIVE TREATMENT’
Pinning (K-wires) & cast fixation:
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OPERATIVE - TREATMENTS
Reduction:
• closed (fluoroscope)• open (operative approach)
Stabilization (‘retention’):
• screw fixation• surface of the bone (plates)• intramedullary (rod/nail)• external fixation (fixateure externe)• ORIF = open reduction and internal fixation
Rehabilitation
• physiotherapy: therapeutic plan: goals & time-frame
Böhler – rules !!
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OPERATIVE - TREATMENTS
Level of Stability:
• load-stable: allows full weight-bearing
• motion-stable: full range of motion of the bone
• `bed-stable`
• unstable - that’s not good..
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• screw fixation
• tension band
• intramedullary nailing
• plate osteosynthesis
• external fixation – ‘fixateur externe’
• special devices: periprosthetic fractures
OPERATIVE - TREATMENTS
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Screw fixation
Cortical screw, medullar screw, compression screw (lag screw)
OPERATIVE - TREATMENTS
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Screw fixation tools
OPERATIVE - TREATMENTS
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Steps of screw fixation
OPERATIVE - TREATMENTS
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Tension band
Indication: olecranon fracture, patella fracture, AC-dislocation, lateral clavicle fracture
OPERATIVE - TREATMENTS
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Tension band
Olecranon fracture
OPERATIVE - TREATMENTS
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Tension band
Patella fracture
OPERATIVE - TREATMENTS
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Intramedullary fixation devices
Marchetti-Vicenzi nail
Gamma-nail (IMHS, PFNA, etc)
OPERATIVE - TREATMENTS
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Intramedullary nails (rods): unreamed femoral/humeral/tibial locking nail: UFN, UHN, UTN
reamed / unreamed Küntsher-nail (traditional)
OPERATIVE - TREATMENTS
Intramedullary fixation devices
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Plate fixation
OPERATIVE - TREATMENTS
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Reconstruction plate
DC (dynamic compression)-plate
KFI DC - plate
OPERATIVE - TREATMENTS
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Locking screw
OPERATIVE - TREATMENTS
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Locking Compression Plate (LCP)
(Fixateur interne)
OPERATIVE - TREATMENTS
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Fixateur externe
OPERATIVE - TREATMENTS
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Fixateur externe
Indications
• Open fractures
• Septic conditions
• Comminuted fractures
• Bone lenghtening
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Fixateur externe
Pre-builtModular
rod
joint
pin
OPERATIVE - TREATMENTS
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Raoul Hoffmann
1881 - 1972
Unilateral fixateur externe
OPERATIVE - TREATMENTS
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Fixateur externe
Triangular fixateur externe
Bridging fixateur externe
OPERATIVE - TREATMENTS
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Ilizarov ring fixateur
OPERATIVE - TREATMENTS
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Fixateur externe
Hibrid fixateur externe
OPERATIVE - TREATMENTS
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Periprosthetic
fractures
Locking plate + attachment
plates: Synthes
Cable ready plate: Zimmer
OPERATIVE - TREATMENTS
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Operative or non-operative treatment?
• Non-operative:
• No anaesethesia
• No risk of bleeding
• No infection
• No need for special
instruments
• Cheap?
• Operative:
• Anatomical fracture reduction
• Stabil fixation, no need for extra
fixation(plaster)
• Early physiotherapy
• Faster recovery
Advantege
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Operative or non-operative treatment?
• Non-operative:
• Non-anatomical reduction
• Long immobilization
• Weakness, atrophy,
• Stiffness
• Slow
• Operative:
• Invasive
• Anaestesia
• Risk of bleeding
• Risk of infection
• Special instuments
• Expensive (?)
• Special knowledge
Disadvantage
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QUIZ
SUMMARY:
• 89 years old patient
• history of hypertension
• ischemic cardiac disease
How would you treat this fracture?
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QUIZ
SUMMARY:
• 89 years old patient
• history of hypertension
• ischemic cardiac disease
How would you treat this fracture?
Early functional treatment – Pölchen - therapy
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QUIZ
SUMMARY:
• 31 years old patient
• no history of any diseases
• favorite sport: tennis
How would you treat this fracture?
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QUIZ
SUMMARY:
• 31 years old patient
• no history of chronic
diseases
• favorite sport: tennis
How would you treat this fracture?
Operative treatment – ORIF: plate or nail
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QUIZ
SUMMARY:
• 31 years old patient
• no history of chronic
diseases
• favorite sport: tennis
How would you treat this fracture?
Operative treatment – ORIF: plate or nail
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SUMMARY
• Risk / benefit & cost / benefit
• Purpose – correct indication
• Fracture type, classification, bone
consistency
• Correct (available) method
• Length of treatment (cost / benefit!!)
• Consider alternative treatment methods
• Informed consent – talk to the patient
‘Take home messages’
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SUMMARY
If you are interested in, please, check the following links for
further information:
1.
www.aotrauma.org: AO Surgery Reference & Online Education
2.
www.wheelessonline.com - Wheeles’ Textbook of Orthopaedics
THANKS FOR YOUR ATTENTION!
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CONSERVATIVE OR OPERATIVE TREATMENT?
http://www.youtube.com/watch?v=3rTsvb2ef5k
There is a fracture…
I need to fix it…
OK.. Let’s start at the
basics.. Where is the
fracture?.. To whom the
fracture belongs?.. etc
Funny conversation between the trauma surgeon and anesthetist registrar