Asso.

Professor Theerasan k kiriratnikom f h k

Reduction Retention R i rehabilitation

Inflammatory Reparative(repair) p ( p ) Remodeling

Inflammation Repair

Remodelling

Hematoma formation

Time

Source of signal molecules, such as S f i l l l h TGF1, PDGF , to initiate induction of inflammation and h li i fl i d healing. Fibrin scaffold for conduction of healing. g

Cellular C ll l events of i d i f induction Vasodilatation + Angiogenesis

OSTEOGENESIS

Bone formation to t connect th f t t the fracture.

The function of living osteoblasts

Only living bone can heal !

To stay alive and repair itself, b it lf bone must have an th adequate blood supply supply.

depends on mechanical environment

direct or primary healing indirect or secondary healing

Motion exists between fracture f fragments.

healing b h li by specialized g granulation tissues

=

CALLUS

Union by a Callus

Secondary Healing S d H li = Healing by a Callus g y

Direct Healing (Primary)

Gap healing Contact healing

No ll f N callus formation ti Need anatomical reduction and f fixation with interfragmentary f g y compression

Primary healing

Callus (secondary) h li C ll ( d ) healing

Healing H li by a y callus

Primary Healing

Injury variables Patient Variables Treatment Variables T V i bl Reduction Retention/Stabilization

Injury variables Patient Variables Treatment Variables T V i bl Reduction Retention/Stabilization

Temporary Splint p Definite Cast Traction Internal f l fixation External fixation

Femoral Fractures Knee Injuries Tibia Fractures Tibi F Ankle Fractures Aim to reduce pain ,prevent further injury

Slap Cylinder cast y Plaster of Paris Fiberglass cast

Three point fixation Hydro dynamic or hydrostatic effect

Three point fixation

hydrostatic

Fiberglass cast Plaster f Paris Pl t of P i cast t

slap

Long arm cast Hanging cast g g Short arm cast Thumb spica

long arm cast with the elbow at 90 degrees and the wrist included in the cast is less commonly used now because forearm and e bow actu es a e o te elbow fractures are often internally fixed, but it is still used for less severe fractures. fractures The cast is applied from just below the axilla to just proximal to the metacarpophalangeal joints of the digits but leaving the thumb f l i h h b free. The wrist is placed in 30 degrees of dorsiflexion and the elbow in 90 degrees of flexion

Forearm cast, is the most widely used upper limb cast and i li b t d is used for most distal radial and ulnar fractures as well as f f ll for some carpal injuries. The cast extends from below the elbow to just proximal to the metacarpal necks of p the digits with the thumb left free

These casts are routinely used to treat humeral diaphyseal fractures in the acute phase. p The arm is placed over the lower chest with the elbow at 90 degrees. A collar and cuff support can be used to maintain the position. A cast is then applied as shown , so that the top of the humeral component of the cast is above the humeral fracture. Gravity is used to regain humeral length and the alignment of the fracture

To treat fracture scaphoid

Used to treat fracture humerus

Hip spica Long leg cast g g Short leg cast Short leg walking cast Patella tendon baring cast(PTB)

Below Knee Cast This is the Cast. most common cast used for lower limb injury including ankle fractures, foot fractures, and soft tissue injuries. It is d ft ti i j i i occasionally used to treat undisplaced lower tibial diaphyseal fractures or minor pilon f t il fractures. Th cast i The t is applied from below the level of the fibular neck proximally to the level of the metatarsal heads distally with the ankle at 90 d ll h h kl degrees and the foot in the plantigrade position .(The below knee cast may be applied y pp as a first stage in a long leg cast used to treat an unstable tibial diaphyseal fracture.

Use to treat unstable tibial diaphyseal fracture in the acute phase changing to a patellar tendon-bearing cast after a few weeks weeks. They may also be used to treat fractures around the knee. A long leg cast is best constituted by applying a below knee cast and then flexing the g knee to about 10 degrees

Used to treat tibial diaphyseal fractures after a f ft few weeks i a k in long leg cast. In this cast the proximal end of a below knee cast f b l k is extended upward as far as the lower pole in the patella and moulded around the patellar tendon to provide a degree of rotational stability

Body jacket d k Minerva cast

o o

o o

Skin traction Temporary traction p y Traction in children Skeletal traction Temporary traction When Wh surgery i not possible is ibl

Often used preoperatively for femoral fractures Can use tape or pre-made d boot No more than 10 lbs Not used to obtain or hold reduction

Bucks with sling May be used in more distal femur fx in children Can be modified to hip p and knee exerciser

Used for distal 2/3rd femoral shaft fx Femoral pin allows rotational moments Easy to avoid joint and growth plate 1 inch distal and posterior to tibial tubercle

Enables elevation of limb to correct angular malalignment Counterweighted support system y Four suspension points allow angular and rotational control t ti l t l

BHLER-BRAUN BHLER BRAUN FRAME

Useful for subtroch and proximal 3rd femur fx Especially in y p y young g children Matches flexion of proximal f i l fragment Can cause flexion contracture in adult

Skull traction

1. Displaced intraarticular fractures suitable for surgical reduction and stabilization . 2. Unstable fractures in which an appropriate trial of nonoperativemanagement has failed 3. 3 Major avulsion fractures associated with disruption of important musculotendinous units or ligamentous groups p that have been shown to have a poor result with nonoperative treatment 4. Displaced pathological fractures in patients not imminently terminal

High probability for internal fixation for optimal result

5. Fractures for which non operative treatment is known to yield poor functional results, such as femoral neck fractures, Galeazzi fracture-dislocations, and Monteggia fracture-di slocations 6. Displaced physeal injuries that have a propensity for g growth arrest ( (Salter-Harris type III and IV) yp ) 7. Fractu res with compartment syndromes that require fasciotomies 8. Nonunions, especially malreduced ones, in which previous nonoperative or surgical treatments have failed f il d

1. Unstable spinal injuries, long bone fractures, and unstable pelvic fractures, especially in poly trauma patients 2. Delayed unions after an appropriate trial of y nonoperative management 3. Impending pathological fractures 4. Unstable open fractures 5. Fractures associated with complex soft-tissue lesions (Gustilo type IIlB open fractures, burns over fractured areas, or preexisting dermatitis)

6. F t 6 Fractures i patients i whom prolonged in ti t in h l d immobilization would lead to increased systemic complications ( g hip y p (e.g., p and femoral fractures in elderly patients and multiple fractures in patients with ISS <18) 7. U 7 Unstable infected fractures or unstable septic bl i f df bl i nonunlOns ? 8. 8 Fractures associated with vascular or neurological deficits that require surgical repair, including long bone fractures in patients with spinal cord, conus, or proximal

nerve root lesions ?

K wire Tension wire Screw Plate and screw Nail Interlock nail I l k il

- Circulation - Stability - Soft tissue coverage g

screw

- Direct exposure to fracture area - Detachment of soft tissue while reduction and applying instruments - Time consuming - R Require accurate reduction with i d i ih absolute stability

- Multifragmentary fracture of diaphysis of long bone - Most metaphyseal Fx - Minimally invasive plate osteosynthesis - Require relative stability

Small incisions , indirect reduction p g No opening of fracture site No interfragmentary compression No forced attempt to achieve anatomical reduction - No bone grafts necessar necessary - Application of special plates and screw

Accepted Indications Accepted indications are as follows: 1. Severe type II and III open fractures 2. F 2 Fractures associated with severe b i d ih burns 3. Fractures requiring subsequent cross leg flaps, free vascularized grafts, or other reconstructive procedures Multiple injury (damage control orthopaedic) 4. Certain fractures requiring distraction (e.g., fractures associated with significant bone loss or fractures in g paired bones of an extremity in which maintenance of equal length of the paired bones is important) 5. 5 Limb lengthening 6. Arthrodesis 7. Infected fractures or nonunions 8. 8 Correction of malunions

1. 1 Certain pelvic fractures and dislocations 2. Open, infected pelvic nonunion 3. 3 Reconstructive pelvic osteotomy (i.e., exstrophy of the bladder) 4. Fixation after radical tumor excision with autograft or allograft replacement ih f ll f l 5. Femoral osteotomies in children (use of this method eliminates the necessity of subsequent removal of internal fixation appliances such as p pp plates and screws) 6. Fractures associated with vascular or nerve repairs orreconstructions 7. Limb reimplantation

Question?