607 - Fracture Management Flashcards
What factors can you use to help you decide on the best option to repair a fracture?
Is it anatomically reconstructable or not?
Location of the fracture
How strong does the repair need to be for it to heal properly according to the fracture biomechanics?
What is the fracture biology? - how long will it take to heal?
How can you tell if a fracture is anatomically reconstructable or not?
Depends how many pieces there are!
2 piece fractures are often anatomically reconstructable
3 pieces may or may not be reconstructable
>3 pieces/comminuted fractures can NOT be anatomically reconstructed
Describe the benefit of anatomic reconstruction (when it is done correctly).
Load-sharing between the bone and implant
Discuss the biologic price of anatomic reconstruction.
Fractured bones rely on extraosseous periosteal blood supply through muscle attachments until the medullary artery reforms, which can take several weeks
In reducing the fracture you are inevitably going to do some damage to the periosteal blood supply which can compromise fracture healing further
What type of bone healing MUST an articular fracture repair be and why?
Direct
Callus healing within a joint will lead to severe arthritis
Describe the requirements we must meet to achieve direct bone healing.
Perfect anatomic reconstruction
Interfragmentary compression
What are the options for articular fracture repair?
Lag screw
What are the options for simple non-comminuted greenstick long bone fractures of the radius or tibia?
Cast
What are the repair options for long oblique or spiral simple long bone fractures?
IM pin + cerclage
Neutralisation plate and lag screws
In what bone can you NEVER use IM pin + cerclage as a fracture repair option?
Radius
What type of plate can be used to repair a simple transverse fracture of a long bone?
Compression plate
Discuss the repair options for comminuted long bone fractures. Are they reconstructable?
Not reconstructable
Bridging fixation - bridging plate, external fixation device, or interlocking nail
What type of bone healing is used for comminuted fractures?
Indirect/callus bone healing
What level of stability does bridging fixation achieve? What do we need to consider when determining how strong the repair needs to be?
Relative stability
No load sharing - repair needs to be strong enough to withstand all the load
Healing is usually prolonged because comminuted fractures are high energy and do massive damage to the soft tissue envelope - repair needs to last a long time
Maintaining muscle attachments to the fragments is critical because they provide healing blood supply
In what circumstance would you decide not to reconstruct a reconstructable fracture?
Immature dogs with very good/favourable fracture biology (simple fractures)
List the consequences of making a fracture repair not strong enough vs too strong.
Not strong enough –> implant failure before healing
Too strong –> no stimulus for bone to heal, bone resorption
List the 5 things which the stability of a repaired fracture depends on.
- Type of fracture
- Whether the fracture can be anatomically reconstructed - determines whether load sharing can be achieved
- Method of fracture repair
- Whether it was a single or multiple limb injury
- Patient size and level of activity during repair
Give 3 examples of lightweight fracture repair methods and how they work.
IM pins +/- cerlcage wire
External coaptation - casts, splint, sling
Smooth pin external skeletal fixators (ESF)
Rely on friction or immobilisation
Give an example of a heavyweight fracture repair method and how it works.
Bone plates, ESFs, interlocking nails
Neutralise forces by threaded fixation
List the 4 key things that affect fracture biology.
- 4.
Explain how you can limit the damage you do to the soft tissue envelope as a surgeon.
Discuss the 2 types of fracture healing that can occur.
Whether a fracture heals or not after your surgical repair depends on what factors?
Fracture biomechanics
Fracture biology
Clinical context
What 3 things determine how good the blood supply from the soft tissue envelope is?
- Soft tissue envelope prior to the fracture - depends on location of the fracture
- Soft tissue envelope after the fracture - depends whether it was a high or low energy fracture
- Soft tissue envelope after the fracture repair - depends on the type of repair done and surgeon skill
Name the 2 primary sites for non-union in dogs and cats.
Distal radius
Distal tibia
Which types of fractures are most commonly high energy and what affect do they have on the soft tissue envelope?
Comminuted +/- open fractures most commonly
Significant damage to STE
Which types of fractures are most commonly low energy and what affect do they have on the soft tissue envelope?
Spiral + simple oblique and transverse fractures
Minimal damage to STE
What are the 3 major options for fracture repair?
Closed reduction
Minimally invasive percutaneous osteosynthesis
Open reduction - either open reduction for internal fixation (ORIF) or open but do not touch (OBDNT)
When would you consider doing open reduction for internal fixation over open but do not touch?
For anatomically reconstructable fractures
BUT you need to make sure you can achieve absolute stability including anatomic reconstruction with interfragmentary compression
