607 - Fracture Management

Question 1

What factors can you use to help you decide on the best option to repair a fracture?

Answer 1

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?

Question 2

How can you tell if a fracture is anatomically reconstructable or not?

Answer 2

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

Question 3

Describe the benefit of anatomic reconstruction (when it is done correctly).

Answer 3

Load-sharing between the bone and implant

Question 4

Discuss the biologic price of anatomic reconstruction.

Answer 4

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

Question 5

What type of bone healing MUST an articular fracture repair be and why?

Answer 5

Direct
Callus healing within a joint will lead to severe arthritis

Question 6

Describe the requirements we must meet to achieve direct bone healing.

Answer 6

Perfect anatomic reconstruction
Interfragmentary compression

Question 7

What are the options for articular fracture repair?

Answer 7

Lag screw

Question 8

What are the options for simple non-comminuted greenstick long bone fractures of the radius or tibia?

Answer 8

Cast

Question 9

What are the repair options for long oblique or spiral simple long bone fractures?

Answer 9

IM pin + cerclage
Neutralisation plate and lag screws

Question 10

In what bone can you NEVER use IM pin + cerclage as a fracture repair option?

Answer 10

Radius

Question 11

What type of plate can be used to repair a simple transverse fracture of a long bone?

Answer 11

Compression plate

Question 12

Discuss the repair options for comminuted long bone fractures. Are they reconstructable?

Answer 12

Not reconstructable

Bridging fixation - bridging plate, external fixation device, or interlocking nail

Question 13

What type of bone healing is used for comminuted fractures?

Answer 13

Indirect/callus bone healing

Question 14

What level of stability does bridging fixation achieve? What do we need to consider when determining how strong the repair needs to be?

Answer 14

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

Question 15

In what circumstance would you decide not to reconstruct a reconstructable fracture?

Answer 15

Immature dogs with very good/favourable fracture biology (simple fractures)

Question 16

List the consequences of making a fracture repair not strong enough vs too strong.

Answer 16

Not strong enough –> implant failure before healing

Too strong –> no stimulus for bone to heal, bone resorption

Question 17

List the 5 things which the stability of a repaired fracture depends on.

Answer 17

1. Type of fracture
2. Whether the fracture can be anatomically reconstructed - determines whether load sharing can be achieved
3. Method of fracture repair
4. Whether it was a single or multiple limb injury
5. Patient size and level of activity during repair

Question 18

Give 3 examples of lightweight fracture repair methods and how they work.

Answer 18

IM pins +/- cerlcage wire
External coaptation - casts, splint, sling
Smooth pin external skeletal fixators (ESF)

Rely on friction or immobilisation

Question 19

Give an example of a heavyweight fracture repair method and how it works.

Answer 19

Bone plates, ESFs, interlocking nails

Neutralise forces by threaded fixation

Question 20

List the 4 key things that affect fracture biology.

Answer 20

3. 4.

Question 21

Explain how you can limit the damage you do to the soft tissue envelope as a surgeon.

Question 22

Discuss the 2 types of fracture healing that can occur.

Question 23

Whether a fracture heals or not after your surgical repair depends on what factors?

Answer 23

Fracture biomechanics
Fracture biology
Clinical context

Question 24

What 3 things determine how good the blood supply from the soft tissue envelope is?

Answer 24

1. Soft tissue envelope prior to the fracture - depends on location of the fracture
2. Soft tissue envelope after the fracture - depends whether it was a high or low energy fracture
3. Soft tissue envelope after the fracture repair - depends on the type of repair done and surgeon skill

Question 25

Name the 2 primary sites for non-union in dogs and cats.

Answer 25

Distal radius
Distal tibia

Question 26

Which types of fractures are most commonly high energy and what affect do they have on the soft tissue envelope?

Answer 26

Comminuted +/- open fractures most commonly
Significant damage to STE

Question 27

Which types of fractures are most commonly low energy and what affect do they have on the soft tissue envelope?

Answer 27

Spiral + simple oblique and transverse fractures
Minimal damage to STE

Question 28

What are the 3 major options for fracture repair?

Answer 28

Closed reduction
Minimally invasive percutaneous osteosynthesis
Open reduction - either open reduction for internal fixation (ORIF) or open but do not touch (OBDNT)

Question 29

When would you consider doing open reduction for internal fixation over open but do not touch?

Answer 29

For anatomically reconstructable fractures
BUT you need to make sure you can achieve absolute stability including anatomic reconstruction with interfragmentary compression