Fracture Reduction Flashcards
Define fracture reduction
The process of replacing the fracture segments in their original anatomical position
After classifying a fracture and reviewing the diagnostic images, one critical question must be answered, as the answer will significantly affect further treatment planning..?
Can this fracture be reconstructed or not?
If anatomic reconstruction is required or elected, what principles of fracture fixation to achieve primary bone healing?
AO (Arbeitsgemeinschaft für Osteosynthesefragen)
The reduction of fractures can be challenging, especially in bigger patients due to (2)
- Tension
- Contraction of soft tissue structures
Open reduction and internal fixation (ORIF) is suitable for the what fractures? (3)
- Simple fractures (e.g. transverse and oblique fractures);
- Fractures that can be reconstructed (e.g. segmental fractures, fractures with one large butterfly fragment;
- Articular fractures (require accurate anatomical reconstruction to minimise the progression of degenerative changes)
What cases are ORIF mandatory?
Articular fracture
When reducing fractures, what needs to be preserved? (2)
- Neurovascular structures
- Soft tissue envelope
Advantages of anatomical reconstruction (2)
Promoting of primary bone healing.
Bone column can participate in the load sharing straight after fixation.
Disadvantages of anatomical reconstruction (2)
Inevitably iatrogenic damage to the soft tissue envelope, periosteum and fracture haematoma – this can be minimised by careful tissue handling!
Could delay healing.
What are used occasionally during reduction to reduce muscle contraction?
Muscle relaxants
Reduction techniques (7)
- Elevation
- Levering
- Toggling
- Using bone plate to aid reduction
- Countertraction
- Pusher pin
- Distraction with devices
What type of # is elevation used for?
Transverse
How is elevation reduction performed?
By elevating the fractured bone ends out of the incision and bringing them into contact with each other. Pressure is slowly applied to replace the bones in a normal position.
What is required for “levering”? (2)
Either Hohmann retractor or periosteal elevator
How is levering reduction performed?
Levering involves using an instrument such as a Hohmann retractor or periosteal elevator to lever the bone fragments apart.
How is toggling performed?
Toggling involves traction to allow one side of the fracture fragments to be brought into contact. A ‘V’ shape is formed and the fracture is forcefully reduced as the fragment ends are kept in contact.
When “toggling” care must be taken not to..
Propagate any fissures present
What # type may be better reduced and maintained in reduction by securing a contoured plate to the short distal segment and reducing the proximal segment to the plate?
Eccentrically placed fractures such as transverse distal radial fractures
Describe technique of using a plate to aid reduction.
Securing a contoured plate to the short distal segment and reducing the proximal segment to the plate.
The reduction is maintained by securing the plate to the proximal segment with plate holding forceps.
What might be needed to contour the plate appropriately? (e.g. when using a plate to reduce #)
Torque
How to perform counteraction? How can soft tissue contracture be overcome during reduction?
Counteraction involves applying traction (pulling) distal to the fracture while applying countertraction proximal to the fracture.
Slow application of the force is more effective and holding the fracture in traction for a few minutes fatigues the muscles and can overcome soft tissue contracture.
What can be done prior to counteraction to aid reduction?
A hanging limb preparation can apply significant countertraction.
If performing open counteraction; what can be used to help?
Bone forceps
Discuss hanging limb - how to/amount?
For a hanging limb preparation the pull should create a force which lifts the animal slightly off the table. Once the fracture is reduced, the force can be slightly relieved to allow positioning on the table.
Countertraction can also be applied when performing closed fracture reduction. What are useful to achieve good reduction when distracting oblique fractures?
Pointed reduction forceps
How is the pusher pin technique used to reduce fractures?
A large Steinmann pin (‘pusher pin’) can also be used to distract fractures. The pin is placed in the medullary cavity and driven across the fracture into the metaphysis of the distal fragment. Continued pressure distracts the limb and aids in alignment of other fragments. It can be left in situ as part of a plate-rod construct.
What type of ESF can be used as a distractor?
Ia
What is temporary fixation?
- Reducing via different methods until primary fixation applied
What does bridging osteosynthesis refer to?
an implant being attached to the major proximal and distal bone fragments and that initially bears all the load placed on the limb (load bearing
True or false:
With comminuted fractures, accurate reconstruction is normally impossible, but load sharing can be achieved
FALSE - With comminuted fractures, accurate reconstruction is normally impossible and load sharing cannot be achieved
Comminuted #:
raditional open approaches and attempts at reconstruction can result in complications such as (4)
- Delayed union
- Non-union
- Implant failure
- Infection
What is the aim of biological osteosynthesis?
Preserve blood supply to # fragments
Biological osteosynthesis can be achieved by indirect fracture reduction through: (3)
- limited surgical approach with minimal or no disturbance of the fracture haematoma;
- fracture stabilisation using bridging osteosynthesis rather than anatomic reconstruction;
- limited use of bone graft.
Define alignment
Alignment refers to the position of the bone in three-dimensional space
What are the 2 forms of biological osteosynthesis?
Open but do not touch (OBDNT),
Minimally invasive osteosynthesis
What is avoided during “open but do not touch” (2)
Manipulation of:
- Haematoma
- Fragments
During OBDNT what are useful tooks to distract the # and align the bones?
IM pins
What is damaged during OBDNT (2)
- Soft tissue
- Vascular
What is the indirect benefit of OBNT?
Visualisation
Placing IM pin in femur (normograde); how should the femur be held? Why
Extended + adducted
- AVOID SCIATIC
Describe OBDNT with the femur.
After distraction of the distal fragment with bone holding forceps, the IM pin is directed into the distal fragment and advanced.
What is not performed with minimally invasive osteosynthesis?
Open # exposure
with MIO - How is the # reduced and how are implants applied?
The fracture is reduced indirectly and the implants are applied through small incisions away from the fracture site.
What approaches are mainly used for MIO of the femur? (2)
Proximal
Distal
Why are pre-operative radiographs (also of other side) advised for MIO? (2)
- Reference in surgery
- Pre contour
MIO; What facilitates the assessment of limb alignment and fracture fragment apposition and helps to ensure appropriate positioning of the implants?
Intraoperative fluoroscopy
Which fractures is Intraoperative fluoroscopy absolutely necessary for MIO? (2)
- Metaphyseal
- Articular
Minimally invasive osteosynthesis most effectively preserves…?
an optimal biologic environment for fracture healing
Askeleton can help you when planning to perform a biological osteosynthesis in the following ways: (2)
- The bone can act as a model to pre-contour the implants;
- To aid with intra-operative orientation.
