Treatment of Fracture by Dr. Nimer Khraim DVMS, BVMS, MVSc, PhD(Dr.med.vet)

Treatment of Treatment of Fracture Fracture

byby

Dr. Nimer Khraim Dr. Nimer Khraim

DVMS, BVMS, MVSc, PhD(Dr.med.vet)DVMS, BVMS, MVSc, PhD(Dr.med.vet)

Treatment of FractureTreatment of Fracture

Immediate treatment Immediate treatment

Control h. Control h.

Prevent infectionPrevent infection

Control pain Control pain

Treat shock Treat shock

Treatment of FractureTreatment of Fracture

Temporary immobilizationTemporary immobilization

To prevent further soft T. To prevent further soft T. damage damage

Treatment of FractureTreatment of Fracture

The basic principle of fracture treatment The basic principle of fracture treatment include: include:

Accurate reduction Accurate reduction

Stable fixation Stable fixation

Preservation of blood supply and early Preservation of blood supply and early return to function return to function

Treatment of FractureTreatment of Fracture

Accurate reductionAccurate reduction Close reduction by manipulationClose reduction by manipulation The fragment are angulated until one The fragment are angulated until one

cortex of each fragment are touchingcortex of each fragment are touching The limb is then gradually extended to The limb is then gradually extended to

overcome the muscle spasm and over-overcome the muscle spasm and over-righting righting

Treatment of FractureTreatment of Fracture

Open reduction its indications:Open reduction its indications:

Failure to a chief reduction by Failure to a chief reduction by close manipulationclose manipulation

Intra-articular fracture Intra-articular fracture

Treatment of FractureTreatment of Fracture

Distracted fracture Distracted fracture

Delay union, mal-union or non-Delay union, mal-union or non-union union

Application to internal fixation Application to internal fixation

Treatment of FractureTreatment of Fracture

ImmobilizationImmobilization

The ideal fixation of fracture should The ideal fixation of fracture should be be

Maintain stable reduction Maintain stable reduction

Not interfere with blood supply Not interfere with blood supply

Treatment of FractureTreatment of Fracture

Allow free range of movement Allow free range of movement

Chief Chief

Removable Removable

Treatment of FractureTreatment of Fracture

There is tow type of fixation There is tow type of fixation

Internal fixation Internal fixation

External fixation External fixation

Internal Fixation Internal Fixation

Internal Fixation Internal Fixation

Internal fixation Internal fixation

Rigid fixation Rigid fixation

Adequate reduction Adequate reduction

Impossible to maintain an acceptable Impossible to maintain an acceptable position by external fixation position by external fixation

External fixation will not be tolerate External fixation will not be tolerate

Type of internal Type of internal fixation fixation

Intramedullary pinningIntramedullary pinning

Intramedullary pinningIntramedullary pinning

Type of internal fixation Type of internal fixation

Intramedullary pinningIntramedullary pinning

Commonly use round pin like Commonly use round pin like

Steinmann pin, kirschner pin, rush Steinmann pin, kirschner pin, rush pin pin

Intramedullary pinningIntramedullary pinning

The pin should be approximately The pin should be approximately the diameter of morrow cavity at the diameter of morrow cavity at the fracture sitethe fracture site

Fixation of pin to both end of the Fixation of pin to both end of the bone with impingment of the bone with impingment of the inner surface of the cortex at the inner surface of the cortex at the fracture site fracture site

Intramedullary pinningIntramedullary pinning

Fracture that is readily palpation Fracture that is readily palpation and reductionand reduction

In open method a pin may In open method a pin may

inserted through the end of the inserted through the end of the bone or retrograde direction from bone or retrograde direction from the fracture sitethe fracture site

Intramedullary pinningIntramedullary pinning

Protruding end of the pin is cut Protruding end of the pin is cut enough to baired under the skin enough to baired under the skin and soft T. and soft T.

The pin is remove when the The pin is remove when the clinical union has been a chief clinical union has been a chief

Intramedullary pinningIntramedullary pinning

Inter medullary pinning dose not Inter medullary pinning dose not provide sufficient stability provide sufficient stability

fixation medullary fixation that fixation medullary fixation that include include

Intramedullary pinningIntramedullary pinning

Wire Wire Kirschner splint Kirschner splint 2 pin or more 2 pin or more Screw Screw In large animal cast or splint to In large animal cast or splint to

prevent blent of pin prevent blent of pin

Intramedullary pinningIntramedullary pinning

Kirshner splint (Kirshner Ehmer splint)Kirshner splint (Kirshner Ehmer splint) Insert 2 pin in proximal and distal bone Insert 2 pin in proximal and distal bone

segment and the pin connected by segment and the pin connected by external barexternal bar

The splint may be apply following The splint may be apply following

close or open reduction using pin-close or open reduction using pin-chuck to drill the both cortex chuck to drill the both cortex

Kirshner splintKirshner splint

The 2 pin in each segment are inserted The 2 pin in each segment are inserted at approximately 34 to 40 degree into at approximately 34 to 40 degree into each other each other

as healing approach the stage of as healing approach the stage of clinical union it may be tested by clinical union it may be tested by removing the bar and gentile bending removing the bar and gentile bending the bone to determine the strength of the bone to determine the strength of the callus the callus

Bone plate Bone plate

Bone plate Bone plate

Bone plate Bone plate

The technique provide rigid The technique provide rigid internal fixation which eliminate internal fixation which eliminate all shortening rotation and all shortening rotation and angular forces at the fracture angular forces at the fracture

Bone plate Bone plate

Its type are:Its type are:

Compression bone plate insertion Compression bone plate insertion under tension under tension

Neutralizing bone plate insertion not Neutralizing bone plate insertion not under tensionunder tension

Bridging bone plate used to short up a Bridging bone plate used to short up a gap in the bone gap in the bone

Bone plate Bone plate

Buttress bone plate: holdup one Buttress bone plate: holdup one cortex relative to the other mainly cortex relative to the other mainly use in epiphyseal and use in epiphyseal and metaphysical fracture metaphysical fracture

Dynamic compression bone plate Dynamic compression bone plate used in any of these method used in any of these method

The basic principle in The basic principle in application of bone plate application of bone plate and screw and screw

Bone plate Bone plate

One of the most stable forms of fracture One of the most stable forms of fracture fixation.fixation.

Loaded bones have compression and Loaded bones have compression and tension sides. tension sides.

Bone plates should be applied to the tension Bone plates should be applied to the tension side of a bone to provide maximum stability.side of a bone to provide maximum stability.

Bone plate Bone plate

Clinically these surfaces are the lateral Clinically these surfaces are the lateral side of the femur, medial or cranial side of the femur, medial or cranial surface of the tibia, cranial or lateral surface of the tibia, cranial or lateral surface of the humorous, and the surface of the humorous, and the cranio-medial or cranial surface of the cranio-medial or cranial surface of the radius. radius.

Bone plate Bone plate

Bone plates are capable of Bone plates are capable of neutralizing compression, tension, neutralizing compression, tension, shear, bending and torsion forces.shear, bending and torsion forces.

The bending stiffness of a plated bone The bending stiffness of a plated bone is related to the length of the plate; the is related to the length of the plate; the longer the plate the greater the longer the plate the greater the stiffness.stiffness.

Bone plate Bone plate

Filling all screw holes with screws Filling all screw holes with screws improves the strength and stiffness of improves the strength and stiffness of a plate.a plate.

The use of wider and/or thicker plates The use of wider and/or thicker plates can enhance a plate’s ability to can enhance a plate’s ability to counteract the disruptive forces.counteract the disruptive forces.

Bone plate Bone plate

Dynamic Compression Plate (DCP)Dynamic Compression Plate (DCP)

– A plate applied to a bone so that it is A plate applied to a bone so that it is under tension and the fracture fragments under tension and the fracture fragments are under compression.are under compression.

Bone plate Bone plate

– As the screw is tightened the fragment As the screw is tightened the fragment into which it is being placed is displaced into which it is being placed is displaced toward the fracture line and the center of toward the fracture line and the center of the plate.the plate.

Bone plate Bone plate

– By alternate tightening of “loaded” screws By alternate tightening of “loaded” screws on each side of a fracture line the on each side of a fracture line the fragments are compressed. fragments are compressed.

DCP TypesDCP Types

DCP TypesDCP Types

Narrow DCP: Narrow DCP:

the width of the plate is just slightly the width of the plate is just slightly greater than the screw holes and the greater than the screw holes and the holes are arranged in a straight line.holes are arranged in a straight line.

DCP TypesDCP Types

Broad DCP:Broad DCP:

the plate is considerably wider than the the plate is considerably wider than the screw holes; the holes may be in a screw holes; the holes may be in a straight line or staggered, and the plate is straight line or staggered, and the plate is thicker than a narrow DCP. thicker than a narrow DCP.

DCP TypesDCP Types

Limited contact DCP:Limited contact DCP:

Not all of the surface of the plate is in Not all of the surface of the plate is in contact with the bone.contact with the bone.

Special PlatesSpecial Plates

Special PlatesSpecial Plates

C-shaped plates for dorsal acetabular C-shaped plates for dorsal acetabular fracturesfractures

T-shaped plates have a variety of T-shaped plates have a variety of applications including distal radial applications including distal radial fractures and certain types of fractures and certain types of arthrodesisarthrodesis

Special PlatesSpecial Plates

Cuttable plates. They can be cut to the Cuttable plates. They can be cut to the specific length needed and can be specific length needed and can be stacked one on the other if additional stacked one on the other if additional strength is needed. strength is needed.

Plate FunctionPlate Function

Plate FunctionPlate Function

Neutralization plate: is applied to the Neutralization plate: is applied to the tension side of a fractured bone.tension side of a fractured bone.

Buttress plate: The plate is placed to Buttress plate: The plate is placed to span or bridge a fractured area to span or bridge a fractured area to maintain length when fragments are maintain length when fragments are left unreduced or are missing and left unreduced or are missing and replaced with a cancellous bone graft.replaced with a cancellous bone graft.

Plate ApplicationPlate Application

Plate ApplicationPlate Application

• Plates are placed on the tension side of a Plates are placed on the tension side of a long bone and secured to the bone with long bone and secured to the bone with bone screws. bone screws.

• A minimum of 3 to 4 screws must be A minimum of 3 to 4 screws must be placed on each side of a fracture for a placed on each side of a fracture for a compression, neutralization or bridging compression, neutralization or bridging plate.plate.

Plate ApplicationPlate Application

• Screws are placed so they engage both Screws are placed so they engage both cortices of the bone. cortices of the bone.

• The minimum distance between a screw The minimum distance between a screw and a fracture line should be between 4 and a fracture line should be between 4 and 5 mm. and 5 mm.

Plate ApplicationPlate Application

• Long plates are more effective than short Long plates are more effective than short plates in neutralizing disruptive forces.plates in neutralizing disruptive forces.

• The ideal in most cases is to use a plate The ideal in most cases is to use a plate that is just short of the entire length of the that is just short of the entire length of the bone. bone.

Plate ApplicationPlate Application

The plate must be in contact with and The plate must be in contact with and conform to the shape of the bone to which it conform to the shape of the bone to which it is being applied.is being applied.

Plates are bent or twisted so that they can fit Plates are bent or twisted so that they can fit the contours of a bone. the contours of a bone.

The bends and twists must be placed The bends and twists must be placed between the screw holes.between the screw holes.

CERCLAGE OR HEMICERCLAGE CERCLAGE OR HEMICERCLAGE WIREWIRE

CERCLAGE OR HEMICERCLAGE CERCLAGE OR HEMICERCLAGE WIREWIRE

Circle of wire that completely or Circle of wire that completely or partially goes around the partially goes around the circumference of a bone circumference of a bone

They are not used as sole They are not used as sole method of repair or fixation in any method of repair or fixation in any type of fracturetype of fracture

CERCLAGE OR HEMICERCLAGE CERCLAGE OR HEMICERCLAGE WIREWIRE

IndicationsIndications

Long oblique, spiral & Long oblique, spiral & comminuted Fr comminuted Fr

For auxillary fixationFor auxillary fixation

CERCLAGE OR HEMICERCLAGE CERCLAGE OR HEMICERCLAGE WIREWIRE

Use wires of sufficient strength Use wires of sufficient strength 10, 20,22 gauge 10, 20,22 gauge

Apply tightly Apply tightly

CERCLAGE OR HEMICERCLAGE CERCLAGE OR HEMICERCLAGE WIREWIRE

Space them about l cm apart & 0.5 cm Space them about l cm apart & 0.5 cm from Fr. line from Fr. line

Never use less than 2 wires Never use less than 2 wires

ScrewsScrews

ScrewsScrews

INDICATIONSINDICATIONS

– Screws can be used by themselves for Screws can be used by themselves for fractures of the femoral neck and for fractures of the femoral neck and for intercondylar fractures of the distal intercondylar fractures of the distal humerus and femur. humerus and femur.

ScrewsScrews

In these situations one screw is In these situations one screw is often used together with a often used together with a Kirschner wire to prevent rotation.Kirschner wire to prevent rotation.

ScrewsScrews

– Screws should never be used alone Screws should never be used alone for diaphyseal fractures, since for diaphyseal fractures, since weight bearing will cause loosening weight bearing will cause loosening and collapse of the fracture siteand collapse of the fracture site. .

ScrewsScrews

– Screws are used together with Screws are used together with plates for diaphyseal fractures and plates for diaphyseal fractures and all comminuted fractures of long all comminuted fractures of long bones, including fractures into joints.bones, including fractures into joints.

ScrewsScrews

Two basic types of screwsTwo basic types of screws

– Fully threaded cortical screw Fully threaded cortical screw

– The partially threaded cancellous screwThe partially threaded cancellous screw

ScrewsScrews

A cortical screw is a fully threaded A cortical screw is a fully threaded screw screw

produces interfragmentary produces interfragmentary compression by means of a large compression by means of a large gliding hole in the ciscortex (near gliding hole in the ciscortex (near cortex) and a smaller threaded hole in cortex) and a smaller threaded hole in the transcortex (far cortex). the transcortex (far cortex).

ScrewsScrews

A cancellous screw is a partially A cancellous screw is a partially threaded screwthreaded screw

exerts its interfragmentary exerts its interfragmentary compression by having all its threads compression by having all its threads on one side of the fracture plane on one side of the fracture plane

Lag Screw EffectLag Screw Effect

Lag Screw EffectLag Screw Effect

In addition to securing plates to bone, In addition to securing plates to bone, screws are used to provide static screws are used to provide static interfragmentary compression by interfragmentary compression by means of the lag screw principle. means of the lag screw principle.

Lag Screw EffectLag Screw Effect

To function as a lag screw the screw To function as a lag screw the screw head engages the first (near) cortex head engages the first (near) cortex and the threads engage bone only on and the threads engage bone only on the opposite side of the fracture line in the opposite side of the fracture line in the second cortex. the second cortex.

Lag Screw EffectLag Screw Effect

As the screw is tightened the threads As the screw is tightened the threads engage the bone on the far cortex and engage the bone on the far cortex and compress the fracture line. compress the fracture line.

External Fixation External Fixation

First AidFirst Aid

To prevent complicationsTo prevent complications

– Splinting the affected limbSplinting the affected limb

– Safe transportationSafe transportation

– Sedation to relieve anxietySedation to relieve anxiety

First AidFirst Aid

– Assessment of the general status of Assessment of the general status of the animalthe animal

– Radiograph the affected partRadiograph the affected part

Principles of Principles of ManagementManagement ReductionReduction

RealignmentRealignment

ImmobilizationImmobilization

Physical therapyPhysical therapy

Principles of Principles of ManagementManagementReduction:Reduction:

is the process of apposing the fracture fragments is the process of apposing the fracture fragments It is usually described as It is usually described as

anatomic reductionanatomic reduction

near anatomic reductionnear anatomic reduction

or non-anatomic reductionor non-anatomic reduction

Principles of Principles of ManagementManagement Reduction should be undertaken as Reduction should be undertaken as

soon as the patient's condition permitssoon as the patient's condition permits

Delay typically results in a more Delay typically results in a more

difficult and then traumatic reduction difficult and then traumatic reduction processprocess

Principles of Principles of ManagementManagement

AlignmentAlignment

refers to the relative orientation or refers to the relative orientation or position of the fragments, or more position of the fragments, or more specifically, deal with the joints above specifically, deal with the joints above and below the fracture. and below the fracture.

Principles of Principles of ManagementManagement Anatomic alignment is always strivedAnatomic alignment is always strived

for that it has a large bearing on for that it has a large bearing on function following healing function following healing

Principles of Principles of ManagementManagement Alignment can be anatomic without Alignment can be anatomic without

anatomic reductionanatomic reduction

however, anatomic reduction will however, anatomic reduction will always achieve anatomic alignment.always achieve anatomic alignment.

Principles of Principles of ManagementManagement

FixationFixation

is the mechanism by which the fracture is the mechanism by which the fracture fragments are stabilized until sufficient fragments are stabilized until sufficient healing occurs. healing occurs.

Principles of Principles of ManagementManagement The combination of the fixation device The combination of the fixation device

and the fracture segments is called an and the fracture segments is called an osteosynthesis.osteosynthesis.

Principles of Principles of ManagementManagement In general, the fixation should allow In general, the fixation should allow

near normal function during the near normal function during the healing process. healing process.

External CoaptationExternal Coaptation

Proper coaptation device for fractures in the darkly shaded area should extend the length of the lightly shaded area

External CoaptationExternal Coaptation

Advantages of coaptationAdvantages of coaptation

Applied immediately following closed Applied immediately following closed reductionreduction

Additional trauma of surgery is Additional trauma of surgery is avoidedavoided

Fracture healing is not disrupted.Fracture healing is not disrupted.

External CoaptationExternal Coaptation

Disadvantages of splints and castsDisadvantages of splints and casts

Substantial amount of motion at the Substantial amount of motion at the fracture site may persistfracture site may persist

Limit limb functionLimit limb function

External CoaptationExternal Coaptation

Require constant monitoring and/or Require constant monitoring and/or changingchanging

Fracture disease may occurFracture disease may occur

External CoaptationExternal Coaptation

Used for:Used for:

Fractures distal to the elbow and stifleFractures distal to the elbow and stifle

Fractures that are relatively stableFractures that are relatively stable

Fractures that do not involve articular Fractures that do not involve articular structuresstructures

Fractures in young animalsFractures in young animals

The cast should extend from the digits and extend above the joint proximal to the fracture.

When applying casts which are molded to conform to the limb, it is protuberances that receive additional padding, rather than depressions.

Robert Jones Bandage

• It immobilizes the limb and applies even pressure to prevent or reduce edema

Robert Jones Bandage

Indications:1. Temporary bandage for the

initial treatment of traumatized limbs

2. Initial postoperative treatment following internal fixation.