Вы находитесь на странице: 1из 57

Fracture Fixation-

Find a way to Win

Mike Conzemius, DVM, PhD


Diplomate ACVS
Iowa State University
Ames, Iowa USA
Goals of Fracture Fixation
„ Restore patient to normal function as quickly
as possible
„ Multiple treatment options
– most can be successful
– margin of safety varies
„ Decision factors on:
– Patient-age, activity level, housing
– Fracture-limb, fracture classification
– Owner-finances, goal for pet, intelligence?
– Surgeon-expertise, equipment, opinions
Fracture Fixation Options

„ External Coaptation
„ Bone Plates
„ Plate-Pin Constructs
„ Pins and wires
„ External fixators
„ Interlocking Nails
External Coaptation

-casting, Al bars, splints


-margin of safety
-bandage care
Kapaktin et. al.
Intramedullary Pins and wires

„ Poor mechanical stability


– compliment with cerclage wires, external
fixator, or splint to reduce rotation
„ Technically simple, inexpensive
– margin of safety is small so must do well
„ Interlocking nails
„ Absorbable pins
Tibial Fracture
-simple, oblique
Tibial Fracture
-IM pin and full cerclage wires
-6 weeks post-op
-fracture callus present
-no lucency near implants
Salter-Harris Fracture Classification

-Type I-V
-Prognostic value?
Salter-Harris I
Distal Femoral Physeal Fx
Salter-Harris I
Distal Femoral Physeal Fx

-Cross-Pinning
-no change in strength if
enter opposite cortex
Bone Plating-Screws
„ Length
– head (1), shaft (2), thread (3), total (4)
„ Partially Threaded
„ Thread Diameter
– inside vs. outside diameter=thread height
– 3.5 mm cortical screw (thread height 1.0 mm)
– 4.0 mm cancellous screw (thread height 1.5 mm)
„ Pitch (7)
„ Cancellous vs. Cortical
– thread height and pitch different
„ Self-Tapping (8)
Terminology-Plates
„ Plate size
– determined by screw
– 4.5 DCP is not 4.5 mm thick
„ Narrow vs. Broad
– 4.5 DCP is 3.8 thick and 12 mm wide or 4.8 mm
thick and 16 mm wide
„ Shape
– straight, semitubular, T-, L-, spoon, reconstruction
Terminology-Plates
„ Distance between holes and between
central holes
– DCP, VCP, Lengthening plate
„ Limited contact-DCP
– grooved undersurface ↓ plate-bone contact
– similar strength to DCP b/c of additional width and
thickness
– resist bending equally over length of plate; DCP
bends at screw hole
Terminology-Screw hole

„ Round
– 20° of angulation, VCP
– limited to use in buttress or neutralization
„ Oval
– reconstruction plates
„ Gliding-DCP
„ Spherical Gliding Principal
– 40° of angulation for LC-DCP, segmental fxs
LC-DCP
-allows for increased angulation
-dynamic compression in either
direction (segmental fractures)
Screw Application

„ Lag vs. Positional Screw


„ Interfragmentary compression
„ Interfragmentary strain theory
– ∆L/L, 2% tolerance for bone
„ Reconstruction of bony cylinder or
reconstruction of fragments
Screw Application
„ Depth gauge
– add 1-2 mm to measured length
„ Bone tap
– cuts threads, can use self tapping screws
„ Over drilling
– glide hole on near or cis-cortex
„ Countersink
– ↑ points of contact which protects screw
„ Two-finger tight
– generally get about 70-80% of maximum torque
Plate Application
„ Buttress
– bony column not reconstructed
– try to place gap under plate
„ Neutralization
– bony column reconstructed with screws and plate
supporting the repair
„ Dynamic compression
– bony column reconstructed with interfragmentary
compression created by plate
Bone Plating

-Buttress Function

-best to place defect under plate

-full cerclage wires stronger if


placed under the plate

-plate-pin construct, external


fixator, or interlocking nail???
Bone Plating

-Neutralization

-Reconstruct before stabilization

-Interfragmentary compression
screws and DCP
Bone Plating

-Dynamic Compression
-Simple Transverse Fracture
-Reconstruct and compress
bony column
Plate Application
„ Contour plate
– ↑ bone-plate contact (30% is done well)
– ↑ load sharing between screws
– bony column remains in alignment when screws
tightened
– prestress
• plate is not in neutral axis, compression on cis-cortex
• allows for more equally distributed compression
• would rather have compression on trans-cortex

„ Neutral vs. compression guide


Pin-Plate Constructs
„ Nonreconstructable fractures that will
require buttress plating
– especially when dealing with gap fx or with gap on
the trans-cortex
„ Bone plate is susceptible to bending
– ability to resist bending is most dependent upon
location with respect to neutral axis
„ Pin-plate construct
– IM pin is very near neutral axis
– ↓ bending forces on plate; ↑ plate life
Pin-Plate Constructs

-IM pin 50% of canal size


strain in bone plate is reduced by
factor of 2 when IM pin occupies
50% of canal

-6 cortices secured by screw


between monocortical and bicortical screws
Comminuted distal
humeral fracture
Acetabular Fracture
-Caudal fxs need reconstruction
or OA and lameness will occur
Acetabular Fracture
T-plate or screws + PMMA
Acetabular Fracture
-screws, wires, PMMA
Acetabular Fracture
-reconstruction plate
Interlocking Nails
„ Intramedullary rod with interlocking screw
fixation
„ Strength
– Excellent resistance to compression, tension,
bending, shear and rotation
– Central location increases area moment of inertia
– 6 mm nail as stiff as a 3.5 mm broad DCP
„ Indications
– Humeral, femoral, tibial shaft fractures
– Static vs. dynamic fixation
– largest diameter nail as possible
Nonunion/Malunion Fractures

„ Goal is to restore limb function


– Perfect reconstruction can be difficult
– Most are from instability-so focus on this

„ Bone graft improves margin of safety


– Required if it is an atrophic nonunion
Pelvic Fracture Malunion
-2 yo dog HBC as puppy
-6 month history of obstipation
-remove fracture callus
Pelvic Fracture Malunion
-5 yo cat with megacolon for 2 months
Pelvic Fracture Malunion
-remove fracture callus
-open pelvic inlet
-50% chance of megacolon resolution
if signs <6 months duration
C-arm technology
„ 3-D real-time fluoroscopy
„ You get what you pay for out of the
equipment ($20-300,000)
– tissue penetration, width of visualization,
continuous fluoroscopy
„ Indications
– Interlocking nails, sacroiliac luxations, humeral
condylar fractures, capital femoral physeal
fractures
– positive contrast studies (cardiac, portograms,
arthrograms)
External Fixators
„ KE, Securos, Imex, Circular ring
systems
„ Type I, II, or III fixation
„ Principles
– three full pins above and below fracture
– use positive profile pins when possible
– pre-drill all pins
– pre-tap if possible
– have side bar ~1 cm from skin
– double side bars if needed
Comminuted Tibial Fracture
-multiple repair options
Tibial Fracture
-0 weeks
-positive profile pins
-Type II fixator
4 week Recheck
-healing
-pin loosening
-hydroxyapetite
coated pins
9 month old Basset
-premature closure of distal
ulnar growth plate
-opening osteotomies
Common Mistakes
-open screw holes
-plate not long enough
BE CREATIVE-KNOW OPTIONS
Common Mistakes
-over exposure
-loose cerclage wires
-stress-shielding

Похожие интересы