Extracortical (extracortical) osteosynthesis is an operation to restore the integrity of a bone after a fracture by applying a specially selected plate to it. Performed in an open way. Modern plates make it possible to securely fix parts of the bone by blocking the screw heads in the holes, which are inserted into the bone fragments.
Indications for this type of surgery for fractures may include bone fragments that cannot be reduced using a closed method, the presence of one or more bone fragments, or fractures involving joints (intra-articular fractures).
Features of bone osteosynthesis
This type of operation is performed using titanium plates of different sizes. The latest achievement in this area is compression-type plates that have special holes along their entire length. They allow you to fix the heads of the screws in the plate, which in turn are inserted into the bone tissue of the fragments. After tightening the screws, maximum fixation of bone fragments is ensured and compression is created between them.
This method of installing plates allows for faster bone healing and ensures proper fixation. This eliminates the possibility of improper fusion or other complications.
From above, the fracture site is covered with the patient's viable soft tissues.
Even before performing external osteosynthesis surgery, it is important to choose the right plate. The choice depends on:
- type of injury
- number of bone fragments,
- location of the fracture,
- anatomical shape of the bone.
A correctly selected plate allows you to completely restore the anatomical shape of the damaged bone. This helps the patient return to normal activities as quickly as possible.
Rehabilitation after osteosynthesis
The recovery process after external osteosynthesis with plates is quite long. The period of complete rehabilitation is individual and depends on the severity of the injury and the complexity of the operation. In some cases it takes 1-2 months, in others - from 2 to 4 months.
In the postoperative period, it is important to strictly adhere to the doctor’s recommendations. To speed up recovery and avoid complications, it is recommended:
- perform a set of exercises recommended by your doctor;
- limit the load on the bone, increase it gradually in accordance with the recommendations of the traumatologist;
- physiotherapeutic procedures: ultrasound, electrophoresis and others;
- massotherapy.
All materials on the site were prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative in nature and are not applicable without consulting a doctor.
Osteosynthesis - surgery for the connection and fixation of bone fragments formed during fractures. The purpose of osteosynthesis is to create optimal conditions for anatomically correct fusion of bone tissue. Radical surgery is indicated when conservative treatment is considered ineffective. The conclusion about the inappropriateness of a therapeutic course is made on the basis diagnostic study, or after unsuccessful use traditional methods for healing of fractures.
To connect fragments of the osteoarticular apparatus, frame structures or separate fixing elements are used. The choice of the type of fixator depends on the nature, scale and location of the injury.
Scope of osteosynthesis
Currently, well-developed and time-tested osteosynthesis techniques are successfully used in surgical orthopedics for injuries of the following departments:
- Shoulder girdle; shoulder joint shoulder; forearm;
- Elbow joint;
- Pelvic bones;
- Hip joint;
- Shin and ankle joint;
- Hip;
- Brush;
- Foot.
Osteosynthesis of bones and joints involves restoring the natural integrity of the skeletal system (comparing fragments), fixing fragments, and creating conditions for the fastest possible rehabilitation.
Indications for osteosynthesis
Absolute indications for osteosynthesis are fresh fractures, which, according to accumulated statistical data and due to the structural features of the musculoskeletal system, cannot heal without surgery. These are, first of all, fractures of the femoral neck, patella, radius, elbow joint, clavicle, complicated by significant displacement of fragments, formation of hematomas and rupture of the vascular ligament.
Relative indications for osteosynthesis there are strict requirements for rehabilitation periods. Urgent surgeries are prescribed for professional athletes, military personnel, sought-after specialists, and also for patients suffering from pain caused by improperly healed fractures ( pain syndrome causes pinching of nerve endings).
Types of osteosynthesis
All types of surgery to restore joint anatomy by mapping and fixation bone fragments carried out using two methods - submersible or external osteosynthesis
External osteosynthesis. The compression-distraction technique does not involve exposing the fracture site. As fixators, the needles of the guide apparatus are used (Dr. Ilizarov’s technique), passed through the injured bone structures (the direction of the fixation structure must be perpendicular to the bone axis).
Immersion osteosynthesis– an operation in which a fixing element is inserted directly into the fracture area. The design of the fixator is selected taking into account the clinical picture of the injury. In surgery, three methods of performing submersible osteosynthesis are used: extraosseous, transosseous, intraosseous.
External transosseous osteosynthesis technique
Osteosynthesis using a guide apparatus allows you to fix bone fragments while maintaining the natural mobility of the articular ligament in the injured area. This approach creates favorable conditions for the regeneration of osteochondral tissue. Transosseous osteosynthesis is indicated for fractures tibia, open fractures of the tibia, humerus.
The guide apparatus (type of design by Ilizarov, Gudushauri, Akulich, Tkachenko), consisting of fixing rods, two rings and crossed spokes, is assembled in advance, having studied the nature of the location of the fragments using an x-ray.
From a technical point of view correct installation apparatus in which they are used different types knitting needles is a difficult task for a traumatologist, since the operation requires mathematical precision of movements, understanding of the engineering design of the device, and the ability to make operational decisions during the operation.
The effectiveness of competently performed transosseous osteosynthesis is extremely high (recovery period takes 2-3 weeks), no special preoperative preparation of the patient is required. There are practically no contraindications for performing surgery using an external fixation device. The transosseous osteosynthesis technique is used in each case if its use is appropriate.
Technique of bone (submersible) osteosynthesis
Bone osteosynthesis, when fixators are installed on the outside of the bone, is used for uncomplicated displaced fractures (comminuted, flap-like, transverse, periarticular forms). Metal plates connected to the bone tissue with screws are used as fixing elements. Additional fixators that the surgeon can use to strengthen the joining of fragments are the following parts:
Structural elements are made of metals and alloys (titanium, stainless steel, composites).
Technique of intraosseous (immersion osteosynthesis)
In practice, two techniques are used for intraosseous (intramedullary) osteosynthesis - these are closed and open type operations. Closed surgery is performed in two stages - first, bone fragments are compared using a guide apparatus, then a hollow metal rod is inserted into the medullary canal. The fixation element, advanced using a guide device into the bone through a small incision, is installed under X-ray control. At the end of the operation, the guidewire is removed and sutures are applied.
At open method the fracture area is exposed, and the fragments are compared using a surgical instrument, without the use of special equipment. This technique is simpler and more reliable, but at the same time, like any abdominal surgery, is accompanied by blood loss, violation of the integrity of soft tissues, and the risk of developing infectious complications.
Locked intramedullary fusion (BIOS) is used for diaphyseal fractures (fractures of long bones in the middle part). The name of the technique is due to the fact that the metal fixation rod is blocked in the medullary canal by screw elements.
In cases of femoral neck fractures, the high effectiveness of osteosynthesis has been proven. at a young age when bone tissue is well supplied with blood. The technique is not used in the treatment of elderly patients who, even with relatively good health indicators, experience degenerative changes in the joint-skeletal system. Brittle Bones cannot withstand the weight of metal structures, resulting in additional injuries.
After intraosseous surgery on the hip, a plaster cast is not applied.
For intraosseous osteosynthesis of the bones of the forearm, ankle and lower leg, an immobilization splint is used.
The femur is the most vulnerable to a fracture of the diaphysis (at a young age, the injury most often occurs in professional athletes and fans of extreme car driving). For fastening fragments femur they use elements of various designs (depending on the nature of the injury and its scale) - three-bladed nails, screws with a spring mechanism, U-shaped structures.
Contraindications to the use of BIOS are:
- Arthrosis of 3-4 degrees with pronounced degenerative changes;
- Arthritis in the acute stage;
- Purulent infections;
- Diseases of the hematopoietic organs;
- Impossibility of installing a fixator (the width of the medullary canal is less than 3 mm);
- Childhood.
Osteosynthesis of the femoral neck without splinter displacements is carried out using a closed method. To increase the stabilization of the skeletal system, a fixing element is inserted into the hip joint and subsequently secured in the wall of the acetabulum.
The stability of intramedullary osteosynthesis depends on the nature of the fracture and the type of fixation chosen by the surgeon. The most effective fixation is provided for fractures with straight and oblique lines. The use of an excessively thin rod can lead to deformation and breakage of the structure, which is a direct need for secondary osteosynthesis.
Technical complications after operations (in other words, doctor errors) are not often encountered in surgical practice. This is due to the widespread introduction of high-precision monitoring equipment and innovative technologies Detailed osteosynthesis techniques and extensive experience accumulated in orthopedic surgery make it possible to foresee all possible negative aspects that may arise during the operation or during the rehabilitation period.
Technique for transosseous (submersible) osteosynthesis
Fixing elements (bolts or screw elements) are inserted into the bone in the fracture area in a transverse or oblique-transverse direction. This technique osteosynthesis used for helical fractures (that is, when the fracture line of the bones resembles a spiral). For strong fixation of fragments, screws of such a size are used that the connecting element protrudes slightly beyond the diameter of the bone. The head of the screw or screw tightly presses the bone fragments against each other, providing a moderate compression effect.
For oblique fractures with a steep fracture line, the technique of creating a bone suture is used, the essence of which is to “bind” the fragments with a fixing tape (round wire or flexible stainless steel plate tape)
In the area of the injured areas, holes are drilled through which wire rods are pulled, used to fix the bone fragments at the points of contact. The clamps are firmly pulled together and secured. After signs of healing of the fracture appear, the wire is removed to prevent atrophy of the bone tissues compressed by the metal (as a rule, a second operation is performed 3 months after the osteosynthesis operation).
The technique of using a bone suture is indicated for fractures of the humeral condyle, patella and olecranon.
It is very important to carry out as soon as possible primary osteosynthesis for fractures in the elbow and knee area. Conservative treatment is extremely rarely effective, and, moreover, leads to limited flexion-extension mobility of the joint.
The surgeon chooses a technique for fixing fragments based on X-ray data. For a simple fracture (with one fragment and without displacement), the Weber osteosynthesis technique is used - the bone is fixed with two titanium wires and wire. If several fragments have formed and they have been displaced, then metal (titanium or steel) plates with screws are used.
Application of osteosynthesis in maxillofacial surgery
Osteosynthesis has been successfully used in maxillofacial surgery. The purpose of the operation is to eliminate congenital or acquired abnormalities of the skull. To eliminate deformities of the lower jaw formed as a result of injuries or improper development of the masticatory apparatus, the compression-distraction method is used. Compression is created using orthodontic structures fixed in the oral cavity. The clamps create uniform pressure on the bone fragments, ensuring a tight marginal connection. IN surgical dentistry A combination of different structures is often used to restore the anatomical shape of the jaw.
Complications after osteosynthesis
Unpleasant consequences after minimally invasive forms of surgery are extremely rare. When performing open operations, the following complications may develop:
- Soft tissue infection;
- Osteomyelitis;
- Internal hemorrhage;
- Arthritis;
- Embolism.
After the operation, antibiotics and anticoagulants are prescribed for preventive purposes, painkillers are prescribed according to indications (on the third day, drugs are prescribed taking into account patient complaints).
Rehabilitation after osteosynthesis
The rehabilitation time after osteosynthesis depends on several factors:
- Complexity of injury;
- Locations of injury
- Type of osteosynthesis technique used;
- Age;
- Health conditions.
The recovery program is developed individually for each patient and includes several areas: physiotherapy, UHF, electrophoresis, therapeutic baths, mud therapy (balneology).
After elbow surgery patients experience severe pain for two to three days, but despite this unpleasant fact, it is necessary to develop the arm. In the first days, the exercises are carried out by a doctor, rotational movements, flexion-extension, extension of the limb. IN further patient performs all points of the physical education program independently.
For developing the knee, hip joint special simulators are used, with the help of which the load on the joint apparatus is gradually increased, muscles and ligaments are strengthened. IN mandatory therapeutic massage is prescribed.
P after immersion osteosynthesis of the femur, elbow, patella, tibia The recovery period takes from 3 to 6 months, after using the transosseous external technique - 1-2 months.
Conversation with a doctor
If osteosynthesis surgery is planned, the patient should receive as much information as possible about the upcoming treatment and rehabilitation course. This knowledge will help you properly prepare for your stay in the clinic and for the rehabilitation program.
First of all, you should find out what type of fracture you have, what type of osteosynthesis the doctor plans to use, and what the risks of complications are. The patient must be aware of the methods further treatment, terms of rehabilitation. Absolutely all people are concerned about the following questions: “when can I start work?”, “how fully can I serve myself after surgical intervention?”, and “How bad will the pain be after surgery?”
The specialist is obliged to cover all the important points in detail, consistently, and in an accessible form. The patient has the right to find out how the fixators used in osteosynthesis differ from each other, and why the surgeon chose this particular type of design. Questions should be thematic and clearly formulated.
Remember that the work of a surgeon is extremely complex, responsible, and constantly associated with stressful situations. Try to follow all the instructions of your doctor, and do not neglect any recommendations. This is the main basis for rapid recovery after a complex injury.
Cost of the operation
The cost of osteosynthesis surgery depends on the severity of the injury and, accordingly, on the complexity of the methods used. medical technologies. Other factors affecting the price medical care, are: the cost of the fixing structure and medicines, level of service before (and after) surgery. For example, osteosynthesis of the clavicle or elbow joint in different medical institutions can cost from 35 to 80 thousand rubles, surgery on the tibia - from 90 to 200 thousand rubles.
Remember that the metal structures must be removed after healing of the fracture - for this, repeated surgery is performed, for which you will have to pay, although an order of magnitude less (from 6 to 35 thousand rubles).
Free operations are carried out according to a quota. This is quite real opportunity for patients who may wait 6 months to a year. The traumatologist writes a referral for additional examination and passing a medical commission (at your place of residence).
If the patient is diagnosed dangerous fracture bones, in which separate pieces of hard tissue have formed, he needs to undergo osteosynthesis. This procedure allows you to correctly compare the fragments using special devices and devices, which will ensure that the pieces do not move on long time. All types surgical reduction retain the functionality of the movement of the segment axis. The manipulation stabilizes and fixes the damaged area until healing occurs.
Most often, osteosynthesis is used for fractures inside joints, if the integrity of the surface has been compromised, or for damage to long tubular bones or the lower jaw. Before proceeding with such a complex operation, the patient must be carefully examined using a tomograph. This will allow doctors to draw up an accurate treatment plan, choose the optimal method, set of instruments and fixatives.
Types of procedure
Since this is a very complex operation that requires high precision, it is best to carry out the manipulation on the first day after the injury. But this is not always possible, so osteosynthesis can be divided into 2 types, taking into account the time of execution: primary and delayed. The latter type requires more accurate diagnosis, because there are cases of formation of a false joint or improper fusion of bones. In any case, the operation will be performed only after diagnosis and examination. For this purpose, ultrasound, x-ray and computed tomography are used.
The next method of classifying the types of this operation depends on the method of introducing fixing elements. There are only 2 options: submersible and external.
The first is also called internal osteosynthesis. To carry it out, use the following clamps:
- knitting needles;
- pins;
- plates;
- screws.
Intraosseous osteosynthesis is a type of submersible method in which a fixator (nails or pins) is inserted under X-ray control into the bone. Doctors carry out closed and open surgery using this technique, which depends on the zone and nature of the fracture. Another technique is bone osteosynthesis. This variation makes it possible to connect the bone. Main fasteners:
- rings;
- screws;
- screws;
- wire;
- metal tape.
Transosseous osteosynthesis is prescribed if the fixator needs to be inserted through the wall of the bone tube in the transverse or oblique transverse direction. For this, an orthopedic traumatologist uses knitting needles or screws. The external transosseous method of repositioning fragments is carried out after exposing the fracture zone.
For this operation, doctors use special distraction-compression devices that stably fix the affected area. The fusion option allows the patient to recover faster after surgery and avoid plaster immobilization. It is worth mentioning separately ultrasound procedure. This new technique osteosynthesis, which is not yet used so often.
Indications and contraindications
The main indications for this treatment method are not that extensive. Osteosynthesis is prescribed to a patient if, along with a bone fracture, he is diagnosed with pinched soft tissue that is pinched by fragments, or if a major nerve is damaged.
Besides, surgically They treat complex fractures that are beyond the capabilities of a traumatologist. Typically these are injuries to the femoral neck, olecranon or displaced patella. Separate view considered a closed fracture, which can turn into an open one due to perforation of the skin.
Osteosynthesis is also indicated for pseudarthrosis, as well as if the patient’s bone fragments have separated after a previous operation or they have not healed (slow recovery). The procedure is prescribed if the patient cannot undergo a closed operation. Surgical intervention is performed for injuries to the collarbone, joints, lower leg, hip, and spine.
- Contraindications for such manipulation consist of several points.
- For example, this procedure is not used when an infection is introduced into the affected area.
- If a person has an open fracture, but the area is too large, osteosynthesis is not prescribed.
- You should not resort to such an operation if general state the patient is unsatisfactory.
- venous insufficiency of the extremities;
- systemic hard tissue disease;
- dangerous pathologies of internal organs.
Briefly about innovative methods
Modern medicine is significantly different from early methods through minimally invasive osteosynthesis. This technique allows you to fuse fragments using small skin incisions, and doctors are able to carry out both bone surgery, and intraosseous. This treatment option has a beneficial effect on the fusion process, after which the patient no longer needs cosmetic surgery.
A variation of this method is BIOS - intramedullary blocking osteosynthesis. It is used in the treatment of fractures of tubular bones of the extremities. All operations are monitored using an x-ray installation. The doctor makes a small incision 5 cm long. A special rod, made of titanium alloy or medical steel, is inserted into the medullary canal. It is fixed with screws, for which the specialist makes several punctures (about 1 cm) on the surface of the skin.
The essence of this method is to transfer part of the load from the damaged bone to the rod inside it. Since during the procedure there is no need to open the fracture zone, healing occurs much faster, because doctors are able to maintain the integrity of the blood supply system. After the operation, the patient is not put in plaster, so the recovery time is minimal.
There are extramedullary and intramedullary osteosynthesis. The first option involves the use of external devices of a spoke design, as well as the combination of fragments using screws and plates. The second allows you to fix the affected area using rods that are inserted into the medullary canal.
Femur
Such fractures are considered extremely serious and are most often diagnosed in older people. There are 3 types of femur fractures:
- at the top;
- in the lower part;
- femoral diaphysis
In the first case, the operation is performed if the patient’s general condition is satisfactory and he does not have impacted injuries to the femoral neck. Typically, surgery is performed on the third day after injury. Osteosynthesis of the femur requires the use of the following instruments:
- three-bladed nail;
- cannulated screw;
- L-shaped plate.
Before the operation, the patient will undergo skeletal traction and an x-ray. During the reposition, doctors will accurately compare the bone fragments, and then fix them with the necessary instrument. The technique for treating a midline fracture of this bone requires the use of a three-bladed nail.
In type 2 fractures, surgery is scheduled on the 6th day after the injury, but before that the patient must undergo skeletal traction. For fusion, doctors use rods and plates, devices that will fix the affected area externally. Features of the procedure: it is strictly forbidden to perform it on patients in serious condition. If fragments of hard tissue can injure the hip, they should be immediately immobilized. This usually occurs with combined or fragmented injuries.
After such a procedure, the patient is faced with the question of whether it is necessary to remove the plate, because this is another stress for the body. Such an operation is urgently necessary, if fusion does not occur, its conflict with any joint structure is diagnosed, which causes contracture of the latter.
Removal of metal structures is indicated if the patient had a fixator installed during surgery, which over time developed metallosis (corrosion).
Other factors for plate removal surgery:
- infectious process;
- migration or fracture of metal structures;
- planned step-by-step removal as part of recovery (the stage is included in the entire course of treatment);
- playing sports;
- cosmetic procedure to remove a scar;
- osteoporosis.
Options for upper limb surgery
The operation is performed for fractures of the bones of the extremities, so the procedure is often prescribed to fuse the hard tissues of the arm, leg, and hip. Osteosynthesis of the humerus can be performed using the Demyanov method, using compression plates, or Tkachenko, Kaplan-Antonov fixators, but with removable contractors. Manipulation is prescribed for fractures on the diaphysis of the humerus if conservative therapy does not bring success.
Another surgical option involves treatment with a pin, which must be inserted through the proximal fragment. To do this, the doctor will have to expose the broken bone in the damaged area, find the tubercle and cut the skin over it. After this, an awl is used to make a hole through which the rod is driven into the medullary cavity. The fragments will need to be accurately compared and the inserted element advanced to the full length. The same manipulation can be performed through the distal piece of bone.
If a patient is diagnosed with an intra-articular fracture of the olecranon, it is best to undergo surgery to install metal structures. The procedure is performed immediately after the injury. Osteosynthesis of the olecranon requires fixation of the fragments, but before this manipulation the physician will need to completely eliminate the displacement. The patient wears the cast for 4 weeks or more, as this area is difficult to treat.
One of the most popular methods of osteosynthesis is Weber fusion. To do this, the specialist uses a titanium knitting needle (2 pieces) and wire, from which a special loop is made. But in most cases, the mobility of the limb will be permanently limited.
Lower limb
Separately should be considered different fractures dyphyses of the tibia bones. Most often, patients come to a traumatologist with problems of the tibia. It is the largest and most important for normal functioning lower limb. Previously, doctors carried out long-term treatment using plaster and skeletal traction, but this technology is ineffective, so now they use more stable methods.
Osteosynthesis of the tibia is a procedure that reduces rehabilitation time and is a minimally invasive option. In the event of a fracture of the diaphysis, the specialist will install a locking rod, and treat intra-articular damage by inserting a plate. External fixation devices are used to heal open fractures.
Ankle osteosynthesis is indicated in the presence of a large number of comminuted, helical, rotational, avulsion or comminuted fractures. The operation requires a mandatory preliminary X-ray, and sometimes a tomography and MRI are needed. The closed type of injury is fused using an Ilizarov apparatus and needles are inserted into the damaged area. In case of foot fractures (usually the metatarsal bones are affected), the fragments are fixed using the intramedullary method with the introduction of thin pins. In addition, the medic will apply a plaster cast, which should be worn for 2 months.
Patient rehabilitation
After the operation, you need to carefully monitor your well-being and at the slightest negative symptoms contact a specialist ( sharp pain, swelling or fever). These symptoms are normal in the first few days, but they should not appear until several weeks after the procedure.
Osteosynthesis- connection of bone fragments. The purpose of osteosynthesis is to ensure strong fixation of the compared fragments until their complete fusion.
Modern high-tech methods osteosynthesis require a thorough preoperative examination of the patient, a 3D tomographic examination for intra-articular fractures, and clear planning of the course surgical intervention, image intensifier technology during the operation, the availability of sets of tools for installing fixators, the ability to select a fixator in a size range, appropriate training of the operating surgeon and the entire operating team.
There are two main types of osteosynthesis:
1) Internal (submersible) osteosynthesis is a method of treating fractures using various implants that fix bone fragments inside the patient’s body. Implants are pins, plates, screws, knitting needles, and wire.
2) External (transosseous) osteosynthesis when bone fragments are connected using distraction-compression external fixation devices (the most common of which is the Ilizarov apparatus).
Indications
Absolute indications for osteosynthesis are fractures that do not heal without surgical fastening of the fragments, for example, fractures of the olecranon and patella with divergence of fragments, some types of fractures of the femoral neck; intra-articular fractures (condyles of the femur and tibia, distal metaepiphyses of the humerus, radius) fractures in which there is a danger of perforation by a bone fragment of the skin, i.e. transformation closed fracture in open; fractures accompanied by interposition of soft tissues between fragments or complicated by damage main vessel or nerve.
Relative indications are the impossibility of closed reposition of fragments, secondary displacement of fragments during conservative treatment, slowly healing and non-union fractures, false joints.
Contraindications to immersion osteosynthesis are open fractures of limb bones with a large area of damage or contamination of soft tissues, local or general infectious process, general severe condition, severe accompanying illnesses internal organs, severe osteoporosis, decompensated vascular insufficiency limbs.
Osteosynthesis using pins (rods)
This type of surgical treatment is also called intraosseous or intramedullary. The pins are inserted into internal cavity bones (medullary cavity) of long tubular bones, namely their long part - the diaphysis. It provides strong fixation of fragments.
The advantage of intramedullary osteosynthesis with pins is its minimal trauma and the ability to load a broken limb within a few days after surgical treatment. Non-locking pins, which are rounded rods, are used. They are inserted into the medullary cavity and jammed there. This technique is possible for transverse fractures of the femur, tibia and humerus, which have a bone marrow cavity of a sufficiently large diameter. If more durable fixation of fragments is necessary, drilling of the spinal cavity using special drills is used. The drilled spinal canal should be 1 mm narrower than the diameter of the pin in order for it to be firmly jammed.
To increase the fixation strength, special locking pins are used, which are equipped with holes at the upper and lower ends. Screws are inserted through these holes and pass through the bone. This type of osteosynthesis is called blocked intramedullary osteosynthesis (BIOS). Today there are many various options pins for each long bone (proximal humeral pin, universal humeral pin for retrograde and antegrade placement, femoral pin for pertrochanteric placement, long trochanteric pin, short trochanteric pin, tibial pin).
Self-locking intramedullary pins of the Fixion system are also used, the use of which makes it possible to minimize the time of surgical intervention.
Using locking screws, a strong fixation of the pin is achieved in the areas of the bone above and below the fracture. Fixed fragments will not be able to shift along their length or rotate around their axis. Such pins can also be used for fractures near the end portion of long bones and even for comminuted fractures. For these cases, pins of a special design are made. In addition, the locking pins can be narrower than the medullary canal, which does not require drilling out the medullary canal and helps preserve intraosseous blood circulation.
In most cases, blocked intramedullary osteosynthesis (BIOS) is so stable that patients are allowed dosed loads on the damaged limb the very next day after surgery. Moreover, such a load stimulates the formation of callus and fracture healing. BIOS is the method of choice for fractures of the diaphysis of long tubular bones, especially the femur and tibia, since on the one hand it least disrupts the blood supply to the bone, and on the other hand it optimally accepts the axial load and allows you to reduce the time of using a cane and crutches.
Overbone osteosynthesis with plates
Bone osteosynthesis is performed using plates of various lengths, widths, shapes and thicknesses, in which holes are made. Through the holes, the plate is connected to the bone using screws.
The latest advances in bone osteosynthesis are angular stable plates and now polyaxial stable plates (LCP). In addition to the threads on the screw, with which it is screwed into the bone and fixed in it, there are threads in the holes of the plate and in the screw head, due to which the head of each screw is firmly fixed in the plate. This method of fixing screws in the plate significantly increases the stability of osteosynthesis.
Plates with angular stability were created for each of the segments of all long tubular bones, having a shape corresponding to the shape and surface of the segment. The presence of pre-bending of the plates provides significant assistance in repositioning the fracture.
Transosseous osteosynthesis with external fixation devices
A special place is occupied by external transosseous osteosynthesis, which is performed using distraction-compression devices. This method of osteosynthesis is most often used without exposing the fracture zone and makes it possible to perform reposition and stable fixation of fragments. The essence of the method is to pass wires or rods through the bone, which are fixed above the surface of the skin in an external fixation device. Exist different kinds devices (monolateral, bilateral, sector, semicircular, circular and combined).
Currently, preference is increasingly being given to rod-based external fixation devices, as they are the least massive and provide the greatest rigidity of fixation of bone fragments.
External fixation devices are indispensable in the treatment of complex high-energy trauma (for example, gunshot or mine explosion), accompanied by massive defects of bone and soft tissue, with preserved peripheral blood supply to the limb.
Our clinic provides:
- stable osteosynthesis (intramedullary, extraosseous, transosseous) of long tubular bones– shoulder, forearm, thigh, lower leg;
- stable osteosynthesis of intra-articular fractures (shoulder, elbow, wrist, hip, knee, ankle joints);
- osteosynthesis of hand and foot bones.
A skin incision is made 1 cm outward from the anterior crest of the tibia, in accordance with Langer's lines. In the supramalleolar region, the incision line is extended along an arc anterior to the inner malleolus. The edges of the bone fragments are treated with a rasp. The periosteum is separated no more than 1-2 mm from the fracture line. If necessary, internal access is used, and for access to the fibula - lateral.
After reduction, spiral and anterior torsion wedge fractures are held in place using a reduction clamp. Fractures with a posterior torsion wedge are more complex and sometimes require temporary intraoperative fixation with pins. Typically, fixation begins with the insertion of 3.5 mm or 4.5 mm cortical lag screws. Later, a fracture neutralizing plate is added. Depending on the plane of the fracture, the lag screw may pass through the hole in the plate.
Torsion wedge fractures require the use of a lag screw in combination with a neutralizing plate. The neutralizing plate must be bent and twisted exactly to the shape of the lateral surface of the tibia. To achieve the required degree of bending, a bending press is used; twisting is performed with bending keys or bending pliers. To fix the plate at the level of the metaphysis, 6.5 mm cancellous screws with threads along the entire length are used. At the level of the diaphysis, 4.5 mm cortical screws are used.
Postoperative treatment
Postoperative treatment after internal fixation includes a complex of active and passive movements; special mechanical splints are used for constant passive movement.
During the first 3-4 months. the load with body weight should be limited to 10 kg, which depends on the severity of the fracture in each case and the degree of osteoporosis, as well as the nature of the damage to the cartilage tissue.
If sutures are placed on ligaments, tendons and menisci, then intraoperative checking of flexion and extension in knee joint. For a period of 4-6 weeks, splints with a fixed angle of mobility in the joint can also be used, which facilitates the healing of damaged structures.
Application of Angular Stable Inserts
The use of plates with angular stability has its own particularities. This is due to the design features of the plates, and the new capabilities that these features provide.
Traditional plates provide stability of fixation due to the frictional force between the plate and the bone, for this they perform direct anatomical reduction, extensive bone exposure is carried out to ensure access and reach good review fracture zone, the plate is preliminarily modeled according to the shape of the bone.
Locking the screws into the plate by means of tapered threads in the screw head and corresponding plate holes minimizes plate pressure on the bone and does not necessarily require plate-to-bone contact.
In LCP, the distance between screws is greater than in LC-OSR, which reduces the load on the plate. The longer working length of the plate, in turn, reduces the load on the screws, thus requiring fewer screws to be driven through the plate. It is possible to use monocortical and bicortical fixation. The choice is made depending on the quality of the bone. It is important to drive the screw into the threaded portion of the plate holes at the correct angle to ensure locking.
Tribological performance studies have shown that stability is affected by several factors, both under compression and torsion. Axial load tolerance and resistance to torsional forces are determined by the working length of the plate. If the holes closest to the fracture line in both fragments are left empty, the structure becomes twice as flexible when exposed to compression and torsion forces. Inserting more than three screws into each of the two main fracture fragments does not result in a significant increase in strength, either under axial load or under torsional load. The closer to the fracture zone additional screws are located, the stiffer the structure becomes during compression. Resistance to torsional forces is determined only by the number of screws inserted. The further the plate is from the bone, the less stable the structure.
For fractures of the lower limb, it is enough to insert two or three screws on both sides of the fracture line. For simple fractures with a small interfragmentary gap, one or two holes can be left free on both sides of the fracture line to stimulate spontaneous healing, accompanied by the formation of callus. For comminuted fractures, screws must be inserted into the holes of the plate closest to the fracture zone. The distance between the plate and the bone should be small. To ensure sufficient axial rigidity of fixation, long plates are used.
The AO system of LCP implants with combination holes can be used, depending on the fracture, as a compression plate, as an internal fixator with locking, or as an internal fixator combining both techniques.
The combination hole plate can also be used depending on the fracture according to the traditional fixation technique, the fracture zone technique, or a combined technique. Combining both types of screws makes it possible to use both internal fixation techniques. If the LCP plate is used as a compression plate, the surgical technique is similar to that of traditional plates, in which appropriate instruments and screws can be used. Covering the fracture zone with a bridge plate is carried out using both open and minimally invasive approaches.
Compression: indications are simple transverse or oblique fractures of the metaphysis and diaphysis of the tibia with minor damage to the soft tissues.
Bridge plate or non-slip splinting: indications are comminuted and comminuted fractures of the tibia. The system consists of an implant and a broken bone. Stability depends on the strength of the plate and how securely the plate is anchored in the bone. LCP uses bi- and monocortical self-drilling and self-tapping locking screws, but for osteoporosis the use of bicortical screws is recommended.
Combined technique:
multisegmental fractures, having a simple fracture at one level and a comminuted fracture at another; accordingly, a simple fracture will be fixed with interfragmentary compression, and a comminuted fracture will be splinted with a bridge plate;
in osteoporosis, a simple fracture will be fixed with a simple lag screw passed through a plate, but the remaining, neutral screws will be lockable.
Screw selection. There are 4 types of screws used:
ordinary spongy;
ordinary cortical;
lockable: self-drilling and self-tapping screws.
Conventional screws are inserted when they need to be inserted at an angle to the plate to avoid penetration into the joint, or when interfragmentary compression with eccentric screw insertion is chosen.
Self-tapping screws are used mainly as monocortical screws, with excellent bone quality. If, due to the small depth of the medullary cavity, a self-tapping screw rests on the opposite cortical layer, then it immediately breaks the thread in the bone and continues at least beyond the opposite cortical layer.
Self-tapping screws are used in all segments when bicortical fixation is planned. The protruding part of a self-tapping screw is shorter than that of a self-drilling screw, since the latter has a cutting tip. For good fixation in both cortical layers, even a self-tapping screw should protrude slightly from the bone.
With osteoporosis, the cortical layer is thinned, the working length of the monocortical screw decreases, and accordingly, the fixation of even a blocked screw is poor.
This can lead to instability. This is especially pronounced when exposed to torsional forces. Bicortical fixation is recommended for all osteoporotic bones. It should be noted that when tightening the screw, the surgeon cannot feel the quality of the bone, since the head of the screw is blocked in the conical hole of the plate.
Inserting short monocortical screws through the skin into the distal holes of the plate, if the plate is not axially aligned, may result in poor bonding to the bone. If this happens, you need to replace the screw with a longer one, or insert a regular screw at an angle.
Length selection.
When choosing the length of a conventional plate, surgeons sometimes chose a plate that was smaller than needed to avoid additional soft tissue damage associated with a larger exposure. LCP can be inserted through small incisions, which minimizes these damages.
The concept of plate overlap coefficient is introduced. It has been empirically found that for comminuted fractures it should be 2-3, i.e. the length of the plate should be 2-3 times longer than the fracture. For simple fractures the coefficient will be 8-10.
The density of screws in a plate is an indicator of how filled the holes of the plate are with screws. It is empirically determined to be between 0.5 and 0.4, indicating that less than half of the plate holes are occupied by screws. In comminuted fractures, not a single screw is inserted into the fracture zone, but in the main fragments more than half of all holes can be occupied.
Number of screws.
From a mechanical point of view, for fixation of a simple fracture in the LCP, 2 monocortical screws in each fragment are sufficient. In practice, this is only possible if the bone quality is excellent and the surgeon is confident that all screws have been inserted correctly. Instability of one of the screws will lead to loosening of the entire structure. Accordingly, at least 3 screws must be inserted into each fragment.
The procedure for inserting screws.
If a plate is used to achieve compression, it is achieved by inserting a conventional screw in an eccentric position. It is possible to fix one fragment to the plate with locking screws, and then achieve compression by inserting the screw in an eccentric position or using a special compression device. Osteosynthesis is supplemented with locking screws.
Reposition technique.
The basic principles of reposition are preserved with the new technology of internal fixation - anatomical reposition and stable fixation of the articular surface, restoration of the axis and length of the limb, correction of rotational deformity. Reposition can be open or closed; from a biological point of view, closed reposition is preferable. For the lower limb, restoration of limb length is carried out mainly by traction: manual, on an orthopedic table, skeletal traction or a distractor. Angular deformity is assessed using radiographs in two projections, rotational deformity is determined by clinical signs.
The advantage of closed, indirect reduction is the minimization of soft tissue damage and devascularization of bone fragments, which results in a more natural course of fusion and the active involvement of fragments that have retained their blood supply in the process of callus formation. Technically, closed reduction is much more difficult to perform, which requires careful preoperative preparation.
Offset on the plate.
Incorrect use of conventional or locking screws may result in loss of previous reduction results. So the data X-ray control dictate which type of screw should be inserted into which hole to avoid displacement on the plate.
Minimally invasive stabilization system
Indications for use: periarticular fractures, intra-articular fractures, fractures of the proximal part of the diaphysis.
The plate has a given anatomical shape. The screws lock into the conical holes of the plate and create angular stability of the structure. A special guide ensures precise insertion of screws through punctures in the skin.
External curved or direct approaches are recommended. The length of the incision should be sufficient to insert the plate. The tibialis anterior muscle moves 30 mm, 5 mm away from the anterior tibial spine.
If there is a fracture involving the articular surface, it should first be repaired using compression screws. Closed reduction is performed; external fixator, distractor, and Schanz screws are effective.
The plate is connected to a radiolucent guide and, moving it along the bone, is inserted under the tibialis anterior muscle. The position of the plate is controlled by palpation. Preliminary fixation of the proximal end of the plate is carried out using knitting needles. Using an image intensifier, the position of the plate is checked; it should be positioned so that the screws inserted through it fall into the center of the diaphysis. A puncture is made with a scalpel through the distal hole; it can be made slightly larger than necessary for inserting a screw in order to visualize the plate and avoid damage to the superficial peroneal nerve, which runs approximately at the level of the 13th hole of the plate. A sleeve with a trocar is inserted along the guide of the distal hole of the plate. Then, instead of them, a stabilizing bolt is inserted, through which a 2-mm wire is inserted. Check the reduction and position of the plate before inserting the locking screws. A needle is inserted into hole E along the guide to make sure that the screw that will be inserted through this hole does not protrude into the area of the neurovascular bundle in the popliteal fossa. Control using image intensifier. If necessary, change the position of the plate or insert a shorter screw.
Screws are inserted based on the biomechanical principles of external fixation. 4 or more screws must be inserted into each main fragment. For osteoporotic bones, more screws need to be inserted. Using a tightening device, the reposition on the plate is corrected and the proximal fragment is fixed.
Start from the proximal segment. First, a 5-mm self-drilling screw is inserted into the proximal hole II along the guide, having previously made a hole with a scalpel and trocar. Final blocking is possible when the screw head is level with the plate. The guide holes through which the screws are inserted are closed with plugs.
The proximal screw of the distal fragment is inserted, then fixation is performed with the remaining screws.
The plate can be removed only after complete fusion and restoration of the bone marrow cavity. The procedure is the reverse of the procedure for installing the plate.
Features of damage ankle joint determined mainly by the mechanism of injury. Knowledge of the patterns of damage occurrence under the influence of various mechanical influences is a necessary condition their correct diagnosis and treatment.
Fractures caused by direct force account for only 3-7%. At the same time, the complexity of the structure of the ankle joint leads to the fact that some of its elements are damaged indirectly.
The mechanism of ankle injuries is described based on the movement of the foot or, more precisely, the direction of the forces applied to it at the time of injury.
The entire infinite variety of injuries to the ankle joint from the indirect influence of force consists of the following elements, described in the form of pathological movements of the foot relative to the conditionally motionless tibia:
Around the sagittal axis
pronation,
supination;
Around the vertical axis
external rotation = eversion,
internal rotation = inversion;
Around the frontal axis
bending,
extension.
The terms “abduction” and “adduction” in relation to the mechanism of injuries of the ankle joint are used in publications in different senses: firstly, to denote abduction and adduction of the forefoot, and then these are synonyms for eversion and inversion, secondly, to denote abduction and adduction of the heel, i.e. in the meaning of pronation and supination. Therefore, they speak of both “abduction-pronation” and “abduction-eversion” injuries, meaning “pronation-eversion”.
The described possible components of the injury mechanism can be combined in a variety of ways, both simultaneously and sequentially over time, which leads to an infinite variety of damage options.
The patterns of occurrence of damage to different structures of the ankle joint are best considered using the example of the pronation and supination mechanisms.
When the foot is turned inward, tension occurs on the external collateral ligaments of the ankle joint. This leads either to their rupture or to an avulsion fracture of the lateral malleolus, the plane of which is perpendicular to the direction of the avulsive force and, therefore, horizontal. The level of the fracture is not higher than the horizontal section of the ankle joint gap. The talus bone receives freedom of movement inwards and, if the impact continues, puts pressure on the inner malleolus and “breaks out” it in an obliquely upward direction. The course of the fracture plane: from the outside from below - inwards and upwards. If the traumatic force continues to act, then the talus, having lost support in the form of the inner malleolus, freely moves inward. After the impact ceases, the foot may, due to the elasticity of the soft tissues, return to its previous position or remain in a position of subluxation or dislocation inwardly.
