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Fractures and Surgical Fixation 2 CE Hours

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Fractures and Surgical Fixation 2 CE Hours Fractures and Surgical Fixation 2 CE Hours By: Gordon Ward Learning objectives Summarize the structure of the bone and discuss the basic types of Discuss the various operative and non-operative fixation fractures and their classifications. techniques employed by doctors; explain the advantages, Discuss the contribution of Maurice Müller and the importance of disadvantages and considerations of each technique. the AO Foundation within the history of orthopedics. List the specific rehabilitation considerations, describe physical Demonstrate an understanding of the stages of the healing process, and occupational therapy interventions used and summarize a and identify complications and factors that may adversely affect basic plan of care for postsurgical facture management. the healing process. Explain the various phases of orthopedic protocols for physical therapists and the goals and indications of each. Introduction Bone fractures affect thousands of Americans each year. The most operative) or if the fracture is displaced or angulated, doctors may common causes of bone injuries are falls, followed by motor vehicle turn to operative fracture management to position the bone into proper accidents, sports injuries and assaults. Although long bone fractures alignment for optimum healing. Operative techniques include the use are often results from traumas, more and more fractures are being of screws, plates, intramedullary nails and external fixation and depend associated with osteoporosis. Osteoporosis is a leading underlying cause upon the severity of the facture, the bone involved, or if it is open. of fractures, especially among the elderly: each year an estimated 1.5 Rehabilitation considerations after a surgical fixation of fractures are individuals suffer a fracture due to a bone disease, such as osteoporosis required to restore strength, functional mobility and joint motion. Post- (NCBI, 2016). The incidences in the United States for all types of operative complications are correlated with a patient’s health status fractures are 21 per 1000 people annually, according to BMJ Best and/or comorbidities. Complications may include infection, nerve/ Practice (2015). The tibia is the most commonly fractured long bone in blood vessel damage, poor/delayed healing, compartment syndrome the human body. or unequal leg length. Smoking increases delayed healing, as does Fracture management can be operative or non-operative. When more osteoporosis and diabetes. conservative techniques are not enough to treat fractures (non- BONE BASICS Structure of bone tissue The human skeleton is made of two types of bone tissue: cortical bone 80 percent of the human skeleton. Long bones, such as the femur and and cancellous bone. They differ in structure and distribution within humerus, are examples of cortical bone. the body. Cortical bone - also referred to as compact bone or lamellar Cancellous bone - also called “spongy” bone or “trabecular” bone - bone - is dense and strong. Cortical bone constitutes approximately has a larger surface area and is ideal for metabolic activity. Cancellous bone is located at the ends of long bones, as well as in flat bones. Physiology of bone tissue Bone tissue is in a constant state of turnover: osteoclasts remove bone, osteoporosis, osteoclast activity is greater than osteoblast activity. and osteoblasts are continually creating new bone. The metabolic When fractures occur, the osteoblast activity increases to allow the needs of the tissue and the biomechanical loads placed on the bone bone to heal. The blood supply and health of surrounding soft tissue determine the balance between these processes. In the case of are important factors. Bone healing occurs in four stages (Ito & Perren, 2016) 1. Inflammatory stage (3-5 days): 3. Bone callus formation stage (3 weeks up to 12 weeks): The inflammatory stage begins when the fracture occurs and may Minerals – including calcium and phosphate – release into the last for up to five days. The injury causes a disruption of blood cartilage as the fibrocartilage callus continues to transform into vessels and results in the formation of a hematoma at the site of bone. A fracture union occurs when the hard callus formation is the fracture. Any bone fragments without soft tissue attachment are complete. To promote bone growth, controlled weight-bearing devascularized and die, causing the release of cytokines. The blood activity may be allowed at the end of this stage. vessels dilate and the local tissue temperature rises. 4. Bone remodeling stage (up to several years): 2. Fibrocartilage callus formation stage (4 days – 3 weeks): The fracture site is slightly enlarged after the hard callous forms. Chemical and metabolic reactions form a soft, fibrocartilage callus. The bone remodeling process restores the normal shape of the Fibroblasts begin to form cartilage and fibrocartilage that fill the bone by removing mature bone and forming new bone. Osteoclasts gap between the fracture segments. The fracture remains weak to remove the mature bone, and osteoblasts form new bone. external stresses for up to six weeks and is usually immobilized with a sling or a removable plastic cast. PT.EliteCME.com Page 1 Classification of fractures Fracture classification systems can be simple or more complex Other terms used when describing types of fractures are (Kellam & (e.g. AO Foundation method). The simple classification system Audige, 2016): describes the fracture based on the severity and pattern. It includes ● Non-displaced fracture (a.k.a. “undisplaced” fracture): The two transverse, oblique, spiral, comminuted, segmental, and impacted. This ends of a fractured bone do not separate and remain in proper classification is appropriate for many general situations. Listed below alignment. are the definitions of each type of basic fracture. ● Displaced fracture: The two ends of a fractured bone separate and Basic types of fractures (Singh, 2007): are out of their normal positions. ● Transverse fracture: Occurs at a right angle to the axis of the ● Stable fracture: Remains in proper alignment after reduction. long bone. ● Unstable fracture: Tends to displace after reduction. ● Oblique fracture: Occurs at an oblique angle relative to the axis ● Complete fracture: Extends through both sides of bone, including of the long bone. the cortex and the periosteum. ● Spiral fracture (torsion fracture): Occurs with a rotational force ● Incomplete fracture: Involves only one side of the cortex and relative to the axis of the long bone. periosteum of the bone (i.e., Greenstick fractures). ● Comminuted fracture: A fracture of a long bone into more than ● Extra-articular fracture: The fracture line does not extend into two fragments; usually occur after high-impact trauma. the joint space. ● Segmen tal fracture: Occurs in two places on a long bone; are ● Intraarticular fracture: The fracture line extends into the joint difficult to reduce and often result in nonunion. space. ● Impacted fracture: A fracture in which the bone fragments are ● Complicated fracture: Involves significant soft tissue damage jammed together and the fracture line is difficult to distinguish. (including muscles, nerves, artery, and ligament). ● Uncomplicated fracture: Has minimal or no soft tissue damage. ● Closed fracture: The skin over the fracture site is intact. ● Open fracture: The skin over the fracture site has been penetrated - either by a fragment of bone or a foreign object. AO Foundation and Maurice Müller, MD: “The orthopedic surgeon of the century” Maurice Müller, MD – a Swiss orthopedic surgeon – created the The Foundation began as the study group “Arbeitsgemeinschaft AO Foundation with a small group of surgeons in 1958. Müller für Osteosynthesefragen” (German for “Society for the Study of was instrumental in the development of techniques and equipment Internal Fixation” or “AO”). The original intent of the study group for the internal fixation of bone fractures and was named “The was to scientifically evaluate the role and appropriateness of surgical Orthopedic Surgeon of the Century” by SICOT - an international fixation for fractures.In 1990, the AO Foundation released the Müller society of orthopedic surgeons. The AO Foundation was responsible AO Classification of Fractures in Long Bones, which has become a for creating a more complex fracture classification system.The AO worldwide standard and a source of training and reference materials Foundation is a nonprofit organization of international orthopedic for surgeons worldwide. surgeons who specialize in the treatment of trauma and disorders of the musculoskeletal system. The Müller AO Classification of Fractures According to the AOFoundation.org, the Müller AO Classification of Bone and segment are considered to be part of the localization of the Fractures is a comprehensive system for classifying bone fractures, injury. Type, group, and subgroup fall under morphology. based on the location and severity. This system uses a five digit Müller AO Classification format: alphanumeric code to give a detailed description of the fracture. The five digit alphanumeric code given to a fracture is composed of Sub- Bone Segment Type Group two parts: localization and morphology. There are five components of Group 1/2/3/4 1/2/3/4 A/B/C 1/2/3 the fracture classification:bone , segment, type, group, and subgroup. .1/.2/.3 Müller classification of fractures: Explanation ● Bone: The first digit in the alphanumeric code describes which ○ For proximal and distal segments: of the four
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