Basic Principles of Fracture Management, Dr. Anjan R. Shah

We’re gonna talk about some trauma.
Scenarios here for there for the rest of the evening. First Dr. Gasser and all y’all thank you very much for the invitation back and for your attention. We talked about some basic principles of fracture management. The whole purpose of this talk is to help you communicate with us so we can manage our patients better.
You know this is certain language we use from the weight bearing restrictions to the description of fractures but it’s really not that hard. For example, we’re going to talk a little bit about some patterns or fractures. So just looking quickly at this how would you describe this pattern? Does it look like a spiral pattern transverse or what fracture maybe you don’t see it. Let’s put on a third grade Thinking Hats. Literally it’s that simple. So we call this a spiral fracture. When we go a little bit further, this is a transverse fracture. Yes. If I had crayons my talk would be made out of crayons, but it’s a little bit more intelligent. This is a common neuter fracture of the lower tibia.
So first thing we asked for is just communication so that your doctors call on us and say okay we have a closed fracture. We have an open fracture and a v bone and then some description. This is a shaft fracture of the femur. What is this? Is this a radio shaft fracture? Is this a fracture the proximate humerus? Was this a fracture of the distal radius location right.? So yes just a radius. It’s that simple. Why does this matter though. Because if you take the fracture pattern and you add that with the bone quality the host the mechanism of injury within that directs our treatment.
So what we’re going to do for that patient. Because then what we do directs the weight bearing status directs the what the rehabilitation specialists can cannot do for us and all that matters because that affects the patient’s long-term outcomes and that’s really what it’s all about. All right. So we’ve figured out what the fracture looks like. Now we’re gonna go ahead and stabilize a fracture. This is where the real science comes in two ways bone heals. She put the two edges of bone together and you can hold them you can squeeze them together the bones communicate. They have cutting cones and you can actually recreate where the bone forms and heals very similar to the contour and shape of it was prior to the injury.
Often you know when you put two pieces of tile together there’s always a little bit of grout. Well there’s always a little bit of that but with primary bone healing and limits that the most. This is important because articular injuries you don’t want your joints to be anything except smooth and it’s very rigid fixation which allows for that. For example, this distal tibia we saw earlier you want this anatomic and you want the cartilage to be preserved so it undergoes fixation primary bone healing and hopefully the patient goes on without any long-term arthritis. Secondary bone healing. This is a little different. This is a lot of casting. So a lot of rods you’re not trying to worry so much about all the little pieces you want the overall alignment. This is something we do along with shaft fractures. It’s still very important to still. It’s probably equally as common as the other methods. The fixation is not as stiff the bone that has fractured has leaked some bone marrow that bone marrow becomes a callous. And that’s a secondary way of bone healing that’s a rush. You see that all the time so you can see that big.Oval area that’s all callus but that’s not in the joint. The patient’s going to do fine he or she will never see that. We’ll never know. Patient will Be great.
Now intra-articular fractures we kind of touched upon it. The reason this is so critical. Imagine walking around in your shoe with a pebble in it doesn’t feel too good. Imagine having that in your joint. That’s destined for pain and long-term complications. So you want these little pieces all together. You want them to kill without any ridges. You don’t want any step off. Right. You went really nice and smooth. So you put the pieces back together and you get primary bone healing and that’s why we use plates and screws like any good marriage. If you have two people working together and both bearing the load or sharing to load things you usually end up being fine.
But if a good husband, for example, ends up having to be a load bearing implant problem with it is is that he can eventually fail. And so it’s better to have a balance of equality. This is a fracture of the proximal tibia. You can see all the pieces here. We put this back together plate screws primary bone healing. We want everything to heal anatomic. And so you’re going to let this patient, that we just reconstructed all these little pieces with, immediately weight bear. Yes or no. Why not. Because you want to protect the cartilage. Because the problem is if you don’t and you have failures. That’s a problem. Post-traumatic arthritis. And so you have to limit weight bearing you have a good fixation and then there’s certain things you just can’t control like the host.
This an example of an intraarticular fracture and a shaft distal femur and the femoral shaft. The articular injuries stabilized with primary bone healing in the shaft to stabilize with secondary bone healing a stable of fractures. Again pretty common. Same thing you want all these pieces back together. So you have limited risk of arthritis. This radius fracture we saw the. Same thing. Or the plate screws primary bone healing limited weight bearing early range of motion long bone fractures.
So now we’re getting into the other more meat potatoes of orthopedics. You know we just put a nail in it. Get it done get the patient out of bed. The goal is a little different here. It’s not so much or they’re going to limit arthritis in three months. I want this patient mobilized the night the next day maybe even the same day. What are the long bones humerus, femur, and the tibia. We’ll talk femur fractures the second most common after Tibia fractures in terms of long bone injuries. These numbers are going up every year. We see it all the time high energy long bones strong bone. It’s not ground level false. That’s a hip fracture that’s a whole different host right. There’s a motorcycle accident, fall from construction scaffold, etc. Initially a patient comes in and they’re stabilized temporarily and some sort of splint or traction.
And as soon as the patient is optimized not waiting for them to be in the best shape ever but long as they can get to the owner safely and one which chest trauma is not a complication make sure other injuries. You’re not missing the patients. Shaft fractures again are going to be stabilized and we talked about earlier a secondary bone healing. You want to at the length you on rotation you want it’s stable. You want to load share and get implants and it’s going to be able to get you up moving. It’s an example of a female shaft fracture. You can approach it integrate come out from the knee. This is coming from the need as an incision as a starting pin to make sure we’re right where we want to be. We use a Reamer to size the canal and get some of the metal contents out of the way as we pressurized with this rod and you get a retrograde from running all lock to place immediate weight bearing Tibia fractures are the most common along Bones.
This number is above half a million now yearly thing with Tibia fractures and simply with femur ever more common tibia.
There’s a lot of associated injuries so anytime you get X-rays of any type of fracture you always have x rays of the joint above and below. We don’t miss anything because most injuries are very common. And again, not every fracture needs surgery. You can treat it not opportunity. We have parameters common sense like if you’re within a few degrees of angular motion for within a few degrees of translation you don’t really want any type of shortening. You can put in a cast. The problem is six weeks eight weeks of a long lake cast non weight bearing. Not ideal. But if you’re gonna avoid surgery sometimes I guess it’s beneficial. But what are surgical options where we can nail things, we can plate things, we connect things combination since we’re talking about nails. Let’s talk about nails. The beauty of it nails is immediate weight bearing. The less malunion. This earlier weight bearing earlier motion.
A summary of long bones, an injury can occur at any level. The key things with long bone fractures is if we can nail it, we can get you up out of bed faster. Thank you.