Fracture Internal Fixation

The main members of the aliphatic polyester family are presented in Table 4.1. All these polymers have been tentatively investigated for temporary therapeutic applications during the last twenty years and only a few of them are now on the market, in the form of sutures e.g. Dexon (PGA), Vicryl (90/10 GA/l-LA copolymer), Biopol (HB/HV copolymer, 0-30% HV), PDS [poly(parfl-dioxanone)], Maxon (67.5/32.5 GA/l,3-dioxane-2-one copolymer), and as devices for bone-fracture internal fixation (Biofix , Phusiline ). This situation results mostly from the fact that there is a huge gap... 

Treatments used for various types of fractures are cast immobilization, traction, and internal fixation. A plaster or fiber glass cast is the most commonly used device for fracture treatment. Most broken bones heal successfiiUy once properly repositioned, ie, fixed in place via a cast. This type of cast or brace is known as an orthosis. It allows limited or controlled movement of nearby joints. This treatment is desirable for certain fractures. 

Total joint replacement, internal fixation of fractures... 

A 10-year-old child sustained a compound fracture of the left forearm and has returned to the unit after an open reduction and internal fixation (ORIF). Which interventions should the nurse implement ... 

Jacob, E., et al., 1993. Evaluation of biodegradable cefazolin sodium microspheres for the prevention of infection in rabbits with experimental open tibial fractures stabilized with internal-fixation. Journal of Orthopaedic Research 11 (3), 404—411. 

Bostman, O., Hirvensalo, E., Vainionpaa, S. et al, 1990. Degradable polyglycolide rods for the internal fixation of displaced bimalleolar fractures. Intern. Orthop. (Germany), 14 1-8. 

PMMA is also injected into vertebral bodies for fixation of fragility fractures of the spine, injected into screw holes to augment internal fixation in osteopenic bone, and injected into stmctural voids following resection of benign tumors to control dead space and support the surrounding bone. In many of these applications antimicrobial powder can be added to the PMMA for drug delivery when local delivery of antimicrobials is needed. 

Keating, J.F., Hajducka, C.L., Harper, J. 2003. Minimal internal fixation and calcium-phosphate cement in the treatment of fractures of the tihial plateau. A pilot study. J Bone Joint Surg Br 85(1), 68-73. 

Furukawa, T., Matsusue, Y., Yasunaga, T., Nakagawa, Y., Shikinami, Y., Okuno, M., and Nakamura, T. (2000), Bone bonding ability of a new biodegradable composite for internal fixation of bone fractures, Clin. Orthop. 16(379) 247-258. 

Schildhauer, T. A., Bauer, T. W., Josten, C., and Muhr, G. (2(XX)), Open reduction and augmentation of internal fixation with an injectable skeletal cement for the treatment of complex calcaneal fractures, /. Orthop. Trauma 14(5) 309-317. 

Tormala R, Vasenius J., Vainionpaa S., Laiho J., Pohjonen T., Rokkanen R, Ultra-high-strength absorbable self-reinforced polyglycolide (SR-RGA) composite rods for internal fixation of bone fractures In vitro and in vivo study, J. Biomed. Mater. Res., 25, 1991, 1-22. 

Table 5.3 Malignancies Associated with Internal Fixation of Fractures...

McDonald, I. (1981) Malignant lymphoma associated with internal fixation of a fractured tibia. Cancer 48, 1009-1011. 

Louis et al. treated 17 pediatric patients (age 6-16 years) with type II fractures by open reduction and internal fixation with sutures or a suture anchor. They reported that none of the patients showed obvious instability, and all patients were able to return to their original sports activities. The authors, therefore, recommended surgical treatment for type II tibial intercondylar eminence fractures in children [39]. Casalonga et al. retrospectively examined 32 children with avulsion fractures of the ACL, including 8 type I, 17 type II, 5 type III, and 2 type IV fractures, who were treated both conservatively and surgically, with a mean followup of 9 years. Type I and II fractures were treated conservatively, and types III and IV were treated by open reduction and fixation with either sutures or a screw. The mean side-to-side anteroposterior difference on KT-1000 testing was 0.88 mm for... 

Other rare postoperative complications following ACL reconstruction include femoral, tibial, and patellar fractures [65-67], rupture of the patellar ligament [68], and migration or breakage of internal fixation materials [69]. Most of these complications occur during the early postoperative period. These complications should be borne in mind before repair of the surgically invaded bone and soft tissues and incorporation of the tendon graft are frilly accomplished. 

Highly comminuted or segmental fractures may require internal fixation because of their inherent instability (Fig. 8.9). Open reduction increases the risk of complications, particularly in the case of high energy injuries with severe soft tissue injury. Further insult in the form of surgery will increase the risk of infection and delayed/non-union. 

Fig. 8.9. Segmental fracture of the femur. Internal fixation with three intramedullary nails...

Fig. 8.15a-c. Oblique grade II open fracture of the tibia treated initially with external fixator, a An AP radiograph post-fixator removal is suggestive of non-union, b Coronal CT reconstruction demonstrates hypertrophic non-union after 5 months, c Union achieved with bone graft plus rigid internal fixation... 

Older children are more difficult to manage non-operatively. Internal fixation reliably maintains fracture reduction and allows early mobilisation, precluding the necessity for prolonged in-patient treatment. Close evaluation of the fracture will determine the appropriate implant to be utilised. Comminuted fractures lack both axial and rotational stability. By comparison, in the reduced position, a transverse fracture will display axial stability but may remain rotationally unstable. 

Fig. 9.3. Transverse fracture of femur stabilized with Nancy nails. Note periosteal callus. This is not rigid internal fixation. The nails cross proximal and distal to fracture but are separated at the fracture site giving optimal stability...

If it is felt that a femoral fracture merits internal fixation but the medullary canal is too narrow to accommodate two Nancy nails (generally, 6 mm), plate and screw fixation remains a viable alternative. 

Fractures of both the femur and the tibia results in an unstable middle segment, the floating knee . These injuries are fortunately rare and typically result from road traffic accidents. One or both fractures may be open and there is often associated head or thoracic trauma. Healing is slow due to the significant soft tissue trauma and it is difficult to maintain alignment of the limb. In view of this, it is recommended that at least one of the fractures should be surgically stabilised. The advent of ESIN which can be inserted with minimal soft tissue trauma has seen a trend towards internal fixation of both fractures, providing the local anatomy allows. This approach is precluded if one or other fracture is in close proximity to the joint. The fractures have been classified by Letts and Vincent (Letts et al. 1986). 

Fig. 9.9. Segmental fracture of tibia with intact fibula. Tibia remains in varus despite internal fixation. ESIN may not provide sufficient axial stability in unstable comminuted or segmental injuries...

The elbow and wrist differ from most other joints in that certain movements (pronation/supination) are inextricably linked. This is accomplished by the mobile radius rotating around the static ulna. Proxi-mally, the radial head articulates with the radial notch on the lateral aspect of the coronoid process of the ulna. Distally, the ulnar notch of the radius rotates around the head of the ulna. In addition, the shafts of the bones are linked by the interosseous membrane. Damage to any of these structures may restrict pronation or supination. In adults, angulation or malrotation of more than 10 can result in restricted rotation of the forearm. For this reason, adult fractures are usually managed by open reduction and internal fixation. In children, the potential for remodelling is good around the wrist and more deformity can be accepted. 

Narayanan UG, Hyman JE, Wainwright AM, Rang M, Alman BA (2004) Complications of elastic stable intramedullary nail fixation of pediatric femoral fractures, and how to avoid them. J Ped Ortho 24 363-369 Parsch KD (1997) Modern trends in internal fixation of femoral shaft fractures in children. A critical review. J Ped Orthop (B) 6 117-125... 

With a displaced acetabular fracture, open reduction, stable internal fixation and early motion is often indicated. Reduction of a femoral head dislocation should be paramount, as there is a relationship between the occurrence of avascular necrosis and prolonged dislocation (Heeg et al. 1989). Recurrent dislocation may occur from a capsular defect, loose fragments within the joint and remodelling of the joint. 

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