introduction to traumatology -...
TRANSCRIPT
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INTRODUCTION TO
TRAUMATOLOGY
Dr Károly FEKETE
Head of Department of Trauma- and Hand Surgery
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OUTLINE
• About the TRAUMATOLOGY
• Epidemiology
• Theory of bone healing
• Pathology of fractures
• Fracture classification
• Principles of fracture treatment
• Types pf conservative and operative
fracture treatment
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Traumatology in Hungary:(in Germany, Austria, Slovakia…)
independent speciality!
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Country Title
Espana
Orthopaedics and
traumatology
France
Italia
Lietuva
Polska
Finland
Danmark
Orthopaedics Luxembourg
Nederland
Portugal
Sweden
Great Britain
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”What does it mean to be a
trauma surgeon?”
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ETYMOLOGY
trauma, traumatos
logos
traumatology
orthos
pes
orthopaedics
• injury
• science
• science of injury
• straight
• leg
• straight leg
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The traumatology:
treatment of all kinds of
injury
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The orthopaedics : Management of injuries and the
chronic and hereditary diseases of themusculosceletal organ (spine).
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Trauma surgeon is experienced In the management of injuries to the hollow organs
– thorax
– abdomen
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Trauma surgeon is experienced:–Injuries of the central nervous system
–craniocerebral trauma
Acute Subdural Haematom (ASDH)10.
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Epidural Haematom (EDH)
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POLYTRAUMA.
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EPIDEMIOLOGY
Trauma is the main cause
of death
1 to 45 years
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12% of hospital beds!
• 50 million injured per year
• 10 million disabled!
• Daily expenses for injuryes equal 265million dollars ! (USA)
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HUNGARY:
• 100-120 billion Forint / year
• 300 million Forint/ day!
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HUNGARY
the mortality rate of accidents :
11,5 /10 000
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MORTALITY STATISTICS:
1. Circulatory
2. Tumorous
3. Trauma
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Average age of deceased from
accidents is 28 years!
(Working age group!)
(In cardiovascular diseases 68 years.)
„TRAUMA IS THE EPIDEMIC
OF OUR TIME”18.
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HIP FRACTURE:
the most frequent type of injuries in
the elderly
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USA (Sweden, Hungary) data:
1/3 of beds is occupied in Orth.Dep.
hip frxs!
Treatment costs the government more
than the health care of all diabetic
patients!
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THE THEORY OF BONE
HEALING
• Forms of fr. healing
• Histology
• Biomechanic
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REGENERATION OF THE
BONE:Bone tissue is the only one in our organism
which regeneration occurs where its own tissue of full value
bone tissue - bone tissue
bone tissue - scar tissue
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FORMS OF FRACTURE
HEALING
Contact bone healing Gap healing
DIRECT
(angiogenous,primary)
INDIRECT
(secndray, healing with callus formation)
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CONTACT HEALING:
Requires the presence of connecting bone ends with compression!Connection: tight and stable!
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„DRILLING
SHIELD”
Haversian canals
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„DRILLING
SHIELD”
Underground building
face with concrete
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DIRECT BONE HEALING II.
GAP HEALING:
between the fractured ends:
No strong contact
Stabil fixation
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GAP HEALING
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INDIRECT (SECONDARY) BONE
HEALING: fracture healing with
callus formation. Preconditions:
appropriate fixation
mechanical stimuli
micromovements
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Stages of secondary bone healing
• soft callus formation
• callus mineralisation
• callus remodelling
• 1. the early inflammatory stage
• 2. the repair stage
• 3. the late remodelling stage
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I. Inflammatory phase(first few hours and days)
• Bioactive substances (cytochines,
neuropeptids)
• (monocytes, neutrophil granulocytes,
macrophages)
• acidosis, hyperemia of the bones
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2, nerve fibres and capillaries
1-5days
10.day 10.day
1. fibroblasts
I.
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Soft callus: chondrous tissue develop
• Precursor cells:
– fibroblasts connective tissue
– chondroblasts chondrous islands
33.
I.
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STRAIN:
Coefficient of change of the
shape
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Practical example:• Spiral fractures:
– Contact on a major
surface
– Effect of forces,
movements etc.
small
– Strain is low
RAPID BONY
UNION!
• Oblique fractures
– Contact on a minor
surface
– High exposure of
forces
– Strain is high
SLOW BONY
UNION!
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II. Callus mineralisation (1-2 month)(The bone ends become joined and stabilized)
36.
Cambium layer bridge callus
Chondrous islands endochondral ossif.
Connective tissue endesmal ossif.
The callus in tihis fase is weak! Has to be protected!
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SUBSTANCES:
• BMP (Bone Morphogenetic Protein)
• BDGF (Bone Derived Growth Factor)
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ROLE OF BIOMECHANICAL
EFFECTS:
• Mechanical conditions
• Surrounding structures
• Enviromental effects
• Power impulses
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THE ROLE OF SURGEON:
The surgeon with his activity intervenes in this
process by selecting the fracture treatment option,
with its proper or wrong application
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Bridge callus – cable bridge
6-8 week:
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Structural, functional
transformation under the
forces, applied on the
bone, occurs after 3-4
months, to years!.
The bony should be
restored to its original
shape.
41.
III. REMODELLING:
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Quality of the newly formed
bone:The secunder callus is much stronger
as the pre-fracture normal bone!
Primary
callus
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To sum up: The stable internal fixation
contributes to the primary direct
fracture healing.
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The pathology of fractures.
The hard skeleton of the locomotor system is created by the bones. Under the effect of
forces this solid, elastic tissue is able to flexibly change its shape for a while.
Fracture: The stress exceeds
the limit…
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Displacement of the fractured
bones
is induced by the effect of muscles
and the pull of gravity
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Good functional state
Original anatomical conditions
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Diaphyseal displacement types
• shortening (dislocatio ad longitudinem)
• rotation (dislocatio ad peripheriam)
• angulation (dislocatio ad axim)
• lateral displacement (ad latus)
• combinations
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angulation (dislocatio ad axim)
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shortening
(dislocatio
ad longitudinem)
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shortening
rotation
angulation
lateral
displacement
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Fracture classificationDiaphyseal fractures
– transverse
– short oblique
– long oblique (the fracture surface is twice as
much as the diameter of the bone)
– spiral
– comminuted fractures
– segment or etage fracture.
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transverse short oblique long oblique
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spiral comminuted fractures
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segment or etage fracture.
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Fracture classification• Special fractures
– Hairline fractures
– Fracture with impression
– Greenstick fractures
– Compression (crush) fr.
– Avulsion fractures
– Impacted fractures
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Fracture classification
• Metaphyseal fractures
• Articular fractures
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Fracture classification
• Closed
• Compound (opened)
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Stages of the opened (diaphyseal) frx.
Gustilo-Anderson classification
• I. 1 cm or shorter wound with minimal soft
tissue stripping, minimal fracture
comminutions. Therapy: as it were a
closed one.
• II. > 1 cm wound, moderate soft tissue
damage, moderate fracture comminutions.
Therapy: intramedullary nailing
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• III. > 10 cm wound with extensive soft
tissue damage (high energy trauma.)
– III. A.: Extensive wound, laceration or flaps, fracture
comminuted. Therapy: intramedullary nailing
– III.B.: Extensive soft tissue lost, periosteal stripping
and exposure of bone, usually associated with massive
contamination. Fracture comminuted. Therapy:
Fixator externe
– III. C.: Severe, mutilated wound with vascular and
nerve injuries, poor bone soft tissue coverage. Fract.
Comminuted. Therapy: fixator externe. Treatment of
the vascular and nerve injuries or amputation
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II.
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III.A. extensive wound
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III. A.
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III.B. III.C.
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III.c.
64.Case from Dr.Antal Varga
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Classification like M. Müller:
AO (ASIF)
Morphological classification of regions
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Principles of fracture treatment
• Fracture healing requires relative rest of thefractured ends.
– Reduction of the fracture
– Immobilization of the fracture fragments long enoughto allow union
– Rehabilitation of the soft tissues and joints
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Methods of frx. immobilization and
fixation:
-Conservative treatment (operation is not performed)
- Traction
- Internal splint (POP)
- Braces
- Functional fracture treatment
- Operative treatment
- External fixation
- Internal fixation (osteosynthesis)
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Traction: (skin or sceletal) should be
sufficient to pull the bones out to lenght
and overcome local muscle contraction
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Equalization of the angle
Reduction and splint fixation of the
fracture
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Splinting (Plaster of Paris)• The joint above and under the fractured
bone should be stabilized
• Duration of fracture treatment: 4-12 weeks
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Fracture treatment
• with brace (early active movements of the
muscles and joints)
• not applicable for all fracture types.
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OSTEOSYNTHESIS
• Absolut stable OS
– Lag screw
Compression screw)
– DCS (Dinamic
Compression Plates)
– Tension band wiring
Primary bone healing!
• Relatively stable OS
– Intramedullary
splinting
– Intramedullary nailing
– Fixateur externe
– Bridging plates
Secondary bone healing!
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• Absolut stable OS
– Lag screw
Compression screw)
– DCS (Dinamic
Compression Plates)
– Tension band wiring
Primary bone healing!
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Relatively stable OS
• Relatively stable OS
– Intramedullary
splinting
– Intramedullary nailing
– Fixateur externe
– Bridging plates
Secondary bone healing!