Internal fixation of extremity fractures

The treatment of limb fractures can not be corrected later, especially in young and middle-aged patients. It is feasible to open and reset, and appropriate internal fixation such as steel screws, lag screws or Kirschner wires should be used according to the situation. However, for comminuted fractures, internal fixation can not effectively maintain the reduction, surgery can damage the blood flow of the fracture block, generally do not cut open, internal fixation. However, if the intra-articular comminuted fracture and the long bone butterfly fracture cannot be maintained after the reduction, internal fixation should be performed. Treatment of diseases: humeral shaft fractures, ulnar and radial fractures, ulnar and radial fractures Indication (1) Open fracture: soft tissue and bone debridement and internal fixation of fracture should be performed early. (2) Fractures with vascular and nerve injury: the use of internal fixation and repair of nerve vessels. (3) Floating elbow: When the middle and lower 1/3 fracture of the humeral shaft is accompanied by an elbow fracture, it is difficult to reset and maintain the reduction. The open reduction and internal fixation should be performed. (4) Segmental fracture: When non-surgical treatment is used, it is easy to produce non-healing of one or more bones. Internal fixation should be performed. (5) bilateral bone fractures: non-surgical treatment can cause inconvenience to patients and difficulties in nursing. Internal fixation should be performed. (6) Unsatisfactory fractures with manual reduction: such as spiral fractures, soft tissue is embedded between the fracture ends, even if the fracture is satisfactory to the line, it will lead to non-healing, and internal fixation should be performed. (7) Unsatisfactory results of non-surgical treatment: such as the application of drape gypsum for transverse fractures, non-union due to excessive traction; non-surgical treatment of short oblique fractures with obvious displacement at the fracture end, and internal fixation should also be performed. (8) Multiple injuries combined with fractures: Non-surgical treatment is difficult to maintain a satisfactory alignment of the fracture end. Once the condition is stable, surgery should be actively performed. (9) Pathological fracture: Surgical treatment can make the patient feel comfortable and increase the function of the upper limb. Contraindications 1. For comminuted fractures, internal fixation can not effectively maintain the reduction, surgery can damage the blood flow of the fracture block, generally do not cut open, internal fixation. However, if the intra-articular comminuted fracture and the long bone butterfly fracture cannot be maintained after the reduction, internal fixation should be performed. 2. Open fractures for more than 12 hours, or within 12 hours, but the pollution is more serious. 3. There are acute infections in the fracture area. Preoperative preparation 1. If there is obvious swelling in the fracture site, the affected limb should be raised to promote swelling. 2. If there is abrasion or blisters in the fracture site, the blisters should be twitched with a syringe. The wound should be completely healed, the blisters dry up, and the epidermis can be removed before surgery. 3. The ankle joint fracture is usually fixed with screws for internal fixation. The appropriate length and length of the screw should be selected according to the x-ray film before operation. Surgical procedure There are many surgical treatment methods. Clinicians should choose the method that is most beneficial to the patient based on their own experience, equipment, fracture type, soft tissue condition and general condition. 1Rush needle fixation: The Rush needle is a needle that has a certain elasticity and is elastic. According to the fracture site, a needle of suitable length is used, and the medullary cavity is inserted from the hole above the olecranon. Generally, two needles are used to make the arc face the cortical bone, and the two needles cross each other in the medullary cavity to form a tension and fix the fracture. 2Kuntscher fixed needle: a type of intramedullary nail. Select the appropriate length of the needle to enter from the large bone nodule, through the medullary cavity through the fracture end up to the top of the olecranon. The above two internal fixation methods are easy to operate but not strong enough to effectively control the rotation and shortening of the fracture end. Needle tails left outside the bone can affect the movement of the shoulder or elbow joint, so it is not commonly used clinically. 3 external fixation: for open fractures with extensive soft tissue contusion or burns. It is also suitable for patients who are unable to perform strong internal fixation and infections in the fracture. The outer fixing frame is divided into one arm and two arms. In a few cases, a three-arm external fixator is required. An annular rod or straight rod coupling can be used between the arms and the arms to increase the stability of the frame. In general, when using a single-arm external fixator, three fixed needles, that is, six fixed points, should be inserted into each end of the fracture. A firmer fixing can be achieved. Complications of external fixation include needle infection, stab wounds in nerve vessels and tendons, and non-union of fractures. After using the external fixator, X-ray examination should be carried out regularly, and the alignment of the fracture end should be adjusted in time, and the functional exercises should be performed in the early stage in order to obtain satisfactory results. 4 with interlocking intramedullary nail fixation: the humeral shaft with interlocking intramedullary nail is derived from the femoral shaft and the tibia with interlocking intramedullary nail. Relying on the proximal and distal screws of the intramedullary nail provides stability of the fracture end to the line, preventing the fracture end from shortening and rotating. The interlocking intramedullary nail can be inserted antegradely, that is, from the large tibial tuberosity through the fracture to the distal end of the humerus. It can also be retrogradely drilled, that is, drilled 3cm above the olecranon nest, and the intramedullary nail is drilled with a silk tapping to increase the contact surface between the cortical bone and the intramedullary nail to enhance stability. For intramedullary fixation, the C-arm or G-arm fluoroscopy machine is used for dynamic positioning and observation of the condition and location of the intramedullary nail into the medullary cavity. Take the humerus as an example. The operation method is that the patient lies on the X-ray surgical bed, the sandbags are raised between the shoulders, the head is turned to the healthy side, and the proximal end of the humerus is maximally exposed, and a 3 to 4 cm long incision is made along the deltoid from the lateral side of the shoulder. The soft tissue of the deltoid muscle fibers should not be more than 5cm to avoid damage to the phrenic nerve. Determine the position of the rotating shaft, retract it, and use the bone cone to punch into the medullary cavity at the inner edge of the large tibial tuberosity. Insert the guide needle into the proximal end of the fracture under the monitoring of the fluorescence enhancement screen, reduce the fracture, and insert the guide needle into the distal fracture end. If the fracture end is difficult to reset, a small incision can be made in front of the fracture, and the finger is assisted to reset. If the insertion of the guide pin is difficult, the needle can be rotated or the distal end of the fracture can be rotated to allow the guide needle to pass smoothly. The intramedullary nail of the humerus is generally selected from 8 to 9 mm thick. The young man's medullary cavity is relatively thin, and it is often necessary to ream the medulla along the guide needle before the intramedullary nail is inserted, and then the intramedullary nail is inserted along the guide needle. Older people have more wide medullary cavities, and sometimes they can get more intramedullary nails. The length of the intramedullary nail can be measured with a guide pin of the same length or by the length of the upper arm of the healthy side. The tail of the intramedullary nail should be placed below the shoulder rotation axis. The proximal locking pin is screwed from the outside to the inside by means of the guide, and does not penetrate the inner cortex. The distal locking pin is screwed in from front to back or from back to front. 5AO dynamic compression plate screw internal fixation: according to the different fracture parts, use steel plates of different shapes, widths and thicknesses. A wider plate is used for the mid-section fracture, and the upper and lower fractures use a narrower steel plate and a curved profiled plate. When using AO powered compression steel, the biomechanical properties of the bone should be considered. Some cortical bones are prone to splitting, even in long spiral fractures, after reinforcement with a lag screw, it is still necessary to use a neutral steel plate to reinforce, and a wide steel plate with staggered holes is used to increase the distance between adjacent screws. Should not rely solely on lag screws to fix the fracture to avoid the possibility of bone splitting in the long axis direction. Complications in a small number of patients due to internal fixation is not strong, bone non-joining and malunion.

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