Hello and a warm welcome to this part of the course. Today, we would like to familiarise you with the principles underpinning the treatment of fractures. Perhaps you are asking inwardly: Do I really need to know about this? In answer to that, I would like to quote some figures for the year 2010 compiled by the Federal Office for Statistics: 8% of the population suffers an accident every year. Due to such accidents, 2% of the adult population have to undergo in-patient treatment and 20% of all accidents result in fractures occurring. This will make you realise how every one of you will come into contact with trauma surgery in one form or another. This is why it is a very relevant subject for you to learn about. And so to the question: How do fractures even occur? I would like to show you now. If the forces acting on the bone exceed the limit of elasticity of the bone, it will break. [NOISE] A bone acts in a relatively static manner. Having said that, it is more elastic than is often assumed. Its level of rigidity is about one tenth that of steel. The various influencing factors acting on a bone can clearly lead to different types of fractures occurring. If there is a tendency for the bone to be weakened, for example due to osteoporosis, then quite different types of fracture occur than with a young, healthy bone. It has been established over the years that different types of fracture require different types of treatment. In order to be able to compare the different types of treatment, it has been very helpful to introduce classifications, e.g. according to how the fracture was caused, whether any direct or indirect exertion of force was involved, in accordance with the accompanying injuries to soft parts, open or closed injury or according to the relationship of the fracture to the joint, e.g. whether a metaphyseal or diaphyseal injury was involved. The principles underpinning the treatment of fractures can be summarised as involving three key factors: The first factor is that of reposition. This means returning the broken bone to its original shape once again. The second factor is that of retention. This means that we have to keep this repositioned bone in place until it has healed. The third factor covers rehabilitation, i.e. that the limb has to be exercised so as to enable the original function to be restored. These principles apply irrespective of whether a fracture is to be treated without or by means of an operation. Treatment not involving surgery is referred to as non-operative and that involving surgery as operative treatment. Fractures have repeatedly occurred in the course of human history and the treatment of fractures was accordingly one of the earliest medical activities undertaken by human beings. We can see here one of the earliest methods for treating fractures. Our ancestors used such branches as braces for fractures in order to bring about corresponding immobilisation. I have also brought along a few pictures to show you which have kindly been provided by the State Collection for Anthropology and which reveal how such fractures are treated at all stages. Here you can see a bone of the upper arm which has obviously been broken and then healed in a malaligned manner. On the right, we can likewise see an upper arm bone which has healed in pseudarthrosis. It is obvious from this that the treatment of the fracture is not working well. Human beings needed quite a long time before being able to conduct operations on bones with a sufficiently high degree of safety. This was mainly due to the high risk of infection. Bones have relatively poor levels of protection against infection if they are not covered by soft tissue. This means that any operations carried out on a bone have a relatively high risk of causing an infection. This means that it has only been possible to conduct effective operative treatment on fractures since it has been possible to create a highly sterile operative environment. This means that even today it is still unfortunately the case that in large parts of the world, the treatment of fractures has mostly to be conducted in a non-operative manner as operating conditions are not available providing adequately sterile conditions. I would now like to ask you to accompany me on a short trip through time covering various treatments for fractures and show you, based on some examples, how different forms of treating fractures has been carried out on non-operative and operative bases. [MUSIC] [MUSIC] [MUSIC] [MUSIC] The human skeleton consists on average of 206 bones, depending on how they are counted. The role of the skeleton is to act as a framework for stability, an extensive store of minerals for calcium and magnesium and in haematosis. Tubular bones consist of the epiphysis close to the joint, the metaphysis and the diaphysis, the periosteum as well as both osseous components of the cortical bone and of the cancellous bone. There are various sorts of bones: tubular bones, flat bones, short bones or bones containing air. This graph shows the development of musculoskeletal illnesses and injuries over time. It can clearly be seen that, based on the demographic development of the western industrialised nations, the number of musculoskeletal illnesses and injuries is set to increase markedly. Approx. 8.5 million people have an accident per year. Of these, 1.6 million have to undergo in-patient treatment. In 30% of cases, the diagnoses involve concussion, in 7% injuries to the trunk, in 13.8% fractures of the upper limbs and in 31% fractures of the lower limbs, in addition to a series of other injuries. A fracture involves a separation of the connection of the bone due to the direct or indirect effects of force exceeding the elasticity threshold of the bone. Fractures always involve damage to the soft tissue. Osteoporosis is a systemic illness of the skeleton characterised by reduced bone mass and deterioration of the micro-architecture of the bone. This results in increased brittleness and the frequent occurrence of fractures. 40-45% of patients treated on an in-patient basis in trauma surgery suffer injuries linked to osteoporosis. 43% of limb fractures operated on are linked to osteoporosis. Whether a fracture occurs depends on the type, strength and direction of the force having an impact and also depends on the quality of the individual bone. [NOISE] Fractures can be described according to the most varied qualities: Firstly, according to the effect of force, the quality of the bone, localisation, the accompanying damage to soft tissue, x-ray morphology, age or the fact of whether an individual injury is involved or multiple ones. A distinction can be made between transverse fractures, fractures with bending wedges, oblique fractures, spiral fractures, multifragment fractures or comminuted fractures. In addition, there are fissures, joint fractures, diaphyseal fractures, avulsion fractures or epiphyseal fractures. Dislocation of fractures is a subject which you will often encounter in the following course. This is therefore an especially important term. Fractures can be displaced in a total of four planes: Firstly, ad latus, that is to say sideways, secondly, ad longitudinium, length-wise, thirdly, ad axim, that is to say forwards or backwards and fourthly, ad peripheram, in the form of malrotation. As modern trauma surgery was evolving in the 1950s and 1960s, the recording and comparison of clinical courses of treatment played a crucial role. In order to be able to compare like fractures with like fractures and therewith like schemes of treatment with each other, it is essential that fractures be described as precisely as possible. To this end, the AO has developed a system which enables the fracture and the severity of the injury to be described precisely. Within this, various numbers are assigned to the various bones, for example 1 for the upper arm bone, 2 for the forearm. These can then be further divided into proximal, medial and distal. This determines the second figure. A distal humerus fracture is for example designated as 13. The severity of the injury is then further divided using three letters, A. B and C. Within this, the severity of the injury increases in step with the rise in letters. This means, for example, that A stands for simple diaphyseal fractures, B for diaphyseal fractures with a wedge and C for diaphyseal comminuted fractures. As mentioned above, accompanying tissue damage is present with each fracture. According to Osetern and Tscherne, this is divided into Level 1 to 3. Level 1 designates superficial abrasions, skin contusions and fragment pressure sites. Level 2 designates deep contaminated abrasions, circumscribed skin and muscle contusions or the threat of compartment syndrome. Level 3 means a manifest compartment syndrome, with extensive skin contusions, crush injuries with subcutaneous decollement or supplementary vascular injuries. Compound fractures are categorised according to Gustilo/Anderson. Level I designates small skin lesions of < 1 cm, Level II of > 1 cm, Level III covers extensive damage to the soft tissue and Level IV means amputation. The greater the energy exerted on the bone, the more extensive will the concomitant injuries be. The principles of treating fractures consist of reposition, retention and rehabilitation. This means that, to begin with, we have to reposition the bone in its original shape, then fix this shape for the duration of the fracture healing period and then have to exercise the function of the limb affected once again. The basic principles of treating fractures consist of ensuring adequate blood supply, adequate stability, that soft tissue is intact, the absence of infection and the exclusion of any systemic illnesses. A distinction can basically be drawn between two different types of fracture healing: primary and secondary. Primary fracture healing describes the process of bone cells being able to grow directly over the fracture gap. The basic precondition for this is that the ends of the bones can be positioned very close to one another and are not capable of moving against each other. Primary fracture healing therefore requires absolute stability. No external callus occurs in response to primary fracture treatment. Trabeculae grow together by means of the accretion of newly formed bone tissue. To begin with, primary fracture treatment entails slight mechanical stress. The bone has developed from the sixth to eighth week to such an extent that corresponding remodelling can be carried out. [PAUSE] Secondary fracture healing describes the process operating via callus-fracture healing. This means that in the case of the bone ends adapting less well or, with larger bone defects, a connective tissue scar forms between the fracture sites. This is then transformed into bone in the course of time via fibrous cartilage. Remodelling likewise occurs in this process. If a fracture is suspected to have occurred, it is first of all important to ask the patient about the exact details of how this occurred so as to establish the trauma mechanism. A clinical examination is then undertaken in order to determine possible malalignment, crepitations, the status of the soft tissue as well as the peripheral perfusion, motor function and sensitivity. This is a term which we will likewise come across very often in the following course. This term is a very important one indeed, as, in the event of a lack of blood flow, motor function or sensitivity, possible accompanying structures of the bone can be injured. If any restriction can be established in this peripheral blood flow, motor function and sensitivity, then you must assume that such an injury has been sustained, until such time as the opposite can be proven. Imaging of a fracture takes place by at least x-ray imaging in two planes with the adjacent joints. If any lack of clarity exists with regard to potential comminuted fractures, then the indication is given for a computerised tomogram, sonography or MRI investigation to be conducted. There are certain and uncertain signs of fractures. Certain signs of fractures are axial malalignment, abnormal mobilisation, compound fractures and crepitations. Uncertain signs of fractures are pain, tumours and the formation of haematoma or impaired function. As an initial measure, fractures are covered with a sterile dressing. Definitive exploration should only be conducted in the operating theatre under sterile conditions. Dislocation fractures should be repositioned as quickly as possible. This is undertaken by means of longitudinal traction of the peripheral limb towards proximal. Diaphyseal fractures with malalignment are likewise repositioned by means of longitudinal traction. The primary goal of every treatment of a fracture is to ensure the repair of function by means of the fracture healing in the correct position while simultaneously treating any potential concomitant injuries such as those to nerves, vessels, soft tissue defects or joint components. The answer to the question as to whether fractures are to be treated operatively or non-operatively depends on a number of factors: on the one hand, non-operative treatment tends more to be indicated in the absence of concomitant injuries, isolated injuries or if a stable situation can be created following repositioning. Surgical treatment, on the other hand, tends to be indicated more if concomitant injuries are present, if irreducible injuries to the epiphysis have been sustained or in cases of pathological fractures, within the context of treating polytrauma or in the case of unstable fractures which cannot be adequately immobilised with non-operative treatment. Furthermore, irreducible fractures are to be treated surgically, with any relevant dislocation, by means of an operation. Non-operative treatment is basically carried out initially by means of closed repositioning of the fracture. To this end, traction and countertraction are exerted on the distal segment. Following parietal pressure application and rotation, the peripheral segment is placed in a central position. This repositioning must then be retained. This is accomplished with an initial plaster cast, ideally a split white plaster variety one. After the plaster cast has been applied, peripheral blood flow, motor function and sensitivity must be examined and recorded in all cases. Once the wound oedema has regressed, a circular plaster cast can be applied after about one week. It is important to remember that an x-ray check must be carried out every time the plaster cast is changed or a new plaster cast is applied. The retention measures or stabilisation options depend on a number of factors. This method depends on the form of fracture, the extent to which the soft tissue has been damaged, whether mono- or polytrauma has been sustained, the age of the patient and whether they can possibly relieve the limb. Furthermore, neither infrastructure factors nor individual bone structure play a role. The AO developed the surgical treatment of fractures in the 1950s and 1960s and called this osteosynthesis. This picture, for example, shows you compression osteosynthesis. This induces primary fracture healing as the fragments are pressed against each other under compression. In contrast to this is plate and screw osteosynthesis, as shown on the next slide. Both these slides show forms of osteosynthesis which induce secondary fracture healing. This means that fractures heal by means of callus formation without primary fracture healing occurring. A whole series of different materials are now available for treating fractures. The simplest form is wire osteosynthesis, followed by tension band wiring. This is then followed by plate and screw osteosynthesis and plate osteosynthesis. Fixateur interne and intramedullary stabilisation lead to secondary fracture treatment occurring in exactly the same way as fixateur externe do. If osteoporotic joint fractures are present, then joints have to be replaced in part by means of primary fracture prostheses. [NOISE] [PAUSE] If primary fracture healing is to be achieved, then compression of the fragments against each other is helpful. This can be induced either by means of a compression screw or by tension band wiring. If plate osteosynthesis is to be conducted, then additional compression can be exerted onto the fragments by means of plate clamps. We call this form of osteosynthesis Dynamic Compression Plate. In the case of DHS or Dynamic Hip Screw, the effect of body weight on the proximal femur exerts compression on the femoral neck or pertrochanteric fracture. The same principle is applied in the case of dynamic nails. K-wire osteosynthesis can be carried out if a single brace and fixation is adequately retained in one plane, for example a Lisfranc dislocation fracture or metacarpal fracture. The principle which applies is that of temporary fixing with the aim of a soft tissue scar forming. Tension band wiring osteosynthesis combines K-wire osteosynthesis in addition to the application of tension band wiring. This is used to exert compression onto the fracture. Classic applications are MT-V base fractures, olecranon or patella fractures. This slide shows the principles underpinning compression screw osteosynthesis. To begin with, a 3.5 mm hole is drilled and then a drill guide is threaded onto this. Drilling of the cortical bone opposite is then undertaken, into which a thread is cut. If a cortical screw is now inserted into this hole and tightened, then compression is exerted by means of the proximal thread sliding through the cortical bone in the vicinity of the drill. In biomechanical terms, compression screw osteosynthesis would already be sufficient to induce fracture healing. The leverage forces, however, acting on such a compression screw osteosynthesis are in part too large to guarantee adequate stabilisation. Compression screw osteosyntheses are therefore often protected by means of supplementary neutralisation plates. As an example, the x-ray image of an ankle fracture is shown here. You can identify the compression screw by means of the ring. A plate is also applied which is intended to neutralise the leverage force of this compression screw osteosynthesis. I would now like to demonstrate a plate and screw osteosynthesis to you. We have made some preparations for this. A plastic bone. We have sawn a defect in this plastic bone so that you can also see what happens. We need a 3.2 mm spiral drill, a 3.2 mm drill bushing through which the drill will pass precisely. This drill bushing will later fix the position of the drill on the bone and protect the patient's soft tissue. We need a drill with an appropriate drill chuck. The drill is clamped by pulling back the drill chuck, inserting the drill and engaging it. We then also need a device for measuring depth. This depth-measuring device is used to establish precisely how long the screw is. This operates in such a manner that a small wire with a hook is placed here and this is introduced through the drilled hole and the hook is hooked onto the cortical bone opposite. This is then led under the cortical bone on this side and it is then possible to read the length of the screw required very easily on this scale. [PAUSE] There are various types of screws, either with a self-cutting or non-cutting thread. We will start with the simplest form to begin with. This is the one with the self-cutting thread and which is used when we have to cut a thread. For this reason, we also need a thread cutter here as well. A corresponding screwdriver and screws in the various lengths are of course then also required. We now take the drilling machine, the 3.2 mm drill and the drill bushing. This is placed at 90° opposite the defect. [NOISE] The hole is then drilled. [NOISE] [NOISE] The first cortical bone, [NOISE]. [NOISE] the second cortical bone. [NOISE] [NOISE] The length of the screw is then measured. We use this depth measuring device for this. In order to do this, the depth measurement device is introduced, this hook is hooked in the cortical bone opposite and the depth measuring device is then placed into the depression onto this side of the cortical bone. The length of the screw can now be read off from this scale (and is 28 mm in this case). We then need this thread cutter which is likewise also pushed in through the corresponding bushing. [NOISE] This is required in order to cut the corresponding thread into both cortical bones. [NOISE] [NOISE] Care must be taken in doing this to ensure that the tissue on the other side is not penetrated too deeply as this can lead to severe injuries being caused there. We then take the appropriate screw out of the screw box here, measure this screw once again, find it is 28 mm, [NOISE] and and then screw it [NOISE] into the bone. [NOISE] [NOISE] [NOISE] If the screw now tightens, it is important that the gap here is not narrowed. As a thread is cut into both cortical bones, [NOISE] no narrowing occurs and therefore no compression screw effect is exerted. We call this a setting screw. In order to transform setting screw osteosynthesis into compression screw osteosynthesis, we have to over-drill the cortical bone on this side. In order to do this, we need the 4.5 mm spiral drill and the corresponding drill bushing. The drill is then placed onto the cortical bone and the cortical bone is over-drilled on this side. [NOISE] When doing this, it is important to ensure that only one side is overdrilled as otherwise the screw just goes through without inducing any compression effect. [NOISE] The screw is then inserted into the hole [NOISE] and it can be seen immediately that it goes through on the cortical bone on this side much more easily. It now engages on the cortical bone opposite and when the gap is now observed, it can be seen very well how the gap becomes narrowed and therefore how this compression is exerted. This compression screw is one of the basic principles of absolute stability of osteosyntheses and is applied in many areas of trauma surgery. One example is a compression screw for a tibial plateau fractures or an ankle fracture. Anatomical repositioning of the fracture ends is first required for plate osteosynthesis. Interfragmentary compression can then be exerted with the plate. In the case of a Dynamic Compression Plate, this operates either via axial compression without any plate clamps by means of drilling far from the fracture or by means of displacing the fragments with plate clamps. In the case of the LC-DCP plate, the periosteal side of the plate is also reamed in order to ensure as low compromising of the periosteal blood flow as possible. This slide shows an example of an application of an LC-DCP plate for a diaphyseal fracture of the ulna. I would now like to demonstrate plate osteosynthesis. To do this, we have sawed a fracture into our bone, as can be seen nice and clearly here, and we are now going to reposition this and fix it with an 8-hole large fragment LC-DCP plate. We also need reduction clamps, here is an AO reduction clamp, also known as a lambotte. This clamp has a locking mechanism here which I will then demonstrate to you in situ straight away. This reduction clamp is named after Verbrugge and likewise has a clamping mechanism here. [NOISE] We now place the plate onto the fracture. It is important whilst doing this that the fracture gap is positioned in the centre of the plate. This plate has eight holes which means that the fracture gap is positioned precisely between the fourth and fifth hole so that the forces are as evenly balanced as possible. [NOISE] We now place the plate here. This plate is then fixed transient to the bone by means of these reduction clamps. The plate is precisely aligned for this purpose, fastened using these disimpaction forceps and then fixed in place with the clamping mechanism. Fixation in the second fragment is then undertaken. [NO_AUDIO] The clamping mechanism is tightened and the reposition of the fraction is then fastidiously checked in order to ensure that this is sufficient. Plate osteosynthesis means that we do not use any head-locking screws, i.e. we use normal cortical bone screws. This means that we have a relatively free selection as regards the angle of the screw in relation to the plate and it is important that we drill through the bone in as orthograde a manner as possible. Both cortical bones are drilled through. The length of the screw is then measured with the depth measurement device. [NO_AUDIO] In this case, a 32 mm screw has been measured. Thread cutting then follows, using the thread cutter. In doing this, it is again important to ensure that the thread cutter does not penetrate too deeply into the tissue on the opposite side so as to avoid any injuries occurring there. The thread cutter can then be removed again. We then take a 32 mm cortical bone screw from the screw box, check this and insert the screw into the screw hole. The repositioning and position of the plate are checked again in order to determine whether anything has shifted. The second hole is now drilled. This plate model can lead to our exerting additional pressure on the fracture by our causing the bone to move in relation to the plate via the position of the bone. We call this a compression effect. The plate is called an LC-DCP one, standing for “Low Contact Dynamic Compression Plate”. This means that we can cause supplementary compression of the bone to occur above the position of the screw holes and the position of the drill. That is to say that when I drill as closely as possible to the edge of the plate hole with my drill, I can cause supplementary pressure to be exerted via the screw. [NO_AUDIO] Both cortical bones are drilled through here as well. We now measure the length again. 32 millimeter. We must now cut a thread again again using the large segment thread cutter. In doing this, it is once again important to ensure that the thread cutter does not penetrate too deeply into the tissue on the opposite side so as to avoid any injuries occurring there. [NO_AUDIO] The thread cutter is now removed again. We take a 32 mm cortical bone screw from our screw box, check this and I can now explain to you here how, via the head of the screw, the compression effect is generated. You will see that this screw has a conical screw head and if this conical screw head now comes into contact with a correspondingly flattened screw hole, then pressure is generated against the plate and the bone by the screw being screwed in. I will now demonstrate this. The important thing is for you please to keep an eye on this fracture gap as you will see what happens in this process. When the screw head turns into the plate, you can see how the turning of the screw narrows the distance between both bones and this leads to an additional compression effect being generated. Osteosynthesis is now advanced to such a degree that we can remove the clamps. The remaining holes are now filled with screws in the operating theatre and the entire procedure is checked again in the image converter. Further developments in plate osteosynthesis have been achieved with the assistance of plate systems with fixed angles. Within these, a fixed-angle connection is established between the screw and the plate by means of an additional thread. The example of the philos plate shows a typical fixed angle plate which is inserted for proximal humerus fractures. A disadvantage is that the unidirectional screws mean that the position of the screw head in the plate hole cannot be freely selected. The advantage is the increased stability which is gained by the screws being inserted at a fixed angle. A fixateur interne induces secondary fracture healing. This means a fixed-angle implant beneath the skin surface. The fixateur interne allows for relative stability and oscillation within the fracture region. Typical examples are the dorsal stabilisation of the spine, the philos plate or the NCB plate. Intramedullary stabilisation can take place after the lent, axis and rotation of the limb has been restored. A series of implants are available to promote intramedullary stabilisation. Intramedullary nails which have not been opened by drilling and are unlocked can, for example, be employed for the treatment of clavicular fractures. Nails opened by drilling and unlocked are hardly used any more. The nail which has been opened by drilling and locked is currently the workhorse in this area, for example as the locking nail used on the tibia. The nail which has been opened by drilling and locked has likewise been largely left behind now. The advantage of intramedullary stabilisation are to be found in the maintenance of periosteal blood flow, the lack of any additional soft tissue trauma and early functional follow-up treatment. In addition, the removal of fixing screws after a certain phase can lead to the treatment being administered in a dynamic manner. This means that the stability of the treatment is reduced somewhat after approx. six weeks in order to allow for compression of the fracture in the longitudinal axis. These x-ray images show examples of the treatment of a fracture of the femur with an intramedullary rod. The nail which comes to lie in the medullary cavity of the femur can be clearly recognised. Proximal locking takes place via a femoral neck screw and distal locking via two transverse bolts. Treatment with fixateur externe envisages two Schanz screws being drilled into the bone in the proximal segment, two Schanz screws likewise in the distal segment and these being connected to each other via fixed-angle jaw connections. Fixateur externe applications are used for primary stabilisation in the case of damage to soft tissue, primary stabilisation in cases of polytrauma and for the temporary stabilisation of joint fractures. There are a number of specialist fixateurs, such as the ring fixateur according to Ilizarov or the Taylor Special Frame, which is used for cases of displacement osteotomy of paediatric fractures. This x-ray image shows examples of how an ankle fracture is treated by means of fixateur externe. The proximal and distal Schanz screws can be clearly recognised, as can the connection jaws. The x-ray permeable carbon rods are hard to recognise in this image. If total comminution of the joint has occurred, then it may be necessary to treat a joint fracture with a primary fracture prosthesis. Potential complications arising from the surgical treatment of fractures are infection, pseudarthrosis, axial malalignment, failure of implants or injuries being incurred by adjacent structures. In summary, it can be stated that the operative treatment of fractures has developed into a form of treating fractures incurred by human beings which is largely associated with only a low number of complications occurring. [MUSIC] [MUSIC] [MUSIC]