Spine Biomechanics
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Transcript Spine Biomechanics
Fracture Fixation
Internal & External
Fracture Types
http://health.allrefer.com/health/bone-fracture-repair-fracture-types-1.html
Influencing Healing
Systemic Factors
Age
Hormones
Functional activity
Nerve function
Nutrition
Drugs (NSAID)
http://www.orthoteers.co.uk/Nrujp~ij33lm/Orthbonefracheal.htm
Local Factors
Energy of trauma
Degree of bone loss
Vascular injury
Infection
Type of bone fractured
Degree of immobilization
Pathological condition
Stages of Fracture Healing
1.
Inflammation & Hematoma
Osteoprogenitor cells, Fibroblasts
2.
Callus Formation
Periosteal and Endosteal
Fibro-cartilage differentiation
3.
Woven Bone
Substitution of avascular and necrotic tissue
Haversian remodeling
4.
Remodeling
Lamellar or trabecular bone
Restoration of continuity and ossification
Bone union
**When compression is applied via implant, these stages are minimized**
http://www.orthoteers.co.uk/Nrujp~ij33lm/Orthbonefracheal.htm
http://www.ivis.org/special_books/ortho/chapter_03/03mast.asp?Type=IPRP&LA=1
Healing Complications
Most often due to severe injury
Energy dissipation to bone and soft tissue results in
damage to blood supply
Compartment syndrome
Severe swelling resulting in decreased blood supply can cause the
muscles around the fracture to die
Bad osmotic pressure lets blood out instead of across damaged muscle
Neurovascular injury
As pressure remains high, blood cannot get to damaged muscle
Arteries and nerves around the injury site are damaged
Infection
Imbalance of bacteria and body’s ability to cope with it when amount of
necrotic tissue and contraction of bacteria are not being cleared (by
surgeon or patient)
http://www.hughston.com/hha/a.fracture.htm
Healing Complications (Cont’d)
Delayed union
Nonunion
Abnormal alignment
Post-traumatic arthritis
Failure to heal
Malunion
Extended healing time
Fractures that extend into the joints can cause premature arthritis of a
joint
Growth abnormalities
A fracture through an open physis, or growth plate, could result in
premature partial or complete closure of the physis; Part or all of a
bone will stop growing unnaturally early
http://www.hughston.com/hha/a.fracture.htm
Treatment
When will a cast suffice?
Fracture is stable
Patient preference
No complications (Ex.-infection, burn)
When is fixation necessary?
Fracture is unstable
Quick Mobilization
Occupation
Athletes
http://www.defence.gov.au/dpe/dhs/infocentre/publications/journals/NoIDs/ADFHealthApr01/adfhealthapr01_2_1_24-28.pdf
Principles of fracture fixation
Obtain and maintain alignment
Reduction
Transmission of compressive forces
Minimum motion across fracture site
Achieve stability
Avoid tensile/ shear/torsion forces
Across fracture site
Prevent motion in most crucial plane
Fixation: Internal vs. External
Internal
Plates, screws, etc. completely within the body
Less expensive
Types
Comminuted – nail with interlocking screw
Transverse or Oblique –plates or screws
External
Pins coming through skin interconnected by external
frame
Has complications
http://www.defence.gov.au/dpe/dhs/infocentre/publications/journals/NoIDs/ADFHealthApr01/adfhealthapr01_2_1_24-28.pdf
Internal Fixation
http://www.nlm.nih.gov/medlineplus/ency/imagepages/18023.htm
Internal Fixation Priciples
Rigid, anatomic fixation
Allows an early return to function
Reserved for those cases that cannot be
reduced and immobilized by external
means
Open reduction of a fracture
Good blood supply to undisturbed tissues
http://www.umm.edu/ency/article/002966.htm
Physiological Response to IF
Primary healing
Minimal extramedullary callus
Minimal intra-medullary callus
Sub-periosteal
Rapid
Related to motion
Crosses miniature gaps
Depends on soft tissue viability
Stress Concentrations
Geometric discontinuities (hole, base of
threaded screw, corner)
Local disturbance in stress pattern
High stresses at site of discontinuity
Drilling a hole reduces the bone strength
by 10 – 40 %
Types of IF Devices
Lag screws
Kirschner wire
Wire loop
Tension band wiring
Combination of wire loop and screw
Combination of Kirschner and wire loop
Plate
Intramedullary rods and nails
Interlocking screws
Hemi-Arthroplasty
In the hip, used for
femoral neck fractures
Avascular necrosis
Fractures of the proximal
humerus
Early mobilization is
facilitated
http://www.orthogastonia.com/patient_ed/html_pages/hip/hip_hemiarthrooplasty.html
Bilboquet Device
http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/100_bilboquet/bilboquet_us.shtml
Problems in IF
Infection
Delayed union
Non-union
External Fixation
http://www.nlm.nih.gov/medlineplus/ency/imagepages/18021.htm
External Fixation
Method of immobilizing fractures
Employing percutaneous pins in bone
attached to
Rigid external metal
Plastic frame
For treatment of open and infected
fractures
Indications for EF
Open grade III fractures
Compound tibia fractures
Generally from motorcycle injuries
Gunshot wounds
Major thermal injuries
Open fractures associated with polytrauma
Management of infected nonunions
Forces in an External Fixator
Compression
Neutralization
Distraction
Angulation
Rotation
Translation or displacement
Compression
For transverse
fractures
Adds stability
at nonunion
site
Neutralization
For comminuted
fracture
Compression may
lead to excessive
shortening
Used to maintain:
Length
Alignment
Stability
Distraction
For distal
metaphyseal or
intra-articular
injuries
Same principle of
traction
Distraction of
fragments
Alignment of injury
Angulation
A – unacceptable alignment B – loosening clamps; loss of distr. and compr. force
C – after frames completely loosened; angulation is corrected
D - compression on distraction forces are reapplied
Rotation
Exert rotational
force
Along longitudinal axis
Release of forces
first
Can be done with
repositioning pins
Most of present
frames cannot apply
rotational forces
Translation or Displacement
Volkov apparatus
Double ring unit
Moves one ring in
parallel to other
For translation
Types of EF Devices
Unilateral
Bilateral
Triangular
Quadrilateral
Semicircular & Circular ring
Ilizarov
http://www.ilizarov.org.uk/content.htm
Unilateral EF
Bilateral EF
Triangular EF
Quadrilateral EF
Semicircular and Circular EF
Advantages of EF
Easy application
Good stability
Excellent pain relief
Adjustable
Alignment, Angulation, Rotation
Access to open wounds
Frequent dressing change
Monitoring of damaged tissue
Disadvantages of EF
Application may cause soft tissue damage
Lacks advantages of cyclic loadings as
seen in casts
Constrained in time
Pins may drain
Infection
The End
Granulation
Tissue damage repair
begins with growth of
new capillaries
Red dots are new
clusters of capillaries
Bleed easily
Bright red tissue of a
healing burn is
granulation tissue
http://medweb.bham.ac.uk/http/depts/path/Teaching/FOUNDAT/repair/grantiss.html
Hematoma
Blood collection localized to an organ or tissue
Usually clotted
Example: Contusions (bruises), black eye, blood
collection beneath finger or toenail
Almost always present with a fracture
http://www.healthscout.com/ency/68/677/main.html
Fibrocartilage
Cartilage with a fibrous matrix and approaching
fibrous connective tissue in structure
Produced by fibroblasts
Forms in areas where size of the fracture gap is 1mm
or greater
Subsequently replaced by bone
Mechanical properties inferior to other types of
cartilage
Contains:
Large amounts of collagen type I
Reduced amounts of proteoglycans
Collagen type II, found only in cartilage
http://www.vetmed.ufl.edu/sacs/notes/Cross-Healing/page9.html http://wberesford.hsc.wvu.edu/histolch6.htm
http://www.nuigalway.ie/anatomy/wilkins/practicals/bone/html/bone_1.html
http://www.bm.technion.ac.il/courses/336529/web/Cartilage/major%20types.htm
Inflammation & Hematoma
http://www.ivis.org/special_books/ortho/chapter_03/03F2.jpg
Inflammation & Hematoma
Inflammation begins immediately after a fracture
Initially consists of hematoma and fibrin clot
Hemorrhage and cell death at location of
fracture damage
Fibroblasts, mesenchymal cells, osteoprogenitor
cells appear next
Formation of granulation tissue
Ingrowth of vascular tissue
Migration of mesenchymal cells
http://www.aans.org/education/journal/neurosurgical/apr01/10-4-1.pdf
Simon, SR. Orthopaedic Basic Science. Ohio: American Academy of Orthopaedic Surgeons; 1994.
Inflammation & Hematoma (Cont’d)
Primary nutrient and oxygen supply provided by
exposed cancellous bone and muscle
Use of anti-inflammatory or cytotoxic medication
during first week may alter the inflammatory
response and inhibit bone healing
http://www.healthscout.com/ency/68/677/main.html
Callus Formation
http://www.ivis.org/special_books/ortho/chapter_03/03mast.asp?Type=IPRP&LA=1
Callus Formation
Begins when pain and swelling subside
Ends when bone fragments are immobilized by
tissue
Size inversely dependent on immobilization of
fracture
Mesenchymal cells form cells which become
cartilage, bone, or fibrous tissue
Increase in vascularity
Stable enough to prevent deformity
Callus does not appear on x-ray images
http://www.orthoteers.co.uk/Nrujp~ij33lm/Orthbonefracheal.htm
Simon, SR. Orthopaedic Basic Science. Ohio: American Academy of Orthopaedic Surgeons; 1994.
Mechanical Role
Enlarge diameter at fracture site
Reduces mobility
Reduces resulting strain
Granulation Replaces Hematoma
Granulation differentiates into
Connective tissue
Random orientation of collagen fibrils
Their direction reflects the direction of tensile forces
Fibrocartilage
Deformation of Callus
Strength of initial
reparative tissue is low
If forces surpass the
strength of callus
Unstable fracture
Functional load deforms
fracture
Fracture fixation is
recommended
Woven Bone
Woven Bone
Callus changes from cartilaginous tissue to
woven bone
Callus mineralized but internal architecture is not
fully matured/arranged
Connective tissues and fibrocartilage thickens
Osteon organization is not complete
Fracture becomes increasingly stable
Mineralization is sensitive to strain
Mechanically stable scaffold
Increased strength and stiffness with increase of
new bone joining fragments
Simon, SR. Orthopaedic Basic Science. Ohio: American Academy of Orthopaedic Surgeons; 1994.
Bone Remodeling
Woven bone becomes lamellar bone
Bone union occurs at fracture gap
Callus gradually reabsorbed by osteoclasts
Replaced by bone
Medullary canal reconstitutes
Begins within 12 weeks after injury
May last several years
http://www.glaciermedicaled.com/bone/bonesc3p2.html
Simon, SR. Orthopaedic Basic Science. Ohio: American Academy of Orthopaedic Surgeons; 1994.
Mesenchymal Cells
Source of cells for new bone production
Derived from bone marrow cells
Intramembranous bone formation
Formation of bone directly from mesenchymal cells
Cells become osteoprogenitor cells then osteoblasts.
Development of Cartilage model
Mesenchymal cells form a cartilage model of the bone
during development
http://www.grossmont.edu/shina.alagia/lectures/144/Bone%20physiology.ppt
http://www.ecmjournal.org/journal/supplements/vol005supp02/pdf/vol005supp02a07.pdf
Fracture Stability
Direction of fracture & material (type of bone)
define stability
Stable
Definition of direction of force important
Fissure (Hairline) – not complete break, minimal
trauma
Greenstick – crack on outside of “bend”
Unstable
Comminuted – many bone fragments
Oblique – break at an angle
Spiral – corkscrew-like crack pattern
http://pain.health-info.org/Pain%20Pages/fractures.htm
Lag Screw
Lag Screw
Stability
Exerts inter-fragmentary
compression
Static compression
Distal head must be
engaged
Screw Holding Force
Increase in area of bone
within screw threads
Decrease in pilot hole
size
Increase in length of
engaged threaded
portion
Area available to resist
shear
Kirschner Wire
Kirschner Wire (Cont’d)
Rotational stability
May be a problem
Anchorage to tension band
Twisting of wires on both sides
Almost equally distributed compression
Tension Band
Tension Band (Cont’d)
Dynamic compression
When tension applied
Compressive forces are at the fracture site
Used
Substitutes torn ligaments & tendons
Allows injured ligaments to heal
When fragments too small to be screwed
http://www.wheelessonline.com/o2/1536.htm
Tension band & Screw
Tension Band & Screw
Plating of Vertebral Column
Vertebral Column
Intramedullary Pin
Types
Open
Closed
3-point fixation
End fixed in epiphyses
Intramedullary Pin (Cont’d)
Stability is dependant
on
Friction / pressure
between
Deformable nail (elastic
recoil)
Endosteal surface of
medullary canal
Fracture “personality”
Intramedullary Pin (Cont’d)
Blood
supply is from the medullary canal
Compromised
More
by intramedullary fixation
care has to be taken
Open Fracture
Bone ends have penetrated through and
outside skin
Important features
Polytrauma victims
Varying soft tissue damage
Contaminated wound
Requires emergency treatment
Types of Open Fracture
Type I – Low Energy
Type II
Puncture wound (1 cm dia. or lesser)
Not much soft tissue contusion
Usually simple transverse, short oblique fracture
No crushing component
Laceration (more than 1 cm long )
Not extensive soft tissue damage
Not severe crushing component
Type III – High Energy
Extensive damage to soft tissue
High velocity injury or severe crushing component
Type I
Type II
Type III