Internal & External Fixation

Fracture Healing
Disruption of the endosteal and periosteal
blood supply occurs in initial trauma and
maintaining adequate blood supply to the
fracture site is essential for healing.
Hunter described the 4 classic stages of
natural bone repair:
inflammation
soft callus
hard callus and
remodeling.
BONE REPAIR
Inflammation appears as swelling, pain,
erythema, and heat.
Disrupted local vascular supply at the injured
site creates hematoma and prompts the
migration of inflammatory cells, which stimulate
angiogenesis and cell proliferation.


Soft callus stage begins with an infiltration of fibrous
tissue and chondroblasts surrounding the fracture
site.
The replacement of hematoma by this structural
network adds stability to the fracture site.
In the hard callus stage, soft callus is converted into
rigid bone, by enchondral ossification and
intramembranous bone formation.
Once the fracture has united, the process of
remodeling begins
Fibrous bone is eventually replaced by lamellar
bone. This process is called secondary bone
union or indirect fracture repair,( it is the natural
and expected way fractures heal)

BONE REPAIR EXTERNAL FIXATION
Fractures with less than an anatomic
reduction and less rigid fixation (ie, those
with large gaps and low strain via external
fixator, casting, and intramedullary [IM]
nailing) heal with callous formation or
secondary healing with progression through
several different tissue types and eventual
remodeling.
Anatomical reduction and absolute stabilization
of a fracture by internal fixation alters biology of
fracture healing by diminishing strain (elongation
force) on the healing tissue at the fracture site.

Absolute stability with no fracture gap presents a
low strain and results in primary healing without
the production of callus

BONE REPAIR-INTERNAL FIXATION
The small gaps between fragments fill with
membranous bone, which remodels into
cortical bone.

This method of bone healing is known as
direct bone healing or primary bone union.

2 patterns of stability can result :
Absolute stability (ie, no motion between
fracture fragments) results in direct or primary
bone healing (remodeling).

Relative stability (ie, a certain amount of
fragment motion) heals with secondary or
indirect bone union.
Goal:
Place the fracture gap between the two sets of holes,
Place screws through the holes and through both
cortices if possible
Angle the screws towards the fracture gap in order to
create compression across the fracture gap.
Most commonly used in region where it is not possible to
easily place external fixators. Eg. Craniofacial region
Holds fracture securely, thus movement can begin at
once
Internal Fixation
Indication
Fracture that cannot be reduced except by operation
Fracture that are unstable and prone for dis-placement
after reduction
Fractures that unite poorly and slowly.Eg: fracture of
femoral neck
Pathological fractures where the bone disease may
prevent healing
Multiple fractures
Fractures in patients who presents with severe nursing
difficulties
Types
Screws
Wires
Plates and Screws
Intermedullary nails
Screws
2 types based on variability of
bone density are
Cortical screws - designed for
compact diaphyseal bone
Cancellous screws - designed
for the more trabecular
metaphyseal bone
Pins & Wires
Kirschner wires and Steinmann pins
provide provisional fixation for
reconstruction of fractures
incurs minimal bone and soft tissue
damage
leaves room for additional hardware
placement
Plates & Screws
Useful to treat metaphyseal fractures of long
bones and diaphyseal fracture of radius and
ulna

Intermedullary nails
Suitable for long bones
allows faster ambulation of the patient

Complication
Infection chronic osteomyelitis
Non union excessive stripping of soft
tissue, damage to blood supply
Implant failure due to stress
Refracture removal of implant too soon
External fixation
Principle
Transfix bone above and below the fracture with
screws or pins.
Clamp to a frame or connect with rigid bars
Allows adjustment of length and angulations
and reduction of fractures
Mostly applicable to long bones and pelvis
Indication
Fracture with severe soft tissue damage
Severe comminuted and unstable fractures
Fracture of pelvis
Fracture with nerve or vessel damage
Infected fracture
Ununited fracture

Taylor Spatial Frame
Self-lengthening
nail & prosthesis
Orthofix External
Fixator Ilizarov
Complication
Damage to soft tissue structure injury to
vessels, nerves and tendons due to fixing
pins and wires
Over-distraction union maybe delayed if no
contact between the fragments
Pin- track infection antibiotics given if
infection occurs