I choose this topic because I like medicine and shadowing at the hospital. My portion of the Senior Project was the project it self. This was my favorite because I got to shadow and learn a lot from it. The biggest take away from my project is that the ER is a cool place. The most difficult aspect of my project was Matching my schedule with the doctors schedule.
ER and OrthopedicsFor my project I shadowed at Mercy Hospital in orthopedics and in the emergency room. I was shadowing at these two places because my thesis and ted talk were about orthopedic trauma technologies. I shadowed at these two places because you see orthopedics and fractures in both. You also get to see what happens after somebody fractures a bone and the plan of action for that like reduction, casting, heal time etc.
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I was inspired to this because I enjoy learning about medicine, and in that I enjoy orthopedics. I focused on orthopedic trauma for my thesis and ted talk so for my senior project I shadowed in the ER where orthopedic trauma is relatively common. I also shadowed at Mercy Orthopedics where major orthopedic trauma is less common but orthopedics.
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TED TalkThis is my Ted Talk on orthopedic trauma technologies used to treat fractures.
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Senior thesis paper:
What technologies are being used in orthopedic long bone trauma surgery and what factors should be considered when deciding if it should be used?
What technologies are being used in orthopedic long bone trauma surgery and what factors should be considered when deciding if it should be used?
Ben Black
Senior Project Advisor: Tina Hott
Abstract:
Orthopedic trauma and bone fractures affect about 7.9 million people each year in the US. The different technologies used to treat fractures can vary and it is important to know how each of these affect patients financially and physically in both the long and short term. In this thesis, I assess popular technologies used in long bone fractures and healing techniques, and two new technologies. Academic sources and journals were used to gather information on benefits and drawbacks of each technology and when they should be used. Through my research I have found that of the many technologies that exist, each one is used in specific situations where they have the most benefits to the patients. Of the two new technologies I researched it shows they are promising, however more research and design is needed to conclude how they benefit people before they are implemented. The findings show that each fracture case needs to be individually analyzed for the patient's history, age, fracture, fracture type, location of fracture, bone fractured and soft tissue damage.
12th Grade Humanities
Animas High School
3-5-18
Osteocyte Trauma
Part I: Introduction
When you think of a bone fracture you may think of breaking your wrist or ankle when you were a kid. It hurt a lot, you had surgery, had a big cast put on for about a month, it was healed and then you went on and kept having fun. What you might not realize is the intricate analyzation of your fracture and what the best plan of action is to help heal it correctly and quickly, from the plate used, to the bone stimulator the surgeon may use, to the healing time. About 7.9 million fractures occur each year in the United States (Victoria et al. 1). At the end of this thesis you will have a much stronger understanding of what happens to your body and your bones when they experience trauma in the form of fractures, a concept termed orthopedic trauma.
Orthopedic trauma is an injury from accident or violence relating to the bones and soft tissue (muscles, tendons, ligaments and nerves) (Orthopedic Trauma). More serious orthopedic trauma affects long bones which are part of the upper and lower extremities and they make up the majority of fractures. As mentioned above, orthopedic trauma is really common in our country. Recently there have been new advances in technology that can improve healing time and the quality of fracture repair. Knowing how different materials and technology can affect patients physically and financially is very important, from revision surgery to chronic problems that can arise later in life. Two cases studies will be analyzed at the end of this to showcase the different technologies that may be used. Orthopedic long bone trauma healing and fixation technology have numerous techniques and materials, however the bone fractured, fracture location, and technology are all factors that need to be considered when providing care.
Part II: Historical Context and Background
Orthopedics is a branch of medicine that studies the injuries and diseases of bones, muscles, tendons, ligaments, cartilage and nerves. Orthopedists or orthopedic surgeons are physicians who are the experts of the musculoskeletal system. When you fracture a bone an orthopedic surgeon or an orthopedic trained physician assistant will assess you and see if surgery necessary. As an orthopedist, it is imperative to have a strong knowledge of anatomy and physiology, especially of the skeletal system.
The adult human body’s skeletal system contains 206 bones that allow the body to stand and have shape. Our skeletal system in our body gives us structure, protection and support through bones, cartilage and ligaments (Zimmermann). It also allows for the storage of lipids, minerals and blood cell production (Anatomy and Physiology). Without a skull or ribs, your body would be extremely vulnerable to injury due to lack of bones protecting it (Totora & Anagnostakos 124). Cartilage is material that is located where flexible skeletal tissue is needed (Skeletal Cartilages). Common locations of cartilage are: at the end of bones, meniscus, external ear, nose, larynx, costal cartilage, etc. Ligaments are connective tissues that hold bones together; they are located around every bone joint in the body. The skeletal system works together with skeletal muscles to create the musculoskeletal system. This allows you to walk, grip, eat and move your eyes freely. Muscles attach bone to bone and the section of muscle that attaches to the bone is called a tendon. To illustrate the obvious importance of bones in the human body a strong knowledge of long bones is important.
Of the 206 bones you have in your body, 90 of them are long bones. Long bones are exactly that, long, they are longest and biggest bones in the body examples of these include femur, tibia, fibula, humerus, radius, ulna and clavicle. Long bones can also be very small examples are: metatarsals, metacarpals and phalanges. Fractures can occur to any bone and can happen in a number of ways and in a number of patterns. Fractures generally occur from three different causes (etiology): trauma, pathologic, and stress. A traumatic fracture is caused by direct or indirect violence usually from a high amount of force (White et al. 2). Pathological fractures occur within
... abnormal or diseased bone and are often caused by relatively little violence or energy; they are the effect of a normal force on an abnormal bone. The pathology may be localized to one part of the bone (e.g. a tumour deposit) or generalized (e.g. osteoporosis and osteomalacia)...[stress] fractures are the result of the cyclical application of normal forces to normal bone with excessive frequency. These often occur following a change in the level or intensity of activity. (White et al. 2-3)
A common example of a stress fracture is a second metatarsal fracture, which is a long bone in your foot. This usually occurs in novice long distance runners or army recruits, they start suddenly, run excessively and do not give their body time to adapt to the new activity (White et al. 3). Fracturing a bone can result in different fracture patterns throughout the bone which is known as morphology (White et al. 3). The fracture patterns shown in Figure 1 are some of the most common fractures of the diaphysis; the middle portion of the bone, also known as the shaft.
Figure 1: Common diaphyseal fractures of long bones (Types of Fractures).
Fixation is the process of fixing fractured bones. There are two types of fixation, internal and external. Internal involves opening up through the skin and using an internal fixator like a metal plate. External fixation is using wires and pins outside of the skin to hold the fracture together. Both are used for specific scenarios depending on the condition of the patient and the extent of the fracture(s). Radiographs are medical imaging used to view the condition of your body. Significant tests include X-ray, CT, MRI and PET. X-rays are most commonly used for fracture identification and degree of injury. When more complex fractures (e.g. comminuted fracture or pelvic fracture) or injuries affect multiple areas, an MRI or CT may be done to understand the complexity of it, allowing for more accurate fixation and a better plan for treatment ahead of time. Proximal and distal are common terms used to describe the position of an injury or fracture relative to the bone. Distal means the far end of the bone or the piece of the bone that is farthest from where the limb attaches to the body, and proximal is vice versa. For example, the distal part of the humerus is where the radius and ulna (forearm bones) attach whereas the proximal end attaches to the glenoid cavity of the scapula (shoulder bone).
The technology and knowledge our society possess now about fractures, treatment, anesthesia, radiographs and sterilization have been an ongoing learning process since the 1840s. In the early to mid 19th century it was common for injuries from war and other incidents to result in amputation. Fractures minor enough to not need amputation were treated non-operatively with the main goal of reducing the fracture and immobilizing the limb. The two main concerns for operating on a fracture were pain and lack of sterilization, which frequently resulted in infection. In 1846 ether vapor was found to be an effective anesthetic that could be used during surgery. This changed the course of medicine in being able to diminish pain associated with injuries and during surgery. In 1865 medicine drastically changed when an antiseptic carbolic acid spray was used to treat an open femoral fracture on an 11 year old boy, which without antiseptic would have needed amputation. About a decade later asepsis, keeping surgery sterile, was introduced which was widely used. In the 1890s surgical gloves were created which also helped prevent infection of the patient from the physician and environment. X-rays were discovered in 1895 which changed the course of fracture fixation forever allowing for high accuracy in treating fractures and understanding the extent to which the patient would be affected. In 1912 Emil H. Beckman stated, “The use of the X-ray first showed us how very inferior our bone repair work has been” (qtd. In Bartoníček). This quote eloquently shows how X-rays changed medicine forever in being able to properly identify fractures, which gave a better plan of action for the physician.
In the late 1800s, surgeons were experimenting and creating plates and other implant devices to help fractures heal correctly. Historically, implant devices were made of ivory, bone, and metal. Most metals were problematic due to the mechanical properties and corrosion; stainless steel was found to be the safest metal for internal fixation. External fixation on the other hand was commonly used to treat fractures. Most people would have large screws and pieces of ivory in their limb literally holding the fracture together. Implants and methods used back then to treat fractures would be extremely primitive when compared to today's technology, however, these experiments and trials were paving the way to better and safer implants (Bartoníček). Physicians back then pioneered orthopedic medicine and made it what it is today. Without their experiments and curiosity we as a society wouldn't have the advanced technology that we possess now.
Part III: Research and Analysis
There are 5 different types of bones in the body: long, short, irregular, flat and sesamoid, and depending on the type, the buildup of the bone changes. In Figure 2 you can see the different anatomy of long bone and how it changes throughout. In the article “Bone Structure” the author explains the anatomy of a long bone:
A long bone has two parts: the diaphysis and the epiphysis. The diaphysis is the tubular shaft that runs between the proximal and distal ends of the bone. The hollow region in the diaphysis is called the medullary cavity, which is filled with yellow marrow. The walls of the diaphysis are composed of dense and hard compact bone. The wider section at each end of the bone is called the epiphysis (plural = epiphyses), which is filled with spongy bone. Red marrow fills the spaces in the spongy bone. The outer surface of the bone is covered with a fibrous membrane called the periosteum (peri– = “around” or “surrounding”). The periosteum contains blood vessels, nerves, and lymphatic vessels
that nourish compact bone. Tendons and ligaments also attach to bones at the periosteum. (Bone Structure)
This just brushes on how intricate the anatomy of a long bone is, the biology and physiology show how all of those parts work together tremendously to create a strong, healthy body. One of the pieces that allow us to have a strong, healthy body, is the healing process bones go through when broken.
Figure 2: The anatomy of a long bone (Bone Structure).
The healing process after fracturing a bone is complex. It involves several different stages that over time cohesively heal your bones back to their original state. There are four phases of bone healing: inflammation, soft callus, hard callus and bone remodeling. Immediately after you fracture a bone a hematoma is formed from blood taken from the surrounding bone tissue. This creates an inflammatory response which helps stimulate healing and continues for several days after the fracture. The blood deposited to the fracture site clots and forms a soft callus made of fibrous tissue and cartilage. This forms after a couple of weeks, through mineralization, and turns into a hard callus. Figure 3 shows a diaphyseal fracture of the fibula and shows the hard callus formed. After approximately a month bone remodeling will begin which is necessary because the hard callus does not restore biomechanical properties to the bone. Bone remodeling turns the hard callus into lamellar bone (compact and spongy) through mineralization, with a medullary that cavity restores the natural state of the bone. This can take years to completely finish (Marsell & Einhorn) (Bone Healing).
Figure 3: X-ray of a fibular fracture (a) and shows a follow up x-ray of a fibula with a hard callus (b) (Bone Healing).
Fractures are assessed through multiple radiography technologies: X-ray, CT and MRI. The most common way fractures are evaluated is through X-rays. X-rays allow you to see bones and bone defects very easily due to the clear contrast seen on the films, making fractures easy to identify. In chapter 1 of the book “Orthopedic Trauma” White et al. explain how CT and MRI scans are beneficial: “This [CT scan] allows complex bony injuries to be viewed in multiple planes and in three-dimensional reconstruction… This [MRI scan] is most useful for assessment of intra-articular and soft tissue abnormalities, and for detecting some occult fractures such as those of the scaphoid and hip” (14). X-rays are the ideal technology for viewing bones and fractures financially and health-wise. X-ray costs can range from 5 to 30 times cheaper than MRI and CT scans, making them more financially viable (Pallarito). X-rays also give lower doses of radiation than a CT does, making it healthier for your body. While MRIs give no radiation, they are used more for soft tissue injuries associated with bones and much less for fractures.
Recent technologies that have come out are showing that we are moving more towards a more artificial intelligence world. Radiologists are physicians who specialize in radiography and identifying problems in X-rays, CTs, MRIs, PET scans, etc. Radiology takes many years of training and there is the important question of reliability when assessing radiographs. Having computer software that could analyze fractures and other radiographic imaging quickly can be beneficial when radiologists or orthopedists are tied up. A new technology has recently come out allowing artificial intelligence (AI) to assess orthopedic trauma/fracture radiographs which exhibits a high percentage accuracy. The algorithms in the AI are able to recognize laterality, body part, examview, and fracture. Laterality, body part and exam view showed an accuracy of 90%, while the fracture accuracy was 83% when compared to senior orthopedic surgeons. The main problem that affects better accuracy was human error in taking the radiographs. It was found that human error in positioning the X-rays led to the AI making faulty identifications the majority of the time. Until there are AI taking X-rays for us, there will always be human error even if it is minimal. Other than those limitations this technology shows a lot of promise for being implemented into society. Olczak et al. quote in the journal “Artificial Intelligence for Analyzing Orthopedic Trauma Radiographs” that, “The ability to classify an unlimited amount of radiograph images will most likely have a major impact on orthopedics. We can now review images on an unprecedented scale in our digital picture archives and link them to outcomes” (Olczak et al. 4). Realistically implementing this into society would be difficult, but with sufficient time invested in the development of this, it could prove to be an extremely useful tool.
Another new technology that has come out recently to evaluate oblique long bone fractures is low order ultrasonic guided waves. This technology is becoming popular due to it being quick, portable, noninvasive, and inexpensive; it also emits no radiation making it safe for all ages, especially pediatrics. Using different measurements from the guided waves of the ultrasound the machine is able to read values of the fracture angle and crack width. Using the amplitude ratio of fracture angle to crack width, they are able to calculate and identify the long bone fracture status including the crack width and angle. This can be useful financially (when compared to X-ray) and healthwise, this also could be used for follow up appointments to check healing which would otherwise use X-rays. The limitations of this are distributing the technology, training personnel to use it and training personnel to understand the ratio that it is calculating. Although this is an up and coming technology it is unfavorable to use because of the better assessment that results from using X-rays. X-rays can also show complications that the ultrasound might not which could make it unreliable and unsafe (Li et al. 1-3,8).
Fixation is the technique of fixing a fracture and using implants or materials to heal it. There are a multitude of techniques and materials used for fracture fixation. Reduction or reducing a fracture is positioning the bone pieces back to their anatomical place. This is used in cases where bones are displaced, in comminuted fractures, off-ended fractures, etc (White et al. 5-7). A commonly used term in orthopedic trauma is open reduction internal fixation (ORIF). This is one of the most common ways to treat fractures that need surgery. Open reduction results in surgically opening up the affected limb or area to get to the fractured bone. Internal fixation is the means of fixing the fracture by using a plate, screws, nails and wires (Internal Fixation for Fractures). Closed reduction is another method of reducing a fracture, this is done without surgical incisions and manipulates the bone through traction and/or pressure (White et al. 7). For example, one of the classifications of a distal radial fracture is called a Colles fracture. A Colles fracture can be managed through closed reduction by providing traction and pressure to reduce it back into its anatomical position. This is usually done under fluoroscopy which can be thought of as video X-rays. This allows the physician to ensure that it is properly reduced. If proper reduction can not be done, ORIF will happen and both methods will finish with a cast. Figure 4 is an example of how to reduce it, which can happen in the operating room (OR) or in the emergency room (ER).
There are two types of fixation used in orthopedic trauma, internal fixation and external fixation. External fixation is fixing and reducing the fractured bone externally through pins, wires and scaffolding. Figures 5 a and b give a real example and a diagrammatic example (Fragomen & Rozbruch 1). These materials support the injured limb after the accident through
Figure 4: The closed reduction of a Colles fracture (Brown et al.).
Figure 5: shows circular fixation technique (a) and unilateral fixation technique (b) for tibia fractures (Life On A Broken Leg) (External Fixation).
stabilization. External fixation is commonly used when there is soft tissue damage, open fractures, multiple fractures, lower extremity fractures, and for limb deformity. Some of the advantages of external fixation over internal fixation are less soft tissue damage, less disruption of osseous blood supply and the periosteum. Other advantages include quick access to wound and surveillance, ability to change dressings and check healing easily, postoperative adjustability, elevation, minimal scarring, no revision surgery and no disruption of the physes (growth plates) in pediatric care.
In some orthopedic trauma, skin grafts may be necessary to properly heal the skin if there is soft tissue lost. Doing ORIF on top of this makes healing time longer and harder for the body, due to the long incision(s) made into the limb for fixation. Skin grafts also need to be monitored to ensure infection does not occur and that it is working. External fixation may be more beneficial to people who have poor skin healing from diseases and to kids. Because the bones of children are still developing and the physes have not yet ossified, doing internal fixation could cause problems associated with the physes. For example, if an intramedullary nail (IM nail) were to be used (for a femur or tibia fracture) it could inhibit bone growth. External fixation is done by drilling pins and wires into the bone proximal and distal to the fracture site. These are then attached to the external scaffold pieces, these provide stability and can be adjusted if necessary. Closed reduction of the fracture is done through traction and the fixator device is mounted after reduction occurs. There are two main types of fixator devices for external fixation, unilateral and circular. In the journal “The Mechanics of External Fixation” Fragomen & Rozbruch quote that, “Unilateral frames are distinguished from circular frames in that they are positioned on one side of the limb. Unilateral frames allow the limb to remain functional avoid complications and provide bony stability” (2). Circular rings are also known as the Ilizarov external fixator, named after Gavriil Ilizarov who invented it. The authors go on to say, “Full rings provide the most stability, and arches the least. However, partial rings and arches are helpful near joints and in areas where a closed ring would prevent normal extremity function or positioning” (2). There are a lot of factors that go into deciding what fixator would be the most beneficial for the patient. Depending on if the patient needs more stability, flexion, room or comfortability it can change the fixator used. External fixation has many benefits however there are problems that can arise while using it.
Problems associated with external fixation are infection, malunion and comfortability. The biggest problem associated with external fixation is malunion. Malunion is when the bone ends do not properly align in healing or reduction. Because the orthopedic surgeon does not perform open reduction the union/healing of the bone can be poor. This can occur when there is trauma to other parts of the patient’s body, because their main goal is to provide stability. Most malunions are noticed and treated before the bone heals, using another fixator, but if not caught it may require revision surgery. Figure 6 is a malunion of the distal femur after a fracture. Infection is common due to the number of punctures in the skin and lack of dressing, even with regular cleaning. The most common treatment is local pin/wire care and antibiotics. Finally, external fixation can be uncomfortable considering you have to have metal pins and wires sticking out of your skin for weeks. Some fixators do not allow movement restricting you to bedside for a-
Figure 6: Malunion of a femoral fracture (Wang et al.).
certain amount of time. Although this would happen with internal fixation it can be much more comfortable to have a cast. External fixation patients may also limited to the hospital so that they can monitor the patient and the wound (Fragomen & Rozbruch 1-4,15,16) (GPC Medical Limited). The counterpart to external fixation is internal fixation which is the more popular method to fracture fixation.
Metal plates are one of the most commonly used internal fixation tools for fractures. These metal plates have holes in them to allow screws to go through the metal and secure the plate to the bone. In the journal “Analysis Of An Internal Fixation Of A Long Bone Fracture” Ramakrishna et al. write:
Screws are used to fasten plate on to bone, to there by hold together fragments of bone, transfer the load between bones and plate, so that during the healing process the plate bears the majority portion of the applied loading and transfers it to the bone as the fracture heals. Fractured bone fixation by a plate stimulates an adaptation by the bone to accommodate for the new stress levels through remodeling. (2)
This quote shows the physiology of the plates, screws and bone.
The two most commonly used plate materials for internal fixation are stainless steel and titanium alloys. Cobalt chromium alloys are also used but are not as popular in orthopedic surgery. 316L stainless steel is one of the most commonly used metals for plates. The 316 stainless steel is a certain name for the metal. The L indicates it is different from just 316 because it has lower carbon amounts which is healthier for the body (Bell). This material was introduced in the early 1900s and became very popular after it was utilized successfully in surgery. Prior to that many metals were used, but due to the biochemistry found in the body some metals were reactive causing problems. Due to its corrosion resistance 316L stainless steel is ideal for plates and implants. Titanium is also a popular material used because it is the most corrosion resistant metal. Titanium rose to prominence in the 1960s and there are 3 different alloys of it used today (Hansen 2). Figure 7 shows one of the many types of internal fixation plates. Comparison of titanium and stainless steel plates yields no difference in beneficialness for the patient.
Figure 7: A titanium plate (Orthopedic Implant Distal Femoral Lateral Locking Compression Plate).
In the journal “Titanium Versus Stainless Steel Plating in the Surgical Treatment of Distal Radius Fractures” the authors did a randomized trial of titanium and stainless steel plates. They concluded that there was no difference in complications and revision surgeries and their results support the use for both (Shakir et al. 3). While these are the most common metal plates used, there are new materials being used.
Two new materials that are being implemented and tested are called auxetic and bioresorbable bone plates. Mehmood et al. explain what auxetic materials are in the journal “Auxetic polymeric bone plate as internal fixator for long bone fractures: Design and fabrication and structural analysis” by saying, “Auxetic materials have a negative Poisson’s ratio and they show lateral expansion when stretched longitudinally, becoming narrower when compressed… The Auxetic materials have gained popularity in commercial applications due to their increased shear stiffness, strain fracture toughness and indentation resistance” (3). The Auxetic plate is made of polyurethane which does not harm the body or create an immune response, which is a possibility when using some metal plates. These plates are proposed to have better union of fractures which aids in bone healing. Through stability and flexibility the Auxetic plates enhance healing of fractures due to how the material is constructed. Although there have not been human trials yet, the journal suggests that the most beneficial use of the plate be when fracture gaps are small. There have been new studies that have come out showing that flexible plates can be more beneficial due to minimal stress shielding. Stress shielding is the loss of bone density due to decreased weight on the bone because the weight is transferred to the plate (Millis). The Auxetic design reduces this problem due to its flexible but strong nature (Mehmood et al. 2,3,13). Human or animal trials of this material are needed to see if it is beneficial and works.
One of the bigger problems with using metallic plates is the necessity of revision surgery to remove them. Bioresorbable plates solve this problem because:
Bioresorbable and biodegradable fracture fixation implants have been considered as an effective fixation system with several advantages over metallic fixation, including no need to remove the implants after osseous healing, radiolucency, no corrosion, no implants bear less load initially and gradually transfer the load as they degrade… The ideal biodegradable material provides appropriate strength whilst degrading in a predictable fashion throughout the healing process without causing adverse reactions. (Pina & Ferreira 2)
There are two different types of materials available that are biodegradable, they are ceramics/calcium phosphates and polymers. Polymers have been found to be more efficient than ceramics due to their strength properties. These materials can also be manipulated to alter the properties and the degradation characteristics. Problems with these materials include inflammatory response, rapid loss of initial implant strength, higher refracture rates, inadequate stiffness of the implants, and weakness in comparison to metallic implants. Due to the low mechanical strength this leads to possibly a less stable fracture. In conclusion, the positives for most scenarios in using biodegradable material outweigh the negatives. Future research needs to be done on improving the mechanical strength of the material.
Another internal fixation material is an intramedullary (IM) nail. IM nails are primarily used for fractures of the biggest long bones: femur, tibia and humerus. An IM nail is a long rod that is inserted into the medullary cavity of a long bone. IM nails work well because they form a self contained internal splint for the fracture. They provide strong support, good alignment, can lead to earlier weight bearing and is minimally invasive. During an IM nail procedure the surgeon will make about 3 or 4 small incisions in the skin. From there they position the bone to put the nail down the medullary cavity and then put 2-6 screws perpendicular to it. This procedure works fast, is safe and heals the fracture properly. The nails are also made of titanium or stainless steel. Figure 8 shows an IM nail in a tibia. There are two different techniques for inserting IM nails, reamed and unreamed, these both have positives and negatives. When the bone is reamed it widens the medullary cavity while unreamed leaves the medullary cavity as is. The positives of reaming are high union rate, low infection and nonunion rate, higher biomechanical stability, rapid fracture healing and lower frequency of secondary procedure. Drawbacks of reaming are decreased blood flow to the diaphysis, necrosis (death of tissue due to lack of blood), emboli (blood clot, body material, foreign body) and longer surgery time. Unreaming uses a smaller diameter nail than reaming allowing for less blood flow disruption, less blood loss, faster insert time/quicker surgery, and do not disrupt cortical bone structure. Unreaming is not as strong, does not heal as quickly and does not have as high of union rates as reamed does. According to the study done by Li et al. in the journal “Reamed versus unreamed intramedullary nailing for the treatment of femoral fractures” that compared multiple studies of reamed and unreamed nailing. The conclusion was reached that reamed nailing is a shorter time to bone union, and lower rates of delayed union, nonunion and reoperation. It did not increase blood loss, implant failure and mortality when compared to unreamed nailing (Li et al. 1,4,5,8) (Bagheri 1-2) (Understanding Your Intramedullary Nail).
Figure 8: An IM nail in a tibia with plate fixation on the fibula (Closed Reduction; Intramedullary Nailing (Reamed)).
Bone healing is an extremely important part of the fracture process as poor healing can result in physical problems and financial problems with revision surgery. Victoria et al. explain this in the journal “Bone Stimulation for Fracture Healing: What’s All the Fuss?” by stating:
... out of the estimated 7.9 million fractures that occur annually in the United States, 5–10% of them develop nonunions and/or delayed unions, which are major sources of complications in the treatment of bone fractures. Fracture healing is a complicated metabolic process and requires the interaction of many factors, including the recruitment of reparative cells and genes. If these factors are inadequate or interrupted, healing is delayed or impaired, resulting in a nonunion of the bone. The cause of nonunions and delayed healings of fractures is usually unknown. The known reasons of delayed or impaired unions include problems with operative and nonoperative interventions, comprising inadequate mobilization of the fracture, distraction of fracture fragments by fixation devices or traction, repeated manipulations or excessive early motion of a fracture, excessive periosteal stripping, and damage to other soft tissues during operative exposure. Other risks for impaired fracture healing include contamination at the time of injury or operation, smoking, diabetes, and the skeletal location of the injury. (1)
This highlights the importance of healing and the many risk factors of nonunion and malunion. Thankfully, there are two main bone stimulators that induce healing. These are electrical stimulation and low intensity pulsed ultrasound. There are a few different forms of electrical stimulation but they all generally work by sending low level pulses of electromagnetic energy to the fracture site. This usually occurs at fracture sites when there is union, however doing this stimulates that process to start (About Bone Growth Therapy). More evidence is needed to conclude whether electrical stimulators are cost-effective and successful. It is possible that this works due to the placebo effect, but more information is needed on this technology. Ultrasonic stimulation on the other hand, does have quality evidence that it works. This works by
Increasing the incorporation of calcium ions in cultures of cartilage and bone cells and stimulate the expression of numerous genes... involved in the healing process. The most important effect that ultrasound has on bone healing may be on chondrocyte population, as suggested by studies that demonstrate an increase in the formation of soft callus and early onset of endochondral ossification after ultrasonic applications. Many preclinical and clinical studies have demonstrated promising results using low-intensity pulsed ultrasounds for healing fresh fractures and treatment of delayed union or nonunions. (Victoria et al. 4)
As mentioned, data on using electrical stimulators are inconclusive due to poor studies. Low intensity pulsed ultrasounds do have extensive evidence from studies behind them making them one of the most beneficial bone stimulators.
A new bone healing technology has recently come out called demineralized bone matrix (DBM), an orthobiologic agent which is an allograft (tissue from a donor) product, that has proven safety and efficacy to enhance bone healing in fractures. DBM has many positives including no limitation of quantity, shorter operative time, no additional procedures and no donor site morbidity. A study was done to compare healing effects using DBM and not using DBM on femoral fractures. The results are drastic because the fracture that used DBM completed healing at 11 months whereas the fracture that did not receive it took 14 months to completely heal. This was done on atypical subtrochanteric femoral fractures which have low blood supply compared to the diaphyseal region, which is why it takes so many months to heal. This technology is promising for use on fractures or bones that typically result in nonunion or delayed union (Kulachote 1,2,5,6).
Part IV: Conclusion
There are many factors that go into orthopedic trauma care and long bone fractures. Everything from the anatomy of the bone, to technology on viewing it, to the fixator device to the healing process. There is not one answer as to how to solve fractures and how to induce healing. There are a multitude of ways to solve fractures, this was focused on diaphyseal fractures of bones. There are many different classifications for fractures that all are unique and need to be addressed individually. This thesis is the tip of the iceberg for starting to understand how fractures happen, how bones heal, how fixation devices work, how heal time varies, etc. Even with the extensive research done for this thesis there are many avenues not touched on that play big roles in long bone fractures, like the physics of bone healing and plate fixation. Using the information and data collected in this thesis, two specific fracture scenarios and their course of action will be analyzed in how they might be treated.
Case 1: A 61 year old female with a closed, spiral, diaphyseal femoral fracture with displacement from a three foot fall. The first step here would be to obtain radiographs. X-rays would most likely be the only radiology used due to this not being complex. Next step would be to anatomically reduce it as close as possible through traction. In surgery implant a reamed IM nail into femur laterally with multiple screws. Due to the female most likely having osteoporosis due to menopause, it will most likely take a longer time to heal especially with her age. When women go through menopause they stop producing hormones that help keep bones strong, like estrogen. This is why it is more common for women than men, who have gone through menopause to have weakened bones and experience more fractures. Follow up every couple months to check on the healing process. The use of a bone stimulator like the low intensity pulsed ultrasound may be used to enhance healing and prevent nonunion or delayed union of the fracture. Wait 2-4 months for fracture healing to finish.
Case 2: A 25 year old male with a closed, comminuted, proximal humerus fracture with displacement. The first step again would be to take X-rays to assess the injury. A CT scan may be done to evaluate the fracture and make sure the glenoid cavity, acromion or scapula are not injured. From here do open reduction and internal fixation (ORIF). A stainless steel or titanium alloy plate would be used and properly sized to fit the proximal humerus precisely. Multiple screws would be needed because of the comminution. Because the patient is young and does not have osteoporosis a bone healing device would not be necessary. Heal time would be about two months and then the patient could go back to full activity. Revision surgery to remove hardware might be necessary due to age and possible problems.
As mentioned there is not one perfect answer for which technology is most beneficial, many factors go into deciding care from your orthopedic surgeon. The information presented in this thesis is based on clinical research and studies. Orthopedic surgeons go through four years of undergraduate, four years of medical school, about five years of residency and one to two years of fellowship(s). That time is spent learning the most beneficial techniques for patients and patient care. They have much more experience than I do and the information presented in this should be for learning purposes only.
Further areas of research that are needed and would be beneficial are developing Auxetic and biodegradable plates and bone stimulation. These show some of the most prominences for new technology in long bone fractures. If developed correctly these can really make a difference in surgery financially and physically. Not having revision surgery saves a lot of healing time and money making it beneficial. Since Auxetic plates have not been tested on humans or animals it is difficult to know whether or not they will work. The science backing them is strong, but that could change in testing the material. One other place more research is needed is in bone stimulators, lots of information is still not known of whether or not they work, especially when it comes to electric stimulators.
To conclude in radiography fractures are most commonly viewed on X-rays which are cost efficient and healthier when compared to MRI and CT scans. Implementing ultrasonic guided waves would be difficult due to the technology and training needed. AI, on the other hand, can and most likely will be implemented in the future. Depending on the type of fracture and the bone fractured, this will change what type of reduction and fixation is used. When it comes to external fixation the unilateral and circular designs both have appropriate uses depending on the location of the fracture and the extent of the injuries to the limb. Internal fixation plates have no differences between stainless steel and titanium in outcomes. Auxetic plates seem beneficial however no research has been done to confirm this. Biodegradable plates can be argued to be better than metallic plates. However due to availability and lack of stability biodegradable plates are not the standard implant. Reamed intramedullary nails are proven to be more beneficial than unreamed because of the characteristics that reaming has. Low intensity pulsed ultrasound is the strongest and most backed by evidence bone healing device. The demineralized bone matrix healing technique also has strong evidence for it, however, it is not commonly used. All the information in this thesis is based on data collected from a multitude of academic sources and journals. I am able to use the information learned in this to increase my knowledge for my internship that I do with a local orthopedic clinic and OR.
Works Cited
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Ben Black
Senior Project Advisor: Tina Hott
Abstract:
Orthopedic trauma and bone fractures affect about 7.9 million people each year in the US. The different technologies used to treat fractures can vary and it is important to know how each of these affect patients financially and physically in both the long and short term. In this thesis, I assess popular technologies used in long bone fractures and healing techniques, and two new technologies. Academic sources and journals were used to gather information on benefits and drawbacks of each technology and when they should be used. Through my research I have found that of the many technologies that exist, each one is used in specific situations where they have the most benefits to the patients. Of the two new technologies I researched it shows they are promising, however more research and design is needed to conclude how they benefit people before they are implemented. The findings show that each fracture case needs to be individually analyzed for the patient's history, age, fracture, fracture type, location of fracture, bone fractured and soft tissue damage.
12th Grade Humanities
Animas High School
3-5-18
Osteocyte Trauma
Part I: Introduction
When you think of a bone fracture you may think of breaking your wrist or ankle when you were a kid. It hurt a lot, you had surgery, had a big cast put on for about a month, it was healed and then you went on and kept having fun. What you might not realize is the intricate analyzation of your fracture and what the best plan of action is to help heal it correctly and quickly, from the plate used, to the bone stimulator the surgeon may use, to the healing time. About 7.9 million fractures occur each year in the United States (Victoria et al. 1). At the end of this thesis you will have a much stronger understanding of what happens to your body and your bones when they experience trauma in the form of fractures, a concept termed orthopedic trauma.
Orthopedic trauma is an injury from accident or violence relating to the bones and soft tissue (muscles, tendons, ligaments and nerves) (Orthopedic Trauma). More serious orthopedic trauma affects long bones which are part of the upper and lower extremities and they make up the majority of fractures. As mentioned above, orthopedic trauma is really common in our country. Recently there have been new advances in technology that can improve healing time and the quality of fracture repair. Knowing how different materials and technology can affect patients physically and financially is very important, from revision surgery to chronic problems that can arise later in life. Two cases studies will be analyzed at the end of this to showcase the different technologies that may be used. Orthopedic long bone trauma healing and fixation technology have numerous techniques and materials, however the bone fractured, fracture location, and technology are all factors that need to be considered when providing care.
Part II: Historical Context and Background
Orthopedics is a branch of medicine that studies the injuries and diseases of bones, muscles, tendons, ligaments, cartilage and nerves. Orthopedists or orthopedic surgeons are physicians who are the experts of the musculoskeletal system. When you fracture a bone an orthopedic surgeon or an orthopedic trained physician assistant will assess you and see if surgery necessary. As an orthopedist, it is imperative to have a strong knowledge of anatomy and physiology, especially of the skeletal system.
The adult human body’s skeletal system contains 206 bones that allow the body to stand and have shape. Our skeletal system in our body gives us structure, protection and support through bones, cartilage and ligaments (Zimmermann). It also allows for the storage of lipids, minerals and blood cell production (Anatomy and Physiology). Without a skull or ribs, your body would be extremely vulnerable to injury due to lack of bones protecting it (Totora & Anagnostakos 124). Cartilage is material that is located where flexible skeletal tissue is needed (Skeletal Cartilages). Common locations of cartilage are: at the end of bones, meniscus, external ear, nose, larynx, costal cartilage, etc. Ligaments are connective tissues that hold bones together; they are located around every bone joint in the body. The skeletal system works together with skeletal muscles to create the musculoskeletal system. This allows you to walk, grip, eat and move your eyes freely. Muscles attach bone to bone and the section of muscle that attaches to the bone is called a tendon. To illustrate the obvious importance of bones in the human body a strong knowledge of long bones is important.
Of the 206 bones you have in your body, 90 of them are long bones. Long bones are exactly that, long, they are longest and biggest bones in the body examples of these include femur, tibia, fibula, humerus, radius, ulna and clavicle. Long bones can also be very small examples are: metatarsals, metacarpals and phalanges. Fractures can occur to any bone and can happen in a number of ways and in a number of patterns. Fractures generally occur from three different causes (etiology): trauma, pathologic, and stress. A traumatic fracture is caused by direct or indirect violence usually from a high amount of force (White et al. 2). Pathological fractures occur within
... abnormal or diseased bone and are often caused by relatively little violence or energy; they are the effect of a normal force on an abnormal bone. The pathology may be localized to one part of the bone (e.g. a tumour deposit) or generalized (e.g. osteoporosis and osteomalacia)...[stress] fractures are the result of the cyclical application of normal forces to normal bone with excessive frequency. These often occur following a change in the level or intensity of activity. (White et al. 2-3)
A common example of a stress fracture is a second metatarsal fracture, which is a long bone in your foot. This usually occurs in novice long distance runners or army recruits, they start suddenly, run excessively and do not give their body time to adapt to the new activity (White et al. 3). Fracturing a bone can result in different fracture patterns throughout the bone which is known as morphology (White et al. 3). The fracture patterns shown in Figure 1 are some of the most common fractures of the diaphysis; the middle portion of the bone, also known as the shaft.
Figure 1: Common diaphyseal fractures of long bones (Types of Fractures).
Fixation is the process of fixing fractured bones. There are two types of fixation, internal and external. Internal involves opening up through the skin and using an internal fixator like a metal plate. External fixation is using wires and pins outside of the skin to hold the fracture together. Both are used for specific scenarios depending on the condition of the patient and the extent of the fracture(s). Radiographs are medical imaging used to view the condition of your body. Significant tests include X-ray, CT, MRI and PET. X-rays are most commonly used for fracture identification and degree of injury. When more complex fractures (e.g. comminuted fracture or pelvic fracture) or injuries affect multiple areas, an MRI or CT may be done to understand the complexity of it, allowing for more accurate fixation and a better plan for treatment ahead of time. Proximal and distal are common terms used to describe the position of an injury or fracture relative to the bone. Distal means the far end of the bone or the piece of the bone that is farthest from where the limb attaches to the body, and proximal is vice versa. For example, the distal part of the humerus is where the radius and ulna (forearm bones) attach whereas the proximal end attaches to the glenoid cavity of the scapula (shoulder bone).
The technology and knowledge our society possess now about fractures, treatment, anesthesia, radiographs and sterilization have been an ongoing learning process since the 1840s. In the early to mid 19th century it was common for injuries from war and other incidents to result in amputation. Fractures minor enough to not need amputation were treated non-operatively with the main goal of reducing the fracture and immobilizing the limb. The two main concerns for operating on a fracture were pain and lack of sterilization, which frequently resulted in infection. In 1846 ether vapor was found to be an effective anesthetic that could be used during surgery. This changed the course of medicine in being able to diminish pain associated with injuries and during surgery. In 1865 medicine drastically changed when an antiseptic carbolic acid spray was used to treat an open femoral fracture on an 11 year old boy, which without antiseptic would have needed amputation. About a decade later asepsis, keeping surgery sterile, was introduced which was widely used. In the 1890s surgical gloves were created which also helped prevent infection of the patient from the physician and environment. X-rays were discovered in 1895 which changed the course of fracture fixation forever allowing for high accuracy in treating fractures and understanding the extent to which the patient would be affected. In 1912 Emil H. Beckman stated, “The use of the X-ray first showed us how very inferior our bone repair work has been” (qtd. In Bartoníček). This quote eloquently shows how X-rays changed medicine forever in being able to properly identify fractures, which gave a better plan of action for the physician.
In the late 1800s, surgeons were experimenting and creating plates and other implant devices to help fractures heal correctly. Historically, implant devices were made of ivory, bone, and metal. Most metals were problematic due to the mechanical properties and corrosion; stainless steel was found to be the safest metal for internal fixation. External fixation on the other hand was commonly used to treat fractures. Most people would have large screws and pieces of ivory in their limb literally holding the fracture together. Implants and methods used back then to treat fractures would be extremely primitive when compared to today's technology, however, these experiments and trials were paving the way to better and safer implants (Bartoníček). Physicians back then pioneered orthopedic medicine and made it what it is today. Without their experiments and curiosity we as a society wouldn't have the advanced technology that we possess now.
Part III: Research and Analysis
There are 5 different types of bones in the body: long, short, irregular, flat and sesamoid, and depending on the type, the buildup of the bone changes. In Figure 2 you can see the different anatomy of long bone and how it changes throughout. In the article “Bone Structure” the author explains the anatomy of a long bone:
A long bone has two parts: the diaphysis and the epiphysis. The diaphysis is the tubular shaft that runs between the proximal and distal ends of the bone. The hollow region in the diaphysis is called the medullary cavity, which is filled with yellow marrow. The walls of the diaphysis are composed of dense and hard compact bone. The wider section at each end of the bone is called the epiphysis (plural = epiphyses), which is filled with spongy bone. Red marrow fills the spaces in the spongy bone. The outer surface of the bone is covered with a fibrous membrane called the periosteum (peri– = “around” or “surrounding”). The periosteum contains blood vessels, nerves, and lymphatic vessels
that nourish compact bone. Tendons and ligaments also attach to bones at the periosteum. (Bone Structure)
This just brushes on how intricate the anatomy of a long bone is, the biology and physiology show how all of those parts work together tremendously to create a strong, healthy body. One of the pieces that allow us to have a strong, healthy body, is the healing process bones go through when broken.
Figure 2: The anatomy of a long bone (Bone Structure).
The healing process after fracturing a bone is complex. It involves several different stages that over time cohesively heal your bones back to their original state. There are four phases of bone healing: inflammation, soft callus, hard callus and bone remodeling. Immediately after you fracture a bone a hematoma is formed from blood taken from the surrounding bone tissue. This creates an inflammatory response which helps stimulate healing and continues for several days after the fracture. The blood deposited to the fracture site clots and forms a soft callus made of fibrous tissue and cartilage. This forms after a couple of weeks, through mineralization, and turns into a hard callus. Figure 3 shows a diaphyseal fracture of the fibula and shows the hard callus formed. After approximately a month bone remodeling will begin which is necessary because the hard callus does not restore biomechanical properties to the bone. Bone remodeling turns the hard callus into lamellar bone (compact and spongy) through mineralization, with a medullary that cavity restores the natural state of the bone. This can take years to completely finish (Marsell & Einhorn) (Bone Healing).
Figure 3: X-ray of a fibular fracture (a) and shows a follow up x-ray of a fibula with a hard callus (b) (Bone Healing).
Fractures are assessed through multiple radiography technologies: X-ray, CT and MRI. The most common way fractures are evaluated is through X-rays. X-rays allow you to see bones and bone defects very easily due to the clear contrast seen on the films, making fractures easy to identify. In chapter 1 of the book “Orthopedic Trauma” White et al. explain how CT and MRI scans are beneficial: “This [CT scan] allows complex bony injuries to be viewed in multiple planes and in three-dimensional reconstruction… This [MRI scan] is most useful for assessment of intra-articular and soft tissue abnormalities, and for detecting some occult fractures such as those of the scaphoid and hip” (14). X-rays are the ideal technology for viewing bones and fractures financially and health-wise. X-ray costs can range from 5 to 30 times cheaper than MRI and CT scans, making them more financially viable (Pallarito). X-rays also give lower doses of radiation than a CT does, making it healthier for your body. While MRIs give no radiation, they are used more for soft tissue injuries associated with bones and much less for fractures.
Recent technologies that have come out are showing that we are moving more towards a more artificial intelligence world. Radiologists are physicians who specialize in radiography and identifying problems in X-rays, CTs, MRIs, PET scans, etc. Radiology takes many years of training and there is the important question of reliability when assessing radiographs. Having computer software that could analyze fractures and other radiographic imaging quickly can be beneficial when radiologists or orthopedists are tied up. A new technology has recently come out allowing artificial intelligence (AI) to assess orthopedic trauma/fracture radiographs which exhibits a high percentage accuracy. The algorithms in the AI are able to recognize laterality, body part, examview, and fracture. Laterality, body part and exam view showed an accuracy of 90%, while the fracture accuracy was 83% when compared to senior orthopedic surgeons. The main problem that affects better accuracy was human error in taking the radiographs. It was found that human error in positioning the X-rays led to the AI making faulty identifications the majority of the time. Until there are AI taking X-rays for us, there will always be human error even if it is minimal. Other than those limitations this technology shows a lot of promise for being implemented into society. Olczak et al. quote in the journal “Artificial Intelligence for Analyzing Orthopedic Trauma Radiographs” that, “The ability to classify an unlimited amount of radiograph images will most likely have a major impact on orthopedics. We can now review images on an unprecedented scale in our digital picture archives and link them to outcomes” (Olczak et al. 4). Realistically implementing this into society would be difficult, but with sufficient time invested in the development of this, it could prove to be an extremely useful tool.
Another new technology that has come out recently to evaluate oblique long bone fractures is low order ultrasonic guided waves. This technology is becoming popular due to it being quick, portable, noninvasive, and inexpensive; it also emits no radiation making it safe for all ages, especially pediatrics. Using different measurements from the guided waves of the ultrasound the machine is able to read values of the fracture angle and crack width. Using the amplitude ratio of fracture angle to crack width, they are able to calculate and identify the long bone fracture status including the crack width and angle. This can be useful financially (when compared to X-ray) and healthwise, this also could be used for follow up appointments to check healing which would otherwise use X-rays. The limitations of this are distributing the technology, training personnel to use it and training personnel to understand the ratio that it is calculating. Although this is an up and coming technology it is unfavorable to use because of the better assessment that results from using X-rays. X-rays can also show complications that the ultrasound might not which could make it unreliable and unsafe (Li et al. 1-3,8).
Fixation is the technique of fixing a fracture and using implants or materials to heal it. There are a multitude of techniques and materials used for fracture fixation. Reduction or reducing a fracture is positioning the bone pieces back to their anatomical place. This is used in cases where bones are displaced, in comminuted fractures, off-ended fractures, etc (White et al. 5-7). A commonly used term in orthopedic trauma is open reduction internal fixation (ORIF). This is one of the most common ways to treat fractures that need surgery. Open reduction results in surgically opening up the affected limb or area to get to the fractured bone. Internal fixation is the means of fixing the fracture by using a plate, screws, nails and wires (Internal Fixation for Fractures). Closed reduction is another method of reducing a fracture, this is done without surgical incisions and manipulates the bone through traction and/or pressure (White et al. 7). For example, one of the classifications of a distal radial fracture is called a Colles fracture. A Colles fracture can be managed through closed reduction by providing traction and pressure to reduce it back into its anatomical position. This is usually done under fluoroscopy which can be thought of as video X-rays. This allows the physician to ensure that it is properly reduced. If proper reduction can not be done, ORIF will happen and both methods will finish with a cast. Figure 4 is an example of how to reduce it, which can happen in the operating room (OR) or in the emergency room (ER).
There are two types of fixation used in orthopedic trauma, internal fixation and external fixation. External fixation is fixing and reducing the fractured bone externally through pins, wires and scaffolding. Figures 5 a and b give a real example and a diagrammatic example (Fragomen & Rozbruch 1). These materials support the injured limb after the accident through
Figure 4: The closed reduction of a Colles fracture (Brown et al.).
Figure 5: shows circular fixation technique (a) and unilateral fixation technique (b) for tibia fractures (Life On A Broken Leg) (External Fixation).
stabilization. External fixation is commonly used when there is soft tissue damage, open fractures, multiple fractures, lower extremity fractures, and for limb deformity. Some of the advantages of external fixation over internal fixation are less soft tissue damage, less disruption of osseous blood supply and the periosteum. Other advantages include quick access to wound and surveillance, ability to change dressings and check healing easily, postoperative adjustability, elevation, minimal scarring, no revision surgery and no disruption of the physes (growth plates) in pediatric care.
In some orthopedic trauma, skin grafts may be necessary to properly heal the skin if there is soft tissue lost. Doing ORIF on top of this makes healing time longer and harder for the body, due to the long incision(s) made into the limb for fixation. Skin grafts also need to be monitored to ensure infection does not occur and that it is working. External fixation may be more beneficial to people who have poor skin healing from diseases and to kids. Because the bones of children are still developing and the physes have not yet ossified, doing internal fixation could cause problems associated with the physes. For example, if an intramedullary nail (IM nail) were to be used (for a femur or tibia fracture) it could inhibit bone growth. External fixation is done by drilling pins and wires into the bone proximal and distal to the fracture site. These are then attached to the external scaffold pieces, these provide stability and can be adjusted if necessary. Closed reduction of the fracture is done through traction and the fixator device is mounted after reduction occurs. There are two main types of fixator devices for external fixation, unilateral and circular. In the journal “The Mechanics of External Fixation” Fragomen & Rozbruch quote that, “Unilateral frames are distinguished from circular frames in that they are positioned on one side of the limb. Unilateral frames allow the limb to remain functional avoid complications and provide bony stability” (2). Circular rings are also known as the Ilizarov external fixator, named after Gavriil Ilizarov who invented it. The authors go on to say, “Full rings provide the most stability, and arches the least. However, partial rings and arches are helpful near joints and in areas where a closed ring would prevent normal extremity function or positioning” (2). There are a lot of factors that go into deciding what fixator would be the most beneficial for the patient. Depending on if the patient needs more stability, flexion, room or comfortability it can change the fixator used. External fixation has many benefits however there are problems that can arise while using it.
Problems associated with external fixation are infection, malunion and comfortability. The biggest problem associated with external fixation is malunion. Malunion is when the bone ends do not properly align in healing or reduction. Because the orthopedic surgeon does not perform open reduction the union/healing of the bone can be poor. This can occur when there is trauma to other parts of the patient’s body, because their main goal is to provide stability. Most malunions are noticed and treated before the bone heals, using another fixator, but if not caught it may require revision surgery. Figure 6 is a malunion of the distal femur after a fracture. Infection is common due to the number of punctures in the skin and lack of dressing, even with regular cleaning. The most common treatment is local pin/wire care and antibiotics. Finally, external fixation can be uncomfortable considering you have to have metal pins and wires sticking out of your skin for weeks. Some fixators do not allow movement restricting you to bedside for a-
Figure 6: Malunion of a femoral fracture (Wang et al.).
certain amount of time. Although this would happen with internal fixation it can be much more comfortable to have a cast. External fixation patients may also limited to the hospital so that they can monitor the patient and the wound (Fragomen & Rozbruch 1-4,15,16) (GPC Medical Limited). The counterpart to external fixation is internal fixation which is the more popular method to fracture fixation.
Metal plates are one of the most commonly used internal fixation tools for fractures. These metal plates have holes in them to allow screws to go through the metal and secure the plate to the bone. In the journal “Analysis Of An Internal Fixation Of A Long Bone Fracture” Ramakrishna et al. write:
Screws are used to fasten plate on to bone, to there by hold together fragments of bone, transfer the load between bones and plate, so that during the healing process the plate bears the majority portion of the applied loading and transfers it to the bone as the fracture heals. Fractured bone fixation by a plate stimulates an adaptation by the bone to accommodate for the new stress levels through remodeling. (2)
This quote shows the physiology of the plates, screws and bone.
The two most commonly used plate materials for internal fixation are stainless steel and titanium alloys. Cobalt chromium alloys are also used but are not as popular in orthopedic surgery. 316L stainless steel is one of the most commonly used metals for plates. The 316 stainless steel is a certain name for the metal. The L indicates it is different from just 316 because it has lower carbon amounts which is healthier for the body (Bell). This material was introduced in the early 1900s and became very popular after it was utilized successfully in surgery. Prior to that many metals were used, but due to the biochemistry found in the body some metals were reactive causing problems. Due to its corrosion resistance 316L stainless steel is ideal for plates and implants. Titanium is also a popular material used because it is the most corrosion resistant metal. Titanium rose to prominence in the 1960s and there are 3 different alloys of it used today (Hansen 2). Figure 7 shows one of the many types of internal fixation plates. Comparison of titanium and stainless steel plates yields no difference in beneficialness for the patient.
Figure 7: A titanium plate (Orthopedic Implant Distal Femoral Lateral Locking Compression Plate).
In the journal “Titanium Versus Stainless Steel Plating in the Surgical Treatment of Distal Radius Fractures” the authors did a randomized trial of titanium and stainless steel plates. They concluded that there was no difference in complications and revision surgeries and their results support the use for both (Shakir et al. 3). While these are the most common metal plates used, there are new materials being used.
Two new materials that are being implemented and tested are called auxetic and bioresorbable bone plates. Mehmood et al. explain what auxetic materials are in the journal “Auxetic polymeric bone plate as internal fixator for long bone fractures: Design and fabrication and structural analysis” by saying, “Auxetic materials have a negative Poisson’s ratio and they show lateral expansion when stretched longitudinally, becoming narrower when compressed… The Auxetic materials have gained popularity in commercial applications due to their increased shear stiffness, strain fracture toughness and indentation resistance” (3). The Auxetic plate is made of polyurethane which does not harm the body or create an immune response, which is a possibility when using some metal plates. These plates are proposed to have better union of fractures which aids in bone healing. Through stability and flexibility the Auxetic plates enhance healing of fractures due to how the material is constructed. Although there have not been human trials yet, the journal suggests that the most beneficial use of the plate be when fracture gaps are small. There have been new studies that have come out showing that flexible plates can be more beneficial due to minimal stress shielding. Stress shielding is the loss of bone density due to decreased weight on the bone because the weight is transferred to the plate (Millis). The Auxetic design reduces this problem due to its flexible but strong nature (Mehmood et al. 2,3,13). Human or animal trials of this material are needed to see if it is beneficial and works.
One of the bigger problems with using metallic plates is the necessity of revision surgery to remove them. Bioresorbable plates solve this problem because:
Bioresorbable and biodegradable fracture fixation implants have been considered as an effective fixation system with several advantages over metallic fixation, including no need to remove the implants after osseous healing, radiolucency, no corrosion, no implants bear less load initially and gradually transfer the load as they degrade… The ideal biodegradable material provides appropriate strength whilst degrading in a predictable fashion throughout the healing process without causing adverse reactions. (Pina & Ferreira 2)
There are two different types of materials available that are biodegradable, they are ceramics/calcium phosphates and polymers. Polymers have been found to be more efficient than ceramics due to their strength properties. These materials can also be manipulated to alter the properties and the degradation characteristics. Problems with these materials include inflammatory response, rapid loss of initial implant strength, higher refracture rates, inadequate stiffness of the implants, and weakness in comparison to metallic implants. Due to the low mechanical strength this leads to possibly a less stable fracture. In conclusion, the positives for most scenarios in using biodegradable material outweigh the negatives. Future research needs to be done on improving the mechanical strength of the material.
Another internal fixation material is an intramedullary (IM) nail. IM nails are primarily used for fractures of the biggest long bones: femur, tibia and humerus. An IM nail is a long rod that is inserted into the medullary cavity of a long bone. IM nails work well because they form a self contained internal splint for the fracture. They provide strong support, good alignment, can lead to earlier weight bearing and is minimally invasive. During an IM nail procedure the surgeon will make about 3 or 4 small incisions in the skin. From there they position the bone to put the nail down the medullary cavity and then put 2-6 screws perpendicular to it. This procedure works fast, is safe and heals the fracture properly. The nails are also made of titanium or stainless steel. Figure 8 shows an IM nail in a tibia. There are two different techniques for inserting IM nails, reamed and unreamed, these both have positives and negatives. When the bone is reamed it widens the medullary cavity while unreamed leaves the medullary cavity as is. The positives of reaming are high union rate, low infection and nonunion rate, higher biomechanical stability, rapid fracture healing and lower frequency of secondary procedure. Drawbacks of reaming are decreased blood flow to the diaphysis, necrosis (death of tissue due to lack of blood), emboli (blood clot, body material, foreign body) and longer surgery time. Unreaming uses a smaller diameter nail than reaming allowing for less blood flow disruption, less blood loss, faster insert time/quicker surgery, and do not disrupt cortical bone structure. Unreaming is not as strong, does not heal as quickly and does not have as high of union rates as reamed does. According to the study done by Li et al. in the journal “Reamed versus unreamed intramedullary nailing for the treatment of femoral fractures” that compared multiple studies of reamed and unreamed nailing. The conclusion was reached that reamed nailing is a shorter time to bone union, and lower rates of delayed union, nonunion and reoperation. It did not increase blood loss, implant failure and mortality when compared to unreamed nailing (Li et al. 1,4,5,8) (Bagheri 1-2) (Understanding Your Intramedullary Nail).
Figure 8: An IM nail in a tibia with plate fixation on the fibula (Closed Reduction; Intramedullary Nailing (Reamed)).
Bone healing is an extremely important part of the fracture process as poor healing can result in physical problems and financial problems with revision surgery. Victoria et al. explain this in the journal “Bone Stimulation for Fracture Healing: What’s All the Fuss?” by stating:
... out of the estimated 7.9 million fractures that occur annually in the United States, 5–10% of them develop nonunions and/or delayed unions, which are major sources of complications in the treatment of bone fractures. Fracture healing is a complicated metabolic process and requires the interaction of many factors, including the recruitment of reparative cells and genes. If these factors are inadequate or interrupted, healing is delayed or impaired, resulting in a nonunion of the bone. The cause of nonunions and delayed healings of fractures is usually unknown. The known reasons of delayed or impaired unions include problems with operative and nonoperative interventions, comprising inadequate mobilization of the fracture, distraction of fracture fragments by fixation devices or traction, repeated manipulations or excessive early motion of a fracture, excessive periosteal stripping, and damage to other soft tissues during operative exposure. Other risks for impaired fracture healing include contamination at the time of injury or operation, smoking, diabetes, and the skeletal location of the injury. (1)
This highlights the importance of healing and the many risk factors of nonunion and malunion. Thankfully, there are two main bone stimulators that induce healing. These are electrical stimulation and low intensity pulsed ultrasound. There are a few different forms of electrical stimulation but they all generally work by sending low level pulses of electromagnetic energy to the fracture site. This usually occurs at fracture sites when there is union, however doing this stimulates that process to start (About Bone Growth Therapy). More evidence is needed to conclude whether electrical stimulators are cost-effective and successful. It is possible that this works due to the placebo effect, but more information is needed on this technology. Ultrasonic stimulation on the other hand, does have quality evidence that it works. This works by
Increasing the incorporation of calcium ions in cultures of cartilage and bone cells and stimulate the expression of numerous genes... involved in the healing process. The most important effect that ultrasound has on bone healing may be on chondrocyte population, as suggested by studies that demonstrate an increase in the formation of soft callus and early onset of endochondral ossification after ultrasonic applications. Many preclinical and clinical studies have demonstrated promising results using low-intensity pulsed ultrasounds for healing fresh fractures and treatment of delayed union or nonunions. (Victoria et al. 4)
As mentioned, data on using electrical stimulators are inconclusive due to poor studies. Low intensity pulsed ultrasounds do have extensive evidence from studies behind them making them one of the most beneficial bone stimulators.
A new bone healing technology has recently come out called demineralized bone matrix (DBM), an orthobiologic agent which is an allograft (tissue from a donor) product, that has proven safety and efficacy to enhance bone healing in fractures. DBM has many positives including no limitation of quantity, shorter operative time, no additional procedures and no donor site morbidity. A study was done to compare healing effects using DBM and not using DBM on femoral fractures. The results are drastic because the fracture that used DBM completed healing at 11 months whereas the fracture that did not receive it took 14 months to completely heal. This was done on atypical subtrochanteric femoral fractures which have low blood supply compared to the diaphyseal region, which is why it takes so many months to heal. This technology is promising for use on fractures or bones that typically result in nonunion or delayed union (Kulachote 1,2,5,6).
Part IV: Conclusion
There are many factors that go into orthopedic trauma care and long bone fractures. Everything from the anatomy of the bone, to technology on viewing it, to the fixator device to the healing process. There is not one answer as to how to solve fractures and how to induce healing. There are a multitude of ways to solve fractures, this was focused on diaphyseal fractures of bones. There are many different classifications for fractures that all are unique and need to be addressed individually. This thesis is the tip of the iceberg for starting to understand how fractures happen, how bones heal, how fixation devices work, how heal time varies, etc. Even with the extensive research done for this thesis there are many avenues not touched on that play big roles in long bone fractures, like the physics of bone healing and plate fixation. Using the information and data collected in this thesis, two specific fracture scenarios and their course of action will be analyzed in how they might be treated.
Case 1: A 61 year old female with a closed, spiral, diaphyseal femoral fracture with displacement from a three foot fall. The first step here would be to obtain radiographs. X-rays would most likely be the only radiology used due to this not being complex. Next step would be to anatomically reduce it as close as possible through traction. In surgery implant a reamed IM nail into femur laterally with multiple screws. Due to the female most likely having osteoporosis due to menopause, it will most likely take a longer time to heal especially with her age. When women go through menopause they stop producing hormones that help keep bones strong, like estrogen. This is why it is more common for women than men, who have gone through menopause to have weakened bones and experience more fractures. Follow up every couple months to check on the healing process. The use of a bone stimulator like the low intensity pulsed ultrasound may be used to enhance healing and prevent nonunion or delayed union of the fracture. Wait 2-4 months for fracture healing to finish.
Case 2: A 25 year old male with a closed, comminuted, proximal humerus fracture with displacement. The first step again would be to take X-rays to assess the injury. A CT scan may be done to evaluate the fracture and make sure the glenoid cavity, acromion or scapula are not injured. From here do open reduction and internal fixation (ORIF). A stainless steel or titanium alloy plate would be used and properly sized to fit the proximal humerus precisely. Multiple screws would be needed because of the comminution. Because the patient is young and does not have osteoporosis a bone healing device would not be necessary. Heal time would be about two months and then the patient could go back to full activity. Revision surgery to remove hardware might be necessary due to age and possible problems.
As mentioned there is not one perfect answer for which technology is most beneficial, many factors go into deciding care from your orthopedic surgeon. The information presented in this thesis is based on clinical research and studies. Orthopedic surgeons go through four years of undergraduate, four years of medical school, about five years of residency and one to two years of fellowship(s). That time is spent learning the most beneficial techniques for patients and patient care. They have much more experience than I do and the information presented in this should be for learning purposes only.
Further areas of research that are needed and would be beneficial are developing Auxetic and biodegradable plates and bone stimulation. These show some of the most prominences for new technology in long bone fractures. If developed correctly these can really make a difference in surgery financially and physically. Not having revision surgery saves a lot of healing time and money making it beneficial. Since Auxetic plates have not been tested on humans or animals it is difficult to know whether or not they will work. The science backing them is strong, but that could change in testing the material. One other place more research is needed is in bone stimulators, lots of information is still not known of whether or not they work, especially when it comes to electric stimulators.
To conclude in radiography fractures are most commonly viewed on X-rays which are cost efficient and healthier when compared to MRI and CT scans. Implementing ultrasonic guided waves would be difficult due to the technology and training needed. AI, on the other hand, can and most likely will be implemented in the future. Depending on the type of fracture and the bone fractured, this will change what type of reduction and fixation is used. When it comes to external fixation the unilateral and circular designs both have appropriate uses depending on the location of the fracture and the extent of the injuries to the limb. Internal fixation plates have no differences between stainless steel and titanium in outcomes. Auxetic plates seem beneficial however no research has been done to confirm this. Biodegradable plates can be argued to be better than metallic plates. However due to availability and lack of stability biodegradable plates are not the standard implant. Reamed intramedullary nails are proven to be more beneficial than unreamed because of the characteristics that reaming has. Low intensity pulsed ultrasound is the strongest and most backed by evidence bone healing device. The demineralized bone matrix healing technique also has strong evidence for it, however, it is not commonly used. All the information in this thesis is based on data collected from a multitude of academic sources and journals. I am able to use the information learned in this to increase my knowledge for my internship that I do with a local orthopedic clinic and OR.
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