Upload
others
View
4
Download
0
Embed Size (px)
Citation preview
Specialespecifikt kursus i Traumatologi 2014
Tibiaskaft og marvsoslashmning
Udredning Implantater Behandling Problemer Tipsrsquo n Tricks
Soslashren Kring Ortopaeligdkirurgisk afdeling M
Bispebjerg Hospital
Afgraelignsning
bull Vi kommer ind paring foslashlgende bull Marvsoslashmning af tibiafrakturer bull Indikationer for marvsoslashmning bull Implantater bull Typiske sposlashrgsmaringl og problemer
ndash Hvem hvad hvor hvordan og hvorfor ndash Praelig- per- og postoperative overvejelser ndash Tipsrsquon Tricks
bull Vi kommer ikke ind paring foslashlgende bull Tibiakondyl- og Pilonfrakturer bull Ringfixatorer og skinnesteosyntese bull Aringbne frakturer
Maringl med behandlingen
bull Frakturen skal hele hurtigst muligt bull Frakturen skal hele i (naeligr)anatomisk stilling bull Vaeliggtbelastning fra dag 1 tilstraeligbes bull Fuld bevaeliggelighed i ankel- og knaeligled bull Undgaring komplikationer bull Hoslashj SSF (Surgeonrsquos Satisfaction Factor)
Case 1
bull 30-aringrig kvinde ASA 1 aktiv bull Lavenergifraktur bull Fine bloslashddele bull Intakte NV forhold bull Plan
Case 2
Case 1 + 2
bull Hvad nu
Case 1+2
bull Hvilket soslashm er blevet anvendt ndash specielle features
bull Hvilke principper er der blevet brugt (stabilitet)
Operativ eller konservativ behandling
bull Operativ ndash Hurtigere heling ndash Kortere sygemelding ndash Faeligrre non- og malunions ndash Faeligrre roslashntgenoptagelser ndash Flere smerter (initielt) ndash Flere infektioner ndash Plejemaeligssige fordele ndash Hoslashj SSF
bull Konservativ ndash Nedsat ledbevaeliggelighed ndash Nedsat muskelkraft ndash Tryksaringr
Indikation
bull I NEJ bull II Ja men vanskelig bull III Ja bull IV JA ideel bull V Ja bull VI Ja afhaeligngig af
fraktur-type
Indikation
bull Alle de proximale og distale frakturer boslashr CT scannes
bull J Trauma 2011 Jul71(1)163-8 doi 101097TA0b013e3181edb88f Results of a computed tomography protocol evaluating distal third tibial shaft fractures to assess noncontiguous malleolar fractures
bull Purnell GJ Glass ER Altman DT Sciulli RL Muffly MT Altman GT
bull CONCLUSION Plain radiographs are often insufficient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures Using a preoperative CT protocol for tibial shaft fractures can significantly improve the ability to diagnose associated intra-articular fractures that may not be evident on plain radiographs Knowledge of these associated intra-articular fractures may prompt fracture stabilization and can prevent displacement during intramedullary nailing of tibia shaft fractures
bull CT er et vigtigt redskab naringr den endelige beslutning om valg af metode skal tages
Implantater
bull Kend dit soslashm ndash laeligs manualen (og goslashr det igen)
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Lejring og placering af gennemlyser
bull Ekstensionleje bull rdquoPoslashlle paring pindrdquo +- ankelstraeligk bull Frithaeligngende ben bull Undgaring tryk i fossa poplitea bull Nye soslashm kraeligver 100-110 graders
fleksion i knaeliget (NB semiextended teknik)
bull Rotationsfejlstilling pga rotation i hoften
bull Kan hele tibia visualiseres med gennemlyser
Reponering
bull Holdes under hele proceduren ndash optimalt set
bull Muligheder ndash Selve opstillingen ndash Assistent ndash Elastiske bandager ndash Ex-fix ndash Lus ndash Andet
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Afgraelignsning
bull Vi kommer ind paring foslashlgende bull Marvsoslashmning af tibiafrakturer bull Indikationer for marvsoslashmning bull Implantater bull Typiske sposlashrgsmaringl og problemer
ndash Hvem hvad hvor hvordan og hvorfor ndash Praelig- per- og postoperative overvejelser ndash Tipsrsquon Tricks
bull Vi kommer ikke ind paring foslashlgende bull Tibiakondyl- og Pilonfrakturer bull Ringfixatorer og skinnesteosyntese bull Aringbne frakturer
Maringl med behandlingen
bull Frakturen skal hele hurtigst muligt bull Frakturen skal hele i (naeligr)anatomisk stilling bull Vaeliggtbelastning fra dag 1 tilstraeligbes bull Fuld bevaeliggelighed i ankel- og knaeligled bull Undgaring komplikationer bull Hoslashj SSF (Surgeonrsquos Satisfaction Factor)
Case 1
bull 30-aringrig kvinde ASA 1 aktiv bull Lavenergifraktur bull Fine bloslashddele bull Intakte NV forhold bull Plan
Case 2
Case 1 + 2
bull Hvad nu
Case 1+2
bull Hvilket soslashm er blevet anvendt ndash specielle features
bull Hvilke principper er der blevet brugt (stabilitet)
Operativ eller konservativ behandling
bull Operativ ndash Hurtigere heling ndash Kortere sygemelding ndash Faeligrre non- og malunions ndash Faeligrre roslashntgenoptagelser ndash Flere smerter (initielt) ndash Flere infektioner ndash Plejemaeligssige fordele ndash Hoslashj SSF
bull Konservativ ndash Nedsat ledbevaeliggelighed ndash Nedsat muskelkraft ndash Tryksaringr
Indikation
bull I NEJ bull II Ja men vanskelig bull III Ja bull IV JA ideel bull V Ja bull VI Ja afhaeligngig af
fraktur-type
Indikation
bull Alle de proximale og distale frakturer boslashr CT scannes
bull J Trauma 2011 Jul71(1)163-8 doi 101097TA0b013e3181edb88f Results of a computed tomography protocol evaluating distal third tibial shaft fractures to assess noncontiguous malleolar fractures
bull Purnell GJ Glass ER Altman DT Sciulli RL Muffly MT Altman GT
bull CONCLUSION Plain radiographs are often insufficient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures Using a preoperative CT protocol for tibial shaft fractures can significantly improve the ability to diagnose associated intra-articular fractures that may not be evident on plain radiographs Knowledge of these associated intra-articular fractures may prompt fracture stabilization and can prevent displacement during intramedullary nailing of tibia shaft fractures
bull CT er et vigtigt redskab naringr den endelige beslutning om valg af metode skal tages
Implantater
bull Kend dit soslashm ndash laeligs manualen (og goslashr det igen)
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Lejring og placering af gennemlyser
bull Ekstensionleje bull rdquoPoslashlle paring pindrdquo +- ankelstraeligk bull Frithaeligngende ben bull Undgaring tryk i fossa poplitea bull Nye soslashm kraeligver 100-110 graders
fleksion i knaeliget (NB semiextended teknik)
bull Rotationsfejlstilling pga rotation i hoften
bull Kan hele tibia visualiseres med gennemlyser
Reponering
bull Holdes under hele proceduren ndash optimalt set
bull Muligheder ndash Selve opstillingen ndash Assistent ndash Elastiske bandager ndash Ex-fix ndash Lus ndash Andet
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Maringl med behandlingen
bull Frakturen skal hele hurtigst muligt bull Frakturen skal hele i (naeligr)anatomisk stilling bull Vaeliggtbelastning fra dag 1 tilstraeligbes bull Fuld bevaeliggelighed i ankel- og knaeligled bull Undgaring komplikationer bull Hoslashj SSF (Surgeonrsquos Satisfaction Factor)
Case 1
bull 30-aringrig kvinde ASA 1 aktiv bull Lavenergifraktur bull Fine bloslashddele bull Intakte NV forhold bull Plan
Case 2
Case 1 + 2
bull Hvad nu
Case 1+2
bull Hvilket soslashm er blevet anvendt ndash specielle features
bull Hvilke principper er der blevet brugt (stabilitet)
Operativ eller konservativ behandling
bull Operativ ndash Hurtigere heling ndash Kortere sygemelding ndash Faeligrre non- og malunions ndash Faeligrre roslashntgenoptagelser ndash Flere smerter (initielt) ndash Flere infektioner ndash Plejemaeligssige fordele ndash Hoslashj SSF
bull Konservativ ndash Nedsat ledbevaeliggelighed ndash Nedsat muskelkraft ndash Tryksaringr
Indikation
bull I NEJ bull II Ja men vanskelig bull III Ja bull IV JA ideel bull V Ja bull VI Ja afhaeligngig af
fraktur-type
Indikation
bull Alle de proximale og distale frakturer boslashr CT scannes
bull J Trauma 2011 Jul71(1)163-8 doi 101097TA0b013e3181edb88f Results of a computed tomography protocol evaluating distal third tibial shaft fractures to assess noncontiguous malleolar fractures
bull Purnell GJ Glass ER Altman DT Sciulli RL Muffly MT Altman GT
bull CONCLUSION Plain radiographs are often insufficient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures Using a preoperative CT protocol for tibial shaft fractures can significantly improve the ability to diagnose associated intra-articular fractures that may not be evident on plain radiographs Knowledge of these associated intra-articular fractures may prompt fracture stabilization and can prevent displacement during intramedullary nailing of tibia shaft fractures
bull CT er et vigtigt redskab naringr den endelige beslutning om valg af metode skal tages
Implantater
bull Kend dit soslashm ndash laeligs manualen (og goslashr det igen)
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Lejring og placering af gennemlyser
bull Ekstensionleje bull rdquoPoslashlle paring pindrdquo +- ankelstraeligk bull Frithaeligngende ben bull Undgaring tryk i fossa poplitea bull Nye soslashm kraeligver 100-110 graders
fleksion i knaeliget (NB semiextended teknik)
bull Rotationsfejlstilling pga rotation i hoften
bull Kan hele tibia visualiseres med gennemlyser
Reponering
bull Holdes under hele proceduren ndash optimalt set
bull Muligheder ndash Selve opstillingen ndash Assistent ndash Elastiske bandager ndash Ex-fix ndash Lus ndash Andet
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Case 1
bull 30-aringrig kvinde ASA 1 aktiv bull Lavenergifraktur bull Fine bloslashddele bull Intakte NV forhold bull Plan
Case 2
Case 1 + 2
bull Hvad nu
Case 1+2
bull Hvilket soslashm er blevet anvendt ndash specielle features
bull Hvilke principper er der blevet brugt (stabilitet)
Operativ eller konservativ behandling
bull Operativ ndash Hurtigere heling ndash Kortere sygemelding ndash Faeligrre non- og malunions ndash Faeligrre roslashntgenoptagelser ndash Flere smerter (initielt) ndash Flere infektioner ndash Plejemaeligssige fordele ndash Hoslashj SSF
bull Konservativ ndash Nedsat ledbevaeliggelighed ndash Nedsat muskelkraft ndash Tryksaringr
Indikation
bull I NEJ bull II Ja men vanskelig bull III Ja bull IV JA ideel bull V Ja bull VI Ja afhaeligngig af
fraktur-type
Indikation
bull Alle de proximale og distale frakturer boslashr CT scannes
bull J Trauma 2011 Jul71(1)163-8 doi 101097TA0b013e3181edb88f Results of a computed tomography protocol evaluating distal third tibial shaft fractures to assess noncontiguous malleolar fractures
bull Purnell GJ Glass ER Altman DT Sciulli RL Muffly MT Altman GT
bull CONCLUSION Plain radiographs are often insufficient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures Using a preoperative CT protocol for tibial shaft fractures can significantly improve the ability to diagnose associated intra-articular fractures that may not be evident on plain radiographs Knowledge of these associated intra-articular fractures may prompt fracture stabilization and can prevent displacement during intramedullary nailing of tibia shaft fractures
bull CT er et vigtigt redskab naringr den endelige beslutning om valg af metode skal tages
Implantater
bull Kend dit soslashm ndash laeligs manualen (og goslashr det igen)
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Lejring og placering af gennemlyser
bull Ekstensionleje bull rdquoPoslashlle paring pindrdquo +- ankelstraeligk bull Frithaeligngende ben bull Undgaring tryk i fossa poplitea bull Nye soslashm kraeligver 100-110 graders
fleksion i knaeliget (NB semiextended teknik)
bull Rotationsfejlstilling pga rotation i hoften
bull Kan hele tibia visualiseres med gennemlyser
Reponering
bull Holdes under hele proceduren ndash optimalt set
bull Muligheder ndash Selve opstillingen ndash Assistent ndash Elastiske bandager ndash Ex-fix ndash Lus ndash Andet
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Case 2
Case 1 + 2
bull Hvad nu
Case 1+2
bull Hvilket soslashm er blevet anvendt ndash specielle features
bull Hvilke principper er der blevet brugt (stabilitet)
Operativ eller konservativ behandling
bull Operativ ndash Hurtigere heling ndash Kortere sygemelding ndash Faeligrre non- og malunions ndash Faeligrre roslashntgenoptagelser ndash Flere smerter (initielt) ndash Flere infektioner ndash Plejemaeligssige fordele ndash Hoslashj SSF
bull Konservativ ndash Nedsat ledbevaeliggelighed ndash Nedsat muskelkraft ndash Tryksaringr
Indikation
bull I NEJ bull II Ja men vanskelig bull III Ja bull IV JA ideel bull V Ja bull VI Ja afhaeligngig af
fraktur-type
Indikation
bull Alle de proximale og distale frakturer boslashr CT scannes
bull J Trauma 2011 Jul71(1)163-8 doi 101097TA0b013e3181edb88f Results of a computed tomography protocol evaluating distal third tibial shaft fractures to assess noncontiguous malleolar fractures
bull Purnell GJ Glass ER Altman DT Sciulli RL Muffly MT Altman GT
bull CONCLUSION Plain radiographs are often insufficient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures Using a preoperative CT protocol for tibial shaft fractures can significantly improve the ability to diagnose associated intra-articular fractures that may not be evident on plain radiographs Knowledge of these associated intra-articular fractures may prompt fracture stabilization and can prevent displacement during intramedullary nailing of tibia shaft fractures
bull CT er et vigtigt redskab naringr den endelige beslutning om valg af metode skal tages
Implantater
bull Kend dit soslashm ndash laeligs manualen (og goslashr det igen)
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Lejring og placering af gennemlyser
bull Ekstensionleje bull rdquoPoslashlle paring pindrdquo +- ankelstraeligk bull Frithaeligngende ben bull Undgaring tryk i fossa poplitea bull Nye soslashm kraeligver 100-110 graders
fleksion i knaeliget (NB semiextended teknik)
bull Rotationsfejlstilling pga rotation i hoften
bull Kan hele tibia visualiseres med gennemlyser
Reponering
bull Holdes under hele proceduren ndash optimalt set
bull Muligheder ndash Selve opstillingen ndash Assistent ndash Elastiske bandager ndash Ex-fix ndash Lus ndash Andet
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Case 1 + 2
bull Hvad nu
Case 1+2
bull Hvilket soslashm er blevet anvendt ndash specielle features
bull Hvilke principper er der blevet brugt (stabilitet)
Operativ eller konservativ behandling
bull Operativ ndash Hurtigere heling ndash Kortere sygemelding ndash Faeligrre non- og malunions ndash Faeligrre roslashntgenoptagelser ndash Flere smerter (initielt) ndash Flere infektioner ndash Plejemaeligssige fordele ndash Hoslashj SSF
bull Konservativ ndash Nedsat ledbevaeliggelighed ndash Nedsat muskelkraft ndash Tryksaringr
Indikation
bull I NEJ bull II Ja men vanskelig bull III Ja bull IV JA ideel bull V Ja bull VI Ja afhaeligngig af
fraktur-type
Indikation
bull Alle de proximale og distale frakturer boslashr CT scannes
bull J Trauma 2011 Jul71(1)163-8 doi 101097TA0b013e3181edb88f Results of a computed tomography protocol evaluating distal third tibial shaft fractures to assess noncontiguous malleolar fractures
bull Purnell GJ Glass ER Altman DT Sciulli RL Muffly MT Altman GT
bull CONCLUSION Plain radiographs are often insufficient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures Using a preoperative CT protocol for tibial shaft fractures can significantly improve the ability to diagnose associated intra-articular fractures that may not be evident on plain radiographs Knowledge of these associated intra-articular fractures may prompt fracture stabilization and can prevent displacement during intramedullary nailing of tibia shaft fractures
bull CT er et vigtigt redskab naringr den endelige beslutning om valg af metode skal tages
Implantater
bull Kend dit soslashm ndash laeligs manualen (og goslashr det igen)
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Lejring og placering af gennemlyser
bull Ekstensionleje bull rdquoPoslashlle paring pindrdquo +- ankelstraeligk bull Frithaeligngende ben bull Undgaring tryk i fossa poplitea bull Nye soslashm kraeligver 100-110 graders
fleksion i knaeliget (NB semiextended teknik)
bull Rotationsfejlstilling pga rotation i hoften
bull Kan hele tibia visualiseres med gennemlyser
Reponering
bull Holdes under hele proceduren ndash optimalt set
bull Muligheder ndash Selve opstillingen ndash Assistent ndash Elastiske bandager ndash Ex-fix ndash Lus ndash Andet
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Case 1+2
bull Hvilket soslashm er blevet anvendt ndash specielle features
bull Hvilke principper er der blevet brugt (stabilitet)
Operativ eller konservativ behandling
bull Operativ ndash Hurtigere heling ndash Kortere sygemelding ndash Faeligrre non- og malunions ndash Faeligrre roslashntgenoptagelser ndash Flere smerter (initielt) ndash Flere infektioner ndash Plejemaeligssige fordele ndash Hoslashj SSF
bull Konservativ ndash Nedsat ledbevaeliggelighed ndash Nedsat muskelkraft ndash Tryksaringr
Indikation
bull I NEJ bull II Ja men vanskelig bull III Ja bull IV JA ideel bull V Ja bull VI Ja afhaeligngig af
fraktur-type
Indikation
bull Alle de proximale og distale frakturer boslashr CT scannes
bull J Trauma 2011 Jul71(1)163-8 doi 101097TA0b013e3181edb88f Results of a computed tomography protocol evaluating distal third tibial shaft fractures to assess noncontiguous malleolar fractures
bull Purnell GJ Glass ER Altman DT Sciulli RL Muffly MT Altman GT
bull CONCLUSION Plain radiographs are often insufficient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures Using a preoperative CT protocol for tibial shaft fractures can significantly improve the ability to diagnose associated intra-articular fractures that may not be evident on plain radiographs Knowledge of these associated intra-articular fractures may prompt fracture stabilization and can prevent displacement during intramedullary nailing of tibia shaft fractures
bull CT er et vigtigt redskab naringr den endelige beslutning om valg af metode skal tages
Implantater
bull Kend dit soslashm ndash laeligs manualen (og goslashr det igen)
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Lejring og placering af gennemlyser
bull Ekstensionleje bull rdquoPoslashlle paring pindrdquo +- ankelstraeligk bull Frithaeligngende ben bull Undgaring tryk i fossa poplitea bull Nye soslashm kraeligver 100-110 graders
fleksion i knaeliget (NB semiextended teknik)
bull Rotationsfejlstilling pga rotation i hoften
bull Kan hele tibia visualiseres med gennemlyser
Reponering
bull Holdes under hele proceduren ndash optimalt set
bull Muligheder ndash Selve opstillingen ndash Assistent ndash Elastiske bandager ndash Ex-fix ndash Lus ndash Andet
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Operativ eller konservativ behandling
bull Operativ ndash Hurtigere heling ndash Kortere sygemelding ndash Faeligrre non- og malunions ndash Faeligrre roslashntgenoptagelser ndash Flere smerter (initielt) ndash Flere infektioner ndash Plejemaeligssige fordele ndash Hoslashj SSF
bull Konservativ ndash Nedsat ledbevaeliggelighed ndash Nedsat muskelkraft ndash Tryksaringr
Indikation
bull I NEJ bull II Ja men vanskelig bull III Ja bull IV JA ideel bull V Ja bull VI Ja afhaeligngig af
fraktur-type
Indikation
bull Alle de proximale og distale frakturer boslashr CT scannes
bull J Trauma 2011 Jul71(1)163-8 doi 101097TA0b013e3181edb88f Results of a computed tomography protocol evaluating distal third tibial shaft fractures to assess noncontiguous malleolar fractures
bull Purnell GJ Glass ER Altman DT Sciulli RL Muffly MT Altman GT
bull CONCLUSION Plain radiographs are often insufficient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures Using a preoperative CT protocol for tibial shaft fractures can significantly improve the ability to diagnose associated intra-articular fractures that may not be evident on plain radiographs Knowledge of these associated intra-articular fractures may prompt fracture stabilization and can prevent displacement during intramedullary nailing of tibia shaft fractures
bull CT er et vigtigt redskab naringr den endelige beslutning om valg af metode skal tages
Implantater
bull Kend dit soslashm ndash laeligs manualen (og goslashr det igen)
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Lejring og placering af gennemlyser
bull Ekstensionleje bull rdquoPoslashlle paring pindrdquo +- ankelstraeligk bull Frithaeligngende ben bull Undgaring tryk i fossa poplitea bull Nye soslashm kraeligver 100-110 graders
fleksion i knaeliget (NB semiextended teknik)
bull Rotationsfejlstilling pga rotation i hoften
bull Kan hele tibia visualiseres med gennemlyser
Reponering
bull Holdes under hele proceduren ndash optimalt set
bull Muligheder ndash Selve opstillingen ndash Assistent ndash Elastiske bandager ndash Ex-fix ndash Lus ndash Andet
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Indikation
bull I NEJ bull II Ja men vanskelig bull III Ja bull IV JA ideel bull V Ja bull VI Ja afhaeligngig af
fraktur-type
Indikation
bull Alle de proximale og distale frakturer boslashr CT scannes
bull J Trauma 2011 Jul71(1)163-8 doi 101097TA0b013e3181edb88f Results of a computed tomography protocol evaluating distal third tibial shaft fractures to assess noncontiguous malleolar fractures
bull Purnell GJ Glass ER Altman DT Sciulli RL Muffly MT Altman GT
bull CONCLUSION Plain radiographs are often insufficient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures Using a preoperative CT protocol for tibial shaft fractures can significantly improve the ability to diagnose associated intra-articular fractures that may not be evident on plain radiographs Knowledge of these associated intra-articular fractures may prompt fracture stabilization and can prevent displacement during intramedullary nailing of tibia shaft fractures
bull CT er et vigtigt redskab naringr den endelige beslutning om valg af metode skal tages
Implantater
bull Kend dit soslashm ndash laeligs manualen (og goslashr det igen)
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Lejring og placering af gennemlyser
bull Ekstensionleje bull rdquoPoslashlle paring pindrdquo +- ankelstraeligk bull Frithaeligngende ben bull Undgaring tryk i fossa poplitea bull Nye soslashm kraeligver 100-110 graders
fleksion i knaeliget (NB semiextended teknik)
bull Rotationsfejlstilling pga rotation i hoften
bull Kan hele tibia visualiseres med gennemlyser
Reponering
bull Holdes under hele proceduren ndash optimalt set
bull Muligheder ndash Selve opstillingen ndash Assistent ndash Elastiske bandager ndash Ex-fix ndash Lus ndash Andet
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Indikation
bull Alle de proximale og distale frakturer boslashr CT scannes
bull J Trauma 2011 Jul71(1)163-8 doi 101097TA0b013e3181edb88f Results of a computed tomography protocol evaluating distal third tibial shaft fractures to assess noncontiguous malleolar fractures
bull Purnell GJ Glass ER Altman DT Sciulli RL Muffly MT Altman GT
bull CONCLUSION Plain radiographs are often insufficient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures Using a preoperative CT protocol for tibial shaft fractures can significantly improve the ability to diagnose associated intra-articular fractures that may not be evident on plain radiographs Knowledge of these associated intra-articular fractures may prompt fracture stabilization and can prevent displacement during intramedullary nailing of tibia shaft fractures
bull CT er et vigtigt redskab naringr den endelige beslutning om valg af metode skal tages
Implantater
bull Kend dit soslashm ndash laeligs manualen (og goslashr det igen)
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Lejring og placering af gennemlyser
bull Ekstensionleje bull rdquoPoslashlle paring pindrdquo +- ankelstraeligk bull Frithaeligngende ben bull Undgaring tryk i fossa poplitea bull Nye soslashm kraeligver 100-110 graders
fleksion i knaeliget (NB semiextended teknik)
bull Rotationsfejlstilling pga rotation i hoften
bull Kan hele tibia visualiseres med gennemlyser
Reponering
bull Holdes under hele proceduren ndash optimalt set
bull Muligheder ndash Selve opstillingen ndash Assistent ndash Elastiske bandager ndash Ex-fix ndash Lus ndash Andet
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Implantater
bull Kend dit soslashm ndash laeligs manualen (og goslashr det igen)
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Lejring og placering af gennemlyser
bull Ekstensionleje bull rdquoPoslashlle paring pindrdquo +- ankelstraeligk bull Frithaeligngende ben bull Undgaring tryk i fossa poplitea bull Nye soslashm kraeligver 100-110 graders
fleksion i knaeliget (NB semiextended teknik)
bull Rotationsfejlstilling pga rotation i hoften
bull Kan hele tibia visualiseres med gennemlyser
Reponering
bull Holdes under hele proceduren ndash optimalt set
bull Muligheder ndash Selve opstillingen ndash Assistent ndash Elastiske bandager ndash Ex-fix ndash Lus ndash Andet
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Lejring og placering af gennemlyser
bull Ekstensionleje bull rdquoPoslashlle paring pindrdquo +- ankelstraeligk bull Frithaeligngende ben bull Undgaring tryk i fossa poplitea bull Nye soslashm kraeligver 100-110 graders
fleksion i knaeliget (NB semiextended teknik)
bull Rotationsfejlstilling pga rotation i hoften
bull Kan hele tibia visualiseres med gennemlyser
Reponering
bull Holdes under hele proceduren ndash optimalt set
bull Muligheder ndash Selve opstillingen ndash Assistent ndash Elastiske bandager ndash Ex-fix ndash Lus ndash Andet
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Typiske sposlashrgsmaringl ndash og problemer 1 Hvem skal udfoslashre operationen og hvornaringr 2 Anaeligstesiform og supplerende blokader 3 Lejring og placering af gennemlyser 4 Reponering ndash hvordan opnarings og fastholdes den 5 Antibiotika hvad hvor meget og hvor laelignge 6 Blodtomhed 7 Entrypoint hvad er bedst 8 Guidewirens placering 9 Soslashmstoslashrrelse Tykkelse og laeligngde 10 Reamning janej hvor meget og hvor langt 11 Tvaeligrskruer hvor mange hvor hvordan statiskedynamiske 12 Kompression over frakturen primaeligr kompression eller sekundaeligr dynamisering 13 Poller skruer (Blocking Screws) hvad er det 14 Skal fibula osteosynteres 15 Skal bagkanten osteosynteres
Lejring og placering af gennemlyser
bull Ekstensionleje bull rdquoPoslashlle paring pindrdquo +- ankelstraeligk bull Frithaeligngende ben bull Undgaring tryk i fossa poplitea bull Nye soslashm kraeligver 100-110 graders
fleksion i knaeliget (NB semiextended teknik)
bull Rotationsfejlstilling pga rotation i hoften
bull Kan hele tibia visualiseres med gennemlyser
Reponering
bull Holdes under hele proceduren ndash optimalt set
bull Muligheder ndash Selve opstillingen ndash Assistent ndash Elastiske bandager ndash Ex-fix ndash Lus ndash Andet
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Lejring og placering af gennemlyser
bull Ekstensionleje bull rdquoPoslashlle paring pindrdquo +- ankelstraeligk bull Frithaeligngende ben bull Undgaring tryk i fossa poplitea bull Nye soslashm kraeligver 100-110 graders
fleksion i knaeliget (NB semiextended teknik)
bull Rotationsfejlstilling pga rotation i hoften
bull Kan hele tibia visualiseres med gennemlyser
Reponering
bull Holdes under hele proceduren ndash optimalt set
bull Muligheder ndash Selve opstillingen ndash Assistent ndash Elastiske bandager ndash Ex-fix ndash Lus ndash Andet
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Reponering
bull Holdes under hele proceduren ndash optimalt set
bull Muligheder ndash Selve opstillingen ndash Assistent ndash Elastiske bandager ndash Ex-fix ndash Lus ndash Andet
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
16
Entrypoint - hvad er bedst
Tornetta et al J Orthop Trauma 13(4) 1999
Safe zone 9+5 mm lat for midtlinie (tibial plateau) og 3 mm lat for centrum tuberositas tibiae
bull Anteriort for lig transversum
bull I den anatomiske akse bull Paring rdquoSweet Spotrdquo bull Kontroller i
gennemlysning
16
Hernigou amp Cohen JBJtSurg 82B(1) 2000 Safe zone ant for lig transversum og begge meniskers forhorn
J Trauma 2008 Jun64 ToivanenJ CONCLUSION Compared with a transpatellar tendon approach a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture In long term anterior knee pain seems to disappear from many patients
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
17
Guidewire placering
17
Centralt i begge plan
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Soslashm - biomekanik
bull Soslashmmets laeligngde bull Soslashmmets diameter bull Antal skruer distalt bull Reametureamet
Summa summarum Et langt tykt soslashm vil kunne tilfredsstille de fleste frakturer
men hvordan faringr vi det ind
bull Laeligngere soslashm rarr stivheduarr stress fordeles
bull Tykkere soslashm rarr Gripping Strengthuarr bull Mindst 2 vinkelrette skruer bull Det er et mandagsemne
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
19
Isaeligttelse af soslashmmet
bull Forsigtig indfoslashring af soslashm ndash med hammer bull Check rotation bull Indsaeligt distale tvaeligrskruer
ndash Ikke fra lateralsiden ndash Minimum 2 skruer gerne 3 ndash Vinkelrette skruer mindsker pendulering ndash Statiske huller og ikke dynamiske
bull Soslashm skal ndash for helvede ndash bankes i
19
Implant failure in tibial nailing Injury Volume 31 Issue 5 Pages 359-362 ARuiz
Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures Journal of Bone and Joint Surgery - British Volume Vol 88-B Issue 2 227-231
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
20 20
Indsaeligttelse af distale tvaeligrskruer
bull 1 Korrekt placering af gennemlyser bull 2 rdquoRunde hullerrdquordquoSvenskerrdquo bull 3 Pas paring rotation i frakturen bull 4 Pas paring bloslashddele (hvordan) bull 5 Brug den teknik du bedst kan bull 6 Kontroller altid i flere planer
Distal third tibial fractures are prone to non-union following tibial nail insertion The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed Our results showed that 80 of non-unions in distal third fractures had only one distal locking screw compared to 20 who had two distal locking screws This is statistically significant (plt001) We therefore conclude that two distal locking screws are essential for distal third fractures Aso Mohammed1 Ramaswamy Saravanan2 Jason Zammit3 and Richard King4Journal International Orthopaedics
ALTID mindst 2 skruer
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
21
Kompression over frakturen
21
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
22
Kompression ndash primaeligr eller sekundaeligr
bull Primaeligr kompression er at foretraeligkke ndash hvis det er muligt Copyright copy 2006 by British Editorial Society of Bone and Joint Surgery Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G I Drosos MD PhD Consultant Orthopaedic Surgeon1 M Bishay FRCS Consultant As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient- injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis The patients were reviewed until clinical and radiological evidence of union at a mean of 133 months (4 to 60) Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 238 times for highly comminuted fractures by 314 times when nail dynamisation was applied and by 165 times when the locking screws failed In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was 3 mm
22
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Hvad er en Poller skrue
23 23
Reposition af distale frakturer
Maring man aringbne og saeligtte fx en lus over frakturen for at opnaring en bedre reposition
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Skal fibula osteosynteres
Ja i den distale 13 bull J Orthop Trauma 2007 21(3) 172-7 bull J Orthop Trauma 2006 20(2) 94-113 bull JBJS (Am) 2003 85(4) 604-8
bull Raeligkkefoslashlge ndash tib-fib eller
fib-tib bull Kan lette reposition af tibia bull Oslashget stabilitet bull Opretholdelse af alignment bull Men altidhellip
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Skal fibula osteosynteres
bull Oslashstrigsk multicenterstudie 185 tibiafrakturer 81 kom til 1-aringrs follow up 51 af dem er i den distale 13
bull 11 non-union bull 8-14 gange foroslashget risiko for delayed union hvis fibula blev osteosynteret
bull Mere stabile soslashmtyper bedre kirurgisk teknik og introduktion af ASLS vil maringske mindske behovet for samtidig osteosyntese af fibula
bull Arch Orthop Trauma Surg 2012 Jul132(7)975-84 doi 101007s00402-012-1502-y Epub 2012 Mar 20 bull A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) bull Attal R Hansen M Kirjavainen M Bail H Hammer TO Rosenberger R Houmlntzsch D Rommens PM bull Department of Trauma Surgery and Sports Medicine Innsbruck Medical University Anichstrasse 35 Innsbruck
Austria bull CONCLUSION Intramedullary ETN fixation of tibia fractures results in low rates of delayed union primary and
secondary malalignment implant-related complications and secondary surgery Fibula plating had a negative effect on the healing of the tibia
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Skal bagkanten osteosynteres
bull J Trauma 2011 Jul71(1)163-8 Purnell et al bull Twenty-nine of 67 (43) distal third tibial shaft fractures had associated intra-
articular fractures determined by CT scan There were 23 posterior malleolus fractures 3 anterolateral fragments and 3 medial malleolus fractures Twenty-seven of 29 fractures (93) were associated with spiral type fracture patterns (p = 0001) Seventeen of 29 (59) intra-articular fractures required operative fixation
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Skal bagkanten osteosynteres
Hvis gt 25 ledflade Ja lt 25 ledflade Maringske
Mobilisering med belastning efter osteosyntese
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
28 28
Proximale tibia amp marvsoslashmning
bull Svaeligrt bull Hyppig fejlstilling (80) bull Hyppig non-union bull Brug soslashm med det rigtige design bull Brug Poller-skrue teknik bull Semi-extended teknik
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Postoperativ regime bull Smertebehandling
ndash Risiko for compartment syndrom ndash Ingen spinalanalgesi ingen smertekatetre-blok initielt
bull Alle ndash Bevaeliggelighed (passiv+aktiv) over knaelig- og ankelled umiddelbart postoperativt ndash Antithrombotisk behandling indtil mobilisering
bull Lukkede ndash Stabile frakturer fuld stoslashtte ndash Instabile frakturer delvis stoslashtte de foslashrste 6 uger ndash Intraartikulaeligre frakturer Individuelt Oftest delvis stoslashtte
bull Aringbne ndash Afhaelignger af bloslashddelene
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
bull Nej
bull Ses i ca 11 af alle tibiafrakturer (8 i diafysen 3 proxdist) ndash J Orthop Trauma 2009 Aug23(7)514-8 doi 101097BOT0b013e3181a2815a Compartment syndrome in tibial fractures
Park S Ahn J Gee AO Kuntz AF Esterhai JL
bull 36 af alle compartment syndromer ses paring underbenet
bull De 5 Prsquoer ndash Pain out of proportion Pain by (passive) movement Paresthesia Paralysis Pulse present
bull Den typiske patient er en
ndash Yngre mand udsat for traume mod UE ndash Der ses associeret fraktur (corpus tibiae) ndash Alkohol ofte involveret ndash Udvikles oftest inden for det foslashrste doslashgn
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Compartment Syndrom
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Compartment Syndrom
Sposlashrgsmaringl
Saring er der frokost
Sposlashrgsmaringl
Saring er der frokost
Saring er der frokost