Surgical treatment of fractures through open reduction and internal fixation

According to specialists, external fixation (plasters or splints) can solve most of the fractures, however, their problems are evident as the limitation in the reduction by the difficulty to manipulate the bone fragments through the tissues surrounding the bone. Associated with the socio-labor limitation, functional alterations secondary to immobilization, such as muscular atrophy, osteoporosis due to disuse, and joint stiffness that require prolonged rehabilitation, prolonging the treatment and patient recovery.

Advantages and disadvantages of internal fixation of fractures

The main advantage of internal fixation is the anatomical reduction of the fracture, which rarely achieves a closed treatment. It allows solid fixation of the fragments and external immobilization is unnecessary, allowing early mobilization, avoiding complications and shortening the healing period.

The drawbacks are its costs, subsequent interventions to remove the osteosynthesis material, anesthetic complications, and especially the fearsome bone infection, difficult to resolve and often accompanied by failure or delay of bone healing. During surgery, the focus of the fracture is exposed and, even in the operating room, there is the possibility of contamination of the bone, especially of the skin and the bruised muscle, a great growth medium for the proliferation of germs.

The exposure of the fragments for the reduction and placement of osteosynthesis involves muscular and periosteal deinsertion, which are pathways of bone vascular supply, which are important in the consolidation of the fracture. The intervention involves leaving a foreign body although biocompatible.

Indications of internal fixation of fractures

Open reduction and internal fixation is indicated in unstable fractures, intraarticular, very slow consolidation, delayed consolidation or pseudoarthrosis, pathological fractures, complex associated with vascular and / or nervous injury as well as intolerance to external immobilization.

In general, all fractures in which an advantage over conservative treatment is indicated. In those in which the fracture has a chance of achieving a functionally acceptable reconstruction, sufficient fixation and a risk of controlled infection.

Osteosynthesis systems

All osteosynthesis systems recognized as valid for their robustness can be grouped into 4 sections:

- Screws

The screws are used for fixing the plates, but can also be applied as single osteosynthesis looking for the interfragmentary compression, which provides great strength because the forces act with short lever arms.

- Cerclages

Wired cerclage is a good osteosynthesis system when placed as a tension band, converting tensile forces into compression forces. In those fractures subjected to an eccentric traction that tends to open the fracture focus, if we place the cerclage in the zone of greater opening where the tension forces are concentrated, not only these are controlled, but also compressive forces occur in The rest of the fracture, stabilizing and stimulating the consolidation.

- Plates

In diaphyseal fractures, screwed plates can be used as a simple neutralization method after fracture reduction, but are usually used for interfragmentary compression, since this is the way to achieve the most solid immobilization. This compression can be achieved by tensioners or with self-compression plates.

With the tensors applied to one of the bone fragments a great force of interfragmentary compression is obtained, that thanks to the design of its orifices, that are oblique and with the walls in slope, the screws are tightened and the compression between the fragments takes place. The degree of compression achieved is less than with the tensioners.

With the introduction of the plates with screws screwed to them or angular stability has been extended its use, being its main indications the fractures articular or close to them, fractures in osteoporotic bone, some diaphyseal as the forearm, and failures of Consolidation by other means.

- Intramedullary interlocking

It is a fixation system for long bones with nails or needles inside the medullary cavity. It has the great advantage that it can be introduced under radioscopic control, through a small incision and bone perforation at one end of the bone (closed sky), in fractures that can be reduced by means of orthopedic table or small accessory approaches. Lesion of the peripheral soft tissues and the devitalization of the fragments with lower risk of infection and delay of consolidation. With the proximal and distal locking systems (accessory screws), it is possible to expand its range of use and control the rotation of the bone fragments, allowing an early loading and mobilization with which the patient's recovery time is reduced.