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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 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 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

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

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

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 - 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

• Specialespecifikt kursus i Traumatologi 2014Tibiaskaft og marvsoslashmningUdredning Implantater Behandling Problemer Tipsrsquo n Tricks
• Afgraelignsning
• Maringl med behandlingen
• Case 1
• Case 2
• Case 1 + 2
• Case 1+2
• Operativ eller konservativ behandling
• Indikation
• Indikation
• Implantater
• Typiske sposlashrgsmaringl ndash og problemer
• Typiske sposlashrgsmaringl ndash og problemer
• Lejring og placering af gennemlyser
• Reponering
• Slide Number 16
• Slide Number 17
• Soslashm - biomekanik
• Isaeligttelse af soslashmmet
• Slide Number 20
• Kompression over frakturen
• Kompression ndash primaeligr eller sekundaeligr
• Reposition af distale frakturer
• Skal fibula osteosynteres
• Skal fibula osteosynteres
• Skal bagkanten osteosynteres
• Skal bagkanten osteosynteres
• Proximale tibia amp marvsoslashmning
• Postoperativ regime
• Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
• Compartment Syndrom
• Compartment Syndrom
• Sposlashrgsmaringl
• Saring er der frokost

Compartment Syndrom

Sposlashrgsmaringl

Saring er der frokost

• Specialespecifikt kursus i Traumatologi 2014Tibiaskaft og marvsoslashmningUdredning Implantater Behandling Problemer Tipsrsquo n Tricks
• Afgraelignsning
• Maringl med behandlingen
• Case 1
• Case 2
• Case 1 + 2
• Case 1+2
• Operativ eller konservativ behandling
• Indikation
• Indikation
• Implantater
• Typiske sposlashrgsmaringl ndash og problemer
• Typiske sposlashrgsmaringl ndash og problemer
• Lejring og placering af gennemlyser
• Reponering
• Slide Number 16
• Slide Number 17
• Soslashm - biomekanik
• Isaeligttelse af soslashmmet
• Slide Number 20
• Kompression over frakturen
• Kompression ndash primaeligr eller sekundaeligr
• Reposition af distale frakturer
• Skal fibula osteosynteres
• Skal fibula osteosynteres
• Skal bagkanten osteosynteres
• Skal bagkanten osteosynteres
• Proximale tibia amp marvsoslashmning
• Postoperativ regime
• Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
• Compartment Syndrom
• Compartment Syndrom
• Sposlashrgsmaringl
• Saring er der frokost

Sposlashrgsmaringl

Saring er der frokost

• Specialespecifikt kursus i Traumatologi 2014Tibiaskaft og marvsoslashmningUdredning Implantater Behandling Problemer Tipsrsquo n Tricks
• Afgraelignsning
• Maringl med behandlingen
• Case 1
• Case 2
• Case 1 + 2
• Case 1+2
• Operativ eller konservativ behandling
• Indikation
• Indikation
• Implantater
• Typiske sposlashrgsmaringl ndash og problemer
• Typiske sposlashrgsmaringl ndash og problemer
• Lejring og placering af gennemlyser
• Reponering
• Slide Number 16
• Slide Number 17
• Soslashm - biomekanik
• Isaeligttelse af soslashmmet
• Slide Number 20
• Kompression over frakturen
• Kompression ndash primaeligr eller sekundaeligr
• Reposition af distale frakturer
• Skal fibula osteosynteres
• Skal fibula osteosynteres
• Skal bagkanten osteosynteres
• Skal bagkanten osteosynteres
• Proximale tibia amp marvsoslashmning
• Postoperativ regime
• Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
• Compartment Syndrom
• Compartment Syndrom
• Sposlashrgsmaringl
• Saring er der frokost

Saring er der frokost

• Specialespecifikt kursus i Traumatologi 2014Tibiaskaft og marvsoslashmningUdredning Implantater Behandling Problemer Tipsrsquo n Tricks
• Afgraelignsning
• Maringl med behandlingen
• Case 1
• Case 2
• Case 1 + 2
• Case 1+2
• Operativ eller konservativ behandling
• Indikation
• Indikation
• Implantater
• Typiske sposlashrgsmaringl ndash og problemer
• Typiske sposlashrgsmaringl ndash og problemer
• Lejring og placering af gennemlyser
• Reponering
• Slide Number 16
• Slide Number 17
• Soslashm - biomekanik
• Isaeligttelse af soslashmmet
• Slide Number 20
• Kompression over frakturen
• Kompression ndash primaeligr eller sekundaeligr
• Reposition af distale frakturer
• Skal fibula osteosynteres
• Skal fibula osteosynteres
• Skal bagkanten osteosynteres
• Skal bagkanten osteosynteres
• Proximale tibia amp marvsoslashmning
• Postoperativ regime
• Compartment Syndrom - er det bare rdquoPeter og Ulvenrdquo
• Compartment Syndrom
• Compartment Syndrom
• Sposlashrgsmaringl
• Saring er der frokost