Intramedullary osteosynthesis. Bony osteosynthesis of tibial diaphysis fractures according to AO Variants of operations on the upper extremities

Not every person will understand the meaning of the expression “osteosynthesis of a bone” and what it actually is. Some even become afraid when a specialist doctor prescribes this procedure for them. Panic and fear immediately arise... And it all comes from simple ignorance. This article will help you deal with this difficulty.
Osteosynthesis is a surgical operation prescribed for various bone fractures (often limbs). Its essence is that the broken bone is fixed with various fixing structures (knitting needles, bolts or plates made of metal) to ensure its long-term immobility. The goal of this procedure is to align all bone fragments in the correct position while maintaining functional mobility of the area of ​​the limb, and to provide rest and immobility until the bone heals completely.
There are several types of bone osteosynthesis:
- External transosseous compression-distraction - in other words, the fracture site is fixed with knitting needles. This allows you to use the limb as before, with full load, and does not require the application of a cast;
- Submersible - insertion of a fixator directly into the fracture zone. This is necessary in some cases. It also does not require the application of a cast, however, it will no longer be possible to fully use the limb without experiencing discomfort;
- Intraosseous - as the name says. The rod or fixator is inserted into the bone. With it, most likely you will no longer be able to use the limb at all until the fracture is completely healed, or, when using the limb, you will feel pain and discomfort. However, doctors advise providing the damaged area of ​​the body with complete rest and immobility;
- On the bone - just like the previous one, this is an internal operation. With it, the fixator is placed near or around the damaged bone;
- Transosseous - fixators (rods are most often used) are passed directly through the bone, i.e. across it.
Osteosynthesis is prescribed for severe cases of comminuted bone fractures, internal (closed) fractures, external (open) fractures, and osteoporosis.
The main thing is, in case of a fracture, immediately consult a doctor, and not self-medicate or think that “it will heal on its own.” This can lead to rather disastrous consequences for a person who is indifferent to his health (up to and including disability or various inflammatory diseases, in which, if they are common and pose a threat to the entire body, simply amputation of a limb is most often prescribed).
Let's consider this procedure using the example of a tibia fracture.
The operation itself takes place under anesthesia, i.e. you will neither feel anything nor remember what was done to you.
To begin with, the doctor will prescribe you many examinations, the main one of which is x-rays. With its help, the specialist will be able to determine the location, structure and nature of the fracture, which will help him competently prepare for the operation and carry it out correctly.
In itself, a fracture of the tibia is a fairly common case. Most often, it affects older people, but with the development of sports and its various extreme types, young people and even teenagers may encounter a similar problem.
Surgery for a tibia fracture most often involves opening the fracture (in the case of a closed one) and fixing the broken bone using various instruments (knitting needles, bolts and plates).
The operation is performed under anesthesia. Only the preparation for it is painful and unpleasant.
The fracture, after a correctly performed operation, heals within 1-3 months. The speed of healing depends on the physiological characteristics of the patient’s body (age, metabolic rate, etc.).
Fractures are not such a terrible problem that can happen. Main. It’s time to contact a specialist. To avoid improper healing and... Subsequently, disability and other problems with a damaged and improperly treated limb. Therefore, when the doctor prescribes this operation for you, you should not refuse it, because after it the chances of a full recovery really increase significantly.

I always thought that severe fractures were something to consider for older people. At the beginning of February this year, I very unfortunately broke my leg. When I was going by ambulance to the hospital, I thought that they would put a cast on me and let me go home, but they told me the terrible word OPERATION. At that moment, I had no idea that everything would be so complicated, painful, difficult and long.

_________________________ Osteosynthesis of the tibia____________________

I think everyone has heard that numerous reforms are currently taking place in the medical system. Some things were done well, some not so much. The Ministry of Health received numerous complaints and outrage. In our city, for example, a maternity hospital was closed. Now women in labor are forced to go to another city, where a modern perinatal center has been built. Expectant mothers reacted very anxiously to this news. But those whose lives were saved thanks to the modern equipment of the new cent are definitely grateful for such changes.

In addition to modern maternity hospitals, modern trauma departments are being built. Unlike the maternity hospital, a trauma center was opened in our city. At the time of the fracture, I had not even heard of its existence.

A modern trauma center is still the same Soviet-style hospital, into which expensive modern equipment was brought in and surgeons were trained to perform operations on it.

We don’t have any of the beauties and amenities shown on TV. A wheelchair is a luxury. We had one chair per room, and it was taken away if it was necessary to take someone for an X-ray. That is, our ward was lucky.

And so, I return to my turning point. They brought me in an ambulance and sent me for an x-ray. The pain was hellish. An x-ray showed that both bones were broken and displaced. The surgeon informed me that I would spend at least 2 weeks in the hospital. He also said that they would now insert a needle into my heel and put me on traction. At that time I didn’t even know what a hood was. But I was terribly afraid that they would put holes in my heel.

I spent 5 days on the hood! And these are our modern centers where patients should spend a minimum of time. To my surprise, the doctors were in no hurry with the operation. I understand everything, they have a queue, plans, etc. But these 5 days were the hardest time of my life for me.

Cost of the operation.

As you know, our medicine is free. But upon admission, I was offered two options: either I do it for free and the rehabilitation period will be long, or I buy imported metal myself, then everything will be much easier and faster.

The purchase of imported metal is carried out according to a very strange scheme. The surgeon examined me and the pictures to determine the size of the necessary pin. He gave me the phone number of some “his” little man through whom I should order this metal myself. I gave money for the metal to this “my little man.” What is the cost of the metal itself - I will never know. I will never know whether the cost includes a protégé from the surgeon and any other expenses. I paid 40,000 rubles for the metal pin and the 4th screw.

The day of the operation was the happiest event for me. during your stay in the hospital. Before the operation, I was given diazepam (a tranquilizer) so that I could sleep and not worry. But I didn’t worry without him. I would never have thought that I would be waiting for the operation like manna from heaven. For me, this event was the end of the torment in the hood.

During osteosynthesis I was given spinal anesthesia. A completely painless procedure. During the operation, I saw, heard, understood and communicated with the doctors, but I didn’t feel anything below the belt. The operation was quite funny. The surgeons were more like mechanics. Their tools are iron, drills, hammers, etc.

During the operation, I was x-rayed several times. X-rays were taken directly on the operating table. The picture was taken digitally and displayed on the monitor. I could see the results of the pictures. Thus, I gradually watched as a pin, as long as the tibia, and four screws appeared in my leg.

After the operation, I returned to the ward the happiest person in the world. The anesthesia was still in effect and I didn’t feel any pain. There was no binding in the hood. I didn't feel sick.

When the anesthesia wore off, the pain returned, but not as sharp as it had been before. I had the opportunity to move around the ward, jumping on my good leg, move on a wheelchair, wash myself, and eat while sitting. So many incredible opportunities have appeared that a healthy person is unlikely to appreciate.

After the operation you are required to stay in the hospital for 12 days. Due to the fact that my discharge date fell on a long weekend, I begged to go home on the ninth day after the operation.

A medical relative removed my stitches on the 12th day after the operation. This procedure is not at all painful, or rather unpleasant.

Painkillers

While I was in the hospital, I was injected with Ketonal twice a day. In the first days after admission, its effect lasted for 1-2 hours, no more. Then I had to wait ten hours until the next injection. In order to somehow exist during this period, I was advised to buy Nise (nimesulide). Nimesulide saved me at home after discharge.

I was given diazepam (a tranquilizer) in the hospital every day before bed until discharge. To be honest, it was scary to drink it; after all, it is a narcotic drug. But there was no withdrawal or dependence on it. As a side effect - dizziness and double vision.

At home, as they say, even the walls heal.

Arriving home, the first few days were psychologically difficult. In the hospital around me there were the same cripples. They brought and took away breakfast, lunch and dinner for us. At home, every once familiar action was given with great difficulty. The main thing is not to feel sorry for yourself at this moment!

Rehabilitation.

During the osteosynthesis operation, I did not spend a day in a cast. Those who were luckier than me with a fracture were given a cast instead of my traction. After the operation, the metal structure works instead of plaster.

For a month after the operation, I moved around by jumping on my healthy leg, which made it very painful, or with the help of crutches. Crutches are another psychological moment that must be experienced. I never wanted to see myself on crutches or with a cane.

At first she moved with the help of two crutches, and then with the help of one. A little more than a month after discharge, I was able to move around at home without support.

In addition to damaged ligaments, muscles and bones at the fracture site, the knee through which the pin was inserted was severely damaged. The knee takes as long to recover as the injured muscles.

After a month and a half, I could go outside for a short walk. It was hard, but I did it myself!

Many people told me that after such a fracture you can forget about heels - don’t believe them!!! It’s even easier for me to walk in heels than without them. By standing on heels, the knee and foot have to make less movements when walking. I even wore stiletto clogs at home.

Two months after surgery, one of the four screws must be removed. Surgeons call it blocking. I went to the hospital on my own feet to have the screw removed. She reached the stop herself, climbed into the minibus and, standing on her feet, walked along with everyone else.

The doctors looked with some surprise at how I was already walking without support and in high heels. Well, how can I explain to them that I wouldn’t have gotten there without heels....

The operation to remove the screw was done quite quickly, 10-15 minutes. Most of this time was spent removing the screw that had grown into the bone. Even after being injected with novocaine, I felt like the surgeon was pressing and trying to unscrew the screw. I didn’t think that in a couple of months it would have time to grow in so firmly. They gave me the screw as a souvenir:

If I easily walked to the hospital on my own feet, it was very difficult to get back out. Again, the features of our miracle medicine. Seeing that I came without crutches, they did not offer me help to get down and get to the taxi. If it weren’t for the effect of novocaine, I would not have gotten home.

I didn’t expect it, but recovery after removing the screw turned out to be quite difficult. I returned to crutches and jumping on my good leg. The leg did not hurt all the time, but only when I stepped on it. The knee and the place from which the screw was removed were very painful. The fracture site began to hurt. As I understand it, after removing the blocking screw, the bones closed closer. Previously, most of the load was on the screw, but now it has shifted more to the bones. The muscles at the site of the fracture seemed to swell and become dense.

If a patient is diagnosed with a dangerous bone fracture, in which separate pieces of hard tissue have formed, he needs to undergo osteosynthesis. This procedure allows you to correctly compare the fragments using special devices and devices, which will ensure that the pieces do not move for a long time. All types of surgical reduction preserve the functionality of movement of the segment axis. The manipulation stabilizes and fixes the damaged area until healing occurs.

Most often, osteosynthesis is used for fractures inside joints, if the integrity of the surface has been compromised, or for damage to long tubular bones or the lower jaw. Before proceeding with such a complex operation, the patient must be carefully examined using a tomograph. This will allow doctors to draw up an accurate treatment plan, choose the optimal method, set of instruments and fixatives.

Types of procedure

Since this is a very complex operation that requires high precision, it is best to carry out the manipulation on the first day after the injury. But this is not always possible, so osteosynthesis can be divided into 2 types, taking into account the time of execution: primary and delayed. The latter type requires more accurate diagnosis, because there are cases of formation of a false joint or improper fusion of bones. In any case, the operation will be performed only after diagnosis and examination. For this purpose, ultrasound, x-ray and computed tomography are used.

The next method of classifying the types of this operation depends on the method of introducing fixing elements. There are only 2 options: submersible and external.

The first is also called internal osteosynthesis. To carry it out, use the following clamps:

• knitting needles;
• pins;
• plates;
• screws.

Intraosseous osteosynthesis is a type of submersible method in which a fixator (nails or pins) is inserted under X-ray control into the bone. Doctors perform closed and open surgery using this technique, which depends on the area and nature of the fracture. Another technique is bone osteosynthesis. This variation makes it possible to connect the bone. Main fasteners:

• rings;
• screws;
• screws;
• wire;
• metal tape.

Transosseous osteosynthesis is prescribed if the fixator needs to be inserted through the wall of the bone tube in the transverse or oblique transverse direction. For this, an orthopedic traumatologist uses knitting needles or screws. The external transosseous method of repositioning fragments is carried out after exposing the fracture zone.

For this operation, doctors use special distraction-compression devices that stably fix the affected area. The fusion option allows the patient to recover faster after surgery and avoid plaster immobilization. Separately, it is worth mentioning the ultrasound procedure. This is a new method of osteosynthesis, which is not yet used so often.

Indications and contraindications

The main indications for this treatment method are not that extensive. Osteosynthesis is prescribed to a patient if, along with a bone fracture, he is diagnosed with pinched soft tissue that is pinched by fragments, or if a major nerve is damaged.

In addition, complex fractures that are beyond the power of a traumatologist are treated surgically. Typically these are injuries to the femoral neck, olecranon or displaced patella. A separate type is considered a closed fracture, which can turn into an open one due to perforation of the skin.

Osteosynthesis is also indicated for pseudarthrosis, as well as if the patient’s bone fragments have separated after a previous operation or they have not healed (slow recovery). The procedure is prescribed if the patient cannot undergo a closed operation. Surgical intervention is performed for injuries to the collarbone, joints, lower leg, hip, and spine.

1. Contraindications for such manipulation consist of several points.
2. For example, this procedure is not used when an infection is introduced into the affected area.
3. If a person has an open fracture, but the area is too large, osteosynthesis is not prescribed.
4. You should not resort to such an operation if the patient’s general condition is unsatisfactory.

• venous insufficiency of the extremities;
• systemic hard tissue disease;
• dangerous pathologies of internal organs.

Briefly about innovative methods

Modern medicine differs significantly from earlier methods due to minimally invasive osteosynthesis. This technique makes it possible to fuse fragments using small skin incisions, and doctors are able to perform both extraosseous and intraosseous surgery. This treatment option has a beneficial effect on the fusion process, after which the patient no longer needs cosmetic surgery.

A variation of this method is BIOS - intramedullary blocking osteosynthesis. It is used in the treatment of fractures of tubular bones of the extremities. All operations are monitored using an x-ray installation. The doctor makes a small incision 5 cm long. A special rod, made of titanium alloy or medical steel, is inserted into the medullary canal. It is fixed with screws, for which the specialist makes several punctures (about 1 cm) on the surface of the skin.

The essence of this method is to transfer part of the load from the damaged bone to the rod inside it. Since during the procedure there is no need to open the fracture zone, healing occurs much faster, because doctors are able to maintain the integrity of the blood supply system. After the operation, the patient is not put in plaster, so the recovery time is minimal.

There are extramedullary and intramedullary osteosynthesis. The first option involves the use of external devices of a spoke design, as well as the combination of fragments using screws and plates. The second allows you to fix the affected area using rods that are inserted into the medullary canal.

Femur

Such fractures are considered extremely serious and are most often diagnosed in older people. There are 3 types of femur fractures:

• at the top;
• in the lower part;
• femoral diaphysis

In the first case, the operation is performed if the patient’s general condition is satisfactory and he does not have impacted injuries to the femoral neck. Typically, surgery is performed on the third day after injury. Osteosynthesis of the femur requires the use of the following instruments:

• three-bladed nail;
• cannulated screw;
• L-shaped plate.

Before the operation, the patient will undergo skeletal traction and an x-ray. During the reposition, doctors will accurately compare the bone fragments, and then fix them with the necessary instrument. The technique for treating a midline fracture of this bone requires the use of a three-bladed nail.

In type 2 fractures, surgery is scheduled on the 6th day after the injury, but before that the patient must undergo skeletal traction. For fusion, doctors use rods and plates, devices that will fix the affected area externally. Features of the procedure: it is strictly forbidden to perform it on patients in serious condition. If fragments of hard tissue can injure the hip, they should be immediately immobilized. This usually occurs with combined or fragmented injuries.

After such a procedure, the patient is faced with the question of whether it is necessary to remove the plate, because this is another stress for the body. Such an operation is urgently necessary, if fusion does not occur, its conflict with any joint structure is diagnosed, which causes contracture of the latter.

Removal of metal structures is indicated if the patient had a fixator installed during surgery, which over time developed metallosis (corrosion).

Other factors for plate removal surgery:

• infectious process;
• migration or fracture of metal structures;
• planned step-by-step removal as part of recovery (the stage is included in the entire course of treatment);
• playing sports;
• cosmetic procedure to remove a scar;
• osteoporosis.

Options for upper limb surgery

The operation is performed for fractures of the bones of the extremities, so the procedure is often prescribed to fuse the hard tissues of the arm, leg, and hip. Osteosynthesis of the humerus can be performed using the Demyanov method, using compression plates, or Tkachenko, Kaplan-Antonov fixators, but with removable contractors. Manipulation is prescribed for fractures on the diaphysis of the humerus if conservative therapy is not successful.

Another surgical option involves treatment with a pin, which must be inserted through the proximal fragment. To do this, the doctor will have to expose the broken bone in the damaged area, find the tubercle and cut the skin over it. After this, an awl is used to make a hole through which the rod is driven into the medullary cavity. The fragments will need to be accurately compared and the inserted element advanced to the full length. The same manipulation can be performed through the distal piece of bone.

If a patient is diagnosed with an intra-articular fracture of the olecranon, it is best to undergo surgery to install metal structures. The procedure is performed immediately after the injury. Osteosynthesis of the olecranon requires fixation of the fragments, but before this manipulation the physician will need to completely eliminate the displacement. The patient wears the cast for 4 weeks or more, as this area is difficult to treat.

One of the most popular methods of osteosynthesis is Weber fusion. To do this, the specialist uses a titanium knitting needle (2 pieces) and wire, from which a special loop is made. But in most cases, the mobility of the limb will be permanently limited.

Lower limb

Separately, we should consider various fractures of the dyphyseal bones of the leg. Most often, patients come to a traumatologist with problems of the tibia. It is the largest and most important for the normal functioning of the lower limb. Previously, doctors carried out long-term treatment using plaster and skeletal traction, but this technology is ineffective, so now they use more stable methods.

Osteosynthesis of the tibia is a procedure that reduces rehabilitation time and is a minimally invasive option. In the event of a fracture of the diaphysis, the specialist will install a locking rod, and treat intra-articular damage by inserting a plate. External fixation devices are used to heal open fractures.

Ankle osteosynthesis is indicated in the presence of a large number of comminuted, helical, rotational, avulsion or comminuted fractures. The operation requires a mandatory preliminary X-ray, and sometimes a tomography and MRI are needed. The closed type of injury is fused using an Ilizarov apparatus and needles are inserted into the damaged area. In case of foot fractures (usually the metatarsal bones are affected), the fragments are fixed using the intramedullary method with the introduction of thin pins. In addition, the physician will apply a plaster cast to the damaged area, which should be worn for 2 months.

Patient rehabilitation

After the operation, you need to carefully monitor your well-being and, at the slightest negative symptoms, contact a specialist (acute pain, swelling or fever). These symptoms are normal in the first few days, but they should not appear until several weeks after the procedure.

Other complications after surgery that require urgent medical consultation:

• arthritis;
• fat embolism;
• osteomyelitis;
• gas gangrene;
• suppuration.

Rehabilitation is a significant stage of the entire course of therapy. To prevent the muscles from atrophying and blood to flow into the damaged area, you should start doing physical therapy on time, which is prescribed the day after surgery.

After a week, the patient will need to begin to move actively, but in case of a fracture of the lower limb, he must use crutches.