Category Archives: Fracture Treatment

You Can Now Get Waterproof Casts

by AquaCast Liner

When you have a cast, it can make everyday tasks difficult and time consuming. Something that used to be simple, like taking a shower or bath, now becomes complicated and involves serious maneuvering to try to keep the cast dry. Now, there are options for casts to be waterproofed, eliminating the need to cover the cast while being around water as explained in this article.

Benefits of a Waterproof Cast

  • Makes bathing easier, facilitating better hygiene
  • Allows for participation in water sports
  • Reduces the odor of a traditional cast
  • Provides kids with a way to maintain their normal routine

Great for Young Children, Adults, and Seniors

Waterproof casts for children work well for those who are too young to understand the importance of keeping their cast dry. It also helps give parents peace of mind that you don’t have to constantly be beside your child when they are near water. Showering or bathing with a cast is very frustrating if you have to work around the cast to keep it dry.  Waterproof cast padding minimizes the lifestyle changes for anyone with a broken bone.  Vocations that require frequent hand washing, from restaurant servers to auto mechanics, can continue to maintain their hygiene even with a cast.  Seniors benefit from independence that may have been limited with a broken bone or cast. They need less help around the house to do simple tasks such as washing the dishes or taking a shower without a slippery plastic bag over one of their limbs.

Gives Older Kids More Independence

If you have a child who is old enough to bathe alone under normal circumstances, they’ll probably prefer to continue that practice, even while wearing a cast. The waterproof cast allows children the privacy they want while bathing or showering. Being able to continue with normal activities helps to lessen the burden felt when wearing a cast or the need to ask for help.

Warm Weather Fun

Having a cast during warm weather can be very disheartening for anyone who enjoys playing in the water or who is active in spring and summer sports. Swimming with a cast is nearly impossible as you can’t immerse a traditional cast in water due to damaging the cast padding or liner. Wearing a cast can put a damper on your family’s summer vacation if someone cannot play in the ocean or get in the pool. Being active in sports also is tough to do with a traditional cast as many wearers and family members of wearers want to keep the cast from getting sweaty and smelly. A waterproof cast allows more freedom with sports and extra-curricular activities during the warmer months.

Keep Life Easy with a Waterproof Cast

Waterproof casts can make life easier for everyone in the home. Paitents are able to better maintain their regular routine, while also keeping some independence. Showering, taking a bath or even washing ones hands and face with a traditional cast can prove to be a task that requires a lot of assistance from a parent to ensure the cast remains dry. Trying to wrap a cast to prevent water seepage is time consuming and not something kids or parents want to deal with. Swimming with a cast is also possible with a waterproof cast, so that a broken bone does not mean you have to miss out on summer fun.

Please click on AquaCast® Liner for information about waterproof cast liners.

 

The Quest for Flexible Fixation with Locking Plates

By Michael Bottlang, PhD, Director, Legacy Biometrics Laboratory

Tuesday, January 4th, 2011

A 2004 editorial entitled ‘‘When Evolution Begets Revolution’’ described locking plates as the next great advance in orthopaedic traumatology that was adopted at an unprecedented speed [1]. The editorial concluded with the prudent prediction that ‘‘this wave of enthusiasm will surely be followed with an analysis of the inherent problems, followed by a truer understanding of the role of these implants.” Today, locking plates are recognized for the superior fixation strength of fixed-angle locking screws, particularly for metaphyseal fixation in osteoporotic bone. They furthermore support biological fixation, allowing subcutaneous plating while preserving periosteal perfusion. Hence, they satisfy two out of three principal aspects of fracture fixation, being stable fixation, preservation of biology, and promotion of fracture healing.

The latter aspect of fracture healing is increasingly being recognized as an inherent problem of the current generation of locking plates. If locking plates do not provide a mechanical environment that promotes fracture healing, they become prone to losing the race between healing and fixation failure, leading to late implant breakage and loss of fixation. There is growing evidence from clinical and animal studies that the inherent stiffness of a locked plating construct can suppresses fracture motion to a level that is insufficient to promote fracture healing by callus formation [2-4].

With hindsight, locked bridge plating constructs pose an apparent conundrum: They provide inherently rigid stabilization, yet they should facilitate secondary bone healing that relies on flexible fixation to stimulate callus formation. To resolve this conundrum, we developed a modified locked plating concept, termed Far Cortical Locking (FCL) that enables flexible fixation with locking plates [4,5]. FCL reduces the stiffness of a locked plating construct by means of FCL screws that are fixed in the plate and in the far cortex while retaining a controlled motion envelope in the near cortex of a diaphysis. FCL screws have a flexible shaft with a reduced diameter that can elastically deflect within the near cortex motion envelope. The motion envelope is controlled by the diameter of a collar segment adjacent to the FCL screw head. FCL constructs therefore resemble a monolateral external fixator, the bar of which has been applied close to the bone surface and the pins of which are secured in the far cortex rather than in the near cortex.

A biomechanical study has shown that FCL screws reduce the stiffness of locked plating construct by over 80% while retaining comparable strength [5]. An in vivo study has furthermore shown that FCL constructs reliably yielded bridging of all cortices, causing healed fractures to be 156% stronger than control fractures stabilized with standard locked plating constructs [4]. Most interestingly, standard locked constructs suppressed fracture healing at the cortex under the plate where fracture motion is minimal. A clinical study is currently being conducted to document the effect of FCL screws on healing of supracondylar femur fractures.

The facts that controlled interfragmentary motion can promote fracture healing while absence of motion will suppress callus formation have long been recognized in the external fixator literature, particularly by the landmark studies of Goodship and Kenwright [6] and Claes [7]. As such, the evolution of locked plating towards more flexible fixation is both novel and conservative. If clinical results should support the prior finding on improved healing with FCL, they will likely inspire a variety of implant solutions aimed at providing flexible fixation with locking plates. These solutions will be key for the quest on flexible fixation with locking plates. However, solutions should be supported by evidence on their ability to promote fracture healing while ensuring that flexible fixation is not gained on cost of fixation strength. Such next generation of flexible locking plates will resemble true internal fixators that replicate the biomechanical behavior of external fixators by allowing adequate interfragmentary motion to promote the natural fracture healing cascade via callus formation. It is the hope of the author that this evolution will in turn resolve the misnomer “secondary” bone healing by recognizing the prime importance of this natural healing cascade for the vast majority of fractures.

Dr. Bottlang is the Director of the Legacy Biomechanics Laboratory in Portland, OR, USA. His research is focused on orthopaedic trauma and fracture care. His line of research on FCL was funded by the NIH and has received the Award of Excellence at the 2010 meeting of the American Association of Orthopaedic Surgeons. He holds several patents and has contributed to the development of several devices, including Zimmer “MotionLoc” FCL screws for which he receives royalties.

Note:  Listings of the MotionLoc FCL screws and the NCB Polyaxial Plate can be found on OrthopaedicLIST.com and x-ray examples of plate and screw fixation of fractures can be seen in the OrthopaedicLIST.com Implant Identification section.

[1] Sanders R. When evolution begets revolution. J Orthop Trauma. 2004;18:481-482.

[2] Henderson CE, Bottlang M, Marsh JL, Fitzpatrick DC, Madey SM. Does locked plating of periprosthetic supracondylar femur fractures promote bone healing by callus formation? Iowa Orthop J. 2008;28:73-6.

[3] Lujan TJ, Henderson CE, Madey SM, Fitzpatrick DC, Marsh JL, Bottlang M. Locked plating of distal femur fractures leads to inconsistent and asymmetric callus formation. J Orthop Trauma. 2010;24-3:156-62.

[4]  Bottlang M, Lesser M, Koerber J, Doornink J, von Rechenberg B, Augat P, Fitzpatrick DC, Madey SM, Marsh JL. Far cortical locking can improve healing of fractures stabilized with locking plates. The Journal of bone and joint surgery. 2010;92:1652-1660.

[5] Bottlang M, Doornink J, Fitzpatrick DC, Madey SM. Far Cortical Locking can reduce the stiffness of locked plating constructs while retaining construct strength. J Bone and Joint Surg. 2009; 91(8):1985-1994.

[6] Goodship AE, Kenwright J. The influence of induced micromovement upon the healing of experimental tibial fractures. J Bone Joint Surg Br. 1985;67-4:650-5.

[7] Claes LE, Wilke HJ, Augat P, Rubenacker S, Margevicius KJ. Effect of dynamization on gap healing of diaphyseal fractures under external fixation. Clin Biomech (Bristol, Avon) 1995;10-5:227-34.

A Triumph of Matter over Mind

by Augusto Sarmiento, MD

January 25th, 2014 

The current pervasive and misguided infatuation with the idea that in the care of fractures it is indispensable to achieve perfect restoration of anatomy in all instances in order to obtain good clinical results continues to blind many in our profession. I have previously made reference to this obsession suggesting that we train our residents to be cosmetic surgeons of the skeleton rather than physicians/scientists1.

My belief that Orthopaedics is losing its scientific primacy and rapidly becoming an entirely technical discipline was reinforced a short time ago when I learned of a clinical situation where passion prevailed over reason with very likely adverse serious consequences.

The clinical case consisted of a 21 year old man who was involved in automobile accident rendering him paraplegic. In addition he had suffered bilateral comminuted, distal intraarticular fracture of both forearms. The fractures were treated by means of internal fixation using plates and screws as well as multiple pins that held together the diligently repositioned small fragment. Radiographs obtained following surgery demonstrating excellent reduction of the fractures.

For reasons not known to me, the surgeon chose to improve upon the fixation achieved from the plates and screws by placing on the dorsum of the patient’s right arm a long plate that extended from the neck of the third metacarpal to the mid-radius. Several screws filled the holes in the long plate. This plate, I was told, would be removed six weeks after surgery; therefore I assumed it was not intended to encourage fusion of the wrist.

I cannot express strong disagreement with the procedure performed for the care of the radius fractures that must have taken a great deal of time plus the likely possibility that the extensive dissection of the bony fragments could result in major stiffness of his wrists joints. After all this is the current party line. However, I cannot help but question the wisdom of inserting a plate that inevitably will increase the degree of limitation of motion of the wrist from which the patient will never completely recovered.

This very realistic scenario provokes an even greater discomfiture when one realizes that the young man was paraplegic and will remain paraplegic for the rest of his days. As such, his only mode of locomotion will be a wheel chair, from which he will transfer to his bed and automobiles. A bit of thought should have made the surgeon aware that transfer activities from a wheel chair require a significant degree of dorsiflexion of the wrists. In order to lift one’s body with the use of the hands, dorsiflexion of the wrists is essential. The young man, I anticipate, will not be able to do so, and if he masters s technique to accomplish the task it will be a very complicated and difficult one.

I have surmised that the surgeon performing the surgery was very likely a technically skillful one, but either because of his blind reliance on the virtues of internal fixation and perfect reapproximation of fragments, or lack of objectivity, he has condemned a young man to a disability greater than the one that the paraplegia had already imposed on him.2. It does not suffice to adhere to the aphorism expressed by Simon Bolivar, the Latin American liberator, “Good judgment comes from experience and experience comes from bad judgment”, at least not when we are dealing with the health and future of other human beings.

The rampant lack of objectivity, clearly demonstrated in this instance, can be improved if we, the educators, emphasize objective reasoning to our students. Unharnessed enthusiasm and fascination with surgical experiences must be tempered with reason. “La raison avant la passion”.

REFERENCES:

1.   Sarmiento A. The future of our specialty. Acta Orthopedica Scandinavica. 71 (6): 574-579, 2000

2.   Sarmiento A. Have we lost Objectivity?  Jour. Bone and Joint Surgery. Vol. 84A:  1254-58, 2002.

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on OrthopaedicList.com and has guest authored a number of other articles for this blog.

Reflections on Fracture Healing and Care

by Augusto Sarmiento, MD

Fifty-five years after completion of my residency I have finally stopped working at the University and Hospital. It was a painful decision, precipitated by the deteriorating health of my wife.  We ended up leaving Miami and moving to Punta Gorda, a small community in Southwest Florida. Only four months have passed since my new life began, so I hope additional time will assuage the profound unhappiness I now experience from not being able to teach orthopaedic residents.

Trying to identify topics that I could dwell on with some confidence and share with my colleagues, I quickly ran into fracture healing and care, because since the early 1960’s I worked on these subjects with great enthusiasm and perseverance. I first published my initial work on what I considered the positive role that motion plays in fracture healing. The concept was severely criticized in orthopaedic/scientific circles as being anathema to well-established principles.  At that time, the AO, a powerful scientific/commercial organization, was making rapid advances in marketing the use of surgical appliances aimed at obtaining rigid immobilization of fracture fragments, which they considered to provide the best and most expeditious environment for healing.

More than one hundred publications from our laboratories and clinics at the Universities of Miami and Southern California have solidified my firm belief that diaphyseal fractures rather consistently heal, not because they are rigidly immobilized  but despite the immobilization. Rigid immobilization deprives the injured bone from the stresses that every tissue in the body must be subjected in order to maintain desirable biological and mechanical properties.

Following the initial injury there is bleeding at the fracture site, a phenomenon that has led some to mistakenly believe that the hematoma plays a role in osteogenesis. However, there is nothing to support such a mythological idea. Quite the contrary, it is likely that the hematoma is an obstacle to healing and must be gradually absorbed. If that were not the case, we should be injecting blood into fractures in order to enhance healing.

When a fracture is not rigidly immobilized and the injured limb is subjected to the gradual stresses that come from the gradual introduction of muscle activity, as well as motion of the extremity, a massive capillary invasion at the level of the fracture takes place. (Figs.   1.a. & b.).

Fig. 1.a. Massive capillary Invasion

Fig. 1.a. Massive capillary invasion when the fracture is not rigidly immobilized.

Fig. 1b) When the fracture is rigidly immobilized the capillary invasion does not take place. The medullary circulation is rapidly restored.

Fig. 1.b.) When the fracture is rigidly immobilized the capillary invasion does not take place. The medullary circulation is rapidly restored.

 This vascular phenomenon is the single most important one in the process of fracture repair because the perithelial and endothelial cells of the capillaries undergo osteoblastic metaplasia and form peripheral callus.(Figs. 2.a. & 2.b.).

Fig. 2.a.

Fig. 2.a.

Fig. 2.b.

Fig. 2.b.

In the rigidly immobilized fracture the healing occurs from growth of osteons but without peripheral callus.  Mechanically, the strength of a callus is measured by the diameter of the callus.

The next related important observation is the fact that in fractures of both bones in the lower leg and forearm the initial shortening experienced does not increase with the gradual introduction of weight bearing activities. The interosseous membrane, an elastic structure, prevents the increase in shortening while still permitting elastic pistoning. (Fig. 3a and 3b). Needless to say, fractures with extensive damage to the membrane experience greater shortening and lack the benefits of acceptable of the initial shortening or the maintenance of manually corrected length.

Fig. 3.a.

Fig. 3.a.

Fig. 3.b.

Fig. 3.b.

I am not aware of any work that has negated the validity of the observations I have just made. Furthermore, I am keenly aware of the many advantages that surgical stabilization possesses, which explains the fact that despite its biological negative features, it is taught to current generations of orthopaedists as the only sound approach to fracture management. A logical balance between the two opposing schools is necessary since there is a place for both of them. Economic considerations should not be ignored.

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on OrthopaedicList.com and has guest authored a number of other articles for this blog.