DR.

KANWAL ARSHAD,PT
AS S I S T AN T P R O F E S S O R , U I P T , U O L

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
Dr. Kanwal Arshad, Assistant
Professor, Uipt, Uol
Dr. Kanwal Arshad, Assistant
Professor, Uipt, Uol
APPLIED BIOMECHANICS

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
 Introduction to the
Biomechanics of Fracture
Fixation

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
 FLASHBACK

• BASIC TERMINOLOGY
• KINEMATIC CONCEPTS FOR ANALYZING
HUMAN MOTION

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
• BIOMECHANICS OF HUMAN BONE AND MUSCLES
• BIOMECHANICS OF THE HUMAN UPPER EXTREMITY
• BIOMECHANICS OF HUMAN LOWER EXTREMITY

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
INTRODUCTION TO THE BIOMECHANICS
OF FRACTURE FIXATION

OBJECTIVES:
o Different factors effecting fracture fixation and bone healing.
o Theories on Fracture stability and bone healing.
o Biomechanical principles of treating fractures.
o Methods of fixation of fractures and their advantages and
disadvantages
o Post operative care and weight bearing considerations
o Mechanical consideration such as type and magnitude of
force to which
fixation will be subjected
o The energy involved in original injury and amount of soft tissue
damage
Dr. Kanwal Arshad, Assistant
Professor, Uipt, Uol
 BIOMECHANICS OF FRACTURE
FIXATION

• Factors
1. Fracture stability
o Age
o Site
o Type
o Soft tissue involvement

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
 1. Bone Healing
• Hematoma
• Inflammation
• Callus
• Woven Bone
• Remodelling
• Techniques and devices
o Conservative(Traction,Cast,Braces)
o Surgical(External fixation,ORIF open reduction internal fixation)

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
 THEORIES ABOUT HEALING

Rigid fixation v/s micromotion

Micro motion biological repair process

Load bearing V/S load shearing

Localized osseous bone resorption as a result unloading of bone

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
FIXATION DEVICES AND METHODS

Goals of Fracture treatment

o Rapid healing
o Prevention of deformity and shortening
o Restoring at previous level of function
o Treat the Patient, not only the fracture

Main obj’s = REDUCE! HOLD! EXERCISE!

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
• Dual Conflict
• Hold vs Move
• Speed vs Safety Speed Hold

Move Safety

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
 CLOSED FRACTURES

REDUCTION
• No undue delay in attending to the fracture
• Reduction unnecessary when:
– There is little or no displacement
– Displacement does not matter
– Reduction is unlikely to succeed

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
• Aim of reduction
– Adequate apposition
(the positioning of things side by side or close together)
– Normal alignment of the bone fragments
• Methods of reduction
– Manipulation
– Mechanical traction
– Open operation

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
 1.MANIPULATION

• Closed manipulation is suitable for

1. All minimally displaced fractures
2. Most fractures in children
3. Fractures that are likely to be stable after reduction

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
• Unstable fractures are sometimes reduced ‘closed’
prior to mechanical fixation
• Three fold maneuver: under anesthesia and muscle
relaxation
1. The distal part of the limb is pulled in the line of the bone
2. The fragments are repositioned as they disengage
3. Alignment is adjusted in each plane

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
Dr. Kanwal Arshad, Assistant
Professor, Uipt, Uol
 2.MECHANICAL TRACTION

• Some fractures are difficult to reduce by

manipulation
• They can often be reduced by sustained
mechanical traction, which then serves also to hold
the fracture until it starts to unite
• In some cases, rapid mechanical traction is applied
prior to internal fixation

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
 3.OPEN OPERATION

• Operative reduction under direct vision is indicated:

1. When closed reduction fails
2. When there is a large articular fragment that
needs accurate positioning
3. For avulsion fractures in which the fragments are
held apart by muscle pull

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
1. When an operation is needed for associated
injuries
2. When a fracture will anyhow need internal fixation
to hold it

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
 HOLD

• Restriction of movement
– Prevention of displacement
– Alleviation of pain
– Promote soft-tissue healing
– Try to allow free movement of the unaffected parts
• Splint the fracture, not the entire limb

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
• Methods of holding reduction:
– Sustained traction
– Cast splintage
– Functional bracing
– Internal fixation
– External fixation
• Closed vs. operative methods

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
 1.SUSTAINED TRACTION

• Traction is applied to the limb distal to the fracture, so

as to exert a continuous pull in the long axis of the
bone
• In most cases a counterforce will be needed
• Particularly useful for spiral fractures of long-bone
shafts, which are easily displaced by muscle
contraction

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
• The “hold” is not perfect, but it is “safe” and the
patient can “move” the joints and exercise the
muscles.
• The problem is the lack of “speed”complications

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
• Traction by gravity
• Eg. Fractures of the humerus
• Balanced Traction
• Skin traction: adhesive strapping kept in place by
bandages
• Skeletal traction: stiff wire/pin inserted through the bone
distal to the fracture

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
 CAST SPLINTAGE

• Plaster of Paris: still used as splint, esp for distal limb

fractures and for most children’s fractures
• “safe” (not applied too tightly or unevenly)
• “speed” of union same as traction, but pt goes home
sooner
• “holding” is not a problem, and patients with tibial
fractures can bear weight on the cast

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
• Big drawback is that joints encased in plaster
cannot “move” and are liable to stiffen. This
complication can be minimized by:
1. Delayed splintage- using traction until movement has
been regained, and then applying plaster
2. Starting with a cast but after a few weeks replacing it by
a functional brace which permits joint movement

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
• Complications of cast splintage
– Liable to appear once the patient has left the hospital;
added risk of delay before the problem is attended to
1. Tight cast
2. Pressure sores
3. Skin abrasion or laceration
4. Loose cast

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
 3.FUNCTIONAL BRACE

• Prevents joint stiffness while still permitting fracture

splintage and loading
• Most commonly for fractures of the femur or tibia
• Since its not very rigid, it is usually applied only when
the fracture is beginning to unite
• Comes out well on all four of the basic requirements: “hold”
“move” “speed” “safe”

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
Dr. Kanwal Arshad, Assistant
Professor, Uipt, Uol
 4.INTERNAL FIXATION

• “holds” securely with precise reduction

• “movements” can begin at once (no stiffness and
edema)
• “speed”: patient can leave hospital as soon as
wound is healed, but full weight bearing is unsafe
for some time
• “safety”= biggest problem! SEPSIS!!!
– Risk depends on: the patient, the surgeon, the facilities

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
• Indications for internal fixation
1. Fractures that cannot be reduced except by operation
2. Fractures that are inherently unstable and prone to re-
displacement after reduction
3. Fractures that unite poorly and slowly

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
1. Pathological fractures
2. Multiple fractures
3. Fractures in patients who present severe nursing difficulties

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
1. Interfragmentary/Lag 2. Kirschner Wires
Screws: o Hold fragments together where
o Fixing small fracture healing is predictably
fragments onto the quick
main bone

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
3. Plates and screws 4. Intramedullary nails
o Metaphyseal o Long bones
fractures of long o Locking screwsresist rotational forces
bones o T
o Diaphyseal
fractures of the
radius and ulna

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
Dr. Kanwal Arshad, Assistant
Professor, Uipt, Uol
Dr. Kanwal Arshad, Assistant
Professor, Uipt, Uol
ANY QUESTION???

Dr. Kanwal Arshad, Assistant

Professor, Uipt, Uol
Dr. Kanwal Arshad, Assistant
Professor, Uipt, Uol