Osteosynthesis is the surgical fixation of bone fragments using screws, metal plates, wires, and nails. Two procedures are distinguished: Compression involves fixation of bone fragments using static lag screws or dynamic tension strapping. Compressive forces are applied to the bone fragments so that the fragments can grow back together optimally. The splinting method, on the other hand, allows both extramedullary and intramedullary (outside or inside the bone marrow, respectively) treatment by means of plates or so-called intramedullary nails that hold the bone fragments in their physiological position. The following text Osteosynthesis for Fractures of the Arm provides a summary overview of indications, treatment options, complications, and contraindications (contraindications).
Indications (areas of application)
- Fracture of the proximal humerus at the greater or lesser tuberosity (greater or lesser humeral tuberosity).
- Supracondylar humerus fracture – fracture of the humerus just above the elbow joint.
- Ulna fracture or radius fracture – fracture of the shaft of the forearm or forearm shaft.
- Ulna fracture or radius fracture near the joint or intracondylar (within the joint).
- Ulna fracture or radius fracture with dislocation of the other bone in the elbow or wrist respectively.
Contraindications
- Prolonged blood clotting – Taking substances that result in prolonged blood clotting may need to be stopped before surgery.
- Severe systemic disease that makes survival after surgery unlikely.
Before surgery
- Because the procedure is an invasive surgical intervention, optimal preparation of the patient is necessary. This includes taking a medication history. Of particular importance is the group of anticoagulants (anticoagulants) such as acetylsalicylic acid (ASA) or clopidogrel, which would significantly prolong the bleeding time. Discontinuation of such substances must be done only on medical advice.
- Comprehensive laboratory diagnostics are performed in preparation for surgery. This includes a blood count and other laboratory parameters (coagulation parameters: e.g. Quick value or INR (International Normalized Ratio) and the partial thromboplastin time (PTT, aPPT), liver enzymes such as AST (formerly GOT) and ALT (formerly GOT), LDH, inflammation parameters such as CRP (C-reactive protein) and many more) are determined.
- Anamnestically, drug allergies and allergies to surgical materials should be excluded if possible.
- From an infectiological point of view, it is considered particularly important that the patient’s length of stay in the hospital before surgery is as short as possible, so as to minimize the risk of nosocomial infection (infection by hospital pathogens).
The surgical procedures
Osteosynthesis is a surgical procedure that replaces conservative treatment using casts and splints. The procedure is performed under general anesthesia (general anesthesia) or regional local anesthesia (usually as brachial plexus anesthesia – brachial plexus). Different methods of osteosynthesis are used depending on the type of fracture:
- Intramedullary nailing – insertion of metal nails or rods into the bone marrow canal to fix the fracture.
- Wiring, plating, and screwing – fragment fixation using wires (e.g., Kirschner wire), metal plates, and metal screws
- External fixator – bridging of the bone fracture with an external metal frame anchored to or in the bone with metal rods on both sides of the fracture site
- Intramedullary splinting of the bone by inserting wires into the medullary canal of the bone
After surgery
After surgery, the patient as well as the surgical area is closely monitored, here special attention is paid to edema (swelling), hematoma (bruising) and infection. Following the operation, controlled administration of analgesic (pain-relieving) substances takes place immediately. Furthermore, the risk of thrombosis should be reduced with medication (thrombosis prophylaxis) to prevent subsequent complications such as pulmonary embolism. After the hospitalization period, rehabilitation measures should be carried out directly.The operated bone can be fully loaded again after eight to ten weeks at the earliest. The inserted screws, plates and nails can be removed after about 12 to 18 months; in isolated cases, the metal may remain in the body.
Possible complications
- Injury to soft tissue (musculature, tendons) or hemorrhage and swelling of soft tissue (compartment syndrome: condition in which increased tissue pressure leads to a reduction in tissue perfusion when the skin and soft tissue mantle is closed; this causes neuromuscular dysfunction and, possibly, tissue and organ damage)
- Injury to blood vessels with bleeding complications or subsequent circulatory disorders.
- Injury to nerves with permanent damage (paralysis, numbness, insensitivity) or pressure damage (e.g., due to splints).
- Injury to healthy bone parts (e.g., injury to adjacent joints).
- Syringe abscesses
- Pressure damage to skin and soft tissues despite proper patient positioning
- Skin damage due to disinfectant/electrical current.
- Allergic reactions to medications (skin redness, itching, swelling, nausea (nausea), dyspnea (shortness of breath), convulsions, cardiovascular problems)
- Hematoma (bruising)/postoperative bleeding.
- Infections in the surgical area (e.g. osteomyelitis – bone marrow inflammation).
- Formation of pseudarthrosis (false joint formation; refers to the failure of a fracture to heal).
- Thromboembolism (formation of a blood clot that can be carried to the lungs and brain) or bone marrow/fat embolism.
- Delayed bone healing
- Migration of wires with indication for their removal.
- Metal incompatibilities
- Bone misalignments (axis and rotation misalignments and length discrepancies).
- Keloids (excessive scarring).
- Joint stiffness
- Second fracture (renewed fracture when bone healing is insufficient).
- Bone growth disorders in children
- Instrument or material fracture with retention in the surgical area
