Major surgeries in traumatology

Principles of osteosynthesis and trophic preservation

The success of any osteosynthesis is based on preserving the blood supply to the bone fragments. Without adequate trophics, even ideal fragment apposition will not lead to consolidation.

Surgical intervention always carries the risk of further impairing blood flow. The most destructive intraoperative factors include:

• Extensive bone exposure and stripping (effectively turning living tissue into a devascularized autograft).
• Use of massive plates with a large contact area (causes superficial bone necrosis beneath the implant).
• Application of circular wire cerclages (create a tourniquet effect, completely interrupting periosteal blood flow).

Modern traumatology focuses on minimally invasive techniques. Their goal is secure fixation with minimal surgical trauma, sometimes even without exposing the fracture line. Fixation itself is achieved in two ways: splinting (transferring the load to the implant, e.g., a nail) and compression.

In addition to the specific features of the fracture itself, indications for surgery are expanded in open injuries, the threat of neurovascular bundle injury, delayed consolidation, and to facilitate the care of debilitated patients.

Total hip arthroplasty

In subcapital femoral neck fractures, the management strategy radically depends on age. In young patients, priority is given to osteosynthesis (with objectively proven preservation of blood flow). For elderly patients, arthroplasty becomes the method of choice, as it allows for graded weight-bearing on the leg within 2–5 days, preventing fatal hypostatic complications (pneumonia, pressure ulcers).

Types of arthroplasty:

1. Unipolar (hemiarthroplasty) — replaces only the head and neck. The metal articulates with the natural cartilage of the acetabulum. Indicated for high operative risks.
2. Bipolar — movement occurs primarily within the prosthesis's own hinge, which preserves the patient's acetabulum.
3. Total — the method of choice in modern practice. The entire joint is replaced. It consists of an artificial cup, a polyethylene liner, a head, and a stem.

Management features: skeletal traction is not applied and reduction is not performed prior to joint replacement. Postoperative therapy for concomitant osteoporosis is mandatory, and transition to full weight-bearing is determined by the 2nd–3rd month.

Patellar and clavicle surgery

Patellar injuries At the pre-hospital stage, the leg is splinted in an extended position. Only non-displaced fractures (diastasis up to 2–3 mm) are treated conservatively via joint aspiration and casting for 1 month. If the extensor mechanism of the leg is damaged (diastasis > 3–5 mm) or there is a step-off deformity of the articular surface, surgery is performed on an emergency basis.

The gold standard is tension-band wiring (Weber technique using Kirschner wires and a cerclage loop). This method allows knee motion to begin within a few days. The main rule: with any technique, the surgeon is obligated to restore the supporting patellar ligaments.

Clavicle fractures and acromioclavicular joint (ACJ) dislocations In case of ACJ ligament ruptures (Rockwood types III–VI), surgical treatment is indicated: plastic repair, hook plate fixation, or arthroscopy.

Absolute indications for clavicle osteosynthesis:

• Open injuries or the threat of skin perforation.
• Vascular and nerve damage.
• Polytrauma or a "floating shoulder".
• Pathological fractures.

Refusing surgery for a displaced clavicle risks shortening it by 1.5–2 cm, which permanently reduces the strength of the shoulder girdle muscles.

Class and exam questions

What else to study on this topic

• Classification of acromioclavicular joint dislocations according to Rockwood.
• Biomechanics of patellar osteosynthesis using the Weber method.
• Arthroscopic diagnosis of transchondral lesions in the acute period.
• Management features of patients with concomitant osteoporosis after arthroplasty.
• Alternative patellar fixation methods (semi-purse-string Dacron sutures).

Other topics in the "Specialized Adult Traumatology" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.