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There are multiple difficulties in bone plate fixation of comminuted fractures, which run through the entire process from preoperative assessment, intraoperative operation to postoperative rehabilitation. The following is a detailed elaboration for you:
Difficulties in preoperative assessment
The fracture situation is complex: Comminuted fractures mean that there are many fracture fragments of different sizes and irregular distribution, making it difficult to precisely determine the location, size and interrelationship of each fracture fragment. For example, in comminuted fractures of the distal femur, there may be multiple small fracture fragments scattered in the surrounding soft tissues, increasing the difficulty of preoperative assessment.
Soft tissue injury assessment: Comminuted fractures are often accompanied by severe soft tissue injuries, such as skin contusions, muscle tears, vascular and nerve injuries, etc. Accurate assessment of the degree and scope of soft tissue injury is crucial for formulating surgical plans. However, the manifestations of soft tissue injury may be rather insidious, increasing the difficulty of assessment.
Difficulty in formulating personalized plans: Due to the different fracture conditions of each patient, personalized bone plate fixation plans need to be formulated. However, the complexity of comminuted fractures makes it difficult to formulate an appropriate plan, which requires comprehensive consideration of factors such as the type of fracture, location, soft tissue conditions, and the overall condition of the patient.
Difficulties in intraoperative operation
Difficulty in fracture reduction: Restoring numerous scattered fracture fragments to their normal anatomical positions is the primary challenge in the fixation of bone plates in comminuted fractures. Fracture fragments may have situations such as rotation, displacement, and overlap, and some fracture fragments may be wrapped by soft tissues or embedded in surrounding tissues, making it difficult to be directly exposed and reduced. For example, in comminuted fractures of the tibial plateau, the restoration of the flatness of the articular surface is rather difficult and requires meticulous operation and rich experience.
Bone plate selection and shaping: Selecting the appropriate bone plate and shaping it to adapt to the morphology of the fracture site is another challenge. The morphology of comminuted fracture sites is often irregular, and the bone plates need to have good plasticity and conformability. If the bone plate is improperly selected or the shaping is not ideal, it may lead to unstable fixation or affect fracture healing.
The difficulty of screw fixation is high: In comminuted fractures, due to the small size of the fracture fragments and poor bone quality, the difficulty of screw fixation increases. The screws may not be able to obtain sufficient holding force, resulting in loose fixation or failure. In addition, when placing screws, it is necessary to avoid damaging important structures such as blood vessels and nerves around.
Bleeding control: Comminuted fractures are usually accompanied by a large amount of bleeding, and intraoperative bleeding control is crucial. Excessive bleeding not only affects the surgical field of vision and increases the difficulty of the operation, but also may lead to serious complications such as shock in patients. However, due to the complexity of vascular injury at the fracture site, it is difficult to accurately determine and effectively control the bleeding point.
Difficulties in postoperative rehabilitation
Delayed or nonunion of fractures: Due to severe disruption of blood supply at the fracture site and instability of the fracture fragments, the healing time of comminuted fractures is often long, and they are prone to delayed or nonunion. This may require reoperation intervention, increasing the patient’s pain and financial burden.
Increased risk of infection: Factors such as large surgical trauma, long operation time, and poor soft tissue conditions at the fracture site all increase the risk of infection after comminuted fractures. Once infection occurs, it may lead to delayed fracture healing, loosening or even failure of internal fixation, seriously affecting the rehabilitation process of patients.
Difficult recovery of joint function: If comminuted fractures occur near the joint, the recovery of joint function after surgery often faces considerable difficulties. Factors such as unevenness of the joint surface, adhesion of the soft tissues around the joint, and the existence of internal fixation may all affect the normal movement of the joint, leading to problems such as joint stiffness and restricted movement.