AO Trauma Course—

Basic Principles of Fracture Management

Syllabus for faculty

Learning objectives sorted by activity

(Last update March 2019)

This document contains the learning objectives for the core and optional content of the AO Trauma Course—Basic
Principles of Fracture Management. The sequence of activities in this template follows the course template for a 3-day
Basic Principles course.

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Course objectives for the Basic Principles of Fracture Management Course

At the end of this course, participants will be able to:

 Discuss the concepts of stability, their influence on bone healing, and how to apply implants to achieve
appropriate stability
 Plan a treatment based on assessment, imaging, classification, and decision making
 Apply reduction techniques in fracture management with attention to the importance of the soft-tissue
 Use appropriate fixation techniques to treat diaphyseal and simple (peri)articular fractures
 Evaluate and recognize the special problems related to; fractures in the immature skeleton, pelvic injuries,
osteoporotic fractures, postoperative infection and delayed union and/or nonunion
 Plan the initial treatment of the polytraumatized patient

Overview: Course modules

1 – General principles

2 – Treatment of diaphyseal fractures

3 – Treatment of articular fractures

4 – Preoperative planning and forearm fractures

5 – Emergency management and polytrauma patients

6 – Special issues and problems

Online Faculty Support Package for faculty preparation

Available on the AO Trauma website through your dashboard or at: https://www.aofoundation.org/sites/benefits/AO

TraumaFaculty/Pages/faculty-center.aspx (login required).

Precourse online activities

The Biology of Bone Healing (English)

https://emodules.aoeducation.org/aoelearn/aot_launch/aot_bh/lib/launch.html?bone_healing

Additional information on the 2018 revision of the AO/OTA Fracture and Dislocation Classification Compendium can be
found here:
https://classification.aoeducation.org

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Lectures
Module 1: General principles

The AO World—From history to lifelong learning 15'

 Teaching points: Integrate history, philosophy, current offerings (AO Surgery Reference, online
resources, Research, etc.) into this lecture.

The biology of bone healing 10'

Learning objectives

At the end of the lecture, the participant will be able to:

 Explain the different processes of bone healing and review direct and indirect bone healing
 Describe the factors that influence the healing process and those that may lead to delayed union
or nonunion
 Recognize the importance of soft tissues for bone healing
 Discuss the effects and influence of osteosynthesis on the bone and its healing process

The effect of patient factors and injury mechanism on fracture management 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Name the patient factors which influence fracture healing
 Explain different mechanisms of injuries which influence fracture healing
 Discuss how different treatment options will influence fracture healing

 Teaching points: General and local factors affecting management decisions. The concept of the energy of
the injury. Introduce the priorities of life saving, limb saving, and disability limiting surgery. Discuss the
priorities of the multiply injured patient with orthopaedic injuries; do not go into details and refer to lecture
Treatment algorithms for the polytrauma patient.

The (soft-tissue) injury—a high priority consideration 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Describe the role of soft tissue in fracture healing
 Prioritize the management of the soft-tissue injuries
 Apply the management options for fractures with different degrees of soft-tissue injuries
 Outline the etiology, diagnosis, and treatment of compartment syndrome

 Teaching points: Explain the role of soft-tissues in resisting infection, facilitating healing, and promoting
function. Present the pathophysiology of compartment syndrome and overview of diagnosis and
treatment. Do not go into details of fracture management.

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Absolute stability: biomechanics, techniques, and fracture healing 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Define absolute stability
 Describe how the biological behavior of fractured bone is affected by absolute stability
 Define indications for selection of absolute stability according to AO principles
 Explain techniques for achieving absolute stability

Relative stability: biomechanics, techniques, and fracture healing 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Define relative stability
 Describe the biological behavior of fractured bone and how it is affected by relative stability
 Define indication for selection of relative stability according to AO principles
 Explain techniques for achieving relative stability

The use of plates in fracture fixation 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Appreciate the different plate functions in fracture fixations
 Describe how plate features enable these functions
 Explain how to use plates to achieve absolute or relative stability
 State the indications of locked plates

Principles of external fixation 15

Learning objectives

At the end of the lecture, the participant will be able to:

 Describe the types of external fixators
 Describe the indications for external fixation
 Explain the “spectrum of stability” that can be achieved
 Describe how to determine the stability of the frame by the method of construction
 Describe how a modular frame is constructed and used to reduce and stabilize a fracture
 Explain how to place anatomically safe and stable pins in the tibia

The 2018 AO/OTA Fracture and Dislocation Classification Compendium 15'

Learning objectives

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At the end of the lecture, the participant will be able to:
 Recognize the need and purpose of a fracture classification system
 Describe the Fracture and Dislocation Classification system and its clinical importance for
decision-making and preoperative planning
 Outline the structure of this classification for long-bone fractures
 Name the bone segments and use their numerical code
 List types, groups, subgroups, qualifiers, and universal modifiers
 Properly classify long-bone fractures

Principles of surgical approaches 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Decide on the appropriate surgical approach, depending on the injury
 Realize the soft-tissue preserving concept
 Know the safe zones

Imaging modalities in trauma surgery 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Outline strengths and shortcomings of imaging modalities used in trauma surgery
 Describe appropriate imaging modalities for specific injuries
 Combine imaging modalities to achieve improved patient care

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Module 2: Treatment of diaphyseal fractures

Principles of diaphyseal fracture management—what is important in treating these fractures? 20'

Learning objectives

At the end of the lecture, the participant will be able to:

 The importance of injury mechanism –high v low energy
 To match mode of fixation and implant to fracture pattern
 The roles of Direct/Indirect reduction in diaphyseal fractures
 Describe the importance of Strain theory in fixation
 Understand the concept of the working length of plates and IM nails

Fractures of the humeral diaphysis—management principles 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Classify and identify appropriate treatment strategies for humeral diaphyseal fractures
 Establish the operative indications for humeral diaphyseal fractures
 Understand the benefits and limitations of the various treatment strategies

 Teaching points: This must be a general presentation and specific treatment strategy will be discussed in
the Advances course. Avoid controversial evidence apart from the advice to use two distal interlocking
screws in IM nailing to improve stability.

Fractures of the femoral diaphysis (including subtrochanteric)—management principles 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Discuss IM nailing as the preferred method of stabilization
 Discuss the need for cephomedullary fixation
 Understand reaming issues and the implications
 Consider alternative fixation options to IM nailing

 Teaching points: The force required to fracture femur should be emphasized. The soft-tissue cover favors
good results with IM nailing. Dynamization techniques need to be mentioned. Classification can be added.

Fractures of the tibial diaphysis —management principles 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Outline the assessment of the closed tibial fracture.
 Describe nonoperative and operative treatment options.
 Discuss how closed soft-tissue injuries should be managed

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 Teaching points: Concentrate on closed fractures, but briefly refer to open fractures.

Intramedullary nailing—to ream or not to ream 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Discuss the benefits and drawback of reaming
 Discuss the benefits and drawback of IM nailing without reaming

 Teaching points: Describe the advantages of the newer generation reamers and other techniques to
decrease thermal and pressure effects of reaming.

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Module 3: Treatment of articular fractures

Management principles for articular fractures—how do they differ from diaphyseal fractures? 20'

Learning objectives

At the end of the lecture, the participant will be able to:

 Describe how articular cartilage heals
 Discuss early management of articular fractures
 Assess and manage associated severe soft-tissue injury
- span, scan and plan
 Appreciate and understand techniques required to
- achieve anatomical reduction of joint and mechanical axis
- obtain rigid fixation
- allow early active movement

Tension band principle and cerclage wiring 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Define what constitutes the tension band principle
 Describe how the tension band principle works
 State the clinical applications of the tension band principle
 Distinguish tension band principle from cerclage fixation

Ankle fractures—a systematic approach for their fixation 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Describe the anatomy of the ankle and mechanism of bony injury
 Classify ankle fractures
 Outline reduction methods and surgical techniques for different types of ankle fractures
 Specify postoperative management based on fracture patterns

 Teaching points: Understanding that multi-directional forces cause different fracture patterns and define
soft tissue involvement.

Femoral neck fractures 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Classify femoral neck fractures
 Outline indications for internal fixation vs arthroplasty
 Describe reduction and surgical techniques for internal fixation

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  Describe potential complications after treatment of femoral neck fractures

 Teaching points: Timing of intervention, rationale for arthrotomy and patient considerations.

Trochanteric fractures 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Describe the biomechanics of extra-capsular fractures and the choice of implant
 Describe the difference of subtrochanteric fractures compared to per- and intertrochanteric
fractures
 Explain the rationale of intra- as opposed to extramedullary fixation
 Describe the causes of failure concerning reduction and placement of implant

 Teaching points: Achievement of cephalo-medullary stability, reduction by distraction, importance of

fluoroscopy.

Introduction to tibial plateau fractures 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Specify classification of tibial plateau fractures according to AO and Schatzker
 Differentiate fractures with and without ligamentous injuries
 Describe the management of tibial plateau fractures with soft-tissue injuries
 Outline the principles of the management of proximal tibial fractures as intraarticular injuries
 Discuss advantages and disadvantages of available implants

 Teaching points: Focus on soft tissue, imaging, and MIO. Do not go into details of fixation!

Proximal humeral fractures—an update on treatment protocols 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Describe the different approaches to treatment
 Consider minimally invasive osteosynthesis as an option
 Discuss the advantage of locking plate constructs and other treatment options (IM nailing)

 Teaching points: Confirm the participants understand the complications.

Distal radial fractures—which to fix? How to fix? 15'

Learning objectives

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At the end of the lecture, the participant will be able to:
 Describe different types of distal radial fractures
 List indication for operative and nonoperative treatment
 Outline surgical approaches for the fixation of distal radial fractures
 Describe appropriate reduction techniques
 Choose appropriate implants according to fracture type
 Discuss indications for conventional and locking plates

 Teaching points: Participants should appreciate the multitude of treatment options and their indications
with regard especially to patient needs.

Distal femoral fractures—management principles 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Summarize the anatomy of the distal femur
 Describe the reduction techniques and surgical approaches for reduction of intra-articular and
metaphyseal fractures
 Discuss the indication of various implants available for fixation
 Describe what has been changed in the surgical treatment of distal femoral fractures

 Teaching points: Participants should recognize that indirect reduction using a distraction tool greatly
facilitates adherence to principles of treating articular fractures. Angular stability should be stressed to avoid
secondary loss of alignment.

Distal tibial fractures 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Describe the anatomical characteristics of the distal tibia and why injuries of the distal tibia are
unique
 Define fractures requiring absolute stability and those amenable to relative stability, focusing on
different fracture patterns
 Recall techniques of internal fixation that avoid soft tissue damage while preserving blood
supply to the bone
 Describe the role of the fibula in the operative treatment of distal tibial fractures

 Teaching points: Indirect reduction utilizing joint-spanning distraction for preliminary stabilization and
correction of length and alignment should be part of this lecture.

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Module 4: Preoperative planning and forearm fractures

Preoperative planning—rationale and how to do it 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Grasp the importance of preoperative planning
 Describe various techniques for preoperative planning
 Formulate and draw an operative plan
 Describe a surgical tactic step by step (e.g. positioning, choice of surgical approach, instruments,
reduction technique, implant(s))
 Incorporate patient safety protocols (mark site, time-out check list) in the preoperative plan

 Teaching points: Using a management concept for each patient and planning each surgical procedure
avoids complications and gives the orthopedic surgeon security in contemplating each step of treatment for
which he or she is totally responsible.

Forearm fractures need understanding of principles for diaphyseal 15'

and articular fractures

Learning objectives

At the end of the lecture, the participant will be able to:

 Describe different types of fractures in the forearm (single bone, both bones)
 Describe why radial and ulnar fractures should be treated as articular fractures
 Explain the common surgical approaches and reduction techniques for forearm fractures

 Teaching points: Correct length and alignment of both radius and ulna are prerequisites for elbow and
wrist congruency.

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Module 5: Emergency management and minimally invasive surgery

Radiation in the operating room—appropriate use and hazards 10'

Learning objectives

At the end of the lecture, the participant will be able to:

 Describe effect of radiation on human organ and cells
 Specify the function and structures of the C-arm
 Outline how the radiation exposure will affect the operation room personnel
 List the various factors for minimizing radiation hazards during intraoperative imaging
 Know how to wear a protection gown to reduce the radiation
 Describe how to use the C-arm to minimize radiation hazards and provide optimal intraoperative
imaging

 Teaching points: Highlight how to use a C-arm correctly.

Treatment algorithms for the polytrauma patient 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Identify the priorities of life saving, limb saving and disability limiting surgery.
 Outline the general and local factors affecting decision making
 Debate the role of the different trauma team members

 Teaching points: Include emergency management of the cervical spine if there is no separate lecture
planned on this topic.

Emergency management of pelvic fractures—a critical skill that can save lives 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Identify and describe the mechanism of injury for pelvic fractures
 Describe the initial treatments to save the life of the patient
 Outline the use of pelvic binding and external fixation to stabilize fractures
 Communicate effectively with trauma surgeons and other specialist team for comprehensive
management

 Teaching points: Focus on pattern recognition on x-rays, describe how to use binders and sheets
appropriately.

Minimally invasive osteosynthesis (MIO)—when to use it? 10'

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Learning objectives

At the end of the lecture, the participant will be able to:

 Describe the concept and principles of MIPO technique
 Specify the effect of implants on fracture stability
 Discuss the bridge plating concept, including the biological and biomechanical principles
 List the risks and benefits MIPO

 Teaching points: Focus on concept of soft-tissue windows and on the importance of diminishing surgical
footprints.

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Module 6: Special issues and problems

Management of open fractures 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Specify the goals and principles of open fracture management
 Outline the classification of open fractures and the implications for treatment
 Describe the initial management of open fractures
 Outline the definitive management of soft tissues and the fracture
 Select appropriate techniques to provide stability in open fractures
 Discuss the issue of early soft-tissue coverage
 Appreciate the necessity to collaborate with soft tissue reconstruction surgeons

 Teaching points: Focus on timing, debridement, and irrigation technique.

Infection after osteosynthesis—how to diagnose and manage 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 List the causes and factors that can lead to a postoperative infection
 Identify the role of surgery and implant in this process
 Describe the diagnosis and treatment of acute infection
 Discuss the difference between acute and chronic infection
 Outline the role of stability and surgical debridement in treatment of infection

 Teaching points: Focus on the importance of early diagnosis and aggressive surgical treatment, on when
to retain/remove implants.

Delayed healing—causes and treatment principles 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 List factors leading to malunion
 Understand the different between delayed union and nonunion
 Recognize different types of nonunion
 Discuss how these complications might be avoided in fracture management
 Outline the principles of treatment of nonunion

 Teaching points: Highlight the impact of disrespect of biomechanics and biology in leading to delayed
healing.

Violation of principles 15'

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Learning objectives

At the end of the lecture, the participant will be able to:

 Realize that principles are there to be followed
 Recognize pitfalls when applying the right principles to wrong indications and vice versa
 Appreciate that complications are often the result of lack of planning, lack of knowledge and
lack of skill

 Teaching points: The lecture should illustrate outcomes that invariably are to be expected when neglecting
the principles of fracture and soft-tissue management.

Fixation principles in osteoporotic bone—the geriatric patient 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Differentiate the structure of osteoporotic bone compared to normal bone architecture
 Explain why the treatment of patients with fragility fractures goes beyond fracture fixation
 Discuss diagnostic and treatment algorithms
 List the different options of implants available for fixation
 Describe the co-management of a geriatric fracture patient and how it impacts patient’s outcome
 Describe the role of prevention of a secondary fracture

 Teaching points: Focus on general principles of orthogeriatric management and the principles of fixing
osteoporotic fractures.

Fractures in the growing skeleton—how are they different? 15'

Learning objectives

At the end of the lecture, the participant will be able to:

 Recognize the difference of treating injuries in the growing skeleton
 Understand the anatomy of the epiphysis in the immature skeleton
 List the indications for operative treatment in the growing skeleton
 Understand the different fixation techniques available to treat these injuries

 Teaching points: Focus on anatomy and principles of fracture care in the growing skeleton. Do not go into
the details of each fracture.

Implant removal—Why, when, and how? 10'

Learning objectives

At the end of the lecture, the participant will be able to:

 Summarize the indications for implant removal

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  Describe the different techniques to do it
 Understand when to remove implants

 Teaching points: Focus on the importance of appropriate planning of these surgical procedures.

The future of fracture treatment 15'

Learning objectives
At the end of the lecture, the participant will be able to:
 Discuss trends in new implant technology
 List research topics currently concerned with bone healing
 Appreciate new theories of fracture treatment such as gene therapy / stem cell research

AO history and philosophy 15'

Learning objectives

 Appreciate the value of reviewing the history and development of fracture treatment
 Respect the contribution of the Founders of the AO
 Realize that success in AO developments depends on clinical expertise, documentation, research
and education (4 pillars of the AO)

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Skills Lab

Original AO Skills Lab 120'

For use in North America, Asia-Pacific, and Brazil

"Torque measurement of bone screws"

After participating in this simulation, the participant will be able to:
 Feel and achieve optimal torque in different bone qualities
 Practice over- and under tightening screws in bone cortex
 Investigate potential problems when inserting the screwdriver into the screw head

"Soft-tissue penetration during drilling"

After participating in this simulation, the participant will be able to:
 Differentiate between sharp and blunt drill bits
 Develop a feel for penetrating the opposite bone cortex, and compare results using blunt and
sharp drill bits or K-wires
 Assess possible damage to soft tissues and neurovascular structures

"Heat generation during drilling"

After participating in this simulation, the participant will be able to:
 Learn to differentiate between sharp and blunt drill bits
 Predict heat distribution in bone cortex
 Recognize and compare results from using blunt or sharp drill bits or K-wires

"Mechanics of bone fractures"

After participating in this simulation, the participant will be able to:
 Describe deformation of material under torque, bending, and axial load
 Discuss typical fracture patterns under torque, bending, and axial load
 Discuss typical fracture patterns under torque, bending, and axial load
 Describe the orientation and nature of stress types and sides (compression, tension or distraction,
and shear)
 Discuss possible implications of each fracture type on the soft-tissue envelope

"Fracture healing"
After participating in this simulation, the participant will be able to:
 Identify the importance of the increasing cross-section
 Identify the importance of tissue transformation between fragments
 Define absolute and relative stability
 Define the importance of initial gap width onto cell deformation under the condition of relative
stability
 Define the effect of tissue differentiation on deformation

"Techniques of reduction"

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After participating in this simulation, the participant will be able to:
 Differentiate between direct and indirect reduction
 Relate both techniques to specific indications and bone segments
 Identify the degrees of freedom for each reduction clamp
 Recognize difficulties in the application of the different devices
 Analyze biological advantages and shortcomings of different clamps

"Mechanics of intramedullary fixation"

After participating in this simulation, the participant will be able to:
 Describe different nail designs and their mechanical characteristics
 Explain radial preload and corresponding concept of stabilization
 Describe indications for nailing without interlocking
 Identify common problems when using nails that are too short or too thin
 Describe possible problems of nailing without interlocking
 Describe different nail locking options and possible influences on stability of fixation (dynamic
versus static locking
 Explain elastic stable intramedullary nailing

"Mechanics of plate fixation I "

After participating in this simulation, the participant will be able to:
 Explain how lever arm length influences screw loading
 Define the term "screw working length"
 Explain principle of load sharing between implant and bone
 Identify the influence of a fracture gap on stiffness of fixation and on plate loading
 Explain the influence of the bending direction on load sharing of the plate‒bone composite
construct
 List reasons for plate failure
 Identify actions to avoid plate failure
 Explain importance of overspan width and screw position on plate loading

"Mechanics of plate fixation II"

After participating in this simulation, the participant will be able to:
 Describe the bending stiffness of isolated beams with respect to composite beams
 Recognize plate fixation of fractures as a composite beam system
 Describe the importance of plate position on overall stiffness of internal fixation using plates

"Damaged implant removal"

After participating in this simulation, the participant will be able to:
 Identify the function of different instruments to aid screw removal
 Remove a screw with a destroyed coupling mechanism
 Remove a broken screw

Updated AO Skills Lab 120'

For use in Europe, Middle-East, Africa, and Latin America (except Brazil)

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"Torque measurement of bone screws"
After participating in this simulation, the participant will be able to:
 Feel and achieve optimal torque in different bone qualities
 Practice over- and under tightening screws in bone cortex
 Investigate potential problems when inserting the screwdriver into the screw head

"Soft-tissue penetration during drilling"

After participating in this simulation, the participant will be able to:
 Differentiate between sharp and blunt drill bits
 Develop a feel for penetrating the opposite bone cortex, and compare results using blunt and
sharp drill bits or K-wires
 Assess possible damage to soft tissues and neurovascular structures

"Heat generation during drilling"

After participating in this simulation, the participant will be able to:
 Learn to differentiate between sharp and blunt drill bits
 Predict heat distribution in bone cortex
 Recognize and compare results from using blunt or sharp drill bits or K-wires

"Mechanics of bone fractures"

After participating in this simulation, the participant will be able to:
 Describe deformation of material under torque, bending, and axial load
 Discuss typical fracture patterns under torque, bending, and axial load
 Discuss typical fracture patterns under torque, bending, and axial load
 Describe the orientation and nature of stress types and sides (compression, tension or distraction,
and shear)
 Discuss possible implications of each fracture type on the soft-tissue envelope

"Techniques of reduction, part 1"

After participating in this simulation, the participant will be able to:
 Differentiate between direct and indirect reduction
 Relate both techniques to specific indications and bone segments
 Identify the degrees of freedom for each reduction clamp
 Recognize difficulties in the application of the different devices
 Analyze biological advantages and shortcomings of different clamps

"Techniques of reduction, part 2"

After participating in this simulation, the participant will be able to:
 Demonstrate use of a femoral distractor as a reduction tool
 List instances in which a distractor is indicated
 Explain use of external fixator for reduction

"Mechanics of intramedullary fixation"

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After participating in this simulation, the participant will be able to:
 Describe different nail designs and their mechanical characteristics
 Explain radial preload and corresponding concept of stabilization
 Describe indications for nailing without interlocking
 Identify common problems when using nails that are too short or too thin
 Describe possible problems of nailing without interlocking
 Describe different nail locking options and possible influences on stability of fixation (dynamic
versus static locking
 Explain elastic stable intramedullary nailing

"Mechanics of plate fixation I "

After participating in this simulation, the participant will be able to:
 Explain how lever arm length influences screw loading
 Define the term "screw working length"
 Explain principle of load sharing between implant and bone
 Identify the influence of a fracture gap on stiffness of fixation and on plate loading
 Explain the influence of the bending direction on load sharing of the plate‒bone composite
construct
 List reasons for plate failure
 Identify actions to avoid plate failure
 Explain importance of overspan width and screw position on plate loading

"Mechanics of plate fixation II"

After participating in this simulation, the participant will be able to:
 Describe the bending stiffness of isolated beams with respect to composite beams
 Recognize plate fixation of fractures as a composite beam system
 Describe the importance of plate position on overall stiffness of internal fixation using plates

"Damaged implant removal"

After participating in this simulation, the participant will be able to:
 Identify the function of different instruments to aid screw removal
 Remove a screw with a destroyed coupling mechanism
 Remove a broken screw

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Small group discussions

Small group discussion 1 60'

Discussion on general principles, classification, concepts of stability, their influence
on bone healing, and how to apply implants to achieve appropriate stability.

As the end of this session, the participant will be able to:

 Appreciate the need to assess and respect the soft-tissue envelope overlying a fracture
 Accurately assess x-rays, establish full extent of the bone injury, and predict likely soft-tissue
injury
 Logically choose the fixation strategy based upon desire to achieve primary or secondary
healing
 Describe the management of open fractures
 Classify fractures using the AO/OTA Comprehensive Classification of Fractures

Small group discussion 2 70'

Management principles for the treatment of diaphyseal fractures

As the end of this session, the participant will be able to:

 Recall the goals of operative care of diaphyseal fractures
 Choose a reduction and a fixation strategy to achieve these goals
 Predict the type of healing that will occur

Small group discussion 3 70'

Management principles for the treatment of articular fractures

As the end of this session, the participant will be able to:

 Describe management principles for articular injuries
 Describe operative treatment of ankle fractures
 Explain management of olecranon fractures
 Explain treatment methods lateral tibial plateau fractures
 Discuss treatment of Monteggia fracture dislocations
 Discuss treatment rationale for femoral neck fractures

Small group discussion 4* 60'

Discussion on special topics such as (to be determined by the Course Chairperson):
 Polytrauma
 Complications
 Special fractures, e.g. pediatric fractures, geriatric patients, osteoporosis, periprosthetic fractures

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Practical exercises

Internal fixation with screws and plates—absolute stability 65'

 Video: 00139, part 1 (lag screw, position screw, plate with overbending)
 Bone model: 0066, 1143
 Power tool (video only)

Learning objectives

At the end of the exercise, the participant will be able to:

 Understand the principles of absolute stability and how to apply them
 Demonstrate the use of screws to achieve axial compression
 Evaluate the use of the LCP as a dynamic compression plate
 Differentiate the use of the LCP as a buttress plate
 Review the advantages and disadvantages regarding the biological impact and biomechanics of
absolute stability

 Teaching points: This exercise builds upon the contents of the lecture Absolute stability: biomechanics,
techniques, and fracture healing. There is a second part of the video with additional exercises. If you plan to
do the exercises of the second part as well, you will need to add another 60 minutes to this exercise for the
second part. See description of second part under “Optional activities”.

Principle of the internal fixator using the locking compression plate (LCP) 70'
 Video: 00112
 Bone model: 1142
 Bone model: 0068 (bridge plating MIPO)
 Bone model: 0081 (angular stability in osteoporotic bone)

Learning objectives

At the end of the exercise, the participant will be able to:

 Understand the principles of the internal fixator using a locking compression plate (LCP)
 Simple fracture: LCP as internal fixator protecting an independent lag screw (neutralization
plate)
 Complex fracture: LCP as internal fixator in a bridging function

 Teaching points: This exercise builds upon the contents of the lectures Fracture fixation using locking
plates and Relative stability: biomechanics, techniques, and fracture healing as well as Absolute stability:
biomechanics, techniques, and fracture healing.

Application of a modular large external fixator 40'

Please choose one of the following. Time permitting, a second exercise can be performed (add an extra 30
minutes)
 Video: 00116 (tibia modular external fixator)
 Bone model: 1111
 Video: 00119 (ankle bridging modular external fixator)
 Bone model: PR0535

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  Video: 00120 (knee bridging modular external fixator)
 Bone model: PR0536

Learning objectives 70'

At the end of the exercise, the participant will be able to:

 State the clinical indication for the application of the large external fixator
 Discuss the choice of frame type
 Describe the positioning and correct insertion of the Schanz screws
 Construct a rod-to-rod modular frame

 Teaching points: Consider temporary vs definitive management issues, and the soft-tissue injury.

Intramedullary (IM) nailing (tibial or femoral shaft) 60'

Please choose one of the following options.

Option 1
Tibial shaft fractures—intramedullary nailing with the expert tibia nail (ETN) (with reaming)
 Video: 00130
 Bone model: 1149 – 01
 Bone model: ASLS perspex model

At the end of the exercise, the participant will be able to:

 State the clinical indications with regard to locking characteristics of the nail
 Demonstrate and carry out locking options
 Describe entry point and define its rationale
 Recall the sequence of instrumentation in opening and reaming the intramedullary canal
 Describe instruments used and their functions
 Explain the use of ASLS with regard to stability requirements

Option 2
Tibial shaft fractures—intramedullary nailing with the expert tibia nail enhanced (ETN Enhanced)
 Video: 00136
 Bone model: LD1149-01

At the end of the exercise, the participant will be able to:

 State the clinical indications and contraindications
 Describe the correct patient positioning
 Identify the appropriate reduction techniques
 Recognize the surgical approach and entry point
 Perform reamed intramedullary nailing using the ETN

Option 3
Intramedullary fixation using the expert retrograde/antegrade femoral nail (R/AFN)–antegrade procedure
 Video 00140
 Bone model: PR0340

At the end of the exercise, the participant will be able to:

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  State the clinical indications and contraindications
 Describe the correct patient positioning
 Identify the correct entry point for antegrade nailing
 Explain the steps used to perform the surgical procedure

 Teaching points: Correct entry points should be discussed, and the steps of the exercise repeated before
starting. It should be mentioned that in the plastic bone the reaming must be evacuated repeatedly to
avoid jamming of the reamer.

Preoperative planning—“plan your forearm operation” 60'

Templating exercise

Learning objectives

At the end of the exercise, the participant will be able to:

 Perform the 4 stages to complete preoperative planning
 Plan a complete operation for a 22-C1.3 fracture
Stage A: template the fracture
Stage B: develop a complete surgical tactic
Stage C: construct a specific surgical instrument and implant list
Stage D: review the mechanism for communication with the team

 Teaching points: Participants are asked to develop a complete preoperative plan for a type 22-C1.3
forearm fracture based on x-rays of the uninjured and injured forearm bone model. A syllabus for this
exercise is available in the online Faculty Support Package.

Operate your plan—fixation of a 22C1 forearm fracture using the LCP 3.5 (8 and 11 holes) 70'
 Video: 00113
 Bone model: 6501
 Bone spreader 399.100 for every table

Learning objectives

At the end of the exercise, the participant will be able to:

 Apply the use of an LCP with a lag screw to achieve absolute stability in a simple radial fracture
 Understand how to apply an LCP 3.5 to achieve relative stability in a multifragmentary ulnar
fracture (bridging technique)
 Perform a technique of indirect reduction for the involved ulna fracture

Tension band wiring of the olecranon 30'

 Video: 00132
 Bone model: 6011

Learning objectives

At the end of the exercise, the participant will be able to:

 Understand the principle of the tension band wiring with regard to the fixation of olecranon
fractures
 Demonstrate the application of K-wire and figure-of-eight wire fixation to a transverse

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 olecranon fracture
 Develop tips and tricks to reduce the incidence of complications

 Teaching points: Participants should remember the fine points of parallel K-wires, producing ease of K-
wire fixation by first penetrating the far cortex and bending the obliquely cut tips of the K-wires through180
degrees, so that they can be tapped into the bone. Emphasize the use of two twirls.

Management of a type 44C malleolar fracture 60'

 Video: 00138
 Bone model: LD3120

At the end of the exercise, the participant will be able to:

 Outline the indications for surgical treatment
 Discuss the preoperative planning and patient positioning
 Perform the surgical steps for the fixation of a type-C malleolar fracture

Management of a trochanteric fracture 70'

The Chairperson decides if this exercise will be done with a DHS or a PFNA.

Option 1
Stabilization of femoral neck fractures using the DHS system
 Video: 00137
 Bone model: LD2220.01

At the end of the exercise, the participant will be able to:

 List the clinical indications for the DHS
 Describe the surgical approach
 Identify correct screw and plate placement
 Describe options for screw fixation and fracture compression

Option 2
Intramedullary nailing of a proximal femur using a proximal femoral nail anti-rotation (PFNA)
 Video 00125
 Bone model: LD2220

At the end of the exercise, the participant will be able to:

 Understand the mechanical advantage of the PFNA in unstable fractures and osteoporotic bone
 Become familiar with patient set-up and correct entry point
 Understand the instrumentation and assembly
 Correctly perform the procedure

 Teaching points: Participants should be made aware of the complexity of the implant and the importance
of following the steps of instrumentation. The correct entry point for the nail and the correct angle of
initial reaming should be stressed.

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Stabilization of the pelvic ring using a large external fixator 70'
 Video: 00122
 Bone model: 4083

Learning objectives

At the end of the exercise, the participant will be able to:

 Understand the clinical indications for external fixation of the pelvic ring
 Apply the technique for insertion of Schanz screws in the supra-acetabular region and the iliac
crest
 Construct an anterior pelvic external fixator

 Teaching points: Focus on safe corridors for insertion of Schanz screws.

Application of the Large Distractor 35'

 Video 20163
 Bone model: 2263G
 Bone model: PRO536

Learning objectives

At the end of the exercise, the participant will be able to:

 Describe indications for the use of the femoral distractor
 Assemble the femoral distractor
 Describe the versatility of the distractor as reduction and stabilizing tool

 Teaching points: Participants should recognize that instruments of reduction can facilitate fixation greatly
and that distraction and correction of length and alignment can be accomplished by traction table and
femoral distractor.

Internal fixation with screws and plates (optional additional part): LCP as a compression plate with a 65'
lag screw, buttress plating
 Video 00110
 Bone model: 0067
 Bone model: 1143

Learning objectives

At the end of the exercise, the participant will be able to:

 Osteoporotic bone model: appreciate the advantages of locking head screws providing angular
stability.

Management of a femoral neck fracture using 7.3 mm cannulated screws 65'

 Video 00104
 Bone model: 2422
Learning objectives

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At the end of the exercise, the participant will be able to:
 List the indications and contraindications for the use of the 7.3 mm cannulated screw in femoral
neck fractures
 Demonstrate the insertion of the screws in optimal position
 Understand the use of the C-arm, its positioning in relation the patient

 Teaching points: Discuss the alternatives of transcutaneous screw placement and open screw placement.
Explain reduction techniques.

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