Operative Techniques: Orthopaedic Trauma Surgery [1 ed.] 9781416049357, 2010015060, 9781455712793, 1455712795, 1416049355

Table of contents :
Orthopaedic Trauma Surgery
Copyright
Dedication
CONTRIBUTORS
PREFACE
FOREWORD
01. Open Reduction and Plate Fixation of Displaced Clavicle Fractures
02. Glenoid Fracture
03. Proximal Humerus Fractures
04. Proximal Humerus Fractures
05. Humeral Shaft Fractures
06. Open Reduction and Internal Fixation of Intra-Articular Fractures of the Distal Humerus
07. Supracondylar Humeral Fractures
08. Terrible Triad Injuries of the Elbow
09. Radial Head Fractures
10. Radial Head Arthroplasty
11. Open Reduction and Internal Fixation of Olecranon Fractures
12. Open Reduction and Internal Fixation of Forearm Fractures
13. Distal Radius Fractures
14. Distal Radius Fractures
15. Scaphoid Fracture Fixation
16. Perilunate Injuries
17. Femoral Neck Fractures
18. Femoral Neck Fractures - Arthroplasty
19. Unstable Intertrochanteric Hip Fractures
20. Intertrochanteric Hip Fractures
21. Subtrochanteric Fractures - Plate Fixation
22. Subtrochanteric Femur Fractures
23. Femoral Shaft Fractures
24. Supracondylar Femur Fractures
25. Supracondylar Femur Fractures
26. Knee Dislocations
27. Operative Treatment of Fractures of the Patella
28. Proximal Tibia Fractures
29. Proximal Tibia Fractures - Intramedullary Nailing
30. Proximal Tibia Fractures - External Fixation I
31. Tibial Shaft Fractures
32. Plate Fixation of Tibial Shaft Fractures
33. Tibial Plafond Fractures
34. External Fixation of Distal Tibial Fractures
35. Operative Management of Ankle Fractures
36. Fractures of the Talus
37. Calcaneus Fractures
38. Repair of Tarsometatarsal Joint (Lisfranc) Fracture-Dislocation
39. Compartment Syndrome
40. Pelvic External Fixation
41. Anterior Pelvic Internal Fixation
42. Open Reduction and Internal Fixation of Intra-articular Iliac Fracture-Subluxation (Crescent Fracture)
43. Open Reduction and Internal Fixation of Sacral Fractures
44. Anterior Approaches to the Acetabulum
45. Open Reduction and Internal Fixation of the Acetabulum
46. Cervical Spine
47. Stabilization of Thoracic, Thoracolumbar, and Lumbar Fractures
48. Treatment of Open Fractures
49. Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined with Minimally Invasive Insertion
50. Acute Total Hip Arthroplasty for Acetabular Fractures
51. Total Hip Replacement for Intertrochanteric Hip Fractures
52. Optimizing Perioperative Fracture Care@

Citation preview

1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899

OPERATIVE TECHNIQUES: ORTHOPAEDIC TRAUMA SURGERY

ISBN: 978-1-4160-4935-7

Copyright © 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail: [email protected]. You may also complete your request on-line via the Elsevier website at http://www.elsevier.com/permissions.

Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Editors assumes any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. The Publisher Library of Congress Cataloging-in-Publication Data Operative techniques : orthopaedic trauma surgery / [edited by] Emil H. Schemitsch, Michael D. McKee. p. ; cm.—(Operative techniques series) Includes bibliographical references and index. ISBN 978-1-4160-4935-7 1. Orthopedic surgery—Atlases. 2. Wounds and injuries—Surgery—Atlases. I. Schemitsch, Emil H. II. McKee, Michael D. III. Series: Operative techniques. [DNLM: 1. Bone and Bones—injuries—Atlases. 2. Bone and Bones—surgery—Atlases. 3. Fractures, Bone—surgery—Atlases. 4. Life Support Care—methods—Atlases. 5. Orthopedic Procedures—methods—Atlases. 6. Wounds and Injuries—surgery—Atlases. WE 17 O603 2010] RD733.2.O64 2010 617.4′7—dc22

2010015060

Publishing Director: Kimberly Murphy Design Direction: Steven Stave

Working together to grow libraries in developing countries Printed in United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1

www.elsevier.com | www.bookaid.org | www.sabre.org

This book is dedicated to my wife Maureen and our four wonderful children, Laura, Geoffrey, Christine and Thomas. Emil H. Schemitsch

For my wife Debra, and our four children, Sacha, Tyler, Robbin and Everett. Michael D. McKee

CONTRIBUTORS

Henry Ahn, MD, FRCSC

Piotr A. Blachut, MD, FRCSC

Assistant Professor, University of Toronto Spine Program, Department of Surgery, University of Toronto; Consultant Spine Surgeon, St. Michael’s Hospital, Toronto, Ontario, Canada

Clinical Professor, Department of Orthopaedics, University of British Columbia; Vancouver General Hospital, Vancouver, British Columbia, Canada

Stabilization of Thoracic, Thoracolumbar, and Lumbar Fractures

Radial Head Fractures: Open Reduction and Internal Fixation; Treatment of Open Fractures

Ghassan B. Alami, MD

Richard A. Boyle, MD, MBBS(Hons), FRACS

Clinical Fellow, University of British Columbia; Clinical Fellow, Division of Orthopaedic Trauma, Department of Orthopaedics, Vancouver Coastal Health Authority, Vancouver General Hospital, Vancouver, British Columbia, Canada

Orthopaedic Surgeon, Institute of Rheumatology and Orthopaedics, Royal Prince Alfred Hospital, Sydney, Australia

Tibial Shaft Fractures: Intramedullary Nailing

Sahal Altamimi, MD, FRCS(C) Clinical Fellow, Division of Orthopaedic Surgery, Department of Surgery, St. Michael’s Hospital and University of Toronto, Toronto, Ontario, Canada Supracondylar Humeral Fractures: The Role of Arthroplasty

George S. Athwal, MD, FRCSC Assistant Professor of Surgery, University of Western Ontario; Consultant, Hand and Upper Limb Centre, London, Ontario, Canada Terrible Triad Injuries of the Elbow

Femoral Neck Fractures: Arthroplasty

Henry M. Broekhuyse, MD, FRCS(C) Clinical Associate Professor, University of British Columbia; Active Staff, Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver, British Columbia, Canada Plate Fixation of Tibial Shaft Fractures

Richard E. Buckley, MD, FRCS(C) Clinical Professor, Orthopedic Trauma Surgery, University of Calgary; Head, Orthopedic Trauma, Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada Calcaneus Fractures: Open Reduction and Internal Fixation

Greg K. Berry, MDCM, FRCSC

Chad P. Coles, MD, FRCSC

Assistant Professor, Faculty of Medicine, McGill University; Staff Orthopaedic Surgeon, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada

Assistant Professor, Dalhousie University; Orthopaedic Surgeon, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada

Open Reduction and Internal Fixation of Olecranon Fractures; Proximal Tibia Fractures: Intramedullary Nailing; Fractures of the Talus

Humeral Shaft Fractures: Open Reduction and Internal Fixation and Intramedullary Nailing; Femoral Shaft Fractures: Intramedullary Nailing

Paul J. Duffy, MD, FRCS(C) Mohit Bhandari, MD, MSc, FRCSC Canada Research Chair in Musculoskeletal Trauma, and Associate Professor, Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, Ontario, Canada Femoral Neck Fractures: Open Reduction and Internal Fixation

Assistant Professor, University of Calgary; Academic Staff Surgeon, Foothills Medical Centre, Calgary, Alberta, Canada Distal Radius Fractures: External Fixation

Contributors

viii

Willliam N. Dust, MD, BMedSc, FRCSC, FACS

Edward J. Harvey, MD, MSc, FRCSC

Professor of Surgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada

Associate Professor, Division of Orthopaedic Surgery, McGill University; Staff Surgeon, Head, Section of Trauma and Section of Upper Extremity Surgery, Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada

Pelvic External Fixation

Alun Evans, MD, MSc, FRCS(Tr and Ortho) Trauma and Orthopedic Fellow, Dalhousie University; Trauma Fellow, and Staff, Orthopedic Division, Department of Surgery, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada Unstable Intertrochanteric Hip Fractures: Open Reduction and Internal Fixation; Anterior Pelvic Internal Fixation

Wade Gofton, MD, MEd, FRCSC Assistant Professor of Surgery, University of Ottawa Hospital, Ottawa, Ontario, Canada Intertrochanteric Hip Fractures: Intramedullary Nailing; Subtrochanteric Femur Fractures: Intramedullary Nailing

Christina Goldstein, MD Resident, Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, Ontario, Canada Femoral Neck Fractures: Open Reduction and Internal Fixation

Chris Graham, MD, FRCSC Assistant Professor, University of Manitoba; Staff Orthopaedic Surgeon, Health Sciences Centre, Winnipeg, Manitoba, Canada Operative Treatment of Fractures of the Patella; Operative Management of Ankle Fractures

Pierre Guy, MD, MBA, FRCSC Assistant Professor, Division of Orthopaedic Trauma, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada Glenoid Fracture: Open Reduction and Internal Fixation and Arthroscopically Assisted Fixation; Proximal Humerus Fractures: Open Reduction and Internal Fixation and Arthroplasty; Treatment of Open Fractures

Jeremy A. Hall, MD, MEd, FRCSC Assistant Professor, University of Toronto; Staff Orthopaedic Surgeon, St. Michael’s Hospital, Toronto, Ontario, Canada Open Reduction and Plate Fixation of Displaced Clavicle Fractures; External Fixation of Distal Tibial Fractures

Distal Radius Fractures: Open Reduction and Internal Fixation; Scaphoid Fracture Fixation

Michael A. Hickey, MD Chief Resident, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada Supracondylar Femur Fractures: Retrograde Intramedullary Nailing

Richard Jenkinson, MD, FRCSC Lecturer, University of Toronto; Orthopaedic Surgeon, Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Open Reduction and Internal Fixation of the Acetabulum: Posterior Approaches

Michael Kelly, MD Clinical Fellow, University of British Columbia; Clinical Fellow, Division of Orthopaedic Trauma, Department of Orthopaedics, Vancouver Coastal Health Authority, Vancouver General Hospital, Vancouver, British Columbia, Canada Tibial Shaft Fractures: Intramedullary Nailing

Graham J. W. King, MD, MSc, FRCSC Professor, University of Western Ontario; Chief of Orthopaedics, St. Joseph’s Health Centre, London, Ontario, Canada Terrible Triad Injuries of the Elbow

Hans J. Kreder, MD, MPH, FRCS(C) Professor, Department of Orthopaedic Surgery and Health Policy Evaluation and Management, University of Toronto; Chief, Holland Musculoskeletal Program, and Marvin Tile Chair and Chief, Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Subtrochanteric Fractures: Plate Fixation; Open Reduction and Internal Fixation of the Acetabulum: Posterior Approaches; Total Hip Replacement for Intertrochanteric Hip Fractures

ix

Mark D. MacLeod, MD, FRCSC

Clinical Fellow, St. Michael’s Hospital and University of Toronto, Toronto, Ontario, Canada

Associate Professor, Department of Surgery, University of Western Ontario; Orthopaedic Surgeon, London Health Sciences Centre, London, Ontario, Canada

Open Reduction and Internal Fixation of Intra-Articular Fractures of the Distal Humerus; Open Reduction and Internal Fixation of Forearm Fractures

G. Yves Laflamme, MD, FRCS(C) Assistant Professor, Department of Surgery, University of Montreal; Assistant Professor and Head of Orthopaedic Trauma, Hôpital du Sacré-Coeur de Montreal, Montreal, Quebec, Canada Open Reduction and Internal Fixation of the Acetabulum: Posterior Approaches; Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined with Minimally Invasive Insertion; Acute Total Hip Arthroplasty for Acetabular Fractures; Optimizing Perioperative Fracture Care

Abdel-Rahman Lawendy, MD, FRCSC Assistant Professor, Division of Pediatric Surgery, Division of Orthopaedics, Department of Surgery, University of Western Ontario; Victoria Hospital, London Health Sciences Centre; Associate Scientist, Lawson Health Research Institute, London, Ontario, Canada Compartment Syndrome

Kelly A. Lefaivre, MD Assistant Professor, University of British Columbia; Orthopaedic Surgeon, Division of Orthopaedic Trauma, Vancouver Coastal Health Authority, Vancouver General Hospital, Vancouver, British Columbia, Canada Proximal Tibia Fractures: Open Reduction and Internal Fixation

Ross K. Leighton, MD, FRCS(C), FACS Professor of Surgery, Dalhousie University; Professor of Surgery, and President of Doctors Nova Scotia, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada Unstable Intertrochanteric Hip Fractures: Open Reduction and Internal Fixation; Anterior Pelvic Internal Fixation

Allan S. L. Liew, MD, FRCS(C) Assistant Professor of Surgery, University of Ottawa; Director of Orthopaedic Trauma, The Ottawa Hospital, Ottawa, Ontario, Canada Tibial Plafond Fractures: Open Reduction and Percutaneous Plating

Proximal Tibia Fractures: External Fixation I: Temporary Knee Bridging External Fixation; Proximal Tibia Fractures: External Fixation II: Circular External Fixation

Dean G. Malish, MD, FRCSC Clinical Instructor, Department of Orthopaedics, University of British Columbia, Vancouver; Clinical Staff, Division of Orthopedics, Kelowna General Hospital, Kelowna, British Columbia, Canada Radial Head Fractures: Open Reduction and Internal Fixation

Scott J. Mandel, MD, FRCSC Assistant Clinical Professor, McMaster University, Hamilton, Ontario, Canada Proximal Humerus Fractures: Hemiarthroplasty Operative Technique; Knee Dislocations

Gerard March, MD PGY5—Orthopaedic Resident, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada Proximal Humerus Fractures: Hemiarthroplasty Operative Technique

Rod Martin, MD, FRCSC Clinical Professor, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada Proximal Humerus Fractures: Hemiarthroplasty Operative Technique

Paul A. Martineau, MD, FRCSC Assistant Professor, Division of Orthopaedic Surgery, McGill University; Staff Surgeon, Section of Upper Extremity Surgery and Section of Sports Medicine, Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada Distal Radius Fractures: Open Reduction and Internal Fixation; Scaphoid Fracture Fixation

Randy Mascarenhas, MD Orthopaedic Surgery Resident, Section of Orthopaedic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada Operative Treatment of Fractures of the Patella

Contributors

Paul R. T. Kuzyk, MD, MASc, FRCS(C)

Contributors

x

Paul K. Mathew, MD, FRCSC

Brad Pilkey, MD, FRCSC

Assistant Clinical Professor, McMaster University; Consultant, Cambridge Memorial Hospital, Cambridge, Ontario, Canada

Assistant Professor and Director of Orthopaedic Trauma, University of Manitoba; Adult Orthopaedic Surgeon and Director of Orthopaedic Trauma, Health Sciences Centre, Winnipeg, Manitoba, Canada

Terrible Triad Injuries of the Elbow

Robert G. McCormack, MD, FRCS(C), DipSportsMed Associate Professor, University of British Columbia, Vancouver; Associate Department Head, Royal Columbian Hospital, New Westminster, British Columbia, Canada Humeral Shaft Fractures: Open Reduction and Internal Fixation and Intramedullary Nailing

Perilunate Injuries: Combined Dorsal and Volar Approach

Rudolf Reindl, MD, FRCSC Assistant Professor, Orthopaedic Surgery, McGill University; McGill University Health Centre, Montreal, Quebec, Canada Cervical Spine: Anterior and Posterior Stabilization

Michael D. McKee, MD, FRCS(C)

Dominique M. Rouleau, MD, MSc, FRCSC

Professor, Division of Orthopaedics, Department of Surgery, St. Michael’s Hospital and University of Toronto, Toronto, Ontario, Canada

Associate Professor, University of Montreal; Director of Orthopaedic Clinical Research, Hôpital du Sacré-Coeur de Montreal, Montreal, Quebec, Canada

Open Reduction and Plate Fixation of Displaced Clavicle Fractures; Supracondylar Humeral Fractures: The Role of Arthroplasty; Radial Head Arthroplasty

Peter J. O’Brien, MD Associate Professor, Department of Orthopaedics, University of British Columbia; Head, Division of Orthopaedic Trauma, Vancouver Coastal Health Authority, Vancouver General Hospital, Vancouver, British Columbia, Canada Proximal Tibia Fractures: Open Reduction and Internal Fixation; Tibial Shaft Fractures: Intramedullary Nailing

Kostas P. Panagiotopoulos, MD, FRCSC Clinical Instructor, University of British Columbia, Vancouver; Orthopaedic Surgeon, Lion’s Gate Hospital, North Vancouver, British Columbia Treatment of Open Fractures

Steven Papp, MSc, MDCM, FRCSC Assistant Professor, University of Ottawa; Orthopaedic Trauma, Ottawa Civic Hospital, Ottawa, Ontario, Canada Radial Head Arthroplasty; Intertrochanteric Hip Fractures: Intramedullary Nailing; Subtrochanteric Femur Fractures: Intramedullary Nailing

Brad Petrisor, MD, MSc, FRCSC Assistant Professor, Department of Surgery, McMaster University; Orthopaedic Trauma Service, Hamilton Health Sciences: General Hospital, Hamilton, Ontario, Canada Supracondylar Femur Fractures: Retrograde Intramedullary Nailing; Repair of Tarsometatarsal Joint (Lisfranc) Fracture-Dislocation

Optimizing Perioperative Fracture Care

Marie-Ève Rouleau, MPS University of Quebec at Montreal, Montreal, Quebec, Canada Optimizing Perioperative Fracture Care

David W. Sanders, MD, MSc, FRCSC Associate Professor, Division of Orthopaedic Surgery, University of Western Ontario; Orthopaedic Trauma Surgeon, Victoria Hospital, London Health Sciences Centre, London, Ontario, Canada Compartment Syndrome

Emil H. Schemitsch, MD, FRCS(C) Professor of Surgery, and Head, Division of Orthopaedic Surgery, Department of Surgery, St. Michael’s Hospital and University of Toronto, Toronto, Ontario, Canada Open Reduction and Internal Fixation of Intra-Articular Fractures of the Distal Humerus; Open Reduction and Internal Fixation of Forearm Fractures

Rajrishi Sharma, MD Chief Resident, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada Repair of Tarsometatarsal Joint (Lisfranc) Fracture-Dislocation

David J. G. Stephen, MD, FRCS(C) Associate Professor, Department of Surgery, University of Toronto; Director of Orthopaedic Trauma, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Anterior Approaches to the Acetabulum

xi

James P. Waddell, MD, FRCSC

Clinical Professor, University of British Columbia, Faculty of Medicine, Department of Orthopaedics, Royal Columbia Hospital, Vancouver, British Columbia, Canada

Professor, Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada

Pelvic External Fixation

Ayman M. Tadros, MD, FRCSI Orthopaedic Trauma Fellow, Division of Orthopaedic Trauma, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada Glenoid Fracture: Open Reduction and Internal Fixation and Arthroscopically Assisted Fixation

Max Talbot, MD, FRCSC Assistant Professor, McGill University; Staff Surgeon, Montreal General Hospital, McGill University Health Centre; Major, and Medical Director, Canadian Forces Trauma Centre (East); National Defence, Government of Canada, Montreal, Quebec, Canada Proximal Tibia Fractures: Intramedullary Nailing; Fractures of the Talus

James Vernon, MSc, MBBS Orthopaedic Surgery Resident, University of Manitoba, Winnipeg, Manitoba, Canada Operative Treatment of Fractures of the Patella

Femoral Neck Fractures: Arthroplasty

Don W. Weber, MD, FRCS(C) Assistant Clinical Professor of Orthopaedics, University of Alberta; Site Chief of Orthopaedics, University of Alberta Hospital, Edmonton, Alberta, Canada Supracondylar Femur Fractures: Open Reduction and Internal Fixation

Neil J. White, MD, FRCSC Chief Resident, Foothills Medical Centre, Calgary, Alberta, Canada Distal Radius Fractures: External Fixation

Jeff Yach, MD, FRCS(C) Assistant Professor of Surgery, Queen’s University at Kingston; Orthopaedic Trauma Service Chief, Kingston General Hospital, Kingston, Ontario, Canada Open Reduction and Internal Fixation of Intraarticular Iliac Fracture-Subluxation (Crescent Fracture); Open Reduction and Internal Fixation of Sacral Fractures

Contributors

Trevor B. Stone, MD, FRCS(C)

PREFACE Fracture surgery occupies a special place in the hearts and minds of orthopaedic surgeons. This book is designed to be a user-friendly and clinically relevant text on common fracture surgery procedures. Every orthopaedic surgeon may be required to have knowledge or involvement in some aspect of fracture care despite their subspecialty practice. The text is designed for those who wish to review the surgical treatment of the conditions that commonly confront them while on call. As fracture surgery becomes more and more sophisticated, it is obvious that the technical component of operative intervention is critical to clinical success or failure. Therefore, there continues to be an important need to understand the technical aspects of fracture surgery. Many pearls of wisdom are detailed by the authors in order to deal with the multiple potential pitfalls seen in patients with complex fracture patterns. Each chapter has been written by a member of the Canadian Orthopaedic Trauma Society (COTS) who is an expert in that particular area. COTS is a group of orthopaedic trauma

surgeons with outstanding surgical skills who are recognized leaders in their field. In addition, through prospective and randomized trials, they are at the forefront of developing the evidence that exists for management of the patient with a fracture. Each chapter provides comprehensive technical descriptions supported by the best evidence in that area. We believe that the production qualities of this text are the highest possible. The illustrations in particular are outstanding and clearly define the complex technical aspects of fracture surgery. We would like to thank all the members of COTS who were contributors to this volume for their outstanding efforts in making it a success. We feel this text should prove to be the “resource of choice” for modern fracture care over the next several years. It will serve those who are novices in the field who wish to concentrate on principles, those experienced surgeons who wish to “fine–tune” their approach, and everyone in between. Emil H. Schemitsch, MD, FRCS(C) Michael David McKee, MD, FRCS(C)

FOREWORD The change in treatment of the orthopedic trauma patient has been very impressive over the last 20 years and the “standard of care” has changed significantly over a short time. The Canadian Orthopaedic Trauma Society (COTS), as a subsection of the Canadian Orthopaedic Association, has been a major world contributor to this change. The Canadian literature accounted for 30% of the level one evidence in orthopaedic trauma published in 2008; the majority performed by COTS (either individually or collectively). The success of this group as “the major player” in conducting prospective multicenter randomized trials has been well recognized by the Canadian Orthopaedic Association, the Orthopedic Trauma Association and was detailed in an invited article for the journal “Injury” in September 2009.1 The COTS group has won every possible award from these world organizations as a testament to their excellence in the field of clinical randomized trials and their impact on changing the way we treat fractures in our day to day practice.1 As such, Emil Schemitsch, MD was approached to put together a new text on today’s treatment methods that could be used by residents and staff as a resource for “one way” to perform the “best practice” for their patients. The following text is just such a resource. I have been truly amazed with the ability of our members and our publisher, Elsevier Inc., and Bermedica Production, Ltd. to present the material in a very easy-to-use format. This has been further enhanced with truly fantastic clinical photos (and artist’s

1

The Canadian Orthopaedic Trauma Society: A model for success in orthopaedic research. Injury. 2009;40:1131-6.

renditions) to make the clinical presentation very user friendly. The idea of presenting a method of approaching each area with pearls and pitfalls should be a great help to everyone involved in the patients care and I believe this text will become a “must have book” for each and every resident with an additional text close by each orthopaedic trauma operating theatre. The COTS group is the finest group of orthopaedic trauma surgeons with which I have ever had the pleasure to be associated. Their dedication to their patients and to their specialty is only surpassed by their surgical skills and desire to share that information with the orthopaedic world as invited speakers locally, nationally, and internationally. This they perform on a daily basis via didactic teaching, skills labs instruction and now this wonderful text on Orthopedic Trauma Surgery. This text should prove to be the “resource of choice” for current orthopedic trauma care over the next five years and will be used by all health care providers concerned with the care of the orthopaedic fracture patient. The COTS group would like to dedicate this book to our families who continue to support us despite the long hours and many missed family events, due the erratic nature of our specialty. Their support is essential to our continued success. I know you will find this text very readable and helpful on a daily basis. Ross K. Leighton, MD, FRCS(C), FACS President of COTS President elect of the COA Professor of Surgery Department of Surgery, Dalhousie University Division of Orthopedics, QE II HSC Halifax, Nova Scotia Canada

PROCEDURE 1

Open Reduction and Plate Fixation of Displaced Clavicle Fractures Jeremy A. Hall and Michael D. McKee

Displaced Clavicle Fracture

4

PITFALLS • Operative treatment of clavicle fractures must consider both patient and fracture factors.

Indications ■ ■

■

• Relative contraindications: ■

Noncompliance

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Advanced age (>60 years)

■

Medical comorbidities, especially diabetes

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Alcoholism

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Prior radiation to area

■

Poor skin/soft tissue condition

■

■ ■ ■

Examination/Imaging ■

■

Controversies • Controversy still exists regarding operative versus nonoperative treatment of clavicle fractures as nonoperative treatment has been the standard of care since the 1960s. • Debate continues regarding intramedullary versus plate fixation. • Questions remain regarding less than 2 cm of shortening as an indication.

Open fracture Fracture with associated upper extremity neurovascular compromise Clavicle fracture with associated scapulothoracic dissociation Completely displaced midshaft clavicle fracture in young active individuals, especially with shortening Displaced lateral third clavicle fracture Lateral third intra-articular clavicle fracture Associated displaced glenoid fracture (floating shoulder)

■

■

The overlying skin and soft tissues are examined for deficits, old scars, or previous incisions. The length of the injured clavicle is measured from the sternoclavicular joint to the acromioclavicular joint, and compared to the opposite uninjured side both clinically and radiographically. A carefully documented neurovascular examination of the upper extremity is done to exclude preoperative injury. Anteroposterior and 20° cephalad upshot views of the clavicle are obtained to assess fracture configuration. • Figure 1 shows an anteroposterior radiograph of a completely displaced midshaft clavicle fracture with significant displacement and rotation at the fracture site.

Treatment Options • Options for treatment of displaced clavicle fractures include open reduction and internal fixation or use of a sling for comfort. • For operative treatment, open reduction and internal plate fixation is preferred as intramedullary fixation controls length and rotation poorly. • For nonoperative treatment, a simple sling is preferred. • A figure-of-8 bandage can lead to brachial plexopathy if not applied appropriately, and has little influence on fracture outcome.

FIGURE 1

5

■

■

■

■

The clavicle forms an anterior strut to maintain the position of the shoulder on the thoracic cage (Fig. 2). • It is an S-shaped bone with a cephalad-to-caudad bow. • The subclavian vessels and brachial plexus pass posterior/posteroinferior to the clavicle before passing inferior to the coracoid and into the arm. • The apex of the lung lies posterior/posteroinferior to the clavicle. • Superficially, cutaneous braches of the intermediate supraclavicular nerve fan out over the anterior-superior region of the middle third of the clavicle. The sternoclavicular joint is a diarthrodial joint allowing movement in both the horizontal and vertical planes, as well as 20–40° of rotation relative to the manubrium, and is stabilized by the joint capsule. The acromioclavicular joint is a planar joint allowing approximately 20° of rotation relative to the acromion. This joint is stabilized by the capsule and intracapsular ligaments, as well as the conoid and trapezoid coracoclavicular ligaments. Together, these joints allow movement of the clavicle of up to 60° in the vertical plane and 20° in the horizontal plane, and up to 40° of rotation. Clavicle

FIGURE 2

Displaced Clavicle Fracture

Surgical Anatomy

Displaced Clavicle Fracture

6

PEARLS • A bump under the shoulder girdle will aid in fracture reduction, as it allows the shoulder and lateral fragment to lateralize or “fall away” from the fracture site. • Positioning the head and endotracheal tube away from the operative site will allow greater access to the clavicle.

Positioning ■ ■

■

■

■

• Tape across the forehead may be used to further stabilize the head position.

Use of a general anesthetic is preferred. The patient is placed in the beach chair position using a footboard to support the weight of the body and cushioned safety straps over the knees to prevent knee flexion (Fig. 3). A small bump is placed under the posteromedial aspect of the shoulder girdle. The clavicle is prepared and draped using a pediatric laparotomy drape with the arm at the side. The operative arm may be free draped, but this is not typically necessary.

PITFALLS • Keep the head and endotracheal tube out of the way to allow unhindered superior access for the drill, tap, and screwdriver.

Equipment • Commercially available shoulder positioning frames, such as the Tennent shoulder table, can be used.

FIGURE 3

Portals/Exposures PEARLS • A superior subcutaneous approach to the clavicle allows for fracture visualization without significant soft tissue dissection. • A two-layer exposure allows for a two-layer closure, providing greater soft tissue coverage of the hardware and fracture. This results in a reduced infection rate and, if a superficial infection does occur, the hardware is still covered by soft tissue.

■

■

■

■

■

The clavicle is exposed along the anterosuperior subcutaneous border. A 5- to 10-cm incision is centered over the fracture site (Fig. 4). As experience improves, smaller incisions are possible and preferred. If noted, superficial branches of the intermediate supraclavicular nerve are identified and protected. The skin edges are undermined in the subcutaneous plane to facilitate a mobile window of exposure. The fascia and periosteum are often disrupted, and this defect is extended medially and laterally to create anterior and posterior soft tissue flaps for fracture visualization.

7

Displaced Clavicle Fracture

Instrumentation • Low-profile, precontoured plating systems are preferred. • A pelvic reconstruction plate is often too weak, especially in patients greater than 70 kg. • Bulky straight compression plates are often too prominent.

Controversies • An anteroinferior approach to the clavicle has been described and has the advantage of directing drills and screws away from neurovascular structures, and allows for longer screws.

PEARLS • A posteriorly directed force on the shoulder and distal fragment will aid in obtaining proper fracture length.

FIGURE 4

Procedure STEP 1 ■ The fractured ends are exposed and débrided of interposed hematoma and soft tissues. ■ The fracture ends or butterfly fragments are reduced and held in place with Kirshner wires (Fig. 5) while lag screws are placed perpendicular to the fracture plane (if possible).

• Reduction forceps on the proximal and distal fragments may also be used to attain the proper fracture length.

PITFALLS • Carefully dissect the fracture fragments to maintain soft tissue attachments—do not devascularize the fragments to get them reduced. • Dissection along the inferior aspect of the clavicle fragments must be cautious given the proximity of the lung, subclavian vessels, and brachial plexus. FIGURE 5

Displaced Clavicle Fracture

8

Instrumentation/ Implantation • Many clavicle fixation sets are equipped with mini-fragment screws for lag screw applications.

PEARLS • Precontoured clavicle plates can be used as a guide to the reduction of complex or comminuted fractures.

A

• Extra-long drills, taps, and screwdrivers will aid in the insertion of screws around the head and neck, especially for medial-third clavicle fractures.

PITFALLS • Beware the proximity of the lung, subclavian vessels, and brachial plexus when drilling, tapping, and measuring screw length—beware “plunging.” • Careful retractor positioning about the fracture is necessary to protect delicate surrounding structures.

FIGURE 6

B

STEP 2 ■ To stabilize the fracture fragments, a precontoured, low-profile clavicle plate is placed along the superior edge of the clavicle and affixed using appropriately sized screws (Fig. 6A). ■ A minimum of six cortical screws and a lag screw or eight cortical screws on either side of the fracture is preferred (Fig. 6B).

Instrumentation/Implantation • Precontoured plates are useful adjuncts to the treatment of clavicle fractures and come in a variety of lengths and contours. • Lateral-third fractures and intra-articular fractures involving the acromioclavicular joint may necessitate the use of a subacromial hook plate if adequate lateral fixation is not provided by precontoured clavicle plates. • Pelvic reconstruction plates may be adequate fixation for smaller individuals (70 kg or less).

Controversies • The debate continues regarding superior versus anteroinferior plate positioning and intramedullary fixation techniques. • The authors prefer superior plate positioning using precontoured, low-profile clavicle plates as this exposure facilitates relatively straightforward fracture reduction and this plate position provides the greatest axial and torsional stability.

9

Displaced Clavicle Fracture

FIGURE 7

PEARLS • Two-layer closure provides better soft tissue coverage over the plate and fracture.

PITFALLS • The Valsalva maneuver may provide evidence of intraoperative pneumothorax, but this is not a guarantee. A postoperative chest radiograph should be performed if ventilation concerns arise (very rare).

STEP 3 ■ Stability of the fracture fixation is assessed. ■ The wound is irrigated and a Valsalva maneuver is performed to evaluate for pleural integrity. ■ The fascia and skin are closed in two layers (Fig. 7).

Postoperative Care and Expected Outcomes ■

■

■

■

Postoperatively, the wound is dressed and the arm is placed in a sling for comfort. Postoperative radiographs are taken for assessment and documentation (Fig. 8). Range-of-motion exercises begin on the first postoperative visit at 2 weeks, followed by strengthening exercises at 6 weeks given favorable radiographs. Sports are delayed until 8–12 weeks.

FIGURE 8

Displaced Clavicle Fracture

10

PEARLS • Many patients will describe numbness in the infraclavicular region as a result of traction or injury to the intermediate supraclavicular nerve(s); patients should be warned preoperatively of this possibility. • This deficit typically resolves with time, and neuroma formation is extremely rare.

PITFALLS • Early aggressive range of motion or patient noncompliance may lead to early failure of fixation.

Evidence Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures: a multicenter, randomized clinical trial. J Bone Joint Surg [Br]. 2007;89:1–10. This prospective, randomized multicenter study compared sling treatment to open reduction and internal fixation of completely displaced middle-third clavicle fractures. The authors concluded that operative treatment in young active individuals provided improved functional outcome and a lower symptomatic malunion and nonunion rate, with a low incidence of operative complication. (Grade A recommendation) Hill E, McGuire M, Crosby L. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg [Br]. 1997;79:537–9. This prospective cohort study evaluated the outcomes of 242 consecutive fractures of the clavicle treated nonoperatively; 66 were displaced middle-third clavicle fractures, and 52 patients were available for review. Radiographic and patient-oriented outcomes were reported and showed a 15% nonunion rate and a 31% unsatisfactory result in patients with completely displaced middle-third clavicle fracture. (Grade B recommendation) McKee MD, Wild LM, Schemtisch EH. Midshaft malunions of the clavicle. J Bone Joint Surg [Am]. 2003;85:790–7. This case series reported 15 patients with middle-third symptomatic clavicle malunions who underwent clavicular osteotomy and fixation. Radiographic and patient-oriented outcomes were collected pre- and postsurgery. Postoperatively, the mean clavicular shortening improved from 2.9 to 0.4 cm, and the mean DASH score improved from 32 to 12 points, suggesting clavicle fracture malunions that cause significant residual morbidity can be ameliorated with surgical correction. (Grade C recommendation) Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg [Am]. 2004;86:1359–65. This prospective observational cohort study evaluated the prevalence of nonunion after nonoperatively treated clavicle fractures. The authors reported an overall nonunion rate of 6.2%; however, completely displaced fractures with comminution had a higher risk of nonunion. (Grade B recommendation)

PROCEDURE 2

Glenoid Fracture Pierre Guy and Ayman M. Tadros

Figure 3 modified from Romero J, Schai P, Imhoff AB. Scapular neck fracture: the influence of permanent malalignment of the glenoid neck on clinical outcome. Arch Orthop Trauma Surg. 2001;121:313–6. Figure 15 modified from Mallon WJ, Brown HR, Vogler JB 3d, Martinez S. Radiographic and geometric anatomy of the scapula. Clin Orthop Relat Res. 1992;(277):142–54. Figure 16 modified from Goss TP. Fractures of the glenoid cavity. J Bone Joint Surg [Am]. 1992;74:299–305. Figure 17 modified from Goss TP. Fractures of the glenoid neck. J Shoulder Elbow Surg. 1994;3:42–52. Figure 20 modified from Van Noort A, Van Loon CJM, Rijnberg WJ. Limited posterior approach for internal fixation of a glenoid fracture. Arch Orthop Trauma Surg. 2004;124:140–4.

12

Glenoid Fracture

Open Reduction and Internal Fixation and Arthroscopically Assisted Fixation Indications PITFALLS • Prioritize commonly associated life-threatening injuries: head, spine/spinal cord, chest, brachial plexus, vascular • Indication individualized to injury, patient health, and functional demand • Contraindications to open reduction and internal fixation: infections, pre-existing shoulder arthritis, or severe comminution not allowing stable fixation

Controversies • Anterior rim fractures may be treated nonoperatively if the glenohumeral joint remains concentric. • No clear evidence is available comparing operative and nonoperative treatment. Indications are based on principles of articular injury treatment, not on high-level comparative trials.

■

■

General indications • Open fractures • Neurovascular injuries that need exploration • Symptomatic pseudoarthrosis Specific indications: relative to the portion of the glenoid involved • Glenoid fossa fractures (intra-articular glenohumeral joint) ◆ Articular step 4 mm or more. ◆ Articular gap more than 10 mm (risk of nonunion) ◆ Glenoid rim fracture involving greater than ¼ of fossa anteriorly, greater than 1⁄3 posteriorly ◆ Associated with persistent dislocation or subluxation of the humeral head • Glenoid neck fractures (extra-articular fractures) ◆ Translational displacement greater than 2 cm ◆ Significant angulation: transverse or coronal plane greater than 20–40° or glenopolar angle (GPA) less than 20° (normal, 30–45°) (Romero et al., 2001). The GPA is measured on an anteroposterior radiograph as the angle between the line connecting the most cranial with the most caudal point of the glenoid cavity and the line connecting the most cranial point of the glenoid cavity with the most caudal point of the scapular body (the lateral boder of the scapula) (Fig. 1).

GPA= 30°-45°

FIGURE 1

13

Relative indications • Associated displaced clavicle fracture (>2 cm) shortening or comminution • Associated acromioclavicular, coracoacromial, or coracoclavicular injury • Associated double disruption of the superior shoulder suspensory complex

Examination/Imaging PHYSICAL EXAMINATION ■ Goal: identify/rule out associated injuries ■ Assess for concurrent: • Neurologic injury: head, spine/spinal cord, brachial plexus • Vascular injury ◆ Inspection and palpation for pulse and perfusion signs ◆ Side-to-side comparison of blood pressure (particularly in presence of first rib fracture); if abnormal, consider angiography/computed tomography (CT) angiography • Open fracture and/or ipsilateral limb–shoulder girdle injury: to define timing of care • Other system injury: primary and secondary surveys PLAIN RADIOGRAPHY ■ Chest radiograph • Important in assessing commonly associated chest trauma • May represent the first chance to identify scapular fracture or scapulothoracic dissociation • Not sufficient for assessment and preoperative planning for scapular fractures ■ Cervical spine imaging: radiography or CT as per center’s protocol

Glenoid Fracture

■

14

Glenoid Fracture

■

■

■

A

C

FIGURE 2

Shoulder trauma series • Obtain anteroposterior (x-ray beam tangential to glenoid/perpendicular to the plane of the scapular body), trans-scapular lateral, and transaxillary views. • Consider a “bumped-up view” if a standard axillary view with the arm abducted is not clinically feasible (Fig. 2A–C). Assess scapula-glenoid fractures and detect associated shoulder girdle injuries: clavicle; proximal humerus; disruptions of the acromioclavicular, glenohumeral, sternoclavicular, and scapulothoracic articulations; suspensory ligamentous complex injury. It is important to differentiate true fossa fractures from anterior and posterior rim fractures.

B

15

A

C FIGURE 3

B

Glenoid Fracture

• Anterior and posterior rim fractures (type I; see Surgical Anatomy) are larger than Bankart “bony avulsions,” which occur when the humeral head loses its congruity as it dislocates anterior to the glenoid. Rim fractures result from a relatively eccentric lateral force that drives the humeral head against the anterior or posterior portion of the glenoid fossa depending on arm position. ◆ Figure 3A–C shows an anterior rim fracture with maintained concentric glenohumeral alignment in a 63-year-old female accountant who was treated nonoperatively (Case 1).

16

Figure 4A–C shows an anterior rim fracture with loss of glenohumeral alignment in a 36-year-old male who sustained this injury while skimboarding, when he noticed his shoulder dislocate and self-reduce (Case 2). • In contrast to type I, true glenoid fossa fractures (types II–VI; see Surgical Anatomy) follow a more centrally applied lateral force producing, in most cases, a transverse fracture of the glenoid, which then extends in one of several directions depending on the direction of the load.

Glenoid Fracture

◆

A

C FIGURE 4

B

17

Glenoid Fracture

A

B

C FIGURE 5

◆

Figure 5A–C shows a displaced extra-articular fracture of the scapula in a 31-year-old overhead worker (electrician) who sustained this injury while mountain biking (Case 3). He has a significant past history of an acromioclavicular joint injury treated with late distal clavicle resection.

Glenoid Fracture

18

A

B

C FIGURE 6 ◆

◆

Figure 6A–C shows a displaced comminuted, intra-articular fracture of the scapula (glenoid fossa type VI) in a 39-year-old male who sustained this injury catching his front wheel and falling from his bicycle (Case 4). Figure 7 shows a displaced intra-articular transverse fracture of the glenoid fossa (type III) with associated clavicle and first rib fractures in a 36-year-old male triathlete who sustained this injury while road cycling (Case 5). He was neurovascularly intact with symmetric blood pressure in both upper extremities.

19

Glenoid Fracture

FIGURE 7

COMPUTED TOMOGRAPHY AND MAGNETIC RESONANCE IMAGING ■ Two-dimensional CT reconstruction may be useful in preoperative assessment if done in orthogonal planes to the glenoid to assess fragments and their relative displacement. • Figure 8A–C shows two-dimensional CT views of the large anterior rim injury sustained by the skimboarder in Case 2.

A FIGURE 8

B

C

Glenoid Fracture

20

■

• Figure 9A–D shows two-dimensional CT views of the type III injury sustained by the triathlete in Case 5. Axial CT slices with three-dimensional reconstruction are the most useful modality in fracture assessment and preoperative planning. Centers could decide to make these part of chest trauma CT studies (time, resource utilization, radiation minimization). • Figure 10A and 10B shows three-dimensional CT views of the small anterior rim injury sustained by the 63-year-old accountant in Case 1. • Figure 11A and 11B shows three-dimensional CT views of the large anterior rim injury sustained by the skimboarder in Case 2.

A

B

C

D

FIGURE 9

21

Glenoid Fracture

A

B

FIGURE 10

A FIGURE 11

B

Glenoid Fracture

22

Treatment Options • Nonoperative treatment is advocated for undisplaced/ minimally displaced fractures, severely comminuted unreconstructible fractures (when stable fixation cannot be expected), and cases in which no functional use of the limb is expected. • Operative care includes open techniques, closed reduction and percutaneous fixation techniques, and arthroscopically assisted techniques. Figure 14A and 14B shows postoperative radiographs confirming preserved glenohumeral alignment of the anterior rim fracture in the 63-year-old accountant in Case 1.

■

• Figure 12 show a three-dimensional CT view of the extraarticular glenoid neck/body fracture sustained by the mountain biking electrician in Case 3. • Figure 13A and 13B shows three-dimensional CT views of the type VI injury sustained by the bicyclist in Case 4. Magnetic resonance imaging may be of value in detecting associated rotator cuff tears or ligament injuries; however, it is not practical in an acute trauma setting.

FIGURE 12

A FIGURE 13

B

23

■

A

Bony anatomy • Internal fixation is limited by the osseous anatomy of the scapula, which is mostly thin. • The thick regions suitable for internal fixation are the glenoid process, the coracoid process, the acromion/scapular spine, and the lateral border of the scapular body (Fig. 15).

B

FIGURE 14

FIGURE 15

Glenoid Fracture

Surgical Anatomy

24

Glenoid Fracture

■

Soft tissue anatomy • The scapula is covered by muscle and surrounded by nervous and vascular structures. These must be avoided, protected, and/or mobilized during the surgical dissection.

CLASSIFICATION OF GLENOID FRACTURES ■ Important for surgical decision making ■ Glenoid fossa fractures (intra-articular) • Goss (1992, 1995) modified Ideberg’s original classification, which is useful in planning approaches. • Types of glenoid fossa fractures (Fig. 16): ◆ IA—anterior rim fracture; IB—posterior rim fracture ◆ II—fracture line through the glenoid fossa exiting at the lateral border of the scapula ◆ III—fracture line through the glenoid fossa exiting at the superior border of the scapula ◆ IV—fracture line through the glenoid fossa exiting at the medial border of the scapula

IA

IB

II

VA

FIGURE 16

III

VB

IV

VC

VI

25

■

Type I fracture

AP view

AP view

Type II Fractures

Translational Displacement

Angulatory displacement

Axillary view

Axillary view

FIGURE 17

Glenoid Fracture

VA—combination of types II and IV; VB— combination of types III and IV; VC— combination of types II, III, and IV ◆ VI—comminuted fracture Glenoid neck fractures (extra-articular) • Their typical displacement is toward the midline with angulation in the transverse and coronal planes. • Indications for open reduction and internal fixation (ORIF) are based on Ada and Miller’s (1991) recommendations and follow Goss’ (Fig. 17) classification (1994) of glenoid neck fracture displacement (translation and angulation). ◆ Type I includes all minimally displaced fractures. ◆ Type II includes all significantly displaced fractures (translational displacement ≥1 cm; angulatory displacement ≥40°) • Of note, some relative displacement of the lateral border of the scapula to the glenoid may contribute to the apparent medial translation of the glenoid (Obremsky et al., 2007; Patterson et al., 2007). ◆

26

Glenoid Fracture

Positioning ■

PEARLS • Final position should allow safe access to the approached side (posterior or anterior), limb mobilization, and adequate intraoperative imaging.

■ ■

Posterior approach • The prone or lateral decubitus position with the operative side up may be used. • The lateral decubitus position is favored in most trauma patients. ◆ Figure 18A shows a patient in the lateral decubitus position on a beanbag for a planned posterior approach and the use of a Mayo stand to support the operated arm. ◆ Figure 18B shows the use of table-based practitioners, as well as the position of the surgical team. Anterior approach: beach chair position Arthroscopic surgery: beach chair or lateral decubitus position with traction and slight shoulder abduction and flexion

B

A

Assistant

Surgeon

FIGURE 18

Portals/Exposures ■

The choice of the approach depends on the type of fracture. • Type IA fractures may be approached anteriorly or arthroscopically. • The other glenoid fossa fracture types and operatively treated glenoid neck fractures are preferably approached posteriorly, supplemented by a superior approach for lag screw fixation for transverse fossa fractures as needed.

27

• Given the frequency of associated life-threatening injuries to the chest, head, and cervical spine, which might preclude proper patient positioning, the final surgical approach and positioning decision should be made in collaboration with the anesthesiologist, intensivist, and general surgeon.

■

• The beach chair is the preferred position for arthroscopy to allow conversion to an open technique if required.

A

• Isolated type III fractures may be reduced indirectly percutaneously and fixed by percutaneous superior-to-inferior screw placement (see Fig. 21C in ORIF procedure below). Posterior approach • Two posterior surgical approaches have been described for ORIF of glenoid fractures. • Extensile exposure described by Judet (authors’ preferred approach) (see Video 1): ◆ The skin incision extends from the posterolateral acromion angle, along the whole length of scapular spine to the superomedial corner, then curves distally along the medial border of the scapula (Fig. 19A). ◆ A skin flap is then elevated, exposing the posterior deltoid and infraspinatus muscles (Fig. 19B).

B

D

Deltoid muscle Axillary nerve

Infraspinatus muscle Teres minor muscle

Posterior circumflex humeral artery

Teres major muscle

C FIGURE 19

E

Glenoid Fracture

PITFALLS

Glenoid Fracture

28

• A conventional operating table with beanbag stabilization is suitable for management of most fractures, allowing surgical access and intraoperative imaging (see Fig. 18A). • A well-padded Mayo stand is used as a mobile adjustable armrest for the operated limb (see Fig. 18B).

PITFALLS • Care must be taken to avoid nerve injuries: the suprascapular, axillary, and XIth cranial accessory nerve in a posterior exposure and the brachial plexus and artery axillary in an anterior exposure. Converting to a more extended approach may be necessary to relieve nerve tension

■

• One concern with the more limited posterior approach, which abducts the arm at 90°, is that this places the axillary nerve more lateral and closer to the surgical site. • Fluid extravasation during arthroscopically assisted procedures should be monitored closely.

Controversies • Arthroscopically assisted ORIF has not been compared or shown superiority to a standard deltopectoral approach.

The deltoid-infraspinatus muscle interval is then developed and the posterior deltoid is sharply detached from the lateral scapular spine to its tip (Fig. 19C; see also Video 2). ◆ The safe infraspinatus–teres minor interval (respectively supplied by the suprascapular and axillary nerves; see Fig. 19C) is then developed, exposing the lateral border of the scapula to the inferior aspect of the glenoid and safely freeing the infraspinatus for further dissection. ◆ The infraspinatus and teres minor muscle bellies are then detached from the medial border of the scapula and from the infraspinatus fossa (Fig. 19D). ◆ The infraspinatus is carefully reflected laterally and superiorly, keeping it moist and avoiding traction to its neurovascular pedicle originating from the spinoglenoid notch (Fig. 19E). Also note careful elevation of the supraspinatus. ◆ A posterior arthrotomy can help in monitoring articular reduction. The limited posterior approach (popularized by van Noort) • An alternative to Judet’s exposure, avoiding elevation of the infraspinatus, was described by van Noort et al. (2004): “An angular incision is made, starting medially along 2⁄3 of the scapular spine, then curving 2 cm medial from the posterior edge of the acromion and proceeding caudad for 10 cm . . . By abducting the arm 90 deg, the inferior border of the deltoid is raised, which allows easy retraction” (Fig. 20A and 20B). • Minimal release of its medial attachment to the scapular spine may be needed. • The plane between the infraspinatus and teres minor muscles, respectively supplied by the suprascapular and axillary nerves, is developed, exposing the lateral border of the scapula to the inferior aspect of the glenoid. • A small posterior glenohumeral vertical arthrotomy is then made to allow joint visualization. • A retractor is inserted into the joint to retract the humeral head anteriorly. Anterior approach • A standard deltopectoral approach is used. • A subscapularis tenotomy is usually carried as per the traditional open Bankart repair, protecting the vessels running along the inferior portion of the tendon. ◆

Equipment

■

29

Deltoid muscle

A

Deltoid muscle

B FIGURE 20

■

■

• A longitudinal or H-shaped capsulotomy allows joint visualization for reduction and fixation. Superior approach • A superior approach is typically used for placement of a lag screw following reduction via open anterior or posterior approaches or indirectly percutaneously (see Fig. 21C). • As these injuries commonly have associated clavicle or acromioclavicular joint injuries, which will be repaired, the afforded surgical access can also be used for ORIF of the clavicle. Arthroscopically assisted glenoid fracture fixation • A standard posterior camera portal and two anterior working portals, centered 2 cm medial and 1 cm inferior to the anterolateral border of the acromion, just lateral to the coracoid process, are used (see Video 3).

Glenoid Fracture

Spine of scapula Trapezius muscle Medial margin of scapula Infraspinatus muscle Teres minor muscle Teres major muscle Major rhomboid muscle Erector spinae muscle

Glenoid Fracture

30

Procedure: Open Reduction and Internal Fixation

PEARLS • Add arthrotomy to monitor reduction during a posterior approach.

STEP 1 ■ Clear the fracture lines, removing hematoma and loose fragments, with preservation of sufficient soft tissue attachments. ■ Reduce articular fracture(s) first if present, apply provisional fixation with Kirschner wires (K-wires), and monitor reduction with imaging or direct visualization. Figure 21A and 21B shows percutaneous reduction of the glenoid using a joystick attached to the acromion in the triathlete in Case 5.

• Consider indirect reduction through manipulation of the coracoid for type III fractures. • In arthroscopically assisted cases, the first steps best involve establishing a posterior and an anterosuperior portal for initial irrigation and hematoma evacuation to assist reduction.

STEP 2 ■ Definitive rigid articular fracture fixation is performed, typically using lag screws. ■ Most fixation is from posterior to anterior (posterior approach). Anterior and arthroscopic approaches typically use fixation from anterior to posterior. ■ As most fractures have a transverse component, now is a good time to place a lag screw from superior to inferior from a superior (possibly percutaneous) approach, just posterior to the lateral end of the clavicle. Figure 21C shows fixation of the fracture in the triathlete in Case 5 by a screw placed through a superior approach. ■ Implants would typically start posterior to the lateral aspect of the clavicle, directed from superior to inferior through the muscle belly/musculotendinous junction of the supraspinatus muscle, to fix the transverse component of a fossa fracture (see Fig. 21C).

PEARLS • Small-size implants (2.0– 2.7 mm) achieve sufficient purchase and prevent overcrowding. • Articular fixation may also be combined with buttress plate fixation to increase initial construct rigidity.

A FIGURE 21

B

C

31

• Avoid large implants around the joint to prevent overcrowding. • Consider version and the GPA of the glenoid when aligning the articular fragment and body.

FIGURE 22

FIGURE 23

A

STEP 3 ■ Internal fixation is completed, stabilizing the articular segment to the scapular body and spine. ■ Final imaging is done to confirm reduction and safe implant position. • Figure 22A and 22B shows postoperative radiographs confirming reduction of the neck fracture to the mountain biker in Case 3. • Figure 23A and 23B shows postoperative radiographs confirming reduction of the type VI injury to the bicyclist in Case 4.

A

B

B

Glenoid Fracture

PITFALLS

Glenoid Fracture

32

Instrumentation/ Implantation • Small-size implants (2.4–2.7 mm in diameter) are used in the periarticular area, while 3.5-mm implants may be used to join larger segments.

A

C FIGURE 24

■

• Figure 24A–C shows postoperative radiographs confirming reduction and safe implant position of the injuries to the triathlete in Case 5. Wound closure • Posterior approach: at completion of fixation, closure consists of a heavy resorbable suture to repair the medial origin of the infraspinatus and teres minor to the medial border of the scapula, and to similarly repair the posterior deltoid to the spine. • Anterior approach: the capsule and tenotomy are closed in layers.

B

33

■

PEARLS • Two provisional K-wires is used per anterior working portal. • If cannulated screws are used, maintain at least one stable fixation device (K-wire) while the screw is inserted over the other wire. • Use long guidewires and short cannulas.

A FIGURE 25

This procedure is used for type IA fractures, as illustrated by the skimboarder in Case 2.

STEP 1 ■ Arthroscopic portals are established. ■ The joint is thoroughly irrigated, followed by diagnostic arthroscopy. ■ Any clot is mobilized by introducing a probe hook through the working cannula, and loose fragments are identified and removed. ■ The fracture site is débrided using shavers. STEP 2 ■ The fracture is reduced and provisionally fixed using K-wires. ■ Reduction is confirmed by direct visualisation or arthroscopy. STEP 3 ■ Definitive fracture fixation is achieved by: • Screws introduced percutaneously, preferably cannulated over provisional wires (Fig. 25A and 25B).

B

Glenoid Fracture

Procedure: Arthroscopically Assisted Glenoid Fracture Fixation

Glenoid Fracture

34

■

A

• Alternately or in addition, nonabsorbable sutures may be passed through the labrum and the capsule of the displaced articular fragment, then through the fragment and glenoid. An anterior-toposterior suture technique is used, with the knot tied over the infraspinatus (similar to the Caspari technique for anterior Bankart instability). Final reduction is controlled arthroscopically and radiographically (see Fig. 25) and follow-up x-rays are taken (Fig. 26A and 26B).

B

FIGURE 26

PEARLS • The ability to achieve a rigid internal fixation construct will allow early ROM to prevent postoperative stiffness.

Postoperative Care and Expected Outcomes ■

■

The shoulder on the operated side is immobilized with a sling until pain subsides to allow a threephase rehabilitation program. Phase 1 • If an excellent reduction and stable fixation has been achieved, simple “stooping” range-of-motion (ROM) exercises are instituted for 4 weeks postoperatively. They include pendulum and passive-assisted ROM exercises. The arm is allowed to come to approximately 90° of forward elevation and 30° of external rotation, with internal rotation allowing the patient’s thumb reach to the thoracolumbar junction.

35

• Secondary displacement or fixation failure during the first 6 weeks postoperatively should be investigated for a possible infection. • Heterotopic ossification and adhesive capsulitis may occur following management of these fractures. Although no specific prophylactic regimen has been recommended for heterotopic ossification, early mobilization should diminish the incidence of stiffness.

■

■

■

• During this initial phase, the patient is examined clinically and radiographically with a scapula series (anteroposterior, lateral, and axillary view radiographs) 2 weeks postoperatively, to assess the surgical site, stability of fixation, and glenohumeral joint reduction and congruity (see Fig. 24). Phase 2 • This phase starts with the second postoperative visit at 4 weeks following surgery. • If fracture fixation stability is confirmed clinically and radiographically, active ROM is allowed, as well as active external and internal rotation. Phase 3 • At approximately 10–12 weeks following surgery, the patient is reassessed. If the fracture has united, then resisted exercises are allowed. • Note: If the fracture is highly comminuted or absolute rigidity cannot be achieved, phase 1 ROM exercises are extended up to 6 weeks postoperatively, with careful radiographic fracture evaluation to exclude failure of fixation. If the fixation remains stable, active ROM and resisted exercises progress according to clinical and radiographic assessments. • Rehabilitation aims for maximum ROM and strength. This generally takes 16–24 weeks. Heavy manual labor jobs and athletic activities are prohibited at least until 6 months following surgery. The outcomes are overall favorable following ORIF under the present recommended indications, with 70–98% of patients being pain free. Functional outcome appears tightly linked to the outcome of the patients’ frequently associated system injuries, and to the development of postsurgery/injury complications (e.g., stiffness).

Evidence There are no higher level evidence studies to guide treatment decisions. There have been no comparative studies (randomized controlled trials or comparative cohorts) of operative versus nonoperative care. Most publications consist of small retrospective single-cohort studies with radiographic and surgeon-based endpoints. Some retrospective cohorts with functional outcomes scores and a few small prospective cohort studies have been published. Classification systems, aimed at decision making, have been developed from these clinical studies based on the diagnostic and therapeutic, and in some cases functional, outcomes data.

Glenoid Fracture

PITFALLS

Glenoid Fracture

36

CLASSIFICATION SYSTEMS Goss TP. Fractures of the glenoid cavity. J Bone Joint Surg [Am]. 1992;74:299-305. Goss TP. Fractures of the glenoid neck. J Shoulder Elbow Surg. 1994;3:42-52. Goss TP. Scapular fractures and dislocations: diagnosis and treatment. J Am Acad Orthop Surg. 1995;3:22-33. Obremsky WT, Armitage B, Corr B. Glenoid fractures do not medialize. Paper #54, Annual General Meeting, Orthopedic Trauma Association, Boston, 2007. Patterson JMM, Galatz L, Toman J, Torretta P III, Ricci WM. CT evaluation of extraarticular glenoid neck fractures: Does the glenoid medialize or does the scapula lateralize? Paper #55, Annual General Meeting, Orthopedic Trauma Association, Boston, 2007. Romero J, Schai P, Imhoff AB. Scapular neck fracture: the influence of permanent malalignment of the glenoid neck on clinical outcome. Arch Orthop Trauma Surg. 2001;121:313-6. The authors reported that a GPA less than 20° was associated with poorer functional outcome, hence suggesting it as a relative indication for ORIF.

ANATOMY Mallon WJ, Brown HR, Vogler JB 3d, Martinez S. Radiographic and geometric anatomy of the scapula. Clin Orthop Relat Res. 1992;(277):142-54.

NONOPERATIVE TREATMENT Ada JR, Miller ME. Scapular fractures: analysis of 113 cases. Clin Orthop Relat Res. 1991;(269):174-80. Khallaf F, Mikami A, Al-Akkad M. The use of surgery in displaced scapular neck fractures. Med Princ Pract. 2006;15:443-8. Maquieira GJ, Espinosa N, Gerber C, Eid K. Non-operative treatment of large anterior glenoid rim fractures after traumatic anterior dislocation of the shoulder. J Bone Joint Surg [Br]. 2007;89:1347-51. Nordqvist A, Petersson C. Fractures of the body, neck, or spine of the scapula. Clin Orthop Relat Res. 1992;(283):139-44.

FLOATING SHOULDER Herscovici D, Fiennes AG, Allgöwer M, Rüedi T. The floating shoulder: ipsilateral clavicle and scapular neck fractures. J Bone Joint Surg [Br]. 1992;74:362-4.

LIMITED POSTERIOR APPROACH Van Noort A, Van Loon CJM, Rijnberg WJ. Limited posterior approach for internal fixation of a glenoid fracture. Arch Orthop Trauma Surg. 2004;124:140-4.

ARTHROSCOPY Bauer T, Abadie O, Hardy P. Arthroscopic treatment of glenoid fractures. Arthroscopy. 2006;22:569.

PROCEDURE 3

Proximal Humerus Fractures Pierre Guy

Figure 41 modified from Demirhan M, Kilicoglu O, Altinel L, Eralp L, Akalin Y. Prognostic factors in prosthetic replacement for acute proximal humerus fractures. J Orthop Trauma. 2003;17:181-8.

38

Proximal Humerus Fractures: ORIF

Open Reduction and Internal Fixation and Arthroplasty Indications GENERAL INDICATIONS ■ The decision to operate depends on the patient’s physiologic age/functional demands, fracture fragment displacement, and expected ability to reduce fragments and maintain fixation (as reflected by the “bone quality”). ■ Absolute indications: open fractures, neurovascular injuries that need exploration.

PITFALLS • Beware of posterior displacement of GT fractures not seen on standard radiograph (low threshold for computed tomography scan). • Beware of LT fractures, which may be associated with posterior dislocation (instability, seizure disorder, alcohol withdrawal). • Anatomic neck fractures may be missed with GT fracturedislocation.

Controversies • Precise determination of “number of parts” in a given fracture remains challenging; 3/4-part fractures are grouped because of similar operative treatment. • Indications for primary arthroplasty are controversial. Arthroplasty may be decided intraoperatively if stable fixation is not possible, or pre-/ intraoperatively in cases of significant articular fragment involvement: head-splitting fractures, acute/chronic fracturedislocations.

SPECIFIC INDICATIONS ■ Undisplaced (1-part) fractures are treated nonoperatively. ■ Displaced 2-part fractures (see Surgical Anatomy): most are treated with open reduction and internal fixation (ORIF). • Greater tuberosity (GT) fractures ◆ Greater than 5 mm displacement in physiologically young active individual, overhead worker/athlete ◆ Greater than 10 mm displacement in older adult • Lesser tuberosity (LT) fractures (rare) ◆ Greater than 10 mm displacement • Surgical neck fractures ◆ Greater than 75% translation or 10–20 mm shortening, extensive metaphyseal comminution, varus alignment in physiologically young active individual • Anatomic neck fracture ◆ Greater than 45° angulation ◆ Usually associated with fracture-dislocation when 2-part fracture ■ Displaced 3/4-part fractures (see Surgical Anatomy) • Valgus impacted fractures ◆ Young: ORIF ◆ Older sedentary: nonoperative • Fracture-dislocations, all other 3/4-part fractures ◆ ORIF if feasible ◆ Arthroplasty when ORIF not possible (see Controversies box discussion of osteonecrosis in Postoperative Care and Expected Outcomes)

39

• Nonoperative treatment: predictable results are achieved with residual deficit for undisplaced fractures and some displaced fractures in the elderly treated nonoperatively. • ORIF is favored as a first-line strategy; arthroplasty is reserved for unrepairable fractures and cases that are unstable postfixation.

A

C FIGURE 1

■

■

General examination • Rule out other injuries. • Assess for fitness to undergo surgery. • Inspection: rule out open fracture and severe hemorrhage; assess for dislocation. • Palpation: rule out vascular or neurologic injury. Plain radiography: shoulder trauma series • Anteroposterior (x-ray beam tangential to glenoid/ perpendicular to the plane of the scapular body; Fig. 1A), trans-scapular lateral (Fig. 1B), and transaxillary (Fig. 1C) views will establish the diagnosis in most cases.

B

Proximal Humerus Fractures: ORIF

Examination/Imaging

Treatment Options

40

Proximal Humerus Fractures: ORIF

◆

◆

A

Figure 2A–C shows radiographs of a GT fracture (Case 1). Figure 3A and 3B shows an extensively comminuted surgical neck fracture in a polytraumatized 29-year-old female (Case 2).

B

C

A

B

FIGURE 2

FIGURE 3

41

Proximal Humerus Fractures: ORIF

A

B

C

FIGURE 4 ◆

◆

A FIGURE 5

Figure 4A–C shows an unreducible isolated surgical neck fracture in a 25-year-old female (Case 3). Figure 5A and 5B shows a proximal humeral impacted valgus fracture in a 47-year-old female presenting after a fall from standing height onto her shoulder (Case 4).

B

Proximal Humerus Fractures: ORIF

42

FIGURE 6

Figure 6 shows a preoperative view of a proximal humerus fracture-dislocation (Case 5). • Consider “bumped-up view” (aka “chicken wing” view) if the standard axillary view with the arm abducted is not clinically feasible (usually quite painful). ◆ To obtain an axial (axillary) view while the patient still comfortably wears a sling, the x-ray cassette is placed superior to the shoulder while the x-ray beam is centered in the axilla starting below the level of the x-ray table, aiming cephalad and anterior (Fig. 7A–C). ◆ This view is advantageous as the patient may still wear a sling and, in the trauma setting, may still need to remain supine. • Additional anteroposterior views of the proximal humerus in internal (Fig. 8A) and external (Fig. 8B) rotation that show the humerus free of the overlapping adjacent scapula help quantify the initial diagnosis and assist with assessment of healing in follow-up. ◆

43

Proximal Humerus Fractures: ORIF

C FIGURE 7

B

A

FIGURE 8

B A

Proximal Humerus Fractures: ORIF

44

A

B

C

D

FIGURE 9

Figure 9 shows a displaced proximal humeral fracture (Fig. 9A and 9B) and its reduction (Fig. 9C and 9D) in a 27-year-old female after a fall onto the left shoulder while snowboarding (Case 6). Note the use of internal (Fig. 9A) and external (Fig. 9B) rotation views to define the fracture preoperatively. Computed tomography (CT) • Axial CT supplemented with two- and threedimensional reconstruction is the most useful modality in fracture assessment and preoperative planning. ◆ Figure 10 shows axial (Fig. 10A–C) and threedimensional reconstructed (Fig. 10D–F) CT images of the proximal humerus impacted valgus fracture in Case 4. • Multiplanar imaging may be useful in identifying the displaced fragments (e.g., isolated GT fracture) and for preoperative planning. Magnetic resonance imaging • This may be of value in detecting associated rotator cuff tears or adjacent ligament injuries (acromioclavicular, coracoclavicular); however, it is not practical in the acute trauma setting. ◆

■

■

45

E

Proximal Humerus Fractures: ORIF

F D FIGURE 10

C B A

46

Proximal Humerus Fractures: ORIF

• The decision to operate is based on bony injury diagnosis and patient factors. • Soft tissue lesions (cuff tears) are sought intraoperatively and repaired as needed, or investigated at a later stage.

Surgical Anatomy ■

■

■

Articular fragment Greater tuberosity

The proximal humerus is composed of four parts as described by Codman (Fig. 11). • Classification of proximal humerus fractures is important in surgical decision making. • Codman described the proximal humerus and its injuries, separating them in up to four parts representing the embryologic and growth development in this region. Figure 12 shows the osseous anatomy and muscle attachment to the proximal humerus and the surrounding neurovascular structures. • Rotator cuff tendons: suprapinatus, infraspinatus, teres minor (to GT), subscapularis (to LT) • Nerves: axillary nerve, brachial plexus (not shown) • Vascular: anterior humeral circumflex artery, lateral ascending branch Trabecular and subchondral bone distribution in the proximal humerus is critical to fixation decisions. • Sites of increased accumulation of trabecular bone (in the “calcar” area) and subchondral density in the epiphysis reflect regions of better implant purchase.

Lesser tuberosity Greater tuberosity

Lesser tuberosity

Axillary nerve

Subscapularis tendon Lateral ascending branch of the anterior humeral circumflex artery Anterior humeral circumflex artery

Shaft/surgical neck

FIGURE 11

Supraspinatus tendon

FIGURE 12

47

• Complete routine imaging preoperatively. • Draping the image intensifier into the operative field makes it readily accessible. • Positioning it from the contralateral side (if the image intensifier gantry so allows) facilitates the imaging process (see Fig. 13).

Positioning ■

■

The beach chair or supine position may be used, independent of chosen surgical approach. A radiolucent table facilitates intraoperative imaging, and the image intensifier’s position should also be planned as it is an important part of the procedure. • Options for image intensifier position are on the side contralateral to the injury (Fig. 13A and 13B) or from proximal (Fig. 14A and 14B).

A

A

B FIGURE 13

B FIGURE 14

Proximal Humerus Fractures: ORIF

PEARLS

Proximal Humerus Fractures: ORIF

48

PITFALLS

Portals/Exposures ■

• Avoid excessive raising of the head in the beach chair position in the elderly (potential risk to cerebral and/or retinal perfusion). • Plan for possible arthroplasty requiring free movement (extension) of the shoulder.

Equipment • Always plan for arthroplasty equipment to be available.

PEARLS • Arm abduction relieves tension from the deltoid on the lateral humerus, and facilitates drilling and implant positioning in the deltoid split approach.

PITFALLS • Axillary nerve palpation and protection for the deltoid split can be done safely by progressively mobilizing surrounding tissues. ■

Controversies • Safety of deep submuscular dissection and axillary nerve mobilization in the deltoid split approach concerns all. Recent publications describe its clinical use and delineate its boundaries for implant placement.

Deltoid split lateral approach (Fig. 15A; see Video 1) • Indications ◆ Isolated fractures of the greater tuberosity or of the surgical neck ◆ 3/4-Part fractures (mainly valgus impacted) • Incision (Fig. 15B) ◆ The proximal incision is made from the anterolateral corner of the acromion to a maximum of 5 cm distally in line with the anteromedial deltoid raphe. The subdeltoid bursa is opened, and any hematoma evacuated (Fig. 15C) ◆ The proximal extension separates the anterior deltoid from the anterior trapezius at the lateral clavicle. ◆ The distal incision is made at the deltoid tuberosity. • Cuff tendons are identified and “tagged” with suture. The rotator cuff interval may be opened to improve deep fragment/joint visualization. • Internal and external rotation allows inspection, reduction, and fixation of the tuberosities. • If distal dissection is required for lateral plate placement, blunt finger dissection along the lateral cortex of the shaft will identify the axillary nerve (“like a piano cord”) and carefully mobilize it. This nerve may be visualized directly but is always palpated and protected by the surgeon’s finger. • Thick deltoid/trapezius soft tissue flaps are reattached at closure. Deltopectoral anterior approach (Fig. 16A) • Indications ◆ Displaced 3/4-part fractures ◆ Fracture-dislocations ◆ Planned or high-probability arthroplasty • A classic approach is used for exposure, with some specific fracture care steps carried out for reduction and fixation. • An incision is made from the coracoid tip to the deltoid tuberosity. The cephalic vein is usually retracted laterally. The clavipectoral fascia is incised lateral to the conjoint tendon (Fig. 16B). • Any hematoma is evacuated. The biceps tendon and tuberosities (on each side of it) are identified and cuff tendons are tagged. • The arm is abducted to open the subdeltoid space, which is developed. A Hohmann retractor is placed

49

Proximal Humerus Fractures: ORIF

Bicipital groove Ascending artery

Axillary nerve

A

B

C

above the tip of the coracoid to expose it superiorly. • Distal extension is possible by detachment of the anterior half of the distal deltoid insertion.

FIGURE 15

Brachial plexus Cephalic Deltoid vein

Clavicle Acromion Bicipital groove

Ascending artery

Ascending artery Axillary nerve

Anterior circumflex humeral

Brachial artery

Axillary nerve Biceps long head tendon Pectoralis major

FIGURE 16

A

B

Proximal Humerus Fractures: ORIF

50

PEARLS • The GT fragment is often retracted posteriorly.

Proximal Humerus Fracture Repair: General Techniques ■

PITFALLS • GT fracture may be associated with anterior dislocation, and LT fracture with posterior dislocation.

■

• Examine the proximal humerus with image intensification under anesthesia; confirm the absence of dislocation and rule out anatomic neck fracture. ■

Instrumentation/ Implantation • Large-diameter (#2, #5) absorbable suture

Closed or limited open reduction may be attempted. If adequate reduction can be achieved, less rigid, percutaneous Kirschner wire (K-wire) techniques may follow. Since the description of a less invasive deltoid split approach for plate fixation of proximal humerus fractures by Lill et al. (2004), less rigid percutaneous K-wire techniques have lost some degree of their popularity. More rigid standard and locked plates that counter the loads applied to the different parts of the proximal humerus (Fig. 17) are the most commonly used implants for fixation of proximal humeral fractures (Fig. 18A and 18B). There are many implants or fixation options for the proximal humerus. A careful preoperative study of individual fragments and their deforming forces will allow the surgeon to appropriately plan definitive fixation. GT - LT: tension Articular compression

Surgical neck: bending/torsion

FIGURE 17

51

Proximal Humerus Fractures: ORIF

A

B

FIGURE 18

PEARLS • Place provisional fixation in the largest, thickest fragment if comminuted.

Instrumentation/ Implantation • Large-diameter (#2, #5) absorbable suture • K-wires

Procedure: ORIF of Isolated GT and LT Fractures STEP 1: INITIAL FRACTURE REDUCTION STEPS ■ A GT fracture is operated through a deltoid split approach, and an LT fracture through a deltopectoral approach. ■ Any hematoma is evacuated, and fragments are localized. ■ Large-diameter (#2, #5) absorbable sutures are placed to the tuberosity at the osteotendinous junction of the cuff tendon. ■ The fracture edge is débrided as a reduction reference. STEP 2: REDUCTION AND PROVISIONAL FIXATION ■ Reduction and provisional fixation is accomplished with K-wires. ■ Reduction is controlled by use of the image intensifier. STEP 3: DEFINITIVE FIXATION ■ Fixation depends on location of the fracture. • GT—large cannulated screw over guidewire (preferred); tension band wire also acceptable. • LT—often a thin shell, best fixed with sutures or screw and spiked washer. ■ Intraoperative imaging is used to confirm reduction and safe implant position, as seen in Figure 19 for Case 1.

FIGURE 19

52

Proximal Humerus Fractures: ORIF

Supraspinatus tendon

A

Subscapularis tendon

B

FIGURE 20

■

PEARLS • Purchase far (medial) cortex with cannulated screw for GT fixation (see Fig. 20). Beware of location of axillary nerve. • Repair the rotator interval (suture space between adjacent rotator cuff tendons) when torn to supplement fracture repair.

■

The anterior edge of the supraspinatus tendon is sutured to the superior edge of the subscapularis to close the rotator interval (Fig. 20A and 20B). Serial sutures are placed and sequentially tied. Postoperative images show the completed repair and can be used to assess healing, as seen for Case 1 (Fig. 21A and 21B).

PITFALLS • Avoid leaving the head of a screw prominent (subacromial impingement). • Assess impingement directly or fluoroscopically (see Fig. 22).

Instrumentation/ Implantation • Implants should counter the loads expected at the tuberosities (tension from the cuff; see Fig. 18). • These are well addressed with large cannulated screw, tension wire, and/or large-diameter sutures.

A FIGURE 21

B

53

• The long head of the biceps tendon may be trapped in a surgical neck fracture, explaining the inability to reduce the fracture.

PITFALLS • In extensively comminuted cases, the more distally located proximal shaft may not be seen through the deltoid split approach.

PEARLS • Place provisional fixation well away from the planned implant location (bicipital groove).

Procedure: ORIF of Surgical Neck STEP 1: INITIAL FRACTURE REDUCTION STEPS ■ After closed reduction has been attempted and reduction or instability are judged unacceptable, the surgeon should proceed to ORIF. ■ A deltopectoral or deltoid split approach may be used. ■ Any hematoma is evacuated, and the long head of the biceps tendon identified. ■ Associated tuberosity fracture must be ruled out (direct visualisation vs. image intensifier). ■ The shaft-to-head/neck fragment is reduced. STEP 2: REDUCTION AND PROVISIONAL FIXATION ■ Provisional K-wire fixation is accomplished. ■ K-wires are placed away from the planned position of the lateral plate, typically in the bicipital groove from distal anterior to proximal posterior (Fig. 22).

PITFALLS • The anterior cortex (at the junction of the shaft and LT) is often comminuted from the shaft driving proximally and anteriorly. Therefore, it may not be reliable as a reduction reference.

Instrumentation/ Implantation • K-wires

FIGURE 22

Proximal Humerus Fractures: ORIF

PEARLS

Proximal Humerus Fractures: ORIF

54

PEARLS • Use low-profile, anatomically contoured plates (locking or standard) to avoid subacromial impingement.

A FIGURE 23

STEP 3: DEFINITIVE FIXATION ■ A standard or a locking plate may be used, depending on implant purchase, surgeon preference, or implantation instruments. • Figures 23 and 24 show definitive fixation of two cases of comminuted surgical neck fractures unreducible by closed means due to “buttonholing” of the proximal shaft into the biceps/coracobrachialis. • In Case 2, minimally invasive fixation was achieved through a deltoid split approach (Fig. 23A and 23B). • In Case 3, a deltopectoral approach was used to reduce and plate the fracture (Fig. 24A–D). ■ Intramedullary nails may be considered for fixation if extensive surgical neck comminution involves the shaft, or for pathologic surgical neck fractures. ■ Postoperative images show the completed repair. Note that internal and external rotation views can be used to assess healing, as seen for Case 2 (Fig. 25A and 25B) and Case 3 (Fig. 26A and 26B).

B

55

Proximal Humerus Fractures: ORIF

A

FIGURE 24

A FIGURE 25

B

C

D

B

A FIGURE 26

B

Proximal Humerus Fractures: ORIF

56

PITFALLS • An image intensifier is useful to: ■

Rule out intra-articular hardware.

■

View the sagittal plane (flexion/extension) along with the usual anteroposterior view.

Procedure: ORIF of 2-Part Anatomic Neck Fractures and 3/4-Part Valgus Impacted Fractures, Fracture-Dislocations, and Other 3/4-Part Fractures ■

■

Instrumentation/ Implantation • Implants should counter the loads expected in the surgical neck region (varus/valgus bending, axial torsion). These are well addressed by plates (see Fig. 17).

Controversies • Indications for operative care are incompletely defined. Many authors are prone to recommend nonoperative treatment. • The superiority of locking plates remains unproven.

■

All of these injuries can be managed through a deltopectoral approach. Consideration may be given to a deltoid split approach for some 3/4-part fractures and for valgus impacted fractures. Fracture-dislocations involving a displaced/dislocated anatomic neck fragment, and cases in which there is a high probability of arthroplasty (see next procedure), are best managed through the deltopectoral approach.

STEP 1: INITIAL FRACTURE REDUCTION STEPS ■ Any fracture hematoma is evacuated, and the long head of the biceps tendon identified. ■ The tuberosities are mobilized and large-diameter absorbable sutures (#2, #5) are applied to the osteotendinous junction of the cuff tendon as per isolated GT/LT fracture procedure above. ■ The articular fragment (AF) is located, and relocated into the joint (as needed). STEP 2: REDUCTION AND PROVISIONAL FIXATION ■ The goal is to restore AF alignment to the medial shaft “calcar humerale” and to restore the tuberosities’ height and offset, resulting in proper PEARLS • Best purchase of suture fixation is obtained at the osteotendinous junction of the cuff tendon to the tuberosity. • Consider opening the rotator cuff interval (to be closed later [see Fig. 21]) to mobilize the tuberosities and to best visualise the AF.

Controversies • Fixation of fracture-dislocation cases with ORIF and avascular necrosis (see Controversies box discussion of osteonecrosis in Postoperative Care and Expected Outcomes).

• The AF should be located and reduced back to its proper alignment to the glenoid, taking care to protect its inferomedial medial blood supply if still attached. The surrounding structures (brachial plexus and artery) also must be protected from injury.

PITFALLS • Poor implant purchase in fixation of some cases.

57

■

K wire

Buttress plate

FIGURE 27

A FIGURE 28

A

B

B

C

Proximal Humerus Fractures: ORIF

alignment to the glenoid surface (valgus and retroversion). Techniques depend on displacement of AF versus other parts. • Valgus impacted ◆ Indirect reduction is attempted using a buttress plate applied to the lateral shaft and GT (Fig. 27A and 27B), loading the GT from lateral to medial, reducing it and the AF into place. ◆ In the intraoperative radiographs in Figure 28A–C, a K-wire has been placed superior to the plate to prevent plate proximal migration.

58

In severely impacted cases in which a buttress plate will not reduce the AF, the surgeon must work between the tuberosities to elevate the AF to restore shaft/tuberosity/glenoid alignment and length alignment at the level of the calcar, then reapproximate the tuberosities to secure AF reduction. • Varus ◆ Apply a precontoured plate to the lateral cortex. ◆ Reduce the AF and tuberosities out of varus using K-wires placed at the superior edge of the plate and into the GT/AF (Fig. 29A and 29B). • Dislocated ◆ Once the AF has been retrieved from its position, the medial calcar blood supply must be protected and the AF realigned to the glenoid. ◆ AF-glenoid alignment is fixed using a fine, smooth K-wire exiting between the tuberosities to provisionally maintain articular reduction (Fig. 30). The wire may be placed through the fracture line separating the tuberosities so as to not block their reduction. The tuberosities are reapproximated and provisionally fixed to each other with sutures or K-wires, and to the AF and/or shaft with K-wires.

Proximal Humerus Fractures: ORIF

◆

■

A FIGURE 29

B

59

Proximal Humerus Fractures: ORIF

FIGURE 30 (COURTESY OF DR. G. KOHUT) ■

■

A FIGURE 31

B

The proximal segment is realigned with the shaft. If a reduction plate has not already been applied, provisional K-wires are placed from the shaft to the AF/tuberosity fragment, away from the planned lateral plate location (bicipital groove is preferred) (see Figs. 22 and 30). Consideration should be given to placing a provisional K-wire along the calcar to maintain AF-shaft reduction (Fig. 31A–C).

C

Proximal Humerus Fractures: ORIF

60

PEARLS • Extend/incise the rotator cuff interval to allow tuberosity mobilization. • Place provisional fixation well away from the planned implant location (bicipital groove). • When realigning the AF to the glenoid, consider fixing AF-glenoid alignment with a fine, smooth K-wire exiting between tuberosities (see Fig. 30) and/or a provisional K-wire from the shaft along the calcar (see Fig. 32) to maintain articular reduction.

A

D

STEP 3: DEFINITIVE FIXATION ■ Plates are preferred to nails, percutaneous wires, or osteosutures. ■ A laterally applied plate and screw construct and supplemental sutures for tuberosities usually offer the desired rigidity of construct. • Figure 32A–D shows the proximal humerus impacted valgus fracture in Case 4 treated through the deltoid split approach by buttress plate reduction and locked plate fixation. • Figure 33A and 33B shows the displaced proximal humerus fracture in Case 6 treated with fracture reduction and fixation with a standard cloverleaf

B

C

FIGURE 32

61

Proximal Humerus Fractures: ORIF

P E A R L S — cont’d • Consider placing a K-wire superior to the plate and into the GT/AF to prevent proximal plate migration from distal soft tissue pressure (see Fig. 27).

PITFALLS • There is a risk of displacement during radiographic confirmation of alignment with provisional fixation. Set up the image intensifier to combine shoulder range of motion and image intensifier positioning for adequate imaging. • Remember reduction of flexion/ extension at the surgical neck.

A

B

FIGURE 33

plate and screws. Note the use of internal and external rotation views to confirm reduction and safe implant position. • Figure 34A–C shows the proximal humerus fracture-dislocation in Case 5 treated by ORIF. The implant supports anatomic reduction and rigid fixation of the proximal segments and bridge

Instrumentation/ Implantation • Use the plate as a reduction tool for some valgus/varus cases. • K-wire provisional fixation

A FIGURE 34

B

C

Proximal Humerus Fractures: ORIF

62

■

A

C FIGURE 35

fixation of the surgical neck section using a locking plate. The clinical results at 9 months are shown in Figure 35A–D. Postoperative images show the completed repair. Note that internal and external rotation views can be used to assess healing, as seen for Case 4 (Fig. 36), Case 5 (Fig. 37A and 37B), and Case 6 (Fig. 38).

B

D

63

Proximal Humerus Fractures: ORIF

FIGURE 36

FIGURE 37

FIGURE 38

B A

Proximal Humerus Fractures: ORIF

64

PITFALLS • An image intensifier is useful to: ■

Rule out intra-articular hardware.

■

View sagittal plane (flexion/ extension) reduction across the surgical neck along with the usual anteroposterior view.

■

PEARLS • Best outcomes result from anatomic reduction of tuberosities during ORIF or arthroplasty and maintenance of fixation until healing has occurred. • Repair is best achieved with a combination of large-diameter (#2, #5) absorbable sutures and low-profile plates (± locking). • Consider adding a ceramic bone graft substitute (calcium phosphate–based compound) to fill any metaphyseal void and add rigidity to the fixation construct.

Assure absence of implant impingement (dynamic fluoroscopy).

Instrumentation/ Implantation • Implants should counter the loads expected in the various parts of the proximal humerus: the tuberosities (tension), surgical neck (varus/valgus bending, axial torsion), and articular segment (compression). These are well addressed by a combination of sutures, screws, and plates.

Controversies • The superiority of locking plates over standard implants remains unproven.

Instrumentation/ Implantation • Implants should allow proper position relative to tuberosities and shaft. • Instrumentation should continue for retroversion (>10°, 95% good to excellent results).

Evidence Bell MJ, Beauchamp CG, Kellam JK, McMurtry RY. The results of plating humeral shaft fractures in patients with multiple injuries: the Sunnybrook experience. J Bone Joint Surg [Br]. 1985;67:293–6. Level IV case series showing good functional results with ORIF in 34 cases of humeral shaft fracture, with only one nonunion, one failure of fixation, and one infection. Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH. Compression plating versus intramedullary nailing of humeral shaft fractures—a meta-analysis. Acta Orthop. 2006;77:279–84. Level II meta-analysis of 3 RCTs indicating lower reoperation rate and less shoulder pain with ORIF than IM nail. (Grade B recommendation)

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Level II RCT of 84 patients randomized to ORIF or IM nail, with similar rates of healing. Increased incidence of shoulder pain with IM nail. Gerwin M, Hotchkiss RN, Weiland AJ. Alternative operative exposures of the posterior aspect of the humeral diaphysis with reference to the radial nerve. J Bone Joint Surg [Am]. 1996;78:1690–5. Level IV case-series of the modified posterior approach, and anatomical study describing the anatomy of the radial nerve in relation to posterior approaches to the humerus. Gupta R, Raheja A, Sharma V. Limited contact dynamic compression in diaphyseal fractures of the humerus: good outcome in 51 patients. Acta Orthop Scand. 2000;71:471–4. Level IV case-series of ORIF of the humerus for various indications, yielding good results, but inadequate evidence to influence treatment recommendation. McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: a prospective, randomised trial. J Bone Joint Surg [Br]. 2000;82:336–9. Level I RCT comparing 44 patients randomized to either ORIF or IM nail, showing fewer complications and reoperations with ORIF. Mills WJ, Hanel DP, Smith DG. Lateral approach to the humeral shaft: an alternative approach for fracture treatment. J Orthop Trauma. 1996;10:81–6. Level IV case series describing the lateral approach to the humerus. Osman N, Touam C, Masmejean E, Asfazadourian H, Alnot JY. Results of non-operative and operative treatment of humeral shaft fractures: a series of 104 cases. Chir Main. 1998;17:195–206. Level III retrospective comparative study of 104 humerus fractures managed with and without surgical stabilization. Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg [Am]. 2000;82:478–86. Level IV, very large case-series of nonoperatively managed humeral shaft fractures showing good results can be obtained (33% loss to follow-up). Scheerlinck T, Handelberg F. Functional outcome after intramedullary nailing of humeral shaft fractures: comparison between retrograde Marchetti-Vicenzi and unreamed AO antegrade nailing. J Trauma. 2002;52:60–71. Level III retrospective comparative study of 22 retrograde and 30 antegrade intramedullary nails, showing better shoulder function with retrograde nailing. Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg [Br]. 2005;87:1647–52. Level III systematic review article describing radial nerve palsies following humerus fractures favoring expectant treatment for 6 months prior to surgical exploration. (Grade B recommendation) Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD. Effect of immediate weightbearing on plated fractures of the humeral shaft. J Trauma. 2000;49:278–80. Level IV case series showing early weightbearing for crutch mobilization through the humerus following ORIF to be safe practice.

Humeral Shaft Fractures: ORIF and IM Nailing

Chapman JR, Henley MB, Agel J, Benca PJ. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma. 2000;14:162–6.

PROCEDURE 6

Open Reduction and Internal Fixation of IntraArticular Fractures of the Distal Humerus Paul R. T. Kuzyk and Emil H. Schemitsch

Figures 1, 5, 6, and 7 modified from Hoppenfeld S, deBoer P. Surgical Exposures in Orthopaedics: The Anatomic Approach. 3rd ed. Philadelphia: Lippincott Williams and Wilkins, 2003. Figures 2, 4, and 11B modified from AO Surgery Reference Online (www. aofoundation.org). Figures 3 and 10 modified from McKee MD, Kim J, Kebaish K, Stephen DJ, Kreder HJ, Schemitsch EH. Functional outcome after open supracondylar fractures of the humerus: the effect of the surgical approach. J Bone Joint Surg [Br]. 2000;82:646–51. Figures 8 and 9 modified from Jupiter JB, Neff U, Holzach P, Allgöwer M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg [Am]. 1985;67:226–39.

ORIF of Distal Humerus Fractures

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Controversies • Elderly patients with comminuted fractures may benefit from primary total elbow arthroplasty.

Indications ■

Examination/Imaging ■

Treatment Options • Open reduction and internal fixation is the “gold standard” treatment for these intraarticular fractures. • Total elbow arthroplasty may be considered for elderly, lowdemand patients with comminuted fractures. • Closed management consisting of 2 weeks of rigid splinting follwed by unrestricted range of motion in a hinge brace (i.e., “bag of bones” technique) may be effective for very elderly low-demand patients who have medical contraindications to surgery.

Displaced intra-articular distal humerus fractures

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Clinical examination should include: inspection of the skin for any lacerations indicating an open fracture; evaluation of median, ulnar, and radial nerve function; and examination of the wrist and shoulder for any associated injuries. Anteroposterior and lateral radiographs are required for preoperative planning. A traction radiograph of the elbow provides an excellent view of comminuted fractures; however, this is difficult to obtain as it is painful for the patient. High-quality computed tomography scans with coronal and sagittal reformats may also be useful for planning reduction and internal fixation in comminuted fractures.

Surgical Anatomy ■

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Muscular anatomy (Fig. 1A): medial head, lateral head, and long head of the triceps; triceps tendon, intermuscular septum, flexor carpi ulnaris, anconeus, and extensor carpi ulnaris Neurologic anatomy (see Fig. 1A): radial nerve, ulnar nerve, and posterior antebrachial cutaneous nerve Bony anatomy (Fig. 1B): medial and lateral epicondyles, trochlea, capitellum, olecranon fossa, and olecranon

Positioning Equipment • Axillary roll • Sterile stockinette for the hand • Sterile tourniquet

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The patient may be placed in the lateral decubitus position with the operative side facing upward (Fig. 2A) or, alternatively, the patient may be placed in the prone position (Fig. 2B). The operative arm is placed over a padded bolster so that the elbow may hang freely at an approximate angle of 90°.

Portals/Exposures ■

Triceps-splitting approach • A midline skin incision is made extending along the subcutaneous border of the ulna, over the olecranon and proximally in the midline of the humerus (Fig. 3A). Generous subcutaneous dissection is performed both medially and laterally to expose both epicondyles. • The ulnar nerve is identified over the posterior aspect of the medial epicondyle (see Fig. 3A). The

107 Lateral head of triceps

Medial head of triceps

Posterior antebrachial cutaneous nerve Lateral intermuscular septum

Triceps tendon Ulnar nerve

Olecranon fossa

Radial nerve

Medial epicondyle

Anconeus Extensor carpi ulnaris

Flexor carpi ulnaris

Lateral epicondyle Capitellum

Trochlea Olecranon

A

B

FIGURE 1

A

B

FIGURE 2

A FIGURE 3

B

ORIF of Distal Humerus Fractures

Long head of triceps

ORIF of Distal Humerus Fractures

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PEARLS • The olecranon osteotomy approach provides the best exposure of the articular surface of the distal humerus. Approximately 52% of the articular surface may be seen through the olecranon osteotomy approach. The triceps-splitting approach provides exposure of 37% of the articular surface, and the triceps-sparing approach provides exposure of 26% of the articular surface. • Choice of approach to the distal humerus is determined by the type of distal humerus fracture. Simple articular fractures (AO type C1 and C2) may be addressed through the tricepssparing approach. More complex articular fractures (AO type C3) require a triceps-splitting or olecranon osteotomy approach.

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Controversies • The most common complication associated with olecranon osteotomy is prominent hardware that requires a second procedure for removal. Nonunion of the osteotomy has also been reported; however, this is an uncommon complication. Some surgeons suggest plate fixation of the osteotomy as this reduces the chance of nonunion.

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nerve is released both proximally and distally and retracted with a vessel loop. • The triceps tendon and muscle are split in the midline (dotted line in Fig. 3A). The radial nerve must be identified and protected if the triceps muscle split is extended proximal to the distal third of the humerus. • Any traumatic defects in the triceps tendon should be incorporated into the triceps split. These traumatic defects are often encountered with open fractures as the bone tears through the triceps tendon before piercing the skin. • The triceps tendon should be sharply dissected off the olecranon, preserving a continuous layer medially and laterally that can be easily repaired at the end of the procedure (Fig. 3B). ◆ The medial and lateral edges are retracted to expose the distal end of the humerus. ◆ A towel clip can be used to retract the olecranon posteriorly, allowing for better visualization of the fracture. Triceps-sparing approach • A midline skin incision is made similar to that used for the triceps-splitting approach and the ulnar nerve is released and retracted (see Fig. 3A). • The ulnar nerve is followed proximally along its course over the intermuscular septum. ◆ The medial (ulnar) window is created by dissecting out the ulnar nerve and mobilizing the medial head of the triceps laterally to expose the humerus (Fig. 4A). ◆ The ulnar window provides some exposure of the medial humerus that may be adequate for simple fracture patterns. • Greater exposure of the lateral side of the humerus is obtained by creating a lateral window. ◆ The lateral window is created by mobilizing the lateral head of the triceps off the lateral intermuscular septum toward the ulnar side (Fig. 4B). ◆ Distally, the anconeus muscle is detached from the radius to allow for greater exposure. Olecranon osteotomy approach • A midline skin incision is made similar to that used for the triceps-splitting approach and the ulnar nerve is released and retracted (Fig. 5). • A hole maybe predrilled through the olecranon to allow for anatomic reattachment of the olecranon at the end of the operation. This hole is made with a 3.2-mm drill bit for fixation with a 6.5-mm cancellous screw (Fig. 6A).

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A

Triceps muscle

Olecranon

Olecranon

B

FIGURE 4

Ulnar nerve

Fascia over triceps tendon

Fascia over extensor carpi ulnaris

Olecranon Flexor carpi ulnaris

FIGURE 5

V-shaped osteotomy

A FIGURE 6

B

ORIF of Distal Humerus Fractures

Cubital tunnel

Triceps muscle

ORIF of Distal Humerus Fractures

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Alternatively, two 1.5-mm Kirschner wires (K-wires) may be used to predrill holes through the olecranon and anterior cortex of the ulna, then removed prior to performing the osteotomy (Fig. 6B). This is useful if if the osteotomy is to be fixed using a tension band technique. • The osteotomy should be made through the nonarticular portion of the olecranon, which is located between the olecranon articular facet and the coronoid articular facet (the bare area). ◆ Subperiosteal dissection along the medial and lateral sides of the olecranon allows the surgeon to view the ulnohumeral joint and locate the bare area. An apex distal chevron osteotomy is then marked on the olecranon (see Fig. 6A). ◆ An oscillating saw is used to cut two thirds of the way through the olecranon. An osteotome should be used to complete the osteotomy through to the articular surface. ◆ The triceps is released off the posterior aspect of the humerus and retracted with the distal portion of the olecranon to expose the distal humerus (Fig. 7). ◆

Joint capsule of humeroulnar joint Triceps Articular surface of ulna

Lateral epicondyle of humerus

Ulnar nerve

Extensor carpi ulnaris Ulna

Trochlea of humerus

FIGURE 7

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• Obtain anatomic reduction of the trochlear groove.

PITFALLS • Do not use lag screws if there is significant comminution of the articular surface. Over-reduction of the trochlear groove will lead to incongruity of the ulnohumeral articulation.

Instrumentation/ Implantation • Small fragment set with reduction forceps and K-wires.

STEP 1 ■ Once the distal humerus has been appropriately exposed, the elbow should be flexed greater than 140° to provide greater access to the distal humerus. ■ The fracture fragments should be identified and cleaned of hematoma or intervening soft tissues. ■ Reduction should begin with restoration of the articular surface (Fig. 8A). • Restoration of the normal anatomic alignment of the trochlea is most important. • Congruency of the ulnohumeral articulation is required for normal range of motion and stability of the elbow. Care should be taken not to over compress the trochlear notch and thereby cause incongruency of the ulnohumeral joint. ■ The reduction of the articular surface should be held provisionally with pointed reduction forceps and K-wires (Fig. 8B). Several 4.0-mm cancellous screws may then be used to rigidly stabilize the articular surface. The surgeon must take care to ensure that these screws do not enter the olecranon fossa or protrude through the articular surface and into the joint.

A FIGURE 8

B

ORIF of Distal Humerus Fractures

Procedure

PEARLS

ORIF of Distal Humerus Fractures

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PEARLS • Two rigid plates are required for any bicondylar distal humerus fracture to provide adequate stability for early postoperative range of motion.

Instrumentation/ Implantation • Small fragment set • 3.5-mm periarticular distal humerus plates or 3.5-mm reconstruction plates • K-wires

Controversies • Arrangement of the plates to provide greatest biomechanical stability is a matter of ongoing debate. Parallel plate (medial and lateral side of the humerus) and perpendicular plate (medial and posterolateral humerus) configurations seem to provide greatest stability.

PITFALLS • Good visualization of the olecranon fossa is required prior to closure to ensure there are no screws within the fossa which may block extension.

STEP 2 ■ After reduction of the articular surface, the nonarticular supracondylar component of the fracture is reduced and the articular surface is provisionally fixed to the humeral shaft using K-wires (Fig. 9A). ■ Rigid fixation of the fracture using two plates (one on each column) is mandatory (Fig. 9B). Either precontoured 3.5-mm periarticular distal humerus plates or 3.5-mm reconstruction plates may be used to provide rigid fixation. ■ Biomechanical studies suggest that plates may be placed either parallel (i.e., one plate medial and one plate lateral) or perpendicular (i.e., one plate medial and one plate posterolateral) to provide rigid constructs. STEP 3 ■ Prior to closure, the elbow should be taken through a range of motion (flexion, extension, pronation, and supination) to ensure the elbow is stable and that there are no blocks to motion. The reduction and the position of the hardware should be checked using fluoroscopy. ■ If a triceps-splitting approach was used, care must be taken to ensure the triceps tendon is appropriately repaired. • After repair of the distal humerus fracture, drill holes are placed in the olecranon to allow for repair of the triceps tendon (Fig. 10A). • Heavy nonabsorbable suture is used to repair the triceps tendon (Fig. 10B). Interrupted sutures are placed through the drill holes in the olecranon. ■ If an olecranon osteotomy was used, this must be rigidly fixed. There are three reported methods for fixation of an olecranon osteotomy: • One 6.5-mm cancellous screw and a tension band wire (Fig. 11A) • Two 1.5-mm K-wires with a tension band wire (Fig. 11B) • A 3.5-mm reconstruction plate contoured to fit the olecranon (Fig. 11C) ■ Subcutaneous transposition of the ulnar nerve may be considered if the nerve is under tension or directly overlying the plate.

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ORIF of Distal Humerus Fractures

FIGURE 9

A

B

FIGURE 10

A FIGURE 11

B

A

B

C

ORIF of Distal Humerus Fractures

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PITFALLS • Early postoperative range of motion is require to prevent posttraumatic elbow stiffness.

Postoperative Care and Expected Outcomes ■

Early gentle range of motion should begin on the first postoperative day to prevent elbow stiffness. • If a triceps-splitting approach or olecranon osteotomy approach was used, then active elbow extenson should be restricted for 6 weeks. • Patients may be fitted for an extension brace to wear at night to prevent flexion contracture. • In selected cases (i.e., associated head injury) nonsteroidal anti-inflammatory medication may be given to prevent heterotopic ossification.

Evidence Coles CP, Barei DP, Nork SE, Taitsman LA, Hanel DP, Bradford Henley M. The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus. J Orthop Trauma. 2006;20:164–71. In this case series of 67 patients with intra-articular distal humerus fractures treated with olecranon osteotomies, no nonunions were encountered, 3% required revision of osteotomy fixation due to malreduction, and 8% required removal of osteotomy fixation due to prominent hardware. The authors concluded that olecranon osteotomy can be useful in the visualization of complex articular injuries, allowing accurate articular reduction. (Grade C recommendation; Level IV evidence) Dakouré PW, Ndiaye A, Ndoye JM, Sané AD, Niane MM, Séye SI, Dia A. Posterior surgical approaches to the elbow: a simple method of comparison of the articular exposure. Surg Radiol Anat. 2007;29:671–4. This cadaveric study examined the amount of articular surfaced exposed by three different posterior approaches to the elbow. The median exposed articular surface for the triceps-sparing approach, the triceps-splitting approach, and the olecranon osteotomy was 26%, 37%, and 52%, respectively. Doornberg JN, van Duijn PJ, Linzel D, Ring DC, Zurakowski D, Marti RK, Kloen P. Surgical treatment of intra-articular fractures of the distal part of the humerus: functional outcome after twelve to thirty years. J Bone Joint Surg [Am]. 2007;89:1524–32. In this case series, 39 patients were evaluated at a mean follow-up of 19 years (range, 12–30 years). The authors found that long-term results of open reduction and internal fixation of intra-articular distal humerus fractures were similar to those reported in the short term (70% good to excellent results), suggesting that the results are durable. They found that functional ratings and perceived disability were predicated more on pain than on functional impairment and did not correlate with radiographic signs of arthrosis. Approximately 40% of patients required a repeat operative intervention. (Level IV evidence) Hewins EA, Gofton WT, Dubberly J, MacDermid JC, Faber KJ, King GJ. Plate fixation of olecranon osteotomies. J Orthop Trauma. 2007;21:58–62. In this case series of 17 patients with intra-articular distal humerus fractures that were treated with an olecranon osteotomy fixed with a 3.5-mm reconstruction plate, there were two reoperations related to the osteotomy. The authors concluded that plate fixation of an olecranon osteotomy provides a construct with predictable healing and few complications. (Grade C recommendation; Level IV evidence)

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This retrospective comparative study evaluated functional outcome of 26 open distal humerus fractures (13 treated using a triceps-splitting approach and 13 treated using an olecranon osteotomy). The authors concluded that immediate open reduction and internal fixation of open intra-articular fractures of the distal humerus is a safe and effective technique with a low rate of complications and good limb-specific outcome. Patients whose fractures were fixed by a triceps-splitting approach, incorporating any traumatic defects in the triceps into the approach, had improved limb-specific and pain scores compared with those who had an olecranon osteotomy. (Grade B recommendation; Level III evidence) McKee MD, Veillette CJ, Hall JA, Schemitsch EH, Wild LM, McCormack R, Perey B, Goetz T, Zomar M, Moon K, Mandel S, Petit S, Guy P, Leung I. A multicenter, prospective, randomized, controlled trial of open reduction—internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg. 2009;18:3–12. This study found that total elbow arthroplasty for the treatment of comminuted intraarticular distal humerus fractures in elderly patients (age > 65 years) resulted in more predictable and improved 2-year functional outcomes compared with open reduction and internal fixation. (Grade A recommendation; Level I evidence) McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR. Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg [Am]. 2000;82:1701–7. This study provided evidence that open reduction with internal fixation of intraarticular distal humerus fractures is an effective procedure that reliably maintains general health status as measured by patient-based questionnaires. There was a significant decrease in the elbow range of motion and muscle strength of these patients as compared to the contralateral elbow at the time of final follow-up (mean 37-month follow-up), indicating that intra-articular distal humerus fractures are severe injuries with long-term sequelae. (Grade C recommendation; Level IV evidence)

ORIF of Distal Humerus Fractures

McKee MD, Kim J, Kebaish K, Stephen DJ, Kreder HJ, Schemitsch EH. Functional outcome after open supracondylar fractures of the humerus: the effect of the surgical approach. J Bone Joint Surg [Br]. 2000;82:646–51.

PROCEDURE 7

Supracondylar Humeral Fractures Sahal Altamimi and Michael D. McKee

Supracondylar Humeral Fractures: TEA

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PITFALLS • Young active patients with high functional demands

The Role of Arthroplasty Indications ■

• High-grade (Gustilio II and III) open fractures • Poor soft tissue coverage or skin lesions

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• Presence of active infection • Lack of familiarity with the technique of TEA

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Controversies • Type I Gustilio open fractures seen within 12 hours of injury can be treated by early incision and drainage and primary TEA. Alternatively, a two-stage procedure with early incision and drainage and insertion of an antibiotic spacer followed by TEA can be done.

Treatment Options • Nonoperative (“bag of bones” technique) • Open reduction and internal fixation • Primary TEA • Distal humeral hemiarthroplasty

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Total elbow arthroplasty (TEA) provides good to excellent results in carefully selected patients with comminuted distal humeral fractures. Poor bone quality and osteoporosis, which are often found in elderly patients, can lead to inadequate fixation and mechanical failure following open reduction and internal fixation (ORIF). In addition, articular comminution and cartilage fragmentation may preclude anatomic reduction. The ideal candidate for TEA is an elderly patient with a comminuted intra-articular distal humeral fracture. Distal humeral fractures in patients with underlying rheumatoid arthritis or pre-existing arthrosis are best managed with primary TEA. Several factors play an important role in decision making for primary TEA versus ORIF. These include: • Intra-articular comminution and cartilage fragmentation • Physiologic age and functional demands of the patient • Pre-existing joint arthrosis or underlying rheumatoid arthritis • Bone quality and degree of osteoporosis • Surgeon experience and familiarity with TEA

Examination/Imaging ■

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A common pitfall is to focus immediately on the obvious injury. Examination of the shoulder and wrist is a must. The skin should be visualized circumferentially, so that an open fracture is not missed. Ecchymosis and deformity are usually apparent. A careful neurologic evaluation that includes motor and sensory functions of the ulnar, radial, and median nerves is critical. The vascular status of the arm should be evaluated by palpation of the distal pulses and assessment of capillary refill. The forearm compartments should be assessed as well.

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Plain radiographs are universally the initial study of choice. • Standard anteroposterior and lateral radiographs of the elbow are adequate in most cases. • Figure 1 shows the preoperative anteroposterior (Fig. 1A) and lateral (Fig. 1B) radiographs of a 68-year-old woman with a comminuted intraarticular distal humerus fracture. • It is important to note the degree of displacement, angulation, intra-articular comminution, and bone quality. Additional traction views or computed tomography maybe obtained in selected cases. Typically, when TEA is chosen, advanced imaging studies are not required.

A

B FIGURE 1

Supracondylar Humeral Fractures: TEA

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Supracondylar Humeral Fractures: TEA

120

Surgical Anatomy ■

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The ulnar nerve is derived from the C8 and T1 nerve roots (Fig. 2). The nerve runs down the anterior compartment of the arm medial to the brachial artery and gives off no branches in the upper arm. At the middle of the arm, it pierces the intermuscular septum and travels along the medial head of the triceps. At the elbow, the nerve passes posterior to the medial epicondyle. Before entering the forearm, the ulnar nerve gives off capsular branches to the elbow joint, the first motor branch to the flexor carpi ulnaris (FCU), and branches to the ulnar half of the flexor digitorum profundis. In the proximal forearm, the nerve runs between the two heads of the FCU.

C8 T1

Ulnar nerve

Medial epicondyle

Flexor carpi ulnaris

FIGURE 2

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Positioning ■

• Ensure that the elbow can be moved through a full range of motion over the bolster before beginning the procedure

PITFALLS • A foam pad should be place under the lower leg to protect the common peroneal nerve.

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Equipment • • • • •

Beanbag Arm bolster Axillary roll Foam pads or gel Sterile tourniquet

We prefer to place the patient in the lateral decubitus position with the injured arm up (Fig. 3). The affected elbow is supported over a bolster. • This position facilitates extensile exposure of the humerus and allows the elbow to flex beyond 90°. A deflatable beanbag is used to secure the patient in place. Great care is taken to pad all bony prominences. The arm is prepped and draped to the shoulder so that a sterile tourniquet can be applied as high as possible. After the extremity is exsanguinated, the tourniquet is inflated. The pressure is set at 250 mm Hg, or 275 mm Hg for an obese arm.

Controversies • Alternatively, TEA can be done in the supine position. The injured arm can be placed across the patient’s chest or, with the shoulder flexed, beside the patient’s head.

FIGURE 3

Supracondylar Humeral Fractures: TEA

PEARLS

Supracondylar Humeral Fractures: TEA

122

Portals/Exposures

PEARLS

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• A Hohmann retractor can be used on either side of the humeral shaft to “lift up” the shaft for exposure, rather than levering on the soft tissue excessively. This is especially important on the lateral side where the radial nerve courses proximally. • In most cases, the radial head will be left intact. However, in the setting of a distal humeral fracture in a joint afflicted with pre-existing inflammatory arthritis, the radial head should be resected. This helps improve exposure.

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A straight posterior midline skin incision is made (see Fig. 3). • Dissection is carried down to the triceps fascia proximally and subcutaneous border of the ulna distally. • Full-thickness medial and lateral fasciocutaneous flaps are elevated. The ulnar nerve is identified, mobilized, and protected throughout the procedure. • The nerve is carefully dissected proximally to the medial intermuscular septum and distally to its first motor branch (Fig. 4A and 4B). The capsular branch to the elbow is sacrificed to mobilize the nerve. • The distal portion of the intermuscular septum is excised to prevent a pressure point of the nerve.

Ulnar nerve

Olecranon

A FIGURE 4

B

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• Ulnar neuropathy can be avoided with meticulous surgical technique. If ulnar nerve transposition is performed, excision of the intermuscular septum is necessary. • Olecranon osteotomy should be avoided in the treatment of distal humerus fracture with TEA. The osteotomy will jeopardize the stability of the ulnar component.

A triceps-sparing approach is used (Fig. 5). • The medial and lateral border of the triceps are defined and elevated from the distal humerus. The triceps is left attached distally to the olecranon. • The flexor-pronator origin and medial collateral ligament are released off the medial epicondyle. • The lateral epicondyle is also freed of the extensorsupinator attachment and lateral collateral ligament. • Next, all free distal fracture fragments, including medial and lateral epicondyles, are excised. Figure 6 shows the articular fragments from the patient in Figure 1.

Instrumentation • Steven’s scissors for ulnar nerve dissection • Penrose drain to protect the ulnar nerve • Two Hohmann retractors

Controversies • There are several techniques to deal with the triceps tendon. These include a “triceps-on” or triceps-sparing approach, a midline split, or a medial-tolateral peel. • Initially, or with complex cases, a midline split is utilized as this is technically simpler. As experience and skill with TEA grows, a “triceps-on” approach is utilized. Excision of the distal fragments creates a “working space” that allows canal instrumentation and component insertion without detaching the triceps from the olecranon (see Fig. 5).

FIGURE 5

FIGURE 6

Supracondylar Humeral Fractures: TEA

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PITFALLS

Supracondylar Humeral Fractures: TEA

124

PEARLS • Typically, we use a 6-inch humeral stem in TEA for distal humerus fractures instead of a 4-inch humeral stem, which is routinely used for standard TEA.

PITFALLS • Correct rotational alignment of the humeral component is important—this can be assured by using the flat posterior surface of the distal humerus just proximal to the olecranon fossa, as a guide.

Instrumentation/ Implantation • • • •

High-speed burr Serial rasps Two Hohmann retractors Trial humeral component

Controversies • There is increasing enthusiasm for using a distal humeral hemiarthroplasty in the setting of comminuted distal humeral fracture. While it is a promising technique, it does require reconstruction of the condyles and ligaments for stability, and there are few reported results.

Procedure STEP 1: HUMERAL PREPARATION ■ A working space is created after removal of all comminuted distal humerus fragments. ■ The distal humerus is delivered, typically lateral to the triceps tendon, with two Hohmann retractors. ■ The medullary canal is prepared by reaming and rasping of the canal to the appropriate size. ■ Progressive rasping is continued until cortical resistance is met. ■ Next, a trial humeral prosthesis is inserted to a depth that replicates the normal axis of rotation (Fig. 7). The top of the olecranon fossa can usually be determined: the anterior flange of the humeral component should abut the cortical bone at the top of the fossa as the distal humerus narrows in the anteroposterior plane. ■ In the setting of complex distal humerus fracture, the fracture fragments are excised and the ligaments released. Therefore, a linked prosthesis is necessary to provide adequate stability in varus/valgus and rotational planes. STEP 2: ULNAR PREPARATION ■ The arm is fully flexed and rotated to facilitate exposure of the olecranon. ■ The tip of the olecranon is resected and the ulnar canal is opened with a high-speed burr. ■ Rush pin inserters of progressively larger size are used to carefully identify the ulnar canal. This is followed by serial rasping of the medullary canal. It is important to avoid proximal ulnar perforation. ■ A trial ulnar component is inserted.

FIGURE 7

125

• Careful insertion of rasps without twisting or applying a torque is essential. • If the trial component is not fully seated, the opening of the medullary canal is enlarged with a high-speed burr. • This is the most difficult part of the procedure when a “triceps-on” exposure is used, and careful attention to surgical technique is mandatory.

PITFALLS • Poor rasping techniques may lead to proximal ulna perforation.

Instrumentation/ Implantation

STEP 3: TRIAL REDUCTION ■ After insertion of the humeral and ulnar trial implants, the elbow joint is reduced (Fig. 8). ■ Range of motion of the elbow and component position are carefully assessed. • Achievement of full flexion and extension should be obtained at this time. • The depth of the humeral component is checked and marked. ■ Once the surgeon is satisfied with the trial reduction, the definitive implants are opened.

• Micro-sagittal saw • High-speed burr • Rush pin inserters (to open medullary canal) • Serial rasps • Trial components

FIGURE 8

STEP 4: INSERTION AND CEMENTING OF THE FINAL PROSTHESIS ■ Several trial reductions should be performed so that the surgeon and assistant are familiar with the sequence of insertion to be followed.

Supracondylar Humeral Fractures: TEA

PEARLS

Supracondylar Humeral Fractures: TEA

126 ■

PEARLS • If the elbow will not extend fully, the components are usually not seated deeply enough. This can be corrected by repeat rasping and inserting the components more deeply, or on occasion by changing to a smaller component. Excessive resection of bone is to be avoided if possible. • Lack of flexion usually indicates some type of anterior impingement.

PITFALLS • Care must be taken to not allow the elbow to hyperextend with the trial components in place. While this is rare, it indicates the components are too deeply inserted. It may be necessary to use a longer stemmed humeral component and leave it slighty “proud,” restoring adequate soft tissue tension anteriorly.

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■

■

■

■

The intramedullary canals of the humerus and the ulna are irrigated with pulsatile lavage, then dried. A cancellous bone plug or plastic cement restrictor is placed in the humeral canal to enhance the cementing technique and prevent proximal flow of cement. Antibiotic-impregnated cement is injected into the humerus and the ulna with a cement gun. The ulnar and humeral prostheses are inserted disarticulated. A trapezoidal wafer of bone graft harvested from the excised distal humerus is placed behind the anterior flange of the humeral component. The new elbow joint is reduced and coupled together with the locking mechanism (Fig. 9). • Figure 10 shows postoperative anteroposterior (Fig. 10A) and lateral (Fig. 10B) radiographs after TEA with a linked prosthesis.

PEARLS • Antibiotic-impregnated cement is routinely used to minimize the risk of infection.

FIGURE 9

A FIGURE 10

B

127

• Poor cementing technique can result in early mechanical failure. • The nozzle of the cement gun is usually too large to be inserted into the medullary canals deeply enough. Therefore, it can be replaced with smaller diameter suction tubing to ensure adequate delivery of the cement into the depth of the canal.

Instrumentation/ Implantation • Antibiotic-impregnated cement (1 bag) • Vacuum mixing container • Cement gun • Suction tubing

STEP 5: WOUND CLOSURE ■ If the triceps has been split or peeled from the olecranon, it is reattached with drill holes through the bone and #2 nonabsorbable suture. ■ Since the medial condyle is already excised, formal anterior ulnar nerve transposition is not necessary. The nerve is left in a tension-free position medially. ■ The common origins of the flexor-pronator and extensor-supinator groups are sutured to the edge of the triceps medially and laterally with #1 Vicryl. In this way, a continuous sleeve of soft tissue is re-established around the prosthesis. ■ It is very important to release the tourniquet before final wound closure. Meticulous hemostasis must be ensured. ■ A suction drain is not routinely used. ■ The subcutaneous tissue is closed with absorbable 2–0 suture. The skin is closed with staples. ■ The arm is placed in a well-padded anterior splint in maximum extension and kept elevated.

Controversies • Use of a suction drain is optional. • The position of full extension decreases swelling, is favorable for neurovascular structures, and helps to minimize flexion contracture.

PEARLS • Early unrestricted active elbow flexion and extension exercises are encouraged with the “triceps-on” approach.

Postoperative Care and Expected Outcomes ■ ■ ■

• If the triceps tendon was detached in the approach, active and resisted elbow extension is restricted for 6 weeks. ■

Postoperative antibiotics are continued for 24 hours. The splint is removed on the first postoperative day. Typically, with the “triceps-on” approach, early unrestricted active range-of-motion exercises are initiated under the supervision of a physiotherapist. • Range-of-motion exercises of the hand, wrist, and the shoulder are encouraged. Usually the patient is discharged home on the second or third day postoperative with written instructions for home exercise. • Active use of the arm for activities of daily living is encouraged.

Supracondylar Humeral Fractures: TEA

PITFALLS

Supracondylar Humeral Fractures: TEA

128

A

B

FIGURE 11

■

PITFALLS • Patients are counseled to limit weight lifted with the involved arm to 5–10 pounds to increase the longevity of the prosthesis. ■

Patients can expect a 90% rate of good or excellent results, with a mean Mayo Clinic Elbow Performance Index score of 85–90. • Clinical photographs taken 3 months after successful TEA show excellent range of motion of the elbow in flexion (Fig. 11A) and extension (Fig. 11B). Potential complications of TEA include wound breakdown, infection, ulnar nerve neuropathy, aseptic loosening, and elbow stiffness.

Evidence Cobb TK, Morrey BF. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg [Am]. 1997;79:826–32. This represents the first report of primary TEA as treatment for distal humerus fractures. Between 1982 and 1992, 20 patients with acute distal humerus fracture were treated with primary TEA. Fifteen patients had an excellent result and five patients had a good result based on Mayo Clinic Elbow Performance Index scores. This report introduced the clinical potential of this technique. (Level IV evidence) Frankle MA, Herscovici D, DiPasquale TG, Vasey MB, Sanders RW. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma. 2003;17:473–80. In this retrospective study, 24 women with intra-articular distal humeral fractures (12 treated with ORIF and 12 treated with TEA) were assessed for a minimum 2 years’ follow-up. The outcomes of ORIF were 4 excellent, 4 good, 1 fair, and 3 poor, compared to 11 excellent and 1 good in the TEA group. The authors concluded that TEA is a viable treatment option for distal humerus fracture in women older then 65 years of age, and may have advantages when compared to ORIF. (Level III evidence) Gambirasio R, Riand N, Stern R, Hoffmeyer P. Total elbow replacement for complex distal humerus fracture. J Bone Joint Surg [Br]. 2001;83:974–8.

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Kamineni S, Morrey BF. Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg [Am]. 2004;86:940–7. This retrospective review is a follow-up of the same groups in the Cobb and Morrey (1997) report, and supports recommendations for TEA in carefully selected patients with distal humerus fracture. Clinical and functional outcome were evaluated in 43 fractures with an average 7-year follow-up. The average Mayo Clinic Elbow Performance Index score was 93 of a possible 100 points. (Level IV evidence) McKee MD, Pugh DM, Richards RR, Pedersen E, Jones C, Schemitsch EH. Effect of humeral condylar resection on strength and functional outcome after semiconstrained total elbow arthroplasty. J Bone Joint Surg [Am]. 2003;85:802–7. The effect of condylar resection on elbow, forearm, and hand strength has always been a concern. This study assessed objective muscle strength in 32 patients who had linked TEA (16 with intact condyles and 16 with resected condyles). The authors concluded that condylar resection had no significant effect on forearm, wrist, and grip strength. (Level IV evidence) Veillette CJ, McKee MD, and the Canadian Orthopaedic Trauma Society. A multicenter prospective randomised controlled trial of open reduction and internal fixation versus total elbow arthroplasty for displaced intra-articular distal humerus fractures in elderly patients. J Shoulder Elbow Surg. 2009;18:3–12. In this study, the functional outcome, complications, and reoperation rates were assessed in 42 patients. The authors concluded that TEA provides improved functional outcome compared with ORIF based on both Mayo Clinic Elbow Performance Index and DASH scores. (Level I evidence)

Supracondylar Humeral Fractures: TEA

The authors reported the result of TEA for distal humeral fracture. The functional outcome was investigated in 10 elderly patients with a mean follow-up of 17.8 months. All patients were women and none had inflammatory arthropathies. The mean Mayo Clinic Elbow Performance Index score was 94 points, with high patient satisfaction, and there were no reoperations. (Level IV evidence)

PROCEDURE 8

Terrible Triad Injuries of the Elbow Paul K. Mathew, Graham J. W. King, and George S. Athwal

Figures 12 and 13 courtesy of Wright Medical Technology, Inc., Arlington, TN.

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132

Indications ■

Treatment Options • Nonoperative treatment can be implemented only if all of the following criteria are met: ■ The ulnohumeral and radiocapitellar joints are concentrically reduced following closed reduction of the elbow dislocation. ■ The elbow can be extended to 30–45° before becoming unstable, suggesting there is sufficient stability to allow early range of motion. ■ The radial head or neck fracture is undisplaced or minimally displaced and is not causing a mechanical block to forearm rotation or elbow flexion/extension. ■ The coronoid fracture is small, typically a type I fracture.

An elbow dislocation associated with radial head and coronoid fractures that renders the articulation incongruous and/or unstable

Examination/Imaging ■

■

■

■

■

■

■

■

The elbow is inspected for obvious dislocation or open injury necessitating immediate reduction and/ or surgical treatment. The joint is palpated for bony alignment and areas of tenderness to locate pathology. The elbow is moved actively and passively to evaluate for stability or a block to motion. The arm is examined above and below the joint for tenderness and mobility. Specifically, examination must ensure that no distal radioulnar joint tenderness is present as this may suggest a concomitant interosseous membrane injury (Essex-Lopresti lesion). A detailed neurologic examination is performed to evaluate the function of the axillary, musculocutaneous, median, ulnar, and radial nerves. The vascular status is assessed by evaluation of capillary refill and distal pulses. Radiographs • Prereduction and postreduction (Fig. 1A and 1B) anteroposterior and lateral radiographs are obtained to examine fracture characteristics and concentricity of the elbow joint. • Regardless of the radiographic projection, a line drawn through the center of the radial neck should intersect with the center of the capitellum. • Lateral radiographs can be used to determine the height of a coronoid fracture. Computed tomography (CT) • CT is obtained following joint reduction to better evaluate fracture patterns, comminution and displacement. • Three-dimensional images can improve visualization and understanding of the fracture pattern and fracture line propagation. ◆ The three-dimensional CT image in Figure 2A demonstrates a radial head and neck fracture. ◆ A three-dimensional anterior CT image shows an anterolateral coronoid fracture (Fig. 2B).

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FIGURE 2

B

A

B A

FIGURE 1

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Surgical Anatomy BONES ■ The proximal ulna • The greater sigmoid notch, with its central guiding ridge, articulates with the trochlea and is made up of the coronoid and olecranon (Fig. 3A). ◆ The coronoid process provides an important anterior and varus buttress to the elbow joint and consists of the tip, body, anterolateral facet, anteromedial facet, and sublime tubercle (insertion for the anterior bundle of the medial collateral ligament). • The lesser sigmoid notch articulates with radial head, forming the proximal radioulnar joint. • The crista supinatoris, located just distal to the radial notch on the lateral aspect of the proximal ulna, provides the insertion for the lateral ulnar collateral ligament (Fig. 3B). ■ The proximal radius • The radial head (Fig. 3C), which is elliptical in shape and offset from the neck, articulates with the capitellum and lesser sigmoid notch. ◆ Hyaline cartilage covers the majority of articular margins and all of the articular dish. ◆ The anterolateral portion of the articular margin does not articulate with the proximal ulna and is devoid of hyaline cartilage (so-called “safe zone”). • The bicipital or radial tuberosity is distal to the radial neck and serves as the attachment site for the biceps tendon (see Fig. 3C). LIGAMENTS ■ Lateral collateral ligament (LCL) • The LCL consists of the lateral ulnar collateral, radial collateral, and annular ligaments (Fig. 4A). • It is an important varus and posterolateral rotational stabilizer of the elbow. • Its origin on the lateral epicondyle is isometric. • The lateral ulnar collateral ligament originates on the lateral epicondyle and attaches to the crista supinatoris. • The radial collateral ligament originates on the lateral epicondyle and fans out to attach to the annular ligament. • The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid (radial) notch.

135

Olecranon

Radial neck

Radial head

Coronoid process

Supinator crest

B

A

Coronoid fossa

Humerus

Lateral epicondyle

Medial epicondyle

Capitellum Trochlea

Radial head

Coronoid process

Bicipital tuberosity

Ulna

Radius

C FIGURE 3

Lateral view

Medial view

Humerus Medial collateral ligament Lateral ulnar collateral ligament Radial collateral ligament Annular ligament

Ulna

FIGURE 4

Anterior bundle Transverse ligament

Annular ligament of radius Radius

A

Posterior bundle

B

Humerus

Terrible Triad Injuries of the Elbow

Lateral epicondyle

Greater sigmoid notch

Terrible Triad Injuries of the Elbow

136 ■

PEARLS • With the arm across the chest, use a 3-L intravenous fluid bag placed under the ipsilateral scapula to protract the shoulder. A second assistant may be needed on the opposite side of the operating table. • When using an arm table, make sure the torso is shifted close to edge of the operating table to move the elbow into the center of the table. A rolled drape placed underneath the medial or lateral aspect of the elbow with the shoulder in internal or external rotation, respectively, facilitates positioning. • When using the lateral decubitus position, ensure the armholder is well padded and is situated over the biceps muscle to avoid pressure points. If using a bean bag for positioning leave the suction attached to maintain deflation during surgery. Tilt the operating table 10 degrees towards the operative side after the patient is secured to prevent the arm from slipping back off the arm support. • Positioning supine with the arm across the chest and lateral decubitus positioning have an advantage over the arm table for unstable injuries as gravity tends to reduce the elbow in the former two positions, while rotation of the shoulder to gain access to the medial and lateral sides of the elbow when using an arm table tends to subluxate the elbow and stress collateral ligament repairs and fracture fixation.

Medial collateral ligament (MCL) • The MCL consists of the anterior bundle, posterior bundle, and transverse ligament (Fig. 4B). • It is an important valgus and posteromedial rotational stabilizer of the elbow. • Its origin on the anteroinferior aspect of the medial epicondyle is distal to the axis of rotation and therefore tension increases in flexion. • The anterior bundle originates from the medial epicondyle and inserts on the sublime tubercle of the coronoid. • The posterior bundle originates from the medial epicondyle and inserts on the ulnar aspect of the greater sigmoid notch. • The transverse ligament has no known function.

MUSCLES ■ Several muscles act as dynamic stabilizers of the elbow joint (Fig. 5). ■ The biceps, brachialis, and triceps compress the joint and stabilize the articulation; however, a posterior vector of forces contributes to posterior subluxation of the elbow when the coronoid and/or radial head are deficient. ■ The flexor pronator muscles arise from the medial epicondyle and provide dynamic valgus stability. ■ The common extensor muscles arise from the lateral epicondyle and provide dynamic varus stability.

Positioning ■

■

For lateral surgery, patients can be placed in the supine position with the arm over the chest supported by a rolled drape to allow the elbow to flex to 90° (Fig. 6A). • Alternatively, an articulated arm positioner can be used to stabilize the arm. For medial surgery, patients can be placed in the lateral decubitus position with the aid of an elbow positioner (Fig. 6B).

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Biceps brachii

Terrible Triad Injuries of the Elbow

Medial view

Triceps brachii

Brachialis

A Anterior view

Posterior view Biceps brachii

Triceps brachii

Triceps brachii Brachioradialis Brachialis Humerus

Extensor carpi radialis longus Brachioradialis

Pronator teres

Extensor carpi radialis longus

Flexor carpi radialis

Anconeus Flexor carpi ulnaris

Extensor carpi ulnaris

B

Palmaris longus

Extensor carpi radialis brevis Extensor digitorum

Extensor carpi radialis brevis

C

FIGURE 5

A FIGURE 6

B

Flexor carpi ulnaris Flexor digitorum superficialis

Terrible Triad Injuries of the Elbow

138

PITFALLS • Lack of a second assistant when using the supine position. • Failure to protract the scapula. • Armholder placed in the antecubital fossa when the patient is in the lateral position. • A stiff shoulder limits medial and lateral exposure with an arm table or with the patient in the lateral decubitus position.

Equipment • A sterile tourniquet will allow more proximal incision length and can be removed if more exposure is required. • A padded armholder placed under the anterior surface of the humerus in the lateral decubitus position is needed to stabilize the arm during surgery. • A beanbag or alternative positioning braces are needed when performing surgery in the lateral decubitus position.

Exposures SKIN INCISION ■ Choice of skin incision(s) location is controversial; it depends on the fracture/instability pattern, soft tissue injury, and surgeon preference. ■ Options are medial, lateral, and posterior skin incisions. ■ A posterior skin incision minimizes injury to the cutaneous nerves and allows both lateral and medial deep exposures if needed; however, larger skin flaps are required. ■ A medial skin incision has highest risk of cutaneous nerve injury. DEEP EXPOSURE ■ Lateral surgical approach to the elbow: access to the radial head and neck, lateral collateral ligament, and most coronoid fractures can be achieved by one of two approaches. • Kocher’s interval ◆ Kocher’s interval between the extensor carpi ulnaris and anconeus is identified (Fig. 7A) and incised (Fig. 7B). ◆ The interval is bluntly developed and the collateral ligament complex is identified deep to the anconeus muscle (Fig. 7C). ◆ An arthrotomy is conducted above the lateral ulnar collateral ligament to avoid its disruption, however, the ligament is typically disrupted due to the injury (Fig. 7D). • Extensor digitorum communis split: splitting the proximal muscle ■ Medial surgical approach to the elbow: once the ulnar nerve has been identified, access to the ulnar nerve, MCL, or difficult coronoid fractures can be achieved by one of three approaches. • For minimal exposure, the flexor pronator mass can be split along its fibers to allow access to the MCL. • The Hotchkiss “over-the-top” approach splits the flexor pronator mass and detaches the anterior half while elevating the brachialis and anterior joint capsule. • For greater exposure, the entire flexor pronator mass can be divided and elevated off the medial epicondyle similar to the procedure described by Taylor and Scham in 1969.

139

Terrible Triad Injuries of the Elbow

A

B

ECU

Capsule

Anconeus

C

ECU

Anconeus Remnants of LUCL

D FIGURE 7

Terrible Triad Injuries of the Elbow

140

Instrumentation • Deep retractors are essential for adequate visualization. • Surgical loupes may assist in identifying and protecting nerves.

PEARLS • Elevate full-thickness skin flaps on the deep fascia to preserve vascularity and protect cutaneous nerves. • Use loupe magnification during medial exposures to protect the medial cutaneous nerve of the forearm and the ulnar nerve.

Controversies • Medial and lateral incisions may be smaller; however, posterior incisions, although longer, decrease the risk of injury to cutaneous nerves while allowing access to both sides of the elbow. • A posterior skin incision is more cosmetic than a lateral incision. • Large medial and lateral skin flaps with a posterior incision can predispose to marginal skin necrosis, seroma, and hematoma formation.

PEARLS • Dislocate the elbow posteriorly to gain a better view of the base of the coronoid when the radial head is intact. This allows for optimal drill hole placement for screws or sutures placed from the subcutaneous border of the ulna.

PITFALLS • Care must be taken when using anterior retractors to view the coronoid from the lateral side due to the close proximity of anterior neurologic structures.

PITFALLS • Thin skin flaps may compromise flap vascularity. • Placement of a tourniquet too distal compromises visualization. • Failure to identify and protect the ulnar nerve.

Procedure STEP 1: TREATMENT OF CORONOID FRACTURE ■ Coronoid fractures can be approached from the lateral or the medial side. ■ Lateral side (most cases) • If the radial head fracture is comminuted and requires replacement, a radial neck osteotomy is conducted in preparation for arthroplasty (Fig. 8A). This allows easy access to the coronoid fracture. Once the radial head is removed, the coronoid fracture is visualized (type II coronoid fracture in Fig. 8B). • If the radial head fracture is repairable, the coronoid can be approached by: ◆ Strategic retractor placement ◆ Working through the radial head fracture fragments ◆ Removing loose radial head fracture fragments to allow visualization of the coronoid and fixating them after the coronoid is addressed ◆ Dislocating the elbow joint

141

Terrible Triad Injuries of the Elbow

A

B

FIGURE 8

Terrible Triad Injuries of the Elbow

142

Instrumentation/ Implantation • An ACL reconstruction guide can be used to precisely position drill holes entering the subcutaneous border of the ulna and exiting through the base of the coronoid fracture (see Fig. 9A). • A suture passer can be used to retrieve the sutures through drill holes from the subcutaneous border of the ulna (see Fig. 9B and 9C).

■

• Coronoid fixation (lateral side) ◆ An ACL reconstruction guide can be used to make accurately placed drill holes from the subcutaneous border of the ulna to the coronoid fracture for either screw or suture passage (Fig. 9A). ◆ Lag screws can be passed from the subcutaneous border of the ulna into the coronoid fragment in a retrograde fashion. ◆ In cases with small comminuted coronoid fractures deemed inappropriate for screw fixation, suture fixation may be used. Nonabsorbable sutures are passed through small coronoid fragments and a portion of the anterior capsule. A suture passer is used to retrieve the sutures (Fig. 9B), which are then passed through the two separate drill holes exiting on the subcutaneous border of the ulna, where they are tied (Fig. 9C). Medial side • If unable to visualize or fixate the coronoid from the lateral side, a medial approach can be used after identification and protection of the ulnar nerve. • The medial approach enables suture fixation, anterograde or retrograde screw fixation, or plate fixation.

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Terrible Triad Injuries of the Elbow

C

FIGURE 9

B A

Sutures

Terrible Triad Injuries of the Elbow

144

PEARLS • The safe zone of the radial head/ neck can easily be identified during surgery by placing the forearm in neutral rotation and applying the plate laterally.

STEP 2: TREATMENT OF RADIAL HEAD FRACTURE ■ The radial head is approached from the lateral side and assessed for repair, partial excision, or arthroplasty.

• Pronation of the forearm moves the posterior interosseous nerve medially and distally during surgical approaches to the radial head and neck. • Avoid radial head replacement until the coronoid fracture has been fixed as the presence of a radial head implant limits exposure of the coronoid. • When performing a radial head arthroplasty, reconstruct the excised radial head fragments to ensure that all of the radial head has been removed and as an aid to accurate prosthesis sizing (see Fig. 13B).

A

Screws

B FIGURE 10

Radial head

145

A

C FIGURE 11

Open reduction and internal fixation options include countersunk traditional screws, headless compression screws, or plates. • A radial head fracture amenable to screw fixation (Fig. 10A) can be fixed with countersunk screws placed in the “safe zone” (Fig. 10B). • Figure 11 shows an anteroposterior radiograph (Fig. 11A), CT image (Fig. 11B), and intraoperative view (Fig. 11C) of a radial head and neck fracture that required a plate for rigid fixation.

B

Terrible Triad Injuries of the Elbow

■

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146

D

E

Radial neck plate

F

Radial head

G

FIGURE 11, cont’d

■

■

PITFALLS • If plates are utilized to fix radial head/neck fractures, they must be placed in the safe zone, which is the area that does not articulate with the proximal radioulnar joint.

• The radial head fragments were pieced together (Fig. 11D) and used to correctly size the implant (Fig. 11E). • A precontoured radial neck plate was placed in the safe zone (Fig. 11F and 11G). Partial excision can be performed if the fragment is less than 25% of the head, or the fragments are too comminuted or osteoporotic to reliably fix and do not articulate with the proximal radioulnar joint. Radial head arthroplasty should be performed if there is extensive comminution, poor-quality bone, or a severely comminuted neck fracture. • With the Evolve Radial Head System (Wright Medical Technology, Arlington, TN), the resected radial head is used to carefully determine the correct diameter of implant, avoiding placement of an implant that is too thick as overlengthening the radiocapitellar joint may cause pain and stiffness (Fig. 12A). The correct thickness is determined by closely matching the size of the smaller articular

147

• Care must be taken during fixation of radial neck fractures to protect the posterior interosseous nerve as dissection approaches the radial tuberosity. • Tenuous fixation of radial head fractures should be avoided in terrible triad injuries due to the importance of the radial head in maintaining stability, and the tendency for fixation failure if any residual instability is present postoperatively. • Complete excision of the radial head in the setting of terrible triad injuries is contraindicated as the radial head: ■

Is critical to valgus stability if the MCL is injured.

■

Resists posterior displacement of the elbow if the coronoid is deficient.

■

Tensions the LCL repair to resist varus and posterolateral rotatory instability.

A

B

C

FIGURE 12

Terrible Triad Injuries of the Elbow

dish (green dashed line and arrows) of the reconstructed native radial head rather than choosing the larger outer diameter of the often elliptical radial head (gold dashed line and arrows) (Fig. 12B). • Figure 12C shows back table assembly of the radial Stem Implant and Head Implant using a sleeve to compress the Morse taper of the modular implant. • For in-situ assembly, the Stem Implant (Fig. 13A) and Head Implant (Fig. 13B) are inserted separately.

P I T F A L L S —cont’d

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148

A

B

C

FIGURE 13

Instrumentation/ Implantation • Open reduction and internal fixation of the radial head can be accomplished with 1.5-, 2.0-, or 2.4-mm countersunk screws after provisional stabilization with Kirschner wires (see Fig. 10B). • Use of a modular prosthesis for radial head arthroplasty allows the surgeon to independently modify head and stem diameter and height to ensure an optimal fit (see Fig. 12). • A bipolar radial head prosthesis may not be preferred in the setting of complex instability.

PEARLS • A suture passer can be used to pass sutures through the drill holes made on the lateral epicondyle. • Begin suturing the LCL and common extensor origin just distal to the point of reattachment to the lateral epicondyle so appropriate tensioning of the lateral repair can be achieved without the sutures “bottoming out” on the lateral epicondyle.

• The In Situ Locker is used to securely compress the Morse taper to prevent implant dissociation (Fig. 13C). STEP 3: LCL REPAIR ■ Once the radial head and coronoid (if possible from the lateral side) have been addressed, the LCL, which is usually avulsed from its humeral origin, needs to be repaired. Figure 14A shows an avulsion of the LCL complex from its origin on the lateral epicondyle. ■ The LCL can be reattached to the lateral epicondyle with suture anchors or transosseous sutures (preferred). • A drill tunnel is made (or a suture anchor is placed) at the center (isometric point) of the capitellum, exiting on the posterior aspect of the lateral epicondyle (Fig. 14B). • Strong fixation can be achieved with locking nonabsorbable braided sutures placed in the LCL and common extensor origin; the tissue can then be pulled to the lateral epicondyle to ensure proper tensioning. • Wires are used to shuttle the sutures through the drill tunnels in the lateral epicondyle. • In patients with osteopenic bone, small plates may be used as washers to reinforce the bone tunnels (Fig. 14C). ■ After repair of the LCL, the extensor origin, which is commonly injured in this setting, is also repaired (Fig. 14D).

149

B

Small plate

C

D

FIGURE 14

P E A R L S —cont’d • A small plate or EndoButton placed on the posterior surface of the lateral epicondyle acts as a washer through which sutures are passed to improve fixation in patients with osteoporotic bone.

Instrumentation/ Implantation • A suture passer or 24-gauge wire is useful to retrieve sutures when using a transosseous repair method (see Fig. 14C). • Suture anchors with nonabsorbable sutures are required.

E

Terrible Triad Injuries of the Elbow

A

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150

PITFALLS • The lateral common extensor origin may be intact in patients with an LCL rupture and may need to be incised to expose the underlying ligament injury, which may not be initially evident when approaching the lateral side of the elbow. • The most important step in achieving isometric repair of the LCL is placing the sutures in the center of rotation of the elbow, which lies in the center of the arc formed by the capitellum when viewed from the lateral side. • If the LCL repair is overtensioned, medial joint gapping may result if the MCL is deficient.

PITFALLS • The medial common flexor origin is commonly intact in patients with an MCL rupture and must be incised to expose the underlying ligament injury, which may not be initially evident when approaching the medial side of the elbow. • The most important step in achieving isometric repair of the MCL is placing the sutures in the center of rotation of the elbow, which lies in the center of the arc formed by the trochlea when viewed from the lateral side. • Care must be taken not to overtension the MCL repair as this may result in a lateral joint gapping if the LCL repair is not tight.

STEP 4: MCL REPAIR ■ After the LCL has been repaired, the stability of the elbow should be evaluated fluoroscopically by flexion and extension with the forearm in pronation, supination, and neutral positions. • If the elbow remains stable and congruous from 30° to full flexion in one or more positions of forearm rotation, the MCL does not require repair. • If the elbow remains unstable after repairing the lateral structures, or a medial approach is needed to fix the coronoid fracture or explore the ulnar nerve, the MCL should be repaired. ■ Similar to the LCL, the MCL most commonly avulses from its origin on the medial epicondyle (Fig. 15A). ■ MCL repair can be accomplished with suture anchors or transosseous sutures through drill holes in the medial epicondyle (preferred) (Fig. 15B). PEARLS • If the coronoid was not fixed from the lateral side and repair is needed, it should be fixed prior to repair of the MCL. • Due to its proximity to the MCL, the ulnar nerve requires constant protection during MCL repair. • A small plate or EndoButton placed on the posterior surface of the medial epicondyle acts as a washer through which sutures are passed to improve fixation in patients with osteoporotic bone. • Begin suturing the MCL and common flexor origin just distal to the point of reattachment to the medial epicondyle so appropriate tensioning of the medial repair can be achieved without the sutures “bottoming out” on the medial condyle.

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Terrible Triad Injuries of the Elbow

Medial epicondyle Medial common flexor tendon MCL

A

B

FIGURE 15

Instrumentation/ Implantation • A suture passer or 24-gauge wire is useful for retrieving sutures when using a transosseous repair technique. • Suture anchors with nonabsorbable sutures are required.

A FIGURE 16

STEP 5: EXTERNAL FIXATOR APPLICATION ■ If all structures have been adequately repaired and the elbow remains unstable, a static or hinged external fixator should be applied to maintain reduction (Fig. 16A and 16B). ■ If a static external fixator is applied, it should not remain in place for a period of more than 3 weeks due to a high risk of residual stiffness.

B

Terrible Triad Injuries of the Elbow

152 ■

■

The use of transarticular Steinmann pins to stabilize the ulnohumeral joint as a temporizing measure should be avoided due to their tendency to break and the potential for pin site infection causing septic arthritis. In cases of tenuous fixation or suboptimal soft tissue repair, a dynamic or static external fixator can be used to maintain stability until healing is adequate. This is especially useful in revision situations.

PEARLS • Accurate placement of the axis pin is critical for an articulated external fixator to maintain joint congruity while allowing early motion. • Use fluoroscopy to ensure correct pin placement and joint congruity.

PITFALLS • Failure to protect the radial nerve when placing lateral distal humeral pins may result in nerve injury. • Inaccurate axis pin placement will result in articular maltracking, elbow subluxation, or limited range of motion.

Postoperative Care and Expected Outcomes REHABILITATION ■ Splinting of the elbow depends on repairs made to the MCL and LCL. • If the MCL is intact, the elbow should be splinted in 90° of flexion and forearm pronation to avoid posterolateral instability and to protect the LCL repair. • If both MCL and LCL are repaired, the elbow should be splinted in 90° of flexion and neutral forearm rotation. • If the LCL has been securely fixed and the MCL has not, the elbow should be splinted in 90° of flexion and forearm supination. ■ Supervised motion should begin 2–5 days postoperatively with active flexion and extension, avoiding terminal extension.

153

■

■

■

PEARLS • When an external fixator is removed, gentle manipulation in the operating room may help facilitate return of motion.

■

■

• If postoperative stiffness occurs, passive stretching and static progressive splinting can be utilized to gain motion beginning at 6 weeeks. Turnbuckle splinting can also be employed if stiffness persists despite therapy and standard splints. • The incidence of heterotopic ossification may be reduced by using indomethacin 100 mg rectally twice a day for 24 hours followed by 25 mg three times a day for 3 weeks in patients without a medical contraindication. However, this may have a negative effect on fracture healing.

Complications • Complications in terrible triad injuries are common and related to the severity of the injury. • Residual instability, malunion, nonunion, stiffness, heterotopic ossification, and infection are most frequent.

■

■

Full active forearm rotation is allowed with the elbow at 90° of flexion to protect the collateral ligament repairs. A resting splint at 90° should be made in the appropriate position of forearm rotation. Isometric contractions of the elbow flexor/extensors and the wrist flexors/extensors should begin immediately to encourage the recovery of muscle tone. In the setting of residual instability, an overhead rehabilitation protocol is helpful to provide gravity forces to maintain joint congruity during the early postoperative period. A static progressive nighttime extension splint can be employed starting at 6 weeks to improve elbow extension. Strengthening can be initiated at 8 weeks once osseous and ligamentous repairs have healed. If a static external fixator is used, it should typically be removed at 3 weeks to avoid joint stiffness. Articulated external fixators are removed at 6 weeks.

OUTCOMES ■ Few studies document the outcomes of terrible triad injuries. ■ Pugh et al. (2002) noted a delay in treatment or revision surgery resulted in 20% greater loss of motion when compared to acutely treated injuries; 25% of the patients required reoperation for residual instability, stiffness, or removal of hardware. ■ In another series of 36 patients (Pugh et al., 2004), at a mean of 34 months’ follow-up, 15 patients were rated as excellent, 13 as good, 7 as fair, and 1 as poor using the Mayo Elbow Performance Index score. ■ Broberg and Morrey (1987) showed that consistently poor results were seen in patients immobilized for greater than 4 weeks. ■ Forthman et al. (2007) reviewed 30 patients with terrible triad injuries and reported, at a mean follow-up of 32 months, an average ulnohumeral arc of motion of 117° and forearm rotation of 137°.

Terrible Triad Injuries of the Elbow

■

Terrible Triad Injuries of the Elbow

154

Evidence Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop Rel Res. 1987;206:109–19. Cohen MA. Lateral collateral ligament instability of the elbow. Hand Clin. 2008;24:69– 77. Forthman C, Henket M, Ring DC. Elbow dislocations with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Surg [Am]. 2007;32:1200–9. McKee MD, Pugh DM, Wild LM, Schemitsch EH, King GJ. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures: surgical technique. J Bone Joint Surg [Am]. 2005;87(Suppl 1 Pt 1):22–32. Pichora JE, Fraser GS, Ferreira LF, Brownhill JR, Johnson JA, King GJ. The effect of medial collateral ligament repair tension on elbow joint kinematics and stability. J Hand Surg [Am]. 2007;32:1210–17. Pugh DM, McKee MD. The “terrible triad” of the elbow. Tech Hand Upper Extrem Surg. 2002;6:21–9. Pugh DMW, Wild LM, Schemitsch EH, King GJW, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg [Am]. 2004;86:1122–30. Ring D. Fractures of the coronoid process of the ulna. J Hand Surg [Am]. 2006;31:1679–89. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg [Am]. 2002;84:1811–5. Taylor TK, Scham SM. A posteromedial approach to the proximal end of the ulna for the internal fixation of the olecranon. Trauma 1969;7:594–602.

PROCEDURE 9

Radial Head Fractures Piotr A. Blachut and Dean G. Malish

Radial Head Fractures: ORIF

156

PITFALLS • The fracture must be amenable to anatomic joint reduction and rigid internal fixation. This will depend on: ■

Number and size of fragments

■

Quality of bone

Open Reduction and Internal Fixation Indications ■

• Low-demand or elderly patients may best be treated nonoperatively or with excision. ■

• Always be prepared to perform a radial head arthroplasty when planning a radial head excision or internal fixation for a radial head fracture. ■

A FIGURE 1

Fracture with significant displacement (Fig. 1A and 1B) • Major joint incongruity • Mechanical block to forearm pronation/supination or elbow flexion/extension • Fracture fragment incarcerated within the joint Associated elbow instability (Fig. 2) • Medial collateral ligament injury (valgus instability) • Elbow dislocation with radial head fracture • Terrible triad injury (radial head fracture, coronoid fracture and elbow dislocation) • Trans-olecranon elbow fracture-dislocation Associated longitudinal instability of the forearm (Fig. 3) • Fractures associated with longitudinal instability of the forearm (i.e., interosseous ligament injury) • Monteggia variant

B

157

Radial Head Fractures: ORIF

Controversies • Reliability of clinical assessment for mechanical block • How much comminution precludes successful open reduction and internal fixation (ORIF) • Role of age and functional demand in the decision-making process • ORIF versus arthroplasty—lack of comparative studies

Treatment Options • • • •

Nonoperative treatment Fracture fragment excision Radial head excision Open reduction and internal fixation • Radial head arthroplasty

FIGURE 2

FIGURE 3

158

Radial Head Fractures: ORIF

Examination/Imaging ■

■

A FIGURE 4

Clinical evaluation • The joint above and below the fracture should be examined for associated injury (e.g., associated distal radioulnar joint injury). • The forearm should be inspected for signs of longitudinal radioulnar dissociation. • The elbow should be examined for medial (valgus) instability. • Neurovascular status must be documented (i.e., posterior interosseous nerve). Imaging • Plain radiographs of the elbow in the anteroposterior (Fig. 4A) and lateral (Fig. 4B) planes must be obtained. • A radiocapitellar view taken with the dorsal aspect of the supinated forearm against the x-ray plate with the beam directed 45° mediolaterally may help identify minimally displaced fractures of the radial head, coronoid, and capitellum. • Radiographs of the ipsilateral and contralateral wrist should be obtained to determine ulnar variance if there is a question of longitudinal instability. • Computed tomography scanning (Fig. 5A) with three-dimensional reformatting (Fig. 5B) allows better definition of the anatomy, the degree of comminution, and the size of the fracture fragments.

B

159

Radial Head Fractures: ORIF

A

B

FIGURE 5

Surgical Anatomy ■

Muscles and nerves • Anconeus muscle/extensor carpi ulnaris (ECU) (Fig. 6A and 6B), as well as the extensor carpi radialis brevis (ECRB), extensor carpi radialis longus (ECRL), and extensor digitorum communis (EDC)

Extensor carpi radialis brevis

Triceps

Brachioradialis Extensor carpi radialis brevis

Lateral epicondyle Extensor carpi radialis longus

Brachioradialis Anconeus Extensor digitorum communis

Extensor carpi radialis longus

Triceps

Extensor digitorum communis

Extensor carpi ulnaris Extensor digiti minimi

Extensor pollicus longus Adductor pollicus longus

A

Extensor pollicus brevis

FIGURE 6

Anconeus

B

Extensor carpi ulnaris

Radial Head Fractures: ORIF

160

■

■

• Posterior antebrachial cutaneous nerve (PABCN; superficial and anterior to common extensor origin) (Fig. 7; LABCN = lateral antebrachial cutaneous nerve) • Supinator muscle (Fig. 8) • Posterior interosseous nerve (PIN) (Fig. 9A and 9B; see also Fig. 8) Capsule • Lateral ulnar collateral ligament (Fig. 10) • Annular ligament The “safe zone”—100° arc of the circumference of the radial head that does not articulate with the radial notch of the proximal ulna (Fig. 11)

Brachialis Lateral antebrachial cutaneous nerve Brachioradialis Extensor carpi radialis longus

A (6.6 cm) Lateral epicondyle

B (2.1 cm) Posterior antebrachial cutaneous nerve

FIGURE 7 Radial nerve (deep branch) entering supinator muscle

Supinator muscle Exodus of nerve from supinator muscle

Recurrent interosseous artery

FIGURE 8

Dorsal interosseous artery

161

Superficial radial nerve Brachioradialis Supinator muscle Extensor carpi radialis brevis

Supinator Muscle Split Over Nerve

Superficial radial nerve

Extensor carpi radialis brevis

Brachioradialis Supinator muscle Extensor carpi radialis longus

Extensor carpi radialis longus Radial nerve

Radial nerve Posterior interosseous nerve

Posterior interosseous nerve

Extensor digitorum communis

A

Extensor digitorum communis

B

Extensor carpi ulnaris

Extensor carpi ulnaris

FIGURE 9

Radial collateral ligament

Anterior capsule

Annular ligament

Posterolateral capsule

Lateral ulnar collateral ligament

Radial styloid Neutral

FIGURE 10

“Safe zone” Lister’s tubercle

Supination

FIGURE 11

Pronation

Radial Head Fractures: ORIF

Overlying Muscles Retracted

Radial Head Fractures: ORIF

162

PEARLS

Positioning ■

• The radial head can be readily approached with the patient in the lateral or prone position.

■ ■

The patient is positioned supine with an armboard and pad under the ipsilateral elbow (Fig. 12). • In a patient with associated injuries about the elbow requiring surgical repair, these injuries may dictate alternate positioning (i.e., lateral, prone) (Fig. 13). A tourniquet is generally used. The arm is prepped and draped free.

FIGURE 12

FIGURE 13

163

■

• Kocher approach ■

Stay anterior to the lateral ulnar collateral ligament to prevent destabilizing the elbow.

■

Pronate the forearm to protect the PIN.

■

Avoid dissection distal to the annular ligament if possible.

• Kaplan approach ■

Kocher approach (anconeus-ECU interval) • A longitudinal incision is made that is based proximally on the lateral humeral epicondyle (Fig. 14A). • The Kocher interval is easiest to identify distally between the ECU and anconeus (Fig. 14B–D). • If dissection distal to the annular ligament is required, a Z-shaped incision is made through the ligament for easy repair. • If exposure distal to the radial tuberosity is required, the PIN should be identified and protected through the Kaplan interval.

The PIN is more at risk but the lateral ulnar collateral ligament is less at risk.

Brachioradialis Triceps

Extensor carpi radialis longus

Extensor carpi radialis brevis

Anconeus (radial nerve)

Lateral epicondyle of humerus

A

Posterior antebrachial cutaneous nerve

Head of radius

Extensor digitorum communis Extensor carpi ulnaris (posterior interosseous nerve)

B

Brachioradialis Triceps

Extensor carpi radialis longus

Extensor carpi radialis brevis Extensor carpi ulnaris

Anconeus

Anconeus

C FIGURE 14

Extensor carpi ulnaris

D

Extensor digitorum communis

Radial Head Fractures: ORIF

Portals/Exposures

PEARLS

Radial Head Fractures: ORIF

164 ■

PITFALLS • Avoid excessive anterior soft tissue retraction to prevent PIN injury.

■

• Raising a posterior capsular flap (with injury to lateral ulnar collateral ligament) can lead to posterolateral rotatory instability.

■

Kaplan approach (EDC-ECRB interval) (Fig. 15A and 15B) • This is the approach of choice if direct exposure of the PIN is desired. Boyd approach (universal direct posterior approach) (Fig. 16A and 16B) • In complex elbow fracture-dislocations and Monteggia variant injuries, open reduction and internal fixation of the radial head (often through the joint) should be carried out prior to reduction and stabilization of the rest of the elbow. Pankovich approach (proximal reflection of the anconeus) Extensor carpi radialis brevis

Brachioradialis

Brachioradialis Extensor carpi radialis longus

Triceps Extensor carpi radialis brevis

Extensor carpi radialis longus

Triceps

Anconeus

Anconeus

Extensor carpi ulnaris Extensor digitorum communis

A

Extensor digitorum communis Extensor carpi ulnaris

B

FIGURE 15

Triceps tendon Reflected anconeus muscle Olecranon Anconeus Line of incision Flexor carpi ulnaris

Reflected portion of supinator muscle from ulna Reflected portion of supinator muscle from radius Divided portion of supinator muscle

Extensor carpi ulnaris Flexor digitorum profundus

FIGURE 16

A

B

165

• Some fracture fragments will be completely surrounded by soft tissue or cartilage, particularly impacted segments. Care must be taken to identify the fracture fragments while preserving the soft tissue/articular cartilage attachments to the pieces.

A

STEP 1 ■ Fracture fragments are identified: • Large fragments with little/no comminution or impaction on preoperative radiographs, as seen in Case 1 (Fig. 17A–C) and Case 2 (Fig. 18).

C

B

FIGURE 17

FIGURE 18

Radial Head Fractures: ORIF

Procedure

PEARLS

Radial Head Fractures: ORIF

166

PITFALLS • Avoid cartilage or soft tissue damage (devascularization of fragments).

■

■

• Avoid comminuting smaller, fragile fracture fragments.

■

• Fragments with poorer bone quality, comminution, and/or impaction on preoperative radiographs, as seen in Case 3 (Fig. 19A–D). Interposed soft tissue and fracture hematoma are removed. Small instruments can be utilized to manipulate or hold fracture fragments. Kirschner wires (K-wires) can be used as joysticks on fracture fragments.

A

B

C

D

FIGURE 19

167

• • • •

K-wires (small sizes) Dental picks Small curettes Small periosteal elevators

PEARLS • Elevate impacted fracture fragments and use bone graft or bone graft substitutes if necessary.

STEP 2 ■ The fracture fragments are reduced and provisionally stabilized. ■ Large fragments can be reduced with small instruments or K-wires, as shown for Case 1 (Fig. 20) and Case 2 (Fig. 21). • If using K-wires for joysticks, the surgeon should try to position the K-wire in a fragment where a proposed screw will be inserted to avoid excessive drill holes in fragments, which could lead to further comminution. ■ Poor-quality, comminuted, or impacted fragments can be provisionally stabilized with screws, as shown for Case 3 (Fig. 22A and 22B).

• Always be prepared to proceed with either excision or arthroplasty if indicated and the fracture is not amenable to internal fixation.

FIGURE 20

A FIGURE 22

FIGURE 21

B

Radial Head Fractures: ORIF

Instrumentation/ Implantation

Radial Head Fractures: ORIF

168

PITFALLS • Avoid further comminuting fracture fragments. • Avoid placing temporary fixation in areas where definitive fixation will best maintain fracture reduction. • Have adequate imaging to plan fragment fixation and possible need for bone grafting.

Instrumentation/ Implantation • Bone reduction clamps • Dental picks • K-wires (small sizes)

STEP 3 ■ Fracture reduction is maintained with rigid internal fixation. • The extent of the fracture into the radial neck is identified to plan the appropriate approach and the need for certain implants such as small plates. • Large fragments can be stabilized with screws alone, as shown for Case 1 (Fig. 23) and Case 2 (Fig. 24A and 24B). • With poor-quality, comminuted, or impacted fragments, plate fixation is usually required, as shown for Case 3 (Fig. 25A and 25B). ■ Repeat radiographs are obtained to check reduction/ realignment. • Figures 26 and 27 show results for Case 1 (Fig. 26A and 26B) and Case 2 (Fig. 27A and 27B). • Figure 28 shows results for Case 3 (Fig. 28A and 28B).

A

B

FIGURE 24

FIGURE 23

FIGURE 25

A

B

169

Radial Head Fractures: ORIF

FIGURE 27

B A

B A

FIGURE 26

Radial Head Fractures: ORIF

170

A

B

FIGURE 28

PEARLS • Ensure that exposed hardware is in the safe zone, and always check for smooth pronation/supination range of motion after fracture fixation. • Countersink screw heads under the articular surface. • Address any corresponding relevant soft tissue injury at the time of fixation.

PITFALLS • Violating the safe zone

• Appreciate the concavity of the radial articular surface to avoid encroachment on the joint surface with internal fixation. • Be prepared for possible radial head arthroplasty.

• Prominent hardware through opposite cortex/chondral surface • Inadequate fixation of associated fractures leading to malreduction of the radial head or neck fracture • Failing to recognize the need for bone graft for impacted fractures

Postoperative Care and Expected Outcomes ■

■

■

Instrumentation/ Implantation • Mini-fragment plate and screw sets • Headless ± variable-pitch screws • Suture anchors • Radial head implants

■

The arm is mobilized in a soft dressing postoperatively (except if there is residual instability). The patient may begin range of motion (ROM) within the safe range as determined intraoperatively. No resisted exercises or activity with the arm is permitted for 6 weeks. Complications • PIN palsy • Hardware impingement • Malunion/nonunion • Infection • Elbow stiffness • Avascular necrosis of radial head fragments • Heterotopic ossification/radioulnar synostosis • Degenerative arthritis

171

• If associated injuries such as an elbow dislocation are present, test safe ROM intraoperatively to plan rehabilitation. • Utilize a ROM brace if necessary.

PITFALLS • Avoid prolonged immobilization.

Controversies • Postoperative nonsteroidal anti-inflammatory drugs or radiation to prevent heterotopic ossification in the context of complex elbow dislocations

Evidence Davidson PA, Moseley JB Jr, Tullos HS. Radial head fracture: a potentially complex injury. Clin Orthop Relat Res. 1993;(297):224-30. This prospective study of 50 consecutive radial head fractures looked at patterns of radial head fracture and resultant valgus and axial instability at the elbow. Furry KL, Clinkscales CM. Comminuted fractures of the radial head: arthroplasty versus internal fixation. Clin Orthop Relat Res. 1998;(353):40-52. This paper reviewed the treatment of radial head fractures with respect to choosing between replacement versus internal fixation when preservation of radial head mechanics is indicated. Hotchkiss RN. Displaced fractures of the radial head: internal fixation or excision? J Am Acad Orthop Surg. 1997;5:1-10. This article reviewed the mechanical role of the radial head, the indications for internal fixation after fracture, the technical details of internal fixation, and the role of radial head excision. Ikeda M, Sugiyama K, Kang C, Takagaki T, Oka Y. Comminuted fractures of the radial head: comparison of resection and internal fixation. J Bone Joint Surg [Am]. 2005;87:76-84. This study compared the results of radial head resection with open reduction and internal fixation in 28 patients with Mason type 3 comminuted radial head fractures, recommending internal fixation in this pattern of injury. Ikeda M, Yamashina Y, Kamimoto M, Oka Y. Open reduction and internal fixation of comminuted fractures of the radial head using low-profile mini-plates. J Bone Joint Surg [Br]. 2003;85:1040-4. This paper reviewed the results of 10 patients with comminuted radial head fractures treated with open reduction and internal fixation with low-profile plates. King GJ, Evans DC, Kellam JF. Open reduction and internal fixation of radial head fractures. J Orthop Trauma. 1991;5:21-8. This paper reviewed the results of open reduction and internal fixation of 14 displaced radial head fractures, indicating that alternate forms of treatment should be entertained intraoperatively if stable reduction and fixation of the radial head fracture fragments cannot be obtained. Morrey BF, Tanaka S, An KN. Valgus stability of the elbow: a definition of primary and secondary constraints. Clin Orthop Relat Res. 1991;(265):187-95. This study defined the medial collateral ligament as the primary constraint of the elbow joint to valgus stress and the radial head as a secondary constraint. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg [Am]. 2002;84:1811-5. This retrospective study analyzed the functional results following open reduction and internal fixation of fractures of the radial head determining that fractures consisting of three or fewer articular fragments are most amemable to this form of treatment. Smith GR, Hotchkiss RN. Radial head and neck fractures: anatomic guidelines for proper placement of internal fixation. J Shoulder Elbow Surg. 1996;5(2 Pt 1):113-7. This cadaveric study defined the 110° “safe zone” on the radial head for placement of internal fixation.

Radial Head Fractures: ORIF

PEARLS

PROCEDURE 10

Radial Head Arthroplasty Steven Papp and Michael D. McKee

174

Radial Head Arthroplasty

Introduction ■

■

■

■

■

■

■

Isolated radial head fractures can occur but are usually minimally displaced. Most comminuted radial head fractures have been shown to occur in conjunction with other associated injuries around the elbow or wrist (Davidson et al., 1993; Itamura et al., 2005). This combination of injuries often makes the elbow more unstable; the radial head becomes an important elbow stabilizer in this scenario. Therefore, nonoperative treatment or a simple radial head resection for a comminuted radial head fracture is an uncommon treatment choice in this scenario. Open reduction and internal fixation or radial head arthroplasty remain the treatment choices for displaced and comminuted fractures. Displaced, comminuted (Mason type 3) radial head fractures are better treated by arthroplasty than marginal fixation, even in the hands of experienced surgeons (Ring et al., 2002). The decision regarding fixation versus arthroplasty can be made intraoperatively. Any surgeon trying to perform fixation of a displaced radial head fracture should be prepared and understand the technical merits of performing a radial head arthroplasty in case it is necessary.

Indications PITFALLS

■

• The decision to fix or replace the radial head is made intraoperatively, and therefore the surgeon should be prepared to perform either as necessary.

Controversies • Isolated comminuted radial head fracture with minimal elbow instability • Young age • Open fracture with contamination • Fixation versus arthroplasty in “technically” reconstructible fracture

The indications for radial head arthroplasty include a comminuted, unreconstructible radial head fracture with: • Associated elbow dislocation with medial collateral injury (Doornberg et al., 2007) (Fig. 1) • Associated fracture of the of the coronoid (terrible triad injury) (Pugh et al., 2004) (Fig. 2A and 2B) • Interosseous membrane injury (Essex-Lopresti lesion) (Sowa et al., 1995) (Fig. 3)

Examination/Imaging ■

■

Locations where the patient is tender—medial epicondyle, lateral epicondyle, radial head, interosseous membrane, distal radioulnar joint—are noted. Bruising and swelling can often point to associated injuries.

175

Radial Head Arthroplasty

FIGURE 1

A

B FIGURE 2

FIGURE 3

Radial Head Arthroplasty

176

Treatment Options • Nonoperative treatment may be indicated for some patients. • Radial head fixation is preferred in simple fracture patterns. • Radial head resection is an option if the elbow remains stable after resection (uncommon in our experience).

■

■

■

■

■

A FIGURE 4

Stable range of motion (ROM) is documented in supination, neutral, and pronation. ROM/stability testing may be most accurate after administration of a general anesthetic. Preoperative neurovascular status is documented thoroughly, with special attention to the posterior interosseous nerve. Radiographic imaging includes high-quality anteroposterior (AP)/lateral radiographs of the elbow (Fig. 4A and 4B). Postreduction radiographs are usually best for understanding the fracture. Preoperative fluoroscopy (after general anesthetic), including AP/lateral and moving fluoroscopic examination, can be helpful.

B

177

Radial Head Arthroplasty

A

FIGURE 5 ■

B

Computed tomography can be helpful (but is not mandatory) preoperatively to understand and plan the surgery; usually two- or three-dimensional reconstuctions are the most informative (Fig. 5A and 5B).

Radial Head Arthroplasty

178

Surgical Anatomy ■

■

■

Bony structures: radial head and neck, capitellum, trochlea, coronoid (Fig. 6) • The normal angle of the radial neck to the shaft is approximately 15° lateral flare (Fig. 7). • The average radial head is elliptical at 22 × 24 mm, and the average height is 12 mm. Ligamentous structures: lateral ulnar collateral, radial collateral, annular ligaments (Fig. 8) • The lateral ulnar collateral ligament is most important for posterolateral instability. Neurovascular structures • The posterior interosseous nerve is in close proximity to the radial neck (Diliberti et al., 2000) (Fig. 9A and 9B). • Pronation and supination have an effect on nerve position. Pronation increases the “safe” working distance.

Lateral supracondylar ridge Radial fossa Lateral epicondyle Capitulum

Medial supracondylar ridge Coronoid fossa Medial epicondyle Trochlea

Radial head Neck

FIGURE 6

15˚

FIGURE 7

179

Annular ligament Accessory lateral collateral ligament

Articular capsule

Lateral ulnar collateral ligament

FIGURE 8

A

2.2

3.8

B FIGURE 9

Radial Head Arthroplasty

Lateral (radial) collateral ligament

Radial Head Arthroplasty

180

PEARLS • Using a popliteal post allows the arm to hang freely, but taping of pillows and then sterile rolls allows the same arm position and easier intraoperative fluoroscopic examination. • Since most dislocations are posterior, in the lateral decubitus position, gravity helps to reduce the elbow (Fig. 11).

Positioning ■

■ ■ ■

The lateral decubitus position allows free hanging of the arm (Fig. 10). Bony prominences must be appropriately padded. The endotracheal tube must be protected. The entire arm to the shoulder must be prepped, and a sterile tourniquet used; a regular tourniquet can limit proximal exposure.

PITFALLS • Pad the axillary area carefully.

FIGURE 10

FIGURE 11

181

■

■

■

■

Equipment • Using a padded sterile Mayo stand allows the arm to be rested on the table when needed.

■

■

A posterior skin incision is made and a lateral fasciocutaneous flap is raised (Fig. 12). Starting along the ulnar border and triceps fascia and elevating laterally allows exposure of the lateral humerus, capitellum, radial head, and lateral collateral ligament. Once a fasciocutaneous flap raised and the lateral side exposed, Kocher’s interval is identified (between the extensor carpi ulnaris and anconeus) (Fig. 13A and 13B). The extensor carpi ulnaris and underlying radial collateral ligament are raised anteriorly. In the distal portion of the incision, the annular ligament needs to be incised to expose the radial head and neck. The lateral ulnar collateral ligament lies under the anconeus muscle posteriorly and is protected using this interval. RCL

Ligament incision

AL

A

B FIGURE 12

FIGURE 13

LUCL

Anconeus

ECU

Radial Head Arthroplasty

Portals/Exposures

Radial Head Arthroplasty

182

Controversies • Some surgeons prefer supine positioning with the arm draped across the chest. This may be a safer position, in particular in patient with polytrauma injury including chest/pelvic/ abdominal injuries.

PEARLS • In many of these fractures, there is an associated lateral ligament injury; most commonly the ligament is torn off the lateral humeral epicondyle (Fig. 14). Work through this defect in this scenario: identify and prepare the injured lateral ligament for closure during exposure, and plan a solid lateral collateral ligament repair at the end of the surgery.

FIGURE 14

PITFALLS • Avoid damaging the lateral collateral ligament (often already injured) by staying anterior to this structure • Careful distal exposure along the radial neck with pronation minimizes the chance of nerve injury. • Careful retractor placement on the radial neck is needed to avoid posterior interosseous nerve injury.

Controversies • A straight posterior skin incision allows full-thickness skin flaps to be mobilized for medial and lateral fascial intervals. The straight posterior skin incision prevents injury to lateral-side cutaneous nerves and is cosmetically hidden, but the skin incision is significantly longer. Alternatively, a shorter, more direct lateral skin incision is preferred by some authors, with an additional medial skin incision as needed.

PITFALLS • Avoid displacing a stable, minimally displaced radial neck fracture with careful retractor postioning.

Procedure STEP 1: PREPARATION ■ With adequate exposure, the radial head is assessed and fixation options are considered. ■ If multiple pieces are present or significant comminution prevents stable reconstruction, then arthroplasty is undertaken. ■ The remaining radial head is removed using a microoscillating saw or rongeur at the head-neck junction (articular surface junction), giving access to the remainder of the elbow joint.

183

• Use a Hohmann retractor on the radial neck and a Langenbach retractor on the anterior capule for adequate exposure.

PEARLS • The stem used should be loose enough to allow some rotation. • If maltracking of the prosthesis occurs, downsizing the stem will allow some toggle and may improve the alignment of the prosthesis. • When assessing elbow stability with the trial prosthesis, temporarily reapproximating the lateral ligament with a Kocher clamp will prevent an impression of recurrent instability (especially in supination) and a tendency to overstuff the radial head. • We tend to choose a slightly smaller arthroplasty (up to 2 mm smaller) than the native head without compromising stability.

PITFALLS • Overstuffing should be avoided to avoid a detrimental effect on motion.

■

■

■

The elbow is irrigated, and loose osteochondral fragments are removed. The major radial head fragments can be loosely pieced together, and the largest of these fragments can be used later for radial head sizing (also ensures complete removal of head). The capitellum, lesser and greater sigmoid notch, coronoid, and trochlea can all be assessed. Osteochondral fragments can be repaired occasionally, or débrided.

STEP 2: RADIAL HEAD SIZING ■ Elbow stability is examined clinically and with fluoroscopic guidance to confirm that there is instability and radial head replacement is indicated. Associated bony/ligamentous injuries usually preclude simple radial head excision. ■ The radial neck cut is confirmed to be perpendicular to the long axis of the radial neck. ■ Retractors are positioned to visualize the medullary canal, and preparation is begun starting with the smallest canal rasp and working up until fit is snug with the rasp (Fig. 15). ■ A trial stem is placed for a non-tight fit. ■ A neck rasp can be used to smooth off the neck, ensuring a 90° cut. ■ A trial head, based on the resected head portion diameter and height (most commonly 22- or 24-mm diameter), is placed. ■ The appropriate neck cut and trial head should restore the normal head height. ■ Several keys allow the head height to be placed appropriately. • The radial head should articulate with the proximal radioulnar joint.

FIGURE 15

Radial Head Arthroplasty

Instrumentation/ Implantation

Radial Head Arthroplasty

184

■

FIGURE 16

• The ulnotrochlear joint is checked fluoroscopically to confirm that the medial and lateral joints are close to symmetric and not overstuffed, as in Figure 16. Also, the medial translation of the ulna on the trochlea is noted. • The relationship of the proximal lip of the radial head to the lateral portion of the coronoid is assessed; they reside near the same level (Doornberg et al., 2006) (Fig. 17). • The elbow is taken through a range of motion. The radial head usually has less space available in full flexion. Overstuffing can lead to loss of flexion. Elbow stability with the trial radial head in place is assessed and improvement noted. If assessing in supination, instability will remain unless the lateral ligamentous structures are temporarily reapproximated.

FIGURE 17

185

Radial Head Arthroplasty

Instrumentation/ Implantation • We use a modular but monopolar radial head arthroplasty (Fig. 18). • Modularity allows matching (or mismatching) of neck size to head size as this ratio varies among individuals. FIGURE 18

Controversies • Bipolar radial head arthroplasty allows some rotation at the polyethylene-metal junction and may lessen capitellar wear. However, polyethylene wear and osteolysis remain a concern (Fig. 19).

FIGURE 19

Radial Head Arthroplasty

186

PEARLS • If the radial head is assembled on the back table, take care not to damage the capitellum during relocation of the head with traction, retractors, and careful manipulation.

PITFALLS • Solid lateral collateral ligament repair is mandatory; inadequate repair will lead to recurrent instability.

A FIGURE 20

STEP 3: PLACEMENT AND CLOSURE ■ Retractors are repositioned and the trial prosthesis is removed. ■ The permanent component (neck and head) can often be linked on the back table using the appropriate impactors; however, sometimes in situ assembly can be used. ■ The radial head is placed and a repeat examination is performed. ■ The lateral ulnar collateral ligament repair is performed to the lateral epicondyle (if avulsed from there) (Fig. 20A and 20B). • If deficient, this may be augmented with a strip of triceps fascia or #5 Mersilene. • Repair is performed using drill holes or suture anchors in this circumstance to allow anatomic repair of the ligament. ■ Midsubstance tears can be managed with direct suture repair.

B

187

Radial Head Arthroplasty

A

B

FIGURE 21

Instrumentation/ Implantation • Suture anchor repair is straightforward. We usually use 2.3-mm suture anchors with #0 Ethibond sutures.

PEARLS • Having an experienced physiotherapist and specific instructions is invaluable. Many therapists are concerned about pushing too far.

■

■

The skin is closed in layers and a temporary splint is applied. • The splint is applied in 90° of flexion in pronation. • If the medial side opens widely in pronation, then the splint is applied in neutral rotation. Postoperative radiographs are obtained (Fig. 21A and 21B).

Postoperative Care and Expected Outcomes ■

Postoperative management • Antibiotics are given preoperatively, and two doses are given postoperatively. • Oral indomethacin 25 mg three times per day is given for 3 weeks (unless contraindicated). • An early ROM program is started. ◆ Full active flexion and extension are started within 7 days of surgery. ◆ If any concern exists for instability (usually in extension), then the postoperative regimen may be modified to avoid the unstable position (30° extension block) with a hinged brace.

Radial Head Arthroplasty

188

• Early ■ Wound breakdown ■ Infection ■ Recurrent instability ■ Stiffness/capsular contracture/ heterotopic ossification • Late ■ Loosening ■ Radiocapitellar arthritis ■ Elbow posttraumatic arthritis

If concern exists for lateral ligament injury and repair, then full supination is not allowed until 4–6 weeks postoperative. Expected outcomes (Grewal et al., 2006; Popovic et al., 2007) • Disability is mild to moderate on average (DASH score: 24). • The amount of disability is dependent on many factors, including successful technical surgery and good postoperative rehabilitation. • Equally important are associated fractures of the elbow, patient age and medical comorbidities, associated injuries, worker’s compensation status, and other factors. • On average, ROM is 25–140° of flexion/extension (normal: 6–140°). • On average, ROM is 71–55° of pronation/ suppination (normal: 78–71°). • On average, 6 months are required to reach final goals, with little improvement afterward. ◆

Complications ■

Evidence Davidson PA, Moseley B, Tullos HS. Radial head fracture: a potentially complex injury. Clin Orthop Relat Res. 1993;(297):224–30. (Level V evidence) Diliberti T, Botte MJ, Abrams RA. Anatomical considerations regarding the posterior interosseous nerve during approaches to the proximal part of the radius. J Bone Joint Surg [Am]. 2000;83:809–19. Doornberg JN, Linzel DS, Zurakowski D, Ring D. Reference points for radial head prosthesis size. J Hand Surg [Am]. 2006;31:53–7. (Level IV evidence) Doornberg JN, Parisien R, van Duijn PJ, Ring D. Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability. J Bone Joint Surg [Am]. 2007;89:1075–80. (Level IV evidence) Grewal R, MacDermid JC, Faber KJ, Drosdowech DS, King GJW. Comminuted radial head fractures treated with a modular metallic radial head arthroplasty. J Bone Joint Surg [Am]. 2006;88:2192–200. (Level IV evidence) Itamura J, Roidis N, Mirzayan R, Vaishnav S, Learch T, Shean C. Radial head fractures: MRI evaluation of associated injuries. J Shoulder Elbow Surg. 2005;14:421–4. (Level III evidence) Popovic N, Lemair R, Georis P, Gillet P. Midterm results with a bipolar radial head prosthesis: radiographic evidence of loosening at the bone-cement interface. J Bone Joint Surg [Am]. 2007;89:2469–76. (Level IV evidence) Pugh DM, Wild LM, Schemitsch EH, King GJW, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg [Am]. 2004;86:1122–30. (Level IV evidence) Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg [Am]. 2002;84:1811–15. (Level IV evidence) Sowa DT, Hotchkiss RN, Weiland AJ. Symptomatic proximal translation of the radius following radial head resection. Clin Orthop Relat Res. 1992;(275):79–84. (Level IV evidence)

PROCEDURE 11

Open Reduction and Internal Fixation of Olecranon Fractures Greg K. Berry

190

ORIF of Olecranon Fractures

Introduction ■

■

■

Fractures of the olecranon are common injuries and vary in scope from simple transverse fractures to complex fractures associated with injury to other structures at the elbow and forearm. The diagnosis of the fracture can be reliably made with history, physical examination, and plain radiographs. Computed tomography (CT) scanning can aid in the preoperative planning of complex injuries. The aim of surgery is the anatomic restoration of the olecranon anatomy (especially the joint surface) and sufficient stability to allow early unhindered range-ofmotion (ROM) exercises.

Indications PITFALLS • Operative care is made simple by the subcutaneous nature of the olecranon; this advantage, however, makes complaints from prominent hardware more likely.

Treatment Options • If nonoperative care is chosen: ■ Weekly follow-up radiographs for 2–3 weeks to ensure there is no secondary displacement ■ A short period of immobilization (7–10 days) followed by progressive active and active-assisted ROM exercises but no passive ROM ■ Strengthening after healing is confirmed clinically and radiographically (6–8 weeks)

■

■

Undisplaced fractures typically have an intact soft tissue sleeve and are unlikely to displace. More typically, the pull of the triceps upon the proximal fragment generates displacement in nearly all olecranon fractures, most of which involve the articular surface, thereby providing the indications for open reduction and internal fixation (ORIF).

Examination/Imaging ■

■

■

A detailed physical examination and close inspection of plain radiographs are necessary to rule out concomitant injuries. This includes assessment of: • Bone, joint and ligament status—the coronoid process, radial head, elbow collateral ligaments, and proximal and distal radioulnar joints • Neurologic status—median, ulnar, and radial nerve sensorimotor function • Vascular status—radial and ulnar artery perfusion • Skin condition—open fracture, swelling, contusion, abrasion Imaging includes plain radiographs (anteroposterior, true lateral, and oblique views). • Figure 1A shows a preoperative lateral radiograph of a transverse fracture of the olecranon, the typical fracture amenable to tension band fixation (Fig. 1B). CT scanning may be required for complex fractures involving joint depression, severe comminution, radial head fracture, intra-articular fragment, or associated distal humerus fracture.

191

ORIF of Olecranon Fractures

A

B

FIGURE 1

Surgical Anatomy ■

Bones, muscles, and tendons of the elbow joint (Fig. 2A and 2B)

Triceps Biceps

Brachialis Biceps

Triceps

Brachioradialis

Brachialis Ulna

Extensor carpi radialis longus

Anconeus

Brachioradialis Humerus Extensor carpi radialis longus

Pronator teres

Extensor carpi ulnaris

Flexor carpi radialis

Flexor carpi radialis Palmaris longus Flexor carpi ulnaris

A FIGURE 2

Extensor digitorum Extensor carpi radialis brevis

B

ORIF of Olecranon Fractures

192

Radial nerve Humerus Ulnar nerve

Humerus

Radial nerve

Median nerve

Median nerve

Ulnar nerve Radial artery

Ulna

Ulnar artery

Radial artery

Ulnar artery Radius

Radius

Ulna

A

B

FIGURE 3 ■

Neurovascular anatomy of the elbow (Fig. 3A and 3B) • Median, ulnar, and radial nerves • Radial and ulnar arteries

CLASSIFICATION AND CHOICE OF FIXATION TECHNIQUE ■ The Schatzker classification (Fig. 4) is a simple and comprehensive scheme to describe these fractures and aids in the choice of fixation technique. ■ Optimal fixation technique is dependent on fracture type. • Type A—the classic pattern for tension band fixation (Weber and Vasey, 1963); plate and screws have also been shown to be effective. • Type B—the joint surface impaction must be recognized, reduced, and stabilized with bone graft and/or an implant; fracture fixation as per type A. • Type C—compression across the fracture is generated by a lag screw(s), which is protected (“neutralized”) with either plate or tension band fixation. • Type D—reduction and fixation of the intermediate fragments with transcortical or intraosseous screws is followed by either tension band fixation (if a stable fracture configuration permitting compression is achieved) or plate and screw fixation (if the fracture configuration either does or does not permit compression).

193

Transverse

B

Transverse-impacted

C

Oblique

D

Comminuted

E

Oblique-distal

F

Fracture-dislocation

FIGURE 4

• Type E—not mechanically amenable to tension band wiring; use plate and screws with lag technique across the fracture. • Type F—complex fracture with significant instability requiring that all osseous and soft tissue components of the injury be addressed.

PEARLS • A tourniquet is used at the discretion of the surgeon.

A FIGURE 5

Positioning ■ ■

Typically the patient is placed supine. One can consider lateral decubitus positioning (Fig. 5A) if operating without assistance as this will allow the elbow to be positioned in extension on a Mayo stand without an assistant to hold it (Fig. 5B).

B

ORIF of Olecranon Fractures

A

194

ORIF of Olecranon Fractures

Portals/Exposures ■

■

PEARLS • If fracture pattern and fixation choice permit, harvesting graft from the metaphyseal bone adjacent to the fracture can be considered if only a small amount is required.

PEARLS • Reduction can be visually and/or fluoroscopically evaluated at this point.

PEARLS • Alternatively, a single length of wire can be used to construct the tension band, but this is more fiddlesome. • Adequate tension is achieved once there is slight bending of the K-wires toward one another and no motion occurs at the fracture site with gentle ROM.

The posterior approach to the olecranon is used: the incision is curved around the tip of olecranon and not over it to avoid a bothersome scar. Minimal dissection of the soft tissues (including the periosteum and the origin of the flexor muscles) at the fracture site will preserve the biologic healing environment but must allow evaluation of fracture reduction, especially at the joint surface, as dictated by the fracture pattern.

Procedure: Tension Band Technique STEP 1 ■ Expose the fracture and clear the periosteum and other soft tissues 2 mm from the margin of the fracture, as well as clot from between fracture fragments (Fig. 6). ■ If needed, the flexor muscle origins (flexor digitorum superficialis, flexor pollicis longus, and pronator teres) can be raised off the medial side to access the joint surface to aid in fracture reduction evaluation. ■ Any joint impaction is raised and back-grafted with autograft or allograft. STEP 2 ■ Two holes are drilled distal to the fracture with a 2.5-mm drill bit. • The first is a transverse hole 10–15 mm from the fracture margin for the tension band wire (Fig. 7). • The second is a unicortical oblique hole angled back toward the fracture for the pointed reduction clamp. ■ The fracture is reduced with a combination of elbow extension and clamping with the pointed reduction clamp. STEP 3 ■ Two 1.6-mm Kirschner wires (K-wires) are drilled from the posterior surface of the olecranon through the triceps insertion, angled toward the volar ulnar surface. Once through the latter surface, they are backed out 8–10 mm to allow for bending and impaction later (see Step 4). ■ The tension band is constructed using two lengths of 18-gauge stainless steel wire.

195

ORIF of Olecranon Fractures

FIGURE 6

FIGURE 7

196

ORIF of Olecranon Fractures

• One strand is passed transversely through the triceps tendon proximal to the two K-wires at the surface of the posterior ulna. This can best be done by passing a large-bore angiocatheter in the same plane (Fig. 8A) and removing the needle, leaving the plastic catheter to receive the wire, which is then brought through the tendon as the catheter is withdrawn (Fig. 8B). • The second strand is passed through the transverse hole distal to the fracture (Fig. 8C).

A

C

B

FIGURE 8

197

■

The distal wire is crossed over the ulnar crest, and two twisted knots are created on either side of the olecranon, progressively developing balanced compression across the fracture site (Fig. 9A). The twisted wires are cut short and buried next to the cortical surface on either side of the olecranon (Fig. 9B).

A

B FIGURE 9

ORIF of Olecranon Fractures

■

198

ORIF of Olecranon Fractures

STEP 4 ■ The K-wires are cut and curved 180° (Fig. 10A), and then impacted into the posterior ulnar cortex with a tamp placed through a vertical incision in the triceps tendon (Fig. 10B). ■ The tendon fibers are reapproximated with resorbable suture to prevent backing out of the wires. ■ Gentle flexion/extension and pronation/supination will help ascertain fracture and implant stability, and will ensure that the K-wires do not protrude into the proximal radioulnar joint (PRUJ).

A

STEP 5 ■ Accuracy of reduction and implant position are confirmed with intraoperative imaging using radiographs or C-arm fluoroscopy. ■ Particular attention needs to be paid to length of K-wire entending across the volar ulnar surface into the anterior compartment on the lateral view. ■ By placing the forearm into maximal supination in an anteroposterior view (Fig. 11), the PRUJ can be imaged to confirm no incursion of hardware, which would lead to limited pronation/supination and increase the risk of synostosis.

B FIGURE 10

FIGURE 11

199

Alternative Modes of Fixation OBLIQUE FRACTURE ■ Fixation of an oblique fracture of the olecranon (Fig. 12A) is achieved by compression across the fracture using an interfragmentary lag screw protected (“neutralized”) with tension band wiring or an interfragmentary plate and screws (Fig. 12B). ■ The plate can be a 1⁄3 tubular plate, a 2.7- or 3.5-mm reconstruction plate, or a precontoured olecranon (locking or nonlocking) plate.

A FIGURE 12

B

ORIF of Olecranon Fractures

STEP 6 ■ The “safe zone” for ROM is evaluated in order to guide postoperative rehabilitation. ■ The wound is irrigated and closed in layers. ■ A sterile dressing and a plaster splint holding the elbow at 90° are applied.

200

ORIF of Olecranon Fractures

COMMINUTED FRACTURE WITH JOINT DEPRESSION ■ For a comminuted fracture of the olecranon with residual joint depression (Fig. 13A), if a simple transverse fracture pattern can be re-created, the tension band technique can be applied. ■ If this is unachievable, or the fracture remains too unstable for this compressive technique, plate and screw fixation must be used to provide greater stability. ■ Joint depression is reduced (Fig. 13B), and small fracture fragments can be secured using 2.0-mm/2.4-mm or 2.7-mm lag screws, either through the cortex or in an intraosseous position (Fig. 13C).

A

B

FIGURE 13

C

201

A FIGURE 14

B

ORIF of Olecranon Fractures

GROSSLY COMMINUTED FRACTURE ■ Especially in the osteoporotic patient, a combination of any of the above techniques can be employed in the repair of a grossly comminuted fracture of the olecranon (Fig. 14A). ■ The role of locked plate technology is promising (Fig. 14B) but remains unclear at this time for these fractures. ■ Alternatively, for the unreconstructable olecranon fracture, resection of the posterior 50% of the olecranon can be performed, with suturing of the triceps tendon to the remaining fracture surface (Gartsman et al., 1981). • The tendon should be reattached as close to the remaining articular surface of the olecranon as possible to provide a sling for the distal and posterior humeral articular surface (trochlea).

ORIF of Olecranon Fractures

202

Complications • Complications of ORIF of olecranon fractures include prominent hardware (with or without olecranon bursitis), wound dehiscence/infection, and reduced ROM. • Prominent hardware is a common complaint and is due to the subcutaneous position of the implants, often necessitating their removal once fracture healing has occurred. • In cases of infection, local wound care with antibiotics as required in general will lead to satisfactory healing, with reoperation necessary in cases of deep infection, septic arthritis, and/or osteomyelitis. • Stiffness can be minimized through early and diligent physiotherapy, which is ensured by stable fixation of the fracture. As in many elbow injuries, lack of terminal extension (15–20%) is common but does not affect function.

Postoperative Care and Expected Outcomes ■

■

■

■

Postoperative care includes a short period of immobilization for patient comfort and wound healing. Typically this lasts 7–10 days; however, some surgeons prefer more rapid mobilization, as early as the first postoperative day. For the first 6–8 weeks, physiotherapy is limited to active and active-assisted ROM exercise, including flexion, extension, and pronation/supination. Passive ROM is proscribed. • The “safe” arc of motion will be based upon the ROM determined at the end of surgery, prior to wound closure. • Longer periods of immobilization or limited ROM may be necessary for the fracture that remains unstable following ORIF, but this should represent the small minority of cases. Immobilization exceeding 3 weeks is to be avoided as it can result in permanent stiffness. Once radiographic healing has been confirmed at 6–8 weeks, strengthening exercises can begin. Once the patient has achieved full (or near-full) ROM and adequate strength, a progressive return to work, sport, and/or leisure activities can be undertaken. Outcomes following ORIF of olecranon fractures are generally favorable. However, studies to date have not provided data based upon prospective evaluations using validated outcome tools. • Patients can expect high rates of union, good to excellent ROM, good strength, and satisfactory overall outcome (Akman et al., 2002; Bailey et al., 2001; Garstman et al., 1981; Murphy et al., 1987). • Increasing instability and fracture complexity have been correlated with worse prognosis (Rommens et al., 2004).

Evidence Akman S, Ertuere RE, Tezer M, et al. Longterm results of olecranon fractures treated with tension-band technique. Acta Orthop Traumatol Turc. 2002;36:401-7. Bailey CS, MacDermid J, Patterson SD, King GJ. Outcome of plate fixation of olecranon fractures. J Orthop Trauma. 2001;15:542-8. Gartsman GM, Sculco TP, Otis JC. Operative treatment of olecranon fractures: excision or open reduction with internal fixation. J Bone Joint Surg [Am]. 1981;63:718-21. Murphy DF, Greene WB, Dameron TB. Displaced olecranon fractures in adults: clinical evaluation. Clin Orthop Relat Res. 1987;(224):215-23. Rommens P, Schneider RU, Reuter M. Functional results after operative treatment of olecranon fractures. Acta Chir Belg. 2004;104:191-7. Weber BG, Vasey H. Osteosynthese bei Olecranonfraktur. Unfallmed Berufskrankheiten. 1963;2:90-6.

PROCEDURE 12

Open Reduction and Internal Fixation of Forearm Fractures Paul R. T. Kuzyk and Emil H. Schemitsch

ORIF of Forearm Fractures

204

PITFALLS • Distal radioulnar joint (DRUJ) instability is associated with the location of the radial shaft fracture: 55% of isolated radial shaft fractures located within 7.5 cm from the midarticular surface of the radius were associated with DRUJ instability, whereas only 6% of fractures located beyond 7.5 cm from the midarticular surface of the radius were associated with DRUJ instability. • Proximal-third ulnar shaft fractures are often associated with posterior radial head dislocation or radial head fracture. Proper clinical and radiologic examination of the radiocapitallar joint is necessary with these injuries.

Indications ■ ■ ■ ■

■

Forearm fractures of both bones in an adult Isolated radial shaft fractures Proximal-third ulnar shaft fractures Displaced distal two-thirds ulnar shaft fractures with greater than 10° of angulation or less than 50% opposition Open radius or ulnar shaft fractures

Examination/Imaging ■ ■ ■

■

■

Examination of the skin for open lacerations Palpation of the radial and ulnar arteries Examination of motor and sensory function of the median, ulnar, and radial nerves Anteroposterior (AP) and lateral radiographs of the forearm. Figure 1 shows orthogonal radiographs of combined radial and ulnar shaft fractures. Dedicated wrist and elbow radiographs of the affected arm

FIGURE 1

A

B

205

■

• Open reduction with dynamic compression plate fixation is the treatment of choice. • Closed reduction with long-arm cast immobilization is reserved for pediatric fractures and isolated fractures of the distal two thirds of the ulnar shaft. • Closed reduction with intramedullary fixation is reserved for pediatric fractures. • Closed reduction with external fixation is not recommended unless used as a temporizing measure in hemodynamically unstable multiple trauma patients or in those with severely contaminated open fractures.

Volar anatomy of the radius • Superficial layer: brachioradialis muscle, flexor carpi radialis muscle, superficial branch of the radial nerve, radial artery ◆ Figure 2 shows the superficial layer of the volar forearm; note the interval between the brachioradialis (radial side) and the pronator teres/flexor carpi radialis (ulnar side). ◆ Figure 3 shows a view of the volar forearm with the brachioradialis and flexor carpi radialis cut away. Note the position of the radial artery and the superficial branch of the radial nerve. Biceps Median nerve Brachioradialis Brachialis

Radial artery

Biceps tendon

Abductor pollicis longus

Flexor digitorum superficialis

Extensor pollicis brevis

Triceps Medial intermuscular septum Brachial artery

Palmaris longus Ulnar artery

Brachialis

Flexor carpi radialis

Ulnar nerve

Pronator teres Bicipital aponeurosis

Flexor carpi ulnaris Median nerve

FIGURE 2 Extensor carpi radialis longus

Posterior interosseous nerve

Arcade of Frohse Radial artery

Brachioradialis Musculocutaneous nerve Radial Biceps nerve Brachialis

Superficial branch of radial nerve Supinator Pronator teres Extensor carpi radialis longus Brachioradialis Flexor carpi radialis

Triceps Ulnar nerve Median nerve

Superficial branch of radial nerve

Ulnar collateral artery Pronator teres (origin) Common flexor tendon of forearm Deep head of pronator teres Flexor digitorum superficialis

Radial artery Median nerve Palmaris longus Ulnar artery

FIGURE 3

Ulnar artery Ulnar nerve Flexor digitorum profundus Flexor digitorum superficialis

Flexor carpi ulnaris

Fibrous superficialis arch

ORIF of Forearm Fractures

Surgical Anatomy

Treatment Options

ORIF of Forearm Fractures

206

■

• Deep layer ◆ Figure 4 shows the deep layer of the volar forearm. Note the insertion of the pronator quadratus on the distal third, the flexor pollicis longus and flexor digitorum superficialis on the middle third, and the pronator teres and supinator on the proximal third of the radius. ◆ Proximal third of radius: supinator muscle, posterior interosseous nerve (see Fig. 4) ◆ Middle third of radius: pronator teres muscle, flexor pollicis longus muscle, flexor digitorum superficialis muscle (see Fig. 4) ◆ Distal third of radius: pronator quadratus muscle (see Fig. 4) Dorsal anatomy of the forearm (Fig. 5) • Flexor carpi ulnaris • Extensor carpi ulnaris • Anconeus

Extensor carpi radialis longus Joint capsule Annular ligament

Lateral intermuscular septum

Biceps insertion Brachioradialis (origin)

Supinator insertion Flexor digitorum superficialis (origin)

Brachialis (origin)

Pronator teres (insertion)

Humerus

Flexor pollicis longus (origin)

Medial intermuscular septum

Radius

Pronator teres (origin) Common flexor (origin) Humeral head of flexor carpi ulnaris

Pronator quadratus (insertion) Brachioradialis (insertion)

Brachialis tendon (insertion) Deep head of pronator teres

Ulnar styloid

Pronator quadratus (origin)

Flexor digitorum profundus (origin)

Ulna Anterior interosseous artery

Posterior interosseous artery Interosseous membrane

FIGURE 4 Extensor carpi ulnaris (posterior interosseous nerve)

Flexor carpi ulnaris (ulnar nerve)

FIGURE 5

207

• A tourniquet is applied to the operated arm and inflated to 250 mm Hg. • A mini C-arm should be draped and brought in from the same side as the armboard.

Positioning ■

■

The patient is placed supine on the operating table with the affected arm placed on an armboard. The forearm may be supinated to allow for a volar approach to the radius, or pronated to allow for an approach to the ulna. For fractures involving the proximal ulnar shaft, the affected arm may be draped over the patient’s body.

Portals/Exposures ■

Volar (Henry’s) approach to the radius • Position the forearm in supination (Fig. 6A). • The skin incision should lie within a line from the lateral side of the biceps tendon proximally to the radial styloid distally. • Superficial dissection ◆ The interval between the brachoradialis (radial side) and the pronator teres/flexor carpi radialis (ulnar side) is developed. The radial artery is retracted with the flexor carpi radialis and the superficial branch of the radial nerve is retracted with the brachioradialis (Fig. 6B–D).

Superficial branch of radial nerve

Brachioradialis Supinator

Flexor digitorum superficialis

Radial artery

A

B

C

D

FIGURE 6

Pronator teres

Flexor carpi radialis

ORIF of Forearm Fractures

Equipment

ORIF of Forearm Fractures

208

The superficial intermuscular interval lies between the brachioradialis and pronator teres muscles for the proximal third of the radius. The interval is between the brachioradialis and flexor carpi radialis muscle for the distal two thirds of the radius. ◆ The radial artery and its two venae comitantes lie directly under the brachioradialis in the middle of the forearm. Care must be taken to identify the radial artery in the superficial interval and mobilize the artery in the medial (ulnar) direction. ◆ The superficial radial nerve runs under the brachioradialis muscle and is retracted in a lateral (radial) direction with the brachioradialis muscle. • Deep dissection ◆ The deep muscle attachments to the radius are identified (Fig. 7A–C): the supinator and pronator teres (proximal third), the flexor digitorum superficialis and flexor pollicis longus (middle third), and the pronator quadratus (distal third). The deep muscle attachments to the radius are reflected subperiosteally off the radius (Fig. 8A and 8B). ◆ In the proximal third of the forearm, the supinator muscle must be stripped off and retracted from its insertion on the radius. The attachment of the supinator muscle to the radius should be incised with the forearm in full supination. This retracts the posterior interosseous nerve away from the operative field. Dissection should continue subperiosteally around the radius to prevent injury to the posterior interosseous nerve. ◆ In the middle third of the forearm, the pronator teres and flexor digitorum superficialis muscles attach to the radius. The forearm should be pronated to expose the insertion of the pronator onto the radius. The pronator teres muscle can be released off the lateral side of the radius. The flexor digitorum superficialis muscle can then be released off the radius with subperiosteal dissection. ◆ In the distal third of the radius, the pronator quadratus and the flexor pollicis longus muscles arise from the volar aspect of the bone. The forearm should be supinated and these muscles may be stripped subperiosteally from the lateral (radial) edge of the radius. ◆

209

Flexor digitorum superficialis

Supinator

Radius Biceps tendon

Radial artery

Flexor carpi radialis Pronator teres

A

B

Brachioradialis

ORIF of Forearm Fractures

Superficial branch of radial nerve

C

FIGURE 7 Superficial branch of radial nerve

Brachioradialis Supinator

Biceps tendon

Periosteal incision

Radial artery

A

FIGURE 8

B

Radius

Flexor carpi radialis Pronator teres

210

ORIF of Forearm Fractures

Extensor carpi ulnaris Anconeus

Periosteum Ulna

Flexor carpi ulnaris

B

A

C

FIGURE 9

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Exposure of the ulna • The skin incision is made along the subcutaneous border of the ulna, in a line running from the middle of the olecranon proximally to the ulnar styloid distally (Fig. 9A). • The intermuscular interval is between the anconeus and flexor carpi ulnaris muscles along the proximal third of the ulna (Fig. 9B and 9C). The interval is between the extensor carpi ulnaris and flexor carpi ulnaris muscles along the distal two thirds of the ulna.

Procedure STEP 1 ■ The fracture sites of the radius and ulna should be exposed prior to reduction and fixation of either fracture. ■ Reduction forceps may be used to obtain reduction and provisionally fix the fracture prior to application of the compression plate (Fig. 10A and 10B).

211

ORIF of Forearm Fractures

B

A FIGURE 10

PEARLS • The simplest fracture to reduce should be addressed first (i.e., in the case of a segmental radius fracture and transverse ulna fracture, the ulna fracture should be reduced prior to reducing the radius fracture).

Instrumentation/ Implantation • Small fragment set • Mini C-arm

A FIGURE 11

STEP 2 ■ After reduction has been obtained, a lag screw should be placed if the fracture pattern allows. • If a lag screw cannot be placed, a 3.5-mm dynamic compression plate may be applied to the bone and compression obtained through the plate. • If the fracture is comminuted, then the dynamic compression plate should be applied as a bridging plate across the fracture. ■ Both bones should be fixed using a 3.5-mm dynamic compression plate with eight cortices obtained above and below the fracture site. • Figure 11 shows the radius (Fig. 11A) and ulna (Fig. 11B) after fixation with 3.5-mm dynamic compression plates. Note that the compression plates are placed on the volar surface of both bones.

B

ORIF of Forearm Fractures

212

PEARLS • An AP radiograph of the contralateral intact forearm may be helpful to measure the radial bow. The amount and location of the maximum radial bow may be obtained from this radiograph and used to help produce an anatomic reduction of the fractured radius.

PITFALLS • Failure to obtain anatomic reduction of the first bone fixed will result in inability to obtain anatomic reduction of the second bone to be fixed.

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• The ulna is a straight bone, and minimal contour of the dynamic compression plate is required. • The radius is a curved bone, and re-creation of the radial bow is necessary to allow for normal forearm supination and pronation. The dynamic compression plate will therefore require appropriate contouring to fit the radius. Figure 12 shows AP (Fig. 12A) and lateral (Fig. 12B) radiographs of the forearm fracture in Figure 1 after fixation with 3.5-mm dynamic compression plates. Note that the bow of the radius has been restored. If the fracture is open with segmental bone loss, the bone should be plated out to length. This may produce a bone defect that can be bone grafted 6–8 weeks after initial fracture fixation.

Instrumentation/ Implantation • 3.5-mm dynamic compression plates

A FIGURE 12

B

213

• The length of the plate used and the number of cortices obtained above and below the fracture site is a matter of some controversy. Biomechanical evidence suggests that the strength of the intact bone is approximated with 10 cortices above and below the fracture site (ElMaraghy et al., 2001). It is often difficult to obtain 10 cortices on either side of the fracture. We therefore recommend eight cortices above and below the fracture site as this provides excellent stability to allow for early range of motion.

STEP 3 ■ The position of the plates and screws should be checked with fluoroscopic imaging prior to closure of the incisions. The forearm should be fully pronated and supinated to ensure that normal range of motion has been achieved. ■ An AP and a lateral fluoroscopic image of the wrist and elbow should also be obtained. Care should be taken to fully examine the DRUJ and radiocapitellar joint to ensure that these joints are reduced and stable. ■ The wound should be irrigated with normal saline prior to closure. The fascia should not be closed to prevent postoperative compartment syndrome.

Postoperative Care and Expected Outcomes ■

Early mobilization at 10–14 days postoperative is recommended to improve strength and endurance.

Evidence Droll KP, Perna P, Potter J, Harniman E, Schemitsch EH, McKee MD. Outcomes following plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg [Am]. 2007;89:2619-24. This case series investigated patient-based functional outcomes and objective forearm and wrist strength after plate fixation for diaphyseal both-bone forearm fractures in adults. Thirty patients were followed for a mean duration of 5.4 years. Plate fixation of diaphyseal both-bone forearm fractures was found to restore normal anatomy and range of motion. A moderate reduction in the strength of the forearm, the wrist, and grip was found when comparing the injured arm to the contralateral limb. (Grade C recommendation; Level IV evidence) ElMaraghy AW, ElMaraghy MW, Nousiainen M, Richards RR, Schemitsch EH. Influence of the number of cortices on the stiffness of plate fixation of diaphyseal fractures. J Orthop Trauma. 2001;15:186-91. This biomechanical study was performed to determine the number of cortices obtained with screw purchase on either side of the fracture required to provide appropriate fixation for a transverse fracture of the radial diaphysis. Torsional stability approximating that of the intact bone was only obtained when 10 cortices of fixation where obtained on either side of the fracture (i.e., five screws with bicortical contact on either side of the facture). We thus suggest that at least four screws with bicortical contact should be obtained on either side of the fracture to obtained adequate stability. (Grade C recommendation)

ORIF of Forearm Fractures

Controversies

ORIF of Forearm Fractures

214 Leung F, Chow SP. A prospective, randomized trial comparing the limited contact dynamic compression plate with the point contact fixator for forearm fractures. J Bone Joint Surg [Am]. 2003;85:2343-8. This randomized controlled trial compared limited-contact dynamic compression plates (conventional screws) to the point-contact fixator (locked screws). There was no significant difference between the two groups with regard to operative time, time to union, callus formation, pain, or functional outcome. The authors concluded that the two implants were equally effective for the treatment of diaphyseal forearm fractures. (Grade A recommendation; Level I evidence) We recommend the use of dynamic compression plates over locked plates for the treatment of standard diaphyseal forearm fractures as the dynamic compression plates allow for compression, may be contoured to the radial bow, and are generally less expensive. Rettig ME, Raskin KB. Galeazzi fracture-dislocation: a new treatment-oriented classification. J Hand Surg [Am]. 2001;26:228-35. In this case-control study of 40 patients with radial shaft fractures, fractures were classified according to distance from the distal radius articular surface: type I fractures were located within 7.5 cm proximal to the midarticular surface, and type II fractures located greater than 7.5 cm proximal to the midarticular surface. Twelve of the 22 type I fracture (54.5%) had an unstable DRUJ, while only one of the 18 type II fractures (5.6%) had an unstable DRUJ. Patients with distal radial shaft fractures should be thoroughly investigated for an unstable DRUJ. (Grade B recommendation; Level III evidence) Ring D, Allende C, Jafarnia K, Allende BT, Jupiter JB. Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bonegrafting. J Bone Joint Surg [Am]. 2004;86:2440-5. In this case series, 32 patients with segmental bone defects (1–6 cm in size) resulting from diaphyseal forearm fracture (22 were open fractures) were treated with cancellous bone autograft and rigid plate fixation. All fractures went on to heal within 6 months of treatment. The authors concluded that, in the presence of a compliant soft tissue envelope that consists largely of healthy muscle, autogenous cancellous bone grafting and stable internal plate fixation result in a high rate of union and improved upper limb function. (Grade C recommendation; Level IV evidence) Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg [Am]. 1992;74:1068-78. This case series of 55 patients with a mean follow-up of 6 years examined the effect of fracture malunion on functional outcome for both-bone forearm fractures. Malunion was quantified by measuring the amount and location of the maximum radial bow in relation to the contralateral, normal forearm. Restoration of the normal radial bow was found to correlate with functional outcome. A good functional result (>80% of normal rotation of the forearm) was associated with restoration of the normal amount and location of the radial bow (p < .05 and p < .005, respectively). The recovery of grip strength was also correlated with restoration of the location of the radial bow toward normal (p < .005). We recommend that attention be given to restoration of the radial bow when reducing both-bone forearm fractures. (Grade C recommendation; Level IV evidence)

PROCEDURE 13

Distal Radius Fractures Neil J. White and Paul J. Duffy

Distal Radius Fractures: External Fixation

216

External Fixation PITFALLS

Indications ■

• If the goals of reduction cannot be obtained using external fixation (with or without augmentation), then the surgeon must be equipped to convert to an open procedure. This occurs in up to 10% of distal radius fractures. ■

It is an error to leave the operating room without obtaining appropriate radial length, inclination, and tilt and a reduced articular surface regardless of reduction and fixation techniques employed.

• Scaphoid or lunate dipunch injuries generally require a direct reduction through open or limited open approaches. These injuries are difficult to treat with external fixation alone.

Controversies • Some authors prefer to avoid external fixation in patients with osteoporosis, while others advocate its use considering that all stabilization techniques are severely compromised in this population. • External fixation should be reserved for the independent adult. It should be used cautiously in patients with mental illness.

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Spanning external fixation • This technique can be used for most fractures of the distal radius that have failed an attempt at closed reduction, excluding volar displaced fracture patterns (Smith’s) and volar or dorsal shear patterns (Barton’s). • Spanning external fixation can be used as primary fixation or to augment or neutralize other techniques of fixation. Nonspanning external fixation • This technique can be used for unstable extraarticular or minimally displaced articular distal radius fractures that have failed an attempt at closed reduction. • It can also be used for severe intra-articular fractures where there is space for the distal pins after reduction of the intra-articular component. ◆ One centimeter of intact volar cortex is generally required for pin fixation. • Nonspanning external fixation can be combined with distal radial osteotomy for the treatment of distal radius malunion. • Nonspanning external fixation cannot be used in the pediatric patient with an open physis.

Examination/Imaging PHYSICAL EXAMINATION ■ Treatment should be directed according to patient’s functional status, occupational requirements, hand dominance, pertinent medical history, and expectations. ■ Examination should focus on identifying other systemic or upper extremity injuries. After diagnosing, prioritizing, and treating systemic injuries, the limb needs to be assessed. • It is essential to examine the forearm and elbow as well as the carpus. Galeazzi, Monteggia, and Essex-Lopresti lesions are often missed in the forearm, while carpal ligament injuries are often missed in the hand (Fig. 1). • The limb must be inspected for open wounds. They are generally low grade and occur on the volar surface of the wrist or occasionally on the

217

Distal Radius Fractures: External Fixation

FIGURE 1

Treatment Options • Most distal radius fractures considered for surgery should have failed an attempted closed reduction. Exceptions include open fractures, polytrauma, ipsilateral upper extremity injuries, and associated neurologic insult requiring surgery. • Many treatment options exist for the distal radius fracture. Most can be used in isolation or in conjunction with external fixation. The general principle is to do what works well and is reproducible in your hands. ■ A second reduction can be attempted, but the results are usually similar to the first attempt. It should only be attempted when at least one or more parameters have been changed to significantly increase the chances of success. Finger traps, deeper sedation, or more experienced physician and assistants may all increase chances of successful reduction.

ulnar side of the wrist when associated with an ulnar styloid fracture). • A careful neurologic examination must rule out neurologic insult. This most commonly occurs in the median nerve and may require an urgent decompression if a severe or progressive neurologic deficit is found. • Although acute tendon ruptures are exceedingly rare, the surgeon should inform the patient of the possibility of late extensor pollicis longus (EPL) rupture. IMAGING STUDIES ■ Anteroposterior (AP), lateral, and oblique films should be obtained for initial assessment. The patient should be splinted for comfort prior to transport to the diagnostic imaging department. ■ Repeating these films postreduction usually provides more information about the specific fracture fragments. Postreduction films should be obtained even if the decision to go to the operating room has already been made, such as for open fracture. • Radiographic parameters for acceptable reduction must be assessed preoperatively and repeatedly during surgery. • Acceptable and normal values differ; these numbers should be intimately well known to the treating surgeon.

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218

Treatment—cont’d ■

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Closed reduction with percutaneous pin fixation ± external fixation. Closed reduction with intrafocal pin fixation ± external fixation (Kapandji). Mini-open reduction with percutaneous or intrafocal pin fixation ± external fixation. As above with bone graft or substitute. Arthroscopic assisted reduction with any of the above. Open reduction and internal fixation with dorsal or volar plating, or with fragmentspecific fixation. This may also be combined with any or all of the above techniques.

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• Radial length ◆ Normal: comparing the lunate facet to the ulnar head ± 2 mm ◆ Acceptable reduction: not more than 2 mm shortening compared to ulnar head or contralateral side • Volar tilt ◆ Normal: 11° volar ◆ Acceptable reduction: neutral tilt • Radial inclination ◆ Normal: 20° from radial styloid to ulnar edge of lunate facet ◆ Acceptable reduction: 10° • Intra-articular displacement ◆ Normal: none ◆ Acceptable reduction: 2 mm of intra-articular step or gap There should be a low threshold to include films of the ipsilateral elbow and forearm. Contralateral films can be obtained to assess the patient’s normal anatomy. This may be useful in assessing anatomic variants or judging radial length. This is not routinely done. Traction films can add value in identifying specific fracture fragments. These are easily obtained in the operating room utilizing the image intensifier. • Figure 2 shows traction views of a 47-year-old female with an injury to her dominant arm; these were taken in the operating room prior to deciding on a definitive treatment plan. The fracture was deemed too comminuted for open

FIGURE 2

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Surgical Anatomy ■

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Extensor pollicis longus Lister’s tubercle Extensor carpi radialis brevis

Pin 2

The bony anatomy of the distal radius must be intimately understood. If distal radial pins are used, this is paramount. The articular surface is a triangle with its base at the lunate facet and its apex the radial styloid. It slopes in an ulnar and volar direction (Fig. 3A). Lister’s tubercle sits dorsally and acts as a fulcrum for the EPL tendon, which passes on its ulnar side. This acts as a landmark to identify and protect the EPL for pin placement or mini-open procedures. • Knowledge of the six dorsal compartments is necessary for fixator pin placement on either side of the third (EPL) compartment (see Fig. 3A).

Pin 1 Extensor digitorum (communis) Extensor digiti minimi Extensor carpi ulnaris

Extensor carpi radialis longus

Ulna

Radius Extensor pollicis brevis Abductor pollicis longus

III

IV V

A

II

I

FIGURE 3

B

VI

Distal Radius Fractures: External Fixation

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fixation and therefore was treated with a spanning fixator in combination with a mini-open dorsal incision and supplementary Kirschner wires (K-wires). This example demonstrates the value of these views in understanding the fracture pattern. Computed tomography is occasionally indicated for distal radius fractures. If utilized, it provides the most information after a reduction maneuver is performed. It should be reserved for use when the surgeon is trying to determine the size, position and orientation of fracture fragments or fragment orientation.

Distal Radius Fractures: External Fixation

220

Compartment I: abductor pollicis longus and extensor pollicis brevis (Fig. 3B) ◆ Compartment II: extensor carpi radialis longus and brevis ◆ Compartment III: extensor pollicis longus ◆ Compartment IV: extensor digitorum communis and extensor indicis ◆ Compartment V: extensor digiti minimi ◆ Compartment VI: extensor carpi ulnaris The superficial branch of the radial nerve and its branches are at risk during proximal and distal fixator pin placement as well as during percutaneous K-wire placement from the radial styloid. Painful neuromata can cause significant morbidity postoperatively. The dorsal-radial anatomy of the radius in the middle third must be well known for proximal fixator pin placement. • From radial to ulnar, the bone is covered by the flat tendons and musculotendinous junctions of the brachioradialis, extensor carpi radialis longus and brevis, and crossing abductor pollicis longus muscles. • The superficial branch of the radial nerve exits from under the brachioradialis and crosses the abductor pollicis longus and extensor pollicis brevis after exiting from below the brachioradialis (Fig. 4). For spanning fixator pins, the anatomy of the second digit must be understood. ◆

PEARLS

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• Image intensification is necessary for this procedure. If a C-arm is used, it is best to bring it in from the distal aspect of the hand and have the surgeon and assistant on either side of the armboard. A wide scope of image is helpful, and to achieve this the tube should be as close as possible to the wrist. Using the C-arm upside-down with the tube under the armboard is one way to achieve this while sitting.

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• A mini C-arm that allows the surgeon to have control is generally more versatile. • Moving the patient’s arm from AP to lateral is easier than attempting to move the C-arm thorough its arc.

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Lateral bands Central slip Dorsal digital expansion First dorsal interosseous Abductor pollicis longus

Extensor indicis Extensor digiti minimi

Expansion of abductor pollicis brevis Extensor digitorum comunis Extensor pollicis longus

Abductor digiti minimi

Abductor pollicis longus

Dorsal cutaneous branch of ulnar nerve

Extensor carpi radialis longus and brevis Superficial radial nerve

Extensor retinaculum Extensor carpi ulnaris

Extensor pollicis brevis Abductor pollicis longus

FIGURE 4

Extensor digitorum comunis

221

Distal Radius Fractures: External Fixation

FIGURE 5

PITFALLS • If there are any concerns with image acquisition (especially when starting out or using new equipment), then images should be sought preoperatively to confirm ease of acquisition during the procedure. It may be helpful to drape the elbow into the operative field to aid with positioning between AP, lateral, and oblique views. ■

Preoperative traction images are essential in confirming that the correct operation is being performed. This is the easiest time to “bail out” on percutaneous fixation in favor of an open procedure.

Positioning ■

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The patient is positioned supine with the affected limb on a radiolucent armboard. The table height is adjusted such that the surgeon and assistant can sit comfortably. A tourniquet is applied to the proximal aspect of the arm. It is set at 250 mm Hg, but it is usually not necessary to inflate this tourniquet. The elbow, wrist, hand, and forearm are prepared and draped in a sterile fashion (Fig. 5).

Portals/Exposures ■

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Fixator pin placement is generally done thorough mini-open approaches. Care is taken to isolate and protect surrounding nerves, vessels, and/or tendons. Blunt dissection is used to isolate a pathway to the bone. The surgeon will never be faulted for taking slightly more skin to ensure atraumatic soft tissue techniques. Conditions should be optimal prior to drilling. Drill guides and soft tissue sleeves should be utilized at all times.

Distal Radius Fractures: External Fixation

222

PEARLS • All pins should be predrilled with pilot holes and then inserted by hand. Using power offers a theoretical risk of a ring sequestrum from heat necrosis, which may predispose to loosening and pin site infection. • Pins should be advanced until they are bicortical and the self-tapping flute is fully past the far cortex (usually 2 full tread pitches).

PITFALLS • If the skin incision is made in the wrong place, it should be abandoned and closed or extended. Minimizing skin tension around pin tracks is essential in preventing pin track complications. • Pin placement should not be attempted when a soft tissue tether is present. Tight fascial bands will serve to redirect drills or pins inappropriately.

Instrumentation • The authors recommend use of 1.5-mm bicortical pilot holes followed by 3-mm self-tapping partially threaded half-pins proximally and distally.

Controversies • Fixator pins can be safely established in the middle of the radius and in the second metacarpal by using one incision or two separate miniincisions (see Fig. 3A). The same principles of tissue handling must be followed, but both are acceptable techniques.

Procedure STEP 1: CLOSED REDUCTION TO CORRECT SIGNIFICANT DEFORMITY ■ With an assistant providing countertraction at the elbow, the key reduction maneuver is prolonged traction. ■ Volar and ulnar deviation of the wrist combined with digital manipulation of the fracture fragments is helpful. A rolled sterile towel can be used as a fulcrum to maintain position. ■ Image intensification is used to assess and confirm reduction. ■ An incarcerated fragment can often be freed by recreating the initial deformity under traction.

PEARLS • This is a key opportunity to convert to an open reduction with internal fixation procedure. The surgeon must be confident that a reduction can be obtained with either percutaneous wires or intrafocal wires, or by elevating the joint surface through a mini-open procedure. • If anatomic reduction is obtained, it is reasonable to proceed with K-wire fixation at this time. Generally two wires directed from the radial styloid in a distal-to-proximal, radial-to-ulnar, and volarto-dorsal direction are combined with one cross wire securing the lunate facet. This wire is directed from dorsal to volar, distal to proximal, and ulnar to radial. This can be used as “stand-alone” fracture care, or can be neutralized by the use of an external fixator.

Controversies • Some authors advocate anatomic reduction prior to application of an external fixator, while others feel that the external fixator pins can be used as a reduction tool. It is cumbersome to operate around an external fixator frame. Either technique is acceptable. In general, the surgeon needs to have a clear view of the steps required to obtain and maintain reduction and, although this is usually accomplished in a stepwise fashion, it is acceptable to gain length, inclination, and tilt with a closed reduction, then externally fix the fracture, and finally address the articular surface through a mini-open procedure. Ultimately, there is no clear stepwise approach, and the surgeon can do whatever he or she wants to in order to accomplish the goals of obtaining and maintaining reduction. Techniques must, however, be effective and reproducible in said surgeon’s hands.

223

• Proximal fixator pins can be placed through two separate mini-incisions (Fig. 6C) depending on surgeon preference. The same principles are employed. • There is a temptation to utilize a small skin incision for proximal fixator pin placement. We suggest use of a generous skin incision to place these pins for two reasons. First, damage to sensory nerves causing painful neuroma, although rare, will leave a patient with significant morbidity. Second, at the end of the case these pin sites must be closed without skin tension.

PITFALLS • Care must be taken to avoid drilling across the interosseous membrane, as there is a small incidence of heterotopic ossification and the potential to create a synostosis.

Instrumentation/ Implantation • A variety of systems are available. Most systems have either self-tapping or selftapping and self-drilling 3-mm half-pins. We recommend drilling a 1.5-mm pilot hole through both cortices and inserting the fixator pins by hand. Fully two threads should cross the far cortex. Self-drilling pins leave sharp ends proud in the soft tissues and are not recommended.

STEP 2: PLACEMENT OF PROXIMAL FIXATOR PINS ■ The most distal of the proximal pins is placed approximately 5 cm away from the zone of injury. This is usually 10 cm proximal to the radial styloid in the middle third of the radius. ■ A mini-open approach is used. In the setting of a nonspanning frame, it is beneficial to have dorsal-tovolar pins, while in the setting of a spanning frame, it is optimal to have pins at 45° to the long axis of the arm. Having the distal and proximal pins in the same orientation allows for easier construction of a quadrangular frame. This is not mandatory. ■ The approach can be planned in the palpable interval between the extensor carpi radialis longus and brevis for dorsal-to-volar pins or in the interval between the brachioradialis and extensor carpi radialis longus for the 45° oblique pins (see Fig. 3A). ■ Image intensification is used to plan the starting point of the most distal proximal pin. • The skin is marked and a 4-cm incision is extended proximally from this point (Fig. 6A). Blunt dissection is used to identify the intramuscular plane. Large subcutaneous veins are often encountered and protected. • Direct identification of the superficial branch of the radial nerve and antebrachial-cutaneous nerve is not necessary; however, their course must be well understood in order to preserve and protect them. One or both of these nerves is often encountered and protected. Injury to these structures carries significant morbidity. • Ultimately, the surgeon needs to visualize each layer and see the periosteum prior to pin insertion. A soft tissue sleeve should be employed for drilling, tapping (if performed) and pin insertion.

Controversies • Proximal or distal fixator pins may be placed first. We see no clear advantage to one technique over the other. A FIGURE 6

Continued

Distal Radius Fractures: External Fixation

PEARLS

Distal Radius Fractures: External Fixation

224

C

B FIGURE 6, cont’d ■

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PEARLS • Stiffness in the postoperative period is of paramount concern. When placing pins into the second metacarpal, do not tether the extensor mechanism. It is recommended to flex the index finger completely during pin insertion. This will ensure free finger range of motion. • In the situation of a dorsally displaced fracture pattern, the distal nonspanning fixator pins are often directed obliquely from proximal to distal. A gentle thumb pressure on the pins will then reduce the dorsal angulation and translation. Forceful thumb pressure can cause pin cutout, and thus, if the reduction does not come easily, an alternate technique must be employed. The nonspanning fixator pins are intended as joysticks with which to gently lever the fracture into the reduced position. Further, these pins act as a powerful reduction tool, and overreduction is a risk.

If using two separate mini-incisions, a second incision is made for the more proximal pin (Fig. 6B). Angled retractors are used to identify the periosteum, and then the fixator pins are sequentially placed. • The most distal of the proximal pins is drilled through both cortices utilizing a drill guide anchored on bone. The fixator pin is then placed by hand to gain bicortical purchase. The second pin is then drilled. • A double drill guide or fixator clamp is ideal to appropriately space the pins. Slight convergence of the pins allows them to be clamped under tension, providing a stiffer construct. • Pin placement and depth should be confirmed with image intensification.

STEP 3: PLACEMENT OF DISTAL FIXATOR PINS ■ For nonspanning external fixation, the pins are planned from dorsal to volar on either side of the EPL tendon. A limited open technique is utilized to protect the extensor tendons. • Separate longitudinal incisions on the radial and ulnar sides of Lister’s tubercle are planned using image intensification to mark the ideal location. A lateral view assists in identifying the ideal entry point exactly halfway between the fracture line and the joint surface (Fig. 7A). • The first pin is placed on the ulnar side of the EPL. Through a short longitudinal skin incision, the extensor retinaculum is identified and entered between the third and fourth extensor compartments. Blunt dissection with a snap is used to create a tunnel to bone. It is important to use the appropriate soft tissue sleeve for drilling and for pin placement.

225

Distal Radius Fractures: External Fixation

A

B

FIGURE 7

PITFALLS • When planning mini-incisions for nonspanning external fixator pins, it is paramount to make the incisions distal to the planned site of insertion. Once a reduction maneuver is performed, the pins will essentially be gently levered distally and hence match up to the distal planned incision without creating skin tension (see Fig. 7). • Distraction of the volar cortex with nonspanning pins is not recommended. The intention is to use a gentle joystick maneuver to lever about the volar cortex. Ultimately, the pins are stronger than the bone, so excessive force will cause the bone to fail.

• The pin is then started halfway between the fracture and the radiocarpal joint and directed toward the same spot on the volar surface. It should be inserted by hand and followed with image intensification. On a true lateral view of the wrist, the pin should be parallel to the floor of the operating room and thus an AP view is not necessary. The pin must have solid purchase in the volar cortex. • This process is repeated on the radial side of Lister’s tubercle between the second and third extensor compartments. In a similar fashion to pedicle screw insertion, the first pin is utilized as a guide for the second. The two fixator pins should appear as one on the trans-styloid lateral view (Fig. 7B). • If either of these pins is not placed with solid volar purchase, the surgeon can try again or convert to a spanning frame. Repeated attempts are unlikely to succeed as bone stock diminishes.

Distal Radius Fractures: External Fixation

226 ■

PEARLS • The external fixator is a powerful reduction tool. Be cautious of over-reduction in the sagittal plane when using the nonspanning external fixator. • When using a spanning frame, there is a tendency to overpronate the distal fragment. This will limit the patient’s supination and should be avoided. To avoid this complication, look specifically for overpronation on final image intensification views. • Overdistraction can lead to delayed union and finger stiffness.

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For spanning external fixation, the distal pins are planned on the dorsal radial aspect of the second metacarpal at 45° to the long axis of the arm (halfway between radial to ulnar and dorsal to volar). • These pins are placed through separate longitudinal mini-incisions with the most proximal pin planned on the bare area just distal and dorsal to the first interosseous muscle (Fig. 8A). If there is any uncertainty, image intensification is used to plan this pin. The second pin is placed through a more distal second incision (Fig. 8B). • The external fixator clamp can be used to plan the distal pin at the correct distance. Be certain that these two pins are in the proximal 60% of the metacarpal to avoid entering the metacarpophalangeal joint capsule distally (Fig. 8C). Pin placement should be confirmed by image intensification (Fig. 9).

STEP 4: ASSEMBLY OF FIXATOR FRAME ■ The incisions around the pin sites are closed in layers with the fracture reduced. A careful closure without skin tension is important to prevent pin tract

A

B

FIGURE 8

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infections. We routinely use interrupted 3–0 nylon mattress sutures for skin. The proximal and distal pins are joined using short bars or clamps that accommodate two pins depending on the fixator system used (Fig. 10A). We prefer carbon-fiber bars to connect the proximal pins to the distal pins (Fig. 10B). This will not obfuscate intraoperative and postoperative radiographs as the fracture is followed to healing.

A

B

C

FIGURE 10

Distal Radius Fractures: External Fixation

FIGURE 9

Distal Radius Fractures: External Fixation

228 ■

PITFALLS • With spanning external fixation, due to viscoelasticity of the wrist ligaments, it is not possible to maintain the same amount of traction obtained in the operating room for 6 weeks. It is usually necessary to utilize percutaneous pin fixation in combination with spanning external fixation. Due to these strong volar ligaments, it is not possible to create volar tilt of the distal radius, but only to bring a dorsal angulated fracture to a zero-tilt position. We specifically recommend against using a spanning external fixator in isolation. In our hands, it is most useful when combined with K-wires and a mini-open dorsal procedure when necessary.

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Instrumentation/ Implantation

Clamps should be close to, but not touching the patient’s skin (one full fingerbreadth away). The apparatus should be situated such that it does not interfere with finger and wrist range of motion. The thumb should be taken into extension to confirm that the apparatus does not impinge on the first metacarpal. The first rod is connected and then image intensification is used to confirm anatomic reduction. At this time, any final modifications to the reduction using percutaneous K-wires or mini-open techniques can be used. It is not too late to convert to an open procedure. Although not ideal, this is a better alternative to knowingly accepting a suboptimal reduction. Once reduction is obtained, the carbon-fiber rod is tightened and a second rod is connected to create a quadrangular frame. Final images are obtained (Fig. 10C). The distal radioulnar joint is assessed at this time. All connectors are tightened firmly using countertorque wrenches so as to not stress the fixator pins (Fig. 11A and 11B).

• It is important to know your equipment well and be aware of exactly what connectors and clamps are available. If working with new equipment, we suggest scrubbing in early to practice with the possible combinations.

A

FIGURE 11

B

229

• Postoperative pin site infection is the most common complication, and can generally be managed by pin care and oral antibiotics. If a pin is loose early in the course, it must be removed and replaced. Generally this can be accomplished without loosening the entire frame by preserving a solid construct to the other intact pin. Rarely have we encountered this problem. • Complex regional pain syndrome (CRPS) needs to be identified and treated aggressively. We feel this situation can generally be avoided by taking great care to protect even the smallest branches of peripheral nerves. If it does occur, it needs to be treated aggressively with a team approach, including chronic pain management techniques, physical and occupational therapy, and occasionally a psychologist or psychiatrist with special interest in CRPS. The key is to identify it before irreversible changes occur. Vitamin C may decrease the prevalence of CRPS when given in low doses from the time of the fracture; 500 mg/day for 50 days is recommended.

A FIGURE 12

Postoperative Care and Expected Outcomes ■

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■

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The pin sites are dressed using petroleum jelly– soaked sterile gauze and a bulky dressing (Fig. 12A and 12B). Patients generally stay one night in the hospital and are discharged the following day. We routinely give these patients a preoperative dose and a postoperative course (1–3 doses) of prophylactic antibiotics. Patients are encouraged to move all joints that do move. In the case of nonspanning frames this would include wrist, fingers, thumb, elbow, and shoulder. They are encouraged to use their limb gently for activities of daily living but to avoid lifting more than 3 lbs. Patients are followed at the 10- to 14-day mark and at the 6-week mark. • At first follow-up, sutures are removed, wounds are checked, and AP and lateral radiographs are obtained and evaluated. Again patients are encouraged to actively and passively move the hand and wrist. We tend to minimize pin care. In our experience, less handling of the wounds generally leads to a better result. At this time patients can shower, but cannot submerge the limb. • At the 6-week mark, the fixator pins are removed in the clinic under local anesthetic, radiographs are obtained, and rehabilitation is initiated. Patients who are stiff undergo formal physical therapy with a focus on return to activity.

B

Distal Radius Fractures: External Fixation

Complications

Distal Radius Fractures: External Fixation

230 ■

Patients are routinely followed at the 3- and 6-month marks, and are followed further only if there are ongoing concerns.

Evidence Hayes A, Duffy JP, McQueen MM. Bridging and non-bridging external fixation in the treatment of unstable fractures of the distal radius: a retrospective study of 588 patients. Acta Orthop. 2008;79:540–7. Knirk JL, Jupiter J. Intra-articular fracture of the distal end of the radius in young adults. J Bone Joint Surg [Am]. 1986;68:647–59. McQueen MM. Non-spanning external fixation of the distal radius. Hand Clin. 2005;21:375–80. Payandeh JB, McKee MD. External fixation of distal radius fractures. Orthop Clin North Am. 2007;30:187–92. Weil WM, Trumble TE. Treatment of distal radius fractures with intrafocal (Kapandji) pinning and supplemental skeletal stabilization. Hand Clin. 2005;21:317–28. Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study. J Bone Joint Surg [Am]. 2007;89:1424– 31.

PROCEDURE 14

Distal Radius Fractures Paul A. Martineau and Edward J. Harvey

Distal Radius Fractures: ORIF

232

PITFALLS • Although volar fixation has become increasingly popular, reports of the complications of volar plates are beginning to appear in the literature • Specific equipment and reduction choices must be made available within the capabilities of the operating surgeon to allow for customization of fixation to fracture type. • We can still expect satisfactory clinical outcomes in distal radius fractures requiring combined volar and dorsal plating.

Controversies • A wide array of fixation option and approaches are available such that almost all distal radius fractures can be treated with open reduction and internal fixation (ORIF). Whether this is always necessary or preferable and can be reliably accomplished with good functional outcome is still open to debate until appropriately powered, well-designed studies are completed. • In terms of volar locking plates, many systems exists with various design features such as multiple rows of distal fixation, availability of locking screw versus locking smooth peg option, and different direction and number of distal locking screws. However, to date, no one volar locking plate has been shown to be consistently superior to other volar locking plate designs.

Open Reduction and Internal Fixation Indications EXTRA-ARTICULAR FRACTURES ■ Type A fracture • A volar fixed-angle locking plate has become the standard approach for distal radius fractures with joint congruity that fail closed reduction. INTRA-ARTICULAR FRACTURES ■ Type B fractures • Volar ◆ A volar buttress plate remains an effective method of fixation of isolated volar lip shearing injuries. • Dorsal ◆ If closed reduction and percutaneous pinning cannot be attained, a volar fixed-angle locking plate can be used. ◆ Volar treatment of dorsal lip fractures requires secure purchase into the distal fragment and use of distally inclined locking screws to provide subchondral support of the dorsal articular surface. ◆ If percutaneous reduction cannot be attained, dorsal plating is required. ◆ If the dorsal fragment is small and or comminuted, a dorsal buttress plate may be required. ◆ Fragment-specific plating systems allow for strong and low-profile fixation. • Radial styloid ◆ A volar fixed-angle locking plate or fragmentspecific fixation is used for displaced radial styloid fractures. ■ Type C fractures • Lunate fossa ◆ A volar fixed-angle locking plate or polyaxial locking plate is used to provide adequate subchondral support to each of the common intra-articular fracture fragments. If comminution necessitates dorsal reduction, then a fragmentspecific plate is used as well.

233

•

•

•

•

Treatment Options • • • •

Volar plating Dorsal plating Fragment-specific fixation Combined volar and dorsal plating • Bridge plating or salvage surgery

Examination/Imaging ■

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All displaced intra-articular fractures should be imaged with computed tomography (CT) scanning in order to determine specific fragment position and displacement. Intraoperative images must include anteroposterior (AP) (or posteroanterior) and lateral views as well as a 30° styloid view to ensure that screws placed subchondrally are not in the lunate fossa or scaphoid fossa. • Figure 1A shows an AP radiograph of a displaced distal radius fracture. An associated styloid fracture may or may not convey instability. An intraoperative stress test of the distal ulna may

Distal Radius Fractures: ORIF

A small, multihole 1.5-mm plate is excellent for the dorsal lunate fossa area, particularly when comminution is present. Lunate fossa split and displaced ◆ A volar fixed-angle locking plate or polyaxial locking plate is used to provide adequate subchondral support to each of the common intra-articular fracture fragments. ◆ However, when attempting to treat complex intra-articular fracture patterns, different plate designs and alternate fixation options should be readily available and familiar to the surgeon undertaking such cases. Comminuted (type C2/C3) ◆ An extended volar fixed-angle locking plate is used, with or without a dorsal plate(s) in a fragment-specific manner. ◆ If severe comminution extending into the metaphyseal-diaphyseal region is present, the volar and dorsal plates may be substituted for a distal radius bridge plate depending on the extent of metaphyseal comminution and energy of the trauma. Comminuted (type C2), osteoporotic ◆ An extended volar fixed-angle locking plate or distal radius bridge plate is used depending on the extent of comminution and energy of the trauma. Comminuted with nonreconstructable dorsal rim ◆ Dorsal pi-plate extending over the first carpal row is used, with or without a volar (fixed-angle locking) plate. ◆

Distal Radius Fractures: ORIF

234

A

B

FIGURE 1

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indicate if fixation of the styloid area is needed. Although this AP image is consistent with a typical extra-articular fracture known as Colles’ fracture, the lateral view shows comminution of the dorsal cortex extending to the joint line (see Fig. 1B). This is a bad prognostic sign for redisplacement if not treated with stable fixation. • In the lateral view (see Fig. 1B), dorsal tilt (and shortening) is obvious. Carpal instability pattern (CIA) is secondary to the distal radius angulation. Dorsal comminution is obvious. This amount of dorsal tilt and comminution denotes an unstable pattern, leading to a high rate of redisplacement with cast treatment alone. Multiple oblique lateral projections in varying degrees of pronation and supination may help visualize dorsal penetration of volar locking screws.

Surgical Anatomy ■

Volar surgical anatomy • A longitudinal incision is made over the distal aspect of the flexor carpi radialis (FCR) tendon. The volar aspect of the FCR sheath is incised and the FCR tendon is retracted ulnarly. The bed of the sheath is then incised longitudinally.

235

Radial artery Pronator quadratus

A

Median nerve Flexor carpi radialis tendon

Distal Radius Fractures: ORIF

Flexor pollicis longus tendon

Palmar extrinsic ligaments Pronator quadratus tissue cuff

B

Pronator quadratus reflected

FIGURE 2

Brachioradialis tendon First dorsal compartment

FIGURE 3

• The flexor pollicis longus (FPL) tendon lies just beneath the FCR sheath. Retraction of the FPL tendon ulnarly will reveal the deep layer of the palmar approach and hence the pronator quadratus (PQ) (Fig. 2A). • The PQ is released sharply from the radius, leaving a small cuff of tissue radially. It is reflected back as an ulnar-based flap. Care must be taken not to detach the palmar extrinsic radiocarpal ligaments (Fig. 2B). • The use of the FCR for the palmar approach keeps the radial artery safely out of the surgical plane just radial to the dissection (see Fig. 2). • The palmar cutaneous branch of the median nerve is only at risk if the dissection strays to the ulnar side of the FCR (see Fig. 2). • The approach allows for exposure of the entire volar distal radius and can be used for most fractures. • Occasionally, particularly for fractures, treated in delayed fashion, dissection can be carried out radial to or below the radial artery, and a brachioradialis tenotomy can then be performed. The brachioradialis tenotomy will release one of the main deforming vectors on the fracture. Care must be taken to avoid injury to the first dorsal compartment during this radial dissection (Fig. 3).

Distal Radius Fractures: ORIF

236 ■

Dorsal surgical anatomy • A longitudinal incision is made just ulnar to Lister’s tubercle. The incision extends 2 cm distal and 3 cm proximal to Lister’s tubercle. • The third extensor compartment and its content, the extensor pollicis longus (EPL), are identified beneath the extensor retinaculum just ulnar to Lister’s tubercle. Sharp dissection is used to release the EPL tendon in its entirety from the third compartment. Blunt dissection beneath the subcutaneous tissue of the radial-sided flap will avoid inadvertent injury to the dorsal branches of the superficial radial nerve (Fig. 4). • A plane of dissection is established subperiosteally on the radius beneath the second and fourth extensor compartments to expose the entire dorsal aspect of the distal radius. The plane of dissection distally is established beneath the second and fourth compartments but superficial to the dorsal joint capsule. • A transverse arthrotomy can be performed just distal to the dorsal rim of the radius to allow for accurate intra-articular reduction under direct visualization (Fig. 5). • The EPL tendon is left transposed out of the third compartment at the end of the surgery. • The dorsal exposure can be used for dorsal plating of the radius or in cases of combined plating. It can also be performed in a less extensile manner (“mini-open” techniques) to aid in accurate intraarticular reduction when using volar plating of complex intra-articular fractures.

Superficial branches of radial nerve Fourth dorsal extensor compartment Fifth dorsal extensor compartment Sixth dorsal extensor compartment

FIGURE 4

Second dorsal extensor compartment Third dorsal extensor compartment First dorsal extensor compartment

237

Second dorsal extensor compartment (retracted) Third dorsal extensor compartment (opened) Distal radius

FIGURE 5

Equipment • Finger traps applied to the index and middle fingers, with 4.5 kg of longitudinal traction applied through a rope and pulley system (see Fig. 6), can facilitate reduction of the fracture and decrease the need for an assistant.

Positioning ■

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The patient is positioned supine with the involved extremity draped free and centered on a radiolucent hand table (Fig. 6). A weight system with sterile rope is seen projecting from the end of the hand table in Figure 6; this aids in some complex fractures. The table is set up to allow frequent radiographic evaluation. A mobile C-arm is used for every case. A tourniquet is placed around the upper arm. One or two towels rolled and held in place with a plastic sticky drape are useful to position the wrist and hand on. The surgeon usually sits in the patient’s axilla, but this is not an absolute rule.

FIGURE 6

Distal Radius Fractures: ORIF

Fourth dorsal extensor compartment (retracted)

Distal Radius Fractures: ORIF

238

Portals/Exposures

PEARLS

■

• A brachioradialis and/or an FCR tenotomy can be a valuable aid in reduction by relieving a deforming vector on the fracture, especially in cases of delayed fixation.

PITFALLS • A paradigm shift toward volar fixation has come about mostly because a dorsal approach and fixation has been associated with extensor tendon irritation, dysfunction, and rupture.

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Controversies • Reports of extensor tendon problems secondary to protruding screws used with volar plating are starting to appear in the literature.

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Radial artery Distal radius

A FIGURE 7

Volar FCR approach (Fig. 7A) • This is the standard volar approach to the distal radius. • The volar and dorsal sheaths of the FCR tendon are incised. The radial artery is retracted toward the radial side. The FCR tendon is retracted ulnarly, thereby protecting the palmar cutaneous branch of the median nerve and the median nerve proper. • The PQ is released from the radial side, allowing visualization of the distal radius. A plate can be slid in a minimally invasive technique beneath the PQ for extra-articular fractures. Universal volar carpal tunnel approach (Fig. 7B) • This approach allows for simultaneous release of the carpal tunnel as well as excellent exposure of the ulnar side of the radius. • Radial styloid instrumentation may be difficult though this exposure. Dorsal 3-4 approach (Fig. 8A) • This is the standard dorsal approach. It is performed through the third dorsal extensor (EPL) compartment. Then the interval between the second and fourth extensor compartments is used to expose the entire distal radius. • The dorsal ligaments may be released in order to visualize the radiocarpal joint and verify the intraarticular reduction and congruity. • The EPL tendon is left transposed at the end of the exposure.

Carpal tendon (released)

Flexor carpi radialis tendon Pronator quadratus muscle

Tendon

Distal radius Tendon

B

239

Distal Radius Fractures: ORIF

Fourth dorsal extensor compartment

Second dorsal extensor compartment

Distal radius

Third dorsal extensor compartment

A

Fifth dorsal extensor compartment

Fourth dorsal extensor compartment Distal radius

B

FIGURE 8 ■

Dorsal 4-5 approach (Fig. 8B) • This approach is used to address pathology in the dorsal ulnar corner of the radius, the sigmoid notch, and the distal radioulnar joint (DRUJ). It utilizes the interval between the fourth and fifth extensor compartments.

Procedure: Volar FixedAngle Locking Plate for Extra-Articular Fractures STEP 1: CLOSED REDUCTION MANEUVER OF AGEE ■ Longitudinal traction is first used to restore length and to assess the benefit of ligamentotaxis for the

A FIGURE 9

B

Distal Radius Fractures: ORIF

240

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■

■

restoration of articular stepoff. This procedure is used for type A fractures such as that shown in Figure 9A and 9B. Next, the hand is translated palmarly relative to the forearm to restore sagittal tilt and to assess the integrity of the volar lip of the radius. Finally, pronation of the hand relative to the forearm is performed in order to correct the supination deformity. Figure 10 shows the clinical (Fig. 10A) and radiographic (Fig. 10B) outcome of the Agee reduction maneuver.

STEP 2: PROVISIONAL FRACTURE FIXATION ■ Provisional fixation is obtained with the use of Kirschner wires (K-wires) from the radial styloid into the radial shaft. • Often the distal fragments are in good anatomic position with reasonable articular congruity but in danger of displacement due to the instability of the metaphyseal fragment. Provisional K-wire fixation of the metaphyseal comminution will allow later reduction of the metaphyseal fracture onto the radius. • Sometimes small incisions in the dorsum of the wrist can allow the articular fragments to be guided into anatomic congruency. They can then be provisionally pinned in place with 1.25-mm K-wires. ■ Figure 11A and 11B shows the use of two periodontal elevators through small dorsal incisions to reduce dorsal fragments and correct the intraarticular step. This reduced fragment then can be pinned to the diaphyseal radius in a conventional fashion.

A FIGURE 10

B

241

Distal Radius Fractures: ORIF

A

B

FIGURE 11

PEARLS • Understanding the geometry and design features of the volar locking plate system used will help the surgeon position the implant optimally. • The volar locking plate should be positioned as distal as possible without joint penetration to be most effective at preventing shortening of the fracture.

Controversies • Other established techniques exist for fixation of distal radius fractures. For example, nonspanning external fixation has shown excellent clinical and radiographic results in the treatment of extra-articular fractures of the distal radius.

• Small K-wires allow more pieces to be pinned in place, as well as permitting some bending of the wires when definitive fixation with plate and screws occurs. Otherwise, the wires and screws often are competing for the same space. • When placing screws into a fracture that is provisionally fixed with K-wires, ensure that the K-wires are in such a position that, if breakage occurs, there is no need to take apart the radius to remove them. This is particularly true of K-wires near the DRUJ. STEP 3: OPEN REDUCTION AND INTERNAL FIXATION ■ A volar FCR approach is performed. ■ A locking plate is positioned onto the volar aspect of the radius. ■ With the fracture held in a reduced position, the plate is rigidly fixed to the radius.

Procedure: Volar Plating for Intra-Articular Fracture STEP 1: CLOSED REDUCTION MANEUVER OF AGEE ■ Longitudinal traction is first used to restore length and to assess the benefit of ligamentotaxis for the restoration of articular stepoff.

Distal Radius Fractures: ORIF

242

PEARLS • If fragment-specific fixation is to be used, the radial plate can be easily placed through the FCR incision. In order to seat it best below the brachioradialis, it should be placed through a new deep dissection plane radial to the radial artery leash.

PEARLS • Understanding the geometry and design features of the volar locking plate system used will help the surgeon position the implant optimally. • In addition to positioning the plate as distal as possible, care must be taken to adequately support the crucial volar ulnar corner fragment.

A FIGURE 12

STEP 2. PROVISIONAL FRACTURE FIXATION ■ If a closed reduction maneuver achieves reduction, provisional fixation is obtained with the use of K-wires. ■ K-wires are inserted from the radial styloid obliquely into the proximal radial shaft. ■ Supplemental K-wires are used parallel to the subchondral bone to reconstruct the articular surface. STEP 3: OPEN REDUCTION AND INTERNAL FIXATION ■ An FCR approach is used to expose the distal radius. ■ A locking plate is positioned onto the volar aspect of the radius. ■ Under fluoroscopic guidance, with the fracture held in a reduced position, the plate is rigidly fixed to the radius with care to ensure that all the intra-articular fragments (radial styloid, dorsal and volar lunate fragments) are solidly held in their reduced position by the locking plate. ■ Figure 12 illustrates two different fractures treated with volar plating with adequate fixation and outcome. The screws in Figure 12A are suboptimal compared to those screws in Figure 12B. Subchondral screws should be 3 mm from the joint in order to have maximal fixation strength and holding power. This obviously had less importance in the young patient in Figure 12A, but must be taken into consideration in the older osteoporotic patient. ■ Theoretically, the fixation shown in Figure 13 is adequate to permit early range of motion (ROM)

B

243

Distal Radius Fractures: ORIF

FIGURE 13

PITFALLS • Avoid releasing the strong volar carpal ligaments and destabilizing the radiocarpal joint. • Reduction of the intra-articular fracture components can be judged with the aid of intraoperative fluoroscopy. If any question remains about the intra-articular reduction, a separate mini–dorsal arthrotomy can be performed to allow direct visualization of the intraarticular reduction. • Alternatively, intra-articular reduction can be assessed through the volar exposure through the fracture site by supinating the distal fragment and hand relative to the proximal fragment and forearm. Reduction of the joint is then assessed in retrograde fashion through the proximal aspect of the distal fracture fragments.

■

and good outcome. However, attention recently has been called to not just the distance from the subchondral surface for screws but also their length. Reports of extensor tendon rupture and pain have been seen with volar plate fixation from screws that penetrate the dorsal cortex. • The screws in the fixation in Figure 13 seem all to be of appropriate length on the lateral and oblique films. However, in the patients with an intact Lister’s tubercle, screw length may be too long especially in those patients in whom use of a depth gauge is difficult due to dorsal comminution. • The groove for the EPL and the extensor digitorum communis on both sides of the tubercle make the actual length of the screws much less than the radiographic appearance of the cortex of the bone itself. The screws in the patient shown in Figure 14 show a long screw into the tubercle and shorter screws in the bone on either side to avoid encroachment on the extensor tendons. The AP view shows that the most ulnar screw hole was not filled.

FIGURE 14

Distal Radius Fractures: ORIF

244

■

Instrumentation/ Implantation • Volarly placed screws are at risk of causing tendon rupture on the dorsal radius. The lateral radiograph gives a false impression of screw containment inside bone due to Lister’s tubercle when, in fact, they may have overpenetrated the dorsal cortex. All screws should be short of the dorsal surface as checked with a depth gauge, not radiographs alone.

A FIGURE 15

• The DRUJ must be closely examined after plate application. Although the plates can be placed quite ulnar in position on the volar side with little worry about pronation and supination, care must be taken that the screws do not enter the DRUJ. Some plates have an exaggerated spread of screws to incorporate the fragment. The patient in Figure 14 was able to return to full activity at week 3 postoperatively as a physician performing operative procedures with no DRUJ or tendon symptoms. The advent of locking plates has expanded the indications for plate fixation of distal radial fractures. • Figure 15 shows a patient with the typical failed result after Kapanji pinning (Fig. 15A). Revision fixation with a volar plate successfully restored an anatomic reduction. If the plate is locked in the fracture fragment without shaft screws, it can be levered into anatomic position. If the initial distal subchondral row of screws is applied with the proximal plate ulnar on the radius, another reduction will also take place. The radial height will be restored as the plate is brought radially when the shaft screws are applied. • Figure 16 presents an example of multiple fragment-specific fixations through a single volar approach. The radial plate has been slid under the surgically developed interval at the brachioradialis insertion until it stops at the most distal portion of the tendon insertion. If the insertion is solid, there is no need to pin this in place, although some plates have a distal K-wire notch that can be used for the same purpose. Use of a clamp proximally will then squeeze the plate to the bone and cause restoration of the radial height. Taking care to protect branches of the superficial radial nerve,

B

245

Distal Radius Fractures: ORIF

FIGURE 16

one or two screws can then be placed percutaneously.

Procedure: Dorsal and Volar Plating for Intra-Articular Fracture ■

A FIGURE 17

In Figure 17, the plain films (Fig. 17A) and CT scans in the coronal and sagittal planes (Fig. 17B) show multiple fragments of the lunate fossa with separate radial styloid displacement and some diaphysealmetaphyseal junction comminution in a comminuted distal radius fracture. A dorsal cortex fracture with a split lunate fossa usually requires a front-and-back approach with a volar plate plus or minus a dorsal plate.

B

Distal Radius Fractures: ORIF

246

PEARLS • Usually the volar plate is placed first in order to prevent volar translation with any reduction maneuver. • The volar plate often must be readjusted as the reduction becomes more anatomic, especially with the locking plate designs. It should be fixed temporarily with one or two screws in a slotted hole to permit translation of the plate.

PEARLS • With volar comminution at the rim, the buttress plate will be distal—sometimes so distal that screws cannot be placed. It is these fractures that necessitate dorsal locking plates in order to fix the distal fragments in position. Use of volar screws is a secondary goal compared to use of the plate as a reduction tool.

FIGURE 18

A

STEP 1: CLOSED REDUCTION MANEUVER OF AGEE ■ Longitudinal traction is first used to restore length and to assess the benefit of ligamentotaxis for the restoration of articular stepoff. STEP 2: PROVISIONAL FRACTURE FIXATION ■ If closed reduction maneuver achieves reduction, provisional fixation is obtained with the use of K-wires. ■ K-wires are inserted from the radial styloid obliquely into the proximal radial shaft. ■ Supplemental K-wires are used parallel to the subchondral bone to reconstruct the articular surface. STEP 3: OPEN REDUCTION AND INTERNAL FIXATION ■ Through a standard FCR approach, a volar locking plate is first applied in buttress mode without distal screws. • In the patient shown in Figure 17, provisional fixation of the distal radius metaphyseal fracture centered on the joint was done. Good congruency of the distal radius can be seen on the intraoperative AP (Fig. 18A) and the lateral (Fig. 18B) films. A volar approach was then used to place a plate. This plate may not be in the ideal position and is to be used primarily as a buttress and reduction guide. It prevents volar translation of the distal radius fragment when traction and palmar tilt forces are applied.

B

247

• An unreconstructable distal radius intra-articular fracture is rare. Using volar and dorsal plating allows fixation of almost all fracture patterns.

Instrumentation/ Implantation • Bridge plating is accomplished with a long, subcutaneously inserted reconstructive plate from the intact radial shaft to the second metacarpal (DRB plate; Synthes, Paoli, PA). Dorsal abutment plating is performed with a dorsal pi-plate used over the proximal carpal row with no screws inserted in the first row.

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Controversies • The patients who need bridge plating are typically difficult to locate for follow-up. In the senior author’s experience, this has resulted in fused wrists. Use of the pi-plate construct allows restoration of functional wrist motion even if the patient is lost to follow-up.

FIGURE 19

A

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• In Figure 18B the volar comminution has resulted in a large volar rim fragment (large arrow). This rim fragment will perch on the volar plate if the plate is not slid distally at this point. This volar rim fragment is the base for building the anatomic tilt back into the distal radius. The provisional fixation distally sometimes needs to be redone at this point as the tilt is reduced. The dorsal cortex cannot be relied on for a reduction (Fig. 18B) as it too comminuted (small arrows). An open dorsal reduction will be needed. The dorsal opening is the only means to gauge joint reduction reliably. Through a standard dorsal 3-4 approach, the intraarticular comminution and displacement are assessed. This approach allows for direct manipulation of articular fragments, placement of subchondral bone grafts, repair of intercarpal ligament injuries, and augmentation of fracture fixation. One or more low-profile dorsal plates are applied as needed to reconstruct an anatomic dorsal rim. • In Figure 19A, the plate has been slid distally and now captures the volar fragment. Through a dorsal approach the joint has been explored, reduced, and grafted as needed. This patient was still missing some lunate fossa chondral bone. • Plate application (Fig. 19B) on the dorsum of the wrist not only locks the reduction of the cortex but also stabilizes the distal DRUJ and ligaments. The ulna is now relocated anatomically at the DRUJ. The distal volar screws are then inserted if possible, as needed. In this fashion, the distal comminution can be “sandwiched” between the two stable plates.

B

Distal Radius Fractures: ORIF

PEARLS

Distal Radius Fractures: ORIF

248

Procedure: Salvage Surgery for Unreconstructable Fractures PEARLS • Some resistance may be encountered as the plate emerges distally, but can usually be easily overcome with gentle manipulation of the plate. Occasionally, the plate will not pass through the compartment. In these cases, a guidewire or stout suture retriever is passed along the compartment from distal to proximal. The plate is secured to the distal end of the wire and delivered into the hand. In the rare instance that these measures fail, a third incision is made directly over the metaphysis of the radius, the proximal half of the second compartment is incised, and the plate is passed under direct visualization. • The third, or periarticular, incision may also be used to assess the articular surface, reduce die-punch fragments, and introduce bone graft.

A FIGURE 20

STEP 1: CLOSED REDUCTION MANEUVER OF AGEE ■ Longitudinal traction is first used to restore length and to assess the benefit of ligamentotaxis for the restoration of articular stepoff. STEP 2: APPROACH AND PLATE INSERTION ■ A distal radius bridge (DRB) plate is superimposed on the skin from the radial diaphysis to the distal metaphysis-diaphysis of the second metacarpal (Fig. 20A). The position of the plate is verified with image intensification, and markings are placed on the skin at the level of the proximal and distal four screw holes of the plate (Fig. 20B). ■ A 5-cm incision is made at the base of the second metacarpal and continued along the second metacarpal shaft (Fig. 20C). In the depths of this incision, the insertions of the extensor carpi radialis longus (ECRL) and the extensor carpi radialis brevis (ECRB) are identified as they pass beneath the distal edge of the second dorsal wrist compartment to insert on the second and third metacarpal bases, respectively. ■ A second incision is made just proximal to the outcropper muscle bellies (abductor pollicis longus and extensor pollicis brevis), in line with the ECRL and ECRB tendons (see Fig. 20C). The interval between the ECRL and ECRB is developed and the diaphysis of the radius exposed.

B

C

249

Distal Radius Fractures: ORIF

A

B

FIGURE 21

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PEARLS • A DRB plate fixed with a minimum of three screws at either end of the plate confers significantly more stability than would an external fixator used to stabilize a comparable fracture.

PITFALLS • Displaced volar medial fracture fragments that are not reduced with this technique; they require a separate volar incision and appropriate buttress support.

The DRB plate is introduced beneath the muscle bellies of the outcroppers extra-periosteally and advanced distally between the ECRL and ECRB tendons. • Figure 21A shows the DRB plate being inserted through the distal wound. The interval between the ECRL and ECRB distally can be developed for plate passage within the second dorsal compartment. • Figure 21B shows the proximal aspect of the plate over the radius and in between the ECRL and ECRB. It is important to ensure that the plate runs within the second compartment and not superficial to the first and third compartment tendons.

STEP 3: PLATE FIXATION AND ARTICULAR FIXATION ■ After passing the bridge plate, it is then secured to the second metacarpal by placing a fully threaded 2.4-mm nonlocking cortical screw through the most distal plate hole. The proximal end of the plate is then identified in the forearm. ■ If the radial length has not been restored, then the plate, secured to the second metacarpal, is pushed distally until the length is re-established and a fully threaded 2.4-mm nonlocking screw is placed in the most proximal plate hole. By using nonlocking screws, the plate is effectively lagged onto the intact bone. ■ Plate alignment along the longitudinal axis of the radius is assured by securing the distal-most and proximal-most screw holes first.

Distal Radius Fractures: ORIF

250

FIGURE 22

Instrumentation/ Implantation • A 22-hole 2.4-mm titanium mandibular reconstruction plate (Synthes, Paoli, PA) can be used for DRB plating. This plate is made of titanium, and has square ends and scalloped edges and threaded holes to accept locking screws. • The 2.4-mm stainless steel plate specifically designed for use as a DRB plate (Synthes, Paoli, PA), which the authors presently use, is made of stainless steel and has tapered ends to facilitate sliding the plate within the extensor compartment, and also has locking screw capability.

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The remaining holes are secured with fully threaded locking screws inserted with bicortical purchase. Figure 22 shows fluoroscopic views of a high-energy comminuted distal radius fracture fixed using the DRB technique.

STEP 4: INTRA-ARTICULAR REDUCTION ■ Intra-articular reduction may be further adjusted by using limited periarticular incisions to allow for direct manipulation of articular fragments, placement of subchondral bone grafts, repair of intercarpal ligament injuries, and augmentation of fracture fixation with K-wires and periarticular plates.

Procedure: Dorsal Abutment Plating—Alternate Salvage for Unreconstructable Distal Radius Fractures ■

Another option for the unreconstructable distal radius is the dorsal abutment plate—a technique that uses the dorsal pi-plate (Synthes, Paoli, PA) in a buttress fashion. However, the nature of the patient population that incurs this fracture may prevent frequent follow-up, resulting in a functionally fused wrist.

STEP 1: CLOSED REDUCTION MANEUVER OF AGEE ■ Longitudinal traction is first used to restore length and to assess the benefit of ligamentotaxis for the restoration of articular stepoff.

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FIGURE 23

STEP 3: PLATE FIXATION AND ARTICULAR FIXATION ■ A dorsal pi-plate is used but inserted more distally on the radius. • Figure 24 shows the AP (Fig. 24A) and lateral (Fig. 24B) views of the appropriate position of the plate for the patient in Figure 23. The limbs of the plate are on the capsule over the scaphoid and the lunate and hold the carpus reduced. This plate, combined with K-wire fixation and manipulation, usually results in a near-anatomic reduction of the carpus relative to the distal radius.

A

FIGURE 24

B

Distal Radius Fractures: ORIF

STEP 2: APPROACH AND PLATE INSERTION ■ A volar FCR appoach is made as above with volar buttress plating (no screws inserted distally). ■ The standard dorsal 3-4 approach as above is also made. If an attempt at reduction is made, it is carried out as typical volar and dorsal plating. • Figure 23 shows a severe distal radius fracture with CT evidence of dozens of fragments of the distal radius, particularly the dorsal rim. Reconstruction with K-wires and external fixation initially resulted in residual dorsal subluxation of the carpus on the distal radius. Conventional plate fixation did not prevent this. Using a pi-plate and positioning it over the carpus to prevent dorsal subluxation can be a useful tool. ■ When it is determined that the dorsal rim is unreconstructable, an extension of the incision 3 cm distal over the first proximal row is done.

Distal Radius Fractures: ORIF

252

A

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FIGURE 25 ■

PEARLS • Bone graft can be placed beneath the lunate fossa just before placing the plate. This often aids in reduction when the two plates are brought together in a sandwich fashion as the screws are tightened.

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• If there is fair joint congruency, expect ROM of 45° of flexion and 20° of dorsiflexion. No limits are imposed on these patients after cast removal.

PITFALLS • The dorsal pi-plate technique cannot be used if the comminution is into the diaphyseal portion of the radius. If that is the case, a DRB technique should be performed as above.

No length should be cut any off the two stems of the dorsal pi-plate. The plate is placed over the capsule below the tendons directly on the proximal carpal row, capturing the scaphoid and lunate especially. No screws are placed into the proximal carpal row. The proximal screws are filled in the intact radius. The patient in Figure 23 was lost to follow-up but did return 4 years later because he had a small bump on the dorsum of his wrist (arrow in Fig. 25A) and desired more dorsiflexion (Fig. 25B), although he was pleased with his flexion (see Fig. 25A). The plate was removed after the patient was told his ROM would not be increased.

Postoperative Care and Expected Outcomes ■

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The patient is placed in a below-the-elbow splint in surgery. Only rarely is an above-the-elbow splint used. The splint is changed to a cast, after suture removal and wound check, for a total of 5 weeks. If locking plates have been used to fix an extra-articular or stable-after-fixation intra-articular fracture, then total cast time is shortened to 4 weeks A sling is used for 1 week, then removed if possible. If present, wires are removed at 4–5 weeks postoperative in the clinic. An occupational therapy splint is used at 4–6 weeks. Rehabilitation protocol • Days 1–21 ◆ Passive ROM of the hand/fingers, hand pumps ◆ Pendulum shoulder ◆ Short-arm cast—start active ROM of the elbow

253

Evidence Benson LS, Minihane KP, Stern LD, Eller E, Seshadri R. The outcome of intra-articular distal radius fractures treated with fragment-specific fixation. J Hand Surg [Am]. 2006;31:1333-9. Retrospective review of 82 intraarticular distal radius fractures treated with fragment specific fixation. Sixty-one excellent and 24 good results according to Gartland and Wesley scoring and ROM 85% and 91% for flexion and extension at 1 year minimum follow-up. No loss of reduction occurred. Drobetz H, Bryant AL, Pokorny T, Spitaler R, Leixnering M, Jupiter JB. Volar fixed-angle plating of distal radius extension fractures: influence of plate position on secondary loss of reduction—a biomechanic study in a cadaveric model. J Hand Surg [Am]. 2006;31:615-22. Biomechanical cadaveric study evaluating effect of plate position on eventual shortening, rigidity and strength of volar plate extraarticular distal radius fracture construct. Locking plates positioned with the screws just subchondral maintained length more effectively and had greater rigidity of the construct. Jakob M, Rikli DA, Regazzoni P. Fractures of the distal radius treated by internal fixation and early function: a prospective study of 73 consecutive patients. J Bone Joint Surg [Br]. 2000;82:340-4. Consecutive series of 74 fractures treated with 20 mm miniplates and early ROM demonstrated good or excellent results and nominal loss of fracture alignment at 1 year follow-up. Clinical support of concept of columnar fixation. Jupiter JB, Fernandez DL, Toh CL, Fellman T, Ring D. Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg [Am]. 1996;78:1817-28. Retrospective review of 49 volar marginal intraarticular fractures. Thirty-one excellent, 10 good and 8 fair results according to Gartland and Wesley. Evidence of osteoarthritis and reversal of volar tilt were significantly associated with poor outcome. Kamath AF, Zurakowski D, Day CS. Low-profile dorsal plating for dorsally angulated distal radius fractures: an outcomes study. J Hand Surg [Am]. 2006;31:1061-7. Retrospective study of 30 patients treated with low-profile dorsal plating. Patients obtained 80% of their ROM and strength. Ninety-three percent of patients had good or excellent functional outcomes. Martineau PA, Berry GK, Harvey EJ. Plating for distal radius fractures. Orthop Clin North Am. 2007;38:193-201. Review of distal radius fracture plating.

Distal Radius Fractures: ORIF

• 3–6 weeks ◆ Slab removed ◆ Forearm pronation/supination active ROM ◆ Grip strength, scar massage • 6–12 weeks ◆ Cast off + pins out ◆ Active ROM of the wrist, contrast baths ◆ Grip strength, manual therapy of the carpus • 12+ weeks ◆ Manual therapy wrist, passive ROM • Restriction: non–weight bearing for 8 weeks

Distal Radius Fractures: ORIF

254 Ring D, Prommersberger K, Jupiter JB. Combined dorsal and volar plate fixation of complex fractures of the distal part of the radius. J Bone Joint Surg [Am]. 2005;87(Suppl 1 Pt 2):195-212. Retrospective review of 25 patients with AO C3.2 fractures treated with combined dorsal and volar plating. Mean of 54 degrees of extension and 51 degrees of flexion and 78% grip strength. Good to excellent results achieved in 96%. Although results are limited by severity of the injury, a stable mobile unit can be obtained in these complex cases. Ruch DS, Ginn TA, Yang CC, Smith BP, Rushing J, Hanel DP. Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution. J Bone Joint Surg [Am]. 2005;87:945-54. Prospective study of 22 patients treated by distraction plating for distal radial fractures with metaphyseal and diaphyseal comminution. Plate was removed at average of 124 days. Flexion and extension were 57 and 65 degrees respectively. Fourteen patients had excellent results, 6 had good results and 2 had fair results according to Gartland and Wesley scoring. Description of a normal and effective technique for treatment of distal radius fractures with extensive metadiaphyseal comminution. Schnall SB, Kim BJ, Abramo A, Kopylov P. Fixation of distal radius fractures using a fragment-specific system. Clin Orthop Relat Res. 2006;(445):51-7. Case series of fractures treated with fragment specific fixation. Grip strength was 67%, flexion 46 degrees and extension 57 degrees. Return to routine daily activities was at 6 weeks postoperatively.

PROCEDURE 15

Scaphoid Fracture Fixation Paul A. Martineau and Edward J. Harvey

Scaphoid Fracture Fixation

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PITFALLS • Extra-articular minimally displaced fractures do not necessarily need open reduction and internal fixation. • Kirschner wire fixation should be reserved for only severely comminuted fractures. • Reduction of the cartilage, or the perimeter of the scaphoid, is more important than bone apposition. • Vascularity of the proximal or distal piece cannot be determined by plain radiographs alone.

Indications ■

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Examination/Imaging ■

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Controversies • Vascularized grafting should be used primarily for very proximal pole fixation (see Fig. 22). • Repeated volar bone grafting may be detrimental to range of motion and function. • Nondisplaced fractures may do better with percutaneous pinning than cast fixation.

Treatment Options • • • • •

Open volar approach Open dorsal approach Percutaneous volar approach Percutaneous dorsal approach Combined volar and dorsal approach • Vascularized grafting • Casting • Electrical or ultrasound stimulation

Displaced scaphoid fractures (1-mm gap visible on radiographs) should be treated with open reduction and internal fixation. Minimally invasive fixation should be used when possible. Early intervention should be undertaken for proximal pole fractures.

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Physical examination of the anatomical snuff-box without ulnar deviation of the wrist can be misleading. Radiographs at the time of injury should include a maximally ulnar-deviated posteroanterior (PA) view in order to rule out fracture. • Figure 1 shows radiographs of a scaphoid waist fracture with delayed union. There is shortening of the scaphoid on the PA view with an obvious cyst (Fig. 1A, arrows). The lunate is triangular in shape (outlined area) as it has slipped into a dorsal intercalated segment instability (DISI) position. • On a lateral view (Fig. 1B), the lunate is tilted into DISI and the scapholunate angle is about 90°. There is a pronounced humpback deformity of the scaphoid itself (tracing outlining volar scaphoid) where the scaphoid has effectively folded into the cyst (large black void). This type of delayed union needs structural bone grafting from the volar side. A large iliac crest graft may be needed. Computed tomography (CT) scans are more helpful in this problem (see Fig. 5). Repeat radiographs at 1 week must be ordered with any suspected radial-sided wrist pain. • Figure 2A and 2B are initial radiographs in an 18-year-old male that were read as negative by radiology. Small arrows in Figure 2B show a fracture line in the proximal pole that was missed. Repeat radiographs should have been scheduled but were not done. • Follow-up at 4 months for the same patient (Fig. 2C) shows obvious nonunion with cyst formation. Splint use might have prevented this complication.

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Scaphoid Fracture Fixation

FIGURE 2

C B A

B A

FIGURE 1

Scaphoid Fracture Fixation

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CT scan or magnetic resonance imaging (MRI) will reliably rule out most fractures at initial presentation. • Figure 3 shows a CT scan of a scaphoid nonunion. There is a loss of volar scaphoid bone stock secondary to cyst formation (arrows). Sclerosis is seen at the fracture ends. • Obvious increase in the intrascaphoid angle is easily seen on a sagittal CT scan (Fig. 4, angle). As for the delayed union shown in Figure 1, this is a structural problem necessitating a large graft. The sclerotic ends must be removed in order to facilitate invagination of a graft to allow reconstitution of scaphoid length. • The MRI in Figure 5 shows a waist fracture of the scaphoid. Signal changes on this coronal view show obvious vascularity loss (arrowhead). Change in vascularity of the proximal pole secondary to the fracture and the distal blood supply result in an avascular proximal pole. ◆ Use of a vascularized graft in waist fractures is controversial. The avascular proximal pole will heal to the distal scaphoid if solid internal fixation with a screw orthogonal to the fracture line is accomplished. ◆ Small proximal poles may be better treated with fixation and vascular grafting because of more tenuous fixation and the ramifications of resorption of even a small amount of bone before final healing. Bone scan may be used if more than 48 hours have passed since injury, and is a sensitive but not specific test.

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Scaphoid Fracture Fixation

FIGURE 3

angle

FIGURE 4

FIGURE 5

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Scaphoid Fracture Fixation

Surgical Anatomy ■

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Scaphoid tubercle Radial artery

Surgical anatomy of the volar approach to the scaphoid (Fig. 6) • Scaphoid tubercle, base of the thenar mass. • Flexor carpi radialis (FCR) tendon. • Scaphotrapeziotrapezoid (STT) joint. • Structures at risk: ◆ Care must be taken to avoid dividing the radioscaphocapitate ligament. ◆ The radial artery lies just radial to the surgical plane and must be protected throughout the exposure. Surgical anatomy of the dorsal approach to the scaphoid (Fig. 7) • Anatomical snuff-box. • Extensor pollicis longus (EPL) and extensor pollicis brevis (EPB) tendons. • Extensor carpi radialis longus (ECRL). • Structures at risk: ◆ The radial artery should be protected as it enters the dorsal ridge of the scaphoid on the radial side. ◆ Care must be taken to avoid injury to dorsal sensory branches of the radial nerve.

Radioscaphocapitate ligament Flexor carpi radialis tendon Extensor pollicis longus tendon

FIGURE 6

Extensor carpi radialis tendon

Radial artery Extensor pollicis brevis tendon Radial nerve

FIGURE 7

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The patient is positioned supine on an operating room table. A radiolucent arm board is used. A tourniquet is used particularly for the vascularized graft techniques. • Exsanguination is not performed before the tourniquet is inflated. Fluoroscopy is used for all techniques.

Portals/Exposures ■

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Both volar and dorsal approaches are commonly used for the fixation of scaphoid fractures. Volar approaches are used for larger defects, humpback deformities, combined volar ligament repairs, and fractures distal or at the waist. • A 3-cm incision is centered over the scaphoid tubercle, extending from the distal aspect of the FCR tendon and then curving toward the base of the thenar mass (Fig. 8). • The FCR tendon sheath is incised, the FCR tendon is retracted ulnarly, and the dorsal sheath is then incised. • A longitudinal arthrotomy is made in the radiocarpal joint, curving transversely to open the STT joint. • Proximal extension of the approach into an FCR approach to the distal radius may be useful in cases in which obtaining bone graft may be required.

Scaphoid tubercle Flexor carpi radialis tendon (retracted)

FIGURE 8

Scaphoid Fracture Fixation

Positioning

Scaphoid Fracture Fixation

262

Instrumentation • Fixation device use is dependent on hospital inventory and surgeon preference. • Kirschner wires can be used for segmental, comminuted fractures where compression would cause malunion. • Cannulated compression screws are used with simple fracture patterns. • Small modular hand screws can be used in combination with other compression devices for more complicated fractures. However, they may not be strong enough when used alone with intercalary grafting. In Figure 10, broken hardware is evident after use of small screws to fix a large intercalary graft. Slow healing associated with this large graft probably resulted in fixation failure. A more robust screw should be used, especially if bone healing is expected at both ends of a large graft.

Controversies

Extensor pollicis longus tendon (retracted)

First metacarpal

Extensor carpi radialis tendon (retracted)

Extensor pollicis brevis tendon (retracted) Scaphoid

FIGURE 9 ■

Dorsal approaches are used for proximal fractures and dorsal revascularization procedures. • A 3-cm curvilinear incision is centered over the anatomical snuff-box, extending from the base of the first metacarpal to 2 cm proximal to the snuffbox (Fig. 9). • The EPL and EPB tendons are identified. The fascia between the two tendons is incised and the tendons are retracted.

• Use of a combined dorsal and volar percutaneous approach (as below) places the thenar eminence at risk if the thumb is not pronated slightly when the guide wire is driven through the volar skin

FIGURE 10

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OPEN REDUCTION AND INTERNAL FIXATION Procedure: Open Volar Approach STEP 1 ■ As seen in Figure 8 above, the volar approach exposes the volar capsule over the scaphoid. Increased exposure can be accomplished by removing the capsule from the rim of the radius. This is approximated later with suture if possible. ■ Joysticks can be placed into the distal and proximal scaphoid fragments in order to reduce the fracture. Figure 11 shows reduction of the scaphoid (SC) fragments of a midwaist fracture by joysticks before pinning. ■ If the fracture is anatomically reduced, the scaphoid can be pinned provisionally in place with small Kirschner wires (K-wires). • Depending on the size of the wound, the K-wires must be placed so that, inside the bone, they do not interfere with provisional fixation (see Fig. 11: single arrow, distal pole wire; multiple arrows,

FIGURE 11

Scaphoid Fracture Fixation

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• The ECRL is retracted ulnarly with the EPL tendon. • A longitunal arthrotomy is made, and the capsule is reflected volarly and dorsally. Percutaneous fluoroscopy-guided volar and dorsal approaches have been described for fractures in the same location that do not need bone grafts and are easily anatomically reducible without an open reduction being required. Combined volar-dorsal approaches may be used for vascularized grafting of humpback deformities (see Fig. 17) or percutaneous fixation of proximal fractures when a distal screw is desirable.

Scaphoid Fracture Fixation

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proximal pole wire). Also, they must be positioned so that after reduction they do not impinge on other anatomic structures, thereby preventing anatomic reduction. • Care should be taken to avoid the center of the scaphoid, as ideally this is where the final fixation device will be placed. If there is still a defect (as in a humpback deformity) in the scaphoid, it will be impossible to anatomically reduce the scaphoid. Care must be taken not to shorten the scaphoid in order to fix the bone. This will hamper the motion of the wrist.

STEP 2 ■ If the scaphoid has sufficient bone loss that shortening occurs when fixation or reduction is attempted, a small laminar spreader can be placed into the defect in order to attain anatomic reduction of the scaphoid (Fig. 12). ■ On lateral fluoroscopy, the spreader is opened until the lunate is no longer in DISI. In Figure 12, the spreader has opened a large gap (black arrows) between the proximal (ScP) and distal (ScD) scaphoid, which have been outlined. The relationship with the lunate (Lun) and capitate (Cap) can be seen for reference. ■ The defect can be measured in order to procure the appropriate-sized bone graft. • Large bone grafts can be used in order to obtain adequate scaphoid and wrist length. • In Figure 13, the radius, the capitate (Cap), the lunate (Lun), and the two scaphoid poles (ScP and ScD) can be seen after the graft has been placed and held provisionally with a K-wire. The graft’s extreme edges are delineated by the black arrowheads. STEP 3 ■ The trapezioscaphoid joint is exposed during the volar approach. ■ A small wedge should be removed from the center of the joint on the trapezium side. This facilitates placement of a K-wire into the center of the scaphoid as well as the central placement of the screw (Fig. 14; black arrows indicate the portion removed from the trapezium at the distal end of the dissection).

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Scaphoid Fracture Fixation

FIGURE 12

FIGURE 13

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In Figure 14, an internal fixation screw has been placed as near as orthogonal to the fracture line as possible (black outline). We have chosen Acutrak miniscrews as our first-line compression screw. • They allow cannulated placement, permitting an open or percutaneous approach. They take up less scaphoid geometry than regular Acutrak screws. • Although extremely rare, if the Acutrak miniscrews fail, salvage with regular Acutrak screws is easily performed.

FIGURE 14

Scaphoid Fracture Fixation

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Procedure: Open Dorsal Approach

PITFALLS • Displaced volar medial fracture fragments that are not reduced with this technique require a separate volar incision and appropriate buttress support.

PEARLS • Appropriate fixation devices must be used. Dorsally placed small screws with a buried subchondral portion will give a better result than a standard screw inserted in an anterograde fashion. Figure 16 provides an example of inadequate planning for a proximal pole fracture. Use of a large screw without adequate compression is not ideal. Because a distal-to-proximal volar approach was used, the proximal pole could not be visualized and the fracture line is not orthogonal or compressed by the device. The screw is longer than needed and has damaged the scapholunate ligament, and the lunate is partially worn away (small arrowheads).

W PP

STEP 1 ■ The dorsal approach is carried out for proximal pole fractures. The dorsal approach can also be used for combination procedures in which the dorsal rim of the radius requires fixation or for concomitant scapholunate ligament repair (see Fig. 9). • In Figure 15, the scaphoid proximal pole fracture (PP) can be easily visualized from this approach just distal to the EPL as it comes around Lister’s tubercle (Lis) in the interval between extensor compartments 2 and 4 distal to the EPL sheath. Fixation direction is shown with a straight oblique line drawn down the length of the scaphoid (SC). • Care must be taken not to place the fixation device guidewire so close to the lunate surface that the drill damages the cartilage while drilling during the procedure. This has even more importance in the percutaneous procedure through the dorsal approach. STEP 2 ■ Exposure through the capsule can be performed in several different ways; however, the authors have seen no difference in any of the various approaches for postoperative morbidity.

Sc

Lun

Lis

FIGURE 15

FIGURE 16

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PITFALLS • The proximal pole fracture may be treated with primary vascularized graft. Waiting for slow revascularization and the eventual collapse seen with attempted primary healing can result in arthritic changes.

PEARLS • Appropriate fixation of the graft within the scaphoid must be obtained. • Use of a K-wire for 3 weeks or use of a small screw are both good options.

The capsule can be lifted off the rim of the radius to allow both reduction and guidewire placement down the center of the scaphoid. The guidewire starting point is just radial to the scapholunate ligament at the midcircumference of the scaphoid. This can only be reached with the wrist in at least 60° of flexion. The cannulated screw can then be advanced over the guidewire with or without fluoroscopic guidance.

Procedure: Open Dorsal Approach with Vascular Graft STEP 1 ■ A dorsal approach is carried out as normal (see Fig. 9). As mentioned, the proximal pole fracture line is best visualized distal to Lister’s tubercle in the interval between extensor compartments 2 and 4 distal to the EPL sheath (see Fig. 15). ■ The fracture is fixed as per the open dorsal approach procedure; however, careful attention must be given to sparing the vascular graft that the surgeon wishes to use. STEP 2 ■ The popular pedicles for a vascular graft are shown in Figure 17. • The assorted grafts include the second metacarpal graft (2nd MCP) based on the distal superficial radial artery arch, and the Zaidenberg (ZGraft) and first/second extensor compartment (1,2 Art) grafts based on the recurrent branch of the radial artery. Their relationships to the radius and Lister’s tubercle (Lis) as well as the capitate (Cap) and the scaphoid (Sc) is well visualized. • The S-shaped incision for exposure of the fracture and the 1,2 Art graft is shown.

Lis Radius

Cap Sc

1,2 Art

2nd MCP Z Graft

FIGURE 17

Scaphoid Fracture Fixation

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Scaphoid Fracture Fixation

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FIGURE 18

The second metacarpal–based graft is better suited to decrease scarring at the wrist; however, it necessitates a much larger incision. We reserve this graft for failures of the more proximal-based grafts. Zaidemberg (1991) has described a graft based on the recurrent leash of the radial artery—identical to the first/second extensor artery origin. This graft has a much shorter pedicle than the first/second extensor compartment graft and cannot be made as large as that graft. We reserve the Zaidemberg graft for very proximal poles or skeletally immature patients where preservation of the growth plate is more important. Otherwise we use the first/second extensor artery graft. • The skin incision is the large S-shaped line over the dorsum of the wrist seen in Figure 17. This allows a proximal approach to the first/second extensor compartment area while still allowing visualization of even more distal waist area fractures. • In Figure 18, the vascular leash is found proximal to the EPL (large arrow) and inferior to the second extensor group (small black arrowheads). There is a consistent penetration of the radial cortex along the first/second extensor artery 1.5 cm from the rim of the radius. A large graft can be lifted from this area (shaded square). • The size of the graft that can be obtained with this method is quite large, and the excursion of the graft pedicle is such that the entire scaphoid can be reached. In Figure 19, a large 1.5 × 2 × 3-cm graft (white arrows) has been harvested.

FIGURE 19

269

• Occasionally, the central axis and “signet ring” may be difficult to identify with intraoperative imaging. In these cases, an external targeting system as described by Slade (2002) can be assembled. Orthogonal K-wires are inserted in the distal scaphoid. One wire is placed perpendicular to the scaphoid in the dorsal-to-volar axis and another placed at 90° to the first in the same plane but perpendicular to the distal scaphoid in the radial-to-ulnar axis. These K-wires, if inserted correctly, can serve as targeting crosshairs and can then easily mark the scaphoid central axis at their point of intersection. We have not had to use this technique ourselves.

PITFALLS • Percutaneous approaches are applicable for minimally displaced or nondisplaced scaphoid fractures. The dorsal percutaneous approach, as with the open dorsal approach, is more suitable for proximal pole fracture fixation.

PERCUTANEOUS FIXATION Procedure: Dorsal Approach STEP 1 ■ Percutaneous approaches are highly dependent on good intraoperative fluoroscopy. ■ The dorsal percutaneous approach requires manipulation of the wrist to obtain a cross-sectional view of the scaphoid waist, or the “signet ring” appearance, on fluoroscopy. • The wrist usually needs to be manipulated into flexion, ulnar deviation, and pronation while holding the elbow flexed in order to obtain this view (Fig. 20). • A line drawn down the longitudinal axis of the scaphoid under fluoroscopic guidance aids in placement of the wire. ■ The guidewire is then centered on the “signet ring” and central on the longitudinal axis with this image. If the scaphoid has been reduced with the manipulation, the guidewire is advanced down the central axis of the scaphoid and its position confirmed with orthogonal views.

• Waist fractures can be addressed either volarly or dorsally. • More distal fractures are usually treated with a volar retrograde approach. • Fractures with comminution, marked displacement, and/or significant collapse are better treated by formal open approaches and possible bone grafting.

FIGURE 20

Scaphoid Fracture Fixation

PEARLS

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Scaphoid Fracture Fixation

STEP 2 ■ A reduction must be obtained prior to guidewire insertion. The use of K-wires as joysticks in the proximal and distal scaphoid can facilitate the reduction maneuver. • In Figure 21A, a K-wire (three arrows) has been placed percutaneously, pinning the distal scaphoid in place to the capitate before flexion of the wrist. Three small arrows in Figure 21B show the wire on the wrist. This will immobilize the carpus enough to accomplish percutaneous fixation without movement of the fracture fragments during manipulation. • A drill (see Fig. 21A, two white arrows) and screw are then placed into the scaphoid in a proximal-todistal fashion. ■ The cannulated screw is then placed antegrade over the guidewire (Fig. 22). Placement of the screw over the guidewire results in a well-reduced fracture and healing.

B

A FIGURE 21

FIGURE 22

271

Procedure: Volar Approach ■

• The guidewire must go through the trapezium lip before it enters the scaphoid to attain central hardware placement. ■

PITFALLS • Failure to recognize the need to have a screw path slightly through the trapezium will result in incorrect screw placement. Failure to obtain central third fixation may lead to increased failure rates.

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PEARLS • The K-wire comes through the trapezial lip when exiting the scaphoid.

PITFALLS • The thumb should be pronated when the K-wire is brought through the skin. • The scalpel should be on the radial side of the K-wire when opening the skin.

A volar percutaneous approach with retrograde screw fixation can be performed for reducible noncomminuted fractures of the scaphoid waist and distal fractures. Reduction of the scaphoid fracture is achieved by closed manipulation or with the use of percutaneously positioned joystick K-wires in the proximal and distal fragments. However, the starting point for the central axis of the scaphoid, just as in the open volar approach, is slightly obstructed by the lip of the trapezium. Positioning the guidewire down the central third of the scaphoid usually requires the guidewire to penetrate the lip of the trapezium prior to entering the scaphoid. The screw passed over the guidewire will, upon insertion, remove a small portion of the trapezium. This is analogous to the step of the open volar approach whereby the trapezium lip is resected.

Procedure: Combined Dorsal and Volar Approach STEP 1 ■ The scaphoid is reduced percutaneously or by manipulation. ■ Reduction can be held with K-wires placed through the distal pole into the capitate (see Fig. 21) as well as with more conventional K-wires down the length of the scaphoid parallel to eventual screw placement. STEP 2 ■ The guidewire for the cannulated system is then placed in the scaphoid from proximal to distal (as per the dorsal percutaneous approach procedure; see Fig. 20). This is performed with the wrist in flexion as above. The guidewire is advanced through the trapezium once adequate wire placement is obtained. ■ The wire is advanced through the skin on the dorsal side (Fig. 23A) and then the driver is put on the distal wire and under fluoroscopic guidance it is brought to the subchondral scaphoid proximal pole area. The wire is backed out through the volar side until it is flush with the dorsal scaphoid on lateral radiograph (Fig. 23B, large arrow).

Scaphoid Fracture Fixation

PEARLS

Scaphoid Fracture Fixation

272

B FIGURE 23 ■

A

The wire exits the scaphoid through the trapezial lip before exiting the skin (see Fig. 23B, small arrows).

STEP 3 ■ A scalpel (Fig. 24A) is used to open up an area for measurement, drilling, and screw placement from volar to dorsal, thereby decreasing the hole size required in the articular cartilage of the proximal pole of the scaphoid and preserving the integrity of the radioscaphoid joint. The scalpel is run along the radial side of the K-wire to ensure safety. ■ After opening the skin up, the fixation device can be paced in an antegrade fashion. This makes the large drill hole in the scaphoid on the volar surface rather than the cartilage of the dorsal surface. As seen in Figure 24B, the large trough (arrowheads) is in the trapezium with only a K-wire hole in the proximal scaphoid.

B FIGURE 24

A

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• Standard radiographs at 3 months have been shown to be unreliable at determining scaphoid healing. Patients with hand-intensive occupations should be cleared to return to full duties when there is CT scan evidence of healing.

Postoperative Care and Expected Outcomes ■

PITFALLS • Despite excellent published surgical results with the various techniques described, scaphoid nonunions can occur. The risk of this complication increases with less stable initial fracture patterns, comminution, displacement, delay to definitive treatment, and patient-related factors. In addition, more proximal fractures can be complicated by avascular necrosis. These complications can be salvaged with success with vascularized and nonvascularized bone grafting

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Length of immobilization is governed by multiple factors such as initial fracture characteristics and complexity, construct stability, acuity of the fracture, surgical approach, and patient factors. • A brief period of immobilization of 10 days in a short-arm splint following fixation of simple acute scaphoid fractures is usually recommended. This will avoid ulnar and radial deviation movements that may cause tension and stress the repair site. A removable thumb spica cast may be used afterward. • In comminuted or proximal pole fractures, or in patients with multiple comorbid factors, we do not hesitate to extend the immobilization period for 6 weeks, with a period of protected mobilization afterward. The union rates described for the operative treatment of scaphoid fractures are extremely high, with several studies reporting 100% healing rates. • Of perhaps greater interest is that many studies report faster healing time than with cast immobilization. Healing times for acute fractures treated early can be on the order of 6–8 weeks. Additionally, patients undergoing scaphoid operative fixation return to work in approximately half the time of conservatively managed patients. • Percutaneous techniques have the benefit of decreasing surgical morbidity, but studies of open and percutaneous fixation of acute scaphoid fractures all display high union rates.

Evidence Cooney WP 3rd, Dobyns JH, Linscheid RL. Nonunion of the scaphoid: analysis of the results from bone grafting. J Hand Surg [Am]. 1980;5:343-54. Scaphoid nonunions treated with bone grafts in 90 fractures volar only 86% union. Dorsal only 91% union. Dorsal regular graft 50% union. Displaced nonunions healed 65% of time and nondisplaced nonunions healed 85% of time. Increased union rate with K-wire fracture in unstable nonunions. (Level IV evidence) Gutow AP. Percutaneous fixation of scaphoid fractures. J Am Acad Orthop Surg. 2007;15:474-85. Review of percutaneous scaphoid fracture fixation technique. Markiewitz AD, Stern PJ. Current perspectives in the management of scaphoid nonunions. Instr Course Lect. 2005;54:99-113. Review of management of scaphoid nonunions.

Scaphoid Fracture Fixation

PEARLS

Scaphoid Fracture Fixation

274 Shin AY, Bishop AT. Pedicled vascularized bone grafts for disorders of the carpus: scaphoid nonunion and Kienbock’s disease. J Am Acad Orthop Surg. 2002;10:210-6. Review of vascularized bone grafting techniques. Slade JF 3rd, Gutow AP, Geissler WB. Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach. J Bone Joint Surg [Am]. 2002;84(Suppl 2):21-36. Article illustrating dorsal percutaneous technique. Waitayawinyu T, Pfaeffle HJ, McCallister WV, Nemechek NM, Trumble TE. Management of scaphoid nonunions. Orthop Clin North Am. 2007;38:237-49, vii. Review of management of nonunions. Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand Surg [Am]. 1991;16:474-8. Initial article to popularize vascularized bone grafts. Eleven patients with scaphoid nonunions treated and achieving 100% union.

PROCEDURE 16

Perilunate Injuries Brad Pilkey

Perilunate Injuries: Dorsal-Volar Approach

276

PITFALLS • Irreducible lunate dislocations cannot be addressed with only a dorsal approach (i.e., lunate trapped in carpal tunnel). • We are unable to decompress the carpal tunnel or repair the disrupted volar capsule through a dorsal approach.

Controversies • For perilunate and transscaphoid perilunate dislocations, many different approaches have been described. Operative approaches include the isolated dorsal, the isolated volar, and the combined dorsal-volar.

Combined Dorsal and Volar Approach Indications ■

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Examination/Imaging ■

Treatment Options • Closed reduction is performed early to restore overall carpal alignment, and to reduce pain and swelling, until such a time that an open reduction and repair can be done. • Closed reduction and percutaneous pinning is extremely difficult in a perilunate dislocation, due to the inability to maintain anatomic alignment during the stabilization maneuver. • In a trans-scaphoid injury, an anatomic closed reduction is virtually impossible (Kozin, 1998).

The combined dorsal-volar approach allows one to address every aspect of the injury pattern. The dorsal approach to the carpus gives the best exposure for open reduction of carpal malalignments, reduction and fixation of fractures, and scapholunate interosseous ligament repair. It is usually the first approach in combined dorsal-volar approaches. The volar approach is used to decompress the carpal tunnel, to reduce an irreducible dislocation if needed, and to repair the volar capsular rent.

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Diagnosis can be challenging with physical examination alone. Injuries can be missed 25% of the time (Herzberg et al., 1993). • The wrist is typically swollen and deformed. • The digits are usually semiflexed with decreased passive motion. • Median nerve compression findings are common. Standard posteroanterior and lateral radiographs are obtained to make the diagnosis. Findings may be subtle. Oblique or traction views may give additional information about the pattern of injury. • Lateral radiograph ◆ The lateral radiograph is examined for a lack of co-linearity between the radius, lunate, and capitate. ◆ An increased scapholunate angle (>70°) is consistent with scapholunate dissociation. ◆ In stage III perilunate instability, the capitate is usually displaced dorsally from the lunate. ◆ In stage IV perilunate instability, the lunate dislocates from the radius, usually in a volar direction. It rotates volarly (“spilled teacup sign”) (Green et al., 1980) (Fig. 1). • Posteroanterior radiograph ◆ The posteroanterior radiograph is examined for any disruption of the smooth arcs formed by the proximal aspect of the distal carpal row and the proximal and distal aspects of the proximal carpal row (Gilula et al., 1984) (Fig. 2).

277

Perilunate Injuries: Dorsal-Volar Approach

FIGURE 1

FIGURE 2

278

The lunate may appear triangular as opposed to its usual trapezoidal shape. ◆ Signs of scapholunate dissociation include widening (“Terry Thomas sign”) or scaphoid flexion (ring sign) (Green et al., 1980). Computed tomography, magnetic resonance imaging, bone scans, and arthrography are not helpful in the acute setting.

Perilunate Injuries: Dorsal-Volar Approach

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Surgical Anatomy ■

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The scapholunate ligament has three main parts (Fig. 3). • The dorsal part is the thickest and strongest (Berger, 2001). The lunotriquetral ligament’s strongest and thickest portion is volar. • The volar capsule is weak between the volar ligaments attached to the capitate and those attached to the lunate (Sauder et al., 2007). It is through this weak area, also known as the space of Poirier (Mayfield, 1984), that the lunate dislocates. Mayfield described the four stages of progressive ligamentous injury based on cadaveric studies, placing wrists through hyperextension, ulnar deviation, and supination (Fig. 4). • Stage I—scapholunate disruption • Stage II—lunocapitate dislocation • Stage III—lunotriquetral disruption • Stage IV—volar lunate dislocation The “trans-” prefix is applied to fractured bone(s).

Volar Lunate

Palmar scapholunate ligament

Metacarpal I

I

Scaphoid Proximal scapholunate ligament

Dorsal scapholunate ligament

Dorsal

FIGURE 3

FIGURE 4

II IV III

279

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The patient is placed supine, and the affected extremity is placed on a radiopaque hand table. Anaesthesia may be general or regional. A tourniquet is placed on the upper arm. The tourniquet is inflated after the extremity is prepared and draped.

Portals/Exposures ■

Dorsal approach • The dorsal approach is a standard longitudinal midline incision over Lister’s tubercle (Fig. 5A). • The extensor retinaculum is exposed. • The capsule is exposed through the third and fourth extensor compartments. • Capsular flaps are elevated to expose the carpus (Fig. 5B).

A

B FIGURE 5

Perilunate Injuries: Dorsal-Volar Approach

Positioning

Perilunate Injuries: Dorsal-Volar Approach

280

A

FIGURE 6 ■

B

Volar approach • The volar approach is done through an extended carpal tunnel incision (Fig. 6A and 6B). • The palmar cutaneous nerve is protected. • The transverse carpal ligament and antebrachial fascia are incised. • The median nerve and flexor tendons are retracted.

Procedure STEP 1: DORSAL APPROACH ■ The joint is thoroughly irrigated to remove any loose debris. The joint is inspected and the full extent of the injury is assessed. • If a closed reduction was not achieved, an open reduction is now done. This can be achieved with traction and a volar-directed force on the carpus in conjunction with volar stabilization of the lunate. A blunt instrument can be used to shoehorn the capitate into the lunate. ■ Fractures are then reduced and stabilized. • The scaphoid is most commonly fractured through the waist. After anatomic reduction and preliminary Kirschner wire (K-wire) stabilization, it is definitively stabilized with a single, headless compression screw. • Other fractures are stabilized with screws or K-wires. ■ The alignment of the carpus is then assessed. K-wires can be placed in the scaphoid and lunate to act as joysticks. The scaphoid is extended and the lunate is flexed to achieve an anatomic scapholunate angle. K-wires are then used to stabilize the scapholunate, lunotriquetral, and scaphocapitate articulations. ■ The scapholunate ligament is then assessed (Fig. 7A and 7B).

281

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• The dorsal component is usually pulled off of the scaphoid. Sufficient tissue is usually available for repair. • 3-0 nonabsorbable sutures are placed through the torn interosseous ligament. The sutures are then passed through the remaining cuff of ligament on the scaphoid, or through the scaphoid at the waist level, with drill holes. Suture anchors may also be used. • Sutures are tied after anatomic reduction is achieved and after the joint has been stabilized with K-wires. The lunotriquetral ligament is usually too severely torn for primary repair.

STEP 2: VOLAR APPROACH ■ An unreduced lunate may be reduced by pushing it dorsally between the capitate and radius. ■ A transverse rent is consistently found in the volar capsule. • It is typically found proximal to the capitate, at the space of Poirier, between the radioscaphocapitate and long radiolunate ligaments. • The capsular rent is repaired with interrupted 3-0 nonabsorbable sutures (Fig. 8A and 8B).

FIGURE 8

A

B

Perilunate Injuries: Dorsal-Volar Approach

FIGURE 7

Perilunate Injuries: Dorsal-Volar Approach

282

Postoperative Care and Expected Outcomes ■

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Following closure, the limb is placed in a splint with the wrist in slight extension for 1–2 weeks. A thumb spica cast is applied for approximately 10 weeks, at which time interosseous pins are removed. Therapy is progressed after immobilization is discontinued.

Evidence Berger RA. The anatomy of the ligaments of the wrist and distal radioulnar joints. Clin Orthop Relat Res. 2001;(383):32-40. Gilula LA, Destouet JM, Weeks PM, et al. Roentgenographic diagnosis of the painful wrist. Clin Orthop Relat Res. 1984;(187):52-64. Grabow RJ, Catalano L 3rd. Carpal dislocations. Hand Clin. 2006;22:485-500. Green DP, O’Brien ET. Classification and management of carpal dislocations. Clin Orthop Relat Res. 1980;(149):55-72. Herzberg G, Comtet JJ, Linscheid RL, et al. Perilunate dislocations and fracture dislocations: a multi-center study. J Hand Surg [Am]. 1993;18:768-79. Kozin SH. Perilunate injuries: diagnosis and treatment [Review]. J Am Acad Orthop Surg. 1998;6:114-20. Mayfield JK. Patterns of injury to carpal ligaments: a spectrum. Clin Orthop Relat Res. 1984;(187):36-42. Sauder DJ, Athwal GS, Faber KJ, Roth JH. Perilunate injuries. Orthop Clin North Am. 2007;38:279-88.

PROCEDURE 17

Femoral Neck Fractures Christina Goldstein and Mohit Bhandari

Femoral Neck Fractures: ORIF

286

PITFALLS • Fixed-angle devices, or arthroplasty for the elderly patient, may give better outcomes in more vertically oriented fractures, which may not be adequately stabilized by cannulated screws due to high shear forces across the fracture site.

Open Reduction and Internal Fixation Indications ■

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Controversies • Multiple treatment options for displaced fractures in elderly individuals exist. A history of groin pain and/or radiographic evidence of degenerative joint disease may favor arthroplasty over internal fixation in this group of patients.

Examination/Imaging ■

Treatment Options • Nonoperative management in the form of bed rest with early bed-to-chair mobilization may be utilized in elderly individuals in whom an unacceptably high risk of perioperative complications exists or in nonambulatory patients with minimal pain. It should be avoided whenever possible due to multiple, well-recognized complications. • Internal fixation may take the form of cannulated screws or fixed-angle devices, most commonly a sliding hip screw. Fixed-angle devices may be preferred in fractures with more vertical orientation and basicervical fractures. • Hemiarthroplasty or total hip arthroplasty tends to be standard treatment for patients 75 years of age or greater and may be considered in individuals with premorbid degenerative joint disease or in low-demand patients 65–75 years old with displaced fractures in whom a high risk of osteonecrosis exists.

All undisplaced intracapsular fractures of the femoral neck Displaced fractures of the femoral neck in individuals younger than 65 years of age Displaced fractures in individuals 65–75 years of age with good bone density and high functional demands

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Clinical diagnosis of a hip fracture is usually obvious in elderly individuals with a history of low-energy trauma. • Patients typically complain of groin pain and may hold the affected extremity in a position of flexion and external rotation. Shortening of the injured leg is usually present. • ”Log rolling” of the affected leg (internal and external rotation in an extended position) produces significant pain and should be done with extreme care. Palpation of the greater trochanter and pubic rami may elicit tenderness and can provide clues as to the nature of injury (intertrochanteric vs. femoral neck fracture) and associated injuries (pubic rami fractures). A thorough neurovascular examination of the affected extremity is mandatory. Elderly individuals with a femoral neck fracture due to a low-energy fall should have a thorough head-totoe examination. In addition, appropriate laboratory and radiographic investigations should be ordered to rule out any underlying causes of the trauma (e.g., transient ischemic attack/cerebrovascular accident, congestive heart failure, myocardial infarction) as well as any associated injuries, such as subdural hematoma and ipsilateral upper extremity injury. Young individuals with hip fractures due to highenergy trauma should be assessed and resuscitated according to Advanced Trauma Life Support guidelines. Plain radiographs • Standard imaging includes anteroposterior (AP) views of the hip (in 15° of internal rotation if

287

Femoral Neck Fractures: ORIF

A

B

FIGURE 1

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possible) (Fig. 1A) and pelvis with a shoot-through lateral view of the affected hip (Fig. 1B). • The images should be evaluated for impaction, displacement, and posterior comminution (best appreciated on the lateral) as well as for signs of degenerative joint disease (i.e., joint space narrowing, osteophytes, subchondral cysts, or sclerosis) and associated pelvic ring injuries. Comparison with the contralateral hip may allow detection of subtle impaction or displacement. Technetium bone scan • A bone scan is used to diagnose occult femoral neck fractures in individuals with negative plain radiographs in whom suspicion of a femoral neck fracture remains high. • Bone scans can effectively diagnose femoral neck fracture in the setting of normal radiographs but may need to be delayed up to 72 hours to improve sensitivity in osteopenic individuals.

Femoral Neck Fractures: ORIF

288

A

B FIGURE 2

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Computed tomography (CT) • CT may be used in the diagnosis of femoral neck fractures and is often already available in individuals involved in high-energy trauma who have undergone CT scanning of the pelvis (Fig. 2A and 2B). • The ability of CT to detect occult femoral neck fracture is dependent on slice thickness and image orientation, and it has been shown to be less accurate in diagnosis than magnetic resonance imaging (MRI). MRI • MRI is as accurate as radionuclide bone scanning in the diagnosis of occult femoral neck fracture, with increased sensitivity when performed in the first 24 hours following injury (Rizzo et al., 1993). • It is useful in assessing for other causes of hip pain, including osteonecrosis, stress fracture, and neoplasia, in individuals with an atypical presentation. • MRI avoids the radioactive exposure associated with technetium bone scans and CT.

289

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Improved outcomes in the treatment of femoral neck fractures can be attained with a thorough understanding of bony anatomy and vascular supply of the proximal femur. Perioperative decision making based on this information can ensure fracture treatment using the most appropriate method. This can help lead to avoidance of the complications most commonly seen with this injury. Osseous anatomy • The neck-shaft angle of the proximal femur in adults is 130 ± 7°. • Average anteversion of the femoral neck with respect to the shaft is 10°. • When viewed from the lateral side, the femoral neck lies anterior to the midaxis of the proximal femur due to a large posterior overhang of the greater trochanter. This must be kept in mind when inserting fixation devices to avoid posterior penetration of the femoral neck. • The calcar femorale is a dense, vertical plate of bone arising from the cortex under the lesser trochanter in the posteromedial femur and projecting laterally to the greater trochanter (Fig. 3). It is thicker medially than laterally and is the site of origin of strong internal trabeculations that support the weight-bearing dome of the femoral head. The calcar femorale acts to reinforce the posteroinferior femoral neck, and unrecognized comminution of this region may lead to failure of fixation. • The weakest bone in the proximal femur lies in the anterosuperior region of the femoral neck and head. Anterior

Medial

Calcar femorale

FIGURE 3

Femoral Neck Fractures: ORIF

Surgical Anatomy

290

Femoral Neck Fractures: ORIF

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Subsynovial intraarticular (intracapsular) arterial ring Ascending cervical arteries

Vascular anatomy • The arterial supply of the femoral neck and head consists of: ◆ An extracapsular arterial ring at the base of the femoral neck formed by braches of the medial and lateral femoral circumflex arteries. ◆ Branches of the extracapsular arterial ring ascending on the femoral neck—the retinacular vessels—of which the lateral group are most important. ◆ The artery of the ligamentum teres (Fig. 4). • Intracapsular anastomosis of the retinacular vessels occurs to form the subsynovial intracapsular arterial ring, which sends branches—the epiphyseal arteries—into the femoral head. The lateral epiphyseal artery, which is the terminal branch of the medial femoral circumflex artery, has been shown to supply the majority of the femoral head. • The close proximity of the retinactular arteries to the femoral neck puts them at risk during femoral neck fracture as well as during open reduction of these injuries.

Anterior

Posterior

Foveal artery

Subsynovial intraarticular (intracapsular) arterial ring

Medial femoral circumflex artery

Ascending cervical arteries

Lateral femoral circumflex artery

Medial femoral circumflex artery

Femoral artery

A FIGURE 4

B

Lateral ascending cervical arteries

291

• An adequate reduction of a femoral neck fracture includes support of the femoral head by the calcar femorale, no varus or inferior displacement of the head, and less than 20° of angulation.

PITFALLS • One failed attempt at closed reduction in flexion warrants an open reduction. Multiple repeated attempts can compromise the remaining blood supply to the femoral head and may increase the risk of nonunion and osteonecrosis.

Positioning ■

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Equipment • A well-leg holder is required to position the unaffected extremity out of the fluoroscopy field. Alternatively, the uninjured extremity may be placed in wide abduction attached to a boot on the second leg extension of the fracture table. • One or two fluoroscopic units may be used during femoral neck fracture fixation. We generally use a single unit and alternate between AP and lateral images as required.

Internal fixation of femoral neck fractures is performed in the supine position on a fracture table regardless of the fixation method chosen: multiple parallel screws or a sliding hip screw. After induction of regional or general anesthesia and insertion of a Foley catheter, the patient is transferred to the fracture table. After placement of a well-padded countertraction post, the unaffected leg is placed in a well-leg holder at 90° of flexion and mild abduction to facilitate positioning for fluoroscopy. Bony prominences, especially the fibular head with the closely associated peroneal nerve, should be well padded (Fig. 5). The fluoroscopy unit is now positioned as necessary to ensure that proper AP and lateral images of the affected hip may be obtained. If the fracture is displaced, closed reduction is now performed. • Many femoral neck fractures can be reduced using the method of Whitman. ◆ The affected leg is secured in a well-padded boot in neutral position with gentle traction applied by the fracture table. The leg is gently abducted and internally rotated while viewing the reduction under image intensification. The medial spike of the femoral head should be supported by the calcar femorale.

Controversies • Closed reduction may take place on the stretcher or fracture table. We perform closed reduction on the fracture table to avoid re-displacement during patient transfer.

FIGURE 5

Femoral Neck Fractures: ORIF

PEARLS

292

Reduction of the fracture is confirmed by restoration of the normal S-shaped curves of the cortex formed by the concave femoral neck and convex femoral head (Fig. 6). A varus reduction should not be accepted due to increased rates of failure of fixation (Chua et al., 1998). • If closed reduction in extension is not successful, a single attempt in flexion should be carried out. ◆ The affected hip is flexed to 90° and, with slight internal rotation, traction is applied in line with the femur. Next, the internal rotation is maintained as the leg is circumducted into abduction and brought into extension. ◆ The affected leg is secured to the traction assembly and the reduction of the femoral neck fracture assessed. If the fracture remains displaced, open reduction under direct visualization is necessary. The affected hip is then prepped using antiseptic solution and the surgical field squared off with towels. A vertical, transparent sterile drape with an adhesive region for application over the incision site is then applied. The fluoroscopy unit is thus excluded from the sterile field (Fig. 7).

Femoral Neck Fractures: ORIF

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A

Undisplaced

B

Displaced

FIGURE 6

FIGURE 7

293

• A percutaneous approach to the proximal femur may be used though a small muscle-splitting approach that usually results in the same amount of soft tissue trauma is also possible.

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PEARLS • Open reduction may be facilitated by flexion of the hip to 20–30°. This relaxes the anterior structures of the hip and will aid in fracture visualization and fragment manipulation.

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Using a sterile marking pen, the proximal tip and anterior and posterior borders of the greater trochanter are identified. A 6-cm straight lateral incision is made starting at the widest portion of the greater trochanter and extending distally. Cautery is used to dissect through the subcutaneous tissue until the fascia lata and fascia overlying the vastus lateralis are reached. Two Gelpie retractors can be used to retract the skin and subcutaneous tissue. Sharp dissection is used to split the fascia lata and fascia of the vastus lateralis in line with the skin incision. Blunt dissection is then used to divide the vastus lateralis and visualize the lateral femoral cortex (Fig. 8).

Controversies • Open reduction may also be performed using a posterior approach. Drawbacks of this approach include the inability to perform it in the supine position and an increased rate of postoperative infection.

Vastus lateralis Lateral femoral cortex exposed

FIGURE 8

Femoral Neck Fractures: ORIF

Controversies

PROCEDURE: CANNULATED SCREW FIXATION Portals/Exposures

294

Femoral Neck Fractures: ORIF

Procedure STEP 1 ■ If closed reduction of the femoral neck fracture has failed, open reduction may now be performed through the lateral incision. The Watson-Jones interval is utilized after extending the skin incision proximally. ■ The interval between the tensor fascia lata and the gluteus medius is identified and divided through bluntly onto the anterior hip capsule. The origin of the vastus lateralis must be elevated off the intertrochanteric ridge. ■ The anterior capsule is then split in line with the femoral neck and elevated off the intertrochanteric ridge 1 cm superiorly and inferiorly. ■ A narrow pointed Hohmann retractor is inserted over the anterior rim of the acetabulum outside the joint capsule to facilitate exposure of the fracture site (Fig. 9A). ■ The fracture is then disimpacted by lateral traction using a bone hook (Fig. 9B) as the hip is externally rotated by an assistant outside the sterile field. Lateral traction is then released as the leg is internally rotated. • Alternatively, the fracture may be disimpacted by insertion of a small osteotome or Cobb elevator into the fracture site to manipulate the femoral head. ■ Reduction is confirmed using fluoroscopy and manual palpation of the anterior femoral neck. The fracture is provisionally fixed using a 2-mm Kirschner wire.

Hohmann retractor

Bone hook

Hip externally rotated

FIGURE 9

A

B

295

• All guidewires and screws must be placed at or above the lesser trochanter. This will avoid creation of a stress riser and subsequent subtrochanteric fracture.

Instrumentation/ Implantation • A 6.5-mm self-tapping cannulated screw set with 3.2-mm threaded guidewires is our equipment of choice for multiple parallel screw fixation of femoral neck fractures.

STEP 2 ■ Once reduction is obtained, definitive fixation using multiple parallel screws may be performed. ■ A threaded guidewire is driven into the femoral head along the anterior aspect of the femoral neck to determine femoral anteversion and to act as a positioning wire. ■ Starting at or above the level of the lesser trochanter in the midline of the femur, a 3.2-mm threaded guidewire is inserted where the most distal screw should be parallel to the positioning wire (Fig. 10A). If the cortical bone is dense, it may be predrilled with a 2.0-mm drill bit. • The wire is advanced into the subchondral bone of the femoral head (Fig. 10B). • The position of the wire is confirmed with fluoroscopy. It should be centered in the neck on the lateral image and rest along the medial cortex of the femoral neck (Fig. 11).

A

B

FIGURE 10

Screw 1 Screw 2 Screw 2 Screw 1

AP position Lateral position Screw 1 Screw 2

FIGURE 11

Inferior Midneck

Midline Posterior

Femoral Neck Fractures: ORIF

PITFALLS

Femoral Neck Fractures: ORIF

296

Controversies • In significantly displaced fractures with posterior comminution, a fourth screw in the superior midline position, forming a diamond pattern, may be added (Fig. 13B). Conflicting evidence exists as to whether this fourth screw improves the stability of fracture fixation (Kauffman et al., 1999; Swiontkowski et al., 1987).

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• If a change in position is necessary, the same cortical hole should be used to avoid creating a stress riser in the lateral femoral cortex. Using a fixed guide in a triangular pattern, a second guidewire is placed. On the AP image this wire should be in the middle of the femoral neck, and it should rest along the posterior cortex of the femoral neck on the lateral projection. A third wire is then placed parallel to the second on the AP projection and anterior to it on the lateral image, creating an inverted triangle pattern (Figs. 12 and 13A).

FIGURE 12

A FIGURE 13

B

297

• The effect of intracapsular hematoma on femoral head blood supply and rates of osteonecrosis is controversial, and hip aspiration has not been shown to affect clinical outcome (Maruenda et al., 1997). We do not routinely perform hip aspiration.

PEARLS • To avoid failure of fixation, screws must not be too short, all screw threads must pass the fracture site to allow compression, and screws must be parallel to allow fracture settling.

PITFALLS • If penetration of the hip joint occurs, a new guidewire and shorter screw should be placed in a new track. Fracture settling may allow repeat joint penetration as opposed to backing out of the screw if the old screw track is used.

FIGURE 14

STEP 3 ■ Using the 4.5-mm cannulated drill bit, drilling is done over the guidewires under fluoroscopic guidance to within 1 cm of the tip of the wires to prevent joint penetration. ■ Using the measuring device included in the cannulated screw set, the screw length is measured off the guidewires and 5 mm is subtracted to allow for fracture compression (Fig. 14). ■ A washer is placed on each screw (Zlowodzki et al., 2005), and the screws are inserted to within 1 cm of the femoral cortex using a power driver. Final tightening of the screws should be performed using the hand driver, tightening the most superior screw first to avoid loss of reduction (Fig. 15). The guidewires and the positioning wire are then removed. ■ Fluoroscopy is used to ensure that the screws are not within the hip joint. ■ The wound is irrigated and hemostasis is achieved using electrocautery. If open reduction has been performed, the joint capsule is not closed. The fascia and subcutaneous tissues are closed in layers using interrupted 1-0 and 2-0 Vicryl sutures, respectively. The skin is closed with staples and a sterile dressing is applied. We do not routinely use a drain.

FIGURE 15

Femoral Neck Fractures: ORIF

Controversies

Femoral Neck Fractures: ORIF

298

PEARLS • If perforating vessels are avulsed, they will retract into the muscle and bleed, making hemostatis difficult. Slow dissection with identification and coagulation of these vessels will reduce intraoperative blood loss and make the remainder of the procedure easier.

PROCEDURE: SLIDING HIP SCREW FIXATION Portals/Exposures ■

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Controversies

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• An alternative to splitting the vastus lateralis is to elevate it off the lateral intermuscular septum. Identification and coagulation of the perforating vessels is still required.

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Patient positioning and closed reduction are performed as described for multiple parallel screw fixation of femoral neck fractures. Identification of bony landmarks of the proximal femur is performed as previously described. A 5-cm straight lateral incision beginning at the flare of the greater trochanter and extending down the shaft of the femur is made. The subcutaneous tissue is again divided using electrocautery. Using sharp dissection, the fascia lata and fascia overlying the vastus lateralis are incised. A Bennett or Hohmann retractor is inserted through the vastus lateralis and over the anterior aspect of the femur. A second retractor is inserted over the posterior aspect of the femur and, using the two, the vastus lateralis is bluntly divided (Fig. 16). The retractors can then be used to walk down the femoral shaft, splitting the muscle as far as is necessary, exposing the lateral aspect of the proximal femur. During division of the vastus lateralis, perforating branches of the profunda femoris artery will be encountered. These should be coagulated prior to avulsion if possible.

FIGURE 16

299

• Confirmation of central positioning of the guidewire will allow safe placement of the lag screw to within 1 cm of the joint with low risk of joint penetration.

PITFALLS • Failure to insert a derotational screw may risk loss of reduction during reaming, tapping, and insertion of the lag screw.

Instrumentation/ Implantation

Procedure STEP 1 ■ After exposure of the proximal femur is obtained, open reduction of the fracture may be carried out in the same manner as for cannulated screw fixation. ■ The appropriate fixed-angle guide (most commonly for a 135° angle plate) is placed flush along the lateral cortex of the femur. The starting point of the threaded guidewire should be at the midpoint of the AP diameter of the femur and roughly in line with the tip of the lesser trochanter. ■ Using a power driver, a 3.2-mm threaded guidewire is inserted, aiming for the center of the femoral head on both the AP and lateral projections (Fig. 17A). The wire is advanced to the level of the subchondral bone (Fig. 17B).

• Dynamic hip screws are available in 125–155° angles, with 135° being the most commonly used implant. • A 6.5-mm cannulated screw set is required for placement of a derotational screw.

A

B FIGURE 17

Femoral Neck Fractures: ORIF

PEARLS

Femoral Neck Fractures: ORIF

300

FIGURE 18 ■

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PEARLS • After insertion of the lag screw, the sum of the tip-apex distances on the AP and lateral images should measure 25 mm or less (Fig. 20) to prevent failure of fixation through lag screw cutout (Baumgaertner et al., 1995).

Controversies • Tapping is not required in osteoporotic bone but is necessary in younger patients to avoid rotation of the femoral head during insertion of the lag screw. We generally tap prior to lag screw insertion in all patients.

After confirmation that the tip of the wire is in the center of the femoral head on both AP and lateral images, the measuring device is used to determine the length of the lag screw. A 2.4-mm threaded guide pin is inserted superior and parallel to the initial guide pin (Fig. 18). This will act to prevent rotation of the femoral head during lag screw insertion and compression.

STEP 2 ■ The 3.2-mm guidewire is advanced a further 5 mm into the subchondral bone of the femoral head. ■ The reamer is set to the depth measured for the lag screw in Step 1 and attached to the power driver. Reaming is done under image intensification, ensuring that the wire is not being advanced into the joint or pelvis, until the stop reaches the lateral cortex of the femur (Fig. 19). • If the guidewire is withdrawn during reaming, the guide pin placement instrument may be inserted backward into the femur and the guide pin reinserted. ■ Attach the lag screw tap to the T-handle and tap to the desired depth of the lag screw. ■ A lag screw of the measured length is then inserted over the guidewire using the centering sleeve. Insertion of the lag screw is finished with the handle of the T-handle correctly positioned in relation to the femoral shaft. This will allow keying in of the side plate over the lag screw. ■ After confirmation of the depth of the screw in both planes, the centering sleeve and guidewire are removed.

301

Tip apex distance = A + B

B

FIGURE 19 FIGURE 20

Controversies • A two- to five-hole side plate may be used in fixation of femoral neck fractures. No difference between a two- or four-hole side plate has been found with regard to strength of fixation in biomechanical testing (McLoughlin et al., 2000).

FIGURE 21

STEP 3 ■ The appropriately angled two- to five-holed side plate can now be opened and inserted over the lag screw (Fig. 21). ■ With the side plate aligned with the shaft of the femur, the side plate is gently impacted against the lateral cortex and secured with the plate clamp. ■ Using the 3.2-mm drill bit, bicortical holes are drilled for the side plate in neutral position (Fig. 22). The depth is measured off the opposite cortex using the depth gauge. ■ After tapping the holes with the 4.5-mm tap, fully threaded cortical screws of the measured length are used to secure the side plate to the bone. Final tightening is performed using the hand driver.

FIGURE 22

Femoral Neck Fractures: ORIF

A

302

Femoral Neck Fractures: ORIF

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■

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All traction is released and the compression screw inserted as needed to obtain up to 5 mm of compression across the fracture site. If desired for additional fixation, the depth of the 2.4-mm guide pin is measured and a 6.5-mm fullythreaded cannulated screw is inserted. The guidewire is then removed. The wound is irrigated and closed in layers in the same fashion as described for multiple parallel screw fixation.

Postoperative Care and Expected Outcomes ■

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■

■

■

PEARLS • The best way to prevent osteonecrosis in patients treated with internal fixation is through anatomic reduction and stable internal fixation.

Postoperative pain control typically takes the form of continuous epidural or patient-controlled analgesia and is progressed to oral analgesia as tolerated. Intravenous antibiotics are continued for 24 hours postoperatively. Weight-bearing status varies and is dependent upon bone quality, fracture reduction, and fixation method. Most patients are at least partially weight bearing immediately after surgery, with the goal of internal fixation being weight bearing as tolerated. Physiotherapy and occupational therapy teams begin rehabilitation on the first postoperative day, at which time patients may sit at the bedside or in a chair. • Active-assisted hip and knee range-of-motion exercises are started immediately. Standing and walking are progressed as tolerated. • Hip girdle and lower extremity strengthening is begun once pain is no longer an issue. Postoperative radiographs are performed at weeks 1, 3, 6, and 12 to monitor for early evidence of failure of fixation or delayed union.

COMPLICATIONS ■ Complications of femoral neck fracture treated by internal fixation can be divided into local and systemic complications. ■ Local complications include infection, failure of fixation, nonunion, and osteonecrosis. • Superficial wound infections occur in approximately 1% of hip fractures and can generally be treated successfully with intravenous antibiotics effective against gram-positive organisms. Septic arthritis and osteomyelitis are rare complications.

303

Femoral Neck Fractures: ORIF

Early failure of fixation with bone erosion may suggest the diagnosis of deep infection as union will not occur in the presence of active infection. Confirmation of infection is made by hip joint aspiration or synovial biopsy for culture. ◆ Treatment involves early irrigation and débridement with placement of local antibiotics followed by a 6-week course of systemic antibiotic therapy. Revision of fixation or conversion to arthroplasty may take place once there is a normal white blood cell count, erythrocyte sedimentation rate, and C-reactive protein and negative intraoperative frozen sections confirm eradication of infection. • Early failure of fixation is most commonly due to technical errors during fracture fixation or a failure to recognize fracture characteristics that lead to increased instability. ◆ Patients tend to complain of groin or buttock pain. Radiographs showing fracture settling, peri-implant radiolucencies, or backing out of the implants confirm the diagnosis. ◆ Treatment depends on the patient’s age, functional demands, medical condition, and bone density. In young individuals with good bone stock, revision of fixation is warranted, while arthroplasty is the treatment of choice in low-demand patients with osteopenia. • Nonunion is a rare complication of undisplaced femoral neck fractures but complicates up to 30% of displaced fractures. ◆ Diagnosis may be suspected in patients who continue to complain of pain 3–6 months after fixation and may be confirmed by CT. ◆ A complete review of treatment of femoral neck nonunion is outside the scope of this text, but generally takes the form of arthroplasty in elderly individuals and revision of fixation with vascularized bone grafting and/or intertrochanteric osteotomy for younger patients. • Rates of osteonecrosis following femoral neck fracture vary and are affected by displacement, timing and adequacy of reduction and fixation method. Avascular necrosis occurs in approximately 10% of undisplaced fractures and up to two thirds of displaced fractures. ◆ Early diagnosis is made using MRI, while bone sclerosis, subchondral collapse, and eventual ◆

Femoral Neck Fractures: ORIF

304

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degenerative joint disease can be visualized on plain radiographs. ◆ Treatment of osteonecrosis is dictated by the patient’s symptoms and location of the necrotic bone. Systemic complications include mortality and venous thromboembolism. • Mortality rates following hip fracture vary and are influenced by age, gender, medical and psychiatric condition, preinjury functional status, and presence of end-stage renal disease. For most elderly individuals, a mortality rate of 25% in the first year is a reasonable value to remember during discussions with patients and families. • Deep venous thrombosis and fatal pulmonary embolism occur at rates of 50% and 2%, respectively, in patients without prophylaxis. All patients at our institution receive chemoprophylaxis with low-molecular-weight heparin starting the first day after admission. It is stopped at the appropriate time interval to allow for fracture fixation and is restarted on the first postoperative day.

Evidence Baumgaertner MR, Curtin SL, Mindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg [Am]. 1995;77:1058-64. Grade B recommendation for positioning of the lag screw in sliding hip screw fixation of peritrochanteric fractures of the hip. Placement of screws at a tip-apex distance greater than 25 mm led to an increased rate of screw cutout and failure of fixation in this Level II investigation. Chua D, Jaglal SB, Schatzker J. Predictors of early failure of fixation in the treatment of displaced subcapital hip fractures. J Orthop Trauma. 1998;12:230-4. Grade B recommendation for the refusal to accept residual varus alignment in fractures of the femoral neck during internal fixation. This Level II study identified a 4.3-times higher rate of failure of fixation in displaced subcapital hip fractures with residual varus alignment after reduction. Kauffman JI, Simon JA, Kummer FJ, Pearlman CJ, ZuckermanJD, Koval KJ. Internal fixation of femoral neck fractures with posterior comminution: a biomechanical study. J Orthop Trauma. 1999;13:155-9. Grade D recommendation for the use of four parallel screws during fixation of femoral neck fractures with posterior comminution. This Level V biomechanical study showed greater resistance to displacement and load-to-failure in simulated fractures with posterior comminution fixed with four cancellous lag screws rather than three. Maruenda JI, Barrios C, Gomar-Sancho F. Intracapsular hip pressure after femoral neck fracture. Clin Orthop Relat Res. 1997;(340):172-80. Grade C recommendation against routine aspiration of the intracapsular hematoma in femoral neck fractures. Hip aspiration did not decrease intracapsular pressure in this Level IV prospective cohort study.

305

Grade D recommendation for the use of a two-hole side plate in dynamic hip screw fixation of intertrochanteric fractures without diaphyseal extension. No difference was shown in peak load-to-failure or strain magnitude of the plate for two-hole versus four-hole side plates in this Level V biomechanical study. Rizzo PF, Gould ES, Lyden JP, Asnis SE. Diagnosis of occult fractures about the hip: magnetic resonance imaging compared with bone-scanning. J Bone Joint Surg [Am]. 1993;75:395-401. Grade B recommendation for the use of MRI in diagnosis of femoral neck fracture in patients with negative plain radiographs. This Level III study showed MRI to be as good as bone scanning in the diagnosis of occult fractures of the femoral neck. Swiontkowski MF, Harrington RM, Keller TS, Van Patten PK. Torsion and bending analysis of internal fixation techniques for femoral neck fractures: the role of implant design and bone density. J Orthop Res. 1987;5:433-44. Grade D recommendation against the use of more than three parallel screws during internal fixation of femoral neck fractures. This Level V biomechanical study showed no improvement in accuracy of reduction or bending or torsional stiffness with four or five implants. Zlowodzki M, Weening B, Petrisor B, Bhandari M. The value of washers in cannulated screw fixation of femoral neck fractures. J Trauma. 2005;59:969-75. Grade B recommendation for the use of washers in cannulated screw fixation of femoral neck fractures. This Level II study found an odds ratio for failure of fixation of 11.2 when washers were not used during parallel screw fixation of femoral neck fractures.

Femoral Neck Fractures: ORIF

McLoughlin SW, Wheeler DL, Rider J, Bolhofner B. Biomechanical evaluation of the dynamic hip screw with two- and four-hole side plates. J Orthop Trauma. 2000;14:318-23.

PROCEDURE 18

Femoral Neck Fractures: Arthroplasty Richard A. Boyle and James P. Waddell

Femoral Neck Fractures: Arthroplasty

308

PITFALLS

Indications ■

• Unrecognized fracture displacement • Complex fracture patterns, including intertrochanteric or calcar extension ■

Controversies • When to attempt internal fixation instead of arthroplasty • Use of monopolar, bipolar, or total hip arthroplasty—differing physiologic ages, osteopenic bone, presence of acetabular degradation • Use of cemented or uncemented components • Use of larger femoral heads with total hip arthroplasty • Use of hard-on-hard bearing surfaces • Surgical approach

Treatment Options • Cemented or uncemented components with a monopolar, bipolar, or total hip articulation may be used, with varying articulation sizes and materials available. • Approaches include anterolateral, direct lateral, and posterior (described here). General wisdom dictates that the approach used should be that with which the surgeon is most comfortable or familiar.

Examination/Imaging ■

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• Pressure mat on operating table • Anterior support superior enough to allow full hip flexion for femoral canal exposure • Posterior support superior enough to allow adequate exposure

True anteroposterior (Fig. 1) and lateral plain radiographs should be obtained. Occasionally computed tomography is required to elucidate complex fracture patterns and to assess posteromedial calcar.

Surgical Anatomy ■

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Anatomic structures specific to the posterior approach to the hip are noted here. Piriformis tendon plus short external rotators are taken down, and repaired on closure (Fig. 2). Posterior capsule • A capsulotomy is performed, and the posterior capsule repaired where possible. • The capsule is often torn secondary to the fracture. The surgeon must be aware of the proximity of the sciatic nerve.

Positioning ■

■

PEARLS

Displaced intracapsular fractures of the femoral neck • Absolute: elderly, osteoporotic bone, pathologic fracture, evidence of antecedent symptomatic arthritis • Relative: younger, more active patients; fractures occurring over 6 hours prior Failed internal fixation, malunion, nonunion, and osteonecrosis

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The patient is placed in the lateral decubitus position on a padded table with supports (Fig. 3): • Anteriorly, the pubic symphysis or anterior superior iliac spine • Posteriorly, the lumbosacral junction/upper sacrum A pillow is placed between the legs, and the contralateral hip and knee are flexed. The upper body is strapped securely with an axillary roll on the dependent side, with pressure areas supported and well padded.

309

Femoral Neck Fractures: Arthroplasty

FIGURE 1

Piriformis and Short rotators taken down

Greater trochanter Anterior support

Posterior support

FIGURE 2

FIGURE 3

Femoral Neck Fractures: Arthroplasty

310

PITFALLS • Ensure true pelvic perpendicularity for acetabular alignment (with total hip arthroplasty). • Preparation and draping of the limb and buttock must be posterior and superior enough to allow wound exposure.

Portals/Exposures ■

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■

■ ■

Equipment • Pressure mat • Side supports • Bolsters or bean bag

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A lateral longitudinal incision is made, centered on the greater trochanter with the proximal portion curved or angled posteriorly (Fig. 4). The fascia lata is split distally in line with the femur, tensor, and gluteus maximus and proximally in line with the muscle fibers (Fig. 5). The inferior edge of the gluteus medius is identified and retracted superiorly to expose the piriformis tendon and superior joint capsule (Fig. 6). The leg is gently adducted and internally rotated. The piriformis is released at or near its attachment deep to the posterior margin of the greater trochanter in the surgical view, and can be tagged for later identification and repair (Fig. 7). The remaining short external rotators are likewise released and separated from the posterior joint capsule (Fig. 8). An arcuate capsulotomy is performed, with maintenance of capsular tissue when possible. Further internal rotation exposes the femoral neck.

FIGURE 4

FIGURE 5

311

Femoral Neck Fractures: Arthroplasty

FIGURE 6

FIGURE 7

Femoral neck fracture

Short rotators released

FIGURE 8

Capsule reflected

Femoral Neck Fractures: Arthroplasty

312

PEARLS • A difficult internal rotation may require further release of the quadratus femoris and hip capsule toward the inferior neck. • Tagging the incised capsular margins aids exposure, acts as a reduction guide, and helps prevent infolding of soft tissue on reduction; it also allows identification for repair.

PITFALLS • Regular anatomy can be distorted. Careful identification of key structures is vital, including the sciatic nerve, which can be displaced into proximity with the femoral neck.

Procedure STEP 1: FEMORAL NECK CUT AND EXCISION OF FEMORAL HEAD ■ The femoral neck is cut at the desired height, which is determined by preoperative templating specific to the chosen implant. Cutting the neck first allows for easier exposure and removal of femoral head (Fig. 9). ■ The femoral head removed using a corkscrew device, tenaculum forceps, or, occasionally, a dislocating skid (Fig. 10). ■ The femoral head is measured for implant sizing. • The femoral head is measured against the Harris femoral head gauge (Fig. 11). • A trial head of the same size is placed on an introducer (Fig. 12). • The trial head is introduced into the acetabulum to ensure that the fit is appropriate (Fig. 13).

Instrumentation • Standard hip arthroplasty instrumentation is used.

Retractors

Saw

Controversies

Femoral neck cut

• Maintenance of the piriformis where possible—it can make exposure more difficult.

FIGURE 9

FIGURE 10

313

FIGURE 12

FIGURE 13

Femoral Neck Fractures: Arthroplasty

FIGURE 11

Femoral Neck Fractures: Arthroplasty

314

PEARLS • Identification of the lesser trochanter/base of neck is mandatory for assessing location of the neck cut. • Inspect the acetabulum and capsule for bony fragments—they may have soft tissue attached. • Lavage the acetabulum for small debris, remove excess ligamentum teres if present (but maintain haversian fat pad). • Place a swab/gauze in the acetabulum to keep it free from debris and/or cement (remove for implantation).

PITFALLS • Cutting into or fracturing the greater trochanter when cutting the femoral neck. • Damage to the acetabulum with corkscrew or skid when removing femoral head—avoid damage to remaining labrum if mono- or bipolar implantation is chosen. • Damage to femoral neck/calcar by levering with corkscrew shaft.

STEP 2: BONE PREPARATION AND TRIALING ■ Bone preparation is specific to the implants used. ■ The femoral neck is cut to remove any residual femoral neck fracture fragments. • The line of the cut should match the inclination between the neck and stem of the femoral component. • A box osteotome is used to resect any residual posterior femoral neck and remove cancellous bone from the medullary canal of the proximal femur (Fig. 14). ■ A broach is used to clear the femoral canal of remaining cancellous bone and ensure an appropriate fit between the implanted prosthesis and the bone (Fig. 15). ■ The broach handle is then removed from the broach and the trial neck placed on the top of the broach (Fig. 16). ■ The trial head is then placed on the trunnion (Fig. 17A) and the bipolar trial component is placed on the trial head (Fig. 17B). Some systems may have a trial bipolar head that is placed directly on the trunnion. ■ The hip is then reduced and checked to ensure appropriate soft tissue tension, stability, and appropriate fit of the bipolar head within the acetabulum (Fig. 18). The hip should be able to be fully flexed in neutral; should be stable in a position of sleep; should be stable in adduction, flexion, and internal rotation; and should come to full extension.

FIGURE 14

FIGURE 15

315

Femoral Neck Fractures: Arthroplasty

Controversies • System without a trialing option

FIGURE 16

A

B

FIGURE 17

PEARLS • Stability is the primary aim—trial through a full range of motion. • Length is guided by the distance from the tip of the greater trochanter to the center of the femoral head axis. • Anteversion of the implant is guided by the patient’s natural neck version.

PITFALLS • Lack of familiarity with implant system being used FIGURE 18

Femoral Neck Fractures: Arthroplasty

316

PEARLS • Some surgeons may prefer to trial again after stem implantation for final head-neck length assessment. • Reduction is most easily achieved using traction in the line of the femoral neck, using the index and long fingers hooked around either side of the femoral neck to essentially “lift” the head into the acetabulum.

STEP 3: IMPLANTATION AND REDUCTION ■ After removal of the broach, the canal is cleaned with a brush and normal saline (Fig. 19). ■ A cement plug is then inserted into the femoral canal sufficiently distal to ensure an appropriate cement mantle between the tip of the stem and the plug (Fig. 20). • The canal is then dried, and cement is introduced in a retrograde fashion from the plug, proximally to the cut surface of the femur, utilizing a cement gun (Fig. 21). • The cement is pressurized (Fig. 22), and the stem is introduced into the cement mantle. • Any excess cement that escapes from the proximal femur is removed and the cement is allowed to set (Fig. 23).

FIGURE 19

FIGURE 20

FIGURE 21

FIGURE 22

317

FIGURE 24

Acetabulum

PITFALLS

Neck of femoral prosthesis

• Irreducible fractures ■

Soft tissue interposition.

■

Components too long—retrial with shorter neck length; remove implant and recut neck.

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FIGURE 25

Mono or bipolar component too large—confirm head and acetabular size.

• Reducible but unstable fractures ■

Debris in acetabulum.

■

Components too short or inadequately offset—retrial, implant longer components to achieve stability.

■

Components malpositioned— assess position of dislocation and antevert or retrovert according to posterior or anterior instability. If total hip arthroplasty, alter acetabular component position now if required.

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Check for fracture—calcar, greater trochanter, femoral shaft, acetabulum.

FIGURE 26 ■

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The definitive bipolar component is then impacted onto the trunnion of the stem (Fig. 24). The hip is reduced by means of grasping the neck of the femoral component between the index and middle fingers and, with gentle traction, lifting the bipolar component into the acetabulum, taking care not to damage the articular cartilage (Fig. 25). With the hip reduced, the capsule and piriformis are reapproximated (Fig. 26).

Femoral Neck Fractures: Arthroplasty

FIGURE 23

Femoral Neck Fractures: Arthroplasty

318

Controversies • Reliance on soft tissue repair for stability. The surgeon should aim for stability of the components alone prior to soft tissue repair.

STEP 4: CLOSURE ■ The remainder of the layers are closed anatomically. ■ A drain, if necessary, is placed prior to fascial closure.

Postoperative Care and Expected Outcomes ■

PEARLS • Change in length and offset can render anatomic reattachment of the piriformis impossible. In this case, repair the tendon onto the deep side of the gluteal tendons at the trochanteric margin.

■

PITFALLS • Care must be taken during transfer of the patient—maintain leg abduction, avoid internal rotation. ■

Day 1 • Hemoglobin, electrolytes, renal function • Thromboprophylaxis (continued for 35 days) • Antibiotic prophylaxis (three doses) • Radiographs • Removal of drain Mobilization and physiotherapy • Full weight bearing is permitted if cemented components were used or the patient has goodquality bone. ◆ If bone quality will not support full weight bearing with uncemented components, cemented components should be utilized. • Standard hip arthroplasty precautions must be taken. Aim: return to prefracture level of mobility

Evidence Baker RP, Squires B, Gargan MF, Bannister GC. Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intrascapular fracture of the femoral neck: A randomized controlled trial. J Bone Joint Surg [Am]. 2006;88:2583-9. Total hip arthroplasty conferred superior short-term clinical results and fewer complications when compared with hemiarthroplasty in this prospectively randomized study of mobile, independent patients who had sustained a displaced fracture of the femoral neck. (Level I evidence) Berry DJ, von Knoch M, Schleck CD, Harmsen WS. Effect of femoral head diameter and operative approach on risk of dislocation after primary total hip arthroplasty. J Bone Joint Surg [Am]. 2005;87:2456-63. Retrospective comparative study, found that in total hip arthroplasty, a larger femoral head diameter was associated with a lower long-term cumulative risk of dislocation, and also that the femoral head diameter had an effect in association with all operative approaches, but the effect was greatest in association with the posterolateral approach. (Level III evidence) Bhandari M, Devereaux PJ, Swiontkowski MF, Tornetta P 3rd, Obremskey W, Koval KJ, Nork S, Sprague S, Schemitsch EH, Guyatt GH. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg [Am]. 2003;85:1673-81. From nine trials that satisfied all criteria, the conclusions drawn were that in comparison with internal fixation, arthroplasty for the treatment of a displaced femoral neck fracture significantly reduces the risk of revision surgery, at the cost of greater infection rates, blood loss, and operative time and possibly an increase in early mortality rates. Only larger trials will resolve the critical question of the impact on early mortality. (Level I-II evidence, systematic review of Level I randomized controlled trials [studies were homogeneous])

319

Comparison study of patient cohorts after (1) primary total hip arthroplasty (THR) and (2) secondary THR after failed internal fixation (IF). Found that a secondary THR after failed IF results in inferior hip function compared to a primary THR for a displaced femoral neck fracture in the active and lucid elderly patient, and also that patients with failed IF had to undergo at least one re-operation and experienced a significant reduction in HRQoL before the salvage THR. (Level III evidence) Flören M, Lester DK. Outcomes of total hip arthroplasty and contralateral bipolar hemiarthroplasty: A case series. J Bone Joint Surg [Am]. 2003;85:523-6. Case series of nine patients who underwent total hip arthroplasty on one side and bipolar hemiarthroplasty on the other, the patients seemed to have better results with, and prefer the side of, the total hip arthroplasty. (Level IV evidence) Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg [Am]. 2004;86:1711-6. Eighty-five percent ten year survival rate of the native femoral head. Concluded that the results of treatment were influenced by fracture displacement and the quality of reduction, with osteonecrosis being the main reason for conversion to total hip arthroplasty (23%). (Level IV evidence [Case series]) Haidukewych GJ, Berry DJ. Salvage of failed treatment of hip fractures. J Am Acad Orthop Surg. 2005;13:101-9. States that unfavorable fracture patterns, poor implant placement, and poor bone quality all increase the likelihood of failure of fracture fixation, and that effective salvage is important because patients typically are severely disabled. Factors determining salvage treatment include physiologic age, activity level, remaining bone quality, viability of the femoral head, and status of the hip joint articular surface. (Review article) Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg [Am]. 2006;88:249-60. Multicenter randomized controlled trial. Reduction and fixation was compared with bipolar hemiarthroplasty with cement and total hip arthroplasty with cement. Concluded that arthroplasty is more clinically effective and cost-effective than reduction and fixation in healthy older patients with a displaced intracapsular fracture of the hip, and that long-term results of total hip replacement may be better than those of bipolar hemiarthroplasty. (Level II evidence) Lee B, Berry D, Harmsen MS, Sim FH. Total hip arthroplasty for the treatment of an acute fracture of the femoral neck. Long term results. J Bone Joint Surg [Am]. 1998;80:70-5. Retrospective review of the long-term results of 126 consecutive total hip arthroplasties performed with cement following an acute fracture of the femoral neck. The patients were followed for a minimum of 10.1 years, and a maximum of 20.4 years. Concluded that total hip arthroplasty performed in elderly patients for the treatment of an acute fracture of the femoral neck was associated with a higher rate of complications (such as dislocation—rate 10%) than usually is reported for hemiarthroplasty in such patients, however the total hip arthroplasty provided good clinical results and was associated with long-term survival of the prosthesis. (Level IV evidence) Macaulay W, Pagnotto MR, Iorio R, Mont MA, Saleh KJ. Displaced femoral neck fractures in the elderly: Hemiarthroplasty versus total hip arthroplasty. J Am Acad Orthop Surg. 2006;14:287-93. States that the decision to perform internal fixation, unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA must be based on patient mental status, living arrangement, level of independence and activity, and bone and joint quality. (Review article)

Femoral Neck Fractures: Arthroplasty

Blomfeldt R, Törnkvist H, Ponzer S, Söderqvist A, Tidermark J. Total hip replacement after failed internal fixation: A 2-year follow-up of 84 patients. Acta Orthopaedica. 2006;77:638-43.

Femoral Neck Fractures: Arthroplasty

320 Pellicci PM, Bostrom M, Poss R. Posterior approach to total hip replacement using enhanced posterior soft tissue repair. Clin Orthop Relat Res. 1998;355:224-8. Comparative study showing significantly reduced dislocation rates with repair as stated. (Level III evidence) Probe R, Ward R. Internal fixation of femoral neck fractures. J Am Acad Orthop Surg. 2006;14:565-71. States that when a closed reduction is unsuccessful, the alternatives are either to proceed with capsulotomy and open reduction and internal fixation, or to switch treatment strategy to prosthetic replacement. In these situations, a complex multivariate assessment is needed that includes patient age, activity, comorbidities, bone quality, fracture comminution, and degree of residual displacement. Also states that the desire to preserve the native femoral head must be balanced against a greater probability that secondary surgery will be required with failure or complications related to internal fixation. (Review article) Soong M, Rubash HE, Macaulay W. Dislocation after total hip arthroplasty. J Am Acad Orthop Surg. 2004;12:314-21. States that dislocation after total hip arthroplasty depends on a combination of patient and surgical factors, and notably the risk of dislocation can be minimized by proper surgical technique, including recently introduced improvements in soft-tissue repair. (Review article) Tidermark J, Ponzer S, Svensson O, Soderqvist A, Tornkvist H. Internal fixation compared with total hip replacement for displaced femoral neck fracture in the elder: A randomised controlled trial. J Bone Joint Surg [Br]. 2003;85:380-8. Randomized study of 102 patients of mean age 80 years, with an acute displaced fracture of the femoral neck treated either by internal fixation with two cannulated screws or total hip replacement. Concluded that results strongly suggest that THR provides a better outcome than IF for elderly, relatively healthy, lucid patients with a displaced fracture of the femoral neck. (Level II evidence)

PROCEDURE 19

Unstable Intertrochanteric Hip Fractures Ross K. Leighton and Alun Evans

Intertrochanteric Hip Fractures: ORIF

322

Open Reduction and Internal Fixation

PITFALLS • Open reduction and internal fixation is not indicated for an intertrochanteric fracture with reverse obliquity or a pure subtrochanteric fracture, for which an intramedullary hip screw (IMHS) (long or short) is indicated.

Indications for Trochanteric Stabilizing Plate ■

Unstable intertrochanteric femoral fracture associated with posterolateral deficiency or lateral wall instability.

Examination/Imaging

Controversies • There is a controversy over the type of the device used for an unstable intertrochanteric hip fracture. • Lateral wall collapse was not considered in the classification of intertrochanteric fractures, so the role (indication) for a trochanteric stabilizing plate (TSP) in such cases has not been well defined.

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Surgical Anatomy ■

Treatment Options • A sliding hip screw alone can be used for stable fracture patterns • An IMHS can be used for unstable fractures interchangeably with a dynamic hip screw (DHS) plus TSP.

Full femoral radiographs in anteroposterior (AP) (Fig. 1A) and lateral (Fig. 1B) views, including the joints above and below the fracture, are obtained. Computed tomography is less likely required (unless a femoral neck fracture is suspected and cannot be confirmed with conventional radiographs). Magnetic resonance imaging is not usually indicated.

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A FIGURE 1

Tensor fascia lata, glutei (medius + minimus), vastus lateralis, perforators (particularly the first perforator), and lateral intramuscular septum (Fig. 2) Ascending branch of the lateral circumflex femoral artery (Fig. 3)

B

323

Gluteus minimus

Tensor fascia lata

1st perforator Lateral intramuscular septum

Vastus lateralis

FIGURE 2

Iliopsoas muscle Femoral artery Gluteus medius muscle Gluteus minimus muscle Pectineus muscle Ascending branch of lateral circumflex femoral artery

FIGURE 3

Intertrochanteric Hip Fractures: ORIF

Gluteus medius (cut)

Intertrochanteric Hip Fractures: ORIF

324

Treatment Options • Dynamic hip screw with trochanteric stabilizing plate (DHS + TSP) • Intramedullary hip screw (IMHS) • Conventional femoral nail

Positioning ■

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Equipment • Fracture table, including traction post and boot. • Belt to stabilize the patient (if required). • Make sure the leg of the fracture table does not interfere with images obtained by image intensifier.

Anesthesia is induced prior to moving the patient to the fracture table. The patient is placed in the supine position on an orthopedic fracture table, with foot-boot traction of the affected limb (Fig. 4). • A well-padded table and perineal post (pressure point) are used. • The foot is secured nicely in the boot (so it will not slip out intraoperatively when traction is applied). • The patient’s body (trunk) is secured with a belt. The affected limb is kept aligned with traction, while the other limb can be placed in a scissor position, with the foot in a boot (see Fig. 4), or flexed on a Well knee-leg holder (Fig. 5).

PEARLS • Align the testes to prevent injury from the perineal post. • Position the image intensifier to obtain the best clear images in both the AP and lateral views. • Tilting the table 10–15° to the nonoperative side might help to overcome femoral anteversion. This allows the screw direction to be parallel to the floor. • Surgical instruments and accessories (suction, diathermy) should be placed away from the imaging field.

Controversies • Position of the contralateral leg: ■ Scissor position in a traction boot (see Fig. 4) ■ Abducted in a Well knee-leg holder (see Fig. 5)

PITFALLS • Be careful of pressure points (heel, perineum, other limb). • Keep the ipsilateral upper limb over the patient’s chest so as not to interfere with the image intensifier. • Utilize surgical assistants in positioning the patient.

325

Intertrochanteric Hip Fractures: ORIF

FIGURE 4

FIGURE 5

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Portals/Exposures

PEARLS

■

• It is advisable to mark the direction of the guide pin over the skin before making the incision.

■ ■

• Minimize excessive use of diathermy. • Sharp, careful dissection is preferred (respect the tissues). • Ligate/cauterize the bleeding points and perforators. • Watch for the ascending branch of the lateral circumflex femoral artery.

■

PITFALLS

The landmark for the incision is the greater trochanteric ridge (Fig. 6). A lateral incision (10–15 cm) is made (Fig. 7). The fascia lata is opened and the vastus lateralis muscle is reflected anteromedially. • A Hohmann retractor is placed in the inferior border of the vastus lateralis at the attachment to the lateral intermuscular septum so the the muscle can be elevated instead of dividing it (less morbidity) (Fig. 8). That retractor is directed anteriorly so the muscle is elevated medially. • Another retractor can be inserted through the same entry and directed posteriorly to help expose the femur. An incision can also be made in the vastus lateralis to divide it (increased morbidity) (see Fig. 8).

• Minimize soft tissue dissection at the site of comminution, particularly the medial fragment. The idea is to reduce and span the fragments and allow healing to occur (minimizes the risk of devitalizing the bone fragments).

Instrumentation • Different sizes of blades • Self-retaining retractors, Hohmann retractors • Ligation sutures

FIGURE 6

Vastus lateralis Greater trochanter

Lateral incision (10-15cm)

FIGURE 7

Incise vastus lateralis

FIGURE 8

Fascia lata

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• It is important to ensure that the initial guidewire is measured within 5 mm from the articular surface of the femoral head to successfully anticipate the proper TAD index. It is prefereable to err posteroinferiorly with the guidewire. • Use a parallel drill guide to insert the anteversion guide pin. • The entry for the guide pin can be drilled using a 4.5-mm drill bit (for better control and centralization of the pin).

Procedure STEP 1 ■ Closed reduction is attempted first (usually successful). • Traction will improve the shortening and varus deformities. • Internal rotation will help to close the gap medially to some extent. ◆ This is not as extreme as femoral neck reduction. ◆ The surgeon must beware of excessive internal rotation. • Closed reduction must be confirmed by AP and lateral images prior to initiating the surgery. • Failure to achieve closed reduction mandates open reduction. ■ Obtain an open reduction if closed reduction is not achieved primarily (Fig. 9A and 9B). • The anteversion of the neck is determined and a free guide pin placed anterior to the neck under image control to act as a guide (Fig. 10).

A

B

FIGURE 9

FIGURE 10

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PITFALLS • Anterior or superior placement of the pins gives a high chance of cutout (i.e., high TAD index). • Malposition of the TSP or poor size choice will still allow the proximal part to displace laterally.

Instrumentation/ Implantation • 135° angle guide • Drill handle, 2-mm pins, reamer (Fig. 11) • DHS set (Fig. 12)

• A 135 → 150° guide is centered over the femoral shaft. A 2-mm pin is inserted using a drill. The guidewire is aimed toward the apex of the femoral head in both AP and lateral views. (Note: 135° is the most common.) • The tip-apex distance (TAD) index is crucial. ◆ The index is determined by combining the distance from the guide pin tip to the apex of the femoral head on AP and lateral views. ◆ Cutout is higher with a TAD index greater than 25 mm and much less with a TAD index less than 25 mm. • Once the first pin is successfully inserted, another antirotation pin should be inserted similar but cephalic to the first one to prevent rotation of the neck of the femur, especially during DHS insertion.

FIGURE 11

FIGURE 12

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• Always use the image intensifier as a guide to locate the implant within the bone (pin, reamer, or screw). • Oblique images might be useful in case of suspicion of joint penetration. • Anticipate future cutout through measurement of the TAD index as described earlier. If it is greater than 25 mm, review the position of the DHS guide pin as noted before.

PITFALLS

STEP 2 ■ The length of the pin is measured, keeping in mind the fracture gap and distance of the pin tip from the articular surface. ■ The triple reamer is adjusted to a desirable length (usually 5 mm shorter than the guide pin) and the pin hole is reamed. ■ The bone is tapped, depending on bone quality (tapping not required with osteoporosis). ■ The DHS screw is inserted to the desired position (in subchondral bone), keeping in mind that the handle of the screw insertion device should be parallel with the femoral shaft at the final screw position (Fig. 13). • The DHS side plate is then slid over the DHS screw, making sure of its position over the femoral shaft. • The plate is impacted to its final position once it engages smoothly with the screw.

• Avoid eccentric positioning of the guide pin as it is related to screw penetration of the joint. Staged insertion of the guide pin helps to reduce joint penetration. • Tapping helps minimize fracture displacement that sometimes occurs with screw insertional torque.

FIGURE 13

Intertrochanteric Hip Fractures: ORIF

PEARLS

Intertrochanteric Hip Fractures: ORIF

330 ■

PEARLS • Make sure that both the DHS plate and the TSP are central over the femur. • No further dissection is needed to position the TSP against the bone. • With certain types of TSP, a tension band can be used with or without screws (especially in severely comminuted greater trochanter fractures).

PITFALLS • Avoid overcontouring of the TSP that might over-reduce the trochanter and thus affect the abductor mechanism. • Avoid excessive hip abductor dissection. • Usually screws and wires are not required in the trochanter (the TSP is truly a patruss plate).

Controversies • Choosing the size of the TSP ■ Smaller seems to be better tolerated by the patient. ■ The plate must be large enough to prevent displacement of the femoral shaft.

■

The plate is held to the femur using plate-holding forceps as required. The first cortical screw is drilled into the second proximal hole of the DHS plate to hold the plate in place.

STEP 3 ■ Once initial fixation of the DHS plate is achieved, the TSP is slid over the DHS plate. • A proper-length TSP is selected (Fig. 14). • The TSP is slid over the DHS plate until it fits and supports the lateral trochantric wall. ■ Complete attachment of the TSP over the DHS plate must be ensured. ■ A cortical screw is drilled through the proximal first, third, and fourth holes of both plates (fitting over each other). ■ Then a 6.5- or 7.3-mm screw can be drilled and inserted through the TSP into the neck and head of the femur cephalic to the standard DHS. ■ Fixation is completed by drilling the rest of the cortical screws through both plates (Fig. 15A and 15B). STEP 4 ■ The wound is irrigated thoroughly and the need for bone grafting judged (usually not required). ■ Drains for the wound are optional. ■ The wound is covered with a light pressure dressing (Fig. 16).

FIGURE 14

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Intertrochanteric Hip Fractures: ORIF

A

B

FIGURE 15

FIGURE 16

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■

A

The fixation and fracture stability are assessed clinically and radiographically. • Postoperatively, the foot is removed from the traction boot and the rotation of the hip tested to determine if the head of the femur is appropriately aligned. • Figures 17 and 18 show postoperative results in an unstable fracture fixed with a TSP device (Fig. 17A and 17B) versus fixation without a TSP device (Fig. 18A and 18B).

B

FIGURE 17

FIGURE 18

A

B

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• Consider each patient individually.

Postoperative Care and Expected Outcomes ■

■

Controversies • Some prefer a longer period before mobilization with weight bearing, so the controversies are: ■ Timing of the motion ■ Timing of weight bearing ■ Assessing union

■

The patient is mobilized the first postoperative day, with sitting in a chair and standing. Mobilization progresses from partial (sometimes difficult in the elderly) to full weight bearing (with walker or crutches) as tolerated. Hip and knee exercises and muscle strengthening for hip abductors and flexors plus knee flexors and extensors) are instituted.

Evidence Babst R, Renner N, Biedermann M, Rosso R, Herberer M, Harder F, Regazzoni F. Clinical results using the trochanteric stabilizing plate (TSP): the modular extension of the dynamic hip screw (DHS) for internal fixation of selected unstable intertrochanteric fractures. J Orthop Trauma. 1998;12:392-9. This paper reviewed the clinical outcome of adding the TSP extension to a DHS to stabilize the unstable intertrochanteric femoral fracture. Bong MR, Patel V, Iesaka K, Egol KA, Kummer FJ, Koval KJ. Comparison of a sliding hip screw with a trochanteric lateral support plate to an intramedullary hip screw for fixation of unstable intertrochanteric hip fractures: a cadaver study. J Trauma. 2004;56:791-4. This biomechanical study on cadavers compared the DHS + TSP with an IMHS for unstable intertrochanteric fractures of the femur and concluded that the stability of the fracture provided with DHS + TSP is comparable to that of the IMHS. Harrington P, Nihal A, Singhania AK, Howell FR. Intramedullary hip screw versus sliding hip screw for unstable intertrochanteric femoral fractures in the elderly. Injury. 2002;33:23-8. This paper compared the DHS and the IMHS. Kulkarni GS, Limaye R, Kulkarni M, Kulkarni S. Intertrochanteric fractures. Indian J Orthop. 2006;40:16-24. This paper compared different modalities for repair of unstable intertrochanteric fracture. Lunsjö K, Ceder L, Thorngren KG, Skytting B, Tidermark J, Berntson PO, Allvin I, Norberg S, Hjalmars K, Larsson S, Knebel R, Hauggaard A, Stigsson L. Extramedullary fixation of 569 unstable intertrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus three other screw-plate systems. Acta Orthop Scand 2001;72:133-40.

Intertrochanteric Hip Fractures: ORIF

PEARLS

PROCEDURE 20

Intertrochanteric Hip Fractures Wade Gofton and Steven Papp

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PITFALLS • Meta-analysis comparing extramedullary devices to intramedullary devices demonstrated no significant advantages, with higher complication rates (intraoperative complications and late femoral fractures, especially with early nails) (Parker and Handoll, 2005). • Newer generation nail constructs appear to have lower late complication rates than early sliding nails (Parker and Handoll, 2005).

Controversies • While intramedullary hip screw devices may have outcomes similar to extramedullary devices in stable fracture patterns, the outcomes in more complex 31-A2 fractures remain unclear at present.

Treatment Options • Open reduction and internal fixation options include extramedullary sliding hip screws or fixed-angle devices for more unstable patterns. • Routine and minimal-incision open techniques have been described.

Intramedullary Nailing Indications ■

■

To stabilize intertrochanteric hip fractures to facilitate pain control, early mobilization, and union Intramedullary devices have been advocated over sliding hip screws for the treatment of more unstable intertrochanteric patterns (OTA 31-A3) (Kregor et al., 2005; Rokito et al., 1993).

Examination/Imaging ■

Plain radiographs • Anteroposterior (AP) and cross-table lateral hip (Fig. 1A), AP pelvis (Fig. 1B), traction views, or full-length femur views should be obtained. • The AP and lateral views are used to assess for signs that may suggest greater instability and potential difficulty in achieving a closed reduction or maintaining reduction: ◆ Increased number of fracture fragments ◆ Posteromedial comminution ◆ Significant posterior displacement of the proximal segment or “posterior sag” ◆ Loss of lateral femoral cortex integrity • The AP pelvis view shows alignment of the normal side to assist in determining an adequate reduction (see Fig. 1B). • In significantly comminuted and displaced fractures, a preoperative traction view can improve understanding of the fracture pattern, aiding in preoperative planning (Fig. 2) • If the fracture pattern warrants, or surgeon preference is for a full-length nail, full-length films should be obtained to assess anatomy and femoral bow.

337

FIGURE 1

FIGURE 2

Intertrochanteric Hip Fractures: IM Nailing

B A

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Intertrochanteric Hip Fractures: IM Nailing

Surgical Anatomy ■

■

PEARLS • In morbidly obese patients, taping the pannus toward the nonoperative side can improve imaging. • Ensuring that the nonoperative leg is clear of the C-arm will allow for switching between the AP and lateral views with minimal effort.

PITFALLS • Abduction of the operative leg to achieve reduction will limit access to the start point and potentially block nail insertion.

Equipment • Fracture table with well-padded perineal post

Gluteus medius • The gluteus medius originates from the iliac wing inferior to the crest, inserting into the lateral and superior surfaces of the greater trochanter. • The muscle belly is at risk of injury if a soft tissue protector is not used when reaming. • The tendon insertion is often partially compromised by the start point opening reamer, but ensuring that subsequent reamer tips are placed intraosseously prior to reaming and use of a soft tissue protector will minimize further injury. Superior gluteal nerve • The superior gluteal nerve arises from the lumbosacral plexus, exiting the greater sciatic notch superior to the piriformis and dividing into a superior and an inferior branch. • The superior branch follows the line of origin of the gluteus minimus, and supplies it and the gluteus medius. The inferior branch crosses obliquely between the gluteus minimus and medius, supplying both, and terminates in the tensor fascia muscle, which it also supplies. • The inferior limb is in close proximity to the path between the skin insertion point and the trochanteric start point, and at risk when the limb is in lower degrees of flexion and adduction (Ozsoy et al., 2007). Figure 3 shows the usual location of the nail entry in relation to the superior gluteal nerve when the hip is in the extended position.

Positioning ■

While there is a trend toward free femoral nailing, supine positioning on a fracture table simplifies reduction and placement of the sliding screw in isolated intertrochanteric hip fractures. • The involved leg is placed in traction and reduced (Fig. 4A). • Shifting the torso to the opposite side and adducting the leg as much as possible while maintaining the reduction will make it easier to access the start point and insert the nail. • The uninvolved leg is flexed, abducted, and externally rotated to allow C-arm access (Fig. 4B). • The ipsilateral arm is held across the body to improve access to the start point.

339

Inferior branch of superior gluteal nerve

Gluteus minimus Gluteus medius Nail

Insertion guide

FIGURE 3

■

■

A FIGURE 4

The fluoroscopy monitor is positioned at the foot of the bed to allow both the surgeon and the fluoroscopic technician to view the image. Cautery and suction are also positioned at the end of the bed so they are out of the way of the C-arm.

B

Intertrochanteric Hip Fractures: IM Nailing

Piriformis Trochanteric start point

Intertrochanteric Hip Fractures: IM Nailing

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Portals/Exposures

PEARLS

■

• The start point skin incision will need to be more proximal in obese patients. • Passing sequential reamer tips into the femur manually before power reaming will avoid unintended abductor injury and eccentric reaming of the start point.

PITFALLS • Making the starting incision proximal to the wire can lead to soft tissue impingement of the percutaneous locking guide on the soft tissue, especially in larger patients. ■

A FIGURE 5

Lateral reduction or sliding screw portal • If an anatomic closed reduction cannot be obtained, a reduction can often be effected through the lateral incision intended for the sliding screw. • The probable screw insertion site (usually 1–2 cm distal to the lesser trochanter) can be determined using implant-specific fluoroscopic guides or by laying a guidewire along the neck at approximately 130° to the shaft (Fig. 5A and 5B). • Sharply dissect through skin, subcutaneous tissue, and fascia lata. Careful blunt dissection to the lateral femur is usually sufficient to allow for placement of reduction tools. • Large retractors or bone clamps passed around the medial side of the femur should be avoided to preserve soft tissue and are rarely required. Start point portal • The start point portal may be identified percutaneously with fluoroscopy. • In the average patient, the starting wire enters the skin 4–5 cm proximal to the greater trochanter, in line with or slightly posterior to the axis of the femur.

B

341

A

B FIGURE 6

Intertrochanteric Hip Fractures: IM Nailing

• The start point is dependent on the implant, but in general it is either at or just off the tip of the trochanter in the AP plane (Fig. 6A) and either in line with the midshaft of the femur or slightly posterior in the lateral plane (Fig. 6B). • Make a 2-cm incision in line with and distal to the guidewire through the skin and fascia, then bluntly dissect to the tip of the trochanter.

Intertrochanteric Hip Fractures: IM Nailing

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Procedure

PEARLS • Characteristic displacement is posterior sag: the distal femur shortens in external rotation and is medially translated by the adductors, and the head and neck displace into varus and translate posteriorly into the posterior intertrochanteric comminution (Carr, 2007).

PITFALLS • In unstable fractures, excessive internal rotation of the limb can result in malreduction.

Instrumentation/ Implantation

STEP 1: OBTAINING REDUCTION ■ It is almost universally recommended to obtain an anatomic reduction prior to fixation. This can usually be achieved with gentle longitudinal traction with the leg externally rotated, followed by internal rotation. ■ If a closed reduction cannot be obtained after one or two attempts, then an open soft tissue–preserving technique can be used to obtain an anatomic reduction. ■ Utilizing the lateral portal (Fig. 7A), a small bone hook can be placed around the medial shaft distal to the lesser trochanter to lateralize the shaft and disimpact the fracture (Fig. 7B and 7C). A small elevator can be inserted anteriorly in the fracture line to elevate and reduce the head neck fragment. Release of the lateral retraction at this point usually results in maintenance of the reduction (Carr, 2007).

• Small bone hook • Jocher elevator • Weber bone reduction clamp

A

B FIGURE 7

C

343

• When there is a large posteromedial fragment or comminution, an intramedullary reduction tool may be required to guide the starting wire or long guidewire into the distal segment.

PITFALLS • In a poorly positioned or large patient, it is common for the starting wire to be directed medially toward the lesser trochanter. Reaming in this position compromises the final reduction and increases the risk of medial cortex perforation.

A FIGURE 8

If the reduction cannot be maintained, a Weber reduction clamp can be carefully placed with one arm slid posterior to the trochanter, and the other arm placed on the anterior cortex of the distal segment. Application of a gentle rotational force will hold the reduction after removal of the bone hook, but this force must usually be maintained until placement of the nail.

STEP 2: START POINT/CANAL PREPARATION ■ The start point is identified percutaneously in both the AP and lateral plane and the starting wire is advanced with a wire driver. ■ If the fracture exits through the planned start point, the wire can usually be passed by hand. • In simple patterns without comminution, the opening reamer may displace the reduction, or the fracture may open sufficiently to allow the reamer to pass without reaming a channel for the nail. When the nail is passed, the reduction will be lost, usually resulting in a varus malreduction. • This can be avoided by utilizing a side plate construct instead of a nail for the simple patterns that exit at the start point, or making a larger proximal incision to allow the placement of a clamp to prevent opening of the fracture during reaming (Fig. 8A and 8B).

B

Intertrochanteric Hip Fractures: IM Nailing

■

PEARLS

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Instrumentation/ Implantation • • • •

Starting guidewire Opening reamer Soft tissue protector Intramedullary reduction tool

Controversies • Length of nail required: It has been argued that the invariably associated osteopenia should be considered pathologic, requiring “whole” bone fixation. • The authors usually use a medium-length nail in this age group to avoid the risk of distal anterior cortex perforation, but use longer nails for unstable patterns (transverse intertrochanteric, reverse obliquity, or significant subtrochanteric extension).

PEARLS • After reduction, evaluating the lateral film to determine femoral anteversion relative to the perineal post can simplify subsequent guide pin insertion. Turning the image to place the post perpendicular to the floor will indicate the amount of angulation required to be centered in the head (see Fig. 1A).

PITFALLS

■

■

Fluoroscopy is used to confirm that the starting wire is centered in the canal of the distal segment, and the opening reamer is used with its soft tissue protector. If a long nail is planned, a guidewire is passed and fluoroscopy is used to ensure that it is seated centrally in the distal femur on both the AP and lateral view. Sequential reamers may be required to ensure an appropriate-sized nail can be passed.

STEP 3: NAIL INSERTION ■ When using a longer nail with an anterior bow, rotating the nail 90° (such that the anterior bow is medial) may help avoid iatrogenic medial perforation (Ricci et al., 2006) (Fig. 9). ■ The nail can usually be passed gently by hand, requiring a gentle mallet for final seating. ■ Fluoroscopy and, depending on the system, a peripheral guide can be used to determine the appropriate depth of nail insertion. • In elderly patients, there is often an increased anterior femoral bow; when using an implant with a low radius of curvature in these patients, there is a high risk of perforation of the distal anterior cortex. • Consideration should be given to sizing the nail slightly shorter than a normal femoral nail and carefully monitoring this during insertion. STEP 4: SLIDING SCREW PLACEMENT ■ The sliding screw should ideally pass through the center of the neck (Fig. 10A) and be positioned subchondrally in the AP (Fig. 10B) and lateral planes. ■ Baumgaertner et al. (1995) demonstrated reduced cutout rates if the tip-apex distance was less than 25 mm; this is presumed to hold true for intramedullary devices (Geller et al., 2009).

• If the screw is not central in the femoral head, it may appear to be subchondral on some views when in fact it is intra-articular (Kumar et al., 2007).

FIGURE 9

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Intertrochanteric Hip Fractures: IM Nailing

A

B

FIGURE 10

Controversies • Since the best bone is in the posteroinferior segment of the head, some have advocated for placement of the screw in this quadrant; however, this will compromise the tip-apex distance and may risk rotatory fixation failure (Den-Hartog et al., 1991).

■

STEP 5: LOCKING SCREW PLACEMENT ■ Distal locking screw placement may be done through the guide for shorter nails or freehand for long nails.

Postoperative Care and Expected Outcomes ■

PITFALLS • Multiple attempts at distal locking screw insertion can create a local stress riser and increase fracture risk.

■

■

Controversies • When using a long nail, the need for distal locking screws in stable patterns is unclear.

Appropriately positioning the guidewire before reaming allows for the correction and optimal final screw position.

■

The goal of fixation is to facilitate early motion and function. Taking time to ensure that an anatomic reduction and appropriate hardware and sliding screw placement are achieved should allow almost all patterns to be weight bearing as tolerated. Fractures that extend into the subtrochanteric region, especially in the setting of medial comminution at the level of the nail taper, may require greater caution in postoperative weight bearing. Unless contraindicated, patients receive postoperative deep venous thrombosis prophylaxis; however, the precise form of prophylaxis remains controversial (Handoll et al., 2002) and patient specific. Postoperative imaging is repeated at 2 and 6 weeks and 3 months.

Intertrochanteric Hip Fractures: IM Nailing

346 ■

Potential postoperative complications • Screw cutout: Cutout rates with intramedullary nailing are similar to those with plate-screw constructs (Parker and Handoll, 2005), and we advise that, similar to plate-screw constructs, the tip-apex distance be less than 25 mm (Baumgaertner et al., 1995). • Early femoral fractures: Rates were reported as high as 5% for first-generation constructs (Parker and Handoll, 2005). These fractures can often be managed with distal locking of the implant or use of a longer implant. It is believed that improved design and technique (over-reaming and gentle nail insertion) have reduced these complications. • Late femoral fractures: Studies suggest that this devastating complication is more frequent with intramedullary nailing than with plate-screw constructs (Parker and Handoll, 2005). Again, it is believed that with newer designs this complication rate may be reduced. • Distal femoral cortical perforation: Elderly patients and some ethnic groups tend to have femurs with an increased femoral bow. Understanding the implant’s design, careful patient selection, monitoring the tip of the nail during insertion, and use of newer nail designs with better matched radii of curvature may reduce this complication.

Evidence Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg [Am]. 1995;77:1058-64. (Level III evidence) Carr JB. The anterior and medial reduction of intertrochanteric fractures: a simple method to obtain a stable reduction. J Orthop Trauma. 2007;21:485-9. (Level IV evidence) Den Hartog BD, Bartal E, Cooke F. Treatment of the unstable intertrochanteric fracture: effect of the placement of the screw, its angle of insertion, and osteotomy. J Bone Joint Surg [Am]. 1991;73:726-33. Geller JA, Saifi C, Morrison TA, Macaulay W. Tip-apex distance of intramedullary devices as a predictor of cut-out failure in the treatment of peritrochanteric elderly hip fractures. Int Orthop. 2009 [Epub ahead of print]. (Level III evidence) Handoll HH, Farrar MJ, McBirnie J, Tytherleigh-Strong G, Milne AA, Gillespie WJ. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. Cochrane Database Syst Rev. 2002;(4):CD000305. Kregor PJ, Obremskey WT, Kreder HJ, Swiontkowski MF. Unstable peritrochanteric femoral fractures. J Orthop Trauma. 2005;19:63-6. Kumar AJ, Parmar VN, Kolpattil S, Humad S, Williams SC, Harper WM. Significance of hip rotation on measurement of “Tip Apex Distance” during fixation of extracapsular proximal femoral fractures. Injury. 2007;38:792-6. Ozsoy MH, Basarir K, Bayramoglu A, Erdemli B, Tuccar E, Eksioglu MF. Risk of superior gluteal nerve and gluteus medius muscle injury during femoral nail insertion. J Bone Joint Surg [Am]. 2007;89:829-34. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2005;(4):CD000093. Ricci WM, Schwappach J, Tucker M, Coupe K, Brandt A, Sanders R, et al. Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures. J Orthop Trauma. 2006;20:663-7. (Level II evidence) Rokito AS, Koval KJ, Zuckerman JD. Technical pitfalls in the use of the sliding hip screw for fixation of intertrochanteric hip fractures. Contemp Orthop. 1993;26:349-56.

PROCEDURE 21

Subtrochanteric Fractures: Plate Fixation Hans J. Kreder

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Indications

PITFALLS • Avoid bridge plating of simple metaphyseal and diaphyseal fracture patterns. Alternatives include: ■

Simple fracture patterns can be treated with absolute stability using lag screw or compression plating techniques.

■

Alternatively, simple fracture patterns can be treated with relative stability and a long working length (between proximal and distal screws) to minimize stress concentration. This can be achieved with an intramedullary nail or a long bridge plate, leaving plenty of space between screws proximal and distal to the fracture.

• Beware plating fracture patterns that are relatively simple but without medial calcar support. ■

Nailing is better able to resist the varus forces in this situation.

■

Plating requires either soft tissue stripping to facilitate absolute stability, with calcar reconstitution via open reduction and lag screw fixation, or minimally invasive fixed-angle bridge plating with a long working length. However, if the fracture pattern is relatively simple, it is difficult to avoid stress concentration with this technique (even if a long working length is used).

FRACTURE PATTERNS AND REPAIR OPTIONS ■ Multifragmentary subtrochanteric femoral fracture pattern (Fig. 1) • Relative stability via nailing or minimally invasive bridge plating ■ Simple subtrochanteric fracture pattern (Fig. 2) • Absolute stability via open reduction, lag screw fixation, plus compression or neutralization plating • Relative stability via nailing or minimally invasive plating with a bridge plate with a long working length (requires special consideration and technique) ■ Complex proximal femur fracture with subtrochanteric extension (Fig. 3A and 3B) • Absolute stability rarely possible • Dynamic compression via sliding implants • Fixed compression of the proximal portion and relative stability (or dynamic sliding compression with a Medoff-type plate) for the subtrochanteric portion (requires special consideration and technique) ■ Base-of-neck and intertrochanteric fractures that extend into the subtrochanteric region • These fractures are considered separate from pure subtrochanteric fractures because the base of the femoral neck and the intertrochanteric region cannot be spanned or bridged using the usual techniques of relative stability. • Sliding implants that allow dynamic compression across these areas must provide some limitation to sliding of the proximal fragment or excessive shaft medialization will occur because the normal trochanteric lateral buttress is usually compromised. • Locking the base-of-neck or intertrochanteric fragments in place without compression results in stress concentration and risks implant failure and nonunion. NAILING VERSUS PLATING ■ Biomechanically, a round nail resists bending in all directions, whereas the laterally positioned plate is weakest in resisting varus forces. ■ In osteoporotic bone, screw fixation (which is essential for successful plating) is suboptimal. Locking plate/screws and bone augmentation with cement or bone substitute can help with screw purchase.

349

Subtrochanteric Fractures: Plate Fixation

FIGURE 1

FIGURE 3

B

A

B A

FIGURE 2

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350

Controversies • Dynamic compression versus locked anatomic fixation for complex proximal femoral fractures in the neck or intertrochanteric region with subtrochanteric extension ■ Dynamic compression via sliding screw/plate implants results in malunion. However, nonsliding devices result in stress risers and possible nonunion with implant failure or screw penetration into the hip joint. ■ The effect of malunion on patient function is not well known. • Immediate total hip replacement for complex proximal femoral fractures ■ In certain complex proximal femoral fractures involving poor-quality bone, such as the very comminuted proximal femoral fracture in an elderly osteopenic patient shown in Figure 4, total hip replacement may be an option. ■ Anatomic locked fixation risks nonunion and implant failure. ■ Dynamic compression fixation results in malunion and shortening. ■ Total hip replacement is technically challenging but can restore proper length and alignment with early return to function.

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The nail position in the canal, versus the lateral plate position, provides a small biomechanical advantage due to a shorter distance from the body weight to the fulcrum (the nail or plate). When employing relative stability, long nails automatically provide for a long “working length” (the distance between the screws proximal and distal to a fracture) to span fractures. When using plates, it is important to similarly consider the working length between the screws closest to the fracture proximally and distally to minimize stress concentration and failure.

Examination/Imaging ■

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Physical examination • Poor soft tissues, degloving injuries, and open wounds: may require a modification of the approach and implants chosen • Thigh compartment syndrome • Injuries to the knee • Distal neurovascular status A plain anteroposterior (AP) radiograph of the pelvis enables comparison with the opposite side (especially useful for complex proximal femoral fractures of the intertrochanteric region or base of neck region). Plain full-length AP and lateral radiographs of the femur, including the hip and knee joints, should be obtained. Rarely, computed tomography can be useful to identify the precise nature of the fracture pattern in the trochanteric region. For example, involvement of the piriformis fossa requires special techniques when performing piriformis start point nailing.

PITFALLS • Note the anterior bow of the femur on a full-length lateral radiograph. ■

A marked anterior femoral bow is common in the elderly and could result in a long plate sitting off the femur over a portion of its length. Care must be taken to ensure that the plate can be secured to the bone proximally and distally.

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A nail may penetrate the anterior cortex distally and also requires careful preoperative planning

351

B

FIGURE 4

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352

Surgical Anatomy

Treatment Options

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• Absolute stability for simple fracture patterns ■ Open reduction, lag screw fixation, and compression or neutralization plating • Dynamic compression with sliding implants (for base of neck and intertrochanteric fractures with subtrochanteric extension) ■ Must be prepared to accept malunion and shortening • Relative stability, especially for multifragmentary metaphyseal/ subtrochanteric fractures ■ Nailing ■ Bridge plating with a long plate working length ■ External fixation has been reported, but there is little experience with this technique in North America.

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Bone (Fig. 5A–C) • Greater trochanter • Lesser trochanter • Linea aspera • Medial calcar • Anteversion and femoral bowing Muscles (Fig. 6) • Gluteus medius • Iliopsoas tendon • Piriformis insertion • Vastus lateralis • Effects of deforming forces (Fig. 7A and 7B) Neurovascular structures (Fig. 8) • Perforating vessels

Trochanteric fossa

Intertrochanteric crest Greater trochanter

Head Neck Calcar

Intertrochanteric crest

Lesser trochanter

Pectineal line

Gluteal tuberosity

Head Neck

Linea aspera

Greater trochanter

A Head Intertrochanteric line

Neck Trochanteric fossa

Greater trochanter

Medial epicondyle

Lesser trochanter

FIGURE 5

B

Lateral condyle

Medial condyle

C

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Subtrochanteric Fractures: Plate Fixation

Piriformis insertion

Gluteus medius

Iliopsoas

Vastus lateralis

FIGURE 6

Gluteus maximus Superior gluteal artery and nerve Pudendal artery and nerve Inferior gluteal artery Sciatic nerve Ischial tuberosity Posterior femoral cutaneous nerve Origin of manstrings Adductor magnus

A Gluteus medius Priformis Gluteus mimimus Quadratus femoris Gluteus medius Greater trochanter Gluteus maximus First perforating artery Second perforating artery

Third perforating artery Termination of profunda

Popliteal artery Lateral superior genicular artery

FIGURE 8

Medial superior genicular artery

B FIGURE 7

354

Subtrochanteric Fractures: Plate Fixation

Positioning ■

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Equipment • Radiolucent table (preferred) or traction table. • Femoral distractor available. • 2.5-mm terminally threaded Steinmann pins (available on the small fragment external fixator set) may be needed to manipulate fracture fragments.

Radiolucent table • Supine with small bump under affected side (Fig. 9) • Lateral with beanbag (Fig. 10A and 10B) Traction table • Supine with opposite leg up • Lateral with legs “scissored” Lateral versus supine position • The lateral position is often preferred as it greatly facilitates reduction by moving the distal segment when an intact iliopsoas insertion results in flexion of the proximal fragment (Fig. 11). • The lateral position is also particularly useful when the patient is obese. • Comparing length and rotation to the other limb is difficult in the lateral position. However, the amount of rotation (in degrees) of the injured limb can readily be determined in the lateral position (see Procedure Step 1). • When using the lateral position, the length of the intact leg should be determined before positioning. Options to measure the intact side include: ◆ Supine fluouroscopic measurement from greater trochanter to distal femoral articular surface ◆ Measurements on preoperative radiographs of the intact femur (beware of true length when the films were taken without using calibration)

PEARLS

Controversies • Radiolucent table versus traction table ■ The radiolucent table is generally preferred if one or more assistants are available to help position and hold the distal shaft fragment. ■ The radiolucent table can be used in conjunction with a femoral distractor to aid in achieving and maintaining reduction.

• If a fracture table is chosen, the surgeon must be prepared to use percutaneous joystick pins to manipulate the proximal fragment or to perform an open reduction because the distal shaft being fixed to the traction apparatus cannot be moved to line up with the proximal fragment, necessitating that the surgeon match the proximal fragment to the stabilized distal shaft. • Always drape the entire leg free with split sheets or a similar drape to allow the distal shaft to be manipulated into position in line with the proximal fragment. Even when using the traction table, the use of a plastic adhesive “shower curtain” drape is discouraged as this drape makes it difficult to access the medial side of the femoral shaft for fracture manipulation intraoperatively.

355

FIGURE 9

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B

FIGURE 10

FIGURE 11

Subtrochanteric Fractures: Plate Fixation

• In the supine position, the length and femoral rotation of the operated leg is easily compared to the intact leg. The intact leg does not need to be draped free.

Subtrochanteric Fractures: Plate Fixation

356

PEARLS

Portals/Exposures ■

• Consider the femoral neck anteversion when making the incision through the fascia lata. The incision should be posterior to the midline to facilitate screw placement into the femoral head and neck.

PITFALLS • Avoid taking down the insertion of the vastus lateralis more distally than the gluteus maximus insertion to avoid injury to the first perforating artery. • Do not disrupt the gluteus insertion on the greater trochanter to avoid muscle weakness. • Avoid using fingers or instruments medially to manipulate fracture fragments as these soft tissue attachments are crucial to fracture healing.

PEARLS • Insert proximal fragment joysticks anteriorly through the open wound to minimize interference with the plate, which is normally situated somewhat posteriorly. • Use only bone pins, the sharp hook, and the large pointed reduction forceps to manipulate and secure bone fragments (to minimize soft tissue injury and stripping).

PITFALLS • Avoid bone-holding forceps and Verbrugge, Lohman, and other large clamps placed around the bone as these cause significant soft tissue injury. • Avoid the use of cerclage wires to minimize medial soft tissue disruption.

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Straight lateral approach • A skin incision is made from the greater trochanter to approximately 4 cm distal to the lesser trochanter level (Fig. 12). • An incision is made distally over the last two or three holes of the chosen plate (see Procedure Step 2 below regarding plate length). The fascia lata is divided both proximally and distally just posterior to the midline. The vastus lateralis is elevated off the linea aspera distally (Fig. 13) and the origin followed proximally to the anterior border of the femur but not beyond.

Procedure STEP 1: OBTAINING AND MAINTAINING THE REDUCTION ■ Correcting angulation • The distal fragment is manipulated to align with the proximal fragment. ◆ The malreduced case in Figure 14A shows a typical deformity that can easily be avoided. Distal shaft manipulation brings the fracture into alignment (Fig. 14B). • Proximal fragment manipulation is performed with joysticks and pointed pushers inserted percutaneously (Fig. 15A). • Percutaneous joysticks are used to manipulate the proximal fragment or both fragments percutaneously if needed (Fig. 15B). • Direct open manipulation of fracture fragments is accomplished using large pointed reduction forceps. • Pay particular attention to avoid varus deformity of the proximal femur. Compare the fractured femur with the intact femur on the preoperative AP pelvis radiograph. ■ Correcting length (note: mainly a problem in multifragmentary injuries) • Note: A preoperative measurement of the length of the intact side must be obtained unless both limbs can be compared intraoperatively (supine patient on a radiolucent table). • Length is obtained intraoperatively via manual traction (or table traction). Temporary paralysis of the patient may be necessary if this is difficult. • A femoral distractor is most useful with proximal pin placement when the lesser trochanter is intact.

357 First perforating artery Vastus lateralis

FIGURE 13

FIGURE 12

Iliopsoas pull

A

B FIGURE 14

A FIGURE 15

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Subtrochanteric Fractures: Plate Fixation

Gluteus maximus

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358

Instrumentation/ Implantation • • • •

Femoral distractor Sharp hook Large pointed reduction forceps 2.5-mm terminally threaded Steinmann pins • Metal ruler

Figure 16 shows the preparation for application of the proximal pin of the femoral distractor (Fig. 16A) and fluoroscopic verification of safe proximal pin placement position (Fig. 16B). ◆ Figure 17A shows the femoral distractor in place, and Figure 17B shows manipulation of fragments with the fixator. • Occasionally a plate can be secured proximally and then used to distract the fracture using a laminar spreader (Fig. 18A) against the distal end of the plate and a more distal screw. ◆ An articulated tensioning device and laminar spreader are used to push against the plate and distract and reduce the fracture (Fig. 18B). ◆ Care must be taken to correct rotation before securing the plate with a distal screw after obtaining correct length. • Length correction must be checked by comparing the two sides directly (supine patient on a radiolucent table) or by comparing with the preoperative measurement from the intact side. ◆

A

B FIGURE 16

359

FIGURE 18

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A

Subtrochanteric Fractures: Plate Fixation

A

B

FIGURE 17

Subtrochanteric Fractures: Plate Fixation

360

Controversies

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• Manual traction on a radiolucent table versus a traction table. Manual traction allows for easier fracture reduction by simply moving the distal fragment to match the direction of the proximal one. However, at least one skilled assistant or facility with use of the femoral distractor is required to maintain the reduction. • Lateral position versus supine position. • Medial bone grafting was traditionally recommended during plate fixation for multifragmentary fractures in the subtrochanteric region. This practice has been abandoned in favor of minimally invasive techniques that involve minimal soft tissue disruption and usually fracture healing without the need for bone grafting.

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Correcting rotation, method 1: matching the injured to the opposite intact side (Fig. 19A–D) • Prerequisites for this method are an intact lesser trochanter, supine patient positioning on a radiolucent table, and a normal relationship between the patella and femoral condyles on both sides. • An AP fluoroscopic image of the injured-side lesser trochanter is copied to the second flouroscopy screen. After this point, C-arm rotation must not be changed and the injured limb must not be moved. • The radiology technician “reverses” the image and then obtains an AP of the intact lesser trochanter. The intact femur is rotated internally or externally until the lesser trochanter of the intact side matches the corresponding image of the injured side. • An AP radiograph of the intact knee is obtained and the position of the patella overlying the femoral condyles is noted. This image is copied to the second flouroscopy screen. • The image is reversed and an AP radiograph of the injured side is obtained. ◆ If the patellar position is similar to the intact side, the rotation is comparable between the two sides. ◆ If the injured-side patella does not lie in the same position, the distal free fragment must be rotated toward the injured patella’s abnormal position (i.e., if it lies too medial, the distal free fragment must be rotated medially relative to the proximal fragment). • The entire process must then be repeated to check the new position (since by rotating the free distal fragment, the proximal position might have been changed as well). Correcting rotation, method 2: applying a predetermined amount of femoral anteversion to the injured side • This method applies to patients on either a radiolucent or fracture table positioned either supine or lateral. • A lateral radiograph at the knee is obtained such that the posterior condyles of the femur overlap precisely (Fig. 20A). After this point, the injured femur must not be moved.

361

Subtrochanteric Fractures: Plate Fixation

A

B

C

D

FIGURE 19

• The C-arm is externally rotated by 20° (or the desired amount of anteversion) and swung up to the neck shaft junction of the proximal femur (Fig. 20B). Note: When the patient is in the lateral position, it may sometimes be necessary to rotate the C-arm internally by 160° (or 180° minus the desired anteversion angle). • If the femoral neck and shaft form a straight line, then the femoral neck anteversion approximates 20° (or the chosen angle). • If the neck appears anteverted, the free distal fragment must be externally rotated relative to the proximal fragment. • If the neck appears retroverted, the free distal fragment must be internally rotated relative to the proximal fragment. C-arm position 2

C-arm position 1

A FIGURE 20

B

Subtrochanteric Fractures: Plate Fixation

362 ■

Once correct length and rotation are obtained, they must be maintained by one of the following methods: • Manual traction or table traction • Femoral distractor • Temporary plate fixation (proximal fixation into the head and neck with temporary distal fixation (single screw or Kirschner wire [K-wire])

STEP 2: PLATE APPLICATION ■ Plate application differs somewhat by system. ■ Usually a guidewire is positioned into the femoral head and neck, either through a guide in the plate (proximal femoral locking plate, which must be inserted fully prior to insertion of the guidewire—see below), through a separate guide at a 95° angle (angled blade plate [ABP] or dynamic condylar screw [DCS]), or at a variable angle (sliding hip screw [SHS]). ■ For an ABP, the seating chisel would then be used to create a channel into the head and neck along the guide pin, taking care to control rotation and varus/ valgus positioning of the chisel. For the DCS or SHS, the proximal lag screw is inserted and seated into the subchondral bone. ■ The plate is then slid beneath the muscles if a minimally invasive bridge plating technique is to be used. • Before sliding the plate into position, it is helpful to draw the plate on the skin and to make an incision over the distal two or three holes of the plate. Some surgeons pass an instrument up from the distal incision under the muscle into the proximal wound to facilitate pulling the plate down directly (using a hook through one of the plate holes) or via a suture attached to the distal plate. • A DCS should be slid backward under the muscle to allow the screw sleeve to be used as a handle (using a second plate and short screw) (Fig. 21A and 21B). First the leg is adducted to slide the plate down, and then it is abducted by the required amount to allow the barrel to be slid over the screw. • An ABP can be slid under the muscle in similar fashion (reversed with the blade facing laterally and the leg adducted). Seating the blade can be somewhat challenging and is facilitated by lateralizing the distal femoral shaft, engaging the

363

B

C FIGURE 21

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plate in the beginning of the prepared groove, and then abducting the leg and seating the blade. • The proximal femoral plate can be slid under the muscle using a proximal guide. A distal incision is made over the last two or three holes of the plate and the plate is temporarily secured (with a K-wire, a drill bit, or temporary single screw) while length and rotation are confirmed before final screw insertion (Fig. 21C).

Subtrochanteric Fractures: Plate Fixation

A

Subtrochanteric Fractures: Plate Fixation

364 Absolute Stability

Relative Stability

Relative Stability

Working length can be short Long working length

Compression

A

B

Long working length due to fracture

C

FIGURE 22

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In a simple fracture pattern treated with absolute stability, the working length of the plate can be short (Fig. 22A). However, the working length of the plate must be considered carefully when relative stability and a bridging technique are used. • For a simple fracture pattern treated with relative stability, the working length must be long to avoid stress concentration (Fig. 22B). It is best to leave three or four holes empty around the fracture site (at least two screws should engage the proximal fragment above the subtrochanteric fracture line). • For a multifragmentary fracture treated with relative stability, a long working length is achieved simply by bridging the fracture (Fig. 22C). One should avoid fixing intercalary fragments as working length will be shortened and stress concentrated without the ability to achieve absolute stability and anatomic reduction. The plate length should be about twice as long as the working length (Fig. 23) (limited only by the length of the femur). It is rare to use a plate with less than 10 holes for relative stability via bridge plating. When the preoperative plan calls for absolute stability of the subtrochanteric fracture, lag screw fixation and neutralization or compression plating is called

365

Subtrochanteric Fractures: Plate Fixation

FIGURE 23

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■

FIGURE 24

for. The aim should be to achieve six to eight cortices on either side of the fracture. Note that the concept of “working length” does not apply when absolute stability is achieved and shorter plates can successfully be used (see Fig. 22A). Compression plating of the subtrochanteric portion of the fracture requires distal exposure and use of the articulated tensioning device or a clamp placed around the end of the plate and a more distally placed screw. Once secured proximally, the plate can also be used to distract the fracture site as required by reversing the articulated tensioning device or using a laminar spreader between the end of the plate and a more distally placed screw. A base-of-neck fracture or the intertrochanteric component of a fracture that extends to the subtrochanteric region requires compression. Compression can be achieved by one of the following methods. • Lag screw fixation separate from a plate (not a fixed-angle device). • Lag screw compression through a proximal femoral locking plate without use of a fixed-angle device (i.e., a nonlocking conical screw left in a proximal femoral plate after lagging the fracture). Figure 24 shows a radiograph of a complex proximal fracture with subtrochanteric extension that has been fixed using a proximal femoral locking plate.

Subtrochanteric Fractures: Plate Fixation

366

• Temporary lag screw compression through a proximal femoral plate subsequently exchanged for a locking fixed-angle screw. Note that compression achieved with the lag screw through the proximal femoral locking plate can be “fixed” or maintained by a second screw locked into the plate above or below the compression screw. The compression screw can then also be exchanged for a locking screw to achieve a fixed-angle construct at all proximal junctions (since no further compression is possible once surrounding locking screws are inserted across the fracture line, and therefore there would be no advantage to retaining the nonlocking screw). • Lag screw fixation as part of a fixed-angle device (DCS, SHS). ◆ Figure 25 shows a DCS with a long working length (Fig. 25A) and the incisions used in fixation (Fig. 25B). ◆ Note: An SHS should only be used if a trochanteric side plate is available as there will otherwise be no limitation to collapse leading to excessive shaft medialization.

PITFALLS • Using a Verbrugge clamp for compression plating tends to lift the plate off the bone under the clamp hook. The articulated tensioning device is preferred as it fits correctly into the distal plate hole

Instrumentation/ Implantation • Select an appropriate plate ■ ABP, DCS, proximal femoral locking plate, SHS • Select an appropriate plate length ■ 10 holes or greater for bridge plating ■ Shorter if absolute stability is obtained with lag screws or compression plating

PEARLS • For the proximal femoral locking plate, ensure that all three proximal screws will be optimally positioned in the head before screw fixation. Insert guidewires into all three screw holes and check the AP and lateral positions before inserting any screws. • Ensure that the guidewires are advanced to subchondral bone for optimal fixation. ■

Some surgeons prefer making the last few turns of the guide pin by hand to get a feel for when the subchondral bone is engaged, but this can be difficult to detect in good-quality bone.

■

Note that in some systems (proximal femoral locking plate) the screws are meant to converge, and the third screw length is therefore limited by the position of the proximal screw.

• Ensure that guidewires have not penetrated the head by slowly bringing the C-arm from a lateral to an AP position and observing the distance from the subchondral bone to the pin as it appears to lessen and then increase again. The arc of C-arm rotation should be as close as possible to an axis in line with the femoral neck. Unless a minimum distance is noted where the pin is within the head (increasing distance between subchondral bone and pin with C-arm rotation in either direction from the minimum distance point), one cannot be certain that the pin has not penetrated.

367

B

C

FIGURE 25

Controversies • There is much discussion about which implants should be used under which circumstances— especially the role of “locking plates.” • The important principle is to preoperatively plan what is required for each fracture component (absolute stability, dynamic compression, relative stability). Select an implant that is suited to the requirements. Note that all plates can be used as compression or bridge plates for the subtrochanteric fracture component. They differ mainly in how the base of neck or intertrochanteric portion of the fracture can be addressed.

P E A R L S —cont’d • When using a minimally invasive technique, it can be challenging to slide the barrel of the DCS over the lag screw. Using a second screw and plate as a handle can facilitate lining up the plate correctly along the screw orientation. Threading the screw removal device through the plate and into the screw minimizes the risk of forcing the screw medial and penetrating the head in soft bone. • Since the DCS sliding mechanism is subjected to distraction forces with loading, a compression screw should be used to avoid barrel screw dissociation and loss of fixation (Fig. 26). A DCS may be used for subtrochanteric fractures as discussed in this chapter. • Distally, be sure to divide the fascia overlying the vastus lateralis as well as the fascia lata, and always use a guide when drilling to avoid capturing the fascia and wrapping it up around the drill bit. If using old-style regular cortex screws that require tapping, drill with the 3.2-mm drill through the 4.5-mm guide to facilitate tapping without guide exchange and thus minimize muscle trauma. • Using nonlocking screws in the distal plate allows one to angle the screws and thereby use a smaller incision.

STEP 3: FINAL EVALUATION OF FRACTURE ALIGNMENT ■ The radiographic evaluation of angulation, length, and rotation is repeated as described above. ■ The surgeon must ensure that no hardware has penetrated into the joint using the method described above. ■ The knee joint is evaluated for ligamentous instability.

Subtrochanteric Fractures: Plate Fixation

A

Subtrochanteric Fractures: Plate Fixation

368

FIGURE 26

PEARLS • Salvage procedures should aim to achieve compression across the subtrochanteric nonunion site if possible. If compression cannot be achieved (comminuted area of bone, nonunion, absent medial buttress), consider nailing across the nonunion site. • If a minimally invasively placed ABP or DCS requires removal, it is helpful to cut the plate just below the top fixed angle and remove the blade or screw part separately from the distal plate to avoid a large dissection.

Postoperative Care and Expected Outcomes ■ ■

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Protected “weight bearing as tolerated” is allowed. Range of motion and strengthening exercises begin immediately. Healing via callus can be expected to be visible radiographically by 12 weeks (unless absolute stability was used). Potential hardware complications include: • Screw penetration into the hip joint • Shortening of the femur with shaft medialization • Varus collapse at the subtrochanteric site with loss of fixation, plate bending or breakage Hardware is not removed routinely, but thin patients may complain of discomfort over the prominent lateral implant that may require plate removal. The possible reasons for fixation failure, if observed, must be carefully evaluated. • Infection must always be ruled out as a cause of nonunion and plate failure. • All plates, including the DCS (Fig. 27A–C) and the proximal femoral locking plate (Fig. 28) can fail due to stress concentration. ◆ Was the working length left too short, resulting in stress concentration?

369

Subtrochanteric Fractures: Plate Fixation

C B A

FIGURE 27

FIGURE 28

Subtrochanteric Fractures: Plate Fixation

370

Controversies • Should a plate failure be treated with another plating or nailing? ■ The rationale for replating is that the soft tissues have already been disrupted on the lateral aspect of the femur; therefore, a replating involves minimal new soft tissue disruption. If the nonunion site allows compression, replating using the articulated tensioning device can apply considerable compression across the fracture site. ■ The rationale for nailing is that the intramedullary preparation (avoid excessive reaming) adds bone graft to the nonunion site and is biomechanically stronger. • Should bone grafting be used when treating a subtrochanteric nonunion? Medial bone grafting involves considerable soft tissue disruption and is not recommended in most situations, although this remains somewhat controversial.

FIGURE 29

Was absolute stability attempted but not achieved, resulting in stress concentration? • The screws may pull out of the bone proximally or distally. ◆ Figure 29 shows a radiograph of an implant that was too short that failed by pulling off the bone distally. ◆ Unicortical or poor locking screw placement in osteopenic bone may result in screws pulling out. • Inappropriate use of an SHS without a trochanteric side plate will often result in fixation failure as the fracture collapses completely without a lateral buttress, resulting in excessive shaft medialization. ◆

371

Subtrochanteric Fractures: Plate Fixation

A

B

C

FIGURE 30

Figure 30 shows immediate postoperative radiographs (Fig. 30A and 30B) of an SHS without a side plate that later failed (Fig. 30C). • An intact lateral cortex is essential if a sliding hip screw is used or a cortex must be “re-created” by using a trochanteric side plate (Fig. 31) so that there is something to slide against.

FIGURE 31

Subtrochanteric Fractures: Plate Fixation

372

A

B

FIGURE 32

• Fracture collapse may result in screw penetration. Figure 32 shows screw penetration after maximal screw collapse with a SHS used without a lateral side plate for a subtrochanteric fracture.

Evidence Kregor PJ, Obremskey WT, Kreder HJ, Swiontkowski MF. Unstable pertrochanteric femoral fractures. J Orthop Trauma. 2005;19:63-6. Krettek C, Müller M, Miclau T. Evolution of minimally invasive plate osteosynthesis (MIPO) in the femur. Injury. 2001;32(Suppl.3):S-C14-23. Lundy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg. 2007;15: 663-71. Parker MJ, Handoll HHG. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database of Systematic Reviews. 2008;(3):CD000093.

PROCEDURE 22

Subtrochanteric Femur Fractures Steven Papp and Wade Gofton

Figure 1 modified from Robinson CM, Houshian S, Khan LAK. Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma. J Bone Joint Surg [Am]. 2005;87:2217-26. Figure 5 modified from Russell TA, Taylor JC. Subtrochanteric fractures of the femur. In Browner BD, Jupiter JB, Levine AM, Trafton PG (eds). Skeletal Trauma, ed 2. Philadelphia: Saunders, 1992:1836. Figure 22 from Ostrum RF, Levy MS. Penetration of the distal femoral anterior cortex during intramedullary nailing for subtrochanteric fractures. J Orthop Trauma. 2005;19:656-60. Special thanks to Don Aker for help with images.

Subtrochanteric Femur Fractures: IM Nailing

374

PITFALLS • Proximal extension into the femoral neck or head may preclude adequate proximal fixation. • Pathologic fractures not amenable or sensitive to local control (typically radiation) will eventually fail, and a tumor prosthesis should be considered in these special situations.

Controversies • Historically, proximal fracture extension into the piriformis fossa (type II) was a contraindication to this technique (see Fig. 1). Careful technique can overcome this problem, and an IM device may still be used.

Intramedullary Nailing Indications ■

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Examination/Imaging ■

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Treatment Options • Intramedullary nail (firstgeneration nail in selected cases) • Blade plate • Dynamic condylar plate • Proximal femoral locking plate

Most subtrochanteric femur fractures (types IA and IB) (Fig. 1) This device is an excellent choice for: • Comminuted, high-energy fractures (Wiss and Brien, 1992) • Low-energy, osteoporotic fractures (Robinson et al., 2005) • Fractures with diaphyseal extension (Cheng et al., 2005) • Fractures with peritrochanteric extension • Pathologic fractures

Assessment • Advanced Trauma Life Support protocol and secondary survey should be completed in patients with this fracture, commonly secondary to highenergy trauma. • Contiguous injuries to the pelvis or knee should be ruled out. Radiology • High-quality imaging should include an anteroposterior (AP) view of the pelvis and AP and lateral views of the femur, including the knee. • Typically, these fractures have significant varus and flexion deformity (Fig. 2A and 2B). • The fracture pattern, including extension into the piriformis fossa, femoral neck, or trochanteric region, can occur and should be noted in the preoperative plan. Figure 3 shows an AP radiograph of a reverse obliquity fracture with extension into the proximal segment (arrow). • Preoperative templating should be performed so that the appropriately sized intramedullary (IM) nail can be made available. Specifically, it is important to document: ◆ Femoral length ◆ Canal diameter ◆ Neck-shaft angle

375

FIGURE 1

FIGURE 2

FIGURE 3

Subtrochanteric Femur Fractures: IM Nailing

B A

IIB IIA IB IA

376

Subtrochanteric Femur Fractures: IM Nailing

Surgical Anatomy ■

■

The initial start point is found by inserting the guide pin in percutaneous fashion through the hip abductors. • Note the proximity of the superior gluteal nerve and the potential risk of injury (Fig. 4). • The nerve stays 5 cm proximal to the tip of the trochanter. Fracture deformity depends on all the muscles around the hip and the location of the fracture. • Classically, the psoas and abductor muscle vectors on the proximal fragment can lead to abduction, flexion, and external rotation of the proximal fragment (Fig. 5).

Gluteus medius

Superior gluteal nerve

Gluteus minimus

FIGURE 4

FIGURE 5

377

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• Supine on fracture table

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Using a well-leg holder instead of the scissoring technique allows easier movement of the C-arm.

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A small open reduction may be necessary to overcome varus deformity; plan for the incision necessary for the cephalic screw insertion and use this incision to perform reduction using a bone hook or clamp.

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There are several alternatives. Lateral positioning on a radiolucent table with the leg prepped free is an excellent choice. • This position makes start point insertion easier. • It also allows hip flexion, which aids in fracture reduction, bringing the distal segment closer to the flexed proximal segment (Fig. 6A and 6B). • Protects superior gluteal nerve. Alternatively, supine or lateral positioning on a fracture table can be used. • With supine positioning, a small bolster is used under the posterior superior iliac spine to slightly role the patient away and make start point insertion easier by avoiding the table (which is often in the way) (Fig. 7, arrow). Place the opposite leg in a well-leg holder.

A

B

FIGURE 6

FIGURE 7

Subtrochanteric Femur Fractures: IM Nailing

Positioning

PEARLS

Subtrochanteric Femur Fractures: IM Nailing

378

PITFALLS • Lateral ■

Make sure prepping is done wide.

■

Judging rotation of the femur when inserting distal locking screws is more challenging.

• Supine on fracture table ■

Positioning in supine on the fracture table with the leg in traction/adduction and the peroneal post at the level of the fracture can push the fracture into varus (Fig. 8).

■

Using too much traction to overcome deforming forces is tempting. This can lead to skin necrosis and pudendal or femoral nerve palsy.

Peroneal post

FIGURE 8

• The upper torso is rolled away and the lower leg placed in some adduction to allow for easier start point insertion.

Portals/Exposures Controversies

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• Lateral positioning makes start point insertion, fracture reduction, and nail insertion much easier. However, fracture table placement in the supine position is acceptable. This may be easier when no skilled surgical assistants are available.

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PEARLS • Minimize stripping at the level of the fracture site while performing a reduction.

PITFALLS • Be careful about starting too proximally, putting the superior gluteal nerve at risk (see Fig. 4A and 4B).

A small incision is made 3–4 cm proximal to the greater trochanter. • Obtaining the start point with the proximal fragment still in varus is more difficult. Note the angle of insertion of the guidewire in Figure 9A. • We find it much easier to reduce the fracture (either by closed or open means) prior to making the start point incision. This makes guidewire insertion (and each subsequent step) much easier (Fig. 9B). A second small incision is made near the level of proximal screw insertion if necessary, and this incision is used to reduce the fracture. • A compliment of reduction instruments are available for use through the lower incision (Fig. 10). These reduction clamps are used to assist in the reduction of the fracture (Fig. 11A–C). • Some surgeons prefer to make the proximal portal and prepare the proximal femur prior to reduction. Then “percutaneous” and “intramedullary “ reduction techniques are used to reduce the proximal fragment. This technique can be used by experienced surgeons, but we have found it to be difficult.

379

Subtrochanteric Femur Fractures: IM Nailing

B A

FIGURE 9

FIGURE 10

Subtrochanteric Femur Fractures: IM Nailing

380

A

B

C

FIGURE 11

◆

◆

This technique leads to acceptance of inferior fracture reduction in many cases. Note the insertion of a nail in “percutaneous fashion,” with unacceptable reduction in both varus and flexion, in Figure 12A–D. Eventual construct failure results (Fig. 13), and in this case required conversion to blade plate fixation (Fig. 14A and 14B).

381

B

C

D FIGURE 12

FIGURE 13

Subtrochanteric Femur Fractures: IM Nailing

A

Subtrochanteric Femur Fractures: IM Nailing

382

PEARLS • Spend time achieving the perfect start point to avoid malreduction at time of nail insertion.

PITFALLS • Varus malreduction is common (French and Tornetta, 1998) • Unlike many isthmus fractures, for which reamers and/or a nail will facilitate reduction, passage of the reamer without reduction can result in eccentric reaming and worsening of the deformity.

Instrumentation/ Implantation • A start point at the medial tip of the trochanter (as described here) relies on the use of a nail device with a 3–5° lateral bend at the proximal end (see Fig. 16). If nail bend is different, this may affect the start point and reduction (Ostrum et al., 2005).

Controversies • Much controversy exists over the best start point. The medial trochanter offers both the least soft tissue damage and the easiest point to maintain a reduction and avoid varus (Dora et al., 2001).

A

B

FIGURE 14

Procedure STEP 1 ■ The start point landmark is identified 3–4 cm superior to the greater trochanter using imaging. • Different possible points include the medial trochanter (blue dot), lateral trochanter (black dot), trochanteric fossa (red dot; often referred to as the piriformis fossa in many texts and manuals) and femoral neck (green dot) (Fig. 15). ■ A small incision is made and the guide pin inserted onto the medial tip of the trochanter. Figure 16 shows a reconstruction nail with a widened proximal nail portion and 5° proximal lateral bend. ■ Good positioning of the guide pin is confirmed on both AP (Fig. 17A) and lateral (Fig. 17B) images before advancing the wire. ■ Note that the lateral start point should be placed on the medial trochanter to allow passage of cephalic screws into the femoral neck and head (Fig. 18).

383

FIGURE 15

FIGURE 16

A

B

FIGURE 17

FIGURE 18

3 to 5 degree lateral bend

Subtrochanteric Femur Fractures: IM Nailing

IM nail widened proximally

Subtrochanteric Femur Fractures: IM Nailing

384

PEARLS • Preoperative templating and intraoperative “feel” and fluoroscopic images are used to decide on nail width (see Fig. 21).

STEP 2 ■ Using the proximal femur opening reamer (available on most sets), the femur is opened to the level of the lesser trochanter (Fig. 19A). ■ The guide pin is advanced into the proximal femur (Fig. 19B and 19C). ■ Some nail sets allow the proximal reamer to be left in position and used as percutaneous access for reaming (Fig. 19D). STEP 3 ■ The guidewire is passed down the femoral canal to the level of the knee (Fig. 20). ■ The reamer is passed down the femoral diaphysis (Fig. 21). The femur is reamed until diaphyseal chatter is felt over the segment of the isthmus.

A

C FIGURE 19

B

D

385

Subtrochanteric Femur Fractures: IM Nailing

PITFALLS • When passing the guidewire, check a lateral radiograph of the knee to ensure that the guidewire is central and the reamer will not perforate the anterior femoral cortex, leaving a stress riser for a supracondylar femur fracture. • Because of the proximal fracture location (leaving the isthmus intact) and the mismatch of most nails with the femoral bow, the distal tip of the reamer and ultimately the nail may ride very anterior in the supracondylar region (Egol et al., 2004). • If the anterior femoral cortex is perforated distally (Fig. 22A and 22B), supracondylar fracture of the femur is a potential intraoperative or postoperative complication (Ostrum and Levy, 2005).

FIGURE 20

Instrumentation/ Implantation • Note that the proximal portion of the nail is wider and stronger in the subtrochanteric region (see Fig. 16). • Nail failure is most likely to occur in the proximal nail (where most stress is located) or at the locking screws. • Increasing the width of the nail inserted is recommended but may not improve the biomechanical strength of the overall construct in proximal femur fractures where the forces exist over the proximal nail (which does not change in size).

FIGURE 21

A FIGURE 22

B

Subtrochanteric Femur Fractures: IM Nailing

386

STEP 4 ■ Nail length is measured and then the appropriate nail is inserted over the guidewire. • When inserting the nail, be aware that rotational adjustments made may lead to malrotation when locking the nail (Fig. 23A and 23B). • If this occurs, the nail must be backed out, rotated, and then reinserted. Figure 24A and 24B shows nail insertion performed and rotated so that the proximal femoral locking screws can be inserted into the femoral head. • The nail is seated to an appropriate height. ■ Through a second incision, guidepins are inserted into the femoral head under fluoroscopic visualization (Fig. 25A and 25B). • Central neck and head position is confirmed on AP and lateral radiographs. • Cephalic proximal locking screws are measured, drilled, and inserted into the femoral head (Fig. 25C and 25D). • These screws should be placed centrally on two views or slightly biased inferiorly and posteriorly.

A FIGURE 23

B

387

A

A

Subtrochanteric Femur Fractures: IM Nailing

FIGURE 24

B

B

C

D

FIGURE 25 Cephalic screws superior in femoral head

PEARLS • Check the nail length at the distal end before locking the nail proximally. If the cephalic screw is running inferior in the neck and superior in the head, the proximal femur may be in varus (Fig. 26).

FIGURE 26

388

Subtrochanteric Femur Fractures: IM Nailing

STEP 5 ■ Once the the nail is locked proximally, the proximal nail guide may be removed. • When nailing on the fracture table, this will allow the leg to be changed from a position of adduction to abduction to allow easier insertion of the distal locking screw. ■ Using the “perfect circle” technique, a small incision is made at the level of the distal locking hole. A hole is drilled (Fig. 27A) and a distal locking screw inserted into the nail in the distal metaphysis (Fig. 27B).

FIGURE 27

A FIGURE 28

A

B

B

C

389

Preoperative (Fig. 28A) and postoperative (Fig. 28B and 28C) radiographs are examined to confirm goals of excellent reduction and good hardware placement.

Postoperative Care and Expected Outcomes ■

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■

■

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Antibiotic prophylaxis is given (e.g., 3 doses of Ancef). Anticoagulation is given for a duration of 7–14 days. Weight bearing as tolerated is permitted for simple fracture patterns. Limited weight bearing is recommended for more comminuted fractures. The patient is regularly followed up to fracture union. Complications include infection, proximal screw cutout or failure, nail breakage, nonunion, malrotation, and shortening. Without complications, acceptable functional results can be expected.

Evidence Cheng MT, Chiu FY, Chuag TY, et al. Treatment of complex subtrochanteric fracture with the long Gamma AP locking nail. J Trauma. 2005;58:304-11. Dora C, Leunig M, Beck M, Rothenfluh D, Ganz R. Entry point soft tissue damage in antergrade femoral nailing: a cadaver study. J Orthop Trauma. 2001;15:488-93. Egol KA, Chang EY, Cvitkovic J, Kummer FJ, Koval KJ. Mismatch of current intramedullary nails with the anterior bow of the femur. J Orthop Trauma. 2004;18:410-5. French BG, Tornetta P III. Use of interlocked cephalomedullary nail for subtrochanteric fracture stabilization. Clin Orthop Relat Res. 1998;(348):95-100. Kang S, McAndrew MP, Johnson KD. The reconstruction nail for complex fractures of the proximal femur. J Orthop Trauma. 1995;9:453-63. Ostrum RF, Levy MS. Penetration of the distal femoral anterior cortex during intramedullary nailing for subtrochanteric fractures. J Orthop Trauma. 2005;19:65660. Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J Orthop Trauma. 2005;19:681-6. Ozsoy MH, Basarir K, Bayramoglu A, Erdemli B, Tuccar E, Eksioglu MF. Risk of superior gluteal nerve and gluteus medius muscle injury during femoral nail inertion. J Bone Joint Surg [Am]. 2007;89:829-34. Robinson CM, Houshian S, Khan LAK. Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma. J Bone Joint Surg [Am]. 2005;87:2217-26. Wiss DA, Brien WW. Subtrochanteric fractures of the femur. Clin Orthop Relat Res. 1992;(283):231-6.

Subtrochanteric Femur Fractures: IM Nailing

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PROCEDURE 23

Femoral Shaft Fractures Chad P. Coles

Femoral Shaft Fractures: IM Nailing

392

PITFALLS • Multiple long-bone fractures may preclude IM nailing of all fractures at a single setting due to increased risk of fat embolism. • Severe pulmonary injury may be exacerbated by IM nailing.

Intramedullary Nailing Indications ■

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• Altered femoral anatomy or small canal dimensions may prevent successful nail insertion.

Controversies • With a severe pulmonary injury or polytraumatized patient, initial external fixation followed by staged conversion to an IM nail may be indicated. • Skeletal immaturity with open physes is a contraindication to antegrade IM nailing through the piriformis fossa, due to an increased risk of avascular necrosis of the femoral head. Nailing through the trochanteric tip reduces these risks.

Treatment Options • Antegrade IM nailing • Retrograde IM nailing • Temporary external fixation followed by IM nailing • Open reduction and internal fixation with plate and screws

Reamed antegrade locked intramedullary (IM) nailing should be considered the treatment of choice for all adult femoral shaft fractures. Relative indications for retrograde IM nailing include: • Bilateral femoral shaft fractures • Ipsilateral femoral neck fracture • Ipsilateral acetabulum fracture • Ipsilateral tibial shaft fracture (floating knee) • Morbid obesity • Pregnancy

Examination/Imaging ■

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In addition to resuscitation of the trauma patient by Advance Trauma Life Support® or similar protocol, and complete history and physical examination, focused examination of the injured extremity should include: • Vascular examination for distal pulses and capillary refill • Neurologic examination, including motor and sensory function • Inspection of soft tissue envelope for evidence of open fracture, including posterior tissues • Examination of ipsilateral foot, ankle, knee, and hip to exclude associated injury Imaging should include anteroposterior (AP) and lateral plain radiographs of the femur. • These seldom include good-quality images of the knee and hip joints, which are essential to detect associated fractures. Figure 1 shows typical AP (Fig. 1A) and lateral (Fig. 1B) radiographs demonstrating femoral shaft fracture, but poorly visualizing hip and knee joints. • Coronal plane (Hoffa) fractures of the distal femur (as seen in the computed tomography scan in Figure 2) and femoral neck fractures (Fig. 3) may occur with surprising frequency with high-energy femoral shaft fractures, and are easily overlooked on plain radiographs.

393

Femoral Shaft Fractures: IM Nailing

B A

FIGURE 1

FIGURE 2

FIGURE 3

Femoral Shaft Fractures: IM Nailing

394

FIGURE 4

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■

If a computed tomography scan of the pelvis has been performed as part of the trauma assessment, look closely at the femoral neck for evidence of occult fracture (Fig. 4). Based on preoperative images, obtain a rough estimate of canal dimension on the lateral image, and an estimate of canal length, particularly in individuals of large or small stature. Ensure that you have an adequate inventory of nail sizes prior to proceeding to surgery!

Surgical Anatomy ■

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The piriformis (or trochanteric) fossa lies just medial to the tip of the greater trochanter, and slightly posterior to the femoral neck, in line with the medullary canal of the femur on both AP (Fig. 5A) and lateral (Fig. 5B) views. The lateral ascending branch of the medial femoral circumflex artery runs just medial to the piriformis fossa, and its branches are at risk (Fig. 6). The piriformis and obturator internus tendon insertions are also at risk. The femur has a natural anterior bow that may increase with advancing age.

395

Femoral Shaft Fractures: IM Nailing

A

B FIGURE 5 Piriformis tendon Joint capsule insertion

Medial femoral circumflex artery

FIGURE 6

Femoral Shaft Fractures: IM Nailing

396

PEARLS • Ensure that the hip is positioned far enough laterally to overhang the edge of the table to prevent impingement of the reamer and nail on the operating table.

Positioning ■

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PITFALLS • One or two surgical assistants are typically required to adequately apply traction and manipulate the fracture into a reduced position while the femur is reamed and nailed. • If assistance is limited, use of a fracture table may be necessary. ■

Equipment • A flat-topped radiolucent table • A rolled flannel blanket or 3-L saline bag to elevate the ipsilateral hemipelvis • Radiolucent ramp pillow or stack of flannels for under the leg • Fine-wire tensioned traction bow for traction (if desired) • Fluoroscopic imager

Femoral nailing is typically performed with the patient in the supine position on a flat-topped radiolucent table (Fig. 7). Free draping on a radiolucent table provides optimal freedom for access to, and manipulation of, the fracture for débridement (if open) and reduction. • This position is also very useful for treatment of any associated ipsilateral lower extremity injuries (femoral neck or condyle, tibial plateau, ankle, etc.). • Use of a standard radiolucent table also avoids the added time of setup, and of rigidity of positioning once in traction on a fracture table, as well as potential pudendal nerve palsy from the perineal post. A rolled flannel blanket or 3-L saline bag is placed beneath the buttock on the operative side, with the affected hip overhanging the edge of the table. Elevation of the hemipelvis on this “bump” facilitates surgical access as well as fluoroscopic imaging on the lateral view, providing a more true lateral view of the femoral neck, as well as avoiding overlap of the contralateral leg (Fig. 8).

Controversies • Use of a fracture table to apply traction, while quite limiting in the flexibility to manipulate fracture fragments, may facilitate restoration of length and alignment without requiring skilled assistants. • Lateral positioning on a fracture table may be helpful for trochanteric access in morbidly obese patients, although setup is time consuming, and lateral positioning may result in respiratory compromise.

FIGURE 7

397

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■

■

■

FIGURE 9

The leg and torso are adducted, exposing the trochanter for surgical access. The ipsilateral arm is draped over the chest to avoid interference with reaming and nailing (Fig. 9). The leg is draped freely over a radiolucent bump to allow fracture manipulation and reduction. Traction can be applied manually, or via a tensioned fine-wire traction bow across the distal femur with a 20-pound weight over the end of the surgical table (Fig. 10). A fluoroscopic imager on the contralateral side provides AP and lateral images.

FIGURE 10

Femoral Shaft Fractures: IM Nailing

FIGURE 8

398

Femoral Shaft Fractures: IM Nailing

Portals/Exposures ■

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■

A percutaneous technique is used. • No initial incision is made. • A skin start point, typically midway between the tip of the trochanter and the iliac crest and slightly posterior to the line of the femur, is selected (Fig. 11). A percutaneously placed guidewire is used to identify the ideal start point in the piriformis fossa, and position is confirmed on biplanar fluoroscopic images (Fig. 12A and 12B). Once proper position is achieved, a 2-cm skin incision is made to incorporate the guidewire.

FIGURE 11

A FIGURE 12

B

399

• An improper start point will result in eccentric nail position, potentially resulting in iatrogenic fracture of the shaft or femoral neck, and may result in malreduction.

Instrumentation • Percutaneous nail insertion requires appropriate instrumentation, with a longer nail insertion arm, particularly in more obese patients.

Controversies • Alternatively, a trochanteric entry point may be used. This is only appropriate with a nail system designed for trochanteric insertion; otherwise, varus malreduction will occur. • A trochanteric entry portal is believed, by some, to be easier and quicker to locate. The offset entry angle may also be of some benefit in obese patients. No clear advantage or disadvantage for either technique has been documented, so this is often determined by personal preference, or type of nailing system available.

PEARLS • With the anterior bow of the femur, a skin start point slightly more posterior will assist in aligning with the femoral canal on the lateral image. • Manual adduction of the leg and proximal femur will assist in proper positioning and alignment of the initial guidewire with the femoral canal on the AP image. • With experience, the piriformis fossa has a distinctive feel on palpation with the tip of the guidewire, which assists in rapid localization with limited use of fluoroscopy.

Procedure STEP 1 ■ Once the desired starting point is established and confirmed on biplanar fluoroscopy, the guidewire is inserted to the level of the lesser trochanter. ■ A larger, cannulated drill is then used to drill over the guidewire to open the proximal femur. ■ The drill and wire are removed, and a ball-tipped reaming wire is then inserted into the femoral canal. Intramedullary position is confirmed on biplanar fluoroscopy, and then the wire is advanced toward the fracture site. STEP 2 ■ Indirect reduction of the fracture is performed with a combination of either manual traction or a tensioned fine-wire traction bow and weights, as well as manipulation of the fracture to restore alignment. ■ Various-sized rolled towels and surgical bumps can be positioned to align the femur in the sagittal plane (Fig. 13).

FIGURE 13

Femoral Shaft Fractures: IM Nailing

PITFALLS

Femoral Shaft Fractures: IM Nailing

400

FIGURE 14

PEARLS • Taking the time to ensure proper entry portal position will help avoid malreduction and potential iatrogenic fracture. • Know your equipment! Every nailing system has slightly different entry systems.

■

PITFALLS • Too medial a start point may increase risk of iatrogenic femoral neck fracture. • Too lateral a start point may lead to varus malreduction, particularly with proximal femur fractures.

■

■

Instrumentation/ Implantation • An assortment of various-sized sterile bumps is key. • A tensioned fine-wire traction bow and 20-pound weight facilitate application of longitudinal traction and replace the ongoing efforts of a surgical assistant. • A ball-spiked pusher or unicortical Shantz pin may be useful for more direct manipulation of fracture fragments, if necessary.

• A towel around the thigh, with counterpressure from a padded hammer, can facilitate reduction of translational deformity (Fig. 14). • Rarely, more direct, percutaneous manipulation of the fracture with a ball-spiked pusher, or unicortical Shantz pin may be necessary (Fig. 15A and 15B). The reaming wire is now passed across the fracture site. • The navigation across the fracture gap can be facilitated by a bend at the tip of the reaming wire to allow the wire to be “steered” across the gap. • Alternatively, an IM reduction tool can be used to more directly reduce the fracture and guide the wire (Fig. 16). The reaming wire is then advanced to a position centered in the distal segment on both the AP and lateral views, at the level of the physeal scar. With the fracture held at an appropriately reduced length, the nail length is selected by either a reverse measuring device, a radiolucent ruler, or measurement from a second equal-length guide rod and Kocher clamp (Fig. 17).

STEP 3 ■ The femoral canal is then sequentially reamed, starting with a relatively small reamer (8 or 9 mm), and increasing in 0.5-mm increments until the desired cortical chatter or nail size is encountered. ■ The canal is typically overreamed by 1 mm more than the selected nail diameter. Depending on the nail system and size of nail, the trochanteric region may need to be reamed to a larger size to accept the broader head of the nail. ■ It is imperative that the fracture be held in a reduced position during reaming, or eccentric reaming and malreduction will occur.

401

Femoral Shaft Fractures: IM Nailing

B A

FIGURE 15

FIGURE 16

FIGURE 17

x

x

Femoral Shaft Fractures: IM Nailing

402

PEARLS • The fracture must be held in a reduced position during reaming to avoid eccentric reaming and malreduction. • Slow advance of the reamer will avoid incarceration in the canal.

PITFALLS • Never ream without a ball-tipped reaming rod in place! In the event of a broken or incarcerated reamer, this can be key in successful retrieval. • Reaming with the fracture malreduced will result in eccentric reaming and malreduction.

STEP 4 ■ Depending on the nail system, the ball-tipped reaming rod may need to be exchanged prior to nail insertion. ■ The nail is inserted by hand initially, and then advanced with measured hammer blows. ■ The fracture site is imaged during nail passage to ensure the fracture is aligned and the nail advances without causing iatrogenic fracture. ■ The nail is seated to the appropriate depth, and proper positioning at the knee and hip as well as fracture reduction are confirmed.

PEARLS • While advancing the nail, take care not to strike the end of the guidewire and inadvertently advance the wire into the knee joint.

PITFALLS

Instrumentation/ Implantation

• Particularly in elderly patients with an exaggerated femoral bow, a relatively straighter nail may inadvertently perforate the anterior cortex of the femur. As the nail enters the distal third of the femur, confirm proper passage of the nail within the femoral canal on a lateral image.

• Always use a ball-tipped reaming wire. • Sharp reamers are key to avoiding fat embolism, thermal necrosis, and incarceration. • Newer generation reamers with sharp, deep flutes, an acornshaped reamer head, and a smaller diameter shaft reduce intramedullary pressure and risk of fat embolism (Fig. 18).

FIGURE 18

403

Femoral Shaft Fractures: IM Nailing

A

B

FIGURE 19

PEARLS • Always ensure that the guidewire is removed prior to attempting placement of locking screws! • Prior to leaving the operating room, confirm the following three items: ■

Absence of a femoral neck fracture

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Length and rotational alignment of the limb

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Stability of the knee ligaments

Controversies • Early, full weight bearing may result in premature failure of locking screws.

STEP 5 ■ The nail is locked proximally with the targeted guides, rotational alignment of the limb is confirmed, and then the nail is locked distally using either a radiolucent drill or, preferably, a freehand technique. ■ A lateral image centered over the distal locking holes, with the imager horizontal to the floor and perfectly perpendicular to the nail, is critical. The leg is then rotated by the proximal insertion arm to obtain an image of perfectly circular locking holes. ■ With the drill hand lowered out of the way of the imager, the drill bit tip is centered in the hole, with the drill bit perpendicular to the nail (Fig. 19A and 19B). ■ Keeping the drill bit tip pressed against the femur to avoid slipping, the drill hand is then raised to a horizontal position, level with the floor, and the hole drilled. ■ With the drill bit in place, the handpiece is disengaged temporarily and an image is taken to confirm passage through the locking hole. The drill bit is then removed, and an appropriate length screw is selected and inserted.

Postoperative Care and Expected Outcomes ■

Perioperative antibiotics and venous thromboembolism prophylaxis are recommended.

Femoral Shaft Fractures: IM Nailing

404 ■

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Patients should be appropriately monitored postoperatively to observe for sequelae of fat embolism and resultant pulmonary dysfunction. Early hip and knee range of motion are initiated, as well as crutch mobilization. Typically “feather” or toe-touch weight bearing is advocated for the first 6 weeks, unless the fracture pattern is extremely stable. Initial healing rates over 90% are expected, with good long-term functional results. In the event of aseptic nonunion, a single exchange nailing procedure is sufficient to achieve successful union in the majority of cases.

Evidence Bhandari M, Guyatt GH, Khera V, Kulkarni AV, Sprague S, Schemitch EH. Operative management of lower extremity fractures in patients with head injuries. Clin Orthop Relat Res. 2003;(407):187-98. Level IV retrospective case-control study comparing femoral fractures treated with reamed intramedullary nail or plate fixation in patients with severe head injury, showing no increase in mortality with IM nail. Bone LB, Anders MJ, Rohrbacher BJ. Treatment of femoral fractures in the multiply injured patient with thoracic injury. Clin Orthop Relat Res. 1998;(347):57-61. Landmark Level I randomized controlled trial showing a significant decrease in pulmonary morbidity with early stabilization of femoral fractures in multiply injured patients. Canadian Orthopaedic Trauma Society. Nonunion following intramedullary nailing of the femur with and without reaming: results of a multicenter randomized clinical trial. J Bone Joint Surg [Am]. 2003;85:2093-6. Level I multicentered randomized controlled trial showing a 4.5 times increased relative risk of nonunion with unreamed intramedullary nailing of the femur compared to reamed nailing. Canadian Orthopaedic Trauma Society. Reamed versus unreamed intramedullary nailing of the femur: comparison of the rate of ARDS in multiple injured patients. J Orthop Trauma. 2006;20:384-7. Level II, small prospective randomized trial showing no increased risk of ARDS in multiply injured patients with reamed intramedullary nailing compared to unreamed nailing. Crowley DJ, Kanakaris NK, Giannoudis P. Femoral diaphyseal aseptic non-unions: is there an ideal method of treatment? Injury. 2007;38(Suppl 2):S55-63. Level III systematic review showing exchange intramedullary nailing remains the treatment of choice for aseptic nonunion of the femur. Egol KA, Change EY, Cyitkovic J, Kummer FJ, Koval KJ. Mismatch of current intramedullary nails with the anterior bow of the femur. J Orthop Trauma. 2004;18:410-5. Anatomic review of 892 cadaveric femora showing mismatch between the anatomic radius of curvature and that of current femoral nail designs.

405

Level I multicentered randomized controlled trial in multiply injured patients showing advantage of intramedullary nailing in stable patients, but increased risk of pulmonary complications in borderline patients when compared to initial external fixation. Gausepohl T, Pennig D, Koebke J, Harnoss S. Antegrade femoral nailing: an anatomical determination of the correct entry point. Injury. 2002;33:701-5. Cadaveric study showing anatomic landmarks for entry portal directly aligned with the femoral canal. Momberger N, Stevens P, Smith J, Santora S, Scott S, Anderson J. Intramedullary nailing of femoral fractures in adolescents. J Pediatr Orthop. 2000;20:482-4. Level IV retrospective review of 50 cases showing safety of trochanteric tip entry antegrade intramedullary nailing of adolescent femur fractures. Pape HC, Hildebrand F, Pertschy S, Zelle B, Garapati R, Grimme K, Krettek C, Reed RL 2nd. Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery. J Trauma. 2002;53:45261. Level IV retrospective cohort study examining the impact of adopting a damage control approach in multiply injured patients. Ricci WM, Schwappach J, Tucker M, Coupe K, Brandt A, Sanders R, Leighton R. Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures. J Orthop Trauma. 2006;20:663-7. Level II prospective cohort study showing comparable clinical results with trochanteric versus piriformis entry point, with reduced fluoroscopy and operative times in obese patients.

Femoral Shaft Fractures: IM Nailing

EPOFF Study Group. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg. 2007;246:491-9.

PROCEDURE 24

Supracondylar Femur Fractures Don W. Weber

Figures 1 and 6 modified from Krettek C. Fractures of the distal femur. In Browner BD et al (eds). Skeletal Trauma, ed 4, vol 2. Philadelphia: Saunders Elsevier, 2009:2073–2130. Figures 7 and 17 modified from Whittle AP. Fractures of the lower extremity. In Canale ST, Beaty JH (eds). Campbell’s Operative Orthopaedics, ed 11, vol 3. Philadelphia: Mosby Elsevier, 2008:3085–3236.

Supracondylar Femur Fractures: ORIF

408

PITFALLS • Medically unstable patients • Nonambulatory patients

Open Reduction and Internal Fixation Indications

• Nondisplaced or stable (impacted) fracture patterns

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• Severe osteopenia (device/ technique sensitive)

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• Severe comminution • Lack of surgical expertise

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■ ■ ■ ■ ■ ■

Controversies • This is a technically demanding fracture, and thorough knowledge of deforming forces, complications, implant limitations, and surgical technique is required.

Examination/Imaging ■ ■

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Treatment Options • Alternatives to open reduction and internal fixation include retrograde intramedullary nailing, cast or brace treatment, and (rarely) revision total knee arthroplasty. • Open reduction and internal fixation can be completed with numerous devices depending on the fracture type, bone quality, and surgical experience. ■ Condylar blade plate ■ Dynamic condylar screw ■ Distal femoral locking plate ■ LISS plate ■ Condylar buttress plate

Displaced/irreducible fracture Unstable/comminuted fracture Intra-articular fractures (partial or complete) Open fractures (staged?) Pathologic fractures Bilateral femur fractures Ipsilateral tibial fractures Vascular compromise (may be staged) Associated knee ligament injuries

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Diagnosis is usually obvious clinically. The minimal imaging required is good-quality anteroposterior (AP) and lateral radiographs. A traction or splinted view can greatly aid in preoperative planning. Imaging of the uninjured femur/knee can also be helpful prior to surgery. Computed tomography scans are rarely necessary unless there is extensive intra-articular involvement.

Surgical Anatomy ■

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The most important structure at risk is the superficial femoral artery, which enters the popliteal fossa around 10 cm proximal to the knee joint as it passes through the adductor magnus. (Be especially cautious with the medial approach.) Soft tissues • The quadriceps muscle anteriorly (rectus femoris, vastus medialis, vastus intermedius, and vastus lateralis) is separated from the posterior compartment (hamstring muscles) by the medial and lateral intermuscular septa. These large muscles shorten the fracture, and their force must be overcome in reduction techniques. • The gastrocnemius muscles attach to the posterior femoral condyles and create an extension force to the condyles. This produces the typical deformity of supracondylar femur fractures which is extension and shortening (Fig. 1).

409

Supracondylar Femur Fractures: ORIF

PEARLS • Prep the limb as high as possible and use a sterile tourniquet during the entire case. If necessary, do the articular reduction under tourniquet control and deflate for the reduction of the condyles to the shaft. • Preparation and exposure of the ipsilateral iliac crest may be useful if bone grafting is anticipated. • Examine the opposite limb prior to preparation to determine rotational alignment. • Use of a femoral distractor or external fixator can greatly aid in reduction of the fracture (especially intra-articular components). • Place the distractor out of the area for plating. One pin should be placed at the level of the lesser trochanter laterally and the second in the lateral proximal tibia. Distract with the knee in approximately 20° of flexion.

FIGURE 1 ■

Bone • The distal femur has many unique features that are critical to understand for reduction and fixation techniques. • The metaphysis widens at the end of the femoral diaphysis and supports the femoral condyles. Anteriorly, a shallow articular concavity between the condyles provides a contact surface for the patella. Posteriorly, the intercondylar fossa separates the condyles and is the attachment area for the cruciate ligaments. • In the lateral projection, the femoral shaft aligns with the anterior half of the lateral condyle (Fig. 2).

PITFALLS • Avoid use of a traction table as it will tension the muscle and make exposure and reduction more difficult.

FIGURE 2

Supracondylar Femur Fractures: ORIF

410

FIGURE 3

• The lateral femoral condyle is larger anterior to posterior than the medial condyle and has a flat lateral surface. The medial condyle is wider posteriorly, and this creates the trapezoidal shape to the distal femur when viewed end on (Fig. 3). This is extremely important in placing fixation devices to avoid errant hardware placement and to avoid malreductions such as medial translation. • The alignment of the knee joint is parallel to the ground, with the anatomic axis of the femur averaging 9° of valgus (range, 7–11°).

Equipment • Use of a radiolucent support such as a triangle, adjustable support, or rolled-up sheeting will reduce the effect of the gastrocnemius muscles and aid reduction attempts.

Controversies • Some surgeons prefer a lateral position; however, this makes AP imaging slightly more difficult.

Positioning ■

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■

The most widely accepted position for fixation of supracondylar femur fractures is with the patient supine on a radiolucent table. This allows for C-arm fluoroscopy intraoperatively. The operative hip can be elevated on a sandbag, rolled flannel, or intravenous solution bag to rotate the femur and knee into a true AP projection. The knee is usually draped free with a sterile tourniquet and partially flexed over a radiolucent support (Fig. 4).

FIGURE 4

411

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PEARLS • Preoperative planning will give a better understanding of the fracture, the exposure required, and the equipment necessary for reduction and fixation. This is especially true if a tibial tubercle osteotomy is anticipated. • Start with articular exposure to reduce blood loss and unnecessary dissection. • A combined lateral and small medial approach may have less morbidity than an extensile exposure and osteotomy.

PITFALLS • Although rarely needed, when performing a tubercle osteotomy, take care to elevate a large enough portion of the tubercle to allow stable fixation and early mobilization.

A FIGURE 5

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■

Most supracondylar fractures can be reduced and stabilized through a single lateral approach. The exceptions to this would be medial condyle fractures and extensively comminuted intra-articular fractures. Surgical technique should include careful soft tissue handling, indirect reduction where possible, anatomic articular reconstruction, and restoration of limb length, rotation, and alignment. Bone grafts should be used where necessary, and stable fixation should be achieved to allow for early active rehabilitation. For the single lateral approach, a straight lateral incision is made over the distal femur extending to the midpoint of the lateral condyle (Fig. 5A). The incision should stay anterior to the lateral collateral ligament. • Proximally the incision can be extended as high as necessary depending on the length of the fracture, reduction technique, and implant chosen (Fig. 5B). The proximal incision is completed after the articular reduction has been achieved if possible. • Distally, the incision can be extended across the knee joint and then curved anteriorly to the lateral border of the tibial tubercle. • The fascia lata is incised in line with the skin incision, and the anterior fibers of the iliotibial band are divided distally. The approach continues through the joint capsule and synovium, taking care to ligate the superior lateral geniculate artery and not damage the lateral meniscus.

B

Supracondylar Femur Fractures: ORIF

Portals/Exposures

Supracondylar Femur Fractures: ORIF

412

A

B

FIGURE 6

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• Next the vastus lateralis is elevated from the intermuscular septum and any perforating vessels are ligated (Fig. 6A and 6B). Only as much soft tissue is elevated as necessary for the reduction and fixation. If using devices such as a dynamic condylar screw (DCS), condylar buttress plate, locking condylar plate (LCP), or Less Invasive Stabilization System (LISS), a minimally invasive technique can be employed. • After reduction and stabilization of the articular component of the fracture, image intensification and reduction manuevers may obviate the need for extensive proximal dissection. • Submuscular application of the plate and percutaneous screw placement will avoid disruption of the metaphyseal/shaft portions of the fracture. If more extensile exposure is required for reduction of the joint, there are a few options. • The most common alternative is the anterolateral approach. This skin incision is approximately the same, but may be brought up more medially; a lateral parapatellar arthrotomy is performed and a portion of the vastus lateralis is divided distally. This may enhance articular visualization but also may increase adhesions postoperatively.

413

MCL

FIGURE 7

Vastus medialis

Supracondylar Femur Fractures: ORIF

■

• Another option, though quite rare, is to perform a tibial tubercle osteotomy. The tubercle is exposed, and one or preferably two 4.5-mm holes are predrilled through the proximal cortex; a 3.2-mm drill is then passed through and just out of the posterior cortex. The holes are countersunk to avoid hardware irritation, and the screw length for 4.5-mm cortical screws is measured. A long segment of the tubercle (4–5 cm long and 1.5 cm thick) is elevated with a fine oscillating saw. The tubercle, patella, and fat pad can now be elevated to expose the medial condyle. • Finally, an even less desirable option is to perform a Z-shaped patellar tendon tenotomy. This necessitates repair of the tenotomy and protection with a tension wire from the patella to the tubercle. In the case of complex medial condyle fractures, coronal fractures (Hoffa fractures), or medial comminution requiring a medial plate, a second medial incision is advised. • A straight medial skin incision is made over the medial femoral condyle and anterior to the adductor tubercle. The fascia is incised in line with the incision, and the vastus medialus elevated from the intramuscular septum (Fig. 7). Any perforators and the medial superior geniculate artery are ligated. • The incision continues through the capsule and synovium to the joint. The surgeon must beware of the medial meniscus at the joint level and the superficial femoral artery and vein approximately 10 cm above the joint line. • This exposure is helpful for placing a small medial plate or obtaining anatomic reduction of medial condyle fractures. Coronal fractures require interfragmentary compression with countersunk screws.

Supracondylar Femur Fractures: ORIF

414 ■

PEARLS • Allowing the articular fragments to remain in a slightly shortened position sometimes reduces the deforming forces of the gastrocnemius and quadriceps muscles. • Large pointed reduction forceps are invaluable for manipulating the condyles against one another or holding a temporary reduction. • A good location to judge rotational reduction of the condyles is in the notch and on the anterior articular margin of the femur at the fracture site. • Femoral distractors or external fixators aid greatly in neutralizing forces on the articular fragments.

PITFALLS • Watch for intercondylar comminution as narrowing the condyles will lead to poor functional outcome. Tricortical grafts work best to span bone gaps.

In the case of a previous total knee arthroplasty, the previous midline skin incision can be utilized and subcutaneous dissection carried out, elevating a larger soft tissue flap to reach the lateral or medial intermuscular interval. • This approach can also be combined with a tubercle osteotomy if more extensile exposure is necessary. • Alternatively, one may use a medial or lateral parapatellar approach. However, these approaches make placement of a lateral plate more difficult.

Procedure STEP 1: TEMPORARY ANATOMIC REDUCTION OF THE JOINT ■ Of paramount importance is anatomic reduction of the articular surface. This usually requires direct visualization and may be aided by C-arm fluoroscopy. ■ Provisional fixation of articular fragments is best achieved by multiple Kirschner wires (K-wires). These should be placed outside of articular areas where possible. They can also be placed percutaneously where necessary. ■ Larger K-wires or threaded pins can be used as joysticks in each condyle to aid in reduction. STEP 2: DEFINITIVE ARTICULAR STABILIZATION ■ After temporary anatomic reduction with K-wires, definitive stabilization of the articular portion of the fracture should take place. ■ Generally speaking, articular fragments can be lagged together with 3.5-mm fully threaded cortical screws. It is unnecessary and inadvisable to penetrate the far cortex. This technique works best with goodquality bone. • Alternatively, 4.5-mm cortical screws can be used in a lag fashion (overdrilling the proximal fragment) or 6.5-mm partially threaded cancellous screws can be used a lag fashion. Cannulated screws may also be used. These larger screws may perform better in poor-quality bone. ■ These screws are placed near the peripheral margins of the condyles, especially anteriorly and posteriorly, as this is where better fixation can be obtained (Fig. 8). Sometimes it is necessary to countersink screw heads to avoid interference with the fixation device. ■ It is critical to know the location of the definitive fixation device at this point in order to avoid placing

415

■

■

screws on the lateral condyle in this location or have hardware in the track of the fixation device. Marking the footprint of the definitive plate is a useful exercise (see Fig. 8). Coronal fractures (Hoffa type) need to be fixed in a lag fashion from anterior to posterior and frequently by countersinking the screw heads. Once the articular surface is reconstructed, the device for reconstruction of the condyles to the shaft can be secured.

PEARLS • If wholly articular fragments need to be stabilized, smallfragment screws should be utilized and countersunk below the articular cartilage.

PITFALLS

FIGURE 9

• Remember the trapezoidal shape of the distal femur to avoid anterior screws penetrating the anteromedial cortex (Fig. 9). They may not be visible as outside of the cortex on an AP fluoroscopy view, and can be irritating for the patient postoperatively. • Watch for distal posterior screws penetrating the femoral notch (Fig. 10). FIGURE 10

Supracondylar Femur Fractures: ORIF

FIGURE 8

Supracondylar Femur Fractures: ORIF

416

PEARLS • The plate may be applied anatomically and securely to the condyles first, and then the final reduction of the fracture may be achieved by simply applying the plate to the shaft proximally. • Nonlocking partially threaded screws can be used to add compression to the condyles, but they provide less rigid fixation. • Plating longer gives better control of the fracture, but beware of the anterior bow of the femur as a straight plate may project anteriorly proximally. • Alignment of the limb may be checked with fluoroscopy intraoperatively by running a Bovie cord from the center of the femoral head over the knee and onto the tibial shaft to the ankle.

PITFALLS • Placement of the plate too posteriorly will result in the common deformity of medial translation of the condyles because the femur is wider posteriorly. Care must be taken with the initial plate position. • Minor differences in anatomy exist between patients, and preoperative templating can help avoid malreductions.

STEP 3A: CONTROL OF THE CONDYLES WITH THE PLATE (DISTAL FIXATION) ■ A number of devices are available for plate fixation of the distal femur, each with advantages and disadvantages. • Historically the first favorable results for internal fixation were achieved with the condylar blade plate (Fig. 11, left), followed closely by the DCS (Fig. 11, right). ◆ These are both fixed-angle devices and give good control of the distal fragment. ◆ The blade plate is technically more demanding to insert but disrupts minimal bone in the condyles. ◆ The DCS is a more forgiving device and can be inserted in a minimally invasive fashion. However, the lag screw does remove a large dowel of bone from the distal femur and may provide less control of flexion/extension. • The distal femoral condylar plate is a good choice for young patients with good bone quality and no medial comminution. • Finally, the device that is rapidly gaining popularity and is likely the most commonly used today in modern trauma centers is the LCP. Variations of this device are produced by different manufacturers, but it has a few distinct advantages over its predecessors. ◆ It is designed anatomically so it does not require bending. ◆ It can be inserted percutaneously. ◆ It can be used in patients with osteoporosis and (with caution) in fractures with medial comminution. ◆ It can act as an internal fixator and sit just off of the periosteum so as not to further disrupt cortical blood flow.

FIGURE 11

417

• The plate sits quite distally on the femur, and it is not uncommon for the distal posterior screw to enter the condylar notch. Usually only fixation to the lateral condyle is possible. • In cases of severe comminution, it is advisable to do minimal dissection in the metaphyseal zone. Care must be taken to restore length and rotation. The opposite limb may be used as a guide to length. Preoperative examination of the opposite leg’s rotation may aid in judgment of the plate’s rotational position on the shaft.

■

• The condylar blade plate, DCS, and LCP all have a distal projection that is parallel to the distal femoral articular surface in the AP projection and parallel to the anterior condylar ridges in the axial projection. This is the blade in the case of the blade plate, the lag screw in the case of the DCS, and the central screw in the case of the LCP. The placement of this distal fixation projection is critical to the ultimate femoral alignment in terms of varus/valgus and flexion/extension. • The focus of this chapter is the technique for the LCP; however, techniques for the other devices are touched upon. The author most commonly uses the Lateral Compression Plate from Synthes (Paoli, PA). • The central screw needs to be parallel to both the anterior and the distal condylar surfaces. One K-wire can be placed on each of these surfaces to aid proper alignment. ◆ The distal guide is placed on the lateral condyle with the central guide (for the 7.3-mm screw) in place (Fig. 12A). The plate sits anatomically on the lateral condylar surface generally with the

A

B

C

FIGURE 12

Supracondylar Femur Fractures: ORIF

P I T F A L L S —cont’d

Supracondylar Femur Fractures: ORIF

418

•

•

•

•

distal anterior hole just back from the articular margin. A central guidewire (2.5 mm) is placed through the guide and parallel to both the distal femoral articular surface and the anterior condylar axis (usually about 10° internally rotated) (Fig. 12B). Fluoroscopy should be used to verify that the guidewire is parallel to the joint distally. ◆ At this point the distal guide can be removed or a second guidewire placed to set the flexion/ extension (Fig. 12C). This is generally the distal anterior hole, and the guide position is confirmed on a lateral fluoroscopy projection. The anterior and posterior surface of the guide should parallel the distal femoral cortex anteriorly and posteriorly. ◆ These two K-wires are driven up to the medial cortex and the required length of plate is measured. An appropriate length is chosen to allow at least eight cortices of fixation proximal to the fracture. This can be checked with an AP fluoroscopy image of the plate on the skin and from preoperative templating. With an open technique, the proximal exposure may now be completed. For more extensive/ proximal fractures, removal of the sterile tourniquet may be necessary at this point. The guide is removed and the plate (with the previously used guides mounted on the plate) is applied firmly to the condyles. It may be held with a large Verbrugge clamp. The plate position on the condyles is verified with fluoroscopy. At this point, a third guidewire may be placed and then proximal reduction completed. This may be held with either a clamp alone or clamp and K-wires proximally (Fig. 13). The central 7.3-mm locking screw is placed first as this will allow for adjustment of flexion/extension if necessary (Fig. 14A). Then one or two of the 5.0-mm locking screws are placed to stabilize the distal construct (Fig. 14B). Proximal fixation can be completed with standard nonlocking screws to reduce the shaft to the plate (Fig. 15A). All proximal fixation can be standard cortical screws if the patient has good bone quality. If not, locking screws should be used in bicortical fashion and spaced as best possible (Fig. 15B). Nonlocking screws should always be placed before locking screws.

419

FIGURE 15

B

A

B A

FIGURE 14

Supracondylar Femur Fractures: ORIF

FIGURE 13

Supracondylar Femur Fractures: ORIF

420

■

• The distal and proximal fixations are completed, all fixation is checked once more. • The wound is closed in layers, with or without a Hemovac. This technique may also be completed with percutaneous fixation. This necessitates experience with the device and a readily reducible fracture. • If the fracture can be reduced and temporarily held with limb positioning, or a simple fracture traction setup, fixation can be completed as follows. ◆ A small distal/lateral exposure is made and the plate is slid under the vastus on the periosteum (Fig. 16). Plate position and fracture reduction are verified on both AP and lateral projections, with special care proximally. ◆ The plate is temporarily secured proximally with a K-wire or drill bit so as not to lose its central position on the shaft. The fixation is completed percutaneously (Fig. 17). • For those fractures a little more difficult to reduce and maintain, a carefully placed femoral distractor can be invaluable. Also, reduction can be assisted with percutaneous Shantz pins (Fig. 18). • Alternatively, the plate may be secured to the condyles distally in an anatomic alignment as previously described and then the final reduction of the shaft achieved with manipulation and the

FIGURE 16

421

Supracondylar Femur Fractures: ORIF

FIGURE 17

FIGURE 18

■

A FIGURE 19

use of nonlocking screws to draw the bone to the plate (see Fig. 15). Figure 19 shows a case example of a severely comminuted supracondylar femur fracture utilizing articular reconstruction (Fig. 19A), spanning fixation (Fig. 19B), and delayed bone grafting (Fig. 19C).

B

C

Supracondylar Femur Fractures: ORIF

422

PEARLS • Early motion with a hinged brace may reduce stiffness and potentially reduce fixation failures.

STEP 3B: ALTERNATIVE DEVICES FOR DISTAL FIXATION ■ The LISS (Synthes, Paoli, PA) uses a plate similar to the LCP (Fig. 20A); distal plate holes are lettered and diaphyseal plate holes are numbered), but has an outrigger (guide) for proximal locking (Fig. 20B) and uses unicortical proximal locking screws. • It is used in a percutaneous fashion proximally. Figure 20C shows the standard lateral incision, and Figure 20D the incision for a lateral parapatellar approach for complex intra-articular fractures. • Reduction of the fracture must be achieved provisionally with a femoral distractor, spanning fixator, or tibial traction pin prior to plating, or can be accomplished after control of the condyles by the plate. There is a tendency for the weight of

Incision

A

C

Incision

B

D

10°

FIGURE 20

E

423

PITFALLS • Avoid the use of long-leg splints as this increases the lever arm at the fracture site and may lead to early failure of fixation. • In cases with medial comminution, weight bearing should be delayed until fracture healing is well underway as varus collapse is still possible even with fixed-angle devices. Do not hesitate to use a medial plate, a bone graft, or even a medial cortical strut in cases of severe comminution and osteopenia. Figure 22 shows an intramedullary fibular graft utilized in such a case.

■

FIGURE 21

FIGURE 22

Supracondylar Femur Fractures: ORIF

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the guide to cause external rotation of the condyles on the shaft; when properly positioned, the guide should be internally rotated approximately 10° relative to the femoral shaft (Fig. 20E). The technique for the femoral blade plate is similar to that for the LCP. • After anatomic condylar reduction, the position of the blade is determined. A provisional wire should be placed 1 cm back from the distal articular surface in the middle third of the anterior half of the lateral femoral condyle (see Fig. 2). It should be parallel to the distal articular surface and to the anterior articular surface. • The seating chisel should follow the provisional wire and be 1.5–2.0 cm proximal to the distal articular surface. The chisel is advanced and pulled back frequently to avoid trapping it in the condyles. The optimal length should be determined without penetrating the medial cortex. • The appropriate-length plate and blade are seated in the distal femur, and a 6.5-mm cancellous screw in the plate is added to the distal fixation to aid in control of rotation. The condyles are reduced to the shaft, and the plate is secured with or without compression depending on comminution. The DCS is technically easier than the blade plate as one can adjust flexion and extension on final seating of the plate. • It can be placed with a minimally invasive technique and can compress the condyles in the

424

Supracondylar Femur Fractures: ORIF

case of an intra-articular split. The major difference in placement is that it should be 2.0 cm back from the distal articular surface in the middle of the anterior half of the distal femur. It does remove more bone than any of the other devices. • The set comes with a guide for placement of the lag screw, and the position should be verified parallel to the distal and patella-femoral articulations. After placing the guidewire, its length is measured and 10 mm is subtracted for the reamer. After reaming, one should tap if there is hard cancellous bone and place a screw 5 mm shorter than the guidewire length. • With a minimally invasive technique, the plate is slid submuscularly up the femur but rotated 180° away from the condyles. When the end reaches the distal lag screw, the plate can be rotated back to capture the end of the lag screw (Fig. 21). Flexion/extension of the condyles is verified and a second screw placed distally. The condyles may now be reduced to the shaft and secured proximally.

Postoperative Care and Expected Outcomes ■

■

Patients are allowed early range-of-motion exercises as the fixation is generally quite rigid. Depending on bone quality, weight bearing may need to be restricted for 3 months. Union rates should approach 85–90% depending on patient factors.

Evidence Aglietti P, Buzzi R. Fractures of the femoral condyles. In Insall JN (ed). Surgery of the Knee, ed 2. New York: Churchill Livingstone, 1993:983–1023. (Level V evidence) Bolhofner BR, Carmen B, Clifford P. The results of open reduction and internal fixation of distal femur fractures using a biologic (indirect) reduction technique. J Orthop Trauma. 1996;10:372–7. (Level IV evidence) Brown BJ, Russ JD, Hicks BM. Percutaneous application of the distal femoral locking compression plate in elderly females. (Level V evidence) Canale ST, Beaty JH (eds). Campbell’s Operative Orthopaedics, ed 10, vol 3. St. Louis: Mosby, 2003:2805–23. (Level V evidence) Helfet DL, Browner BD, Jupiter JB (eds). Skeletal Trauma, vol 2. Philadelphia: Saunders, 1992:1643–78. (Level V evidence) Higgins T, Pittman G, Hines J, Bachus KN. Biomechanical analysis of distal femur fracture fixation: fixed-angle screw-plate construct versus condylar blade plate. J Orthop Trauma. 2007;21:43–6. (Level I evidence) Kegor PJ, Stannard JA, Ziowodzki M, Cole PA. Treatment of distal femur fractures using the Less Invasive Stabilization System: surgical experience and early clinical results in 103 fractures. J Orthop Trauma. 2004;18:509–20. (Level IV evidence) O’Brien PJ, Meek RN, Blachut PA, Broekhuyse HM (eds). Rockwood and Green’s Fractures in Adults, ed 6, vol 2. Baltimore: Lippincott Williams & Wilkins, 2006:1915–32. (Level V evidence) Ruedi TP, Buckley RE, Moran CG. 6.6.3 Femur, Distal. In AO Principles of Fracture Management. Geneva: AO Publishing, 2007:787–94. (Level V evidence)

PROCEDURE 25

Supracondylar Femur Fractures Michael A. Hickey and Brad Petrisor

Supracondylar Femur Fractures

426

PITFALLS • Relative contraindications ■

Subtrochanteric fracture

■

Limited knee mobility

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Patella baja

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Open fracture

Retrograde Intramedullary Nailing Indications ■

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Retrograde nailing is an option in AO/OTA Classification type A, C1, or C2 distal femur fractures (i.e., supracondylar fractures with or without intercondylar fracture, and without significant condylar comminution). The supracondylar fracture line must be proximal enough to allow placement of at least two distal locking screws. Relative indications for retrograde nailing: • Multiply injured patients or polytrauma • Bilateral femur fractures • Morbid obesity • Distal metaphyseal fractures • Associated spine fracture • Ipsilateral femoral neck, acetabular, patellar, or tibia fracture • Ipsilateral through-knee amputation

Examination/Imaging ■

Treatment Options • Options for operative management include lateral locked plating, 95° dynamic condylar screw, or blade-plate fixation. These can be done through traditional open approachs or minimimally invasive approaches. • Temporary spanning external fixation may be used if patient or soft tissue concerns preclude immediate definitive fixation. If a nail is to be used after external fixation for definitive management, the time interval for exchange should be kept to a minimum to decrease the risk of intramedullary sepsis (Bhandari et al., 2005). • Nonoperative management may be indicated in patients with severe medical contraindications to surgery.

Physical examination • The usual mechanism of injury is an axial load in combination with a varus, valgus, or rotational force. • In older patients with poor bone quality such an injury may result from a simple fall on a flexed knee, but in younger patients high-energy trauma is often required. • The physical examination must include a thorough assessment to rule out the possibility of additional injury. ◆ One must assess for the possible presence of concomitant fracture of the pelvis, ipsilateral acetabulum, femoral neck, femoral shaft, patella, tibial plateau, and tibial shaft. ◆ Ligamentous stability of the ipsilateral knee must also be assessed, although this may be difficult in the initial postinjury period. ◆ The femoral and popliteal arteries are at risk of injury (especially in the setting of posterior dislocation of the knee), and circulation should be assessed by palpating for the popliteal, dorsalis pedis, and posterior tibialis pulses. ◆ Sensory and motor function of the affected limb should also be assessed.

427

A FIGURE 1

B

Supracondylar Femur Fractures

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• In a trauma situation, one must consider the broader picture and conduct the appropriate trauma assessment according to Advanced Trauma Life Support guidelines (American College of Surgeons, 2002). • On inspection, tenderness, swelling, and deformity are typical findings. The classic deformity is a combination of shortening, apex posterior angulation, and posterior displacement of the distal fragment. Gross deformity should be gently reduced and the limb splinted in preparation for imaging. • Open fractures can occur, most commonly through the anterior thigh, and may result in disruption of the quadriceps musculature or tendon. Plain radiographs • Minimum imaging includes anteroposterior (AP) (Fig. 1A) and lateral (Fig. 1B) views of the knee, femur, and hip, as well as an AP view of the pelvis. • Additional 45° oblique views of the fracture site should be considered for evaluation of complex intra-articular fractures or fractures not clearly delineated on standard views. • The fracture pattern must be assessed for displacement, alignment, comminution, intraarticular involvement, and joint line congruity.

Supracondylar Femur Fractures

428 ■

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■

Computed tomography is useful for diagnosis and preoperative planning of suspected complex intraarticular fractures and osteochondral lesions. Magnetic resonance imaging is useful in the evaluation of suspected ligamentous and musculotendinous injuries. Angiography may be indicated in the setting of diminished or absent pulses, an expanding hematoma, or arterial bleeding through an open wound. Given that the site of vascular disruption is usually at the site of the fracture, the use of arteriography should be at the discretion of the vascular surgeon and may be done as a “one-shot” examination in the operating room.

Surgical Anatomy ■

■

Bony anatomy (Fig. 2A and 2B) • ”Supracondylar” indicates the zone between the femoral condyles and the junction of the metaphysis with the diaphysis (distal 9–15 cm of femur). • At the distal diaphyseal-metaphyseal junction, the femur flares in the coronal plane into the medial and lateral condyles, and in the sagittal plane the condyles bulge posteriorly. Thus, the central axis of the femoral shaft projects onto the center of the intercondylar notch, 0.5–1 cm anterior to the origin of the posterior cruciate ligament, at the margin of the patellofemoral articular surface. • The femoral shaft has an anterior bow. • The axis of the femoral shaft is normally at 9° (range 7–11°) of valgus angulation relative to a line drawn perpendicular to the distal condylar surface. • Normal axial rotational alignment is such that the posterior condylar surfaces are in the coronal plane when the femoral neck is anteverted by 8–14°. Muscular and ligamentous attachments (Fig. 3) • The quadriceps (rectus femoris, vastus medialis, vastus intermedius, and vastus lateralis), hamstrings (biceps femoris, semitendinosus, semimembranosus), adductor magnus, and medial and lateral heads of the gastrocnemius effect the primary deforming forces acting on the distal femur.

429

Supracondylar Femur Fractures

A

FIGURE 2

Illiotibial tract Quadriceps femoris tendon Patellar retinaculum Patellar ligament

FIGURE 3

B

Quadriceps muscles Rectus femoris Vastus medialis Vastus intermedius Vastus lateralis Hamstring muscles Adductor magnus Biceps femoris Semitendinosus Semimembranosus Sartorius

Plantaris

Gastrocnemius

Supracondylar Femur Fractures

430

Sciatic nerve Common peroneal nerve Superior lateral genicular artery

Femoral artery and vein Adductor hiatus

Superior Medial genicular artery

FIGURE 4

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• In supracondylar fractures, the net deforming forces typically result in shortening as well as posterior displacement and apex posterior angulation of the distal fragment. Neurovascular structures (Fig. 4) • The femoral artery and vein pass posteriorly through the adductor hiatus of the adductor magnus in close association with the medial aspect of the femur in the high supracondylar region and continue in close association with the distal femur as they wind posteriorly through the popliteal fossa. • Superior lateral and superior medial genicular arteries branch off from the femoral artery near the superior border of the femoral condyles and course anteriorly, encircling the condyles. • The sciatic nerve comes into close association with the posterior aspect of the femur in the supracondylar region. The common peroneal nerve branches off laterally while the main tibial branch remains in the posterior midline, both still in relatively close association with the posterior femur down to the level of the knee joint.

431

Positioning ■

• A bump is usually placed under the ipsilateral hip.

PITFALLS

■

• Use a fully “image intensifier friendly” bed allowing for full uninterrupted imaging from the pelvis to the knee. ■

■

■

FIGURE 5

The patient is placed in the supine position on a radiolucent operative table such that fluoroscopic imaging is obtainable for the entire length of the affected femur. The operative limb is placed over a radiolucent adjustable “A” frame so that 90° of knee flexion is obtained (Fig. 5). The foot is allowed to hang just above the bed as this allows for intraoperative manual traction and manipulation of the leg. The operative leg is prepped and draped free up to the level of the iliac crest. Fluoroscopy is brought in from the unaffected side perpendicular to the patient, allowing for AP, lateral, and femoral notch views as required (Fig. 6). No tourniquet is used.

FIGURE 6

Supracondylar Femur Fractures

PEARLS

Supracondylar Femur Fractures

432

Instrumentation • Soft tissue protectors are important to use to protect both the patellar tendon and the patella during reaming.

Portals/Exposures ■

Controversies • One can also use a patellasplitting approach to gain access to the femur.

■

■

Retrograde supracondylar nails can be inserted percutaneously or through an open exposure of the nail entry site. • Percutaneous insertion may be used for purely supracondylar fractures or minimally displaced intercondylar fractures that can be reduced adequately by closed methods. • An open exposure must be employed for anatomic reduction of displaced intercondylar fractures. Open technique • Standard midline longitudinal skin incision • Medial parapatellar arthrotomy to expose the articular surface of the femur Percutaneous technique (Fig. 7) • A medial parapatellar split is made through a small incision over the medial border of the patellar tendon. This incision is usually 2–4 cm. • A soft tissue protector is used to protect the tendon and the undersurface of the patella during reaming.

FIGURE 7

433

STEP 1 ■ Any intercondylar fracture component must be reduced and fixed prior to fixation of the supracondylar fracture with the intramedullary nail. For displaced intercondylar fractures, the reduction can be visualized directly through an open exposure of the distal femoral joint surface in order to obtain anatomic reduction of the joint surface or, if using a percutaneous technique, the reduction is obtained and confirmed with an image intensifier. ■ Temporary fixation of the condylar fragments may be achieved with percutaneously placed Kirschner wires inserted across the fracture line, or a large tenaculum clamp placed across the condyles on either side of the fracture line. ■ Definitive fixation of the intercondylar fracture is typically achieved by lagging the medial and lateral condyles together with at least two partially threaded 6.5-mm cancellous screws inserted percutaneously across the fracture line in the anterior and posterior aspects of the condyles so as to leave enough room for the nail to pass between them (Fig. 8). The Kirschner wires should then be removed.

Intercondyler fracture

FIGURE 8

Cancellous screws

Supracondylar Femur Fractures

Procedure

Supracondylar Femur Fractures

434

PITFALLS • Avoid posterior guidewire placement and reaming as this may disrupt the attachment of the posterior cruciate ligament.

Instrumentation/ Implantation • Either a full-length retrograde nail or a “supracondylar” nail may be used. The supracondylar nail is typically available in shorter nail sizes with more holes for cross-screw use.

STEP 2 ■ The next step is to fix the supracondylar fracture. ■ Reduction of the supracondylar fracture may be achieved by manual traction or a variety of more direct methods. • A traction pin may be inserted transversely across the anterior portion of the femoral condyle. The anterior pin placement, with traction, tends to help correct the apex posterior angulation of the distal fragment that is typical of supracondylar fractures. • Alternatively, Steinmann pins can be inserted into the femoral condyles on either side of the patella in an AP direction in order to manipulate the distal femoral fragment. • Finally, a femoral distracter may be employed to hold the fragments out to length and in alignment, taking care to keep the Schanz pins out of the path of the nail. ■ The intercondylar notch is exposed using either the percutaneous technique or the open technique as described above. • In both techniques, the nail start point (Fig. 9) is identified as the point 0.6 mm to 1.2 cm anterior to the femoral insertion of the posterior cruciate ligament (Carmack et al., 2003; Krupp et al., 2003). • In the medial to lateral plane, the site is either equidistant between the articular margins of the condyles or 1–2 mm medial (Carmack et al., 2003; Krupp et al., 2003). ■ In the percutaneous technique, it is important to obtain proper radiographic confirmation of the start point. • On the AP view, the start point is located at the center of the intercondylar notch (Fig. 10); on the lateral view, the start point is anterior to Blumensaat’s line (Fig. 11A and 11B). The start point should align with the center line of the femoral shaft on the AP and lateral view. • A guide pin is inserted under fluoroscopic guidance at the nail start point and advanced proximally, centered within the distal femoral shaft on the AP and lateral views to a depth of 3–5 cm. ■ The overdrill is then passed over the guidewire to open the femoral canal (Fig. 12).

435

Supracondylar Femur Fractures

Anterior cruciate ligament

Posterior cruciate ligament

FIGURE 9 FIGURE 10

Blumensaat’s line

A

B

FIGURE 11

FIGURE 12

Supracondylar Femur Fractures

436

PEARLS • Blocking screws may be used to help guide the reamer and nail centrally in the distal femur. This will decrease the effective canal size and help with reduction. Either 4.5-mm cortical screws or temporary Steinmann pins may be used.

PITFALLS • Test the distal cross-screw jig for correct alignment with the cross-screw holes prior to insertion and confirm that it is fixed tightly to the nail. If there is any play in the setup, the jig may not accurately place the screw within the appropriate hole in the nail.

STEP 3 ■ A long ball tip guidewire is then advanced across the fracture site into the femoral diaphysis under fluoroscopic guidance (Fig. 13), verifying that the guidewire is within the medullary canal on both AP and lateral views. ■ Retrograde femoral nails for supracondylar fractures can be either short or long. The short supracondylar nail extends only to the distal extent of the femoral shaft. The full-length nail is designed to extend to a point just proximal to the lesser trochanter of the femur such that the most proximal locking screw is level with the lesser trochanter. • Figure 14A shows the nail and insertion handle setup. • Figure 14B shows the nail and cross-screw insertion jig setup. ■ Sequential reaming in 0.5-mm increments is then done until cortical chatter is obtained. Reaming is usually done 1–1.5 mm larger than the diameter of the nail to be inserted. ■ The retrograde supracondylar nail is mounted on its insertion handle and inserted over the guidewire into the reamed canal (Fig. 15A), taking care to orient the nail properly so as to match the bow of the implant with the anterior bow of the femoral shaft. The nail is advanced across the fracture site and into the desired position (Fig. 15B). • The distal end of the nail should be placed deep to the articular surface of (and at the least flush with) the intercondylar notch so as not to impinge on the patellar articular surface (Morgan et al., 1999).

FIGURE 13

437

FIGURE 15

B

A

Supracondylar Femur Fractures

A

B

FIGURE 14

Supracondylar Femur Fractures

438 ■

■

■

■

■

The distal locking screws are inserted percutaneously using the nail-mounted targeting device (Fig. 16), with fluoroscopic verification of screw placement in the AP (Fig. 17A) and lateral (Fig. 17B) planes. A minimum of two screws should be used. With the distal fracture fragment firmly fixed to the intramedullary device, final adjustments may then be made to length and rotational alignment with respect to the proximal femoral fragment. Insertion of proximal locking screws may vary according to the type of implant used. • For short retrograde nails, either the nail-mounted targeting device or a freehand technique may be used, and the screws are typically inserted lateral to medial. • For full-length retrograde nails, only the freehand technique may be used, and the screws are typically inserted from anterior to posterior, but may vary according to the hole orientation on the specific implant. • In the freehand technique, drill bit and screw placement and alignment are achieved by aligning the fluoroscopy beam with the axis of the locking screw hole. It is important to verify screw placement (and length) in the orthogonal plane. The nail-mounted targeting device is then removed and a layered closure is performed, including closure of any defects in the patellar tendon created from longitudinal splitting of its fibers in the percutaneous technique. Postoperative radiographs are taken in AP (Fig. 18A) and lateral (Fig. 18B) views to ensure correct alignment.

FIGURE 16

439

Supracondylar Femur Fractures

B A

FIGURE 17

FIGURE 18

B

A

Supracondylar Femur Fractures

440

Postoperative Care and Expected Outcomes ■

■

■

■

The patient may be placed in a knee immobilizer splint (in extension) for protection prior to being awakened from general anesthetic. Physiotherapy may be initiated immediately, addressing range of motion of the hip, knee, and ankle joints. Patients should start early range of motion with knee flexion as soon as it is tolerable and may do so with or without the use of a continuous passive motion machine within 24–48 hours of their surgery. More active therapies, including weight-bearing activities and quadriceps and hamstrings strengthening exercises, should be initiated gradually and with consideration of postoperative clinical assessment as well as the character and stability of the original fracture. Patients should be permitted touch weight bearing initially and may continue to wear the knee immobilizer splint with weight-bearing activity until fully weight bearing. • With gradually progressive weight-bearing, AO/ OTA type A fracture patients may be allowed to fully bear weight at 4–6 weeks. • Type C1 and C2 fracture patients should not be allowed to fully bear weight for at least 12 weeks.

Evidence American College of Surgeons. Advanced Trauma Life Support Manual, ed 6. Chicago: American College of Surgeons, 2002. Bhandari M, Zlowodzki M, Tornetta P 3rd, Schmidt A, Templeman DC. Intramedullary nailing following external fixation in femoral and tibial shaft fractures. J Orthop Trauma. 2005;19:140-4. Systematic review of available trials resulting in a Grade C recommendation of early exchange to intramedullary nail. Carmack DB, Moed BR, Kingston C, Zmurko M, Watson JT, Richardson M. Identification of the optimal intercondylar starting point for retrograde femoral nailing: an anatomic study. J Trauma. 2003;55:692-5. Experimental cadaver study. (Level V evidence) Krupp RJ, Malkani AL, Goodin RA, Voor MJ. Optimal entry point for retrograde femoral nailing. J Orthop Trauma. 2003;17:100-5. Experimental cadaver study. (Level V evidence) Morgan E, Ostrum RF, DiCicco J, McElroy J, Poka A. Effects of retrograde femoral intramedullary nailing on the patellofemoral articulation. J Orthop Trauma. 1999;13:13-6. Experimental cadaver study. (Level V evidence)

PROCEDURE 26

Knee Dislocations Scott J. Mandel

Knee Dislocations

442

PITFALLS • Ensure that there is no vascular compromise—this is of primary importance. ■

■

This can be done with imaging, but imaging is not necessary. There is good evidence to support use of the ankle-brachial index (ABI) as a screen in this population, and use vascular imaging only if there are abnormalities.

Indications ■ ■

Multiple ligament injuries (i.e., two or more) Irreducible dislocation

Examination/Imaging ■ ■

■

■

The ABI—ankle systolic pressure (numerator) over brachial systolic pressure (denominator)—should be at least 0.9 to be considered satisfactory.

■

Clinical examination is performed (Fig. 1A). Plain radiographs to rule out associated fractures are mandatory. Computed tomography scans may be obtained as needed if any fractures are identified on radiographs. Magnetic resonance imaging (MRI) • MRI provides additional information, such as the residual subluxation shown in Figure 1B, but does not replace the clinical examination! • It can be very helpful in delineating ligamentous injury, such as the medial collateral ligament injury shown in Figure 2. • Magnetic resonance angiography can also be performed to assess the vascular tree. Angiograms are not always needed, but can be helpful in ruling out associated vascular injury.

Controversies

Treatment Options

• Management of combined anterior cruciate ligament (ACL)/medial collateral ligament (MCL) injuries is debatable. They can be treated conservatively initially in a hinged brace to let the MCL heal, followed by reconstruction of the ACL as needed. • Age is not a contraindication— all ages need a stable knee to ambulate, regardless of level of activity.

• Nonoperative treatment is generally not recommended for most two-ligament injuries, or for any three- and four-ligament injuries. The results are unpredictable, with either recurrent instability or stiffness being likely. Recent literature contains multiple articles confirming that operative treatment gives better functional results. • One can temporize while working up a patient for surgery by placing him or her in a knee immobilizer. Usually spanning external fixation is not required (if performed, pin tracks should be kept away from proposed incisions). • Surgical treatment (reconstruction or repair) should be the mainstay of care in most patients, who should ideally be reconstructed/repaired acutely (within 2 weeks—anatomy is more definable at 1 week as compared to 2 weeks). • If the dislocation is irreducible, the patient must be treated operatively. ■ Performing closed reduction immediately, in either the emergency room or the operating room, is essential to improve chances of limb salvage (i.e., the risk of amputation increases the longer the knee is dislocated). ■ It is acceptable to leave the knee subluxed slightly in the operating room as long as it is stabilized (i.e., in an external fixator) and there are good pulses/the ABI is satisfactory/a normal angiogram is obtained. • It is better to wait for a more experienced colleague to become available than for a surgeon with little or no interest or experience to try to deal with these injuries operatively.

443

Knee Dislocations

A

B

FIGURE 1

FIGURE 2

Knee Dislocations

444

PEARLS

Surgical Anatomy ■

• Supine position ■

A kidney rest should be placed against the proximal thigh in the area of the tourniquet.

■

A sandbag taped to the bed can keep the knee in a 90° position and function as another assistant (Fig. 4).

■

• Prone position ■

Ensure that the usual care is taken to pad the bony prominences.

■

Pillows should be placed under the lower legs to keep the knees flexed; this relaxes the posterior muscles to allow easier retraction.

Positioning ■

Equipment • Supine position: kidney rest and sandbag • Prone position: pillows

The surgeon should be familiar with the origins and insertions of the various ligaments that are injured: • Anterior cruciate ligament (ACL) • Posterior cruciate ligament (PCL) • Medial collateral ligament (MCL) • Lateral collateral ligament (LCL) • Posterolateral corner The surgeon should be familiar with the neurovascular anatomy of the knee. • Course of the common peroneal nerve about the knee (inferior to the biceps, running around the fibular neck) for lateral repairs/reconstructions (Fig. 3A) • Proximity of the posterior neurovascular bundle (popliteal artery and vein, tibial nerve) when working at the back of the knee (Fig. 3B)

■

The supine position is used for most injury combinations. The prone position is required to address PCL avulsion fractures from the tibial insertion.

Portals/Exposures ■

■

■

■

■

For chronic cruciate reconstructions (i.e., ACL or PCL), the surgeon can cheat closer to the midline with arthroscopic portals. A posteromedial portal can be very helpful to visualize the tibial tunnel in PCL reconstructions. For acute reconstructions, an open anterior incision with a medial parapatellar arthrotomy (similar to total knee replacement) can give good access to the ACL, PCL, and MCL if a medial flap is developed (Fig. 5). For lateral and posterolateral corner procedures, a lateral-based incision provides excellent exposure (see Fig. 5). The surgeon may need to incorporate fasciotomy incisions if there is a vascular injury requiring repair.

445

Tibial nerve

B

A FIGURE 3

FIGURE 4

FIGURE 5

Knee Dislocations

Popliteal artery and vein

Knee Dislocations

446

PEARLS • Long longitudinal incisions allow for larger areas of retraction under the flaps. • A lateral incision can run from Gerdy’s tubercle on the tibia to just anterior to the lateral epicondyle of the femur, and continue longitudinally up the femoral shaft. ■

Increase the length proximally, and to a lesser extent distally, to allow for a large flap posteriorly to visualize the posterolateral corner and peroneal nerve.

• Putting the scope through the notch to the back of the knee and turning the post to view medially can help transilluminate the correct placement of a posteromedial portal (especially with a 70° scope). • Reducing the posterior translation of the tibia to a forward position can also be extremely helpful in inserting a posteromedial cannula. • With open approaches, remember to keep articular cartilage hydrated throughout the procedure to avoid desiccation.

Instrumentation • Standard self-retaining retractors/Gelpis and Hohmann retractors to keep the patella lateral while working on the notch • Posteromedial cannula— recommended to minimize extravasation

PITFALLS • If incisions are too short, the surgeon may struggle with exposure, especially out to the sides of the operative field. • If the lateral incision is posterior to the lateral epicondyle, the surgeon will be fighting to retract the skin flap anteriorly throughout the whole surgery.

Procedure Controversies • Arthroscopic treatment is not universally recommended for acute reconstruction due to risk of extravasation of fluid and subsequent compartment syndrome. ■ Some authors use gravity-flow techniques for arthroscopicassisted reconstructions. ■ Careful monitoring for swelling and compartment syndrome is mandatory if arthroscopic techniques are being used acutely.

STEP 1: EXPOSURE ■ Anterior incision • As for total knee replacement, a straight midline incision is made, with a medial parapatellar arthrotomy. • Only enough fat pad/ligamentum mucosum is removed to visualize the notch (Fig. 6A). • ACL/PCL remnants are débrided as needed, but footprints are kept to help guide tunnel placement. • An assessment for meniscal injuries is done— peripheral avulsions of the coronary ligament can be seen from the tibia (Fig. 6B). ■ Lateral incision • The first priority is to identify the common peroneal nerve and protect/retract it out of the way.

447

Medial parapatellar incision

Tibia

FIGURE 6

A

B

Avulsion of coronary ligament

• The iliotibial band is split in line with a skin incision down to Gerdy’s tubercle (Fig. 7A). • Disrupted ends/avulsions of the LCL or popliteus tendon, and lateral meniscal avulsions from the tibia, are identified (if possible) (Fig. 7B). • Blunt dissection is done with a finger along the back of the tibia between the gastrocnemius and the bone, freeing up muscle from the back of the fibular head (Fig. 7C).

Skin incision LCL ligament Iliotibial band

Popliteus tendon

Gerdy’s tubercle

A

B

FIGURE 7

Fibular head

Gastrocenemius Peroneal nerve

C

Knee Dislocations

Meniscus

Knee Dislocations

448

A

B

FIGURE 8

PEARLS • Tourniquet time will likely exceed 2 hours for a multiple ligament reconstruction. If two incisions are to be used, a tourniquet “holiday” of at least 15 minutes can be utilized prior to performing the second incision to allow relatively bloodless dissection (more essential for the lateral exposure when dissecting out the common peroneal nerve). • Peripheral avulsion of the anterior and middle thirds of the meniscus can be repaired back to the tibia with suture anchors and decortication (similar to a rotator cuff repair).

A FIGURE 9

STEP 2: GRAFT SELECTION/PREPARATION ■ Autograft, allograft, or synthetic ligaments, or combinations, can be used. ■ The author’s preference is to use allograft and synthetics (LARS ligaments) (Fig. 8A and 8B) • The knee has enough damage to it already without the added morbidity of harvesting an autograft. • Allograft tibialis posterior or anterior (Fig. 9A) or hamstrings can be used for the ACL. • Allograft Achilles (two-tailed) can be used for the PCL. • Synthetic ligaments can be used for collaterals and for the PCL in selected patients.

B

449

• Be careful not to damage articular cartilage while performing an arthrotomy. • Do not place a snap-on vessel loop or Penrose drain around the common peroneal nerve—avoid excess tension.

■

• A posterolateral graft is two-tailed, and an MCL graft is tubular on the femoral end and has a broad insertion designed to be stapled to the proximal tibia (Fig. 9B). No convincing evidence is available to guide graft selection; surgeons should use their own discretion and use grafts with which they are familiar and comfortable. PEARLS

Instrumentation/ Implantation

• Synthetics come in predetermined sizes to allow immediate progression to tunnel drilling without having to prepare or size a graft.

• A vessel loop/Penrose drain is used to protect common peroneal nerve. • A tablespoon (sterilized) is extremely helpful to retract/ protect posterior structures.

• It is easier to pass a synthetic PCL graft through the tibial tunnel (especially arthroscopically).

• Tubularize the ends of the graft for easier passage—at least 30 mm at each end is recommended; consider more for the PCL and tibial end of the ACL.

Controversies • Some authors believe that at least a 7-cm skin bridge is necessary between incisions.

ACL ligament

AM bundle PL bundle

FIGURE 10

• Start thawing allograft immediately to minimize down time. It is ideal to have an assistant prepare the graft on the back table while exposure being performed.

STEP 3: DRILLING TUNNELS ■ Consideration should be given to drilling 2 mm less than graft size (i.e., 6 mm for an 8-mm graft) and dilating up to compact bone for better fixation, especially in older, osteoporotic patients. ■ ACL • The surgeon may consider two-bundle reconstruction; however, there is no evidence to support the use of this technique in a knee dislocation population. • The tibial tunnel is created in the posterior half of the ACL footprint; start near the superolateral corner of the pes anserinus on the anteromedial tibia (Fig. 10). • The femoral tunnel is created in the 10:00 o’clock to 10:30 position for a right knee, and the 1:30 to 2:00 o’clock position for a left knee. ◆ Vertical tunnels (i.e., closer to 12:00) give less rotational control. ◆ Femoral tunnels can be drilled trans-tibial or freehand; some authors believe freehand drilling (through the anteromedial portal if arthroscopic) allows better lateral placement of the femoral tunnel.

Knee Dislocations

PITFALLS

Knee Dislocations

450 ■

PEARLS • Overdrill the PCL tibial tunnel by 1 mm (i.e., 12 mm for an 11-mm graft) to allow for easier graft passage. • Reduce drop-back of the tibia while passing the PCL graft to help with graft passage through the tibial tunnel.

PITFALLS • Avoid making the PCL graft too big for the tunnel if using Achilles tendon with bone block (12 mm is usually the biggest drill available on standard ACL sets).

■

• Aim for a PCL graft that will fit through a 10- or 11-mm sizing cylinder.

Instrumentation/ Implantation • Nonabsorbable #1 or larger sutures to tubularize graft

■

PCL • Two-bundle reconstruction is more mainstream for chronic cases, although some authors advocate a single bundle to act as a stent for ligament healing in the acute setting (Fig. 11). • The tibial tunnel starts lower down on the tibia, below the tibial tubercle and lateral to the tibial crest. (This lower start point minimizes the “killer graft angle”—the angle the graft makes when it exits the tibial tunnel and turns upward to the femur.) • The femoral tunnel is created in the PCL footprint on the medial condylar wall in the notch. MCL • Native MCL can be repaired with sutures (usually a midsubstance rupture). • The capsule is repaired, including posteromedially, in the acute setting. • Plication of the capsule in a “vest-over-pants” fashion is considered in the chronic setting. • If reconstruction is needed, the femoral tunnel is drilled along the epicondylar axis (medial to lateral) (Fig. 12). LCL/PLC • With a two-tailed graft, a femoral tunnel, a tibial tunnel, and a fibular tunnel are needed (Fig. 13). • The femoral tunnel is created along the epicondylar axis (lateral to medial). ◆ Consideration should be given to placing it slightly eccentric to the isometric point on the epicondyle; moving posteriorly and superiorly slightly will tighten the graft in extension and allow some laxity in flexion. Femoral tunnel

Drill

Lateral epicondyle Medial epicondyle PCL ligament

AL bundle PM bundle

FIGURE 11

FIGURE 12

451

7.5mm diameter of graft

• Synthetic grafts are controversial, but in the author’s experience they are very well tolerated for collateral ligament and PCL reconstructions. • Primary repair (rather than reconstruction) has been reported with good results.

Lateral epicondyle Two-tailed graft 6.0mm diameter of grafts Tibial tubercle Fibula

Instrumentation/ Implantation • Standard ACL set with drill guides for either open or arthroscopic use • PCL drill guides with drill stops to avoid penetration through the posterior capsule • 70° scope to visualize placement of guidewire, drilling of tunnel for PCL tibial side • Tablespoon to allow retraction/ protection when drilling through tibia from front to back with PCL/LCL/posterolateral corner reconstruction

Controversies • Not all authors believe tunnel dilation or compaction drilling is necessary.

FIGURE 13

• The tibial tunnel is created from Gerdy’s tubercle to the posterior tibia, aiming as far medial as possible. • The fibular tunnel is created from front to back on the fibular head. PITFALLS • Do not drill the ACL femoral tunnel trans-tibially until posterior drop-back of the knee is corrected (i.e., the PCL is reconstructed), or nonlinear tunnels can result; this makes graft passage difficult. • If two tunnels are used, ensure an adequate bone bridge between the anterolateral and posteromedial bundles for the PCL on the femoral side. • It can be very difficult to fit tunnels for four ligaments on the femur (usually the tibia is not an issue). ■

If reconstructing both cruciates and one collateral, the collateral tunnel can be angled away from the ACL tunnel (PCL femoral tunnels are not usually a problem), but one still must start at the correct point.

■

If reconstructing both cruciates and both collaterals, the tunnel can be drilled from a lateral start point to a medial start point and this tunnel then taken into account while drilling the ACL femoral side.

■

Final collateral tunnel size on the femur must accommodate both medial and lateral grafts simultaneously (usually 10 mm with the author’s usual graft choices).

■

Graft fixation choices may be dictated by tunnel placement (i.e., one may not be able to use cross-pin or button-type fixation due to tunnel impingement).

Knee Dislocations

Controversies

Knee Dislocations

452

PEARLS • Fix the tibial side of the PCL first to allow tensioning separately on each bundle for two-bundle PCL reconstruction. • Fixing at both ends of the collateral ligament tunnel can be done if both the MCL and LCL are reconstructed through the same tunnel on the femur. • Fix the tibial side of the ACL last. • Absorbable interference screws should be upsized more so than metal screws (i.e., an 8-mm soft tissue graft in an 8-mm tunnel can take an 8-mm metal interference screw or a 9-mm absorbable screw).

PITFALLS • Fixing the ACL graft completely before PCL fixation will lead to the knee being in a posteriorly subluxed position. • Absorbable fixation is not recommended for synthetic ligaments.

STEP 4: GRAFT FIXATION ■ The optimal order of graft fixation has not been determined, but the PCL must be fixed before the ACL or the knee can be captured. ■ It is recommended to fix the collateral ligaments (i.e., MCL, LCL) and the PLC at 30° or more of flexion, especially if they are slightly non-isometrically placed, to be tight in flexion. ■ If a two-bundle PCL repair is made, anterolateral bundle should be fixed at 90°, and posteromedial bundle at 20°, of flexion (Fig. 14). ■ The ACL should be fixed at 30° of flexion (usually the tibial side is repaired last of all the ligaments). ■ The surgeon should be familiar with many different types of fixation, such as interference screws, transfixion pin devices, and suspension button–type fixation (i.e., EndoButton), as well as screw posts with washers and staples. • The author’s preference is oversized metal interference screws for synthetic ligaments (staples in a belt-buckle fashion are used for the tibial side of the MCL), and absorbable interference screws for autograft/allograft tendons (cross-pin device for the femoral side of the ACL). • Long grafts can be supplemented with staples, usually to the tibial cortex for the tibial side of the ACL, and to the femoral condyle for the femoral side of the PCL. ■ Stable fixation is desired to allow early range of motion (ROM) and full weight bearing.

FIGURE 14

453

■

FIGURE 15

Postoperative radiographs to assess tunnel placement and graft fixation are helpful. • Figure 15 shows AP (Fig. 15A) and lateral (Fig. 15B) radiographs following ACL, PCL, and MCL repair. • Figure 16 shows AP (Fig. 16A) and lateral (Fig. 16B) radiographs following four-ligament repair.

A

B

Instrumentation/ Implantation • Full set of metal and absorbable interference screw of different diameters and lengths • Staples, screws, and washers if using post fixation • Heavy (i.e., #2) wire-reinforced suture if using screw post • Cross-pin devices • Button option should be available in case of tunnel wall “blowout.”

A FIGURE 16

B

Knee Dislocations

Postoperative Care and Expected Outcomes

Knee Dislocations

454

Controversies • Opinion is divided regarding aperture fixation (i.e., interference screws) versus fixation at a distance (i.e., suspension buttons). Aperture fixation is thought to possibly decrease tunnel widening and graft elongation by elimination of the “bungee-cord effect.”

■

■

■

PEARLS • 90° of flexion is usually achievable at 7 days postoperative, but ROM will regress once the epidural catheter is out. • Consider manipulation/ arthroscopic lysis of adhesions if the patient is not making good progress by 2–3 months postoperative with regard to ROM. ■

Repeat the postoperative protocol of an indwelling epidural catheter, CPM, and ice packs after a motionregaining procedure.

■

■

■

■ ■

The need for a motionregaining procedure is between 5% and 10% in the author’s experience, but rates of up to 57% are quoted in the literature.

Controversies • Most authors do not advocate immediate weight bearing, but progress weight bearing gradually over a variable period of time. • One study supported hinged external fixation (Compass hinge device) as a way to protect the repair/ reconstructions and allow early rehabilitation.

Hemovac drain(s) are placed to help prevent hemarthrosis and facilitate early ROM. Use of an indwelling epidural catheter for 5–7 days allows early aggressive ROM in continuous passive motion (CPM). • If fixation is stable, the patient can weight bear as tolerated immediately in a knee immobilizer (author’s protocol). • Ice packs/Cryo-cuff devices can be used to help control pain and swelling. Prophylaxis for deep venous thrombosis is recommended due to decreased mobility. Prophylactic antibiotics are recommended for at least 24 hours. After removal of the epidural catheter: • Aggressive physiotherapy aimed at regaining motion and strength is begun. Motion is more important in the early postoperative period. • The patient can use a hinged brace, and weight bear as tolerated with crutches. He or she then transitions to a custom brace for at least 1 year postoperatively, and likely permanently for highdemand/sports activities. Patients usually can achieve full or near-full extension and 120° or more of flexion. The PCL is usually mildly lax, and the collaterals usually open up more than normal with good endpoints and stability. The result is not a “normal” knee, but it is usable. Most patients do not return to high-level athletic activities.

PITFALLS • Watch for frostbite with ice packs and an indwelling epidural catheter due to decreased protective sensation. • Heterotopic ossification is possible, but not common (1 in approximately 40 cases in the author’s experience). Some routinely use a nonsteroidal anti-inflammatory drug (NSAID; e.g., Indocid) as prophylaxis, but the benefits of NSAID use (possible prevention of heterotopic ossification) must be balanced against the drawbacks (possible interference with bone healing into grafts/ tunnels).

455

Harner CD, Waltrip RL, Bennett CH, Francis KA, Cole B, Irrgang JJ. Surgical management of knee dislocations. J Bone Joint Surg [Am]. 2004;86:262-73. In this retrospective cohort study of 31 of 47 cases at the author’s institution, all patients were treated operatively with allograft tissue and/or direct repair(19 acute, 12 chronic). There was no difference in outcome between acute and chronic cases in terms of ROM, but the acute group had higher subjective scores and better objective restoration of knee stability. The ability of patients to return to high-demand activities was less predictable. (Level III evidence [retrospect cohort]) LaPrade RF, Johansen S, Wentorf FA, Engebretsen L, Esterberg JL, Tso A. An analysis of an anatomical posterolateral knee reconstruction: an in vitro biomechanical study and development of a surgical technique. Am J Sports Med. 2004;32:1405-14. In this biomechanical study, 10 cadaver knees with ligaments intact were sectioned and then reconstructed using a new two-graft technique developed by the authors. Results showed no difference between intact and reconstructed knees in testing at any flexion angle with regard to external rotation loads. With regard to varus loads, there was a 2.8-mm difference in opening at 30°, but not at other flexion angles. Liow RYL, McNicholas MJ, Keating JF, Nutton RW. Ligament repair and reconstruction in traumatic dislocation of the knee. J Bone Joint Surg [Br]. 2003;85:845-51. In this retrospective case series of 22 dislocations (21 patients), 8 were treated acutely (50 years since 54% required early total hip arthroplasty after failed ORIF. (Level IV evidence) Laflamme GY, Alami G, Zhim F. Cement as a locking mechanism for acetabular screws in revision hip surgery: a biomechanical study. Hip Int. 2008;18:29-34. This biomechanical study supported the concept that cement is an effective locking mechanism for screw heads in acetabular revision shells with trabecular metal. Inserting screws into custom-drilled holes makes their heads protrude into the overlying cement mantle. Mears DC, Velyvis JH. Acute total hip arthroplasty for selected displaced acetabular fractures: two to twelve-year results. J Bone Joint Surg [Am]. 2002;84:1-9. This study assessed the role of acute THA in a selected group of patients with 57 displaced acetabular fractures. Forty-five patients (79%) had an excellent or good outcome. The acetabular cups subsided an average of 3 mm medially and 2 mm vertically. All of the cups then stabilized, and none was loose at the latest follow-up evaluation. (Level IV evidence [case series]) Pakos EE, Ioannidis JP. Radiotherapy vs. nonsteroidal anti-inflammatory drugs for the prevention of heterotopic ossification after major hip procedures: a meta-analysis of randomized trials. J Int J Radiat Oncol Biol Phys. 2004;60:888-95. Grade-A meta-analysis of seven randomized studies (n = 1143) that compared the efficacy of radiotherapy (RT) with nonsteroidal anti-inflammatory drugs (NSAIDs) in the prevention of heterotopic ossification (HO) after major hip procedures. Overall RT tended to be more effective than NSAIDs in preventing Brooker 3 or 4 HO (risk ratio, 0.42; 95% confidence interval, 0.18–0.97). Although absolute differences may be small, postoperative RT is on average more effective than NSAIDs in preventing HO after major hip procedures, and its efficacy is dose dependent. Richmond J, Helfet DL. The elderly patient with an acetabular fracture. In Tile M (ed). Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia: Lippincott Williams & Wilkins, 2003:756-69. These authors determined that acute THA should be reserved for geriatric patients in whom the prognosis for a functional hip joint is hopeless. They recommended the use of standard plates and screws and cautioned against the use of the prosthetic shell as a “hemispherical plate.” (Expert opinion)

877

(Level IV evidence) Tidermark J, Blomfeldt R, Ponzer S, Söderqvist A, Törnkvist H. Primary total hip arthroplasty with a Burch-Schneider antiprotrusion cage and autologous bone grafting for acetabular fractures in elderly patients. J Orthop Trauma. 2003;17: 193-7. In this small retrospective study of 10 patients treated acutely with a THA supported by a reinforcement ring (Burch-Schneider antiprotrusion cage), there were no signs of loosening of the acetabular component or stem in any of the patients at a mean follow-up of 38 months. (Level IV evidence [case series])

THA for Acetabular Fractures

Starr AJ, Reinert CM, Jones AL. Percutaneous screw fixation of fractures of the ilia wing and fracture dislocation of the sacro-iliac joint. J Orthop Trauma. 2002;16:116-23.

PROCEDURE 51

Total Hip Replacement for Intertrochanteric Hip Fractures Hans J. Kreder

THR for Intertrochanteric Hip Fractures

880

PITFALLS • Replacement is a more extensive surgical procedure than fracture fixation and may not be appropriate in the following situations: ■

Bedridden individuals or wheelchair users

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Limited household ambulators or low-demand patients

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Patients with major cardiovascular comorbidity or other surgical risk factors

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Patients with pathologic fractures and life expectancy less than 6 weeks (not expected to survive past the early recovery phase following replacement surgery and thus the added surgical morbidity of replacement would not be expected to provide any benefit)

Indications ■

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All indications should be considered relative as the decision to perform total joint replacement surgery for intertrochanteric hip fractures remains controversial. Patient factor prerequisites: • No major cardiovascular comorbidity (i.e., that would preclude a primary total hip replacement under elective circumstances) • A patient who is at least community ambulatory Relative injury-related indications (in the presence of an intertrochanteric or subtrochanteric fracture): • Pre-existing symptomatic hip joint arthritis • Complex proximal femoral fracture through osteopenic bone(fixation likely to result in significant malunion, including femoral neck shortening, weakness, and decreased function in a community ambulator) • Pathologic fracture • Nonunion or significant malunion with weakness and functional loss after previous fixation attempts

Controversies • Total joint replacement for intertrochanteric hip fractures remains a controversial treatment option at this time. The lack of good quality information regarding the following issues hinders the resolution of this controversy: ■ What is the relative mortality and morbidity of total joint replacement versus fracture fixation? ■ How do various degrees of proximal femoral malunion affect patient pain and function? ■ Does immediate total hip replacement result in a better outcome than salvage after failed fixation attempts? ■ What type of replacement should be performed: cemented versus uncemented? unipolar, bipolar, or total hip replacement? calcar replacement/short-stemmed implant/ long-stemmed implant? trochanteric fixation method?

881

• Fracture fixation ■ Intramedullary ■ Extramedullary ■ With or without bone augmentation—cement or bone substitute • Replacement (implants and fixation) ■ Femoral and acetabular side ■ Bipolar ■ Unipolar ■ Short or long femoral stem ■ Cemented or uncemented femoral stem ■ Trochanteric fixation: claw device attached to femoral component, short claw secured with cables, or long claw/plate secured with cables and screws

Examination/Imaging ■

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Careful templating is mandatory to avoid hip instability and leg length inequality. It is better to template the intact side as the fracture significantly distorts the radiographic landmarks on the injured side. The following plain radiographic films are required for this purpose: • Anteroposterior (AP) pelvis radiograph centered low to show both hip joints and the affected and intact proximal femurs, as in the AP pelvis radiograph in Figure 1, showing a complex osteopenic proximal femur fracture. • Lateral radiograph of the affected hip. • Full-length femur AP and lateral views to include the knee should be considered. On these views, one should: ◆ Note the presence of deformity or hardware. ◆ Pay particular attention to the femoral bow if a long-stemmed implant is considered. ◆ Look for additional lesions if dealing with a pathologic fracture (Fig. 2). Pathologic fractures demand a complete local and systemic workup to detect other lesions locally or in other body regions, and to stage the disease overall (prognosis and systemic treatment requirements).

FIGURE 1

FIGURE 2

THR for Intertrochanteric Hip Fractures

Treatment Options

THR for Intertrochanteric Hip Fractures

882

Surgical Anatomy

PEARLS

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• Drape the affected leg free from just above the iliac crest, with the entire leg covered with a “leg stocking” up to approximately 10 cm below the groin. • An adhesive drape folded in half (adhesive side out), placed into the groin and joined by a second adhesive drape from the top (lateral) side of the leg, allows complete isolation of the groin.

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Bone (Fig. 3) • Greater trochanter • Lesser trochanter • Medial calcar Muscles (Fig. 4) • Gluteus medius • Vastus lateralis • Iliopsoas tendon • Effects of deforming forces (Fig. 5A and 5B)

Gluteus medius

Piriformis insertion

Greater trochanter Medial calcar Iliopsoas

Lesser trochanter Vastus lateralis

FIGURE 4 FIGURE 3

A FIGURE 5

B

883

Positioning ■ ■

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Regular operating room table Lateral decubitus position (must be held securely to avoid cup malposition) (Fig. 6). Bottom knee padded under peroneal nerve Padding between legs

Portals/Exposures ■ ■

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FIGURE 7 Cadaveric Dissection

A modified Hardinge or lateral approach is used. An oblique incision is made from 2 to 5 cm above the posterior margin of the greater trochanter distally for approximately 8–10 cm (Fig. 7). The incision can be enlarged proximally and distally if needed depending on the size of the patient. The iliotibial band is split from distal to proximal, extending into the interval between the tensor fascia lata and the gluteus maximus or into the lateral aspect of the gluteus maximus (Fig. 8).

FIGURE 8

THR for Intertrochanteric Hip Fractures

FIGURE 6

THR for Intertrochanteric Hip Fractures

884 ■

PITFALLS • Beware beanbag use for holding a large patient in the lateral decubitus position as patient orientation relative to the floor may shift during limb manipulation, possibly leading to malorientation of the acetabular component. Secure patient positioning is preferred, especially in large patients. • Frail elderly patients may have stiff shoulders and elbows. Great care must be taken to avoid injury during lateral positioning. All dependent extremities must be carefully padded. The upper arm may be supported by a pillow or lateral arm rest. A flannel sheet placed between the legs provides padding but is thin enough to allow palpation of the opposite limb for intraoperative leg length determination. ■

The deep dissection depends on the precise nature of the fracture. The principles are as follows: • The surgeon should spend some time analyzing the bone fragments and soft tissue attachments before detaching soft tissues. The gluteus medius is identified, and the gluteus minimus tendon palpated from anteriorly deep to the abductors. The relationship of muscle disruption to the trochanteric fragments is noted, and if possible areas of muscle disruption are worked through (using a transtrochanteric approach but without dividing the posterior soft tissue attachments from the trochanter). • Usually the injury has already detached the greater trochanter partially or completely from the intertrochanteric region or the subtrochanteric region. As much soft tissue should be left attached as possible, and the trochanteric fragment retracted posteriorly and superiorly (Fig. 9). • If necessary, the anterior portion of the gluteus medius is detached in a fashion similar to a routine total hip replacement via a modified Hardinge approach (see below). The anterior portion of the gluteus medius and vastus lateralis along with the gluteus minimus tendon is elevated off the joint capsule. • The cleavage point proximally is identified by palpating the small notch in the greater trochanter or by palpating the most anterior aspect of the femoral neck beneath the abductor muscle from anteriorly. • The gluteus is split along its fibers proximally for up to 2 cm. • Distally the tissues are elevated using electrocautery just anterior to a palpable

FIGURE 9

885

• Splitting the gluteus medius along its fibers is important to avoid undue muscle injury. Note that the fibers may be horizontal because the proximal femur is displaced superiorly.

PITFALLS • Be careful to initiate the split of the iliotibial band distally in the midpoint (from posterior to anterior) or even slightly anterior to the midpoint to avoid entering the gluteus maximus insertion. • Elevating the rectus muscle fibers off the joint capsule is relatively safe superiorly and anteriorly. Care must be taken to avoid injury to vessels located inferiorly. A Cobb elevator can be used to isolate the capsule in this area before completing the capsulotomy or capsulectomy.

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prominence on the anterolateral aspect of the greater trochanter to approximately 1 cm into the first muscle fibers of the vastus lateralis. A small sharp Hohmann retractor is placed along the neck of the femur over the brim of the pelvis just below the anterior inferior iliac spine. This helps to initiate the dissection between the hip joint capsule and the overlying rectus femoris muscle fibers. A sharp pair of capsulotomy scissors or a scalpel blade is then used to elevate the rectus off the joint capsule. A second small sharp Hohmann retractor can be inserted into the iliac wing just above the hip joint using a mallet. The capsular exposure can then be completed under direct visualization. A capsulotomy or capsulectomy may now be performed. • A capsulectomy should be initiated from anteriorly and as far inferiorly as can be safely visualized (bleeding is often encountered inferiorly). ◆ The blade is drawn superiorly around the femoral head and posteriorly under the abductor muscles. Posterior retraction of the abductor muscles and abduction of the leg allow for safe posterior capsular incision. ◆ The blade is then drawn along the femoral neck and turned 180° to come from above distally along the femoral neck insertion of the capsule. The resulting upside-down U-shaped flap of capsule is detached distally, taking care to avoid dividing any vessels in the adjacent soft tissues (Fig. 10).

U-shaped capsulectomy

FIGURE 10

THR for Intertrochanteric Hip Fractures

PEARLS

THR for Intertrochanteric Hip Fractures

886

FIGURE 11

Controversies • Alternative approaches include the posterior approach and anterior approach. • Historically the posterior approach was associated with a higher dislocation rate. However, less invasive posterior approaches may have dislocation rates similar to other approaches. • Historically the anterolateral approaches have been associated with a higher risk of injury to the innervation of the gluteus medius (the superior gluteal nerve). However, less invasive anterolateral approaches do not jeopardize the innervation.

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T capsulotomy

• A capsulotomy is made by first adjusting the anterior Hohmann retractor to a position along the middle of the femoral neck and over the brim of the pelvis. A scalpel blade is then drawn from this retractor along the femoral neck. Superior and inferior flaps are then created resulting in a upsidedown T-shaped capsulotomy (Fig. 11). ◆ The limbs of the T are created by placing the scalpel inside the capsule and detaching the capsule from inside out along its insertion on the femoral neck superiorly and inferiorly. ◆ Posterior retraction of the abductor muscles and abduction of the leg allow for safe superior capsular incision. Care must be taken to avoid injury to the abductor muscles. The femoral head is extracted using a “corkscrew” threaded into the femoral head. If total hip replacement is being performed, the acetabulum may now be exposed using four small Hohmann retractors placed around the acetabulum to retract the muscles and capsule (if present).

Procedure STEP 1 ■ If a total hip replacement is chosen (as opposed to a bipolar implant), acetabular preparation is undertaken first. • The acetabulum is prepared in standard fashion and the acetabular component inserted. Even in osteoporotic bone, an uncemented acetabular component (with screws if needed) provides excellent results.

887

• For pathologic fractures of the proximal femur, a cemented component is recommended as radiation and chemotherapy may prevent bone ingrowth. • A stable calcar platform that allows immediate weight bearing must be created. In rare cases where the fracture extends well below the lesser trochanter, a custom prosthesis or strut allograft would be required to replace the missing calcar with metal or to support the compromised host bone with allograft (although implants up to 70 mm of calcar replacement are commercially readily available and should suffice in all but the most extreme cases). Alternatively, the implant may be cemented into position. • Similar to the revision situation, stability of the hip joint is enhanced by selecting a large femoral head and a liner with a lip that can be positioned superolaterally.

PITFALLS • During trial reduction with the greater trochanter not yet repaired, care must be taken to avoid excessive leg lengthening to achieve a sense of stability. The hip will not be stable until the trochanter is repaired. The shuck test is not useful in this situation. Stability should be assessed with the hip placed under axial load.

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• A large-internal-diameter liner with a lip placed superolaterally is recommended to minimize the risk of dislocation. Femoral preparation requires careful attention to detail to ensure that correct length and femoral component anteversion is achieved. • If the fracture involves the lesser trochanter, it is sometimes still possible to use that as a landmark by reducing and temporarily clamping or cabling it into place. The greater trochanter can sometimes also be used as a landmark in this way. • Calcar replacement stems are usually required to create a calcar platform that can bear the patient’s body weight immediately (Fig. 12). This may require a low cut in host bone and a long metal calcar replacement stem. • Once the final femoral implant is correctly positioned in the femoral canal, a trial reduction is undertaken to assess leg length and stability. • Leg length is based partly on the preoperative template and also on the intraoperative comparison with the opposite leg. ◆ With the knees together, the operated leg should be a few millimeters shorter than the opposite leg to account for the relative leg adduction. ◆ With the operated leg abducted to neutral abduction, the two legs should seem the same length, but it may be difficult to ensure that the knees and ankles are in the same position.

FIGURE 12

THR for Intertrochanteric Hip Fractures

PEARLS

THR for Intertrochanteric Hip Fractures

888

Controversies

Instrumentation/Implantation

• Cemented versus uncemented implants ■ Cemented implants achieve immediate stable fixation and allow for antibiotic addition to the cement. However, cement pressurization can cause pulmonary shunting, especially in elderly frail patients. Cement between the shaft and trochanteric fragments may prevent trochanteric union. Cement integrity fails over time, possibly accelerated by falls and other injuries, leading to failure and the need for revision. ■ Uncemented implants are associated with less pulmonary compromise and, once ingrown, failure is limited to interface wear. Implants must be chosen carefully (calcar replacement, long stems) to allow immediate weight bearing in the elderly population to minimize the complications associated with immobility. • Long stem versus short stem for pathologic proximal femur fractures due to bone metastases ■ Traditionally a long cemented stem has been recommended to protect as much of the femoral shaft as possible. However, a short stem is associated with less risk of fat embolization, and a pathologic lesion or fracture below the stem can be treated with extramedullary constructs.

• Revision hip implant sets must be available. Rarely, primary hip implants can be used. • Two large pointed reduction forceps should be available to use for reapproximating the lesser and greater trochanter (needed to gauge implant position). • Wires or cables are rarely needed for this step to recreate an intact femoral tube before femoral preparation. • Strut allograft is rarely required for creating a stable calcar platform. If used, it should be cabled into position at the level of the calcar over the compromised host bone. If possible, it is usually preferable to make a lower cut in host bone and to use a longer calcar replacement metal implant.

• When assessing stability, one must consider the normal contribution of the intact greater trochanter to stability. ◆ Stability is assessed by axially loading the hip (to recreate the effect of the intact greater trochanter) and then assessing rotation, flexion, and adduction. ◆ The “shuck test” is useless in this scenario; rotation must be judged in the absence of landmarks relative to knee position (Fig. 13). Broach handle relative to knee (positioned perpendicular to the floor).

FIGURE 13

889

FIGURE 14

A FIGURE 15

B

THR for Intertrochanteric Hip Fractures

STEP 2 ■ Restoration of hip abductor function through trochanteric reattachment is essential for hip stability and normal gait. The reconstruction should allow immediate weight bearing. ■ A long trochanteric claw/plate construct is preferred. • If possible, screw fixation should be obtained distal to the tip of the implant. However, with longstemmed implants this may not be possible, in which case multiple cables must be used to secure the plate. • Use of a short plate with the proximal wire above the lesser trochanter may result in plate failure (Fig. 14). Replacement with a long plate makes the claw/plate construct more secure (Fig. 15A and 15B). ■ First the plate is slid underneath the vastus lateralis muscle (see Video 1). ■ The claw is impacted into the greater trochanteric fragment. ■ The trochanteric fragment is held in the claw by passing a wire around the greater trochanter and the claw. Some implants have specially designed grooves or holes in the claw and the plate to facilitate wire placement without slippage, but careful wire placement should enable any device to be used. ■ Hip abduction facilitates approximation of the greater trochanter against the remaining femoral shaft. A large pointed reduction forceps may help in this process as well.

THR for Intertrochanteric Hip Fractures

890 ■

PEARLS • Hip abduction facilitates boneto-bone contact between the greater trochanter and the femoral shaft, which is essential if a fibrous union or nonunion is to be avoided. • Cables (as opposed to wires) should be used to achieve secure plate fixation for a long enough period to allow the trochanteric fracture to unite. • If possible, a screw should be passed through the plate below the femoral prosthesis. Fluoroscopy is not required for this step if care is taken to measure out the length of the prosthesis relative to a bone landmark before implant insertion.

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With the trochanteric fragment held in correct position, the plate is secured first proximally with an oblique cable from below the lesser trochanter to the upper portion of the plate/claw. Distally the plate is secured with a screw if possible or multiple cables. A minimum of four cables along the femoral shaft should be used. Some revision hip systems allow placement of sutures through metal flanges that may be useful in attaining additional trochanteric fixation. Once the trochanteric fixation is complete, the wound is closed in layers as per routine total hip replacement. Drains are not used.

PITFALLS • Failure to achieve contact between the greater trochanter and the femoral shaft prevents bone union.

• Most cable instrument sets include cable passers of two or more diameters. The smallest diameter passer that can be placed around the femur should be chosen. This facilitates passage directly on bone, thus avoiding injury to neurovascular structures.

• Failure to pass a cable around the trochanteric fragment to secure it to the claw can result in trochanteric escape from underneath the claw, leading to nonunion and loss of abductor function.

Instrumentation/ Implantation

• Care must be taken to avoid injury to the sciatic nerve, which is vulnerable during the passage of both the proximal cable just below the lesser trochanter and all cables along the femoral shaft distally.

• Long claw/plate construct, preferably one that allows cables to be secured to the plate • Cable passing system and bone cables

• Avoid stripping the entire length of the vastus medialis from the femoral shaft. Cables can be passed with limited exposure underneath the muscle. When selecting a space for cable passing, it is important to carefully expose the site from behind and to identify any perforating vessels that might be encountered. It is often possible to work around these vessels without ligating them. However, blind cable passage may lacerate a vessel, resulting in hemorrhage that may be difficult to control after the cable is passed.

• Rarely, arterial injury can occur due to passage of a cable, especially in the most distal part of the femoral shaft.

Postoperative Care and Expected Outcomes ■

Postoperative care • Immediate weight bearing is permitted as tolerated. • The patient should avoid abductor strengthening exercises for 6 weeks.

891

• Elderly patients should be allowed immediate weight bearing as tolerated. The repair must be secure enough to permit this activity.

PITFALLS • Failure to allow weight bearing as tolerated leads to prolonged hospitalization and a higher risk of multiple complications related to immobility.

Controversies • Trochanteric fixation that allows immediate weight bearing is desireable. ■ Cables alone, short or long claws, and direct suture to implants are possible. There are no comparative studies. Long claws with distal fixation provide sufficient stability for immediate weight bearing. ■ Some advocate locking implants. No comparative studies exist to compare locked and nonlocking implants in this setting. However, locked implants have been successfully used in the setting of periprosthetic fractures.

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• Implementation of so-called hip precautions is at the discretion of the surgeon and should follow the usual revision protocol. • Venous thromboprophylaxis should follow the institution’s routine protocol for revision total hip replacement patients. Potential complications • Immediate postoperative footdrop could be due to a cable having been placed around the sciatic nerve. The patient should be returned to the operating room for exploration immediately. • Rarely, arterial injury resulting from cable passage may manifest as an ischemic foot in the immediate postoperative period. Urgent vascular consultation, angiography (to determine the site of injury), and urgent surgical exploration and vascular repair are required in this situation. • Other complications are similar to those that might occur after routine revision total hip replacement.

Evidence Berend KR, Hanna J, Smith TM, Mallory TH, Lombardi AV, Jr. Acute hip arthroplasty for the treatment of intertrochanteric fractures in the elderly. J Surg Orthop Adv. 2005;14:185-9. Parker MJ, Handoll HHG. Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults. Cochrane Database of Systematic Reviews. 2006;(2):CD000086. Pieringer H, Labek G, Auersperg V, Böhler N. Cementless total hip arthroplasty in patients older than 80 years of age. J Bone Joint Surg [Br]. 2003;85:641-5. Pitto RP, Blunk J, Kößler M. Transesophageal echocardiography and clinical features of fat embolism during cemented total hip arthroplasty: A randomized study in patients with a femoral neck fracture. Arch Orthop Trauma Surg. 2000;120:53-8. Waddell JP, Morton J, Schemitsch EH. The role of total hip replacement in intertrochanteric fractures of the femur. Clin Orthop Relat Res. 2004;429:49-53.

THR for Intertrochanteric Hip Fractures

PEARLS

PROCEDURE 52

Optimizing Perioperative Fracture Care Dominique M. Rouleau, Marie-Ève Rouleau, and G. Yves Laflamme

Optimizing Perioperative Fracture Care

894 ■

PITFALLS • A young patient can compensate for significant blood loss and maintain normal vital signs. • An older patient may be unable to increase the heartbeat secondary to cardiac medication. • An intoxicated patient can be misleading secondary to absence of pain sensation and a poor injury history. • The orthopedic surgeon must not undertake care of unstable traumatized patients alone. Teamwork is more efficient and must be prioritized when possible. Physicians from emergency medicine, intensive care, anesthesiology, and general surgery are most often involved in ATLS.

PEARLS

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ADVANCED TRAUMA LIFE SUPPORT* Indications ■

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• In the case of an unstable or severely traumatized patient, three supportive care measures must be instituted on arrival:

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Supplemental oxygen

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Two large-gauge intravenous access lines

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Monitoring

• A complete blood test and blood typing must be done. Complete vital signs must be taken. • Chin lift or jaw thrust maneuvers can help keep airways open. • Definitive airway management by orotracheal intubation or cricothyroidotomy must be done by the appropriate caregiver while maintaining the cervical spine in the neutral position by manual immobilization.

Any patient who sustains a moderate- to high-energy injury must be evaluated with the Advanced Trauma Life Support (ATLS) protocol. Other indications for ATLS evaluation include: • Pelvis fracture • Femur fracture • Decreased level of consciousness or intoxication • Multiple injuries

Examination/Imaging

• When possible, a complete trauma team must be available on patient arrival.

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This chapter describes several perioperative principles and techniques that are of importance in the care of injured patients. The goal of this chapter is to synthesize relevant information, enabling the orthopedic surgeon to provide the best global care for his or her patient based on actual literature. The subjects selected are Advanced Trauma Life Support, initial care of the injured limb, thromboprophylaxis, antibiotic prophylaxis, psychological reaction to injury, and secondary prevention.

The principle of the “golden hour” is now part of standard care in every health center from the small rural health center to the Level One Trauma Center. ATLS evaluation is done according to the following steps: • A— Airway (with cervical spine protection) • B— Breathing • C— Circulation: includes stopping bleeding • D—Disability: neurologic status • E— Exposure (undress)/Environment (temperature control)

Procedure STEP 1: AIRWAY ■ Airways are evaluated first in the “primary survey.” • In the primary survey, physicians must evaluate and treat the patient following the ABCDE sequence (see Examination/Imaging above). • Injuries must be addressed and treated following logical steps according to vital signs and injury mechanisms. *Portions of this section are adapted from American College of Surgeons. Advanced Trauma Life Support for Doctors—Student Course Manual, ed 7. Chicago: American College of Surgeons, 2004.

895

• Posterior sternoclavicular dislocation can be involved in airway obstruction. This rare condition can be identified by palpation of the sternoclavicular joint during tracheal and neck examination. Closed reduction with traction using a towel clamp can be undertaken in extreme situations with the collaboration of a thoracic surgeon. Posterior dislocations have associated intrathoracic injuries in 30% of the cases. The mortality in this subset of patients is reported to be 12.5%, and such associated conditions must be ruled out before attempting reduction.

PEARLS • Inspection, palpation, and auscultation must be done to identify tension pneumothorax, flail chest, massive hemothorax, open pneumothorax, tracheal or bronchial rupture, or diaphragmatic rupture. Modification of ventilation and chest drainage must be done when necessary.

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To assess the airway, the physician must examine the mouth for any foreign body and signs of burns. A patient who can speak and has a Glasgow score over 8 (see Step 4) is not likely to have airway obstruction.

STEP 2: BREATHING ■ Breathing is the second step of the ATLS sequence. ■ Oxygenation (normal: > 95% saturation) and breathing rhythm (normal: 15–20 breaths/min) out of normal range are red flags for deficient air entry. ■ Ventilation requires proper function of chest wall muscles, diaphragm, and lungs. STEP 3: CIRCULATION ■ Circulation and hemorrhage control represent the next step. ■ Increased heart rate, decreased blood pressure, pale skin color, and a decrease of the level of consciousness are all signs of impaired circulation. ■ Immediate volume repletion must be initiated with 2 L of crystalloid. Units of blood and colloid and coagulation products (platelets and plasma) must be ready for use in patients with unresponsive severe shock. ■ A systematic review of possible bleeding causes includes external blood loss, thoracic bleeding, abdominal bleeding, pelvic bleeding, and internal hemorrhagic bleeding around a long-bone fracture. • Immediate immobilization of a fracture decreases bleeding, decreases pain, and slows the inflammatory reaction. • A pelvic fracture can be immobilized by a simple draping around the greater trochanter and at the knees (Fig. 1). PITFALLS • Direct manual pressure is the safest way to stop external bleeding. Hemostatic clamps can damage neurologic structures when used in a suboptimal setting in the emergency room. • A pneumatic tourniquet must not be used when the extremity is salvageable because the tourniquet can cause irreversible limb ischemia.

PEARLS

FIGURE 1

• The orthopedic surgeon must be particularly attentive to external bleeding of the extremities, unstable pelvis fractures, and femoral fractures.

Optimizing Perioperative Fracture Care

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PITFALLS

Optimizing Perioperative Fracture Care

896

Instrumentation/ Implantation • Specialized pelvic belts must be available in multiple sizes in trauma centers. • Long-bone fractures can be stabilized by longitudinal skin traction and a well-padded splint. • External bleeding must be controlled by direct manual pressure.

PEARLS • This evaluation is not possible after sedation and intubation. When possible, a quick neurologic assessment can be done before the use of sedation.

PITFALLS • The physician must remember that patients with spine or head injury can develop neurogenic shock. Typically bradycardia and low blood pressure are associated with that kind of shock.

PEARLS • Hypothermia is a frequent consequence of trauma; therefore, room temperature in the trauma suite must be adjusted according to patient need.

PITFALLS • The contraindication to urinary catheterization is a suspected urethral injury. • If the cribriform plate is fractured, a gastric tube must be inserted orally to prevent intracranial passage.

STEP 4: DISABILITY (NEUROLOGIC STATUS) ■ Evaluation for neurologic disability must be done at the end of the primary survey using pupillary size and reaction, lateralizing signs, and level of spinal cord injury. ■ The Glasgow Coma Scale score is used to quantify the level of consciousness. Three responses are tested, and the scores for each are totaled: • Eye opening ◆ Spontaneous: 4 ◆ To speech: 3 ◆ To pain: 2 ◆ None: 1 • Best motor response ◆ Obeys commands: 6 ◆ Localizes pain: 5 ◆ Normal flexion (withdrawal): 4 ◆ Abnormal flexion (decorticate): 3 ◆ Extension (decerebrate): 2 ◆ None (flaccid): 1 • Verbal response ◆ Oriented: 5 ◆ Confused conversation: 4 ◆ Inappropriate words: 3 ◆ Incomprehensible sounds: 2 ◆ None: 1 STEP 5: EXPOSURE/ENVIRONMENT ■ Finally, patients must be completely undressed to complete the assessment. ■ Control of the patient’s body temperature should be obtained. ■ At this point, an electrocardiogram can be obtained, and urinary and gastric catheterization can be done. STEP 6: SECONDARY SURVEY AND TRANSFER DECISION ■ Before undertaking the secondary survey, results of blood tests and arterial blood gases must be verified. ■ Judicious radiologic and abdominal tests must be requested. • In the situation of an unstable patient, anteroposterior radiographs of the chest and pelvis can provide important information. Lateral cervical spine radiographs can also be obtained at this time.

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• Initial treatment of lifethreatening injuries or limb salvage can be undertaken before transfer in agreement with the consultant trauma center.

■

• All fractures must be stabilized in a splint or traction before transfer. • Transfer of patients with pelvic fractures must be done with a stabilization device.

PITFALLS • A normal or inadequate radiograph does not exclude spinal injury. When in doubt, the entire spine must be protected at all times. • The orthopedic team must ensure that the patient does not evidence any limb-threatening injuries. These injuries are easy to miss in a polytrauma patient or unconscious patient.

■

• Nondisplaced fractures or isolated dislocations can also be neglected. Liberal use of radiography, vascular Doppler examinations, and compartment pressure monitoring must be done if any doubt arises during physical examination or because of injury mechanism.

■

• Abdominal ultrasonography and diagnostic peritoneal lavage are useful tools when used by an experienced physician. After the primary survey, the physician in charge often has enough information to determine if transfer to a trauma center is needed. Criteria for transfer are: • Glasgow score under 13 • Systolic blood pressure under 90 mm Hg • Respiratory rate under 10 or over 29 breaths/min • Flail chest • Multiple long-bone fractures • Amputation • Penetrating trauma to head, neck, torso, or extremity proximal to elbow or knee • Open or depressed skull fracture • Limb paralysis • Unstable pelvic fracture • Major burns • Significant mechanism of injury • Significant previous comorbidity • Pediatric patients After completion of the primary survey and the resuscitation phase, a second survey can begin. This is done only when the patient is stable and has normal vital signs. • Each part of the body must be examined from head to toe. • A past medical history and a history of the mechanism of injury must be obtained at this point. The AMPLE mnemonic is used to obtain a complete history: ◆ A— Allergies ◆ M— Medications ◆ P— Past illnesses/Pregnancy ◆ L— Last meal ◆ E— Events/Environment related to the injury The role of the orthopedic surgeon in the secondary survey is to identify all significant musculoskeletal injuries, guided by injury mechanism and energy level. • The first step is to look for deformity, redness, edema, wounds, or any sign of blunt trauma. Every part of the body must be examined. • A careful mobilization must be done “en bloc” to examine the back, buttocks, and posterior aspect of the legs (see Logrolling Mobilization Technique below).

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PEARLS

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PITFALLS • Logrolling a patient with an unstable pelvis fracture can increase blood loss and cause a decrease of blood pressure. An intravenous fluid bolus must be give before logrolling in these patients. • The logrolling side must be chosen with respect to the patient’s injury. The side with more injuries must be kept up. • The appropriate analgesia must also be given to prevent excessive pain during mobilization.

• Pelvic and femoral fracture identification is important because either can lead to significant blood loss. The orthopedic surgeon must also check carefully for signs of any limb-threatening injuries. • Vascular injury ◆ Decreased or absent pulse ◆ Cold limb ◆ Pale or white limb ◆ Slow capillary refill ◆ Significant bleeding from an open wound • Compartment syndrome ◆ Tense edema ◆ Positive stretch test ◆ Severe pain ◆ Paresthesia ◆ Paresis • Open fracture ◆ Open wound ◆ Anal or vaginal bleeding (pelvic fracture)

LOGROLLING MOBILIZATION TECHNIQUE Indications ■

■

Every patient at risk of spinal injury must be mobilized using the logrolling technique. This technique must be used during every patient mobilization until the complete spinal evaluation has showed no lesion.

Positioning ■

■

A careful mobilization must be done “en bloc” to examine the back, buttocks, and posterior aspect of the legs. The technique of mobilization is important to minimize spinal movement. Three persons are needed. • One person stabilizes the head and neck. This person must lead every step in patient mobilization. • Two others stand together on the side of the patient that is the least injured. ◆ The second person, standing at trunk level, places one hand on the shoulder furthest from him or her and the other hand on the greater trochanter.

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• Verbal and visual contact among the three persons responsible for patient mobilization is essential.

■

Procedure PEARLS • The person responsible for head and neck immobilization must give a clear order to ensure a coordinated movement of the mobilization team: “On my count, we will turn the patient on his right side at 3, slowly: . . . 1, . . . 2, . . . 3, . . . turn.”

PEARLS • A fourth person must be available to examine the patient’s back, to remove all foreign bodies, or to change drapes.

A FIGURE 2

STEP 1 ■ The person holding the patient’s head must ensure that the team is well positioned to do the logrolling. ■ Figure 2A shows the logrolling starting position. • Note that a rigid cervical collar must be used in a trauma patient. STEP 2 ■ The person holding the patient’s head coordinates logrolling of the patient onto his or her less injured side (Fig. 2B). STEP 3 ■ The patient’s back, buttocks, and posterior aspect of the legs are examined while he or she is stabilized on the less injured side. STEP 4 ■ The person holding the patient’s head coordinates logrolling of the patient back to the supine position.

B

Optimizing Perioperative Fracture Care

The third person is at pelvic level and places one hand at the T12 level and the other hand at thigh level. All movements are done in a coordinated way to keep the patient’s spine as straight as possible. ◆

PEARLS

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PEARLS • The person responsible for head and neck immobilization must give a clear order to ensure a coordinated movement of the mobilization team to roll the patient back to the supine position: “On my count, we will roll back the patient on his back at 3, slowly: . . . 1, . . . 2, . . . 3, . . . turn.”

INITIAL CARE OF THE INJURED LIMB ■

■

PITFALLS • Patient with open fractures can develop severe infection that is impossible to assess under a splint. • Signs of vascular impairment can be hidden by a splint. • Signs of compartment syndrome can be masked by a splint. • Frequent assessment of soft tissue under the splint must be done.

Treatment Options • Traction can also be used for lower limb injuries.

This topic seems very straightforward. Adequate immobilization, sufficient pain management, and providing walking aids are three easy things to do. However, a study undertaken at our center revealed alarming rates of low-level care quality by referring first-line physicians or referring orthopedic surgeons. In our study, 166 patients referred to the fracture clinic for a limb injury were evaluated during a 4-month period (Rouleau et al., 2009). • Thirty percent of patients who needed immobilization for a fracture had not received it after seeing the first referral doctor. • At the time of the orthopedic evaluation, 50% of patients felt pain of 5/10 or more, and 30% of patients did not receive any analgesic medication and stated that they needed it. Twenty-one percent of patients who received pain medication stated that it was insufficient to allow them to sleep or rest peacefully. The group of patients with unacceptable analgesia had a significantly higher level of pain (6/10) compared to 4/10 on average for patients with adequate analgesia (p < .05). • Thirty-two percent of patients who needed a walking aid did not receive any prescription for it. These patients had a significantly higher level of pain (6/10) when compared to patients with appropriate walking aid prescriptions (4/10) (p < .05).

Limb Immobilization PEARLS • All open wounds must be first cleaned and covered by a sterile dressing. • Cotton roll is an easy-to-use padding to protect the skin from pressure points.

PITFALLS • Extra layers must be applied on bony eminences such as the ankle, malleoli, and olecranon.

■

Initial care for limbs that have sustained fracture or dislocation includes the following: • Good immobilization must be done after proper realignment and a neurovascular evaluation. • Splints are recommended for initial management because they can accommodate the initial swelling.

STEP 1 ■ A good splint must immobilize proximal and distal joints of the fractured bone or proximal and distal bone segments of an unstable joint. The splint must be made of three layers. ■ The first layer of a splint is the padding (Fig. 3A).

901

Optimizing Perioperative Fracture Care

A

B

C FIGURE 3

STEP 2 ■ The second layer is made of the stabilization material. ■ A regular plaster of Paris cast slab (Fig. 3B) or fiberglass can be used. PEARLS

• Coverage of 50% of the limb circumference is usually sufficient to create stability. Posterior and dorsal sides are normally used.

PITFALLS • Modeling of the hard material is very important to prevent pressure points and ensure sufficient stability. • More than 12 layers can increase the temperature inside the cast and cause burns. • Use of dip water over 24° C can increase the temperature inside the splint and cause burns.

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902

PEARLS • Neurovascular examination must be repeated after any splint application. • Repeat radiologic evaluation may also be necessary. • Classic use of an elastic bandage requires application from distal to proximal.

PITFALLS • This final step is crucial. A bandage that is too tight can cause neurovascular injury.

STEP 3 ■ The last layer is necessary to hold the splint in place. ■ Elastic (Fig. 3C) or nonelastic bandages can be used in a loose fashion.

Immobilization of Other Injuries ■

■

■

• Use of fiberglass over a regular plaster of Paris slab can increase temperature inside the splint and cause burns. • Resting the limb on a pillow during the drying is associated with dangerous temperature at the skin level.

Shoulder injuries cannot be immobilized by a standard splint. A sling and an abduction pillow are two examples of useful techniques for shoulder trauma. Pelvic and femoral fractures have specific needs. Skin traction and pelvic belts are used to stabilize these injuries. Immobilization of a spine injury cannot be accomplished by a splint. • A semirigid collar can be applied for cervical spine fractures. • Initial immobilization of dorsal and lumbar spine injuries can be achieved by bed rest.

Pain Management ■

■

Pain management is the second important part of initial limb injury care. Every patient with an orthopedic injury must have pain evaluation and management.

PEARLS • Regular checks for the development of compartment syndrome must be done. • The use of special mattresses to prevent pressure points is essential. • Every mobilization of a patient with a spinal injury must be done by “en bloc” mobilization (see Logrolling Mobilization Technique).

PITFALLS • The choice of appropriate medication and dosage must be made after considering the risks of drug interactions, comorbidities, medication allergy, age, weight, and presence of head injury. • High doses of narcotics can only be given under adequate medical observation. • Pain out of proportion to the injury can be a sign of compartment syndrome, neurologic injury, vascular compromise, or aggressive infection.

PROTOCOL ■ We recommend a progressive analgesia protocol. • Step 1: Immobilization, rest, walking aids, ice • Step 2: Acetaminophen 650 mg to 1 g four times daily as needed taken orally • Step 3: Anti-inflammatory drugs if there is no medical risk factor

903

Walking Aids ■

5cm ■

30˚

FIGURE 4

Finally, initial care of an injured limb must include the prescription of an appropriate walking aid in the presence of a lower limb injury. Walking aids vary depending on patient status and ability. • A cane is appropriate when partial weight bearing is safe. • Crutches require good balance and strong upper limbs and are recommended for younger patients. Adjustment of crutches is critical for effective mobilization. ◆ With the patient in a standing position, the crutch length is adjusted to obtain 5 cm of clearance under the axilla (Fig. 4). ◆ The crutch handle must be adjusted to create 30° of flexion at the elbow. • Older patients need more stability, which can be provided by a walker or a wheelchair.

Optimizing Perioperative Fracture Care

Naprosyn 250–500 mg every 12 hours as needed taken orally • Step 4: Non-narcotic analgesics ◆ Tramadol/acetaminophen 1–2 tablets every 4 hours as needed taken orally • Step 5: Narcotics (for moderate pain) ◆ Codeine 30–60 mg PO/subQ every 4 hours as needed taken orally ◆ Oxycodone/acetaminophen 1–2 tablets every 4 hours as needed taken orally • Step 6: Narcotics (for severe pain) ◆ Morphine 0.2 mg/kg PO every 3 hours as needed; 5–10 mg/dose for an adult (max. 20 mg/dose) ◆ Morphine 0.1 mg/kg subQ every 3 hours as needed; 2–5 mg/dose for an adult (max. 10 mg/ dose) ◆ Dilaudid 0.04 mg/kg PO every 3 hours as needed; 1–2 mg/dose for an adult (max. 4 mg/ dose) ◆ Dilaudid 0.015 mg/kg subQ every 3 hours as needed; 0.5–1 mg/dose for an adult (max. 2 mg/dose) ◆

Optimizing Perioperative Fracture Care

904

THROMBOPROPHYLAXIS AND FRACTURE ■

■

■

Preventing venous thromboembolism is of first importance in the treatment of an orthopedic trauma patient. Patients with hip fractures or proximal femur fractures have a 46–60% chance of suffering a deep venous thrombosis (DVT) and a 3–11% chance of having a pulmonary embolism. These numbers increase in the presence of pelvic fractures or spine fractures with neurologic deficit.

Identified Risk Factors for Thrombosis in Orthopedic Trauma Patients ■ ■ ■ ■ ■ ■ ■ ■

Age over 60 years Presence of cancer Prior venous thrombosis Molecular hypercoagulability (genetic disorder) Major trauma Obesity Surgery lasting 2 hours or more Bed rest for more then 72 hours

Current Recommendations ■

■

■

■

■

For thromboprophylaxis in patients with fractures of the pelvis, hip, or proximal femur, the use of lowmolecular-weight heparin (LMWH) is recommended (Grade 1) for at least 10 days and probably up to 28 days after the intervention. There is no clear advantage to LMWH for patients with isolated lower limb injuries below the knee. Patients suffering from spinal fractures are more at risk of DVT in the presence of a neurologic deficit, anterior surgical approach, and associated cancer. In patients other than those with fractures from the pelvis to knee or polytrauma patients, the orthopedic surgeon must use his or her own judgment to identify patients with higher DVT risk in the absence of clear evidence in the literature to guide the decision. Again, the benefits of LMWH must always be balanced by the bleeding risk, especially with trauma patients.

905

■

■

Infection after fixation of a fracture can be a terrible complication. Despite modern aseptic surgical suites and the use of antibiotics, the incidence of infection is still significant. According to a comprehensive study on 2195 patients, the incidence of infection after treating closed fractures is still around 2%.

Current Recommendations ■

■

In the literature, there is no Level I evidence-based article to provide information on the perfect regimen of antibiotics to give patients undergoing surgery for a fracture. In the absence of perfect scientific evidence, we found some serious systematic reviews and some recommendations from experts. • A meta-analysis on hip fracture surgery concluded that the use of intravenous (IV) antibiotics reduces the risk of postoperative infection (Southwell-Keely, 2004). The same study showed no advantage to multiple doses of postoperative antibiotics compared to only one dose (Grade A). • A review done by Schmidt and Swiontkowski (2000) recommended IV first-generation cephalosporin for 24 hours following the fixation of a closed fracture (Grade B). • According to a well-conducted systematic review, all open fracture patients must receive IV antibiotics as soon as possible (Grade A). The exact regimen of antibiotics most favorable to patients is not known. ◆ Experts recommend a first-generation cephalosporin until 24 hours after the skin is closed in an open fracture (Grade B). ◆ Gentamycin adjusted to weight and renal clearance must be given for Gustilo III fractures (Grade C). ◆ We recommend that the clinical evaluation of the wound dictate the length of time to give IV antibiotics for Gustilo III fractures (Grade C). • Penicillin must be given for injuries sustained on a farm or very contaminated injuries.

Optimizing Perioperative Fracture Care

ANTIBIOTIC PROPHYLAXIS AND TETANUS PREVENTION

Optimizing Perioperative Fracture Care

906

PSYCHOLOGICAL REACTION TO INJURY ■

■

■

The orthopedic surgeon treating injured patients is used to dealing with patients’ emotional reaction. Sometimes, it is clear that the emotional reaction is out of the normal range. It is important to identify these patients because psychological pathologies can interfere with patient collaboration in regimens of treatment. Cardiac surgery literature has shown an increased hospitalization length for patients with posttraumatic stress disorder.

Posttraumatic Stress Disorder ■

■

■

■

Posttraumatic stress disorder (PTSD) is a significant physico-psycho-emotional state following an overwhelming traumatic event. The typical symptoms are: • Flashbacks • Nightmares that are intrusive in nature • Sense of numbness and emotional blunting • Detachment from others • Unresponsiveness • Fear and avoidance of reminders of the trauma • Hyperarousal and hypervigilance These symptoms must be present for at least 1 month and they must have a significant impact on the patient’s functional status to be diagnosed as PTSD. If the symptoms have been present for less than 1 month and are still having a significant impact on the patient’s functional status, the patient has acute stress disorder. The prevalence of PTSD is high. • A study done on a cohort of 400 children recovering from a minor orthopedic injury showed that 33% had PTSD. • A similar study done on 580 adults showed a prevalence of PTSD of 51%. These authors devised a key statement to identify patients at risk for PTSD: “The emotional problems caused by the injury have been more difficult than the physical problems.” In patients who responded “yes” to that statement, the study showed a 78% chance of having PTSD.

907

■ ■ ■

Presence of concomitant head injury Hospitalization Social isolation and the loss of a significant person during the trauma

The Orthopedic Surgeon’s Responsibility ■

■

■

The orthopedic surgeon must guide the patient suffering from PTSD to the appropriate professional. A systematic review of various psychological therapies has shown that early cognitive behavioral therapy is efficient in decreasing the length and severity of psychological effects following trauma. When doing research on outcome after fracture treatment, most studies now use standardized questionnaires on patient perception of functions and limitations. It is important to know that patients with PTSD have a biased emotional attention and recall more negative events.

SECONDARY PREVENTION ■

■

■

When the surgeon sees an injured patient, it is already too late to prevent the trauma event. However, the literature shows that several interventions are possible in order to prevent future fractures or accidents. This is known as secondary prevention. Secondary prevention interrupts, prevents, or minimizes the progression of a disease or disorder at an early stage. The orthopedic surgeon can be a key agent of prevention in sports and car accidents, situations of domestic violence, and osteoporosis.

Prevention of Sport- and Accident-Related Injury ■

■

The literature lists some important risk factors for injury recidivism. The orthopedic surgeon must be aware of these risk factors. When a risk factor is noted, the patient must be oriented toward the proper resources.

Optimizing Perioperative Fracture Care

Risk Factors for PTSD

Optimizing Perioperative Fracture Care

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PEARLS • It has been shown that social services intervention is efficient in decreasing risk behavior and risk of injury recidivism.

RISK FACTORS FOR RECIDIVISM OF INJURY ■ Illegal drug or alcohol use • Some studies have shown that an alcohol consumption problem was present in 48% of patients admitted to a Level One Trauma Center. ■ Presence of psychiatric or mental illness ■ Being engaged in illegal activities ■ Being homeless MODALITIES THAT CAN DECREASE THE RISK OF INJURY ■ A recent Cochrane Database review underlined the efficacy of helmet use for cyclists to decrease head injury. ■ Use of wrist protectors when snowboarding has shown a significant reduction in wrist fractures. ■ Use of postinjury proprioceptive training decreases the risk of recurrent injury following an ankle sprain.

Domestic Violence ■

■

■

Domestic violence is an important issue in female health. • Domestic violence is the most common cause of nonfatal injury to a woman in the United States. • Four women in 10 have been victims of violence. • Thirty percent of all murdered females in the United States were killed by a husband or a boyfriend. • Half the mothers who reported that their children had been assaulted were also victims of domestic violence. The most frequent injuries caused by assault were to the head and neck. This type of injury was reported by 40% of women. The second most frequent type of injury, reported by 28% of women, affected the musculoskeletal system.

RISK FACTORS FOR A WOMAN TO OF AGGRESSION ■ Young age ■ Lower social status ■ Pregnancy ■ Short-term relationship ■ Drug or alcohol abuse

BE A

VICTIM

RED FLAGS OF DOMESTIC VIOLENCE ■ Head injury ■ Multiple injuries ■ Strange explanation for the injury ■ Different healing stages for lesions and delayed consultations

909

Osteoporosis ■

■

■

“Fragility fractures,” which result from low-trauma events such as a fall from standing height, affect one half of women and one third of men over 50 years of age. The risk of having a fracture for females over 50 years of age is almost 1 in 2, and the risk for males is 1 in 3. According to Osteoporosis Canada, 1.4 million Canadians suffer from osteoporosis (www. osteoporosis.ca).

DEFINITIONS AND ASSESSMENT ■ Osteoporosis has been defined by the World Health Organization as a bone mineral density of more than 2.5 standard deviations below the young adult mean. ■ Osteopenia has been defined as a bone mineral density of between 1 and 2.5 standard deviations below the young adult mean. ■ The American Academy of Orthopedic Surgeons has issued recommendations regarding fragility fractures. • Consider the likelihood that osteoporosis is a predisposing factor when a patient has a fragility fracture. • Advise patients with fragility fractures that an osteoporosis evaluation may lead to treatment that can reduce their risk of future fractures. • Initiate an investigation of whether osteoporosis is an underlying cause in patients with fragility fractures. The orthopedic surgeon may conduct this evaluation or may refer the patient to another medical provider. • Establish partnerships within the medical and nursing community that facilitate the evaluation and treatment of patients with fragility fractures.

Optimizing Perioperative Fracture Care

RECOMMENDATIONS ■ The orthopedic surgeon can use the following question to open discussion: “Did someone you know do this to you?” ■ We must be ready to inform women about available services. ■ We must support the woman in making a statement to the police. Social workers and community service organizations can be of great help. ■ Hospitalization, in extreme cases, can be indicated to protect our patients.

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910

• Urge hospitals and office practices to establish clinical pathways that ensure that optimal care is provided for patients with fragility fractures. TREATMENT RECOMMENDATIONS ■ Medications • Calcium and vitamin D supplements must be given to all women over 50 years of age and to every person who has had a fragility fracture. ◆ The recommended dose of calcium is 1500 mg/ day, with calcium citrate showing the better rate of absorption. ◆ Vitamin D dosage must be 800 units/day. • A bisphosphonate must be started in every person with osteoporosis or with osteopenia and a fragility fracture. ◆ Bisphosphonates have been shown to decrease the risk of fragility fractures by 50%. ■ Besides medications, other modalities have shown promising results in decreasing fragility fractures. • Weight-bearing exercises were shown to increase bone density in a randomized study. • Training programs and home care prevention programs have been shown to decrease the number of falls in women over 73 years of age.

Evidence ADVANCED TRAUMA LIFE SUPPORT American College of Surgeons. Advanced Trauma Life Support for Doctors—Student Course Manual, ed 7. Chicago: American College of Surgeons, 2004. Carmont MR. The Advanced Trauma Life Support course: a history of its development and review of related literature. Postgrad Med J. 2005;81:87–91. This review article noted that studies have shown significant loss of overall knowledge of ATLS after 4 years, justifying regular recertification. The principle of the “first golden hour” is now part of standard care in every health center from the small rural health center to the Level One Trauma Center. The mnemonic “ABCDE” is the basis of the ATLS sequential evaluation and intervention. (Grade B recommendation) Kuzak N, Ishkanian A, Abu-Laban RB. Posterior sternoclavicular joint dislocation: case report and discussion.Can J Emerg Med. 2006;8:355–7. This article reviewed the literature on posterior sterno-clavicular dislocation and reported 30% of associated thoracic injuries and 12.5% risk of mortality in that subgroup. (Level IV evidence) Shakiba H, Dinesh S, Anne MK. Advanced Trauma Life Support training for hospital staff. Cochrane Database Syst Rev. 2004;(3):CD004173. This 2003 Cochrane review evaluated the efficiency of ATLS training in order to improve knowledge. The reviewers concluded: “There is no clear evidence that ATLS training (or similar) impacts on the outcome for victims of trauma, although there is some evidence that educational initiatives improve knowledge of what to do in emergency situations. Further, there is no evidence that trauma management systems incorporating ATLS training impact positively on outcome. Future research should concentrate on the evaluation of trauma systems incorporating ATLS, both within hospitals and at the health system level, by using rigorous research designs.” (Grade B recommendation; Level II evidence)

911 Styner JK. The birth of Advanced Trauma Life Support (ATLS). Surgeon. 2006;4:163–5.

van Olden GD, Meeuwis JD, Bolhuis HW, Boxma H, Goris RJ. Clinical impact of advanced trauma life support. Am J Emerg Med. 2004;22:522. This study showed a significant decrease in mortality after the institution of ATLS in two teaching hospitals. We recommend that all orthopedic surgeons follow an ATLS protocol because they are part of a multidisciplinary trauma team. (Grade B recommendation; Level II evidence [cohort study])

LIMB IMMOBILIZATION Halanski MA, Halanski AD, Oza A, Vanderby R, Munoz A, Noonan KJ. Thermal injury with contemporary cast-application techniques and methods to circumvent morbidity. J Bone Joint Surg [Am]. 2007;89:2369–77. The authors studied risk factors for thermal injury with cast application techniques. The use of more than 12-ply plaster, the use of dip water at a temperature over 24° C, and resting the limb on a pillow during cast drying were associated with dangerous temperatures at the skin level. Rouleau DM, Feldman DE, Parent S. Delay to orthopaedic consultation for isolated limb injury: cross-sectional survey in a level 1 trauma centre. Can Fam Physician. 2009;55:1006-7. This cohort study describes referral mechanisms for referral to orthopaedic surgery for isolated limb injuries in a public health care system and to identify factors affecting access. This prospective study of 166 consecutive adults (mean age 48 years) referred to orthopedic surgery for isolated limb injuries during a 4-month period. (Level II evidence) Payne R, Kinmont JC, Moalypour SM. Initial management of closed fracturedislocations of the ankle. Ann R Coll Surg Engl. 2004;86:177–81. Immobilization quality or presence is rarely reported in the literature. These authors reported the absence of immobilization in two cases of ankle fracture-dislocation, resulting in re-dislocation, out of a cohort of 23 patients seen by primary care physicians. (Level IV evidence)

THROMBOPROPHYLAXIS

AND

FRACTURE

Bagaria V, Modi N, Panghate A, Vaidya S. Incidence and risk factors for a development of a venous thromboembolism in Indian patients undergoing major orthopaedic surgery: results of a prospective study. Postgrad Med J. 2006;82:136–9. Grade-B recommendation on identification of risk factors that can modify the decision for prophylaxis prescription. (Level II evidence) Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126;338–400. This systematic review is the most recent and extensive source of information available.

Optimizing Perioperative Fracture Care

The ATLS movement was initiated following an orthopedic surgeon’s personal tragedy in 1976. The children of Dr. J. K. Styner received suboptimal care after a plane accident in a regional health care center. Back then, the absence of a clear treatment algorithm brought disorganized care. The American College of Surgeons Committee on Trauma has worked to establish guidelines for optimal care of the trauma patient. Advanced Trauma Life Support (ATLS) regroups the fundamental principles of patient care following injury.

Optimizing Perioperative Fracture Care

912

ANTIBIOTIC PROPHYLAXIS PREVENTION

AND

TETANUS

Boxma H, Broekhuizen T, Patka P, Oosting H. Randomised controlled trial of singledose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch Trauma Trial. Lancet. 1996;347:1133–7. Grade-A recommendation for the use of ceftriaxone compared to placebo in the prevention of infection for the surgical treatment of closed fracture. (Level I evidence) Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev. 2000;(2):CD000244. This study found evidence supporting the use of antibiotics, although no specific antibiotic could be recommended. The authors concluded: “Antibiotic prophylaxis should be offered to those undergoing surgery for closed fracture fixation. On ethical grounds, further placebo controlled randomised trials of the effectiveness of antibiotic prophylaxis in closed fracture surgery are unlikely to be justified. Trials addressing the cost-effectiveness of different effective antibiotic regimens would need to be very large and may not be feasible.” (Level I evidence) Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004;(1):CD003764. This systematic review identified the need to give IV antibiotics for open fracture. The best regimen of IV antibiotic could not be identified. (Grade A recommendation) Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg [Am]. 1990;72:299–304. This article described the Gustilo open fracture classification. (Level IV evidence) Okike K, Bhattacharyya T. Trends in the management of open fractures: a critical analysis. J Bone Joint Surgery [Am]. 2006;88:2739–48. This excellent critical review gave recommendations about different treatment modalities for open fractures. A Grade-A recommendation is made about the use of systemic antibiotic therapy. The type of antibiotic was recommended according to their institution’s current practice. (Grade B recommendation) Schmidt AH, Swiontkowski MF. Pathophysiology of infections after internal fixation of fractures. J Am Assoc Orthop Surg. 2000;8:285–91. This review article supported the use of IV antibiotics for prevention of infection in the surgical treatment of fracture. The type of antibiotic was recommended according to their institution’s current practice. (Grade B recommendation; Level IV evidence) Southwell-Keely JP. Antibiotic prophylaxis in hip fracture surgery: a metaanalysis. Clin Orthop Relat Res. 2004;(419):179–84. This meta-analysis supported the use of IV antibiotics in the treatment of hip fracture surgery. One dose seemed no different than multiple doses, but the quality of the reviewed articles was low according to the authors of the meta-analysis. Grade-B recommendation was made for one dose of antibiotic. (Level I evidence)

PSYCHOLOGICAL REACTION

TO

INJURY

Ehlers A, Clark DM, Hackmann A, McManus F, Fennell M, Herbert C, Mayou R. A randomized controlled trial of cognitive therapy, a self-help booklet, and repeated assessments as early interventions for posttraumatic stress disorder. Arch Gen Psychiatry. 2003;60:1024–32. This article supported the efficacy of psychological support for PTSD. The authors concluded: “Cognitive therapy is an effective intervention for recent-onset PTSD. A self-help booklet was not effective. The combination of an elevated initial symptom score and failure to improve with self-monitoring was effective in identifying a group of patients with early PTSD symptoms who were unlikely to recover without intervention.” (Grade A recommendation; Level I evidence)

913

This study showed a high incidence of PTSD in association with head injury. (No recommendation; Level II evidence) Moore K, Thompson D. Posttraumatic stress disorder in the orthopaedic patient (continuing education credit). Orthop Nurs. 1989;8(1):11–9. This paper provided a definition of PTSD. (No recommendation; Level IV evidence) Oxlad M, Stubberfield J, Stuklis R, Edwards J, Wade TD. Psychological risk factors for increased post-operative length of hospital stay following coronary artery bypass graft surgery. J Behav Med. 2006;29:179–90. This case series of 119 patients following cardiac surgery showed that psychological response can increase hospitalization length when all other medical factors were controlled. (No recommendation; Level II evidence) Sanders MB, Starr AJ, Frawley WH, McNulty MJ, Niacaris TR. Posttraumatic stress symptoms in children recovering from minor orthopaedic injury and treatment. J Orthop Trauma. 2005;19:623–8. This study showed a high incidence of PTSD in children. (No recommendation; Level II evidence) Starr AJ, Smith WR, Frawley WH, Borer DS, Morgan SJ, Reinert CM, Mendoza-Welch M. Symptoms of posttraumatic stress disorder after orthopaedic trauma. J Bone Joint Surg [Am]. 2004;86:1115–21. This study showed a high incidence of PTSD after orthopedic trauma. (No recommendation; Level II evidence) Sutherland AG, Alexander DA, Hutchison JD. The mind does matter: psychological and physical recovery after musculoskeletal trauma. J Trauma. 2006;61:1408–14. This study showed a strong correlation of PTSD with impaired functional outcome after musculoskeletal trauma stresses. (No recommendation; Level II evidence) Vythilingam M, Blair KS, McCaffrey D, Scaramozza M, Jones M, Nakic M, Mondillo K, Hadd K, Bonne O, Mitchell DG, Pine DS, Charney DS, Blair RJ. Biased emotional attention in post-traumatic stress disorder: a help as well as a hindrance? Psychol Med. 2007;37:1445–55. This study showed that patients with PTSD had a biased memory in favored of negative events. (No recommendation; Level II evidence)

SECONDARY PREVENTION: PREVENTION

OF

INJURY

Caufeild J, Singhal A, Moulton R, Brenneman F, Redelmeier D, Baker AJ. Trauma recidivism in a large urban Canadian population. J Trauma. 2004;57:872–6. A retrospective study of 13,057 trauma patients showed a 0.38% recidivism rate. Risk factors were identified and they are mentioned in the present chapter. The study used database covering 1976 to 1999 in two level one trauma centers of Toronto. (No recommendation; Level II evidence [descriptive study]) Gentilello LM, Rivara FP, Donovan DM, Jurkovich GJ, Daranciang E, Dunn CW, Villaveces A, Copass M, Ries RR. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg. 1999;230:473–80. Grade-A recommendation in favor of alcohol interventions in trauma patients. The authors concluded: “Alcohol interventions are associated with a reduction in alcohol intake and a reduced risk of trauma recidivism. Given the prevalence of alcohol problems in trauma centers, screening, intervention, and counselling for alcohol problems should be routine.” (Level I evidence)

Optimizing Perioperative Fracture Care

Levi RB, Drotar D, Yeates KO, Taylor HG. Posttraumatic stress symptoms in children following orthopaedic or traumatic brain injury. J Clin Child Psychol. 1999;28: 232–43.

Optimizing Perioperative Fracture Care

914 Machold W, Kwasny O, Eisenhardt P, Kolonja A, Bauer E, Lehr S, Mayr W, Fuchs M. Reduction of severe wrist injuries in snowboarding by an optimized wrist protection device: a prospective randomized trial. J Trauma. 2002;52:517–20. In this study, nine severe wrist injuries were sustained in the unprotected control group and only one in the protected group. The authors recommended the use of a wrist protector, particularly for novices participating in this sport. Macpherson A, Spinks A. Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries. Cochrane Database Syst Rev. 2007;(2):CD005401. Grade-A recommendation for bicycle helmet legislation. The authors concluded: “Bicycle helmet legislation appears to be effective in increasing helmet use and decreasing head injury rates in the populations for which it is implemented. However, there are very few high quality evaluative studies that measure these outcomes, and none that reported data on a possible decline in bicycle use.” (Level I evidence) Mohammadi F. Comparison of 3 preventive methods to reduce the recurrence of ankle inversion sprains in male soccer players. Am J Sports Med. 2007;35:922–6. Proprioceptive training, compared with no intervention, was an effective strategy to reduce the rate of ankle sprains among male soccer players who suffered ankle sprain. (Grade A recommendation; Level I evidence) Rønning R, Rønning I, Gerner T, Engebretsen L. The efficacy of wrist protectors in preventing snowboarding injuries. Am J Sports Med. 2001;29:581–5. This randomized study of 5029 snowboarders reported 8 wrist injuries in the braced group and 29 in the control group. Beginners were a high-risk group. Orthopedic surgeons should recommend the use of wrist protectors. (Grade A recommendation; Level I evidence) Toschlog EA, Sagraves SG, Bard MR, Schenarts PJ, Goettler CC, Newell MA, Rotondo MF. Rural trauma recidivism: a different disease. Arch Surg. 2007;142:77–81. This cohort study underlined the role of substance abuse in trauma recidivism. Grade-D recommendation in favor of intervention in drug and alcohol abuse. (Level II evidence) Wan JJ, Morabito DJ, Khaw L, Knudson MM, Dicker RA. Mental illness as an independent risk factor for unintentional injury and injury recidivism. J Trauma. 2006;61:1299–304. This retrospective study done on a database covering 2003-2004 in a level 1 trauma center evaluates 1709 cases of patients with unintentional injury. Twenty percent of them also had a psychological illness. They found 20% of recidivism on consultation for injury in the group. The subgroup of patients with mental pathology showed 42% risk of recidivism compared to 10% in the psychologically healthy group. (Level II evidence [descriptive study]).

SECONDARY PREVENTION: DOMESTIC VIOLENCE Bhandari M, Dosanjh S, Tornetta P 3rd, Matthews D, for the Violence against Women Health Research Collaborative. Musculoskeletal manifestations of physical abuse after intimate partner violence. J Trauma. 2006;61:1473–9. This cohort study included 263 women consulting in a community service for domestic abuse. From the most frequent form of abuse, physical violence was reported by 43% of participants. A total of 144 injuries were reported in the group of women. The second most frequent type was related to musculoskeletal system in 28%, after head and neck injuries. Risk factors for physical violence were younger age, short term relation, and other forms of abuse and substance dependency. Women consulting with concomitant head and orthopaedic injury must be questioned about domestic violence. (Level II evidence [descriptive study])

915

This case control study included 256 intestinally injured women and 659 control subjects. Control subjects were women consulting in the emergency for other reasons. Injuries were: 434 contusions, 89 lacerations and 41 fractures and dislocations. Partners risk factors for being violent were: substance abuse, working difficulties, less than high school degree, being former partners. (Level III evidence) Plichta SB, Falik M. Prevalence of violence and its implications for women’s health. Women’s Health Issues. 2001;11:244–58. This study is an American national survey on 1840 women. They excluded 19 women who did not answer to violence questionnaires. The survey asked about abuse in their lifetime and they found that 44% of women experience abuse in their life. According to the authors, this translates into a national estimate of 36,000,000 women who experience violence as a child or as an adult. The prevalence of domestic violence is 34.6%. (Level III evidence) Zillmer DA. Domestic violence: the role of the orthopaedic surgeon in identification and treatment. J Am Acad Orthop Surg. 2000;8:91–6. This article is a review on the importance of the problem of domestic violence in the United States. Also, it gives advice to help orthopaedic surgeons to indentify and help women at risk. (Level IV evidence)

SECONDARY PREVENTION: OSTEOPOROSIS Bouxsein ML, Kaufman J, Tosi L, Cummings S, Lane J, Johnell O. Recommendations for optimal care of the fragility fracture patient to reduce the risk of future fracture. J Am Acad Orthop Surg. 2004;12:385–95. This review article reports the importance of osteoporosis as a health problem and gives American orthopaedic surgeons guidelines to identify and treat patients affected by this pathology. (Level IV evidence) Brown JP, Josse RG, for the Scientific Advisory Council of the Osteoporosis Society of Canada. 2002 Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ. 2002;167(10 Suppl):S1–34. This article on Canadian clinical practice guidelines describes the ideal practice in relation with osteoporosis following the recommendation of the Osteoporosis Society of Canada. (Level IV evidence) Englund U, Littbrand H, Sondell A, Pettersson U, Bucht G. A 1-year combined weight-bearing training program is beneficial for bone mineral density and neuromuscular function in older women. Osteoporos Int. 2005;16:1117–23. This randomized study of 48 women evaluates the impact of a structured program with exercise session to improve bone density and strength. Forty subjects completed the session. Bone density improved by almost 10% in the treatment group. (Level I evidence) Suzuki T, Kim H, Yoshida H, Ishizaki T. Randomized controlled trial of exercise intervention for the prevention of falls in community-dwelling elderly Japanese women. J Bone Miner Metab. 2004;22:602–11. This randomized study of 52 women over 73 years old reports a significant decrease of falls in the group attending exercise courses after 8 months (14% vs 41%) and after 20 months (14% vs 55%). (Level I evidence)

Optimizing Perioperative Fracture Care

Kyriacou DN, Anglin D, Taliaferro E, Stone S, Tubb T, Linden JA, Muelleman R, Barton E, Kraus JF. Risk factors for injury to women from domestic violence against women. N Engl J Med. 1999;341:1892–8.