Orthopaedic Trauma

 

 General Principles

 

 Take-Home Message

•      A TLS protocol provides a systematic approach for assessing trauma patients to identify life-threatening injuries with simultaneous initiation of resuscitation

•      H emorrhagic shock: increased heart rate and increased systemic vascular resistance

•      Neurogenic shock: decreased heart rate and decreased blood pressure

•      P lace pregnant women in the left lateral decubitus position to prevent vena cava compression

1     Epidemiology

•  Traumatic injuries are the fi fth most common cause of death •  The highest incidence in patients 12–24 years old •  Bimodal distribution of death by age:

–     20s: motor vehicle accidents, fi rearms

–     80s: falls, motor vehicle accidents

 

 

 

 

 

2     Trimodal Distribution of Mortality

•      Immediate (50 %): massive hemorrhage, massive devastating neurologic injury

–     Prevention

•      Early (30 %): often sequelae of neurologic injury

–     62 % of in-hospital deaths occur in the fi rst 4 h of admission

•      L ate (20 %): days to weeks, 80 % related to head injuries, 20 % related to multisystem organ failure and sepsis

3     Golden Hour

•      Window to treat potentially survivable life-threatening injuries

•      Approximately 60 % of preventable deaths occur in this time range

4     Advanced Trauma Life Support (ATLS)

•      Primary Survey

–  Airway

•      E stablish a secure airway for GCS < 8 and hemodynamic instability, consider in signifi cant head and neck injuries

•      Always maintain c-spine precautions

–     Breathing

•      Identify and treat life-threatening injuries

•      T ension pneumothorax: urgent needle decompression at second intercostal space in midclavicular line followed by defi nitive chest tube placement

•      Open pneumothorax: “sucking chest wound,” three-sided dressing

•      P ositive pressure ventilation will worse a pneumothorax and possibly create a tension pneumothorax until a chest tube is placed

•      Flail chest: paradoxical chest wall motion creates a VQ mismatch with hypoxia

•      Massive hemothorax: >1,500 cc of blood or >200 cc/h for 4 h

–     Circulation

•      Average adult has 4.5–5 L circulating blood volume

•      Shock: compromise of circulation resulting in inadequate oxygen delivery to tissues

General Principles                                                                                                                  155

•      Hypovolemic shock

–     Increased heart rate and increased systemic vascular resistance

–     Most commonly secondary to acute blood loss

–     Obvious external bleeding

–     Internal bleeding: chest, abdomen, retroperitoneum, pelvis, long bone

–     Classes of hemorrhagic shock

•      Class I: < 15 % blood loss, normal HR, normal BP, UOP >30 mL/h, pH normal, anxious, treat with fl uid

•      Class II: 15–30 % blood loss, HR > 100 bpm, normal BP, UOP

20–30 mL/h, pH normal, confused/irritable/combative, treat with fl uid

•      Class III: 30–40 % blood loss, HR >120 bpm, decreased BP, UOP 5–15 mL/h, pH decreased, lethargic/irritable, treat with fl uid and blood

•      Class IV: >40 % blood loss, HR >140 bpm, decreased BP, UOP min-imal, pH decreased, lethargic/coma, treat with fl uid and blood

•      Neurogenic shock

–     Due to loss of sympathetic tone in spine cord injury

–     Decreased heart rate, decreased blood pressure, warm skin, failure to respond to crystalloids

–     Treat with dobutamine and dopamine

•      Septic shock

–     Hyperdynamic state

–     Increased heart rate, massively decreased systemic vascular resistance, increased cardiac index

–     Treat with antibiotics and norepinephrine

•      Cardiac tamponade more common with penetrating injuries

•      Pregnant patients

–     Trauma is the most common cause of death in pregnant women

–     Place in the left lateral decubitus position to prevent vena cava com-pression by the uterus and reduces cardiac output

–     R  adiation exposure from most x-ray studies does not pose a risk to the fetus

–     Disability

–     Exposure, environmental control, evaluation (neurologic status)

•      Secondary Survey

–  Evaluation of injuries, interventions

•  Tertiary Survey

–  Serial reevaluation

 

 Assessment and Principles of Treatment

 

 Take-Home Message

•      Initiate blood product transfusion in patients who fail to respond to 2 l crystalloid bolus

•      Massive transfusion protocol: 1:1:1 of pRBC:FFP:platelets

•      Employ damage control orthopedics in severely injured patients with decreased base defi cits and increased serum lactate levels

•      Hemodynamic parameters are not suffi cient end points to measure ade-quacy of resuscitation

•      Base defi cit and serum lactate levels are proxies for anaerobic metabolism and more accurately indicate adequacy of resuscitation

•      Glasgow Coma Scale is predictive of injury severity and mortality

1     Radiologic Workup

•      Trauma X-ray series

–  AP chest

•      Mediastinal widening, pneumothorax

 

–     AP pelvis

•  Pelvic ring injury, acetabulum, proximal femur

–     Lateral c-spine

•      Must visualize C7–T1 junction

•      Often replaced by CT c-spine

•      Valuable in patients going emergently to OR prior to CT scan

•      CT scan

–     C-spine, chest, abdomen, pelvis

–     Increasingly used in the initial evaluation of the trauma patient

•  Additional X-rays

–     Investigate potential injuries identifi ed in secondary and tertiary surveys

–     F  ailure to image an extremity is the most common cause of delayed fracture diagnosis

2     Damage Control Orthopedics (DCO)

•      Recognition of the impact of early defi nitive surgical care on resuscitation and brain injury lead to the concept of damage control orthopedics

•      Subset of critically injured patients who may benefi t from initial provisional sta-bilization to improve immediate survival with the least stress to the patient’s physiologic condition

–     Minimize the second hit

–     I  ndicated for patients whose infl ammatory response will be overwhelmed by further stimuli

•      Stabilization of major fractures still imperative to decrease infl ammatory media-tors and catecholamine release, decrease analgesic requirements, and facilitate ICU care

–     A  cute stabilization primarily achieved with external fi xation, pelvic sheets/ binders, and skeletal traction

–     Convert to defi nitive management of pelvic fractures within 7–10 days –  Convert femur fractures to intramedullary nail fi xation within 3 weeks

–     Convert tibia fractures to intramedullary nail fi xation within 7–10 days

3     Systemic Effects of Trauma

•      Systemic infl ammatory response (SIR)

•      Counter-regulatory anti-infl ammatory response (CAR)

Assessment and Principles of Treatment                                                                                 

•      Balance between SIR and CAR needed for homeostasis

•      Parameters for DCO

–     ISS >40 (without thoracic trauma)

–     ISS >20 (with thoracic trauma)

–     Base defi cit >5–6 (normal −2 to 2)

•      Best measure of resuscitation in the fi rst 6 h after injury

•      Direct measure of metabolic acidosis, indirect measure of lactate levels

•      Correlates with organ dysfunction and mortality

–     Serum lactate >2–2.5 mmol/L

–     pH < 7.24

–     Hypothermia with temperature <35 °C

–     Coagulopathy, platelets <90,000

–     IL-6 >800 pg/mL

–     Bilateral femur fractures

–     Pulmonary contusion on chest X-ray

–     Multiple injuries with pelvic/abdominal trauma and hemorrhagic shock

•  Acute infl ammatory window from 2 to 5 days post-injury during which there is increased risk for ARDS and MSOF

–  Only potentially life-threatening injuries should be treated during this time

4     Resuscitation

•      Immediate aggressive fl uid resuscitation with placement of 2 large-bore IVs

•      Crystalloid isotonic solutions to correct most extracellular volume defi cits

–     1–2 l

•      Transfuse blood to patients who fail initial fl uid boluses

–     Failure to respond to 2 l crystalloid bolus should be equated to estimated blood loss of >30 % of blood volume, or Class III–IV hemorrhagic shock, and blood product transfusion should be initiated

–     O-negative blood, type-specifi c blood, cross-matched blood

–     Massive transfusion protocol: 1:1:1 ratio of pRBC:FFP:platelets

–     C  oagulopathy often develops after transfusion secondary to depletion of host clotting factors, platelets, and hypothermia and portends a worse prognosis

•      Adequate resuscitation

–     Heart rate <100 bpm

–     Mean arterial pressure >60 mmHg

–     Urine output >0.5–1.0 mg/kg/h

–     Normalization of base defi cit and lactate levels

5     Trauma Scoring Systems

•      T here are many trauma scoring systems which may be useful in triage and many of which have prognostic value

•      Glasgow Coma Scale (GCS)

–     Quantifi es severity of head injury with gross assessment of CNS function

–     Eye opening (4 pts), best verbal response (5 pts), best motor response (6 pts)

•      3–9: severe head injury

•      9–12: moderate head injury

•      13–15: minor head injury

–     Predictive of injury severity and mortality

–     Patients with femur fracture, head injury, and hypotension have lower GCS on discharge

•      Injury Severity Score (ISS)

–     Scoring system based on injury in nine anatomic regions

–     Calculate via sum of the squares for the highest-grade injury in three different anatomic regions

–     ISS > 15 associated with 10 % mortality rate

–     New Injury Severity Score (NISS) calculation uses the three highest-grade injuries regardless of anatomic region

•      M ore accurate scoring for patients with multiple injuries within a single anatomic region

•      NISS is a better predictor of complications and mortality than ISS •  Mangled Extremity Severity Score (MESS)

–     Predicts the need for amputation of a severely injured lower extremity

–     Points assigned for skeletal/soft tissue injury (1–4), ischemia time (1–3), patient age (1–3), and shock as defi ned by hypotension (0–2) –  MESS > 7 predicts need for amputation

6     Open Fractures

•      Require urgent and aggressive debridement and irrigation

–     Low-pressure lavage more effective at reducing bacterial counts than high- pressure lavage and does not impart additional trauma to compromised soft tissues

–     Saline is the irrigation fl uid of choice

•      Update tetanus prophylaxis as indicated

Assessment and Principles of Treatment                                                                                 161

•      Appropriate antibiotics based on grade and stabilization

–     Continue antibiotics until 24 h after the last surgical debridement

•      Gustillo Anderson Open Fracture Classifi cation

–     Type I: wound <1 cm, no periosteal stripping, fi rst-generation cephalosporin

–     T  ype II: wound 1–10 cm, no or minimal periosteal stripping or soft tissue wound, fi rst-generation cephalosporin

–     Type III: wound >10 cm or high-energy injury, periosteal stripping, possible segmental injury, fi rst-generation cephalosporin, aminoglycoside, +/− penicillin for gross contamination (farm, bowel)

•      Type IIIA: adequate soft tissue for primary closure

•      Type IIIB: insuffi cient soft tissue for primary closure, fl ap required

•      Type IIIC: associated vascular injury requiring repair

•      Antibiotics

–     First-generation cephalosporin: gram-positive coverage

–     Aminoglycosides: gram-negative coverage

–     Penicillin: anaerobic coverage ( Clostridium )

–     Freshwater wounds: fl uoroquinolones or ceftazidime

–     Saltwater wounds: doxycycline and ceftazidime or a fl uoroquinolone

7     Compartment Syndrome

•      Elevated fascial compartment pressures lead to decreased tissue perfusion

–     Local trauma and bleeding →increased interstitial pressure exceeds capillary pressure → vascular occlusion → myoneural ischemia

•      Most commonly occurs in the leg, forearm, hand, foot, thigh, buttock, shoulder, and paraspinous muscles

•      Etiology

–     Trauma: fractures, crush injury, contusion, gunshot injury

–     External compression: tight casts, dressings, or other wrappings

–     Vascular: arterial injury, reperfusion/post-ischemic injury

–     Burns

–     Bleeding disorders

–     Fluid extravasation

•      Clinical assessment

–     5 Ps

•      Pain out of proportion the most critical clinical sign

•      Pain with passive stretch the most critical clinical test

•      Paresthesias, pallor, and pulselessness are late fi ndings

–     Compartment pressure measurement

•      ΔP = diastolic pressure – compartment pressure

•      ΔP < 30 mmHg or absolute compartment pressure >30 mmHg indicate compartment syndrome

•      Intraoperative diastolic pressure decreased from baseline

–     C  ompare intraoperative compartment pressure measurements to preoperative diastolic pressure

–     Maintain a high index of suspicion

•      Diffi cult to assess polytrauma patients and sedated patients

–  May need to rely on compartment pressure measurements with low threshold to proceed with fasciotomies

•      Treatment

–     Emergent decompression with fasciotomy

•      Clinical presentation consistent with compartment syndrome

•      ΔP < 30 mmHg or absolute compartment pressure >30 mmHg

–     4 Cs of viability: color, contractility, capacity to bleed, consistency

–     Serial exam of patients at risk for compartment syndrome

–     F  oot compartment syndrome: nonoperative management vs. surgical fasciotomies debated

–     N  onoperative sequelae of claw toes is more easily treated; possible chronic nerve pain and hypersensitivity are especially diffi cult to treat

•      Complications

– M  issed compartment syndrome results in permanent nerve and muscle injury with contractures and possible loss of the limb

•      Fasciotomies are generally contraindicated in missed compartment syn-drome due to signifi cantly increased risk of infection

•      M ay consider debridement in patients with organ failure secondary to metabolic waste from necrosed tissue

 

 Upper Extremity Trauma

 

1     Sternoclavicular Dislocations  

 Take-Home Message

•      Joint stability depends on the integrity of ligamentous structures.

•      Anterior dislocation most common; majority remain unstable but asymptomatic.

•      P osterior dislocation may present with dyspnea, dysphagia, tachypnea, or stridor.

•      Assess for associated pneumothorax and injury to the trachea, esophagus, or major vascular structures.

•      Imaging studies: serendipity view and CT scan.

•      T horacic surgery should be available prior to undertaking any closed or open reduction procedures.

•      General

–     High-energy chest wall injury (MVA, contact sports).

–     Associated injuries: pneumothorax, nerve injury, injury to the trachea, esoph-agus, or major vascular structures.

–     Joint stability depends on the integrity of ligamentous structures.

 

 

 

                                                                                              

 

•      Posterior capsular ligament: anterior/posterior stability

•      A nterior sternoclavicular ligament: primary restraint to superior displacement of the medial clavicle

•      Costoclavicular    ligaments:             resist      superior/inferior   rotation and  medial- lateral displacement

•      I ntra-articular disk ligament: prevents medial clavicle displacement, secondary restraint to superior clavicle displacement

•      Imaging Studies

–     Serendipity view x-ray (40° cephalic tilt)

•      Anterior dislocation: affected clavicle above contralateral clavicle

•      Posterior dislocation: affected clavicle below contralateral clavicle

–     CT scan

•      Study of choice

•      Allows assessment of mediastinal structures

•      Classifi cation

–     Anterior dislocation

•      D eformity with palpable bump, prominence increases with abduction and elevation

–     Posterior dislocation

•      M ay compress mediastinal structures and present with dyspnea, tachypnea, dysphagia, stridor, or venous congestion or diminished pulse of the affected upper extremity

–     Chronic dislocation

•      Anterior or posterior sternoclavicular joint dislocations >3 weeks old

•      Treatment

–     Nonoperative

•      Consider in atraumatic and chronic dislocations.

•      Accept deformity, local symptomatic treatment, sling for comfort, and return to unrestricted activity in 3 months.

–     Closed reduction under general anesthesia

•      Thoracic surgery should be available prior to any manipulation.

•      Acute anterior dislocations

–     R  eduction maneuver: abduction, extension, and direct pressure over the medial clavicle.

–     S  table reduction: sling and swath for 6 weeks; return to activities at 3 months.

–     Unstable reduction: accept deformity (preferable) vs resect medial clavicle.

•      Acute posterior dislocations

–     Reduction maneuver: abduction, extension, and anterior traction on the medial clavicle with towel clip.

–     S  table reduction: sling and swath for 6 weeks, consider fi gure of eight brace, and return to activities in 3 months.

–     Unstable reduction: resect medial clavicle (preferable) vs surgical stabilization.

–     Operative

•      Thoracic surgery should be available prior to any open procedure.

•      Open reduction with soft tissue reconstruction vs surgical fi xation

–     Consider in unstable posterior dislocations with compromise of medi-astinal structures.

–     Smooth wires should not be used to stabilize the joint because of the risk of migration into the thorax.

•  Complications

–     Recurrent instability of the SC joint: consider tendon graft reconstruction.

–     SC joint arthrosis: treat with medial clavicle excision.

 Bibliography

1 . B icos J, Nicholson GP. Treatment and results of sternoclavicular joint injuries. Clin Sports Med. 2003;22(2):359–70. Review.

 2.  Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C. Skeletal trauma. 4th ed. Philadelphia: Saunders; 2009. p. 1757–8.

3. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 705.

4. W irth MA, Rockwood Jr CA. Acute and chronic traumatic injuries of the sternoclavicular joint. J Am Acad Orthop Surg. 1996;4(5):268–78.

2     Clavicle Fractures  

 Take-Home Message

•      C lavicle fractures are common injuries that most often occur in the middle third.

•      Open clavicle fractures have high rates of associated pulmonary and closed head injuries.

•      Treatment is controversial. The majority of clavicle fractures can be man-aged nonoperatively.

•      I ncreased risk of nonunion in females, elderly, and fractures >100 % displacement or >2 cm shortening.

•      I mproved shoulder function and union rates for signifi cantly displaced and shortened clavicle fractures.

•      General

–     Clavicle fractures are common injuries, comprising 5–10 % of all fractures.

–     H  igh-energy mechanisms may have associated ipsilateral scapula fractures, scapulothoracic dissociation, rib fracture, and pneumothorax and neurovascular injury.

•      Open clavicle fractures associated with high rates of pulmonary injury and closed head injuries

•      Imaging

–     Clavicle fractures are often fi rst identifi ed on trauma series CXR.

–     A  P view and 15° cephalad-oblique views: assess fracture location, confi guration, and displacement.

–     CT scan: consider in medial third fractures; additionally may help evaluate displacement, comminution, and nonunion.

•      Classifi cation

–  Medial third (5 %)

•      Majority can be managed nonoperatively and are rarely symptomatic.

•      Assess for posterior displacement, and treat according to the principles for posterior sternoclavicular joint dislocation if present.

–     Middle third (80 %)

•      Majority can be managed nonoperatively.

•      Deforming forces in displaced fractures.

–     Medial fragment: the sternocleidomastoid and trapezius pull the medial fragment posterosuperiorly.

–     Lateral fragment: pectoralis major and weight of the arm pull the lateral fragment inferomedially.

•      I mproved outcomes with ORIF for middle third clavicle fractures with 100 % displacement and >2 cm shortening.

–     I  mproved function with less pain and improved shoulder strength and endurance, increased union rates with faster time to union

–     Nonoperative management of fractures with 100 % displacement: 5–10 % nonunion

–     Lateral third (15 %)

•      Coracoclavicular ligaments provide superior/inferior stability.

–     Trapezoid ligament: 3 cm from the end of the clavicle

–     Conoid ligament: 4.5 cm from the end of the clavicle

•      Higher rates of nonunion compared to middle third clavicle fractures.

•      Treatment

–     Treatment is controversial.

–     Nonoperative

•      Most clavicle fractures can be successfully treated nonoperatively.

•      Sling immobilization and fi gure-of-eight bandage have no difference in outcomes.

•      Begin range of motion exercises at 2–4 weeks.

–     Operative

•      Indications for surgical treatment continue to evolve.

•      Absolute indications: open fractures, associated vascular injury, skin tent-ing, fl oating shoulder, symptomatic nonunion, some signifi cantly displaced fractures.

•      R elative indications: polytrauma patient, closed head injury, seizure disorder, brachial plexus injury.

•      Plate fi xation

–     Superior plating: improved biomechanical strength, more symptomatic hardware, increased risk of neurovascular injury with drilling

–     Anterior plating: less symptomatic hardware

–     Hook plate: AC joint spanning fi xation, indicated in lateral third clavi-cle fractures, requires plate removal

•      Intramedullary rod and screw

–     Percutaneous insertion possible, symptomatic hardware still possible

–     Increased complication rate, including migration

•      Avoid Steinmann pins for risk of migration into the thorax.

•      Coracoclavicular ligament repair/reconstruction

–  Consider in lateral third clavicle fractures. –  Primary repair, suture supplementation.

•      Rehabilitation

–  Early active motion, strengthening at 6 weeks, return to activities at 3 months

•      Hook plate range of motion restriction: no forward fl exion >90° or abduction >90° until plate is removed

•      Complications

–     Hardware complications

•  Symptomatic hardware

–     30 % of patients request hardware removal.

–     Superior plates associated with increased irritation.

•  Failure of fi xation: 1.5 %

–     Nonunion

•  Nonoperative management: 1–5 % overall

–     Asymptomatic: no treatment indicated

–     Symptomatic: consider nonunion take down and ORIF +/− bone graft (atrophic nonunions)

• R isk factors: female, elderly, smoking, ≥100 % displacement, or ≥2 cm shortening

–     Adhesive capsulitis

•      4 % of patients who undergo surgical fi xation

–     Neurovascular injury

•      3 %, increased risk with superior plating.

•      Acute neurovascular complications are rare, typically associated with scapulothoracic dissociation.

–     Pneumothorax

•      A concern with operative fi xation but actual case reports are rare

 .

3     Acromioclavicular Injuries  

 Take-Home Message

•      Acromioclavicular ligaments provide anterior/posterior stability.

•      Coracoclavicular ligaments provide superior/inferior stability.

•      Bilateral AP radiographs for comparison to contralateral side and zanca view.

•      Nonoperative management: type I, II +/− III.

•      Operative management: type IV, V, VI.

•      AC joint arthrosis best treated with distal clavicle excision.

•      General

–     Common injuries, comprise 9 % of shoulder girdle injuries

–     More common in males

–     Acromioclavicular ligament: provides anterior/posterior stability

–     Coracoclavicular ligaments: provide superior/inferior stability

•      Imaging

–     B  ilateral AP radiograph: compare distance from the top of the coracoid to the bottom of the clavicle to the contralateral side

–     Z  anca view: 10° cephalic tilt and 50 % penetration, improved visualization of

AC joint by eliminating overlying structures

–     Axillary view: assess for posterior clavicle displacement (type IV)

•      Classifi cation

–     Type I: AC ligament sprain, no displacement

–     T  ype II: AC ligament rupture, CC ligament sprain, vertical displacement with <25 % increase of CC interspace

–     T  ype III: AC and CC ligament ruptures, vertical displacement with 25–100 % increase of CC interspace

–     Type IV: AC and CC ligament ruptures, lateral clavicle buttonholed through trapezius posteriorly

–     T  ype V: AC and CC ligament ruptures, vertical displacement with >100 % increase of CC interspace and rupture of deltotrapezial fascia

–     T  ype VI: AC and CC ligament ruptures, distal clavicle translocated inferior to the coracoid

•      Treatment

–     Nonoperative

•      Indicated in type I, II, and most type III injuries

•      Sling for 3 weeks, early range of motion, return to activities at 12 weeks

–     Operative

•      Indicated in type IV, V, and VI injuries

•      Consider in type III injuries in laborers and elite athletes

•      ORIF or ligament reconstruction

–     ORIF with CC screw or suture fi xation: beware of proximity of neuro-vascular structures inferior to the coracoid.

–     ORIF with hook plate: requires second surgery for plate removal.

–     CC ligament reconstruction: transfer of coracoacromial ligament to dis-tal clavicle (modifi ed Weaver-Dunn), free tendon graft. –  Primary AC joint fi xation: rarely performed.

•      R ehabilitation: sling without abduction, shoulder range of motion beginning at 6 weeks, return to activities at 4–6 months

•      Complications

–     AC joint arthrosis: treat with open or arthroscopic distal clavicle excision.

–     Chronic instability: distal clavicle excision with stabilization of the stump.

 .

4     Scapula Fractures  

 Take-Home Message

•      H igh-energy injuries with high rates of associated injuries and 2–5 % mortality rate.

•      Nonoperative management indicated for the majority of scapula fractures.

•      Operative treatment indicated for glenoid fractures with signifi cant articu-lar involvement and displacement or humeral head instability and glenoid neck fracture with signifi cant displacement and/or angulation.

•      Consider fi xation of fl oating shoulder injuries.

•      General

–     Uncommon injuries associated with high-energy mechanisms

–     80–90 % associated injuries: rib fractures, pulmonary injury, pneumothorax closed head injury, vascular injury, ipsilateral clavicle fracture, spine fracture, pelvis/acetabulum fracture, brachial plexus injury

–     2–5 % associated mortality rate

•      Imaging

–     True AP, scapular Y, and axillary lateral.

–     CT scan: assess for intra-articular involvement and displacement.

•      Classifi cation

–     Coracoid fractures

•      Type I: proximal to CC ligament

•      Type II: distal to CC ligament

–     Acromial fractures

•      Type I: nondisplaced or minimally displaced

•      Type II: displaced without compromise of subacromial space

•      Type III: displaced with compromise of subacromial space

–     Glenoid fractures

•      Type Ia/Ib: anterior/posterior rim fracture, respectively

•      Type II/III/IV: glenoid fossa fracture exiting scapula laterally/superiorly/medially, respectively

•      Type Va/Vb/Vc: combinations of types II, III, and IV

•      Type VI: severe comminution

–     Glenoid neck fractures

•      Assess for fl oating shoulder: associated AC joint separation or clavicle fracture.

•      Superior shoulder suspensory complex (SSSC): 2 struts comprised of the clavicle and lateral scapular body linked by a bony and soft tissue ring made up of the coracoid, acromion, AC and CC ligaments, distal clavicle, and glenoid process.

–     Disruption of the complex at two sites is more problematic than disrup-tion at one site.

•      Many fl oating shoulder injuries are stable and can be managed nonopera-tively with good outcomes.

•      U nstable injuries with disruption of the SSSC or >1 cm displacement may benefi t from ORIF.

–     Fixation of clavicle alone is typically suffi cient and may restore ade-quate alignment of the scapula fracture.

–     Scapular body fractures

•      Treatment

–     Nonoperative

•      Indicated for the majority of scapula fractures.

•      Sling for 2 weeks, early range of motion; expect union at 6 weeks and not functional defi cits.

–     Operative

•      Indications for surgical fi xation

–     Glenoid fractures: involvement of >25 % glenoid with humeral head subluxation/instability, >5 mm glenoid articular step-off or major gap

–     Glenoid neck fractures: >40° of angulation, >1 cm translation, transla-tion of the glenoid and humeral head anterior to the proximal fragment or excessive glenoid medialization

–     Coracoid fractures: >1 cm displacement in high-demand patients –  Open fractures

•      Open reduction internal fi xation may be combined with shoulder arthros-copy depending on the fracture pattern.

•      Complications

–     Scapulothoracic crepitation: may develop as sequelae of scapular body frac-ture and cause pain.

–     Open treatment typically utilizes the posterior Judet approach, with risk of injury to the suprascapular nerve and artery and circumfl ex scapular artery.

 Bibliography

 1.  Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C. Skeletal trauma. 4th ed. Philadelphia: Saunders; 2009. p. 1760–5.

2. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 707–9.

3. V an Noort A, van Kampen A. Fractures of the scapula surgical neck: outcome after conservative treatment in 13 cases. Arch Orthop Trauma Surg. 2005;123:696–700.

4. V eysi VT, Mittal R, Agarwal S, Dosani A, Giannoudis PV. Multiple trauma and scapula fractures: so what? J Trauma. 2003;55(6):1145–7.

 5.  Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole PA. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma.

2006;20(3):230–3.

5     Scapulothoracic Dissociation  

Take-Home Message •      Maintain high index of suspicion for scapulothoracic dissociation with neurovascular injury and >1 cm lateral displacement of the scapula on AP CXR •      High incidence of associated trauma to the heart, chest wall, lungs, and ipsilateral shoulder girdle •      Functional outcome determined by the severity of the associated neuro-logic injury •      Mortality rate: 10 %

•      General

–  High-energy injury with traumatic disruption of the scapulothoracic articulation

•      Typically caused by a lateral traction injury

–     High incidence of associated injuries

•      Trauma to the heart, chest wall, lungs

•      N eurologic injury (90 %): brachial plexus most common, poor outcomes, neurologic injury more common than vascular injury

•      Vascular injury: subclavian artery most common, axillary artery

–     Careful neurovascular exam is critical in patient assessment. –  Mortality rate: 10 %.

•      Imaging

–  AP CXR: >1 cm lateral displacement of the scapula from the spinous process compared to the contralateral side

•      Possible additional fi ndings: widely displaced clavicle fracture, AC sepa-ration, sternoclavicular dislocation

–     Angiogram: evaluate for injury to the subclavian and axillary artery.

–     EMG: consider 3 weeks after injury to further evaluate neurologic injury.

•      Treatment

–  Nonoperative

•      Immobilization and supportive care

•      Indicated in hemodynamically stable patients without signifi cant vascular injury

–     Operative

•      V ascular repair indicated in hemodynamically unstable patients with  signifi cant vascular injury.

•      Consider ORIF of associated clavicle and AC joint injuries.

•      Forequarter amputation indicated for complete brachial plexus injury.

•      Complications

–     Poor outcomes overall

•      Functional outcome largely determined by severity of neurologic injury

•      ~50 % of patients will have a fl ail extremity

 Bibliography

1 . A lthausen PL, Lee MA, Finkemeier CG. Scapulothoracic dissociation: diagnosis and treatment. Clin Orthop Relat Res. 2003;416:237–44.

 2.  Clements RH, Reisser JR. Scapulothoracic dissociation: a devastating injury. J Trauma. 1996;40(1):146–9.

3 . M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 709.

 4.  Zelle BA, Pape HC, Gerich TG, Garapati R, Ceylan B, Krettek C. Functional outcome following scapulothoracic dissociation. J Bone Joint Surg Am. 2004;86-A(1):2–8.

6     Glenohumeral Dislocations  

 Take-Home Message

•      Shoulder dislocation must be evaluated with an axillary radiograph.

•      Anterior glenohumeral dislocations are most common.

•      Age at time of fi rst dislocation is an important risk factor for recurrent instability and informs risk of associated injuries.

•      Posterior shoulder dislocation is the commonly missed injury.

•      Luxatio erecta has the highest risk of associated neurovascular injury.

•      Assess for concurrent labral, cartilage, bony, and rotator cuff injuries which inform treatment options.

•      Treatment of fi rst time dislocators is controversial.

•      General

–     T  he shoulder’s extensive range of motion presents risk for instability, making it the most commonly dislocated joint in the body.

–     D  irection of dislocation and age of onset key in determining risk of associated injuries and recurrent instability and in guiding treatment.

•      Imaging

–  Standard x-ray series

•      True AP: unreliable, may see “lightbulb” sign with posterior dislocation.

•      Scapular Y.

•      Axillary: best view to demonstrate dislocation; consider Velpeau view if patient is unable to abduct.

–     Westpoint view: assess for glenoid fracture or bone loss (bony Bankart lesion).

–     Stryker notch view: assess posterior humeral head (Hill-Sachs lesion).

–     CT scan: may help assess location and extent of bony injuries/defects. –  MRI: assess labral tears and rotator cuff tears.

•      Anterior Dislocations

–     Typically traumatic and unilateral

–     Determinants of anterior static shoulder stability

•      SGHL: arm at side

•      MGHL: 45° abduction and external rotation

•      Anterior band of IGHL: 90° abduction and external rotation

–     Examination: apprehension sign, relocation sign, sulcus sign

–     Associated injuries

•  Labral and cartilage injuries

–     Bankart lesion: avulsion of the anterior inferior capsulolabral complex.

–     Humeral avulsion of the glenohumeral ligament (HAGL): increased risk of recurrent dislocation.

–     G  lenoid labral articular defect (GLAD): sheared of articular cartilage with labrum.

–     Anterior labral periosteal sleeve avulsion (ALPSA): torn labrum may heal medially along the glenoid neck.

•      Bone injuries

–     H  ill-Sachs lesion: anterior dislocations, clinically signifi cant if it engages the glenoid

–     Bony Bankart lesion: fracture of the anterior inferior glenoid, present in

50 % of patients with recurrent anterior dislocations

–  Greater tuberosity fracture: anterior dislocations in patients >50

•      Nerve injuries

–     Axillary nerve injury: most common (5 %), transient neurapraxia

–     Musculocutaneous nerve injury second most common

•      Rotator cuff tears

–     Increasing incidence with increasing age

–     Bimodal distribution for risk of recurrent dislocation and associated injury

•      If <20 years old at time of fi rst dislocation

–     High rate of recurrent dislocations

–     High rate of associated labral tears

•      If >40 years old at time of fi rst dislocation

–     Lower rate of recurrent dislocations

–     High rate of associated rotator cuff tears

•      Posterior Dislocations

–     Comprise 2–5 % of shoulder dislocations

–     Missed diagnosis in up to 50 % upon presentation to ED

–     M  ay result from acute traumatic insult or microtrauma with labral injury and posterior capsule stretching (lineman, weight lifters, overhead athletes)

–     Associated with high-energy trauma, seizure and electrocution (internal rota-tors overpower external rotators), ligamentous laxity, glenoid retroversion, or hypoplasia

–     Examination: inability to externally rotate

–     Posterior shoulder stabilizers

•      Posterior band of IGHL: primary static restraint in internal rotation

•      Subscapularis: primary dynamic restraint in external rotation

•      Coracohumeral ligament: primary restraint to interior translation in adduc-tion and external rotation, primary restraint to posterior translation in fl exion, abduction, and internal rotation

–     Associated injuries

•      Labral and cartilage injuries

–     R  everse Bankart lesion: avulsion of posterior inferior capsulolabral complex

–     Posterior labral cyst

•      Bone injuries

–     Reverse Hill-Sachs lesion: present in 50 % of posterior dislocations

–     Reverse bony Bankart lesion: fracture of the posterior glenoid rim

–     Lesser tuberosity fracture: posterior dislocations

•      Inferior Dislocations: Luxatio Erecta

–     Rare injuries, 0.5 % of all shoulder dislocations

–     Associated with MVAs and sports injuries

–     Examination: arm overhead in 100–160° abduction

–     Associated injuries

•      H ighest incidence of neurovascular injury of all types of shoulder dislocation

–     Axillary nerve and artery most common

•      Axillary nerve palsy typically resolves with reduction.

•      M ay have diminished or absent pulses on presentation with return after reduction.

•      Axillary artery thrombosis may develop late.

•      Glenohumeral ligament tears

•      Capsulolabral tears possible

•      Rotator cuff tears common

•      Treatment

–     Nonoperative

•      Closed reduction, sling for 2–4 weeks and physical therapy with rotator cuff and periscapular muscle strengthening, activity modifi cation

–  Immobilize posterior shoulder dislocation in neutral to external rotation.

•      Reduction maneuvers: many described, simple traction-countertraction most commonly used

–     Operative

•  Anterior dislocations

–     TUBS (traumatic unilateral Bankart surgery)

–     Open/arthroscopic Bankart repair +/− capsular shift: high success rate

–     Latarjet procedure: transfer of coracoid to address >20 % glenoid defi ciency

–     R  emplissage: posterior capsule and infraspinatus tendon advancement into >25 % Hill-Sachs lesion

–     H  ill-Sachs bony reconstruction: allograft reconstruction, arthroplasty, or rotational osteotomy to address large engaging Hill-Sachs lesion

•      Posterior dislocations

–     Open/arthroscopic reverse Bankart repair +/− capsular shift: high suc-cess rate

–     McLaughlin: lesser tuberosity and subscapularis transfer to reverse Hill-Sachs defect <50 %

–     H  emiarthroplasty: reverse Hill-Sachs defect >50 %, chronic dislocations, severe humeral head arthrosis or collapse

–     T  otal shoulder arthroplasty: hemiarthroplasty indication with glenoid arthrosis

•      Inferior dislocations

–     O  pen/arthroscopic repair: indicated in young, active patients to address specifi c capsulolabral and rotator cuff pathology

•      Complications

–     Recurrent instability: <10 % after operative treatment

–     Adhesive capsulitis

–     Capsular overtightening: may lead to subluxation or impingement –  Posttraumatic arthrosis

 Bibliography

1.    Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C. Skeletal trauma. Philadelphia: Saunders; 2009. p. 1717–35.

2.    Lynch JR, Clinton JM, Dewing CB, Warme WJ, Matsen FA. Treatment of osse-ous defects associated with anterior shoulder instability. J Shoulder Elbow Surg. 2009;18(2):317–28.

3. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 324–6, 711.

4. M illett PJ, Clavert P, Hatch 3rd GF, Warner JJ. Recurrent posterior shoulder instability. J Am Acad Orthop Surg. 2006;14:464–7.

5. S ewecke JJ, Varitimidis SE. Bilateral luxatio erecta: a case report and review of the literature. Am J Orthop. 2006;35(12):578–80.

7     Proximal Humerus Fractures  

 Take-Home Message

•      M ost proximal humerus fractures result from low-energy trauma in elderly patients.

•      85 % of proximal humerus fractures are minimally displaced and can be treated nonoperatively.

•      M any patients will have signifi cant residual functional defi cits, irrespective of treatment.

•      General

–     Comprise 5 % of all fractures

–     More common in women

–     Low-energy falls: osteoporosis, third most common fracture in elderly

–     High-energy trauma: young patients, increased incidence of neurovascular injures

–     Blood supply to the humeral head

•      Ascending branch of the anterior humeral circumfl ex artery, which runs in the lateral aspect of the bicipital groove, is classically described at the primary blood supply to the humeral head.

•      Posterior humeral circumfl ex artery shown to be the main supply to the humeral head in more recent studies.

•      Vascularity of the articular segment more likely to be preserved if >8 mm of calcar remains attached.

–     45 % associated nerve injury

•      Axillary nerve injury most common

–     Distinguish from deltoid atony with pseudosubluxation of the humeral head.

•      Increased risk with fracture-dislocations

•      Imaging

–     Trauma series x-rays: true AP, scapular Y, axillary.

–     C  T scan: further assess fracture displacement, intra-articular involvement, and preoperative planning.

•      Classifi cation

–  Neer classifi cation: part = displacement >1 cm or angulation >45° of the articular surface, greater tuberosity, lesser tuberosity, and shaft –  One part

•      Nondisplaced or minimally displaced fracture, most commonly involving the surgical neck

–     Two part

•      S urgical neck: anteromedial displacement of the shaft from pull of pectoralis major

•      G reater tuberosity: posterosuperior displacement from pull of supraspinatus, infraspinatus, and teres minor

–     Displacement >5 mm may impinge and block external rotation and abduction.

•      L esser tuberosity: posteromedial displacement from pull of subscapularis, associated with posterior shoulder dislocations

•      Anatomic neck: rare injury pattern

–     Three part

•  Displacement of greater or lesser tuberosity and articular surface

–     Four part

•      Displacement of shaft, articular surface, and both tuberosities

•      Head-splitting variant: split through articular surface

–     Valgus impaction

•      Posteromedial calcar typically intact: preserved blood supply to the  articular segment, decreased risk of AVN

•      Treatment

–     Nonoperative

•      Sling immobilization, early shoulder range of motion, and rehabilitation

•      Indicated for minimally displaced fractures, grater tuberosity fracture with

<5 mm displacement and poor surgical candidates

–     Consider age, fracture characteristics, bone quality, medical comorbidi-ties, and concurrent injuries.

–     Operative

•      Closed reduction percutaneous pinning

–     Two-part surgical neck fractures, some three-part and valgus impacted fractures

–     Consider bone quality, metaphyseal comminution, and involvement of medial calcar

•      Open reduction internal fi xation

–     Greater tuberosity fracture with >5 mm displacement.

•      Techniques include screw fi xation, nonabsorbable suture, and ten-sion band wiring

–     Consider in two-, three-, and four-part fractures and head-splitting frac-tures in younger patients.

•      Lesser tuberosity component: large fragment amenable to ORIF; small fragments may be excised with cuff repair.

•      Intramedullary nailing

–     Consider in surgical neck fractures, some three-part fractures, and com-bined humeral shaft fractures.

–     Improved outcomes in younger patients.

•      Hemiarthroplasty

–     Anatomic neck fractures in the elderly or with signifi cant comminution in younger patients, three- and four-part fractures not amenable to ORIF, fracture-dislocations, head-splitting fracture fractures, humeral head defect >40 %, loss of humeral head blood supply.

–     Consider in nonunions and malunions.

–     Requires an intact glenoid.

–     Humeral height, humeral version, and tuberosity reconstruction are important contributors to outcome.

•      Superior border of the pectoralis major insertion is a reliable  landmark to determine height of the prosthesis.

– I  n elderly patients, hemiarthroplasty may improve pain long term even if there is little functional benefi t compared to nonoperative management.

•      Total shoulder arthroplasty

–     Indications for hemiarthroplasty  plus intact rotator cuff and glenoid compromise

•      Reverse shoulder arthroplasty

–     Consider in elderly patients with nonreconstructable tuberosities

–     May result in improved outcomes when compared to hemiarthroplasty in elderly patients

•      Complications

–     Avascular necrosis

•      20–75 % in four-part fractures.

•      R isk of AVN increased with disruption of the medial periosteal hinge, medial metaphyseal extension less than 8 mm, increasing fracture complexity, displacement greater than 10 mm, angulation greater than 45°.

•      Incidence does not correlate with method of surgical fi xation.

•      If symptomatic, treat with arthroplasty.

–     Nerve injury

•      Axillary nerve most commonly injured.

•      S uprascapular nerve and musculocutaneous nerve are also commonly injured.

•      Some specifi c risks for nerve injury pending type of surgical intervention and approach.

–     Hardware failure

•      S crew cutout, the most common complication following ORIF of the proximal humerus fractures with locking plates.

•      Inferomedial calcar screw in plate and screw constructs can help prevent varus collapse.

•      Intramedullary rods may migrate in the osteoporotic bone.

–     Nonunion

•      Most common after two-part fractures of the surgical neck.

•      If symptomatic, consider treatment with arthroplasty.

–     Malunion

•      Surgical neck fractures with varus and apex anterior deformity are poorly tolerated.

•      May consider osteotomy in symptomatic, young active patients.

–     Rotator cuff defi ciencies

–     Adhesive capsulitis

–     Infection

 Bibliography

 1.  Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C. Skeletal trauma. Philadelphia: Saunders; 2009. p. 1643–712.

2 . C uff D, Pupello D. Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients. J Bone Joint Surg Am. 2013;95:2050–5.

 3.  Hettrich CM, Boraiah S, Dyke JP, Neviaser A, Helfet DL, Lorich DG. Quantitative assessment of the vascularity of the proximal part of the humerus. J Bone Joint Surg Am. 2010;92(4):943–8.

4 . J aberg H, Warner JJ, Jakob RP. Percutaneous stabilization of unstable fractures of the humerus. J Bone Joint Surg Am. 1992;74:508–15.

 5.  Konrad G, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, Luo C, Plecko M, Wendt K, Köstler W, Südkamp N. Open reduction and internal fi xation of proximal humeral fractures with use of the locking proximal humerus plate. Surgical technique. J Bone Joint Surg Am. 2010;92(Suppl 1 Pt 1):85–95.

6 . M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 709–11.

7.    Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Hemiarthroplasty ver-sus nonoperative treatment of displaced 4-part proximal humerus fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg. 2011;20:1025–33.

8.    Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK. Open reduction and internal fi xation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am. 2002;84-A(11):1919–25.

8     Humeral Shaft Fractures  

 Take-Home Message

•      Nonoperative management with coaptation splint converted to functional bracing is indicated for the majority of humeral shaft fractures.

•      A cceptable alignment: <30° varus/valgus angulation, <20° fl exion/extension, <3 cm shortening.

•      A bsolute indications for surgical treatment: open fractures, associated vascular injury requiring repair, brachial plexus injury.

•      R elative indications for surgical treatment: polytrauma, pathologic fractures, soft tissue injury that precludes bracing, some fracture patterns.

•      H olstein-Lewis fracture: spiral distal 1/3 diaphyseal humerus fracture associated with increased risk of radial nerve injury.

•      Intramedullary nail fi xation has higher complication rates compared to plate osteosynthesis.

•      T he vast majority of radial nerve palsies resolve over time; observation is typically indicated as the initial treatment course.

•      General

–     Comprise 3–5 % of all fractures

–     Associated radial nerve injury most common

•      Radial nerve courses through the spiral groove.

•      20 cm proximal to the medial epicondyle.

•      14 cm proximal to the lateral epicondyle.

•      I ncreased risk of radial nerve injury with Holstein-Lewis fracture patterns.

–     Careful neurovascular exam prereduction/splinting and preoperatively is critical

•      Imaging

–     AP and lateral x-rays of the humerus, must include good visualization of the shoulder and elbow joints.

–     Traction views may be considered in some fracture patterns but are not required routinely.

•      Classifi cation

–     Descriptive

•      Fracture location: proximal, middle, distal 1/3

•      Fracture pattern: transverse, spiral, comminuted

–     Holstein-Lewis fracture

•      Spiral distal 1/3 diaphyseal humerus fracture

•      22 % radial nerve injury

•      Treatment

–     Nonoperative

•      Nonoperative management is the treatment of choice when possible.

•      Acceptable alignment: less than 30° of varus/valgus angulation, less than 20° fl exion/extension, less than 3 cm of shortening.

•      C oaptation splint for 7–10 days followed by conversion to functional bracing.

•      Low nonunion rate

–     Proximal 1/3 diaphyseal humerus fracture have an increased risk of nonunion.

–     Operative

•      Absolute indications: open fracture, vascular injury requiring repair, bra-chial plexus injury

•      Relative indications: fl oating elbow, polytrauma (allow early weight bear-ing through humerus), pathologic fractures, soft tissues that preclude functional bracing, segmental fractures, neuromuscular conditions, some fracture patterns

•      Plate fi xation

–     C  onsidered the gold standard for most humeral shaft fractures indicated for surgical fi xation

–     High union rates

–     Decreased secondary operations

–     Safe to allow weight bearing to tolerance

•      Intramedullary nailing

–     May be advantageous with pathologic fractures, segmental fractures, humeral shaft fractures combined with proximal humerus fractures, and poor soft tissues.

–     Antegrade or retrograde technique may be employed.

–     Higher total complication rates including nonunion, shoulder pain, and nerve injury

•      Early weight bearing does not affect union rate.

•      Radial nerve at risk with lateral to medial distal locking screw.

•      Musculocutaneous nerve at risk with anterior to posterior distal locking screw.

•      Complications

–     Radial nerve palsy

•      Occurs in 5–10 % of humeral shaft fractures.

•      Increased incidence with distal 1/3 fractures and transverse fractures.

•      85–90 % resolve over 3–4 months with observation

–     Wrist extension and radial deviation are expected to be regained fi rst.

•      If not improving by 6–12 weeks, obtain EMG.

•      R adial nerve palsy in closed fracture after reduction: typically observe, and consider exploration for new pain.

•      Consider surgical exploration for open fractures with radial nerve palsy, closed fractures that fail to improve at 3–4 months, and fi brillations on

EMG.

–     Nonunion

•  2–10 % overall

–     Slightly higher rates of nonunion with surgical treatment

•      R isk factors: fracture distraction, open fractures, segmental fractures, infection, shoulder/elbow stiffness, patient factors (smoking, obesity, malnutrition, etc.).

•      Treat with compression plating with autogenous bone grafting.

–     Malunion

•  Varus angulation most common but typically asymptomatic

–     I  ncreased risk of malunion in proximal 1/3 diaphyseal fractures and transverse fractures.

–     Pull of the deltoid on the proximal fragment contributes to varus malalignment.

 Bibliography

1.    Chapman JR, Henley MB, Agel J, Benca PJ. Randomized prospective study of humeral shaft fracture fi xation: intramedullary nails versus plates. J Orthop Trauma. 2000;14(3):162–6.

2.    DeFranco MJ, Lawton JN. Radial nerve injuries associated with humeral frac-tures. J Hand Surg Am. 2006;31(4):655–63. Review.

3.    Heineman DJ, Poolman RW, Nork SE, Ponsen KJ, Bhandari M. Plate fi xation or intramedullary fi xation of humeral shaft fractures. Acta Orthop. 2010;81(2):216– 23. Review.

4.    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(3):336–9.

5. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 711–3.

6. S armiento 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(4):478–86.

9     Distal Humerus Fractures  

 Take-Home Message

•      The majority of distal humerus fractures are indicated for surgical fi xation.

•      Distal intercondylar fractures are the most common variant.

•      Maintain a high index of suspicion for nerve injury, brachial artery injury, and forearm compartment syndrome.

•      Goal to restore functional elbow range of motion: 30–130°.

•      For ORIF, both parallel plating and 90–90 plating confi gurations are supported.

•      T riceps splitting, triceps sparring/paratricipital, and transolecranon osteotomies may be employed with different potential advantages and disadvantages pending fracture confi guration.

•      Ulnar nerve transposition not shown to decrease the incidence of ulnar nerve symptoms.

•      Surgical fi xation of comminuted, osteoporotic fractures is very challeng-ing – consider total elbow arthroplasty.

•      General

–     M  ost common in young males (high-energy falls) and elderly females (low- energy falls).

–     Distal intercondylar fractures are the most common variant.

–     Elbow position at injury impacts fracture pattern

•      Axial load with elbow fl exed <90°: transcolumnar fracture

•      Axial load with elbow fl exed >90°: intercondylar fracture more likely

–     Associated injuries include elbow dislocations, terrible triad injury, fl oating elbow, and forearm compartment syndrome.

–     Careful neurovascular exam to assess radial, ulnar, and median nerve as well as distal pulses

•  Maintain high index of suspicion for brachial artery injury and pursue further vascular work-up if there is any abnormality.

–     I  njuries often complicated by low fracture lines, metaphyseal and articular comminution, and poor bone quality.

–     Goal to restore functional elbow range of motion: 30–130°

•      Poor outcomes in up to 25 % of patients

•      Imaging

–     AP and lateral x-rays of the elbow, humerus, and forearm.

–     Obtain dedicated wrist views if additional elbow injury is identifi ed or if there is wrist tenderness.

–     Consider oblique views and traction fi lms for surgical planning.

–     C  T scan often obtained for surgical planning, particularly helpful with coronal shear fractures of the capitellum and trochlea.

•      Classifi cation

–  Extra-articular supracondylar humerus fractures

•      M any variants: high extension, high fl exion, low extension, low fl exion, abduction, adduction.

•      80 % are extension-type fractures.

–     Partial articular “single-column” fractures

•  Milch classifi cation

–     May involve lateral or medial condyle but lateral is more commonly involved

–     Type I: lateral trochlear ridge intact

–     Type II: lateral trochlear ridge is violated

–     Complete articular “double-column” fractures

•      Five major articular fragments: capitellum/lateral trochlea, lateral epicondyle, posterolateral epicondyle, posterior trochlea, and medial epicondyle/trochlea

•      Jupiter classifi cation

–     H  igh T: transverse fracture proximal to or at the upper olecranon fossa with intercondylar split.

–     Low T: transverse fracture just proximal to the trochlea with intercon-dylar split.

–     Y: oblique fracture line through both columns with intercondylar split.

–     H  : bicolumnar fracture with more than one fracture line extending to the articular surface where the trochlea is a free fragment;  increased risk of trochlear AVN.

–     Medial lambda: proximal fracture line exits medially.

–     Lateral lambda: proximal fracture line exits laterally.

–     Multiplane T: T type with an additional fracture in the coronal plane.

•      Treatment

–     Nonoperative

•  Nondisplaced single-column fractures with intact lateral trochlear ridge (Milch type I) may be considered for nonoperative management.

–     Lateral condyle fracture: immobilize in supination

–     Medial condyle fracture: immobilize in pronation

•  “Bag-of-bones” technique: consider in demented patients and patients with severe medical comorbidities.

–     Operative

•      T he majority of distal humerus fractures are indicated for surgical fi xation.

•      Surgical fi xation in older patients with comminuted, osteoporotic bone is very challenging.

•      Closed reduction percutaneous pinning

–     Consider in some partial articular single-column fractures.

•      Open reduction internal fi xation

–     Indicated in extra-articular, partial articular, and complete articular fractures.

–     F  or fractures involving both columns, ORIF with dual plating is typically performed.

–     Biomechanical studies support both parallel plating and 90–90 plating

•      Parallel plating: one plate medial, one plate lateral

•      9 0–90 plating: one plate medially, one plate posterolaterally, interdigitating screws increases strength of construct

–     Triceps split and triceps sparring/paratricipital approaches best for extra-articular fracture and fractures with simple articular splits.

•      T riceps sparring/paratricipital approach may be converted into olecranon osteotomy if needed.

–     T  ransolecranon osteotomies provide the best exposure of the articular surface to facilitate joint reconstruction for complex intra-articular fractures and fractures with coronal shear components.

•      Avoid transolecranon osteotomy if total elbow arthroplasty is being considered.

–     Initiate early elbow range of motion.

–     Consider ulnar nerve transposition if in direct contact with implants.

•      Ulnar nerve transposition not shown to decrease the incidence of ulnar nerve symptoms

–     Total elbow arthroplasty

•      Consider in low bicolumnar fractures in elderly patients, particularly those with osteoporosis or rheumatoid arthritis

•      Complications

–     Elbow stiffness is the most common complication

•      Contracture, fi brosis, and bone block may contribute to loss of motion.

•      Treat with static progressive splinting.

–     Ulnar nerve injury

•      Ulnar nerve a risk both from injury and surgical intervention

–     Critical to identify and protect the ulnar nerve throughout surgery. –  Maintain blood supply to ulnar nerve when mobilizing.

–     Heterotopic ossifi cation

•  Occurs in 4–8 % of patients, routine prophylaxis not recommended

–     Nonunion

•      Low incidence overall

–     Malunion

•      Lateral column fractures at risk for cubitus valgus

•      Medial column fractures at risk for cubitus varus

–     Avascular necrosis

•      Uncommon overall

•      Bicolumnar H-type fracture with free trochlear fragment at increased risk

–     Posttraumatic arthrosis

 Bibliography

1.    Frankle MA, Herscovici Jr D, DiPasquale TG, Vasey MB, Sanders RW. A com-parison of open reduction and internal fi xation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma. 2003;17(7):473–80.

2.    Galano GJ, Ahmad CS, Levine WN. Current treatment strategies for bicolumnar distal humerus fractures. J Am Acad Orthop Surg. 2010;18(1):20–30.

3.    McKee MD, Jupiter JB, Bamberger HB. Coronal shear fractures of the distal end of the humerus. J Bone Joint Surg Am. 1996;78(1):49–54.

4. M cKee 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 fi xation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg. 2009;18(1):3–12.

5. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia:

Elsevier; 2012. p. 713–6.

10     Capitellum Fractures  

 Take-Home Message

•      Simple coronal shear fractures of the capitellum are rare – these injuries are often more complex.

•      High rates of elbow stiffness, but most patients are able to regain func-tional elbow range of motion.

•      N ondisplaced and minimally displaced fracture amenable to nonoperative management with initial splint immobilization and early range of motion.

•      C onsider ORIF if fracture fragments are suffi ciently large versus fragment excision if fracture fragments are too small or too comminuted to support fi xation.

•      C onsider total elbow arthroplasty for unreconstructable capitellum fractures in elderly patients.

•      General

–     Simple coronal shear fractures of the capitellum are rare – these injuries are often more complex.

–     Typically result from a fall on an outstretched hand.

–     M  ore common in females, possibly related to greater carrying angle of the elbow in females.

–     May present with mechanical block to elbow fl exion/extension.

–     ~20 % of capitellum fractures have an associated radial head fracture.

–     High rates of elbow stiffness but most patients are able to regain functional elbow range of motion.

–     High reoperation rates, up to 48 %.

•      Imaging

–     AP and lateral x-rays of the elbow: double arc sign on lateral radiograph rep-resents the overlap of the subchondral bone of the displaced capitellum and the lateral trochlea ridge; isolated effusion may represent a nondisplaced capitellum fracture.

–     C  onsider oblique view to better characterize the main fracture line and radiocapitellar view.

–     M  aintain high index of suspicion for involvement of the trochlea, lateral condyle, and comminution.

–     C  T scan: helpful to further characterize the injury and for surgical planning.

•      Bryan-Morrey Classifi cation

–     Type I (Hahn-Steinthal): complete fracture of the capitellum

–     Type II (Kocher-Lorenz): superfi cial shear fracture of the articular cartilage with little subchondral bone attached

–     Type III (Grantham): comminuted fracture

–     Type IV (McKee modifi cation): coronal shear fracture involving the capitel-lum and portion of the trochlea

•      Treatment

–     Nonoperative

•      Nondisplaced and minimally displaced (<2 mm) type I and type II fractures

–     Splint immobilization for 2–3 weeks and then early elbow range of motion

–     Operative

•      Open reduction internal fi xation

–  Displaced (>2 mm) fractures with suffi cient bone to allow fi xation

•      Headless screw fi xation.

•      Screw placement from posterior to anterior if capitellar fragment is suffi ciently large.

•      L ateral approach often used; consider posterior approach to address concurrent elbow pathology.

•      Fragment excision

–  Fracture fragments that are too small or too comminuted to support fi xation should be excised.

•      Total elbow arthroplasty

– C  onsider in unreconstructable capitellar fractures in elderly patients with medial column instability.

•      Complications

–     Nonunion

•      1–11 % with ORIF

–     Heterotopic ossifi cation

•      4 % with ORIF

–     Avascular necrosis

•      Blood supply to the capitellum comes from the posterolateral aspect of the elbow.

 Bibliography

1 . D ushuttle RP, Coyle MP, Zawadsky JP, Bloom H. Fractures of the capitellum. J Trauma. 1985;25(4):317–21.

2.    Frankle MA, Herscovici Jr D, DiPasquale TG, Vasey MB, Sanders RW. A com-parison of open reduction and internal fi xation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma. 2003;17(7):473–80.

3.    McKee MD, Jupiter JB, Bamberger HB. Coronal shear fractures of the distal end of the humerus. J Bone Joint Surg Am. 1996;78(1):49–54.

4 . M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia:

Elsevier; 2012. p. 715–6.

11     Radial Head Fractures  

 Take-Home Message

•      Maintain high index of suspicion for Essex-Lopresti lesion: radial head fracture with concurrent DRUJ injury and interosseous membrane disruption, indicating length instability of the forearm ring.

•      ORIF of displaced fractures when fi xation is feasible.

•      Keep forearm in pronation with ORIF to decrease risk of injury to poste-rior interosseous nerve.

•      S afe zone for plates: 90–110° lateral arc from the radial styloid to Lister’s tubercle with the forearm in neutral position.

•      May consider partial excision of small fragments, but risk subsequent instability.

•      Metallic radial head replacement recommended for fractures with three or more fragments and concurrent elbow pathology.

•      R adial head resection alone may be considered in elderly, low-demand patients.

•      General

–     One of the most common types of elbow fractures.

–     Associated injuries in 30 % of radial head fractures

•      DRUJ injuries, interosseous membrane disruption, coronoid fractures, MCL/LCL injury, elbow dislocation, terrible triad, carpal fractures

–     Mechanism of injury: axially load on an outstretched hand with pronated forearm.

–     Radial head is the secondary restraint to valgus force at the elbow.

–     Critical points of examination

•      Evaluate for mechanical block to motion with forearm pronation/supina-tion and elbow fl exion/extension.

–     Consider hematoma aspiration and injection of local anesthetic to facil-itate examination.

•      Assess wrist for pain and DRUJ instability; compare to contralateral side.

•      Imaging

–     AP and lateral elbow x-rays: isolated effusion may represent a nondisplaced radial head fracture.

–     Consider radiocapitellar view (oblique lateral) to further characterize fractures.

–     CT scan may be useful in comminuted fractures.

•      Classifi cation

–  Mason classifi cation

•      T ype I: nondisplaced or minimally displaced (<2 mm) partial articular or extra-articular radial head fracture with no mechanical block to forearm rotation

•      T ype II: displaced (>2 mm) partial articular or extra-articular radial head fracture with possible mechanical block to forearm rotation

•      Type III: displaced complete articular radial head fracture or signifi cantly displaced extra-articular radial head fracture with possible comminution and likely mechanical block to forearm rotation

•      Type IV (Hotchkiss modifi cation): radial head fracture with elbow dislocation

–     Essex-Lopresti lesion: radial head fracture with DRUJ injury and interosseus membrane disruption

•      Indicates length instability of the forearm ring

•      Treatment with radial head resection alone contraindicated due to exacer-bation of DRUJ instability and risk of proximal radial migration with resulting ulnocarpal impaction

•      Treatment

–     Nonoperative

•      Short period of immobilization followed by early range of motion

–     Isolated minimally displaced fractures with no block to motion.

–     Elbow stiffness will result from prolonged immobilization.

–     Operative

•      Open reduction internal fi xation

–     Displaced fractures where fi xation is feasible, mechanical block to motion, concurrent elbow injuries.

–     Safe zone for plates: 90–110° lateral arc from the radial styloid to Lister’s tubercle with the forearm in neutral position.

–     Countersink screws on articular surface or use headless compression screws.

–     With lateral and posterolateral approaches, keep forearm in pronation to decrease risk of injury to posterior interosseous nerve.

–     I  f three or more fragments, excision +/− radial head replacement is preferred.

•      Partial radial head excision

–     C  onsider in fragments <25 % of the radial head or <25–33 % of capitellar surface area.

–     May result in instability.

•      Radial head replacement

–     D  isplaced, comminuted fractures where ORIF is not feasible, Essex-L opresti lesions with nonreconstructable radial head, elbow fracture-dislocations. –  Good outcomes with metallic implants

•      Loose stemmed prostheses: act as spacers

•      Bipolar prostheses: cemented into the radial neck

–     Beware of “overstuffi ng the joint” which can lead to capitellar wear, malalignment, and instability.

–     Silastic radial head implants not recommended due to development of synovitis.

•      Radial head resection

– C  onsider radial head resection alone in nonreconstructable radial head fractures in elderly, low-demand patients

•      Young active patients without an Essex-Lopresti lesion may still develop proximal radial migration (to a lesser degree) with symptomatic ulnocarpal impaction overtime.

–     C  ontraindicated with concurrent elbow instability with coronoid fracture, MCL defi ciency, or interosseous membrane disruption

–     May be performed in a delayed fashion for pain control following radial head fracture

–     R  isk of subsequent elbow instability, proximal radial migration, cubitus valgus, decreased strength and pain

–     Complications

•      Elbow stiffness

•      Decreased forearm rotation

•      Posterior interosseous nerve injury with operative management

– P  ronate the forearm to increase the distance between the operative site and PIN to help prevent injury.

•      P roximal radial migration with ulnocarpal impaction in unrecognized Essex-Lopresti lesions with radial head excision

•      Radiocapitellar joint arthritis

 Bibliography

1.    Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Nyqvist F, Karlsson MK. Fractures of the radial head and neck treated with radial head excision. J Bone Joint Surg Am. 2004;86-A(9):1925–30.

2.    Herbertsson P, Josefsson PO, Hasserius R, Karlsson C, Besjakov J, Karlsson M. Uncomplicated Mason type-II and III fractures of the radial head and neck in adults. A long-term follow-up study. J Bone Joint Surg Am. 2004;86-A(3): 569–74.

3 . M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 719.

4.    Paschos NK, Mitsionis GI, Vasiliadis HS, Georgoulis AD. Comparison of early mobilization protocols in radial head fractures. A prospective randomized controlled study. The effect of fracture characteristics on outcome. J Orthop Trauma. 2013;27(3):134–9.

5.    Ring D, Quintero J, Jupiter JB. Open reduction and internal fi xation of fractures of the radial head. J Bone Joint Surg Am. 2002;84-A(10):1811–5.

6.    Tejwani NC, Mehta H. Fractures of the radial head and neck: current concepts in management. J Am Acad Orthop Surg. 2007;15(7):380–7.

12     Coronoid Fractures  

 Take-Home Message

•      R arely occur as isolated injuries, typically associated with elbow dislocations with risk for recurrent elbow instability.

•      Coronoid is the primary restraint to elbow subluxation/dislocation.

•      Anteromedial coronoid facet fractures may result in posteromedial rota-tory instability.

•      C oronoid fractures with a stable elbow are amenable to nonoperative management with a short period of immobilization and early elbow range of motion.

•      Coronoid fractures with elbow instability or current elbow pathology should undergo ORIF with a variety of techniques described pending the specifi c fracture pattern and associated pathology.

•      General

–     Rare as isolated injuries, typically associated with elbow dislocations with increased risk of recurrent instability.

–     Coronoid acts as an anterior buttress and is the primary restraint to elbow subluxation/dislocation.

–     M  echanism of injury: traumatic shear injury as the distal humerus is driven against the coronoid.

–     Assess elbow fl exion/extension and pronation/supination, and perform varus/valgus stress testing.

–     Fractures at the base of the coronoid are particularly prone to elbow instability as the anterior capsule inserts 6 mm distal to the tip of the coronoid and the anterior bundle of the MCL inserts on the sublime tubercle 18 mm distal to the tip. –  Associated injuries/conditions

•      Terrible triad of the elbow: transverse coronoid fracture, radial head frac-ture, and elbow dislocation

•      Olecranon fracture-dislocation: often with a large coronoid fragment

•      P osteromedial rotatory instability: varus force with fracture of the anteromedial facet of the coronoid and LCL disruption

•      Posterolateral rotatory instability: coronoid tip fracture, radial head frac-ture, LCL injury

•      Imaging

–     AP and lateral elbow x-rays. –  CT scan may be helpful.

•      Regan and Morrey Classifi cation

–     Type I: fracture of the tip of the coronoid process

–     Type II: fracture ≤50 % of the coronoid height

–     Type III: fracture >50 % of the coronoid height

–     Anteromedial facet coronoid fractures: caused by varus posteromedial rota-tory force

•      Treatment

–     Nonoperative

•      Brief immobilization with early range of motion

–     Minimally displaced coronoid fractures with stable elbow

–     Operative

•      Open reduction internal fi xation

–     C  oronoid fractures with elbow instability, anteromedial facet fractures with posteromedial rotatory instability, olecranon fracture-dislocations, and terrible triad of the elbow

–     May secure coronoid with cerclage wire or suture fi xation through drill holes, retrograde screws, or plate fi xation

–     Ligament repair as indicated

–     Early active motion in the postoperative period; consider restricting shoulder abduction to prevent varus moment on the elbow

•      Hinged elbow external fi xation

– C  onsider for coronoid fractures with elbow instability in patients with compromised soft tissues, poor bone quality, and complex revision cases.

•      Complications

–     Recurrent elbow instability

–     Elbow stiffness

–     Heterotopic ossifi cation

–     Posttraumatic arthrosis

 Bibliography

 1.  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.

2 . M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia:

Elsevier; 2012. p. 718–9.

3.    Ring D. Fractures of the coronoid process of the ulna. J Hand Surg Am. 2006;31:1679–89.

4.    Ring D, Doornberg JN. Fracture of the anteromedial facet of the coronoid pro-cess. J Bone Joint Surg Am. 2006;88(10):2216–24.

5.    Steinmann SP. Coronoid process fracture. J Am Acad Orthop Surg. 2008;16:519–29.

6.    Tashjian RZ, Katarincic JA. Complex elbow instability. J Am Acad Orthop Surg.

2006;14(5):278–86.

13     Olecranon Fractures  

 Take-Home Message

•      C onsider nonoperative management for fractures with no articular incongruity and intact elbow extensor mechanism.

•      Recommend surgical fi xation for all displaced fractures and all patients without active extension.

•      T ension band wiring converts dorsal distractive forces into compressive forces at the articular surface and fracture site; best for transverse noncomminuted fractures proximal to the coronoid.

•      T ension band constructs: wire loops should be dorsal to the mid-axis of the ulna, and K-wires should engage but not protrude beyond the anterior cortex to prevent loss of forearm rotation and injury to the AIN.

•      Plate fi xation indicated in comminuted fractures and fractures that extend distal to the coronoid process.

•      Consider excision and triceps advancement of up to 50 % of the proximal ulna in elderly, low-demand patients with nonreconstructable comminuted proximal ulna fractures.

•      General

–     Result from high-energy injuries in the young and low-energy falls in the elderly.

–     A  ssess ulnar nerve function and integrity of the elbow extensor mechanism (palpable gap may be present).

•      Imaging

–     A  P and lateral elbow x-rays: true lateral needed to best delineate the fracture.

–     CT scan may be useful for very comminuted fractures and aid preoperative planning.

•      Colton Classifi cation

–     Type I: avulsion fracture

–     Type IIA-D: oblique and transverse fractures, +/− comminution

–     Type III: fracture-dislocations

–     Type IV: high-energy comminuted, multisegmented fractures

•      Treatment

–     Nonoperative

•      Immobilization at 60–90° for 2–3 weeks and then gentle early elbow range of motion

–     Consider in fractures with no articular incongruity (<1–2 mm displacement)

–     Operative

•      Tension band fi xation

–     B  est employed in transverse displaced fractures proximal to the coronoid without articular surface comminution or dorsal cortex comminution

–     C  onverts distractive forces at the dorsal cortex into compression forces at the articular surface and fracture

•      W ire loops should be dorsal to the mid-axis of the ulna to facilitate transformation of tensile forces into compressive forces.

•      K -wires should be anchored in the anterior cortex to prevent migration; however, proud K-wires may injure the anterior interosseous nerve or block forearm rotation.

–  May combine with lag screw fi xation for noncomminuted oblique fractures proximal to the coronoid

•      Plate and screw fi xation

–     Comminuted fractures, fractures extending distal to the coronoid pro-cess, oblique fracture lines.

–     Plate is placed on the dorsal (tension) side of the ulna.

–     May combine with lag screw fi xation for oblique fractures.

•      Intramedullary fi xation

–     Best employed in noncomminuted and oblique fractures.

–     Partially threaded intramedullary screw must engage the distal intra-medullary canal to provide suffi cient fi xation but may generate more torque than compression.

–     Higher rate of fi xation failure compared to tension banding

•      Considered insuffi cient fi xation when used in isolation by many

•      May be combined with tension banding

•      Excision and triceps advancement

–     Consider in elderly, low-demand patients with poor bone quality and                comminuted,        nonreconstructable            proximal                olecranon fractures.

–     E  xcise portion of the olecranon fracture, repair triceps tendon with nonabsorbable sutures passed through drill holes in the proximal ulna so insertion point is close to the articular surface.

–     D  o not excise >50 % of the olecranon and this may cause subsequent elbow instability.

•      Complications

–  Painful hardware the most common complication

•      Hardware removal undertaken in 40–80 % of cases

–     Elbow stiffness

•      Occurs in 50 % of patients.

•      M ajority of patients are able to regain functional elbow range of motion even if they develop some residual stiffness.

–     Nonunion

–     Nerve injury

•      Ulnar nerve

•      Anterior interosseous nerve

–     Posttraumatic arthrosis

 Bibliography

1. B ailey CS, MacDermid J, Patterson SD, King GJ. Outcome of plate fi xation ofolecranon fractures. J Orthop Trauma. 2001;15(8):542–8.

2. C andal-Couto JJ, Williams JR, Sanderson PL. Impaired forearm rotation after tension-band-wiring fi xation of olecranon fractures: evaluation of the transcortical K-wire technique. J Orthop Trauma. 2005;19(7):480–2.

 3.  Duckworth AD, Bugler KE, Clement ND, Court-Brown CM, McQueen MM. Nonoperative management of displaced olecranon fractures in low-demand elderly patients. J Bone Joint Surg Am. 2014;96(1):67–72.

4. H ak DJ, Golladay Jr G. Olecranon fractures: treatment options. J Am Acad Orthop Surg. 2000;8:266–75.

5. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 716–8.

6. P arker JR, Conroy J, Campbell DA. Anterior interosseus nerve injury following tension band wiring of the olecranon. Injury. 2005;36(10):1252–3.

 7.  van der Linden SC, van Kampen A, Jaarsma RL. J Shoulder Elbow Surg. K-wire position in tension-band wiring technique affects stability of wires and longterm outcome in surgical treatment of olecranon fractures 2012;21(3):405–11.

14     Elbow Dislocations  

 Take-Home Message

•      Elbow dislocations are the second most common joint dislocation.

•      80 % are posterolateral dislocations.

•      Simple elbow dislocations have no associated fractures and are typically stable and amenable to nonoperative management.

•      Complex elbow dislocations have associated fractures and often represent unstable injuries for which surgical intervention is warranted.

•      Anterior and divergent elbow dislocations represent high-energy injuries with increased risk of open wounds, neurovascular injury, associated fractures, recurrent instability, and compartment syndrome.

•      E lbow stiffness with loss of terminal extension is the most common complication of simple elbow fractures.

•      General

–     Elbow dislocations are the second most common major joint dislocation, fol-lowing shoulder dislocation.

–     Posterolateral dislocations most common: 80 % of elbow dislocations.

–     Typically occur in young patients 10–20 years old.

–     Elbow functional range of motion: 30–130° fl exion/extension, 50–50° prona-tion/supination (100° arc). –  Elbow stabilizers

•      P rimary stabilizers: ulnar lateral collateral ligament (varus stress), anterior band of the medial collateral ligament (valgus stress), coronoid/ulnohumeral joint

•      S econdary elbow stabilizer: radiocapitellar joint (valgus stress), capsule, fl exor and extensor tendon origins

–     M  echanism of injury: commonly axial loading with supination of the forearm and a posterolaterally based valgus force

•      Progression of injury from lateral to medial: LCL failure (avulsion at lat-eral epicondylar origin > midsubstance ruptures, possible MCL failure depending on energy of injury

–     A  ssociated injuries: medial and lateral epicondyle avulsion fractures, radial head fractures, coronoid fractures, osteochondral injuries.

–     Careful neurovascular examination.

–     Maintain a high index of suspicion for compartment syndrome.

–     Assess elbow stability following reduction to help guide treatment.

•      Imaging

–     AP and lateral elbow x-rays: best to assess joint congruency.

–     Consider oblique views to assess for periarticular and avulsion fractures.

–     CT scan may be useful when complex injury pattern is suspected.

•      Classifi cation

–     Simple vs complex

•      Simple: no associated fractures, 50–60 % of elbow dislocations

•      C omplex: associated fracture(s) present, may represent terrible triad of the elbow or varus posteromedial rotatory instability, increased risk of recurrent elbow instability

–     Anatomic

•      Posterolateral dislocation: 80 %

•      Other variants: direct posterior, anterior, medial, lateral, divergent

–     A  nterior and divergent dislocations typically result from high-energy mechanisms and have a higher incidence of open wound, neurovascular injury, associated fractures, recurrent instability, and compartment syndrome.

•      Treatment

–  Nonoperative

•      B rief splint immobilization in 90° elbow fl exion with forearm rotation guided by assessment of postreduction stability, followed by early active motion.

•      Reduce with inline traction and supination followed by elbow fl exion with pressure on the olecranon

–     Elbow may be unstable in extension postreduction.

–     LCL disruption: splint in pronation.

–     MCL disruption: splint in supination.

•      Indicated for acute stable simple elbow dislocations.

•      I f simple elbow fracture is unstable in extension following reduction, consider treatment in a hinged elbow brace.

–     Operative

•  Open reduction internal fi xation

–     Fixation of associated coronoid, radial and olecranon fractures, LCL and MCL repair as indicated

–     I  ndicated for acute complex elbow dislocations with instability following reduction, dislocations not amenable to closed reduction, and incarcerated osteochondral fragments

•      Open reduction, capsular release, and hinged external fi xator

–  Hinged external fi xator protects repair while allowing early motion. –  Indicated for chronic elbow dislocations.

•      Complications

–     Elbow stiffness with fl exion contracture/loss of terminal extension is the most common complication of simple elbow dislocations

•      Severity of contracture correlates with length of immobilization.

–     Chronic instability

–     V  arus posteromedial instability: associated with anteromedial facet coronoid fracture and LCL injury –  Neurovascular injury

•      Ulnar and median nerve injuries

•      Brachial artery injury

•      A nterior and divergent elbow dislocations: increased risk of associated neurovascular injury

–     Compartment syndrome

–     Heterotopic ossifi cation: often involves the collateral ligaments

 Bibliography

1.    Cohen MS, Hastings 2nd H. Acute elbow dislocation: evaluation and manage-ment. J Am Acad Orthop Surg. 1998;6(1):15–23. Review.

2.    Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study. J Bone Joint Surg Am. 1987;69(4): 605–8.

3. M cKee MD, Schemitsch EH, Sala MJ, O’driscoll SW. Pathoanatomy of lateral ligamentous disruption in elbow instability. J Shoulder Elbow Surg. 2003;12: 391–6.

4. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 719.

 5.  Ring D, Doornberg JN. Fracture of the anteromedial facet of the coronoid process. J Bone Joint Surg Am. 2006;88(10):2216–24.

6 . R oss G, McDevitt ER, Chronister R, Ove PN. Treatment of simple elbow dislocation using immediate motion protocol. Am J Sports Med. 1999;27: 308–11.

15     Terrible Triad of the Elbow  

 Take-Home Message

•      T errible triad of the elbow: posterolateral elbow dislocation with associated coronoid fracture and radial head fracture with high coincidence of LCL disruption.

•      Nearly all terrible triad injuries are unstable and warrant surgical interven-tion with radial head ORIF/replacement, coronoid ORIF, LCL repair, and +/− MCL repair.

•      F racture-dislocations of the elbow are diffi cult to manage with high rate of both persistent instability and elbow stiffness.

•      General

–     Posterolateral elbow dislocation with associated coronoid fracture, radial head fracture

–     High coincidence of LCL disruption, typically avulsion from the lateral epi-condylar origin

–     Mechanism of injury: axial loading with supination of the forearm and a val-gus force

•  Structures fail from lateral to medial: LCL typically disrupted, anterior bundle of MCL the last to fail

–     Inherently unstable injuries that require surgical treatment

•      V arus instability common, may have valgus instability with MCL disruption

•      Imaging

–     AP and lateral elbow x-rays best to assess joint congruency.

–     CT scan may be helpful to further evaluate coronoid and radial head fractures.

•      Classifi cation

–  Terrible triad

•      Historically, elbow dislocations with combined radial head and coronoid frac-tures had consistently poor outcomes, leading to the name “terrible triad.”

•      Treatment

–     Nonoperative

•      Brief immobilization in 90° of elbow fl exion followed by early active motion with terminal extension restrictions.

•      Rarely indicated: nearly all terrible triad injuries are unstable and warrant surgical intervention.

•      May consider nonoperative management for elbows that are concentrically reduced, remain stable up to 30° of extension, and have minor radial head fractures with no block to motion and coronoid fractures involving only the tip.

–     Operative

•      Radial head fi xation/replacement, coronoid ORIF, LCL repair, +/− MCL repair.

•      Indicated for all unstable terrible triad injuries.

•      The primary goal of surgical fi xation is to stabilize the elbow to permit early motion.

•      See sections on radial head fractures and coronoid fractures for further details.

•      Complications

–     P  ersistent instability: more common following type I and type II coronoid fractures.

–     Elbow stiffness: very common; early range of motion and rehabilitation are crucial.

–     Heterotopic ossifi cation.

–     Failure of fi xation.

–     Posttraumatic arthrosis.

 Bibliography

1. F orthman C, Henket M, Ring DC. Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Surg Am. 2007;32(8):1200–9.

2. M athew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg. 2009;17(3):137–51.

3. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 719.

 4.  Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am. 2004;86-A(6):1122–30.

5 . R ing D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am. 2002;84:547–51.

16     Monteggia Fractures  

 Take-Home Message

•      Proximal 1/3 ulna fractures with radial head dislocation in the direction of the apex of the ulna fracture.

•      10–20 % associated PIN injury, usually resolve with observation for 3 months.

•      M onteggia fractures are inherently unstable injuries that warrant surgical fi xation in all adults.

•      Radial head will typically reduce and be stable with ORIF of the ulna.

•      R adial head may remain unreduced or be irreducible with malreduction of the ulna or soft tissue interposition (annular ligament most common).

•      Posterior radial head dislocations (type II) and injuries with associated radial head fractures have higher complication rates.

•      General

–     Proximal 1/3 ulna fracture with associated radial head dislocation.

–     Radial head dislocates in the direction of the apex of the ulna fracture.

–     Rare in adults, most common in children.

–     Posterior interosseous nerve injury: 20 %.

–     Associated injuries: radial head fracture, coronoid fracture, olecranon fracture-d islocation, LCL injury, terrible triad of the elbow, interosseous membrane disruption, TFCC injury.

–     Most Monteggia fractures are unstable injuries that warrant surgical fi xation.

•      Imaging

–     AP and lateral x-rays of the elbow, forearm, and wrist.

–     CT scan may be helpful to further assess associated coronoid, olecranon, and radial head fractures when present.

•      Bado Classifi cation

–     Type I (60 %): apex anterior proximal 1/3 ulna fracture with anterior radial head dislocation

–     T  ype II (15 %): apex posterior proximal 1/3 ulna fracture with posterior radial head dislocation

–     Type III: proximal 1/3 ulna fracture with lateral radial head dislocation

–     Type IV: proximal ulna  and radius fractures with radial head dislocation in any direction

–     “Monteggia equivalent/variant”: proximal 1/3 ulnar fracture with radial head fracture

•      Treatment

–     Nonoperative

•      Closed reduction and supination splint/cast mobilization

–     M  ay consider in children where closed reduction can be obtained and ulnar length maintained.

–     Malreduction leads to poor outcomes.

–     Operative

•      Open reduction internal fi xation

–     Open reduction with plate fi xation of the ulna fracture.

–     R  adial head will typically reduce indirectly with reduction and stabilization of the ulna fracture.

–     If radial head fails to reduce, reassess ulna reduction

•      M alreduction of the ulna is the most common cause for failure of radial head reduction.

–     I  f radial head fails to reduce and ulna fracture is confi rmed to be anatomic, open reduction of the radial head may be required to address an interposed annular ligament, capsule, biceps tendon, or brachial fascia.

–     If there is an associated radial head fracture, repair is preferred over replacement when feasible.

•      Complications

–     Higher complication rates described for Bado type II injuries and Monteggia equivalent injuries –  PIN injury

•      10–20 % of Monteggia fractures.

•      Usually resolves with observation over 3–4 months.

•      If no improvement, obtain EMG.

–     Malunion with radial head dislocation/subluxation

•      Perform corrective ulna osteotomy +/− open radial head reduction.

–     Elbow stiffness

–     Synostosis

 Bibliography

1.    Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967;50:71–86.

2.    Eglseder WA, Zadnik M. Monteggia fractures and variants: review of distribution and nine irreducible radial head dislocations. South Med J. 2006;99(7):723–7.

3. K onrad GG, Kundel K, Kreuz PC, Oberst M, Sudkamp NP. Monteggia fractures in adults: long-term results and prognostic factors. J Bone Joint Surg Br. 2007; 89(3):354–60.

4. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 720.

5. R ing D, Jupiter JB, Waters PM. Monteggia fractures in children and adults. J Am Acad Orthop Surg. 1998;6(4):215–24. Review.

17     Radius and Ulna Shaft Fractures  

 Take-Home Message

•      B oth-bone forearm fractures typically result from high-energy mechanisms, are often open, and are at risk for compartment syndrome.

•      A ll both-bone forearm fractures should undergo ORIF; utilize two-incision approach to decrease the risk of synostosis.

•      I solated nondisplaced or distal 2/3 ulna fractures with <50 % translation and <10° angulation are amenable to trial of nonoperative management.

•      I solated proximal 1/3 and distal 2/3 ulna fractures with greater displacement should undergo ORIF.

•      General

–     “Both-bone forearm fractures”: diaphyseal fractures of the radius and ulna.

–     More common in men.

–     High incidence of open fractures.

–     The ulna acts as an axis around which the radius rotates.

–     Interosseous membrane is comprised of fi ve ligaments: central band, acces-sory band, distal oblique bundle, proximal oblique cord, and dorsal oblique accessory cord.

–     Typically result from direct trauma high-energy mechanisms: motor vehicle accidents, falls from height, athletics.

–     Maintain a high index of suspicion for compartment syndrome.

–     Careful neurovascular exam critical in patient evaluation.

•      Imaging

–     AP and lateral x-rays of the forearm.

–     Consider ipsilateral dedicated wrist and elbow x-rays if not well visualized on forearm fi lms or suspected associated injury.

•      Classifi cation

–     Both-bone forearm fractures

•      Descriptive: closed vs open, location, comminuted/segmental/bone loss, displacement, angulation, rotation

–     Isolated ulna fractures

•      “Nightstick fractures”

•      Stable: <25–50 % translation and <10–15° angulation

•      Unstable: >50 % translation or >10–15° angulation

•      Treatment

–     Nonoperative

•      Short arm cast to functional fracture brace with interosseous mold

–     I  solated nondisplaced or distal 2/3 ulna fractures with <50 % translation and <10° angulation

–     Union rates >96 %

–     Operative

•      Open reduction internal fi xation of the radius and ulna +/− bone grafting

–     Plate fi xation of the radius and ulna via dual-incision approach to decrease the risk of synostosis.

–     Indicated in all both-bone forearm fractures, displaced distal 2/3 ulna fractures, proximal 1/3 isolated ulna fractures, radial shaft fractures.

–     R  estoration of the lateral radial bow is important for pronation/supination and directly relates to functional outcome

•      Radial styloid should be 180° from the bicipital tuberosity.

–     A  cute bone grafting indicated for segmental bone loss >2 cm and bone loss with associated open

• R outine bone grafting for closed, comminuted fracture no longer indicated

–     Initiate immediate range of motion postoperatively.

•      External fi xation

–     May consider with temporizing or defi nitive treatment in Gustilo IIIb and IIIc open fractures and injuries with severely compromised soft tissue envelope

•      Intramedullary nailing

–     May consider with severely compromised soft tissue envelope

–     Diffi cult to maintain axial and rotational stability

•      Increased risk of malunion and nonunion

•      Complications

–     Synostosis

•      Occur in 3–9 % of both-bone forearm fractures

•      Increased risk with ORIF >2 weeks after injury, single-incision approach, fractures at the same level, closed head injury, high-energy mechanisms, infection, long screws, screws or bone graft on the interosseous membrane

•      Treat with early excision and irradiation and/or indomethacin

–     Refracture

•      Increased risk if hardware is removed <12–18 months postoperatively.

•      After hardware removal, recommend functional forearm brace for 6 weeks and restricted activity for 3 months.

–     Nonunion

•      Increased risk with intramedullary fi xation.

•      Treat with revision ORIF and autogenous cancellous bone grafting.

•      Vascularized fi bula grafts may be used for large defects.

–     Malunion

•      Increased risk with defi nitive external fi xation, intramedullary fi xation, segmental bone loss, and extensively comminuted fractures

•      Restoration of lateral radial bow most important for functional outcome

–     Compartment syndrome

•      I ncreased risk with high-energy mechanisms, crush injuries, open fractures, low-velocity gunshot wounds, associated vascular injuries, and coagulopathy

 Bibliography

 1.  Bauer G, Arand M, Mutschler W. Post-traumatic radioulnar synostosis after forearm fracture osteosynthesis. Arch Orthop Trauma Surg. 1991;110(3): 142–5.

2. B eingessner DM, Patterson SD, King GJ. Early excision of heterotopic bone in the forearm. J Hand Surg Am. 2000;25(3):483–8.

3. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 720–2.

4.    Ring D, Allende C, Jafarnia K, Allende BT, Jupiter JB. Ununited diaphyseal forearm fractures with segmental defects: plate fi xation and autogenous cancellous bone-grafting. J Bone Joint Surg Am. 2004;86-A(11):2440–5.

5.    Rumball K, Finnegan M. Refractures after forearm plate removal. J Orthop Trauma. 1990;4(2):124–9.

6 . S chemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fi xation of fractures of both bones of the forearm in adults. J Bone Joint Surg Am. 1992;74(7):1068–78.

 7.  Wright RR, Schmeling GJ, Schwab JP. The necessity of acute bone grafting in diaphyseal forearm fractures: a retrospective review. J Orthop Trauma. 1997; 11(4):288–94.

18     Galeazzi Fractures  

 Take-Home Message

•      Distal 1/3 radial shaft fracture with associated DRUJ injury.

•      I ncidence of DRUJ instability correlates with proximity of the radius fracture to the wrist.

•      DRUJ is most stable in supination.

•      Galeazzi fractures are unstable injuries that should undergo surgical fi xa-tion of the radius with subsequent assessment and treatment of the DRUJ as indicated.

•      General

–     Distal 1/3 radial shaft fracture with associated DRUJ injury.

–     I  ncidence of DRUJ instability correlates with proximity of radius fracture to the wrist

•      Radius fracture <7.5 cm from articular surface: 55 % unstable

•      Radius fracture >7.5 cm from articular surface: 6 % unstable

–     M  echanism of injury: fall onto outstretched hand with forearm pronation, direct wrist trauma.

–     Primary stabilizers of the DRUJ: volar and dorsal radioulnar ligaments.

–     DRUJ is most stable in supination.

–     DRUJ dislocation is almost always dorsal but may be palmar.

•      Imaging

–  AP and lateral forearm, wrist, and elbow x-rays

•      S igns of DRUJ instability: associated ulnar styloid fracture, DRUJ widening on AP view, DRUJ dislocation on lateral view, ≥5 mm of radial shortening

•      Classifi cation

–     Rettig and Raskin classifi cation

•      Type I: radius fracture ≤7.5 cm from the midarticular surface of the distal radius, signifi cantly increased risk of DRUJ instability after fi xation of the radius

•      Type II: radius fracture >7.5 cm from the midarticular surface of the distal radius, decreased risk of DRUJ instability after fi xation of the radius

–     Bruckner classifi cation

•      Simple: DRUJ easily reduced after fi xation of the radius

•      Complex: DRUJ unstable or irreducible after fi xation of the radius

–     Galeazzi equivalent: distal 1/3 radius fracture with associated distal ulna fracture

•      Treatment

–  Nonoperative

•      Not indicated

–     Operative

•  Open reduction internal fi xation of the radius followed by DRUJ assessment

–     A  natomic reduction and plate fi xation of the radius with care to restore/ maintain the radial bow.

–     If DRUJ remains reduced and stable following fi xation of the radius, splint in supination and initiate early range of motion.

–     If DRUJ is reduced but unstable following radius fi xation, closed reduction and percutaneous cross-pinning of the ulna to the radius is indicated.

–     I  f DRUJ is irreducible following radius fi xation, suspect interposed ECU tendon

•      P roceed with dorsal approach to DRUJ to remove interposed soft tissue precluding reduction.

•      Subsequent DRUJ stabilization as indicated.

–     Large associated ulnar styloid fractures benefi t from fi xation with pin-ning or supination immobilization of the DRUJ as indicated.

•      Complications

–     Compartment syndrome: may occur with high-energy injuries

–     Malunion

–     Nonunion

–     DRUJ subluxation

•      Consider bracing versus further surgical intervention with pinning/repin-ing +/− radioulnar ligament repair or dorsal capsulodesis

–  DRUJ arthrosis

•  Consider resection arthroplasty/Darrach procedure (elderly, low demand), hemiresection or interposition arthroplasty, Sauve-Kapandji procedure, ulnar head prosthetic replacement

 Bibliography

1.    Budgen A, Lim P, Templeton P, Irwin LR. Irreducible Galeazzi injury. Arch Orthop Trauma Surg. 1998;118(3):176–8.

2.    Giannoulis FS, Sotereanos DG. Galeazzi fractures and dislocations. Hand Clin.

2007;23(2):153–63. Review.

3.    Korompilias AV, Lykissas MG, Kostas-Agnantis IP, Beris AE, Soucacos PN. Distal radioulnar joint instability (Galeazzi type injury) after internal fi xa-

tion in relation to the radius fracture pattern. J Hand Surg Am. 2011;36(5):847–52.

4 . M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 720.

 5.  Paley D, McMurtry RY, Murray JF. Dorsal dislocation of the ulnar styloid and extensor carpi ulnaris tendon into the distal radioulnar joint: the empty sulcus sign. J Hand Surg Am. 1987;12:1029–32.

6 . R ettig ME, Raskin KB. Galeazzi fracture-dislocation: a new treatment-oriented classifi cation. J Hand Surg Am. 2001;26(2):228–35.

19     Distal Radius Fractures  

 Take-Home Message

•      Most common upper extremity fracture, high-energy trauma in young patients, low-energy fall in elderly/osteoporotic patients.

•      Maintain a high index of suspicion for acute carpal tunnel syndrome and treat with emergent carpal tunnel release.

•      Treatment guided by radiographic parameters, fracture pattern stability, and patient age and functional demands.

•      I ncreased risk of attritional EPL rupture with nondisplaced distal radius fractures.

•      Many methods of surgical fi xation may be successfully employed pending specifi c fracture characteristics.

•      High coincidence of ulnar-sided wrist pathology.

•      M alunions are common; revision is recommended for young patients and symptomatic patients as indicated by the nature of the malunion.

•      General

–     Most common fracture of the upper extremity

•      Greatest incidence in Caucasian women >50 years old •  DEXA scan for all women who sustain distal radius fractures

–     High-energy trauma in young, open fractures more common.

–     Low-energy trauma in elderly/osteoporotic.

–     50 % intra-articular.

–     Always assess for anatomic snuffbox tenderness, ulnar-sided wrist pain, median and ulnar nerve function, DRUJ injury, and TFCC injury.

–     Associated ulnar styloid fracture indicative of higher-energy injury with greater initial displacement.

•      Ulnar styloid base fracture associated with TFCC injury

–     Distal radius fractures are a predictor for sustaining subsequent fractures.

•      Imaging

–     AP x-ray: 12 mm radial height, 23° radial inclination.

–     Lateral x-ray: 11° volar tilt.

–     Acceptable parameters: <5 mm radial shortening, <5° loss of radial inclina-tion, volar tilt within 10–20° of contralateral side or <5° dorsal angulation, <1–2 mm articular step-off.

–     C  T scan may be useful to assess intra-articular involvement and preoperative planning.

–     MRI may be warranted in some cases to assess TFCC and intercarpal ligaments.

•      Classifi cation

–     Frykman classifi cation

•      Joint involvement +/− radial styloid fracture.

•      Type I/II*: extra-articular fracture.

•      Type III/IV*: radiocarpal extension.

•      Type V/VI*: radioulnar extension.

•      Type VII/VIII*: radiocarpal and radioulnar extension.

•      *  Types II ,  IV ,  VI, and VIII have concurrent ulnar styloid fractures.

–     Melone classifi cation

•      Describes four fragments of the radiocarpal joint: radial styloid, radial shaft, volar medial, volar dorsal

•      T ypes I–IV: increasingly comminuted and displaced fractures of the four fragments

•      Type V: severe comminution without identifi able fragments

–     Fernandez classifi cation

•      Based on mechanism of injury, designed to guide treatment decision making

•      Type I: bending fractures

•      Type II: articular shear fractures, associated with perilunate injuries

•      Type III: compression fractures

•      Type IV: fracture-dislocations with associated ligamentous injury

•      Type V: combined mechanism

–     Eponyms

•      Colles’ fracture: apex anterior, dorsally angulated fracture

•      Smith’s fracture: apex dorsal, volarly angulated fracture

•      Barton’s fracture: volar or dorsal lip fractures

•      Chauffer’s fracture: radial styloid fracture

•      Die-punch fracture: depressed fracture of the lunate facet

•      Treatment

–     Outcomes correlate with restoration of anatomic alignment with radial height and volar tilt of greater importance than radial inclination, good articular congruency, and early wrist and digit motion.

–     Radiographic parameters shown to have less importance in management of distal radius fractures in the elderly.

–     Prereduction radiographs are the best predictor of instability

–     Nonoperative

•      Closed reduction and cast immobilization

–     Indicated for distal radius fractures with acceptable parameters (detailed above).

–     Monitor closely for loss of reduction.

–     Nondisplaced distal radius fractures have increased risk of attritional EPL rupture.

–     Operative

•      Indicated for fractures that fail to meet acceptable parameters, unstable fracture patterns (articular shear, volar/dorsal lip fractures, metadiaphyseal extension, associated distal ulnar shaft fracture, etc.), and loss of reduction following closed reduction and casting

•      Percutaneous pinning

–     M  ost effective in maintaining sagittal alignment in extra-articular fractures with stable volar cortex

–     U  nable to maintain sagittal alignment with volar or bicortical comminution

–     80–90 % good outcomes with appropriate indications

•      External fi xation

–     Relies on ligamentotaxis to maintain reduction

•      Diffi cult to restore volar tilt with external fi xation alone, may com-bine with percutaneous pinning or plate fi xation

–     Radial shaft pins should be placed under direct visualization to protect the superfi cial radial nerve.

–     Associated increased risk of malunion/nonunion, stiffness, pin-site complications, injury to superfi cial radial nerve, median neuropathy, RSD/CRPS.

•      ORIF

–  Volar plating most commonly performed

•      Increased risk of FPL rupture

•      Flexor and extensor tendon irritation possible

–     Dorsal plating

•      May be benefi cial in fractures with dorsal comminution, dorsal lip fractures, and dorsal shear patterns

•      Historically associated with increased risk of extensor tendon irrita-tion and rupture, less common today with low-profi le plates

–     Radial column plating

•      Consider with unstable radial column injuries and radial styloid fractures.

–     Complex intra-articular fractures may benefi t from arthroscopically assisted reduction and fragment specifi c fi xation.

–     May be combined with other fi xation techniques.

–     ORIF of ulnar styloid fracture may be indicated in cases with associated instability.

•      Complications

–  Median nerve neuropathy

•      Occurs 1–12 % of distal radius fractures, up to 30 % in high-energy injuries

•      Carpal tunnel pressure lowest with neutral wrist position

•      Treat acute carpal tunnel syndrome with emergent carpal tunnel release

•      C arpal tunnel release recommended for progressive paresthesias and persistent paresthesias that fail to improve with fracture reduction

–     Ulnar nerve neuropathy

•      Associated with DRUJ injuries

–     Refl ex sympathetic dystrophy/chronic regional pain syndrome

•      Postoperative vitamin C supplementation may help prevent RSD/CRPS.

–     Attritional EPL rupture

•      Increased risk in nondisplaced distal radius fractures treated with cast immobilization.

•      Treat with EIP to EPL transfer.

–     DRUJ injuries, TFCC injuries, late ulnar-sided wrist pain, tenosynovitis

•      P oor fracture reduction is the primary contributor to DRUJ pathology in distal radius fractures.

–     Incongruity of the DRUJ with >20° of dorsal tilt

•  ECU or EDM may be entrapped in the DRUJ.

–     Malunion and nonunion

•      Intra-articular malunion: malunion takedown and ORIF.

•      Extra-articular malunion: opening wedge osteotomy with ORIF and bone grafting.

•      Signifi cant radial shortening may lead to ulnar impaction syndrome.

–     2 mm of shortening increases ulnar force transmission by 42 %.

–     If unable to restore radial height, consider ulnar shortening osteotomy.

–     Weakness

–     Radiocarpal posttraumatic arthrosis

•      Develops in 2–30 % of patients, increased risk in young patients with

>1–2 mm of articular incongruency

•      May be asymptomatic

 Bibliography

 1 . D yer G, Lozano-Calderon S, Gannon C, Baratz M, Ring D. Predictors of acute carpal tunnel syndrome associated with fracture of the distal radius. J Hand Surg Am. 2008;33(8):1309–13.

  2.  Fernandez DL. Correction of post-traumatic wrist deformity in adults by osteotomy, bone-grafting, and internal fi xation. J Bone Joint Surg Am. 1982;64(8): 1164–78.

3. H arness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL. Loss of fi xation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg Am. 2004;86-A(9):1900–8.

4. I lyas AM, Jupiter JB. Distal radius fractures–classifi cation of treatment and indications for surgery. Orthop Clin North Am. 2007;38(2):167–73, v. Review.

5. K im JK, Koh YD, Do NH. Should an ulnar styloid fracture be fi xed following volar plate fi xation of a distal radial fracture? J Bone Joint Surg Am. 2010;92(1):1–6.

6. L afontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury. 1989;20(4):208–10.

7.       Lichtman DM, Bindra RR, Boyer MI, Putnam MD, Ring D, Slutsky DJ, Taras JS, Watters III WC, Goldberg MJ, Keith M, Turkelson CM, Wies JL, Haralson III RH, Boyer KM, Hitchcock K, Raymond L. Treatment of distal radius fractures. J Am Acad Orthop Surg. 2010;18(3):180–9.

8.       Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 722–5.

9.       Roth KM, Blazar PE, Earp BE, Han R, Leung A. Incidence of extensor pollicis longus tendon rupture after nondisplaced distal radius fractures. J Hand Surg Am. 2012;37(5):942–7.

10.   Yu YR, Makhni MC, Tabrizi S, Rozental TD, Mundanthanam G, Day

CS. Complications of low-profi le dorsal versus volar locking plates in the distal radius: a comparative study. J Hand Surg Am. 2011;36(7):1135–41.

11.   Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin C p revent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose–response study. J Bone Joint Surg Am. 2007;89(7):1424–31.

20     Carpal Fractures  

 Take-Home Message

•      Primary scaphoid blood supply has retrograde fl ow (distal to proximal) with signifi cantly increased risk of AVN in proximal pole fractures.

•      Nondisplaced, stable scaphoid fractures are treated with thumb spica cast immobilization, the duration of which depends of fracture location.

•      Displaced, unstable, and proximal pole scaphoid fractures as well as frac-tures with delayed diagnosis should undergo operative fi xation.

•      S caphoid nonunion can lead to advanced collapse with progressive arthritis (SNAC wrist) with treatment options guided by the severity of involvement.

•      L unate fractures of the volar pole are most common and may involve the blood supply.

•      Lunate fractures may progress to osteonecrosis with collapse and ultimate radiocarpal arthrosis.

•      Dorsal shear triquetral fractures should undergo a trial of nonoperative management with fragment excision for persistent symptoms.

•      Pisiform fractures are uncommon injuries that should almost universally undergo nonoperative management with excision for persistent symptoms.

•      Trapezium fractures must be assessed for associated Bennett fracture and fi rst carpometacarpal dislocation.

•      C apitate fracture rarely occurs in isolation, and surgical fi xation is recommended to address displaced fractures and associated injuries.

•      Hook of hamate fractures are best visualized on the carpal tunnel view and are treated acutely with cast immobilization with excision for persistently symptomatic chronic fractures.

•      H amate fractures may be associated with ulnar nerve paresthesias and intrinsic motor weakness due to compression at Guyon’s canal and occasionally result in fl exor tendon synovitis with attritional rupture.

•      Scaphoid Fractures

–     General

•      Common fracture with acute wrist injuries.

•      >75 % of the scaphoid is covered by cartilage.

•      Blood supply

–     Major blood supply: a dorsal carpal branch of the radial artery enters at the dorsal ridge and perfuses 80 % of the scaphoid from distal to proximal (retrograde fl ow).

–     M  inor blood supply: a branch of superfi cial palmar arch enters the distal tubercle.

–     Watershed at the scaphoid waist.

•      Mechanism of injury: fall onto a hyperextended and radially deviated wrist.

•      Assess for anatomic snuffbox tenderness, scaphoid tubercle tenderness, and pain with resisted pronation.

•      Time to union correlates with fracture location with longer healing times for more proximal fractures.

•      Increased risk of AVN in proximal pole fractures.

–     Imaging

•      AP and lateral wrist x-rays.

•      Scaphoid view: 30° wrist extension, 20° ulnar deviation.

•      Clenched fi st view.

•      If initial fi lms are negative and clinical suspicion remains high, repeat imaging in 2–3 weeks.

•      MRI: most sensitive to diagnose occult fractures within 24 h; assess liga-mentous injury and vascularity of the proximal pole.

•      Bone scan: highly sensitive and specifi c in identifying occult fractures at 72 h.

•      Fine cut CT scan: further characterize fracture, collapse, and progression to union.

–     Anatomic Classifi cation

•      Waist: 65 %

•      Proximal pole: 25 %, increased risk of AVN

–     Proximal 1/5: 100 % AVN

–     Proximal 1/3: 30 % AVN

•  Distal pole: 10 %, most common in children

–     Treatment

•  Nonoperative

–     Thumb spica cast immobilization.

–     Indicated for stable nondisplaced scaphoid fractures.

–     If high index of suspicion for occult fracture with negative initial imag-ing, immobilize in short arm thumb spica cast until defi nitive diagnosis is made.

–     Short arm vs long arm thumb spica casting is debated

•      No consensus.

•      Long arm casting may have shorter time to union, and decreased nonunion rate, however, risks elbow stiffness.

–     Fracture location guides recommendations for duration of casting

•      Distal fractures: 8–12 weeks

•      Waist fractures: 12–16 weeks

•      Proximal fractures: 16+ weeks, consider casting until union, may opt for surgical fi xation to facilitate earlier motion

–     90 % union rate for fractures with appropriate indications for treatment with cast immobilization.

•      Operative

–  Open reduction internal fi xation vs percutaneous fi xation

•      I ndicated in displaced fractures, unstable fractures, proximal fractures, and delayed diagnosis.

•      Dorsal approach: proximal pole fracture; limit exposure of the proxi-mal scaphoid to protect the blood supply entering at the dorsal ridge.

•      Volar approach: waist and distal pole fractures, humpback fl exion deformity.

•      Screw should be placed through the central axis of the scaphoid to optimize construct rigidity.

•      Increased risk of screw penetration with percutaneous technique.

•      Surgical fi xation facilitates earlier range of motion.

•      90–95 % union rates.

–     Complications

•  Scaphoid nonunion

–     CT scan is the best imaging modality to assess progression to union.

–     V  ascularized bone graft: 1,2 intercompartmental supraretinacular artery, good option for proximal pole fracture with osteonecrosis.

–     I  nlay (Russe) bone graft: minimal deformity and no associated carpal collapse.

–     Intercalary bone graft with internal fi xation: humpback scaphoid defor-mity, may combine with radial styloidectomy for isolated radioscaphoid arthrosis.

–     I  f left untreated, scaphoid nonunion can progress to carpal collapse and degenerative arthritis.

•      Scaphoid nonunion advanced collapse (SNAC wrist)

–     Progressive degenerative changes: (1) radial styloid, (2) capitate, (3) capitolunate articulation, spares the lunate fossa

–     Treatment options guided by severity of degenerative changes

•      Proximal row carpectomy: preserved capitolunate articulation

•      S caphoid excision and four-corner fusion: preserved or arthrosed capitolunate articulation

•      W rist arthrodesis: arthrosed capitolunate articulation and pancarpal arthritis, provides good pain relief and grip strength with sacrifi ce of wrist motion

•      Lunate Fractures

–     General

•      Lunate considered the “carpal keystone.”

•      Mechanism of injury: direct trauma, axial load on a hyperextended wrist.

•      Typically present with volar wrist pain.

•      Lunate fractures must be distinguished from Kienböck disease.

–     Imaging

•      AP and lateral wrist x-rays.

•      Oblique views may help to further delineate fracture.

•      C T scan, MRI, and bone scan may be needed to confi rm diagnosis and/or further characterize injury.

–     Anatomic classifi cation

•      Volar pole coronal fracture (most common, may involve nutrient arteries)

•      Dorsal pole coronal fracture

•      Transarticular coronal fracture of the body

•      Transverse body fractures

•      Osteochondral fractures of the proximal articular surface

–     Treatment

•      Nonoperative

–     Cast immobilization

•      Nondisplaced fractures, requires close follow up to monitor healing

•      Operative

–     Open reduction internal fi xation

•  Displaced fractures, may be advantageous for maintaining vascularity to the lunate

–     Complications

•      Lunate osteonecrosis and collapse

–  May progress to radiocarpal arthrosis

•      Triquetral Fractures

–     General

•      T hird most common carpal fracture, following scaphoid and lunate fractures

•      Multiple mechanisms of injury described: fall onto an extended and ulnarly deviated wrist, fall onto a fl exed wrist, direct trauma

–     Imaging

•      AP and lateral wrist radiographs: dorsal aspect of the triquetrum is best seen on the lateral view.

•      Oblique views may help to further characterize body fractures.

–     Anatomic classifi cation

•      Dorsal shear/avulsion fractures: most common

•      Body fractures: rare

–     Treatment

•      Nonoperative

–     Splint/cast immobilization for 4–6 weeks followed by range of motion

•      Dorsal shear injuries, nondisplaced body fractures

•      Operative

–     Fragment excision

•  Dorsal shear injuries with persistent symptoms following trial of nonoperative management

–     Open reduction internal fi xation

•  Displaced body fractures

–     Complications

•      Rare

•      Pisiform Fractures

–     General

•      Uncommon injuries, comprise 1–3 % of all carpal fractures.

•      Pisiform is a sesamoid bone located within the FCU tendon and is the ori-gin of abductor digiti minimi.

•      The pisiform contributes to stability of the ulnar column but resisting tri-quetral subluxation and fulcrum for force transmission from the forearm to the hand.

•      A ssociated injuries in 50 %: distal radius fracture, hamate fracture, triquetrum fracture.

–     Imaging

•      AP, lateral, and oblique wrist x-rays.

•      L ateral view with 30° wrist supination: best visualization of the pisotriquetral joint.

•      Consider carpal tunnel view.

–     Classifi cation

•      Avulsion fractures

•      Transverse body fractures

•      Comminuted fractures

–     Treatment

•      Nonoperative

–     Short arm cast immobilization with 30° wrist fl exion and ulnar devia-tion for 6 weeks

• N early all pisiform fractures are recommended to undergo conservative treatment with cast immobilization.

–     Complications

•      Symptomatic nonunion

–  Pisiform excision provides reliable pain relief without impacting wrist function.

•      Trapezium Fractures

–     General

•      Uncommon injuries

•      May occur in isolation or in combination with other carpal bone injuries

–     Assess for concurrent fracture of the base of the fi rst metacarpal and/or subluxation or dislocation of the fi rst carpometacarpal joint.

–     Trapezial ridge fractures have an increased coincidence of distal radius fractures.

–     Imaging

•      AP and lateral wrist x-rays

–  Robert’s AP view: hand in full pronation

•      Consider carpal tunnel view

–     Classifi cation

•      Body fracture: vertically oriented, comminuted

•      Trapezial ridge fracture

–     Type I: base of ridge

–     Type II: tip of ridge

–     Treatment

•      Nonoperative

–  Thumb spica cast immobilization for 6 weeks

•      Trapezial ridge fractures and nondisplaced body fractures.

•      T ype II trapezial ridge fractures should have molded abduction of the fi rst ray.

•      Operative

–     Open reduction internal fi xation

•      Displaced body fractures

•      Volar approach, K-wire fi xation often used

–     Complications

•      Symptomatic nonunion of trapezial ridge fractures

–  Treat with excision.

•      Capitate Fractures

–     General

•      Rarely occur in isolation

•      Associated injuries: perilunate dislocations, scaphoid fracture, carpometa-carpal fracture-dislocation

–     Imaging

•      AP, lateral, and oblique wrist radiographs

•      CT scan often helpful

–     Classifi cation

•      Isolated capitate fracture

•      Scaphocapitate syndrome: scaphoid fracture with proximal capitate fracture

–     Treatment

•      Nonoperative

–     Cast immobilization

•      Nondisplaced, isolated capitate fractures

•      Operative

–     Open reduction internal fi xation

•      D isplaced capitate fractures, fractures with associated scaphoid fractures, perilunate dislocation, and carpometacarpal fracture-dislocations

•      Typically approached dorsally with screw and/or K-wire fi xation

–     Complications

•      Osteonecrosis

•      Nonunion

–  May be treated with fusion of the capitate, scaphoid, and lunate

•      Hamate Fractures–  General

•      H ook of hamate fractures are common in golf, baseball, hockey, and racquet sports.

•      Body fractures are associated with fourth and fi fth carpometacarpal fracture-dislocation.

•      Must distinguish from bipartite hamate.

•      Present with hypothenar pain, decreased grip strength, possible ulnar nerve paresthesias and intrinsic motor weakness (compression at Guyon’s canal), and possible median nerve paresthesias (compression at the carpal tunnel).

–     Imaging

•                      AP and lateral wrist x-rays: diffi cult to visualize on AP

•                      Carpal tunnel view: best visualization of the hamate –  Classifi cation

•                      Hook of hamate fractures: most common

•                      Body fractures: uncommon

–     Treatment

•                      Nonoperative

–     Cast immobilization for 6 weeks

•      Acute hook of hamate fractures, nondisplaced body fractures

•      Operative

–     Open reduction internal fi xation

•      Displaced and unstable body fractures

•      Rarely performed in hook of hamate fractures –  Excision

•      Persistently symptomatic, chronic hook of hamate fractures

–     Complications

•      Ulnar nerve symptoms

–     M  ay have ulnar nerve paresthesias and/or intrinsic motor weakness secondary to compression at Guyon’s canal

•      Flexor tendon synovitis and attritional rupture

–     Described following hook of hamate fractures

 Bibliography

1.    Bishop AT, Beckenbaugh RD. Fracture of the hamate hook. J Hand Surg Am. 1988;13(1):135–9.

2.    Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fi xation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am. 2001;83-A(4):483–8.

3.    Kawamura K, Chung KC. Treatment of scaphoid fractures and nonunions. J Hand Surg Am. 2008;33(6):988–97.

4.    Lam KS, Woodbridge S, Burke FD. Wrist function after excision of the pisiform. J Hand Surg Br. 2003;28(1):69–72.

5. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 725–7.

6. O ’Shea K, Weiland AJ. Fractures of the hamate and pisiform bones. Hand Clin. 2012;28(3):287–300. Review.

7. T rumble TE, Salas P, Barthel T, Robert 3rd KQ. Management of scaphoid nonunions. J Am Acad Orthop Surg. 2003;11(6):380–91.

21     Lunate and Perilunate Dislocations  

 Take-Home Message

•      H igh-energy injuries with high incidence of associated median nerve injury and acute carpal tunnel syndrome.

•      I maging may show “spilled teacup sign,” loss of greater and lesser carpal arcs (disruption of Gilula’s lines), overlapping carpal bones, and loss of sagittal colinearity between the radius, lunate, and capitate.

•      T reat with emergent closed reduction followed by ORIF with ligament repair +/− carpal tunnel release.

•      Chronic injuries (>8 weeks) may be treated with proximal row corpec-tomy, triscaphe fusion, or wrist arthrodesis.

•      P oor functional outcomes are common with decreased wrist motion, decreased grip strength, possible persistent carpal instability, chondrolysis, and ultimate posttraumatic arthrosis.

•      General

–     High-energy injuries with poor functional outcomes

–     ~25 % missed on presentation

–     Mechanism of injury: wrist hyperextension and ulnar deviation leading to intercarpal supination and dislocation

–     Associated median nerve injury

•      25 % of patients have median nerve symptoms on presentation.

•      I ncreased risk of median nerve injury and acute carpal tunnel syndrome with volar lunate dislocation.

•      Imaging

–     AP and lateral wrist x-rays

•      A P view: “spilled teacup sign” (rotation of lunate so concavity tipped proximally), loss of greater and lesser carpal arcs (disruption of Gilula’s lines), overlapping carpal bones

–     Great arc disruption: ligamentous disruption with associated fractures of the radius, ulna, and carpal bones

–     Lesser arc disruption: purely ligamentous

•      L ateral view: loss of colinearity between radius, lunate, and capitate, scapholunate angle >70°.

•      Assess for associated fractures.

•      Classifi cation

–     Lunate dislocation

•      Lunate dislocates volar (via space of Poirier, most common) or dorsal to the intact carpus.

–     Perilunate dislocation

•      Carpus dislocates around the intact lunate.

•      Types:    transscaphoid-perilunate,   perilunate,             transradial-perilunate, transscaphoid-trans-capitate-perilunar.

–     Mayfi eld classifi cation

•      Stage I: scapholunate dissociation

•      Stage II: plus lunocapitate disruption (via space of Poirier)

•      Stage III: plus lunotriquetral disruption

•      Stage IV: lunate dislocation

•      Treatment

–     Nonoperative

•      Emergent closed reduction and splinting

–     Decreases risk of permanent median nerve injury and subsequent chondrolysis

–     Follow with early surgical fi xation

–     No role for defi nitive nonoperative management with universally poor outcomes and high risk of recurrent dislocation

–     Operative

•      Open reduction internal fi xation and ligament repair +/− carpal tunnel release

–     Indicated for all acute injuries (<8 weeks)

–     Volar and dorsal approaches described and may be combined

–     Follow with thumb spica splinting/casting for 6 weeks postoperatively

•      Salvage procedures

–     Indicated for chronic injuries (>8 weeks)

–     Proximal row carpectomy

–     Triscaphe fusion

–     Wrist arthrodesis: for chronic injury with associated degenerative changes

•      Complications

–     Median nerve injury

–     Acute carpal tunnel syndrome

•      E mergent carpal tunnel release for symptoms that persist following emergent closed reduction

–     Poor functional outcomes

•      50 % loss of wrist motion, 60 % loss of grip strength

–     Chondrolysis

–     Persistent carpal instability

–     Posttraumatic arthrosis

–     Nonunion/malunion

 Bibliography

 1.  Kozin SH. Perilunate injuries: diagnosis and treatment. J Am Acad Orthop Surg. 1998;6:114–20.

2 . M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 727.

3.    Sawardeker PJ, Kindt KE, Baratz ME. Fracture-dislocations of the carpus: peri-lunate injury. Orthop Clin North Am. 2013;44(1):93–106.

4.    Stanbury SJ, Elfar JC. Perilunate dislocation and perilunate fracture-dislocation.

J Am Acad Orthop Surg. 2011;19(9):554–62. Review.

22     Metacarpal Fractures  

 Take-Home Message

•      Treatment of metacarpal fractures depends on which metacarpal is involved and location of fracture with acceptable angulation and shortening varying by location.

•      Malrotation is never acceptable.

•      7° degree extensor lag for every 2 mm of shortening.

•      Maintain a high index of suspicion for compartment syndrome with mul-tiple metacarpal fractures and crush injuries.

•      O pen wounds overlying the metacarpal head should be considered to be “fi ght bites” until proven otherwise.

•      B ennett fracture deforming forces: volar oblique ligament hold volar lip fragment in place, metacarpal shaft pulled proximally, dorsally and radially by APL and adductor pollicis.

•      F ractures with deformity greater than acceptable parameters allowed should undergo reduction and surgical fi xation.

•      Stiffness is the most common complication and is best prevented with early motion with both nonoperative and operative management.

•      General

–     M  etacarpal fractures comprise 40 % of hand injuries and are most common in men 10–29 years old

•      Most common fracture site: metacarpal neck

•      Most common metacarpal injured: fi fth metacarpal

•      Most common thumb base fracture: Bennett fracture

–     First, fourth, and fi fth metacarpals for the mobile borders while second and third metacarpals form the stiffer central pillar.

–     A  cceptable alignment parameters depend on fracture location and the metacarpal involved.

–     Malrotation is never acceptable

•      Assess malrotation with fi nger cascade (fi ngertips should point to scaph-oid, no scissoring), parallel nail plates

–     7° extensor lag for every 2 mm of shortening

•      “Shortening” may be secondary to fl exion/extension deformity.

–     Associated injuries: dorsal wounds common and almost always represent open fractures, tendon laceration, and neurovascular injury.

–     Maintain high index of suspicion for compartment syndrome with multiple metacarpal fractures and crush injuries.

•      Imaging

–     AP, lateral and oblique hand x-rays.

–     30° pronated lateral: assess fourth and fi fth CMC joints.

–     30° supinated view: assess second and third CMC joints.

–     Brewerton view: metacarpal head fractures.

–     Robert’s view (AP hand in full pronation): thumb CMC joint.

–     Hyperpronated thumb view: thumb base fractures.

–     Semi-pronated, semi-supinated, traction fi lms: small metacarpal base fractures.

–     C  T scan: further evaluation of CMC fracture-dislocations and complex metacarpal head fractures.

•      Classifi cation

–     Metacarpal head fractures

•      Vertical, horizontal, oblique, comminuted.

•      Any associated wound should be considered an open fracture (“fi ght bite”) until proven otherwise.

–     Metacarpal neck fractures

•      “Boxer’s fracture”: fi fth metacarpal neck fracture.

•      Assessment of rotational deformity is critical.

–     Metacarpal shaft fractures

•      Transverse, oblique, spiral, comminuted

–     Acceptable alignment

•      Index and long fi nger: 10–20° shaft angulation, 2–5 mm shortening, 10–15° neck angulation

•      Ring fi nger: 30° shaft angulation, 2–5 mm shortening, 30–40° neck angulation

•      Small fi nger: 40° shaft angulation, 2–5 mm shortening, 50–60° neck angulation

–     Thumb base fractures

•      Bennett fracture: intra-articular volar ulnar lip fracture of the thumb meta-carpal base, most common thumb base fracture

–     V  olar ulnar lip fragment held in place by volar oblique ligament (volar beak ligament).

–     Metacarpal shaft is pulled proximally, dorsally, and radially from deforming forces of APL and adductor pollicis.

•      Rolando fracture: complete articular thumb metacarpal base fracture

–  “Y” fracture, “T” fracture, comminuted fracture

•      Extra-articular fracture: transverse, oblique

–     Acceptable alignment: < 30°angulation

–     Small metacarpal base fractures

•      Reverse Bennett (baby Bennett) fractures: epibasal, two-part, three-part, comminuted

–     Nonoperative vs CRPP/ORIF controversial.

–     Fracture fragment may be displaced by ECU.

–     Assess for possible associated carpometacarpal fracture-dislocation.

–     Nonoperative

•      Immobilization with 70–90° MCP fl exion and PIP extension for 4 weeks

–     Stable injury pattern with acceptable angulation and shortening, no rotational deformity, may consider in severely comminuted thumb base fractures

–     Angulated metacarpal neck fractures may be amenable to closed reduc-tion and casting

•      Jahss technique: 90° MCP fl exion, dorsal pressure through proximal phalanx while stabilizing the metacarpal shaft

–     Operative

•      G eneral indications: intra-articular fractures, angulation and/or shortening outside acceptable parameters, malrotation, multiple metacarpal shaft fractures, loss of inherent stability from border digit, open fractures

•      Initiate early motion in the postoperative period

•      O pen reduction internal fi xation vs closed reduction percutaneous fi xation

–     Techniques include antegrade and retrograde pinning, pinning to adja-cent metacarpal (comminuted metacarpal shaft fractures), lag screw fi xation (ideal for long spiral fractures), and plating (ideal for transverse fracture and bridging of comminuted fractures).

•  Ideal fi xation allows for early motion.

–     D  orsal approach with central extensor mechanism split or sagittal band takedown and repair.

•      External fi xation

–     Consider in severely comminuted metacarpal head fractures and severely comminuted thumb base fractures.

•      MCP arthroplasty

–     Consider in severely comminuted metacarpal head fractures.

•      Complications

–     Stiffness

•      The most common complication

•      Prevent with early motion

–     Tendon hardware irritation

•      Cover plates with periosteum when possible; initiate early motion.

–     Malunion

•      Malrotation poorly tolerated; treat with osteotomy and ORIF.

–     Posttraumatic arthrosis

•      Metacarpal head fractures: MCP arthroplasty, MCP arthrodesis.

•      Thumb base metacarpal fractures: relationship of postoperative joint con-gruency to posttraumatic arthrosis is controversial.

•      Small metacarpal base fractures.

 Bibliography

1.    Henry MH. Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization. J Am Acad Orthop Surg. 2008;16(10): 586–95.

2.    Kawamura K, Chung KC. Fixation choices for closed simple unstable oblique phalangeal and metacarpal fractures. Hand Clin. 2006;22(3):287–95.

3 . M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 729–34.

 4.  Souer JS, Mudgal CS. Plate fi xation in closed ipsilateral multiple metacarpal fractures. J Hand Surg Eur Vol. 2008;33(6):740–4.

5 . S oyer AD. Fractures of the base of the fi rst metacarpal: current treatment options.

J Am Acad Orthop Surg. 1999;7(6):403–12.

23     Phalanx Fractures  

 Take-Home Message

•      D iaphyseal proximal phalanx fractures often present with apex volar angulation due to proximal fragment fl exion from pull of interossei and distal fragment extension from pull of central slip.

•      D iaphyseal middle phalanx fractures may present with volar angulation, dorsal angulation, or no angulation pending fracture location with respect to FDS insertion.

•      Compression (pilon) fractures of the base of the middle phalanx are unsta-ble with greater than 42 % joint involvement and may subluxate with as little as 10–15 % joint involvement.

•      Distal phalanx fracture often has associated nail bed injuries.

•      R egardless of treatment modality, initiate motion within 3–4 weeks to prevent stiffness.

•      F ractures with deformity greater than acceptable parameters allowed should undergo reduction and surgical fi xation.

•      Malunions with functional impairment should undergo corrective osteotomy.

•      Symptomatic posttraumatic DIP and PIP arthrosis should undergo arthrod-esis with position determined by digit and joint involvement; silicone arthroplasty may be used for PIP arthrosis with good bone stock and no deformity.

•      General

–     Phalanx fractures are common injuries that account for 10 % of all fractures.

•  Distal phalanx is the most commonly fractured bone in the hand.

–     Mechanism of injury: sports (young patients), machinery (middle-aged patients), falls (elderly patients).

–     D  istal phalanx fracture frequently has associated nail bed injuries and often results from crush injuries.

•      Imaging

–     Dedicated fi nger AP and lateral x-rays: must get true lateral of any involved joint

–     AP and lateral hand x-rays to assess for associated fractures

•      Classifi cation

–     Proximal and middle phalanx fractures

•      Diaphyseal fractures: transverse, oblique, spiral, comminuted

–  Proximal phalanx fractures deformity

•      A pex volar angulation: proximal fragment fl exion (interossei) and distal fragment extension (central slip)

–  Middle phalanx fracture deformity

•      Apex volar  or dorsal deformity.

•      Apex dorsal angulation: fracture proximal to FDS insertion with proximal fragment extension (central slip).

•      Apex volar angulation: fracture distal to FDS insertion.

•      Fractures through the middle third may exhibit volar angulation, dorsal angulation, or no angulation.

•      Intra-articular base fractures

–     Collateral ligament avulsion.

–     Vertical shear: typically involve volar shear fracture of the middle  phalanx with dorsal subluxation/dislocation, dorsal shear with volar subluxation/dislocation, and lateral shear with lateral subluxation/dislocation also possible.

–     C  ompression (pilon): typically involve the base of the middle phalanx; joint will be stable with involvement of up to 42 % of the volar half of base of the middle phalanx; however subluxation can occur with only 10–15 % joint surface involvement.

•      Other variants: neck, condylar, and extra-articular base fractures

•      Acceptable alignment parameters for extra-articular proximal and middle phalanx fractures: <10° angulation, <2 mm shortening, and no rotational deformity

–     Distal phalanx fractures

•      Transverse, longitudinal, comminuted

•      High coincidence of nail bed injuries

•      Treatment

–     R  egardless of treatment modality, initiate motion within 3–4 weeks to prevent stiffness

–     Nonoperative

•      Buddy taping for 3–4 weeks followed by aggressive motion

–     Stable diaphyseal phalanx fractures, nondisplaced collateral ligament avulsions, nondisplaced neck, condylar and extra-articular base

•      Digital splint +/− nail bed repair

–     Nondisplaced condylar fractures, distal phalanx fractures.

–     Treat nail bed injuries as open fractures with appropriate irrigation and debridement.

–     Nail matrix may be incarcerated within the distal phalanx fracture.

–     Operative

•      Open reduction internal fi xation vs closed reduction percutaneous pinning

–     Unstable or malrotated diaphyseal phalanx fractures, displaced collat-eral ligament fractures (may also tension band), intra-articular compression fractures (+/− bone grafting), intra-articular shear fractures, displaced neck, condylar and extra-articular base.

–     T  echniques include minifragment lag screw fi xation (may be used alone in long oblique fractures), plate fi xation, crossed K-wires, and Eaton- Belsky pinning (transarticular pinning through metacarpal head for extra-articular proximal phalanx base fractures).

–     Minimize extent of surgical dissection to decrease risk of stiffness.

•      Dynamic external fi xation

–     May be utilized in some PIP joint fracture-dislocations

•      Hemi-hamate arthroplasty

–     May be utilized in unstable middle phalanx pilon fractures or as a sal-vage option following failed external fi xation or ORIF of PIP joint fracture-dislocations

•      Complications

–     Stiffness

•      Most common complication

•      Flexor tendon adhesions, fl exion contractures

•      Increased risk with prolonged immobilization, associated joint injury and extensive surgical dissection

–     Malunion

•      Malrotation, volar/dorsal angulation, lateral translation, shortening

•      Corrective surgery indicated for functional impairment

–     Osteotomy at malunion site preferred over metacarpal osteotomy

–     Nonunion

•      Uncommon overall

•      Treat symptomatic nonunions with nonunion takedown and ORIF +/− bone grafting or ray amputation or arthrodesis in salvage situations.

•      Treatment of symptomatic distal phalanx fractures with percutaneous compression screw is described.

–     Posttraumatic arthrosis

•      Observation and NSAIDS for mild symptoms

•      Symptomatic DIP arthrosis: arthrodesis

–     Index and long fi nger: extension

–     Ring and small fi nger: 10–20° fl exion

•      Symptomatic PIP arthrosis

–  Arthrodesis

•      Index fi nger: 30° fl exion

•      Long fi nger: 35° fl exion

•      Ring fi nger: 40° fl exion

•      Small fi nger: 45° fl exion

–  Silicone arthroplasty

•  Indicated for long and ring fi nger PIP arthrosis with good bone stock and no signifi cant deformity

 Bibliography

1. C alfee RP, Kiefhaber TR, Sommerkamp TG, Stern PJ. Hemi-hamate arthroplasty provides functional reconstruction of acute and chronic proximal interphalangeal fracture-dislocations. J Hand Surg Am. 2009;34(7):1232–41.

2. F reeland AE, Orbay JL. Extraarticular hand fractures in adults: a review of new developments. Clin Orthop Relat Res. 2006;445:133–45.

3.    Henry MH. Fractures of the proximal phalanx and metacarpals in the hand: pre-ferred methods of stabilization. J Am Acad Orthop Surg. 2008;16(10):586–95.

4.    Kawamura K, Chung KC. Fixation choices for closed simple unstable oblique phalangeal and metacarpal fractures. Hand Clin. 2006;22(3):287–95. Review.

5.    Meijs CM, Verhofstad MH. Symptomatic nonunion of a distal phalanx fracture: treatment with a percutaneous compression screw. J Hand Surg Am. 2009; 34(6):1127–9.

6 . M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 734.

 Pelvis and Lower Extremity Trauma

 

1     Pelvic Ring Injuries

 Take-Home Message

•      Pelvic ring injuries are most commonly described using the Young-Burgess classifi cation.

•      Hemodynamically unstable patients require emergent intervention with pelvic binder/sheet, volume resuscitation, possible external fi xation and pelvic packing, possible angiographic embolization, skeletal traction in vertically unstable patterns, and possible C clamp.

•      Anterior pelvic ring injuries commonly treated with plate fi xation. External fi xation may be favorable in some patients, and injury patterns place the lateral femoral cutaneous nerve at risk.

•      Posterior pelvic ring injuries require anatomic reduction and stabilization with anterior plating, SI screws, or posterior tension band plating.

•      P lacement of percutaneous sacroiliac screws requires meticulous fl uoroscopic visualization with appropriate inlet, outlet, and lateral sacral views.

•      Vertical sacral fractures are at increased risk for loss of fi xation/reduction.

•      Vertically unstable pelvic ring injuries should be treated with stabilization of the anterior and posterior pelvic ring; consider lumbopelvic fi xation.

 N.  Casemyr ,  MD •  C.  Mauffrey ,  MD, FACS, FRCS (*) •  D.  Hak ,  MD, FACS, MBA

 Department of Orthopaedic Surgery ,  Denver Health Medical Center ,

 777 Bannock Street ,  Denver  80204 ,  CO ,  USA  e-mail: cyril.mauffrey@dhha.org; cmauffrey@yahoo.com

                                                                                             237

C. Mauffrey, D.J. Hak (eds.), Passport for the Orthopedic Boards and FRCS Examination, DOI 10.1007/978-2-8178-0475-0_11

•      High incidence of thromboembolic disease and urogenital injuries.

•      I ncreased risk of mortality with blood transfusion requirement in the fi rst 24 h, open fractures, associated bladder ruptures, and more severe/unstable fracture patterns.

 General   

•      Mechanism of injury: typically high-energy blunt trauma

•      High mortality rates

–     Closed fracture: 15–25 % mortality

–     Open fractures: up to 50 % mortality

•      Complete examination of the perineum, vagina, and rectum to rule out occult open injuries.

•      Open pelvis fractures may require a diverting colostomy.

•      High incidence of associated injuries

–     Chest, head, abdominal, long bone fractures, spine fractures, internal iliac vessels and branches, lumbosacral plexus (L5 and S1 most common), urogenital injuries.

–     U  rogenital injuries: blood at the urethral meatus, high-riding prostate, signifi cant displacement of the anterior pelvic ring.

•      Males (21 %) > females (8 %).

•      I f retrograde urethrogram is negative and there is persistent hematuria, obtain a cystogram.

–     Fracture patterns with signifi cant ilium/crescent components have increased risk of soft tissue degloving and bowel injury or entrapment.

–     Mortality usually results from sequelae of nonpelvic-associated injuries.

•      Hemorrhage is the leading cause of death

–     I  nternal pudendal artery injuries associated with the most signifi cant intrapelvic hemorrhage

–     Must evaluate for nonpelvic sources of bleeding

•      Binders, sheeting, external fi xation, pelvic clamp, and pelvic packing: decrease the volume of the pelvis and tamponade bleeding

–     Good for venous hemorrhage

–     Less effective for arterial hemorrhage

•  Angiography with embolization for ongoing arterial hemorrhage

 Imaging  

•      A P pelvis: assess each hemipelvis for asymmetry, rotation, and displacement and for possible associated fracture of the L5 transverse process, ischial spine, and ischial tuberosity.

•      I nlet view: 25–45° caudad angulation; S1 should overlie S2; assess anteroposterior displacement of the sacroiliac joint, sacroiliac joint widening, rotational deformity, and sacral ala impaction fracture.

•      O utlet view: 45–60° cephalad angulation; pubic symphysis shoulder overlies S2; assess vertical displacement of the sacroiliac joint and fl exion/extension of the hemipelvis and disruption of sacral foramina.

•      CT scan: should be obtained routinely to further evaluate pelvic ring injuries

–  Better characterization of posterior ring injuries, involvement of sacral foramina, comminution, and rotation

 Young and Burgess Classifi cation  

•      Anteroposterior compression injuries

–     High incidence of associated visceral injuries and retroperitoneal injuries

–     APC I: symphyseal diastasis <2.5 cm, posterior pelvic ring intact

–     A  PC II: symphyseal diastasis >2.5 cm, disruption of the sacrotuberous, sacrospinous, and anterior sacroiliac ligaments; posterior sacroiliac ligaments intact

–     A  PC III: symphyseal diastasis >2.5 cm, complete separation of the hemipelvis from the pelvic ring with disruption of the sacrotuberous, sacrospinous, and anterior and posterior sacroiliac ligaments

•      Lateral compression injuries

–     High incidence of closed head injury and intra-abdominal injury.

–     LC I: pubic ramus fracture with sacral compression fracture.

–     LC II: pubic ramus fracture with posterior iliac wing fracture-dislocation (crescent fracture).

–     L  C III: pubic ramus fracture with ipsilateral lateral compression injury and contralateral APC injury (windswept pelvis); common mechanisms include rollover MVC and auto vs pedestrian.

•      Vertical shear injuries

–     Highest incidence of intrapelvic hemorrhage with resulting hemorrhagic shock (~65 %)

–     P  osterior and superior directed force, common mechanism with fall from height

•      Combined mechanism injuries

 Tile Classifi cation   

•      Stable (posterior arch intact)

–     A1: fracture not involving the pelvic ring (avulsion, iliac wing)

–     A2: minimally displaced, stable ring fracture

–     A3: transverse sacral fracture

•      Rotationally unstable, vertically stable

–     B1: anteroposterior compression injury (external rotation)

–     B2: lateral compression injury (internal rotation)

•      B2-1: anterior ring rotation with displacement through the ipsilateral rami

•      B2-2: anterior ring rotation with displacement through the contralateral rami

–  B3: bilateral

•      Rotationally and vertically unstable (complete disruption of the posterior arch)

–  C1: unilateral

•      C1-1: iliac fracture

•      C1-2: sacroiliac fracture-dislocation

•      C1-3: sacral fracture

–     C2: bilateral with one side B type and one side C type

–     C3: bilateral C type

 Treatment  

•      Emergent volume resuscitation and hemorrhage control

–     Massive transfusion protocol: PRBC-FFP-platelets in 1:1:1 ratio improves mortality.

–     B  leeding sources: intra-abdominal, intrathoracic, retroperitoneal, extremity, pelvic

•      Pelvic sources of hemorrhage

–     Venous plexus hemorrhage: 80–85 %

–     Bleeding cancellous bone

–     Arterial injury 15–20 %

•      Superior gluteal > internal pudendal > obturator > lateral sacral

–     Reduce pelvic volume and stabilize fracture.

•      P elvic binder/sheet centered over greater trochanters, may internal rotate lower extremities and bind ankles together; prolonged pressure from binder or sheet can cause skin necrosis.

•      E xternal fi xation, skeletal traction (vertically unstable injuries), pelvic C clamp (rarely used) to decrease pelvic volume and tamponade bleeding and to stabilize fracture allowing clot to form over bleeding bone and venous plexus.

–     External fi xator should be placed before pelvic packing (if performed) or laparotomy.

•  Angiographic embolization may be considered if there is ongoing arterial hemorrhage with the goal to selectively embolize bleeding sources, risk of gluteal necrosis, and impotence.

–     Nonoperative

• M obilization with weight bearing as tolerated indicated for mechanically stable pelvic ring injuries

–     LC I and APC I pelvis fractures, isolated pubic ramus fractures

•  May consider protected weight bearing for some anterior injuries with ipsilateral partial posterior ring injuries

–     Operative

•  Open reduction internal fi xation

–     Indicated for symphyseal diastasis >2.5 cm, complete sacroiliac joint disruption, displaced sacral fractures, vertically unstable fractures, displacement or rotation of hemipelvis.

–     A  nterior injuries: anterior plate fi xation most common, external fi xation with supra-acetabular pins or iliac wing pins (lateral femoral cutaneous nerve at risk, indicated with suprapubic catheter placement).

–     P  osterior injuries: sacroiliac joint dislocations and fracture-dislocations require anatomic reduction.

•      Open reduction and anterior plating of the sacroiliac joint via lateral window, L4 and L5 nerve roots at greatest risk with retractor placement.

•      Sacroiliac screws: L5 nerve root at greatest risk; ensure screws are posterior to the iliac cortical density on the lateral sacral view and appropriately positioned on inlet and outlet pelvis views.

•      P osterior tension band plating: risk of prominent hardware and wound healing problems.

–     V  ertically unstable injury patterns should be treated with anterior and posterior ring stabilization to decrease risk of loss of reduction; consider lumbopelvic fi xation.

 Complications   

•      Poor outcomes associated with SI joint incongruity, increased injury severity and initial displacement, malunion with residual displacement >1 cm, nonunion, leg length discrepancy >2 cm.

–     Vertical sacral fractures have the highest risk of loss of fi xation/reduction.

•      Neurologic injury

–     L5 nerve root at greatest risk as it courses over the sacral ala.

–     L4 and S1 nerve roots at lesser risk.

–     Additional sacral nerve root may be compromised at the time of injury, reduction of sacral fracture, or overcompression of transforaminal sacral fractures.

•      High risk of thromboembolic disease

–     Pharmacologic prophylaxis, mechanical prophylaxis, IVC fi lters in patients otherwise contraindicated for chemical anticoagulation

•      Urogenital injuries

–     Present in 10–20 % of pelvic ring injuries, more common in males. –  Urethral tear, bladder rupture (increased risk of mortality).

•      May result in urethral stricture, impotence, incontinence, and increased risk of anterior pelvic ring infection.

–  Dyspareunia, possible need for cesarean section.

•      Chronic instability is a rare complication.

–  Assess with single-leg stance pelvis x-rays.

•      Increased risk of mortality associated with blood transfusion requirement in the fi rst 24 h, open fractures, associated bladder ruptures, and more severe/unstable fracture patterns.

 Bibliography

 1 . B arei DP, Bellabarba C, Mills WJ, Routt ML Jr. Percutaneous management of unstable pelvic ring disruptions. Injury. 2001;32(Suppl 1):SA33–44.

2.  Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ. Pelvic ring disruptions: effective classifi cation system and treatment protocols. J Trauma. 1990;30(7):848–56.

3.  Croce MA, Magnotti LJ, Savage SA, Wood GW 2nd, Fabian TC. Emergent pelvic fi xation in patients with exsanguinating pelvic fractures. J Am Coll Surg. 2007;204(5):935–9.

4.  Griffi n DR, Starr AJ, Reinert CM. Vertically unstable pelvic fractures fi xed with percutaneous iliosacral screws: does posterior injury pattern predict fi xation failure? J Orthop Trauma. 2006;20:S30–6.

5.  Hak DJ, Smith WR, Suzuki T. Management of hemorrhage in life-threatening pelvic fracture. J Am Acad Orthop Surg. 2009;17(7):447–57.

 6 . K aradimas EJ, Nicolson T, Kakagia DD, Matthews SJ, Richards PJ, Giannoudis PV. Angiographic embolisation of pelvic ring injuries. Treatment algorithm and review of the literature. Int Orthop. 2011;35(9):1381–90.

7.     Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M. Emergent stabilization of pelvic ring injuries by controlled circumferential compression: a clinical trial. J Trauma. 2005;59(3):659–64.

8.     Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 735–8.

9.     Routt ML Jr, Simonian PT, Agnew SG, Mann FA. Radiographic recognition of the sacral alar slope for optimal placement of iliosacral screws: a cadaveric and clinical study. J Orthop Trauma. 1996;10(3):171–7.

10.  Siegel J, Templeman DC, Tornetta P III. Single-leg-stance radiographs in the diagnosis of pelvic instability. J Bone Joint Surg Am. 2008;90(10):2119–25.

11.  S mith W, Williams A, Agudelo J, Shannon M, Morgan S, Stahel P, Moore E. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;21(1):31–7.

1 2. S tarr AJ, Walter JC, Harris RW, Reinert CM, Jones AL. Percutaneous screw fi xation of fractures of the iliac wing and fracture-dislocations of the sacro-iliac joint (OTA Types 61-B2.2

and 61-B3.3, or Young-Burgess “lateral compression type II” pelvic fractures). J Orthop Trauma. 2002;16(2):116–23.

13.  Tile M. Acute pelvic fractures: I. Causation and classifi cation. J Am Acad Orthop Surg. 1996;4(3):143–51.

14.  Tile M. Acute pelvic fractures: II. Principles of management. J Am Acad Orthop Surg.

1996;4(3):152–61.

2     Acetabular Fractures  

 Take-Home Message

•      B imodal distribution with high-energy blunt trauma in the young and lowenergy fall in the elderly.

•      C orona mortis is an anastomosis between the external iliac (or deep epigastric) vessels and the obturator vessels.

•      C orona mortis present in ~30 % of patients, risk life-threatening hemorrhage if injured.

•      Six cardinal lines on the AP pelvis: iliopectineal line, ilioischial line, ante-rior wall, posterior wall, sourcil, teardrop.

•      Iliac oblique profi les the anterior column and posterior wall.

•      Obturator oblique profi les the posterior column and anterior wall.

•      Fractures with roof arc angle >45° on AP; obturator and iliac oblique views do not involve the weight-bearing dome.

•      On axial CT scan, vertical fracture lines represent transverse or T-type fractures, while horizontal line represents column fractures.

•      Letournel classifi cation divides acetabular fractures into fi ve elementary and fi ve associated types.

•      A ssociated both-column fractures: complete dissociation of the articular surface of the acetabulum from the axial skeleton; the spur sign on obturator oblique represents the undisplaced intact posterior ilium.

•      Nonoperative management of minimally displaced fractures, fractures outside the weight-bearing dome, and fractures with secondary congruence.

•      Surgical fi xation indicated for displaced fractures, fractures with roof arc angle <45° on any view, incarcerated intra-articular fragments, irreducible fracture- dislocations, and unstable hips with associated wall fractures.

•      Posterior wall fractures: <20 % presumed to be stable, 20–40 % perform dynamic fl uoroscopic EUA to determine stability, >40 % presumed to be unstable.

•      O RIF and acute total hip arthroplasty for patients >60 years with superomedial dome impact (gull sign), signifi cant osteopenia and/or comminution, and associated femoral neck fractures

•	Posttraumatic arthrosis is the most common complication.
•	Heterotopic ossifi cation is common; increased risk with extensile and posterior approaches.
•	High risk of thromboembolic disease; all patients should receive DVT prophylaxis and/or IVC fi lter.
•	Risk of iatrogenic sciatic nerve injury can be decreased by maintaining hip extension and knee fl exion to reduce tension on the nerve.
•	Quality of reduction is the most important determinant of outcome; increased risk of malreduction with delay to surgery.

 General   

•      Bimodal distribution

–     High-energy blunt trauma in young patients

–     Low-energy falls in elderly patients

•      Fracture pattern determined by position of the hip and force vector

–     Flexed hip with axial load most common (dashboard injury)

•      Associated injuries: hip dislocation, sciatic nerve injury, other lower extremity injuries (35 %), additional organ system injury (50 %)

•      A cetabulum supported by two columns of bone in an “inverted Y” and connected to the sacrum through the sciatic buttress

–     P  osterior column: ischial tuberosity, greater and lesser sciatic notches, posterior wall and dome, and quadrilateral surface

–     Anterior column: lateral superior pubic ramus, iliopectineal eminence, ante-rior wall and dome, anterior ilium

•      Corona mortise: anastomosis of external iliac (or deep epigastric) vessels and the obturator vessels (arising from the internal iliac vessels)

–     Present in 30 % of patients

–     At risk with lateral dissection along the superior pubic ramus

•      Typically located ~3 cm from the symphysis pubis.

•      Variable anomalous branches may be present.

–  Risk of life-threatening hemorrhage if injured

 Imaging Studies  

•      AP pelvis: six cardinal lines

–     Iliopectineal line: radiographic representation of the anterior column

–     Ilioischial line: radiographic representation of the posterior column

–     Teardrop: radiographic representation of the medial acetabular wall

–     Sourcil

–     Anterior wall

–     Posterior wall

–     Shenton’s line: not a cardinal line, helps detect occult hip dislocation

•      Judet views (45° oblique views)

–     O  bturator oblique: involved obturator foramen en face, anterior column, posterior wall

–     Iliac oblique: involved iliac wing en face, posterior column, anterior wall

•      R oof arc angles: angle from a vertical line to the geometric center of the acetabulum to the point where the fracture line intersects the acetabulum on AP, obturator and iliac oblique views

–     If roof arc angle is >45°, fracture does not involve the weight-bearing dome.

–     CT correlate: fracture line >10 mm from the apex of the dome does not involve the weight-bearing surface.

–     Cannot be applied to associated both-column fractures or posterior wall  fractures (no intact portion of the acetabulum on which to base measurements).

•      CT scan: assess articular surface involvement, marginal impaction, posterior wall size, incarcerated intra-articular fragments, preoperative planning

–     Vertical fracture line on axial CT: transverse or T-type fracture.

–     Horizontal fracture line on axial CT: column fracture.

–     3D reconstruction with femoral head subtraction is a useful adjunct for some.

 Letournel Classifi cation   

•      Elementary

–     Posterior wall: most common acetabular fracture, gull sign on obturator oblique

–     P  osterior column: increased risk of injury to superior gluteal neurovascular bundle

–     Anterior wall: rare

–     Anterior column: more common with low-energy fractures in the elderly

–     Transverse: only elementary fracture pattern that involves both columns, ante-rior to posterior directed fracture line on axial CT

•      Associated

–     Posterior column posterior wall: only associated fracture pattern that does not involve both columns.

–     Anterior column posterior hemi-transverse: common in elderly patients.

–     Transverse posterior wall: most common associated fracture pattern.

–     T type: anterior to posterior fracture line on proximal axial CT scan with medial extension through the quadrilateral surface and the ischium distally.

–     A  ssociated both columns: most commonly associated acetabular fracture pattern; no part of the articular surface of the acetabulum remains in contact with the axial skeleton (via the sacroiliac joint), spur sign on obturator oblique represents the undisplaced intact posterior ilium.

 Treatment  

•              Nonoperative management

–  Touchdown versus protected weight bearing for 8 weeks

•              Indications: nondisplaced and minimally displaced fracture (<1 mm step, <2 mm gap), roof arc angle >45°, posterior wall fragment <20 %, associated both columns with secondary congruence, severe comminution in the elderly with plan for total hip arthroplasty following fracture consolidation –  Skeletal traction rarely indicated as defi nitive management

•              Operative

–     Open reduction internal fi xation

•  Indications: displacement with >1 mm step or 2 mm gap with roof arc angle <45° on any view, instability on stress exam of the hip, marginal impaction, incarcerated intra-articular fragments, irreducible fracture-dislocations

–     Posterior wall fracture 20–40 %: dynamic fl uoroscopic examination under anesthesia to assess hip stability

–     Posterior wall fracture >40 %: presumed to be unstable

•      R elative contraindications: morbid obesity, low-demand elderly and nonambulatory patients, known DVT with contraindication to IVC fi lter, delay to surgery >3 weeks.

•      Approach determined by fracture pattern, may be combined.

•      Risks specifi c to surgical approach for ORIF

–     Kocher-Langenbeck: sciatic nerve injury, avascular necrosis of the fem-oral head

–     Ilioinguinal: femoral nerve injury, LFCN injury, femoral vessel throm-bosis, corona mortis laceration

–     Extensile (extended iliofemoral, triradiate): heterotopic ossifi cation, gluteal necrosis

•      Outcomes correlate with quality of articular reduction, hip muscle strength, and restoration of gait.

–     ORIF and acute total hip arthroplasty

•      Relative indications: age >60 years with superomedial dome impaction (gull sign), signifi cant osteopenia and/or comminution, associated displaced femoral neck fracture, signifi cant preexisting hip arthrosis

•      Up to 80 % construct survival at 10 years

•      Worse outcomes in males, patients <50 or >80 years of age, and signifi cant acetabular defects

–     Percutaneous fi xation with column screws

•      I ndications: minimally displaced column fractures, column fractures in elderly and low-demand patients to facilitate early mobilization and weight bearing

•      Imaging

–     Obturator oblique: best to assess joint penetration.

–     Iliac oblique: assess clearance of the sciatic notch and start point for supra-acetabular screws on the apex of the posterior inferior iliac spine (PIIS).

–     Inlet iliac oblique: assess position of screw in the pubic ramus.

–     Inlet obturator oblique: assess position of screw within tables of the ilium.

–     Obturator outlet: assess start point for supra-acetabular screws.

 Complications  

•      Posttraumatic arthrosis is the most common complication

–  Total hip arthroplasty, hip arthrodesis

•      W orse outcomes for total hip arthroplasty following acetabular fracture as compared to osteoarthritis

•      Heterotopic ossifi cation

–     G  reatest risk with extensile surgical approaches, lowest risk with ilioinguinal approach.

•      Extended approaches: 20–50 %

•      Kocher-Langenbeck: 8–25 %

•      Anterior approach: 2–10 %

–     P  rophylaxis: indomethacin ×5 weeks post-op, low-dose external-beam radiation of 600 cGy within 48 h of surgery.

–     Excision of the devitalized gluteal muscle at time of surgery may help decrease incidence and severity.

–     In severe cases where heterotopic ossifi cation interferes with hip function, may consider excision once mature.

•      Avascular necrosis

–     Increased risk with posterior fractures and approaches, fracture-dislocations, and iatrogenic injury to the medial femoral circumfl ex artery

•      Thromboembolic disease

•      High risk of DVT and PE

–     Chemical prophylaxis recommended for all patients unless specifi c contrain-dications exist

•      Place IVC fi lter if not contraindicated.

•      Infection

–  Increased risk with associated Morel-Lavellée lesions (internal degloving)

•      Bleeding

–     E  arly surgery may have greater blood loss; however increased delay to surgery results in longer operative times (reduction more diffi cult to obtain) with resulting increased blood loss.

–     Signifi cant, potentially life-threatening, bleeding possible with injury to corona mortis vessels.

•      Neurologic injury

–     Sciatic nerve injury

•      Increased risk of sciatic nerve injury (especially peroneal division) with associated posterior hip dislocation.

•      Maintain hip extension and knee fl exion intraoperatively to reduce tension on the sciatic nerve.

–     Lateral femoral cutaneous nerve injury

•      Anterior approaches

•      Hardware malposition

–     Intra-articular hardware, violation of sciatic notch

•      Abductor muscle weakness

–     Posterior approach > anterior approach

•      Chondrolysis

•      Malreduction

–     Associated with increased delay to surgery

•      Nonunion

–     Very rare

 Bibliography

  1.  Engsberg JR, Steger-May K, Anglen JO, Borrelli J Jr. An analysis of gait changes and functional outcome in patients surgically treated for displaced acetabular fractures. J Orthop Trauma. 2009;23(5):346–53.

 2 . G ardner MJ, Nork SE. Stabilization of unstable pelvic fractures with supraacetabular compression external fi xation. J Orthop Trauma. 2007;21(4): 269–73.

  3.  Grimshaw CS, Moed BR. Outcomes of posterior wall fractures of the acetabulum treated nonoperatively after diagnostic screening with dynamic stress examination under anesthesia. J Bone Joint Surg Am. 2010;92(17): 2792–800.

4. J imenez ML, Tile M, Schenk RS. Total hip replacement after acetabular fracture. Orthop Clin North Am. 1997;28:435–46.

5. K azemi N, Archdeacon MT. Immediate full weightbearing after percutaneous fi xation of anterior column acetabular fractures. J Ortho Trauma. 2012;26(2): 73–9.

6.    Letournel E. Acetabulum fractures: classifi cation and management. Clin Orthop Relat Res. 1980;151:81–106.

7.    Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 738–43.

 8 . S tarr AJ, Reinert CM, Jones AL. Percutaneous fi xation of the columns of the acetabulum: a new technique. J Ortho Trauma. 1998;12(1):51–8.

  9.  Tornetta P 3rd. Displaced acetabular fractures: indications for operative and nonoperative management. J Am Acad Orthop Surg. 2001;9(1):18–28.

1 0. T ornetta P 3rd. Non-operative management of acetabular fractures. The use of dynamic stress views. J Bone Joint Surg Br. 1999;81(1):67–70.

3     Sacral Fractures  

 Take-Home Message

•      Sacral fractures commonly comprise part of a pelvic ring injury.

•      ~ 25 % associated neurologic injury with increased risk in transforaminal, medial/spinal canal, transverse, and U-type sacral fractures.

•      Lower sacral nerve roots control the anal sphincter, bulbocavernosus refl ex, and perianal sensation.

•      Unilateral sacral nerve root function suffi cient for bowel and bladder control.

•      V ertical sacral fractures at increased risk for loss of reduction/fi xation with resulting nonunion, malunion, and poor functional outcomes

•      Sacral U fractures are unstable injuries that represent spinopelvic dissocia-tion and require stabilization.

•      Stable injuries with incomplete sacral fractures can mobilize as tolerated.

•      Minimally displaced complete sacral fractures may be treated with pro-tected weight bearing or surgical stabilization.

•      U nstable, displaced sacral fractures should undergo reduction and stabilization ± decompression with careful technique to avoid iatrogenic nerve injury.

 General  

•      Bimodal distribution, common in pelvic ring injuries

–     Young adults: high-energy trauma with MVC and fall from height most common

–     Elderly: low-energy falls, insuffi ciency fractures

•      Neurologic injury in 25 %

–     L  ower sacral root function: anal sphincter, bulbocavernosus refl ex, perianal sensation.

–     Neurologic defi cit is the most important predictor of outcome.

•      U nilateral sacral nerve root function suffi cient for bowel and bladder control.

 Imaging   

•      Radiographs demonstrate 30 % of sacral fractures.

–     A  P pelvis: symmetry of foramina, associated L4 and L5 transverse process fractures.

–     Inlet view: sacral spinal canal, S1 body.

–     Outlet view: true AP of the sacrum; assess symmetry of the foramina. –  Lateral view: kyphosis.

•      CT scan study of choice to further delineate fracture pattern and help guide treatment.

•      MRI is for cases with concern for neural compromise.

 Denis Classifi cation  

•      Zone I: alar fracture (lateral to the foramina)

–     5 % neurologic injury, most commonly L5

•      Zone II: transforaminal

–     30 % neurologic injury, most commonly L5, S1, S2.

–     V  ertical and shear-type fractures are highly unstable with increased risk of poor functional outcome.

•      Zone III: medial to the foramina into the spinal canal

–     6  0 % neurologic injury, most commonly the caudal nerve roots with bowel, bladder, and sexual dysfunction.

–     Unilateral sacral root preservation is suffi cient for bowel/bladder control.

 Transverse Fractures  

•      High incidence of neurologic injury

 Sacral U Fracture   

•      High incidence of neurologic injury

•      Typically results from axial loading

•      U nstable injuries, often with kyphosis through the fracture, that represent spinopelvic dissociation and require surgical stabilization

 Treatment Principles   

•      Nonoperative: stable and minimally displaced fractures

– W  eight bearing as tolerated: incomplete sacral fractures where the intact sacrum remains in continuity with the ilium, neurologically intact

•      Anterior impaction sacral fractures with LC mechanism, isolated sacral ala fractures

–     T  oe-touch weight bearing: consider in complete sacral fractures with minimal displacement.

–     Post-mobilization x-rays to assess for subsequent displacement.

•      Operative

–  Open reduction internal fi xation ± decompression

•      Displaced fractures (>1 cm), displacement of fracture with trial of non-operative management, foraminal compromise, unstable fracture patterns

•      Percutaneous sacroiliac screws, posterior tension band plating, transiliac sacral bars, lumbopelvic fi xation

•      Open decompression considered for transforaminal fractures with neuro-logic injury and sacral U fractures with kyphosis and compromise of the spinal canal

 Complications  

•      Neurologic defi cit is the most important predictor of outcome

–     Lower extremity defi cits, bowel/bladder dysfunction, sexual dysfunction

–     Nerve compromise at the time of injury

–     Risk of iatrogenic nerve injury with implant malposition and overcompres-sion of fractures involving the sacral foramina

•      Malunion/nonunion

–     V  ertical sacral fractures at increased risk for loss of fi xation/reduction with resulting malunion, nonunion, and poor functional outcomes

•      Thromboembolic disease

•      Chronic low back pain

 Bibliography

1.    Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res. 1988;227:67–81.

2.    Mehta S, Auerbach JD, Born CT, Chin KR. Sacral fractures. J Am Acad Orthop Surg. 2006;14(12):656–65 (Review).

3. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 738.

4. R obles LA. Transverse sacral fractures. Spine J. 2009;9(1):60–9. Epub 2007 Nov 5. Review.

4     Hip Dislocations  

 Take-Home Message

•      High-energy trauma; position of the hip at the time of injury determines the direction of the dislocation and risk of associated injuries.

•      Hip dislocations require emergent closed reduction within 6 h to decrease the risk of avascular necrosis.

•      If closed reduction is not possible, proceed to the operating room in urgent fashion for open reduction.

•      Obtain a postreduction CT scan to assess for associated fracture and incar-cerated fragments.

•      Commonly associated injuries include acetabular fractures, femoral head fractures, labral tears, sciatic nerve injury, and ipsilateral knee injuries.

 General   

•      Typically occur in young adults following high-energy trauma.

–     Axial loading; position of the hip determines the direction of the dislocation. –  90 % of hip dislocations are posterior.

•      High incidence of associated injuries

–     Acetabular fractures (posterior wall fracture, marginal impaction), femoral head fractures, chondral injury, labral tears (30 %), sciatic nerve injury, ipsilateral knee injuries (25 %)

 Imaging   

•      A P pelvis: dislocated femoral head appears smaller than the contralateral side (posterior dislocation); discontinuity of Shenton’s line; carefully assess femoral neck for possible fracture.

•      Lateral hip: confi rm direction of dislocation.

•      P ostreduction AP pelvis and lateral hip to confi rm reduction; consider Judet views to further evaluate for possible associated acetabular fracture.

•      P ostreduction CT scan mandatory: assess for loose bodies, incarcerated fragments, femoral head fracture, and acetabular fracture.

•      MRI may be useful in follow-up to further evaluate concern for subsequent avas-cular necrosis or labral injury.

 Classifi cation   

•      Simple: hip dislocation with no associated fracture

•      Complex: hip dislocation with associated acetabular or proximal femur fracture

•      Anatomic classifi cation

–  Posterior dislocation (90 %)

•      Hip fl exed, adducted, and internally rotated

•      “Dashboard injury”

•      A ssociated injuries: posterior wall fracture, anterior femoral head fracture, ipsilateral knee injury

–     Increased hip fl exion and internal rotation at the time of injury decreases the risk of associated fracture.

–     Anterior dislocation

•      Hip extended, abducted, and externally rotated

•      Associated injuries: impaction fracture, chondral injury

–  Obturator dislocation

 Treatment   

•      Nonoperative

–  Emergent closed reduction within 6 h; evaluate hip stability postreduction

•      Closed reduction contraindicated with ipsilateral femoral neck fractures

–     W  eight bearing as tolerated vs protected weight bearing for 4–6 weeks: stable hip without associated injuries.

–     Consider traction and/or abduction pillow for unstable hips or associated inju-ries requiring further intervention.

•      Operative

–  Open reduction ± removal of incarcerated fragments

•      Irreducible hip dislocation, incarcerated fragments, incongruent reduction

–     Open reduction internal fi xation

•  Associated acetabular, femoral head, and femoral neck fractures.

–     Femoral neck fracture should be stabilized prior to reduction.

–     Hip arthroscopy

•  May be used to remove incarcerated fragments

 Complications  

•      Avascular necrosis: 10–20 %

–     Increased risk with delay to reduction

•      Posttraumatic arthritis

•      Sciatic nerve injury: 10–20 %

–     Peroneal division most common

–     Increased risk with delay to reduction

•      Rare recurrent dislocation

 Bibliography

1 . M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 743–4.

 2.  Schmidt GL, Sciulli R, Altman GT. Knee injury in patients experiencing a high- energy traumatic ipsilateral hip dislocation. J Bone Joint Surg Am. 2005; 87:1200–4.

3 . T ornetta P 3rd, Mostafavi HR. Hip dislocation: current treatment regimens. J Am Acad Orthop Surg. 1997;5(1):27–36.

5     Femoral Head Fractures  

 Take-Home Message

•      Typically associated with hip dislocations with position of the hip at the time of dislocation, determining the location and size of the femoral head fracture.

•      T reatment goals are to restore congruity of the weight-bearing portion of the femoral head, restore hip stability, remove incarcerated fragments, and address associated femoral head and acetabular fractures appropriately.

•      Smith-Peterson approach favored when possible for not increasing the risk of AVN and providing good access to most femoral head fractures.

•      Risk of AVN greatest in Pipkin III fractures as related to the degree of displacement of the associated femoral neck fracture.

•      I ncreased risk of AVN with delay to reduction of associated hip dislocation.

•      M ay consider arthroplasty in older patients and signifi cantly comminuted fractures not amenable to primary reconstruction.

 General  

•      F emoral head fractures are rare injuries that typically occur in combination with hip dislocations,

–     High-energy mechanism: MVC, fall from height.

–     T  he position of the hip at the time of dislocation determines the location and size of the femoral head fracture.

•      Posterior hip dislocations: 5–15 % associated femoral head fracture

•      Anterior hip dislocations: associated with impaction fractures of the femoral head

•      A ssociated injuries: femoral neck fracture, acetabular fracture, sciatic nerve injury, femoral head avascular necrosis, ipsilateral knee injury (dashboard)

•      Primary blood supply to the femoral head in adults: medial femoral circumfl ex artery

 Imaging   

•      A P pelvis and lateral hip: assess for symmetry, femoral head fracture, and hip dislocation; obtain pre- and postreduction.

•      Judet views: assess for associated acetabular fracture.

•      P ostreduction CT scan: assess for concentric reduction, incarcerated fragments, associated femoral neck, and acetabular fractures.

 Pipkin Classifi cation  

•      T ype I: infrafoveal fracture, below the weight-bearing surface of the femoral head

•      Type II: suprafoveal fracture, involves the weight-bearing surface of the femoral head

•      Type III: type I or II plus femoral neck fracture

•      Type IV: type I, II, or III plus acetabular fracture

 Treatment   

•      Nonoperative

–     Emergent closed reduction of hip fractures within 6 h (see Sect.  4 above)

–     Touchdown weight bearing for 4–6 weeks, hip dislocation precautions

•      Pipkin I fractures, nondisplaced Pipkin II fractures

– F  ollow closely with serial radiographs to assess for subsequent displacement of initially nondisplaced Pipkin II fractures.

•      Operative

–     Open reduction internal fi xation

•      Displaced Pipkin II fractures ± associated acetabular or femoral neck frac-tures (Pipkin III, Pipkin IV), irreducible fracture-dislocation, incarcerated fragments.

•      Smith-Peterson approach preferred, no associated increased risk of AVN, facilitates reduction and fi xation as femoral head fractures are often anteromedial.

–     W  orse outcomes for fractures addressed via a Kocher-Langenbeck approach.

•  Treat associated acetabular fractures according to the type of acetabular fracture.

–  Arthroplasty

•  Consider in femoral head fractures in older patients, particularly with  signifi cant displacement, comminution, and osteoporosis.

 Complications  

•      Avascular necrosis in up to 25 %

–  Highest incidence of AVN in Pipkin III injuries

•      R ate of AVN increases with increasing displacement of the femoral neck fracture.

–  Increased risk with delay to reduction of dislocated hip

•      Sciatic nerve injury in 10–25 %

–     Related to associated hip dislocation

–     Involvement of peroneal division most common

•      Posttraumatic arthritis in 10–75 %

–     Cartilage damage at the time of injury

–     Joint incongruity/imperfect reduction

•      Heterotopic ossifi cation in 5–65 %

–     May consider adjunctive therapy (radiation, indomethacin) at time of surgery in patients at increased risk (head injury)

 Bibliography

1. D roll KP, Broekhuyse H, O’Brien P. Fracture of the femoral head. J Am Acad Orthop Surg. 2007;15(12):716–27 (Review).

2. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia:

Elsevier; 2012. p. 744–6.

6     Femoral Neck Fractures  

 Take-Home Message

•      High-energy femoral neck fractures are more likely to be vertical and asso-ciated with femoral shaft fractures.

•      Depending on fracture characteristics, patient age, functional status, and comorbidities, femoral neck fractures may be treated with cannulated screws, sliding hip screw, hip hemiarthroplasty, and total hip arthroplasty.

•      I ncreased risk of avascular necrosis with increased initial displacement, nonanatomic reduction, and increasing patient age.

•      I ncreased risk of nonunion with displaced fractures, vertically oriented fractures, varus malreduction, and cannulated screw fi xation.

•      Quality of reduction is more important than time to reduction.

•      Cannulated screws should begin above the lesser trochanter to decrease the risk of peri-implant subtrochanteric fracture.

•      Hemiarthroplasty has a lower risk of dislocation compared to total hip arthroplasty.

•      Active elderly patients have improved functional outcomes with total hip arthroplasty.

•      Mortality at 1 year in elderly patients is 15–35 %.

•      Pre-injury cognitive function and mobility are the more important determi-nants of postoperative functional outcome.

 General  

•      Bimodal distribution

–  Young: high-energy injuries

•      More likely to have a vertically oriented fracture and associated femoral shaft fracture

–     Elderly: low-energy injuries

•      Increasing incidence with the aging population.

•      More common in women and Caucasians.

•      E lderly patients should proceed to the OR as soon as medically ready to allow early mobilization.

•      Associated injuries

–     5–10 % of femoral shaft fractures have an associated femoral neck fracture.

–     ~30 % of femoral neck fractures associated with femoral shaft fractures are missed upon initial presentation.

•      Healing potential

–  Intracapsular fractures bathed in synovial fl uid with no periosteum. –  Displaced femoral neck fractures will disrupt the blood supply.

•      Primary blood supply: lateral epiphyseal artery arising from the medial femoral circumfl ex artery.

–  Impact of intracapsular hematoma is debated.

 Imaging  

•      AP pelvis, AP and cross-table lateral of the hip, full-length femur fi lms

–     Obtain AP fi lms with the legs in internal rotation to adjust for femoral neck anteversion.

–     Assess orientation of trabecular lines and displacement.

•      Consider contralateral hip fi lms for arthroplasty templating.

•      Traction views may be helpful in some cases.

•      C T scan is helpful to further assess displacement and comminution in some cases.

•      MRI is the study of choice to evaluate for occult fracture.

 Classifi cation  

•      Garden classifi cation

–     Type I: incomplete, valgus impacted

–     Type II: complete, nondisplaced

–     Type III: complete, 50 % displaced

–     Type IV: complete, >50 % displaced

•      Pauwels classifi cation

–     Increasing vertical orientation increases shear forces across the fracture, which increases the risk of nonunion and fi xation failure.

–     Type I: <30° verticality

–     Type II: 30–50° verticality

–     Type III: >50° verticality

•      Stress fractures

–     T  ension side (superior neck): high risk for fracture completion; treat with surgical stabilization.

–     C  ompression side (inferior neck): lower risk for fracture completion, may treat with protected weight bearing.

 Treatment  

•      Nonoperative

–  Observation

•      May consider in valgus impacted fractures in older patients, nonambula-tors, and patients at excessively high surgical risk

–     Leadbetter maneuver for closed reduction of femoral neck fractures

•      Hip fl exion to 90°, adduction, traction.

•      Then internally rotate to 45° while maintaining traction.

•      T hen bring the leg into slight abduction and full extension while maintaining traction and internal rotation.

•      Typically proceed with surgical fi xation and formal open reduction if frac-ture is not adequately reduced.

•      Operative

–     Open reduction internal fi xation

•      Indications: young (<50) and physiologically young patients with nondis-placed and displaced fractures, older patients with nondisplaced fractures

–     Considered a surgical emergency in young patients.

–     Quality of reduction is the most important factor impacting outcome.

•      Posterior translation or angulation of the femoral head leads to increased reoperation rates.

•      Cannulated screws

–     S  tart point at or above the level of the lesser trochanter to avoid generating a stress riser that propagates into a subtrochanteric femur fracture.

–     M  inimize cortical passes when placing guide wires to minimize additional lateral stress risers.

–     3-screw inverted triangle along calcar; consider 4 screws for posterior comminution.

•      Sliding hip screw ± derotational screw

–     Sliding permits dynamic compression of the fracture with axial loading and can facilitate fracture healing.

–     S  liding/compression may result in shortening of the femoral neck and may make implants prominent and/or affect joint biomechanics.

–     Hip hemiarthroplasty

•      Advocated for displaced fractures in older debilitated patients, demented patients (unable to comply with hip precautions), patients with neuromuscular disorders.

•      Outcomes for cemented technique superior to uncemented.

•      P osterior approach has increased risk of dislocation, while approach has increased risk of abductor weakness.

–  Total hip arthroplasty

•      A dvocated for displaced fractures in older active patients, patients with preexisting hip arthropathy

•      Higher risk of dislocation

 Complications  

•      Avascular necrosis in 10–40 %

–     Increased risk with increased initial displacement, nonanatomic reduction, and increasing patient age.

–     Quality of reduction is more important than time to reduction.

–     Importance of decompressing intracapsular hematoma is controversial.

–     Treatment

•      Y oung symptomatic patients: core decompression (controversial), free vascularized fi bula graft, total hip arthroplasty, hip arthrodesis

•      Elderly symptomatic patients: prosthetic replacement

•      Nonunion in 10–30 %

–     Increased risk with displaced fractures, varus malreduction, and cannulated screw fi xation.

–     Tend to be more symptomatic than AVN and will require intervention.

–     Consider MRI to evaluate for concurrent AVN.

–     Treatment

•      Young patients: valgus intertrochanteric osteotomy (converts shear forces into compression forces across the fracture), free vascularized fi bula graft, total hip arthroplasty, hip arthrodesis

•      Elderly patients: prosthetic replacement

•      Dislocation

–     Higher risk of dislocation for THA vs hemiarthroplasty

–     ~10 % incidence for THA performed for femoral neck fracture

•  Mortality

–     1-year mortality 15–35 %.

–     P  re-injury cognitive function and mobility are the most important determinants of postoperative functional outcome and survival.

–     Increased mortality in patients to undergo surgical fi xation/replacement >48 h after injury.

 Bibliography

 1.  Dedrick DK, Mackenzie JR, Burney RE. Complications of femoral neck fracture in young adults. J Trauma. 1986;26(10):932–7.

2. G urusamy K, Parker MJ, Rowlands TK. The complications of displaced intracapsular fractures of the hip: the effect of screw positioning and angulation on fracture healing. J Bone Joint Surg Br. 2005;87(5):632–4.

3. H aidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fi fteen and fi fty years. J Bone Joint Surg Am. 2004;86:1711–6.

4.    Holt EM, Evans RA, Hindley CJ, Metcalfe JW. 1000 femoral neck fractures: the effect of pre-injury mobility and surgical experience on outcome. Injury. 1994; 25(2):91–5.

5.    Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fi xation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am. 2006;88(2):249–60.

6. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 746–7.

7. P eljovich AE, Patterson BM. Ipsilateral femoral neck and shaft fractures. J Am Acad Orthop Surg. 1998;6:106–13.

7     Intertrochanteric Hip Fractures  

 Take-Home Message

•      Fragility fractures in the elderly typically resulting from low-energy falls, sequelae of high-energy trauma in the young.

•      MRI is the study of choice to evaluate for occult fracture.

•      S tability related to size and location of lesser trochanteric fragment and integrity of the lateral femoral cortex.

•      Sliding hip screw indicated for fi xation of most intertrochanteric fractures; expectations include reverse obliquity fracture, subtrochanteric fractures, and fractures with disruption of the lateral femoral cortex.

•      Cephalomedullary nails indicated for fi xation of most intertrochanteric fractures; long nails should be used for reverse obliquity and subtrochanteric fractures.

•      Lowest risk of implant failure/cutout with tip-apex distance <25 mm.

•      S liding hip screws more likely to have excessive collapse and medialization which can alter hip mechanics.

•      Cephalomedullary nails associated with increased risk of peri-implant fracture, although less common with modern designs.

•      Mortality rates of 15–35 % at 1 year.

•      D elay to surgery >48 h associated with increased risk of mortality at 1 year.

•      ASA classifi cation predicts mortality.

 General  

•      Extracapsular hip fractures between the greater and lesser trochanters

•      Bimodal distribution

–  Elderly: low-energy falls, osteoporosis

•      More common in women

•      Increased risk with osteoporosis, history of prior hip fracture, and history of falls

•      Patients typically older than those sustaining femoral neck fractures

–  Young: high-energy trauma

 Imaging  

•      AP pelvis, AP hip, cross-table lateral of the hip, full-length femur fi lms.

•      Traction views may be helpful to further delineate fracture pattern in some cases.

•      Isolated fracture of the lesser trochanter should be considered pathologic until proven otherwise.

•      MRI is the study of choice to evaluate for occult fracture.

 Classifi cation  

•      Stability (once reduced)

–     Stable: resist medial compressive loads

–     Unstable: risk of varus collapse, medial shaft translation

•      Number of parts

–     Two-part fracture: typically stable, low risk of collapse.

–     Three-part fracture: intermediate stability determined by size and location of lesser trochanter fragment; large posteromedial fragments are less stable.

–     Four-part fracture: comminuted, unstable fractures at increased risk for short-ening, varus collapse, and nonunion.

 Treatment   

•      Nonoperative

–  Touchdown weight bearing for 6–8 weeks, early mobilization

•      N onambulatory patients, excessively high perioperative mortality risk, patients who desire comfort measures only.

•      High rates of pneumonia, thromboembolic disease, urinary tract  infections, and decubitus ulcers.

•      Surgical fi xation may be considered in nonambulatory patients for pain control and/or palliation.

•      Operative

–     Internal fi xation is indicated for nearly all intertrochanteric fractures.

–     G  oal of operative management is to restore neck-shaft alignment and translation.

–     Medial displacement osteotomy has no proven benefi t.

–     Sliding hip screw

•      Dynamic interfragmentary compression with axial loading

•      Goal for center-center screw position, tip-apex distance <25 mm associ-ated with lowest screw failure rate

–     Consider mild valgus overreduction for unstable fracture patterns.

–     R  isk of extension deformity when fi xing left hip fractures from torque forces on screw insertion.

• C ontraindicated in reverse obliquity fractures, subtrochanteric fractures, and fractures without an intact lateral femoral cortex.

–     Cephalomedullary nail

•      Resists excessive fracture collapse and medicalization as the IM nail reconstitutes the lateral buttress

•      Short nails indicated for standard obliquity fractures

•      Long nails indicated for standard obliquity fractures, reverse obliquity fractures, and subtrochanteric fractures

•      G oal for center-center position with tip-apex distance <25 mm for single lag screw or helical blade

•      I ncreased risk of peri-implant fracture and screw cutout compared to sliding hip screws

–     95 blade plate/proximal femoral locking plate

•      Indicated for reverse obliquity fractures, severely comminuted fractures, and nonunion repair.

–     Proximal femoral locking plates have an increased risk of nonunion when used for primary fracture repair.

–     Arthroplasty

•      May consider in severely comminuted fractures, preexisting hip arthropa-thy, salvage of failed surgical fi xation

•      Typically requires a calcar replacing prosthesis

•      Attempt fi xation of the greater trochanter to the shaft

 Complications  

•      Excessive collapse with limb shortening and medicalization

–     Reduces abductor moment arm, alters hip mechanics, and may result in func-tional defi cits

–     More collapse with sliding hip screws compared to cephalomedullary nails and with greater displacement of the lesser trochanter

•      Implant failure and cutout

–     Most common complication, typically within 3 months of surgical fi xation

–     Young: revision ORIF, corrective osteotomy

–     Elderly: arthroplasty

•      Peri-implant fracture

–     More common with cephalomedullary nail fi xation compared to sliding hip screws.

–     Implant design changes have decreased the risk of peri-implant fractures

•      T apered end of the nail, smaller distal interlock screws, reduced trochanteric bend

–     Anterior perforation of the distal femoral cortex with cephalomedullary nail

•      Radius of curvature mismatch between the femur and the implant

•      Nonunion in <2 %

–     Treat with revision ORIF ± bone grafting, arthroplasty ±.

–     Calcar replacing prosthesis or proximal femoral replacement

•      Malunion

–     Varus and rotational deformity

–     May consider corrective osteotomy if very symptomatic

•      Mortality

–     1-year mortality rate 20–30 %.

–     S  urgery within 48 h provided medically ready improves 1-year mortality outcomes.

–     ASA classifi cation predicts mortality.

 Bibliography

1. B arton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial. J Bone Joint Surg Am. 2010;92(4):792–8.

2. B aumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip- apex distance in predicting failure of fi xation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995;77(7):1058–64.

3. B olhofner BR, Russo PR, Carmen B. Results of intertrochanteric femur fractures treated with a 135-degree sliding screw with a two-hole side plate. J Orthop Trauma. 1999;13:5–8.

 4.  Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable peritrochanteric hip fractures. Clin Orthop Relat Res. 2004;425:82–6.

5 . M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 747–8.

 6.  Mohan R, Karthikeyan R, Sonanis SV. Dynamic hip screw: does side make a difference? Effects of clockwise torque on right and left DHS. Injury. 2000;31(9):697–9.

7. S adowski C, Lübbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a prospective, randomized study. J Bone Joint Surg Am. 2002;84-A(3):372–81.

8. Z uckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am. 1995;77(10):1551–6.

8     Subtrochanteric Femur Fractures  

 Take-Home Message

•      Proximal fragment pulled into abduction, fl exion, and external rotation by the gluteus medius and minimus, iliopsoas, and short external rotators, respectively.

•      Bisphosphonate-associated fractures may have preceding thigh pain and are characterized by beaking of the lateral femoral cortex, transverse fracture patterns, and a medial spike. Consider screening and even prophylactic fi xation of the contralateral side in bisphosphonate-associated fractures.

•      Varus and procurvatum (fl exion) is the most pattern of malreduction.

•      Piriformis entry nails better resist varus deformity compared to lateral entry nails.

•      Increased risk of nonunion in bisphosphonate-associated fractures and varus malreduction.

•      Nonunions often treated with conversion to fi xed-angle plate with compression.

 General   

•      Proximal femur fractures from the lesser trochanter to 5 cm distally

–     Proximal fragment deforming forces: gluteus medius and minimus → abduction, iliopsoas → fl exion, short external rotators →external rotation

–     Distal fragment deforming forces: adductors → adduction and shortening

•      Bimodal distribution

–     Young: high-energy trauma

–     Elderly: low-energy falls

•      May be associated with prolonged bisphosphonate use

–     “Fosamax fractures,” beaking of lateral femoral cortex, transverse fracture pattern, medial spike, history of preceding thigh pain

–     Screen for involvement of the contralateral side and consider prophylactic fi xation if there is concern for bisphosphonate-associated fractures

 Imaging  

•      AP pelvis, AP/lateral hip, AP/lateral femur fi lms

•      Dedicated fi lms of the contralateral side warranted if bisphosphonate-associated fracture is suspected

 Russell-Taylor Classifi cation  

•      Type IA: fracture below the lesser trochanter

•      Type IB: fracture involves the lesser trochanter, greater trochanter intact

•      Type IIA: greater trochanter involved, lesser trochanter intact

•      Type IIB: greater and lesser trochanters involved

 Treatment  

•      Nonoperative

–  Observation, comfort care

•      Nonambulatory patients who have exceedingly high risk of perioperative mortality

•      Operative

–     Surgical fi xation indicated in nearly all patients

–     Intramedullary nail

•      Load-sharing implant, stronger construct for unstable fractures.

•      Intramedullary fi xation has a lower reoperation rate at 1 year than fi xed- angle plate fi xation.

•      Stand proximal locking for fractures with intact lesser trochanter.

•      Reconstruction interlocking for fracture with involvement of the lesser trochanter.

•      Piriformis entry nails better resist varus malreduction; contraindicated in fractures involving the piriformis fossa.

•      Lateral nailing: easier reduction of fl exion deformity, facilitates obtaining start point – particularly for piriformis entry nails.

•      S upine nailing: may be indicated in spine-injured and polytrauma patients, easier to assess correction of external rotation deformity.

 Fixed-angle device with side plate

•      Weaker construct, increased risk of varus collapse.

•      Blade plate may function as a tension band construct, converting tensile forces on the lateral cortex to compressive forces on the medial cortex.

•      May consider in fractures with signifi cant proximal comminution,  preexisting femoral shaft deformity, or nonunion.

 Complications  

•      High rates of implant failure

•      Nonunion

–     Increased    risk         in            bisphosphonate-associated                fractures                and         varus malreduction

–     Often treated with conversion to fi xed-angle plate with compression

•      Malunion: varus and procurvatum (fl exion)

 Bibliography

1.    Bellabarba C, Ricci WM, Bolhofner BR. Results of indirect reduction and plat-ing of femoral shaft nonunions after intramedullary nailing. J Orthop Trauma. 2001;15(4):254–63.

2.    Kinast C, Bolhofner BR, Mast JW, Ganz R. Subtrochanteric fractures of the femur. Results of treatment with the 95 degrees condylar blade-plate. Clin Orthop Relat Res. 1989;238:122–30.

3. L undy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg. 2007;15(11):663–71 (Review).

4. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 748–9.

5.    Ricci WM, Bellabarba C, Lewis R. Angular malalignment after intramedullary nailing of femoral shaft fractures. J Orthop Trauma. 2001;15(2):90–5.

6.    Weil YA, Rivkin G, Safran O, Liebergall M, Foldes AJ. The outcome of surgi-cally treated femur fractures associated with long-term bisphosphonate use. J Trauma. 2011;71(1):186–90.

9     Femoral Shaft Fractures  

 Take-Home Message

•      Reamed intramedullary nails are the treatment of choice for nearly all fem-oral shaft fractures.

•      A nterior start point in piriformis entry nails increases hoop stresses and risk of iatrogenic fracture. Piriformis entry nail contraindicated in skeletally immature patients (increased risk of osteonecrosis) and in fractures that involves the piriformis fossa.

•      Maintain a high index of suspicion for associated femoral neck fracture – present in up to 10 % of femoral shaft fractures, often nondisplaced, vertical, and basicervical.

•      Prioritize fi xation of associated femoral neck fractures, when present. Fixation of combined femoral neck and shaft fractures with separate

devices recommended as fi xation with a single device increases the risk of malreduction of at least one of the fractures. •      P olytrauma patients, particular those with signifi cant head and chest injuries, may benefi t from damage control strategies with initial external fi xation and safe conversion to intramedullary nail up to 3 weeks later. •      C omminuted femur fractures are at increased risk for malrotation and leg length discrepancy – compare to the contralateral limb. •      Nonunions may be treated with exchange reamed nailing or conversion to plate fi xation ± bone grafting.

 General   

•      Mechanism

–  High-energy injuries in young patients are most common.

•      High incidence of associated injuries.

•      Ipsilateral femoral neck fracture in 5–10 % of femoral shaft fractures, increased incidence in comminuted midshaft fractures; up to 30 % of these are missed on presentation.

–  Prioritize treatment of neck fractures.

•      Often nondisplaced, vertical, and basicervical.

•      Decreased risk of malunion of concurrent ipsilateral femoral neck and shaft fractures when separate devices are used for fi xation.

•      F avored constructs include cannulated screw or sliding hip screw fi xation of the femoral neck fracture with retrograde nail of plate fi xation of the femoral shaft fracture.

•      Bilateral femur fractures have increased risk of complications.

•      C ritical to avoid hypotension in patients with closed head injuries to prevent second hit. May benefi t from delay to defi nitive fi xation.

–  Low-energy injuries in the elderly

•      Fall from standing

•      Early stabilization associated with: decreased pulmonary and thromboembolic complications, improved rehabilitation, decreased hospital costs

 Imaging  

•      AP and lateral femur

•      A P and lateral hip: assess for associated femoral neck fractures AP and lateral knee.

•      C T scan: frequently obtained in the work-up of polytrauma patients; assess carefully for occult femoral neck fracture.

 Winquist-Hansen Classifi cation   

•      Based on degree of comminution and cortical continuity

•      Type 0: no comminution

•      Type I: comminution <25 %

•      Type II: comminution 25–50 %, >50 % cortical contact

•      Type III: comminution >50 %, <50 % cortical contact

•      Type IV: segmental fracture with no contact between proximal and distal fragments

 Treatment  

•      Nonoperative

–  Splint or cast immobilization

•      Rarely indicated; consider in nonambulatory patients and patients with excessively high risk of perioperative mortality

•      Operative

–     External fi xation

•      Indicated as a damage control measure in polytrauma patients (particularly with head and/or pulmonary injuries), open fractures with severe soft tissue injury, fractures with associated vascular injury

•      May be safely converted to intramedullary fi xation without increased risk of infection or nonunion up to 3 weeks from the time of external fi xation

–     Plate fi xation

•      M ay elect to employ in specifi c circumstances (neck-shaft fractures, periprosthetic fractures)

•      I ncreased risk of infection, nonunion, and implant failure, delay to weight bearing

–     Intramedullary nailing

•      T reatment of choice for nearly all femoral shaft fractures is a reamed intramedullary nail.

•      Unreamed nails associated with increased time to union and increased risk of nonunion.

•      Piriformis entry nails contraindicated when fracture extends into the piri-formis fossa and in skeletally immature patients (increased risk of osteonecrosis).

–     Anterior start point increases hoop stresses and risks iatrogenic comminution.

•      In polytrauma patients, there is no specifi c relationship between pulmo-nary complications and timing of femur fracture fi xation.

–     The severity of injury, not the time of femur fracture fi xation, deter-mines pulmonary outcome.

–     Retrograde nailing

•      Indications: obesity, ipsilateral femoral neck fracture/knee arthrotomy/tibial shaft fracture, bilateral femur fractures

 Complications  

•      Infection

–     Rare, <1 % of closed fractures

–     Intramedullary reaming with exchange nail or removal of implants pending status of fracture healing

–     N  o increased risk of infection with immediate nailing of open fractures  following debridement

•      Nonunion

–     Rare, <2 % of closed fractures

–     Increased risk in smokers and heavy postoperative use of NSAIDS

–     Exchange reamed nailing, conversion to plate fi xation ± bone grafting

•      Malunion

–     Nailing technique associated with specifi c malunion risk

•      Supine: increased risk of internal rotation

•      Lateral: increased risk of external rotation

•      Traction/fracture table: increased risk of lengthening and internal rotation

•      No traction: increased risk of shortening in comminuted fractures

–     Increased risk of malreduction with

•      Retrograde nailing of proximal fractures

•      Antegrade nailing of distal fractures

–     Malrotation diffi cult to assess, particularly with comminuted fractures

•      Compare to contralateral side (when intact).

–     Leg length discrepancy more likely in comminuted fractures

•      Compare to contralateral side (when intact).

•      L engthening or shortening along the anatomical axis leads to mechanical axis deviation.

•      Delayed union

–     Exchange reamed nailing has higher success rate than dynamization.

•      Heterotopic ossifi cation

–     ~25 %, rarely of clinical signifi cance

–     Typically involves the abductors with reaming for antegrade nail insertion

•      Pudendal nerve palsy

–     Perineal post pressure

–     Prolonged traction

 Bibliography

1. B edi A, Karunakar MA, Caron T, Sanders RW, Haidukewych GJ. Accuracy of reduction of ipsilateral femoral neck and shaft fractures – an analysis of various internal fi xation strategies. J Orthop Trauma. 2009;23(4):249–53.

2. C anadian 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-A(11): 2093–6.

3. H ak DJ, Lee SS, Goulet JA. Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. J Orthop Trauma. 2000;14(3): 178–82.

4.    Jaarsma RL, van Kampen A. Rotational malalignment after fractures of the femur. J Bone Joint Surg Br. 2004;86(8):1100–4.

5.    Kobbe P, Micansky F, Lichte P, Sellei RM, Pfeifer R, Dombroski D, Lefering R, Pape HC, TraumaRegister DGU. Increased morbidity and mortality after bilateral femoral shaft fractures: myth or reality in the era of damage control? Injury. 2013;44(2):221–5.

 6 . M cKee MD, Schemitsch EH, Vincent LO, Sullivan I, Yoo D. The effect of a femoral fracture on concomitant closed head injury in patients with multiple injuries. J Trauma. 1997;42(6):1041–5.

7.       Miller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 749–51.

8.       Ostrum RF, Agarwal A, Lakatos R, Poka A. Prospective comparison of retro-grade and antegrade femoral intramedullary nailing. J Orthop Trauma. 2000; 14(7):496–501.

9.       Peljovich AE, Patterson BM. Ipsilateral femoral neck and shaft fractures. J Am Acad Orthop Surg. 1998;6(2):106–13.

10.   Stephen DJ, Kreder HJ, Schemitsch EH, Conlan LB, Wild L, McKee MD. Femoral intramedullary nailing: comparison of fracture-table and manual traction. a prospective, randomized study. J Bone Joint Surg Am. 2002; 84-A(9):1514–21.

10     Distal Femur Fractures  

 Take-Home Message

•      Obtain CT scan if concerned for intercondylar extension or to further char-acterize fracture with obvious intercondylar extension.

•      Coronal plane fractures (Hoffa fractures) present in 40–30 % of intercon-dylar fractures; 80 % of these involved the lateral condyle.

•      Most distal femur fractures are stabilized with fi xed-angle plates. Retrograde intramedullary nails may be used for extra-articular fractures and simple intra- articular fractures.

•      Slight compression and shortening through the metaphysis and/or metadi-aphysis may help decrease the risk of nonunion in osteoporotic bone.

•      P rominent medial screws are poorly tolerated. As the distal femur narrows posteriorly, obtain a 30° internal rotation view to ensure proper screw length.

 General  

•      F emur fracture from 5 cm above the distal metaphyseal fl are to the distal articular surface

•      Bimodal distribution

–     Young: high-energy injury, typically more displaced

–     Elderly: low-energy injury, typically less displaced

•      Increased risk for vascular injury with increased fracture displacement

–     L  ow threshold to initiate further vascular work-up with asymmetric pulses, abnormal ABIs, or other fi ndings concerning for vascular injury

 Imaging  

•      AP and lateral femur x-rays.

•      AP and lateral knee x-rays.

•      Traction views may be helpful to further delineate fracture pattern in some cases.

•      CT scan: concern for intra-articular extension, further characterize fractures with obvious intra-articular extension for operative planning.

–  Hoffa fragment: coronal plane fracture present in 30–40 % of distal femur fractures with an intercondylar split.

•      80 % of these involve the lateral condyle.

– I  mportant to recognize Hoffa fragments for effective preoperative planning – will not be effectively captured by commonly used lateral to medial directed screws.

 Classifi cation  

•      Supracondylar: no intercondylar extension

•      I ntercondylar: associated intercondylar split, possible associated coronal plane fracture (Hoffa fragment)

 Treatment  

•      Nonoperative

–     Non-weight bearing, early knee range of motion with hinged knee brace.

–     C  onsider in nondisplaced fractures, nonambulatory patients, and patients with excessively high perioperative mortality risk.

•      Operative

–     Principles of surgical fi xation

•      Indicated in displaced fractures

•      Anatomic reduction of articular surface (when involved), restoration of length, alignment, and rotation

–  Varus malalignment poorly tolerated

•      Initiate early knee range of motion

–     Non-fi xed-angle plates

•      Historically considered in severely comminuted fractures

•      Increased risk of varus malalignment

•      Largely replaced by fi xed-angle constructs

–     Fixed-angle plates

•      O ptions include blade plates, dynamic condylar screw plates, and a  multitude of locked plates.

•      Options for direct open reduction and indirect reduction with MIPO technique

–     Indirect reduction: high union rate >80 %

–     I  ncreased risk of nonunion with locking condylar plates compared to blade plates

•  Frequently combined with lag screws and positional screws for intercondylar fractures and coronal plane fractures.

–     Retrograde intramedullary nail

•      C onsider in supracondylar fractures without signifi cant comminution, fractures without intra-articular involvement, or fractures with a simple articular split and in obese patients.

•      Good option for osteoporotic bone and many periprosthetic fractures (pro-vided suffi ciently large intercondylar box).

•      Blocking screws may help facilitate reduction and improve stability.

•      May allow for early weight bearing.

–     Arthroplasty

•      Typically requires distal femoral replacement.

•      May consider if reconstruction and stable fi xation is not possible.

•      I n setting of preexisting knee arthropathy, typically proceed with ORIF to constitute bone stock and consider arthroplasty at a later date.

 Complications  

•      Nonunion

–     Treat with revision ORIF ± bone grafting.

–     Slight shortening/compression through the metaphysis and metadiaphysis may be desired at the time of initial fi xation in osteoporotic bone to help decrease the risk of nonunion.

•      Malunion

–     May be symptomatic with >5° of malalignment in any plane.

–     Plate fi xation prone to valgus malalignment.

–     Increased overall risk of malalignment with intramedullary nails.

–     Effects of malunion may be particularly deleterious in patients with peripros-thetic fractures.

•      Failure of fi xation

–     Varus collapse most common, increased risk with non-fi xed-angle plates

•      Symptomatic hardware

–     Lateral plate

•      I rritation from motion of the IT band over the plate with knee range of motion

–  Medial screw prominence

•      Long screws that protrude through the medial cortex are poorly tolerated.

•      As the distal femur narrows posteriorly, screw length should be assessed on a 30° internal rotation view intraoperatively.

•      Arthrofi brosis

•      Knee pain

 Bibliography

 1.  Gwathmey FW Jr, Jones-Quaidoo SM, Kahler D, Hurwitz S, Cui Q. Distal femoral fractures: current concepts. J Am Acad Orthop Surg. 2010;18(10):597–607 (Review).

2 . M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia:

Elsevier; 2012. p. 751–3.

 3.  Nork SE, Segina DN, Afl atoon K, Barei DP, Henley MB, Holt S, Benirschke SK. The association between supracondylar-intercondylar distal femoral fractures and coronal plane fractures. J Bone Joint Surg Am. 2005;87:564–9.

4 . V allier HA, Immler W. Comparison of the 95-degree angled blade plate and the locking condylar plate for the treatment of distal femoral fractures. J Orthop Trauma. 2012;26(6):327–32.

11     Knee Dislocations  

 Take-Home Message

•      Orthopedic emergency that requires urgent reduction.

•      Importance of exam to identify occult injury.

•      High rates of associated neurovascular injury.

•      Physical exam with ABIs and selective arteriography is the standard of care.

•      I f ABI is <0.9 or exam is abnormal but limb is perfused, initiate further vascular injury work-up with arterial duplex ultrasound or CT angiography.

•      Serial exam critical to assess for changes in the neurovascular status of the limb and compartment syndrome.

•      Early reconstruction/repair when possible.

 General  

•      Rare, potentially limb-threatening injuries.

•      Estimated 20–50 % of knee dislocations spontaneously reduce in the fi eld.

–     True incidence is likely underreported.

•      I njury to 3 or more ligaments should be considered a knee dislocation equivalent.

•      High overall incidence of associated injury.

•      Low energy: fall, sports injuries, obesity

–     Lower incidence of associated soft tissue, cartilage, and neurovascular injury

•      High energy: vehicular trauma, fall from height

–     More severe soft tissue injury, increased incidence of neurovascular injury.

–     ~25 % will have associated severe head, chest, and abdominal trauma

•      Increased risk of delayed diagnosis and management in the polytrauma patients.

 Vascular Injury  

•      ~20 % risk of vascular injury across all knee dislocations.

•      40–50 % risk of vascular injury in anterior/posterior dislocations.

–     Anterior dislocation: traction/bowstringing of the popliteal artery, more likely to result in an intimal tear

–     Posterior dislocation: more likely to result in complete arterial tears/disruptions

•      Assess distal pulses, capillary refi ll, popliteal fossa, and ankle-brachial index

–     Collateral circulation may maintain distal pulses and capillary refi ll initially but cannot sustain limb viability.

•      Hard signs of vascular injury: absent pulses, bleeding, expanding hematoma, bruit, thrill.

•      Soft signs of vascular injury: diminished pulses, delayed capillary refi ll.

•      Physical exam with ABI and selective arteriography is the standard of care.

–     If ABI >0.9 and exam is normal, monitor with serial exam.

•      A rteriogram does not have an advantage over serial exam in patients with normal exam and ABIs upon presentation.

•      I f the vascular status of the limb changes on serial exam, then pursue further work-up.

–     If ABI is <0.9 or exam is abnormal but the limb is perfused, pursue further work-up with arterial duplex ultrasound or CT angiography with vascular surgery consultation if vascular injury is confi rmed.

•      When hard signs of vascular injury are present, the patient should proceed directly to the OR.

•      Revascularize within 6–8 h to minimize the risk of amputation.

•      Ischemia time of >3 h increased the risk of reperfusion injury.

–     Perform prophylactic fasciotomies after vascular repair.

•  Late presentation of vascular injury is possible.

–     Intimal tears and partial arterial injuries may develop late thrombosis with complete arterial occlusion and limb ischemia hours or even days after injury.

–     Popliteal artery aneurysm may also develop in a delayed fashion. –  Highlights the importance of serial exam.

 Nerve Injury  

•  10–40 % peroneal nerve injury

–     Increased risk with lateral and posterolateral dislocations

–     Neuropraxia common, transection rare

–     Tibial nerve injured less frequently

 Serial Exam   

•      Critical for assess changes in vascular and neurologic status of the limb.

•      Serial compartment checks are warranted.

–  Compartment syndrome may occur in the absence of vascular injury.

 Imaging   

•      A P and lateral knee x-rays: assess for asymmetric or irregular joint space, avul-sion fractures, and osteochondral defects.

–  X-rays may be normal in multiligamentous injury. –  Physical exam is paramount.

•      MRI obtained after acute treatment to assess soft tissue injury and for surgical planning.

 Classifi cation  

•      Directional classifi cation (Kennedy)

–     Describes the position of the tibia relative to the femur, suggestive of ligament involvement

–     A  nterior (30–50 %): knee hyperextension >30°, associated PCL and possible ACL tear, increasing incidence of popliteal artery injury with increased hyperextension

–     P  osterior (25 %): posterior force against the proximal tibia of a fl exed knee, “dashboard injury,” associated with ACL and PCL disruption, increased risk

of popliteal artery injury with increased tibial displacement

–     Lateral (13 %): vagus force, medial supporting structures disrupted, both the cruciate ligaments often involved

–     Medial (3 %): varus force, lateral and posterolateral structures disrupted

–     Rotational (4 %): varus/valgus force with rotatory component, may see but-tonholing of the femoral condyle through the articular capsule

•      Anatomic knee dislocation classifi cation (Schenck)

–     KDI: one cruciate plus one or both collaterals

–     KDII: ACL and PCL, collaterals intact (rare)

–     KDIIIM: ACL, PCL, and MCL (most common)

–     KDIIIL: ACL, PCL, and LCL, often PLC (higher incidence of peroneal nerve injury)

–     KDIV: ACL, PCL, MCL, and LCL, often PLC (less common, high-energy mechanism, higher incidence of vascular injury)

–     KDV: fracture-dislocation

–     C (added to above): associated arterial injury

–     N (added to above): associated nerve injury

 Treatment  

•      Initial treatment

–     Considered an orthopedic emergency.

–     Treat with emergent reduction and neurovascular examination.

•      I f the limb is grossly deformed upon presentation, do not delay reduction to obtain radiographs.

•      “Dimple sign” – buttonholing of medial femoral condyle through the medial capsule

–  May represent an irreducible posterolateral dislocation

•      Nonoperative

–     H  istorically treatment with closed reduction and immobilization which frequently resulted in late instability.

–     W  ith advanced instrumentation and techniques, these injuries are now typically managed surgically.

•      Operative

–  Emergent surgical intervention

•      Vascular injury repair

•      Open fracture and dislocations

•      Irreducible dislocations

•      Compartment syndrome

–     Delayed reconstruction

•      Paucity of high-level evidence on which to base treatment decisions

•      Controversies regarding early versus delayed surgical treatment, use of joint spanning external fi xation, and simultaneous versus staged reconstruction of cruciates and/or PLC and PMC

–     Outcomes may be improved with early treatment (within 3–4 weeks), provided the condition of the patient and the limb allows.

•  Improved outcomes in patients <40 years old, low-energy mechanism of injury, and functional rehabilitation (vs immobilization)

– S  urgical repair/reconstruction of the cruciate ligaments needed to achieve suffi cient stability for functional rehabilitation

 Complications   

•      Vascular injury

–     Claudication, skin changes, and muscle atrophy may develop as sequelae of vascular injury.

–     Popliteal artery aneurysm may develop as a late sequelae of popliteal vessel injury

•      M ay present with swelling in the popliteal fossa and knee fl exion deformity to accommodate the mass

•      Nerve injury

–     The peroneal nerve is most commonly injured in knee dislocations.

•      Increased incidence with posterolateral dislocation.

•      Poor prognosis with ~50 % partial to full recovery.

•      Outcomes not improved with acute, subacute, or delayed nerve explorations.

•      N eurolysis, tendon transfers, and bracing comprise the primary treatment options.

•      Arthrofi brosis

–     Stiffness is the most common complication (38 %). –  Increased incidence with delayed mobilization.

•  Instability and laxity

–     Occurs in 37 % of patients.

–     Redislocation is uncommon.

 Bibliography

 1.  Harner CD, Waltrip RL, Bennett CH, Francis K, Cole B, Irrgang J. Surgical management of knee dislocations. JBJS . 2004;86-A(2):262–73.

2. L evy BA, Fanelli GC, Whelan DB, Stannard JP, MacDonald PA, Boyd JL, Marx RG, Stuart MJ. Knee Dislocation Study Group. Controversies in the treatment of knee dislocations and multiligament reconstruction. J Am Acad Orthop Surg. 2009;17(4):197–206 (Review).

3. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 753.

4.    Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diag-nosing arterial injury after knee dislocation: a prospective study. J Trauma. 2004;56:1261–65.

5.    Stannard JP, Sheils TM, Lopez-Ben RR, McGwin G Jr, Robinson JT, Volgas DA. Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography. J Bone Joint Surg Am. 2004;86-A(5): 910–5.

6 . W ascher DC. High-velocity knee dislocation with vascular injury. Treatment principles. Clin Sports Med. 2000;19(3):457–77.

12     Patella Fractures  

 Take-Home Message

•      Inability to actively extend the knee indicates a clinically signifi cant exten-sor mechanism injury.

•      Fracture displacement correlates with retinacular disruption.

•      N onoperative management of nondisplaced and minimally displaced fractures with intact extensor mechanism.

•      Operative fi xation of displaced fractures commonly performed with ten-sion band fi xation ± cerclage ± ORIF of comminuted segments.

•      Partial patellectomy may be used when reconstructing distal pole fractures and severely comminuted fractures.

•      Preserve the patella whenever possible – complete patellectomy is contraindicated.

 General   

•      Common fractures most common in patients 20–50 years of age.

•      Mechanism of injury

–     Direct blow

–     Eccentric contraction

•      Inability to actively extend the knee indicates a clinically signifi cant extensor mechanism injury.

•      The patella has the thickest articular cartilage in the body.

 Imaging   

•  AP and lateral knee x-rays: fracture displacement best evaluated on the lateral

–  Displacement correlates with retinacular disruption.

 Descriptive Classifi cation  

•      Transverse

•      Vertical

•      Comminuted (stellate)

•      Proximal pole

•      Distal pole

•      Osteochondral

 Treatment  

•      Nonoperative

–     W  eight bearing as tolerated in a knee immobilizer or hinged knee brace locked in extension for 6 weeks

–     Indicated in nondisplaced and minimally displaced fractures with intact extensor mechanism

•      Operative

–     Tension band fi xation

•      Indicated with simple fracture patterns

•      Converts tensile forces into compressive forces

•      May use k-wires or cannulated screws, wire, or braided nonabsorbable suture

–     Open reduction internal fi xation, cerclage, and tension band fi xation

•      Comminuted stellate fractures with varying degrees of displacement

•      May use minifrag or fi ne k-wire fi xation of independent fragments

–     Partial patellectomy

•      Preserve patella whenever possible.

•      C onsider partial patellectomy in extra-articular distal pole fractures and several comminuted fractures.

•      Preserve the largest fragments for reconstruction of the extensor mechanism.

•      Complete patellectomy is contraindicated.

–     Reduces quadriceps torque by 50 %.

 Complications   

•      Symptomatic hardware

•      Failure of fi xation (up to 20 %)

–     Technical error

–     Patient noncompliance

•      Nonunion <5 %

•      Arthrofi brosis

•      Infection

•      Osteonecrosis of the proximal fragment

–     Observe; most spontaneously revascularize.

 Bibliography

1. E ggink KM, Jaarsma RL. Mid-term (2–8 years) follow-up of open reduction and internal fi xation of patella fractures: does the surgical technique infl uence the outcome? Arch Orthop Trauma Surg. 2011;131(3):399–404. Epub 2010 Dec 15.

2. K astelec M, Veselko M. Inferior patellar pole avulsion fractures: osteosynthesis compared with pole resection. J Bone Joint Surg Am. 2004;86-A(4): 696–701.

3. M elvin JS, Mehta S. Patellar fractures in adults. J Am Acad Orthop Surg. 2011;19(4):198–207 (Review).

4. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia:

Elsevier; 2012. p. 753–5.

13     Quadriceps Tendon Rupture  

 Take-Home Message

•      Typically occurs in patients >40 years of age, more common in males, more common in the nondominant limb.

•      I ncreased risk with chronic renal disease, diabetes, rheumatoid arthritis, gout, hyperparathyroidism, connective tissue disorders, steroid use, and fl uoroquinolones.

•      P atients with bilateral ruptures must be worked up for underlying medical disorder and should receive DVT prophylaxis.

•      Assess for patella baja on lateral knee x-ray with 30° of fl exion: Insall-Salvati ratio <0.8, inferior pole of patella below Blumensaat’s line.

•      T endon rupture occurs most commonly ~2 cm proximal to the superior pole of the patella.

•      Treat partial tears with intact extensor mechanism with immobilization and progressive weight bearing; counsel on increased future risk of complete rupture.

•      Complete tears with disruption of the extensor mechanism should undergo early primary repair.

•      Tendon reconstruction may be required for severely degenerated quadri-ceps tendon, failed prior repairs, and chronic injuries. Complicated by contracture of the quadriceps and may require tendon lengthening and/or allograft.

•      Weakness and knee stiffness are common complications.

 General  

•      Typically occur in adults >40 years old, often with medical comorbidities, males > > females, nondominant limb > dominant limb.

•      Quadriceps tendon rupture is more common than patella tendon rupture.

•      Increased risk with chronic renal disease, diabetes, rheumatoid arthritis, hyper-parathyroidism, connective tissue disorders, steroid use – oral and corticosteroid injection – gout, and fl uoroquinolones.

•      Bilateral ruptures: assess for underlying medical problem, treatment follows guidelines for unilateral injuries but will require period of non-weight bearing and DVT prophylaxis.

•      Mechanism: eccentric loading often with the foot planted and knee slightly bent, direct trauma.

•      On exam, unable to perform straight leg raise or maintain knee extension, pal-pable gap at superior pole of the patella.

 Imaging  

•      A P and lateral x-rays: patella baja (complete rupture), Insall-Salvati ratio <0.8, inferior pole of the patella below Blumensaat’s line

–  Insall-Salvati ratio: ratio of patella tendon length over length of the patella

(TL/PL)

•      Calculate from lateral knee x-ray with 30° of knee fl exion

– B  lumensaat’s line: corresponds to roof of the intercondylar notch of the distal femur on a lateral knee x-ray, should intersect the inferior pole of the patella

•      Ultrasound: not reliable to establish diagnosis in equivocal cases, particular in obese and very muscular patients

•      MRI: adjunct to delineate partial and complete injuries in equivocal cases

 Classifi cation   

•      Partial rupture.

•      Complete rupture.

•      T endon rupture occurs most commonly ~2 cm proximal to the superior pole of the patella (relative watershed area).

 Treatment  

•      Nonoperative

–  Immobilization with progressive weight bearing

•      Partial tear with intact knee extensor mechanism, risk of future complete rupture

•      Operative

–     Primary repair

•      Complete quadriceps tendon ruptures that can be reapproximated.

•      T ransosseous tendon repair: nonabsorbable suture through drill hole construct.

•      End-to-end repair.

•      Suture anchor tendon repair (advocated by some).

•      Repair retinaculum; knee should fl ex to 90° after repair.

•      Rehabilitation: promote motion while protecting repair

–     Prone knee fl exion with passive extension

–     Heel slides with active fl exion and passive extension

–     Tendon reconstruction

•      S everely degenerated quadriceps tendon, failure of prior repair, delayed presentation/chronic injuries

•      V-Y lengthening (Codivilla procedure)

•      Quadriceps tendon lengthening

•      Quadriceps turndown

•      Allograft reconstruction

 Complications  

•      Weakness: 30–50 %

•      Extensor lag

•      Stiffness

•      Inability to return to pre-injury level of activity: 50 % of patients

•      Worse outcomes with delayed reconstruction

–     Q  uadriceps can retract 5 cm in as little as 2 weeks, requiring mobilization and/or quadriceps tendon lengthening to facilitate reconstruction.

–     Increased risk of failure of reconstruction.

 Bibliography

1 . C iriello V, Gudipati S, Tosounidis T, Soucacos PN, Giannoudis PV. Clinical outcomes after repair of quadriceps tendon rupture: a systematic review. Injury. 2012;43(11):1931–8.

 2.  Hak DJ, Sanchez A, Trobisch P. Quadriceps tendon injuries. Orthopedics. 2010;33(1):40–6.

3. M iller MD, Thompson SR, Hart JA. Review of orthopaedics. 6th ed. Philadelphia: Elsevier; 2012. p. 755–6.

4. P ocock CA, Trikha SP, Bell JS. Delayed reconstruction of a quadriceps tendon.

Clin Orthop Relat Res. 2008;446(1):221–4.

14     Patellar Tendon Rupture  

 Take-Home Message

•      Injury typically occurs in the 3rd and 4th decade of life, more common in males.

•      Risk factors include patellar tendinitis, diabetes, rheumatologic disease, renal disease, corticosteroid injections, and fl uoroquinolones.

•      May occur as an avulsion from the inferior pole of the patella (most com-mon), midsubstance tear, or tibial tubercle avulsion (rare).

•      Assess for patella alta on lateral knee x-ray with 30° of fl exion: Insall-Salvati ratio >1.2, inferior pole of patella above Blumensaat’s line.

•      Treat partial tears with intact extensor mechanism with initial immobiliza-tion followed by progressive weight bearing and range of motion.

•      C omplete tears may undergo primary repair via transosseous tunnels, suture anchors, or end-to-end repair.

•      T endon reconstruction with autograft (local hamstring) or allograft if insuffi cient tendon for primary repair, failed prior repair, and delayed presentation.

•      R ehabilitate with prone knee fl exion and heel slides to promote knee range of motion while not stressing the repair.

•      Knee stiffness and extensor lag are the most common complications.

 General   

•      Typically occur in active adults <40 years old, male > female

•      Increased risk with patellar tendinitis, diabetes, rheumatologic disease, chronic renal disease, corticosteroid injection, infection, and fl uoroquinolones

•      M echanism: tensile overload of extensor mechanism, frequently with eccentric contraction, often the result of chronic tendon degeneration

•      Avulsion from the distal pole of the patella more common than midsubstance tendon tears

•      On exam, unable to perform straight leg raise or maintain knee extension, pal-pable gap at inferior pole of patella

 Imaging   

•      A P and lateral knee x-rays: patella alta (complete rupture), Insall-Salvati ratio

>1.2, inferior pole of patella above Blumensaat’s line

– I  nsall-Salvati ratio: ratio of patella tendon length over length of the patella (TL/PL)

•      Calculate from lateral knee x-ray with 30° of knee fl exion.

–  Blumensaat’s line: corresponds to roof of the intercondylar notch of the distal femur on a lateral knee x-ray, should intersect the inferior pole of the patella

•      Ultrasound: may be useful to further evaluate equivocal presentations and chronic injuries

•      MRI: adjunct to delineate partial and complete injuries in equivocal cases  Classifi cation  

•      Inferior pole of patella avulsion (most common)

•      Midsubstance tear

•      Tibial tubercle avulsion (rare)

 Treatment  

•      Nonoperative

–  Immobilization in extension with progressive weight bearing

•      Partial tears, intact extensor mechanism