Textbook Reading

TEXTBOOK READING
TRAUMA
RECI MARDATILLAH, 702013048
PRECEPTOR: DR. RIZAL DAULAY, SPOT.MARS
SECTION 1
CARE OF THE MULTIPLY

INJURED PATIENT
• PRINCIPLES OF TRAUMA CARE
• PRIMARY ASSESSMENT—BEGINS WITH THE PRIMARY SURVEY, WHICH SEEKS TO IDENTIFY

ANY LIFE-THREATENING INJURIES. A RAPID ASSESSMENT OF AIRWAY, BREATHING, AND
CIRCULATION (THE ABCS) IS PERFORMED.
•
NTHE AIRWAY IS OFTEN MANAGED BY INTUBATION, ESPECIALLY IN PATIENTS
EXPERIENCING A GREAT DEAL OF PAIN OR OBTUNDATION. THE INITIAL SURVEY SHOULD
INCLUDE PLACEMENT OF INTRAVENOUS LINES AND TREATMENT OF ANY LIFE-
THREATENING INJURIES THAT ARE ENCOUNTERED.
• FLUID RESUSCITATION
• AGGRESSIVE FLUID RESUSCITATION SHOULD BEGIN IMMEDIATELY IN MOST CASES WITH

THE PLACEMENT OF TWO LARGE-BORE INTRAVENOUS CANNULAS.
• TWO LITERS OF LACTATED RINGER SOLUTION OR NORMAL SALINE SHOULD BE
ADMINISTERED.
•
• IF THE PATIENT REMAINS HEMODYNAMICALLY UNSTABLE AFTER INITIAL CRYSTALLOID
INFUSION, BEGIN INFUSION OF BLOOD PRODUCTS.
• • TYPICALLY REQUIRES GREATER THAN 30% BLOOD LOSS
• N BLOOD PRODUCTS
• • UNIVERSAL DONOR
• • GROUP O NEGATIVE
• • USED IN SEVERE SHOCK WHEN SPECIFIC BLOOD PRODUCTS ARE NOT YET AVAILABLE
• • TYPE-SPECIFIC BLOOD
• • CROSSMATCHED FOR ABO AND RH TYPE
• • TYPICALLY AVAILABLE WITHIN 10 MINUTES

• FULLY TYPED AND CROSSMATCHED
• • MINOR ANTIBODIES ARE CROSSMATCHED.
• • TYPICALLY AVAILABLE WITHIN 60 MINUTES
• • FRESH FROZEN PLASMA
• • CONTAINS COAGULATION FACTOR PROTEINS, IMMUNOGLOBULINS, AND COMPLEMENT
• • PLATELETS
• • TYPICALLY PREPARED FROM WHOLE BLOOD AND SHOULD BE STORED AT 20° TO 24°C
WITH CONTINUOUS GENTLE AGITATION
• • PLATELETS STORED IN THE COLD BECOME ACTIVATED AND LOSE THEIR NORMAL DISCOID
SHAPE.
• TRANSFUSION
• • IF A PATIENT DOES NOT RESPOND TO 2 L OF CRYSTALLOID, 2 UNITS OF PACKED RED
BLOOD CELLS SHOULD BE ADMINISTERED.
• • PATIENTS BECOME COAGULOPATHIC AND THUS REQUIRE BOTH FRESH FROZEN
PLASMA AND PLATELETS.
• • THE AMOUNT ADMINISTERED IS CONTROVERSIAL.
• • RECENT LITERATURE SUPPORTS ADMINISTRATION OF PACKED RED BLOOD
CELLS, FRESH FROZEN PLASMA, AND PLATELETS IN A 1 : 1 : 1 RATIO.
• • MAY PREVENT EARLY COAGULOPATHY
• • THE MOST COMMON COMPLICATION OF MASSIVE TRANSFUSION IS A DILUTIONAL

THROMBOCYTOPENIA, FOLLOWED BY HYPOTHERMIA AND METABOLIC ALKALOSIS.
• • INCREASED CITRATE FROM PACKED RED BLOOD CELLS BINDS CALCIUM DIRECTLY
AND CAN CAUSE HYPOCALCEMIA.
• HEMODYNAMIC INSTABILITY MAY RESULT FROM INTERNAL INJURY OR FRACTURES AND IS THE MOST
IMPORTANT CONSIDERATION FOR THE ORTHOPAEDIC SURGEON.
• • ONCE THE AIRWAY AND BREATHING ARE CONTROLLED, PROBLEMS WITH CIRCULATION REMAIN THE
BIGGEST THREAT TO LIFE.
• • RAPID APPLICATION OF SPLINTS AND REDUCTION OF FRACTURES WHEN POSSIBLE CAN DECREASE
BLEEDING AND RELIEVE PAIN.
• N THE END POINTS OF ADEQUATE RESUSCITATION ARE NOT CLEAR; USE OF HEMODYNAMIC
PARAMETERS IS INADEQUATE.
• • BASE DEFICIT, AS MEASURED BY LACTATE LEVEL, IS A PROXY FOR THE AMOUNT OF ANAEROBIC
METABOLISM BY THE BODY AND IS THE BEST MEASURE OF PATIENT’S RESUSCITATION.
• • LACTATE LEVELS AND BASE DEFICIT ARE FREQUENTLY USED IN TRAUMA TO GUIDE THE ADEQUACY
OF RESUSCITATION.
• • IN GENERAL, LACTATE LEVELS LESS THAN 2.5 INDICATE ADEQUATE RESUSCITATION.
• SHOCK
• • HEMORRHAGIC (TABLE 11-1)

• • DIVIDED INTO FOUR CLASSES
• • CLASS III/IV REQUIRES ADMINISTRATION OF BLOOD PRODUCTS.
• • PRESENTS AS:
• • INCREASED HEART RATE AND INCREASED SYSTEMIC VASCULAR RESISTANCE
• • DECREASED CARDIAC OUTPUT, DECREASED PULMONARY CAPILLARY WEDGE PRESSURE,
DECREASED CENTRAL VENOUS PRESSURE, AND DECREASED MIXED VENOUS OXYGEN
SATURATION
• • TREAT WITH FLUIDS AND BLOOD PRODUCTS.
• NEUROGENIC
• • DUE TO A LOSS OF SYMPATHETIC TONE IN SETTING OF A SPINAL CORD INJURY
• • PRESENTS AS LOW HEART RATE, LOW BLOOD PRESSURE, AND WARM SKIN
• • TREAT WITH DOBUTAMINE AND DOPAMINE.
• • SEPTIC
• • TYPICALLY A HYPERDYNAMIC STATE WITH A MASSIVE LOSS OF SYSTEMIC VASCULAR
RESISTANCE
• • CARDIAC INDEX IS INCREASED AND CENTRAL VENOUS PRESSURE IS DECREASED.
• • TREAT WITH ANTIBIOTICS AND NOREPINEPHRINE (CAUSES VASOCONSTRICTION WITHOUT
INCREASING CARDIAC OUTPUT).
• • HEMODYNAMIC
• • TENSION PNEUMOTHORAX; PERICARDIAL TAMPONADE PREVENTS DIASTOLIC FILLING.
• • PULMONARY EMBOLISM
• • ADRENAL INSUFFICIENCY
• • CARDIOVASCULAR COLLAPSE UNRESPONSIVE TO FLUIDS OR PRESSORS

• THE SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS) IS A GENERALIZED
RESPONSE TO TRAUMA CHARACTERIZED BY AN INCREASE IN CYTOKINES, COMPLEMENT,
AND MANY HORMONES. THESE CHANGES ARE SEEN IN VARYING DEGREES AFTER
TRAUMA, AND THERE IS PROBABLY A GENETIC PREDISPOSITION TO AN INTENSE FORM OF
THESE CHANGES. PATIENTS ARE CONSIDERED TO HAVE SIRS IF THEY HAVE TWO OR MORE
OF THE FOLLOWING CRITERIA:
• • HEART RATE GREATER THAN 90 BEATS PER MINUTE
• • WHITE BLOOD CELL COUNT (WBC) LESS THAN 4/MM3 OR GREATER THAN 10/MM3
• • RESPIRATION GREATER THAN 20 BREATHS PER MINUTE, WITH PACO2 LESS THAN 32 MM
• • TEMPERATURE LESS THAN 36°C OR GREATER THAN 38°C
• N SIRS IS ASSOCIATED WITH DISSEMINATED INTRAVASCULAR COAGULOPATHY, ACUTE
RESPIRATORY DISTRESS SYNDROME (ARDS), RENAL FAILURE, SHOCK, AND MULTISYSTEM
ORGAN FAILURE.
• N TRANEXAMIC ACID IS A SYNTHETIC ANALOGUE OF LYSINE THAT CAN BE USED TO
PREVENT EXCESSIVE BLEEDING. IT’S MECHANISM OF ACTION IS COMPETITIVE
• RADIOLOGIC WORKUP
• A RAPID RADIOLOGIC WORKUP THAT INCLUDES AT A MINIMUM ANTEROPOSTERIOR (AP)
CHEST, AP PELVIS, AND LATERAL CERVICAL SPINE VIEWS IS STANDARD.
• AVAILABILITY AND INCREASED PROCESSING SPEED OF COMPUTED TOMOGRAPHIC (CT)
SCANNERS IS LEADING TO CT OF CERVICAL SPINE REPLACING LATERAL CERVICAL SPINE
RADIOGRAPHY FOR TRAUMA EVALUATION.
• CARE SHOULD BE TAKEN NOT TO FOCUS ON OBVIOUS RADIOGRAPHIC FINDINGS (E.G.,
OPEN-BOOK PELVIC INJURY) AND MISS OTHER IMPORTANT FINDINGS SUCH AS A WIDENED
MEDIASTINUM.
• PELVIC FRACTURES CAN BE LIFE THREATENING. THE ORTHOPAEDIC SURGEON MAY BE
CALLED ON TO STABILIZE PELVIC FRACTURES IN THE EMERGENCY DEPARTMENT AND
SHOULD BE PREPARED TO IMMEDIATELY PLACE A PELVIC BINDER OR SHEET.
•
• PELVIC BLEEDING THAT DOES NOT RESPOND RAPIDLY TO PELVIC COMPRESSION WITH A
SHEET OR BINDER SHOULD BE EVALUATED BY ANGIOGRAPHY AND EMBOLIZATION, IF
INDICATED.
• TRAUMA SCORING SYSTEMS—NUMEROUS SYSTEMS SEEK TO QUANTIFY THE INJURY A
PATIENT SUSTAINED (TABLES 11-2 THROUGH 11-4). ALTHOUGH SOME MAY YIELD
PROGNOSTIC VALUE, NONE IS PERFECT; A THOROUGH WORKUP IS NEEDED TO IDENTIFY
ALL INJURIES AND PRIORITIZE THEIR MANAGEMENT. ALTHOUGH IT MAY BE DESIRABLE TO
REPAIR ALL FRACTURES ON THE DAY OF ADMISSION, IT MAY BE INHERENTLY DANGEROUS
TO DO SO BECAUSE OF HEMODYNAMIC INSTABILITY AND THE ADDED TRAUMA SURGERY
CREATES.
• DAMAGE CONTROL ORTHOPAEDICS. PRINCIPLES OF DAMAGE
CONTROL HAVE BEEN APPLIED TO ORTHOPAEDIC SURGERY
AND ARE NOW WIDELY ACCEPTED. DAMAGE CONTROL
ORTHOPAEDICS INVOLVES STAGING THE DEFINITIVE CARE OF
THE PATIENT TO AVOID ADDING TO THE OVERALL TRAUMA
THE PATIENT HAS UNDERGONE.
• TRAUMA IS ASSOCIATED WITH A SURGE IN INFLAMMATORY
MEDIATORS, WHICH PEAK 2 TO 5 DAYS AFTER TRAUMA.
• AFTER THE INITIAL BURST OF CYTOKINES AND OTHER
MEDIATORS, LEUKOCYTES ARE “PRIMED” AND CAN BE
ACTIVATED EASILY WITH FURTHER TRAUMA SUCH AS
SURGERY. THIS MAY LEAD TO MULTISYSTEM ORGAN FAILURE
OR ARDS.
• TO MINIMIZE THE ADDITIONAL TRAUMA ADDED WITH
SURGERY, TRAUMATOLOGISTS WILL OFTEN TREAT ONLY
POTENTIALLY LIFE-THREATENING INJURIES DURING THIS
ACUTE INFLAMMATORY WINDOW.
• IN THE SEVERELY INJURED POLYTRAUMA PATIENT OR ONE
WITH SIGNIFICANT CHEST TRAUMA, ONLY EMERGENT AND
URGENT CONDITIONS SHOULD BE TREATED.
• • COMPARTMENT SYNDROME, FRACTURES ASSOCIATED WITH
VASCULAR INJURY, UNREDUCED DISLOCATIONS, LONG BONE
FRACTURES, OPEN FRACTURES, OR UNSTABLE SPINE
FRACTURES SHOULD BE STABILIZED ACUTELY.
• ACUTE STABILIZATION IS ACHIEVED PRIMARILY VIA EXTERNAL FIXATION.
• • FEMUR FRACTURES MAY BE CONVERTED FROM AN EXTERNAL FIXATOR TO AN
INTRAMEDULLARY (IM) NAIL WITHIN 3 WEEKS.
• • TIBIA FRACTURES SHOULD BE CONVERTED WITHIN 7 TO 10 DAYS. IF LONGER PERIODS
OF TIME ARE NECESSARY, A STAGED REMOVAL OF THE EXTERNAL FIXATOR AND
SUBSEQUENT NAILING SEVERAL DAYS LATER IS RECOMMENDED.
• N THE DEFINITIVE TREATMENT OF PELVIC AND ACETABULAR FRACTURES MAY BE
DELAYED FOR 7 TO 10 DAYS IN POLYTRAUMA PATIENTS TO ALLOW CONSOLIDATION OF
THE PELVIC HEMATOMA AND RESOLUTION OF THE ACUTE INFLAMMATORY RESPONSE.
• N CARE OF THE PREGNANT PATIENT
• N TRAUMA IS THE MOST COMMON CAUSE OF DEATH IN PREGNANCY.
• N PLACE ALL PREGNANT PATIENTS AT MORE THAN 20 WEEKS’ GESTATION IN THE LEFT
LATERAL DECUBITUS POSITION.
• • THE VENA CAVA MAY BE COMPRESSED BY THE UTERUS, REDUCING MATERNAL CARDIAC
OUTPUT 30%.
• N MOST DIAGNOSTIC RADIOGRAPHS ARE BELOW THE THRESHOLD OF RISK TO THE FETUS.
• • THE FIRST-TRIMESTER FETUS IS MOST AT RISK.
• N PSYCHOLOGIC SEQUELAE
• N POLYTRAUMA HAS A MAJOR IMPACT ON QUALITY OF LIFE.
• N WOMEN ARE MORE AFFECTED THAN MEN, AND AT 10 OR MORE YEARS AFTER SEVERE
POLYTRAUMA WOMEN SHOW HIGHER RATES OF POSTTRAUMATIC STRESS DISORDER
AND TAKE MORE SICK LEAVE TIME.
• CARE OF INJURIES TO SPECIFIC TISSUES
• SOFT TISSUE INJURIES
• VASCULAR INJURY—MAY BE DUE TO PENETRATING OR BLUNT TRAUMA
• DIAGNOSIS—ORTHOPAEDIC SURGEON SHOULD RECOGNIZE THE INJURY AND REFER THE
PATIENT TO A VASCULAR SURGERY SPECIALIST OR A MICROSURGEON AS INDICATED.
• • VASCULAR INJURY CAN BE PRESENT WHEN PULSES ARE PALPABLE; A CHANGE IN PULSE
OR A DIFFERENCE FROM THE CONTRALATERAL SIDE MAY BE THE ONLY HARBINGER OF A
SERIOUS VASCULAR INJURY.
• • IF PULSES ARE NOT EQUAL TO THE UNINJURED SIDE, A WORKUP IS INDICATED.
• • VASCULAR COMPROMISE MAY DEVELOP OVER THE COURSE OF HOURS IN THE CASE OF
KNEE DISLOCATIONS AND MUST BE RECOGNIZED PROMPTLY.
• • HARD SIGNS OF ARTERIAL INJURY—MANDATE IMMEDIATE OPERATIVE TREATMENT.
OBSERVED PULSATILE BLEEDING, RAPIDLY EXPANDING HEMATOMA, PALPABLE THRILL,
AUDIBLE BRUIT, OBVIOUS ARTERIAL OCCLUSION AFTER REDUCTION/REALIGNMENT OF
FRACTURE (6 P’S: PULSELESSNESS, PALLOR, PARESTHESIA, PAIN, PARALYSIS,
POIKILOTHERMIA).
• SOFT SIGNS OF ARTERIAL INJURY—CONSIDER ARTERIOGRAM, SERIAL EXAMINATION,
DUPLEX EXAMINATION. HISTORY OF ARTERIAL BLEED AT SCENE, PENETRATING WOUND OR
BLUNT TRAUMA IN PROXIMITY TO MAJOR ARTERY, DIMINISHED UNILATERAL PULSE, SMALL
NONPULSATILE HEMATOMA, EVOLVING NEUROLOGIC DEFICIT, ANKLE-BRACHIAL INDEX
(ABI) LESS THAN 0.9, ABNORMAL FLOW VELOCITY WAVEFORM ON DOPPLER ULTRASOUND.
• • TREATMENT: REDUCTION OF FRACTURE WILL OFTEN RESTORE VASCULARITY IN THE CASE
OF LONG BONE FRACTURES.
• N COMPARTMENT SYNDROME
• • DIAGNOSIS: INTRACOMPARTMENTAL PRESSURE EXCEEDS CAPILLARY PRESSURE, THUS
PREVENTING EXCHANGE OF WASTE AND NUTRIENTS ACROSS VESSEL WALLS. ONE OF THE
MOST FREQUENTLY MISSED COMPLICATIONS OF TRAUMA.
• • UNLESS TREATED WITHIN 4 TO 6 HOURS, PERMANENT INJURY WILL ENSUE; DIAGNOSIS IS
CLINICAL OR MADE USING A PRESSURE MONITOR.
• • CLINICAL HALLMARKS ARE PAIN OUT OF PROPORTION TO THE INJURY AND PAIN WITH
PASSIVE STRETCHING OF THE MUSCLE.
• • PARESTHESIAS AND MOTOR WEAKNESS ARE LATE FINDINGS.
• • PULSELESSNESS AND PALLOR ARE NOT COMMONLY SEEN IN COMPARTMENT SYNDROME
AND SUGGEST ARTERIAL COMPROMISE.
• • INTRACOMPARTMENTAL PRESSURE MEASUREMENT IS ABNORMAL IF PRESSURE IS WITHIN 30
MM OF THE DIASTOLIC PRESSURE (ΔP) OR GREATER THAN 30 MM OF THE ABSOLUTE PRESSURE
(CRITERIA ARE DEBATED).
• • INTRAOPERATIVE DIASTOLIC BLOOD PRESSURE DURING ANESTHESIA IS APPROXIMATELY 18
MM HG LOWER THAN “BASELINE,” POTENTIALLY GIVING SPURIOUS ΔP VALUES.
• • TREATMENT: EMERGENT DECOMPRESSION VIA FASCIOTOMY
• • IN THE MEDIAL APPROACH OF A TWO-INCISION FASCIOTOMY, THE SOLEUS MUST BE
RELEASED TO ALLOW ACCESS TO THE DEEP POSTERIOR COMPARTMENT.
• • SEQUELAE OF UNTREATED COMPARTMENT SYNDROME ARE COMMON AND INCLUDE CLAW
TOES AND CONTRACTURES IN THE HAND.
• RHABDOMYOLYSIS
• • MAY OCCUR FROM CRUSH INJURY, UNTREATED COMPARTMENT SYNDROME, AND EVEN
STRENUOUS ENDURANCE EXERCISE
• • MYOGLOBIN RELEASED INTO THE BLOODSTREAM FROM DAMAGED MUSCLE CAN LEAD
TO RENAL FAILURE. INITIALLY URINE WILL BE DARK OWING TO PRESENCE OF
MYOGLOBIN.
• • ELEVATED SERUM CREATINE KINASE—LEVELS FIVE TIMES NORMAL UPPER LIMIT
INDICATE RHABDOMYOLYSIS
• • TREATMENT INCLUDES SUPPORTIVE CARE; INTRAVENOUS SODIUM BICARBONATE,
GLUCOSE, AND INSULIN FOR TREATMENT OF HYPERKALEMIA; SODIUM BICARBONATE TO
ALKALINIZE URINE AND REDUCE RISK OF ACUTE TUBULAR NECROSIS; DIURETICS
(MANNITOL AND FUROSEMIDE) MAY BE USED TO MAINTAIN URINE OUTPUT.
• • COMPLICATIONS INCLUDE HYPERKALEMIA WITH ASSOCIATED ELECTROCARDIOGRAPH
ABNORMALITIES AND DISSEMINATED INTRAVASCULAR COAGULATION (DIC)
• NERVE INJURY
• • CAUSE
• • BLUNT TRAUMA—DIRECT IMPACT, CRUSH INJURY, OR SHOCK WAVE FROM MISSILE INJURY
• • LACERATION—SHARP EDGE OF BONE OR PENETRATING TRAUMA
• • MOST COMMON FORM IS NERVE PALSY (NEURAPRAXIA) CAUSED BY STRETCHING OF THE NERVE, WHICH
WILL RECOVER OVER TIME (1 MM/DAY)
• • FOLLOWING GUNSHOT WOUNDS, ULNAR NERVE INJURIES EXHIBIT THE WORST FUNCTIONAL
RECOVERY.
• • TREATMENT
• • NERVE LACERATION (NEUROTMESIS)—MAY BE TREATED BY REPAIR OR GRAFTING. RESULTS VARY ACCORDING TO
THE SPECIFIC NERVE INJURED AND THE DEGREE OF INJURY TO THE NERVE.
• • RADIAL NERVE INJURIES IN HIGH-ENERGY OPEN HUMERAL SHAFT FRACTURES HAVE BEEN SHOWN TO BE
MORE FREQUENTLY DUE TO NEUROTMESIS THAN NEUROPRAXIA IN SOME STUDIES.
• • DISRUPTION OF THE NERVE AXON WITH AN INTACT EPINEURIUM (AXONOTMESIS) MAY BE TREATED INITIALLY BY
OBSERVATION
• • MOTOR RECOVERY POTENTIAL AFTER REPAIR

• • EXCELLENT
• • RADIAL, MUSCULOCUTANEOUS, FEMORAL

• MODERATE
• • MEDIAN, ULNAR, TIBIAL
• • POOR
• • PERONEAL NERVE
• N BITES
• • SNAKE BITES
• • TEND TO OCCUR IN CERTAIN REGIONS OF THE UNITED STATES. ENVENOMATION OCCURS
IN ONLY 25% OF CASES. VENOM MAY BE NEUROTOXIC (CORAL SNAKES) OR HEMOTOXIC
(RATTLESNAKE, COTTONMOUTH).
• • TREATMENT AND COMPLICATIONS
• • TREATMENT IS SYMPTOMATIC AND EXPECTANT: ANTIVENIN IN A MONITORED SETTING,
DÉBRIDEMENT OF NECROTIC TISSUE, AND FASCIOTOMY. ANTIVENIN IS AVAILABLE FOR ALL
ENDEMIC SNAKES, BUT THERE IS A HIGH INCIDENCE OF ANAPHYLAXIS OR SERUM
SICKNESS ASSOCIATED WITH ITS USE.
• • COMPLICATIONS CAN INCLUDE SEVERE LOCAL TISSUE NECROSIS, COMPARTMENT
SYNDROME, COAGULOPATHIES, AND ARRHYTHMIAS.
• • HUMAN AND ANIMAL BITES
• • PATHOGENS—DESPITE ASSOCIATION OF CERTAIN BITES WITH SPECIFIC BACTERIA,
STAPHYLOCOCCUS AND STREPTOCOCCUS REMAIN MOST PREVALENT PATHOGENS. OTHERS
INCLUDE:
• • CAT BITES—PASTEURELLA
• • DOG BITES—EIKENELLA
• • HUMAN BITES—VARIABLE, INCLUDING EIKENELLA
• • TREATMENT—BROAD-SPECTRUM ANTIBIOTIC IS COMMONLY GIVEN, ALTHOUGH
REGIONAL VARIATIONS ARE ALSO COMMON.
• THERMAL INJURY
• • HYPOTHERMIA
• • CAUSE: INJURY CAUSED BY ICE CRYSTALS FORMING OUTSIDE CELL(S)
• • TREATMENT: RAPID REWARMING AND ATTENTION TO ARRHYTHMIAS ARE THE CURRENT
TREATMENTS. AMPUTATION MAY BE NECESSARY.
• • BURNS—GENERALLY TREATED BY BURN SURGEONS, BUT EXTREMITY BURNS MAY BE

TREATED BY ORTHOPAEDIC SURGEONS. DÉBRIDEMENT OF DEEP DERMAL BURNS AND SKIN
GRAFTING ARE HALLMARKS OF TREATMENT AFTER EARLY AGGRESSIVE FLUID
RESUSCITATION. ANTIBIOTIC PROPHYLAXIS AND TETANUS ARE ROUTINE.
• N ELECTRICAL INJURY—MAY CAUSE BONE NECROSIS AND MASSIVE SOFT TISSUE NECROSIS.
EXTENT OF TISSUE INJURY MAY NOT BE APPARENT FOR DAYS AFTER INJURY BECAUSE SKIN
MAY NOT BE BROKEN DESPITE SIGNIFICANT INJURY UNDERNEATH.
• • TREATMENT IS SIMILAR TO THAT OF BURNS; DÉBRIDEMENT FOLLOWED BY
RECONSTRUCTION WITH AMPUTATION, A FLAP, OR A SKIN GRAFT IS REQUIRED.
• CHEMICAL BURNS—FIRST RULE: AVOID CONTAMINATION FROM OTHER PEOPLE AND
FURTHER DAMAGE TO THE VICTIM.
• • INITIAL TREATMENT: DILUTION WITH COPIOUS IRRIGATION. AFTER INITIAL IRRIGATION,
THE DEGREE OF NECROSIS IS ASSESSED, WITH DÉBRIDEMENT OF NECROTIC TISSUE.
HYDROFLUORIC ACID IS EXTREMELY TOXIC, CAUSING PROFOUND HYPOCALCEMIA AND
CARDIAC DEATH WITH LITTLE EXPOSURE; CALCIUM GLUCONATE MAY BE USED TO TREAT
SKIN EXPOSURE.
• N HIGH-PRESSURE
INJURY (WATER, PAINT, GREASE)—HAND INJURIES MOST COMMON. THERE
MAY BE EXTENSIVE DAMAGE TO UNDERLYING SOFT TISSUES DESPITE A SMALL ENTRANCE
WOUND. WIDE DÉBRIDEMENT OF NECROTIC TISSUE AND FOREIGN MATERIAL IS REQUIRED.
• N HYPERBARICOXYGEN—CAN BE USED TO PROVIDE ENHANCED OXYGEN DELIVERY TO
PERIPHERAL TISSUES DAMAGED BY TRAUMA
• PRESSURE-SENSITIVE IMPLANTED MEDICAL DEVICES (E.G., INSULIN PUMP) ARE A CONTRAINDICATION TO
USE OF HYPERBARIC THERAPY.
• N JOINT INJURIES—MAY BE CAUSED BY PENETRATING OR BLUNT TRAUMA
• N DISLOCATIONS—ORTHOPAEDIC EMERGENCIES THAT SHOULD BE REDUCED AS SOON AS POSSIBLE TO

AVOID INJURY TO THE NERVE AND VESSELS AND THE ARTICULAR CARTILAGE; GENERAL ANESTHESIA MAY
BE NEEDED. NEUROVASCULAR STATUS SHOULD BE ASSESSED AND DOCUMENTED BOTH BEFORE AND
AFTER REDUCTION.
• N OPEN JOINT INJURIES
• • ANTIBIOTICS—PENETRATING TRAUMA SUCH AS GUNSHOT WOUNDS MAY BE TREATED WITH ORAL
ANTIBIOTICS IF THERE IS NO DEBRIS IN THE JOINT; HOWEVER, FOREIGN MATTER IS OFTEN CARRIED INTO
THE JOINT AS IT IS PENETRATED, EVEN IN “CLEAN” GUNSHOT WOUNDS.
• • REVERSE ARTHROCENTESIS/SALINE LOAD TEST
• • PERFORMED BY INJECTING SALINE INTO THE JOINT AND OBSERVING THE INJURED AREA FOR SIGNS OF
EXTRAVASATION
• • AT LEAST 155 ML MUST BE INJECTED INTO THE KNEE.
• • THIS MAY MISS A SMALL PUNCTURE WOUND.
• N FRACTURES
INVOLVING THE JOINTS—MUST BE REDUCED AS ANATOMICALLY AS POSSIBLE TO REDUCE
UNEQUAL WEAR
• FRACTURES
• N OPEN FRACTURES
• • CLASSIFICATION—GUSTILO AND ANDERSON GRADING SYSTEM IS WIDELY USED (TABLE 11-
5). THERE IS CONSIDERABLE INTEROBSERVER VARIABILITY, AND THE TYPE MAY CHANGE
OVER TIME WITH FURTHER DÉBRIDEMENT. ABSOLUTE WOUND LENGTH IS LESS IMPORTANT
THAN ENERGY OF INJURY.
• • TYPE I—NO PERIOSTEAL STRIPPING, MINIMUM SOFT TISSUE DAMAGE, SMALL SKIN WOUND (1 CM)
• • TYPE II—LITTLE PERIOSTEAL STRIPPING, MODERATE MUSCLE DAMAGE, SKIN WOUND (1-10 CM)
• • TYPE IIIA—CONTAMINATED WOUND (HIGH-ENERGY GUNSHOT WOUND, FARM INJURY,

SHOTGUN) OR EXTENSIVE PERIOSTEAL STRIPPING WITH LARGE SKIN WOUND (>10 CM)
• TYPE IIIB—SAME AS IIIA BUT WILL REQUIRE FLAP COVERAGE
• • TYPE IIIC—SAME AS IIIA BUT WITH VASCULAR INJURY THAT REQUIRES REPAIR
• • CLASSIFICATION—ORTHOPAEDIC TRAUMA ASSOCIATION (OTA) OPEN FRACTURE
CLASSIFICATION (TABLE 11-6)
• • DEVELOPED TO ADDRESS SHORTCOMINGS OF GUSTILO AND ANDERSON CLASSIFICATION,
WHICH WAS DESIGNED ONLY FOR OPEN TIBIA FRACTURES AND USES TREATMENT (I.E. TYPE
OF WOUND CLOSURE) TO DETERMINE CLASSIFICATION. IDEAL CLASSIFICATION SHOULD
GUIDE TREATMENT RATHER THAN TREATMENT GUIDING CLASSIFICATION.
• • ASSESSES FIVE FACTORS ASSOCIATED WITH OPEN FRACTURES USING SPECIFIC
IDENTIFIABLE SUBCATEGORIES:
• • SKIN
• • MUSCLE
• • ARTERIAL
• • CONTAMINATION
• • BONE LOSS
• TREATMENT
• • ANTIBIOTICS—USUALLY STARTED IMMEDIATELY. ANTIBIOTIC BEAD POUCH WITH
METHYLMETHACRYLATE, TOBRAMYCIN, AND/OR VANCOMYCIN MAY BE USED TO
INITIALLY MANAGE HIGHLY CONTAMINATED WOUNDS.
• • TYPES I AND II—FIRST-GENERATION CEPHALOSPORIN (CEFAZOLIN) FOR 24 HOURS
• • TYPE III—CEPHALOSPORIN AND AMINOGLYCOSIDE FOR 72 HOURS AFTER LAST INCISION AND
DRAINAGE
• • HEAVILY CONTAMINATED WOUNDS AND FARM WOUNDS—CEPHALOSPORIN,

AMINOGLYCOSIDES, AND HIGH-DOSE PENICILLIN
• FRESHWATER WOUNDS—FLUOROQUINOLONES (CIPROFLOXACIN, LEVOFLOXACIN) OR
THIRD- OR FOURTH-GENERATION CEPHALOSPORIN (CEFTAZIDIME)
• • SALTWATER WOUNDS—DOXYCYCLINE AND CEFTAZIDIME OR A FLUOROQUINOLONE
• • TETANUS PROPHYLAXIS
• • TETANUS IS CAUSED BY THE EXOTOXIN OF CLOSTRIDIUM TETANI, WHICH PRODUCES
CONVULSION AND SEVERE MUSCLE SPASMS WITH A 30% TO 40% MORTALITY RATE.
• • REQUIRED TETANUS PROPHYLAXIS TREATMENT IS BASED ON THE CHARACTERISTICS OF
THE WOUND AND THE PATIENT’S IMMUNIZATION STATUS.
• • TETANUS-PRONE WOUNDS ARE MORE THAN 6 HOURS OLD, MORE THAN 1 CM DEEP, HAVE
DEVITALIZED TISSUE, AND ARE GROSSLY CONTAMINATED.
• PATIENTS WITH AN UNKNOWN TETANUS IMMUNIZATION STATUS OR WHO HAVE RECEIVED
FEWER THAN THREE TETANUS IMMUNIZATIONS AND WHO HAVE A TETANUS-PRONE
WOUND SHOULD RECEIVE TETANUS AND DIPHTHEROID TOXOID AND HUMAN TETANUS
IMMUNOGLOBULINS (INTRAMUSCULAR INJECTION OF TOXOID AND IMMUNOGLOBULIN
SHOULD OCCUR AT DIFFERENT SITES).
• • PATIENTS WITH UNKNOWN TETANUS IMMUNIZATION STATES OR WHO HAVE RECEIVED

FEWER THAN THREE TETANUS IMMUNIZATIONS AND WHO HAVE A NON–TETANUS-PRONE
WOUND SHOULD RECEIVE ONLY TETANUS TOXOID.
• • FULLY IMMUNIZED PATIENTS SHOULD RECEIVE TETANUS TOXOID IF THE WOUND IS

SEVERE, MORE THAN 24 HOURS OLD, OR IF THE PATIENT HAS NOT HAD A BOOSTER IN THE
PAST 5 YEARS.
• DÉBRIDEMENT—INITIAL TREATMENT SHOULD CONSIST OF LOCAL WOUND DÉBRIDEMENT THAT IS ADEQUATE TO CLEAN THE
WOUND AND DÉBRIDE ALL NECROTIC TISSUE.
• • STABILIZATION OF BONY INJURIES—WILL DECREASE FURTHER DAMAGE TO SOFT TISSUE
• • EARLY COVERAGE (GOAL: <5 DAYS). HOWEVER, ZONE OF INJURY MUST BE WELL DEFINED BEFORE COVERAGE (FIGURE 11-1).
• • GASTROCNEMIUS FLAP—FOR PROXIMAL-THIRD TIBIAL FRACTURES
• • SOLEUS FLAP—FOR MIDDLE-THIRD TIBIAL FRACTURES
• • FASCIOCUTANEOUS FLAP OR FREE-TISSUE TRANSFER—FOR DISTAL-THIRD FRACTURES
• • NEGATIVE-PRESSURE THERAPY IS COMMONLY USED TO TREAT WOUNDS BUT IS NOT A SUBSTITUTE FOR DEFINITIVE
COVERAGE.
• N STABILIZATION WITH EXTERNAL FIXATION
• • IMMEDIATE TREATMENT: MOST FRACTURES SHOULD BE REDUCED AND SPLINTED PROMPTLY TO AVOID FURTHER SOFT
TISSUE DAMAGE. EXTERNAL FIXATION MAY BE USED TO TREAT GROSSLY CONTAMINATED WOUNDS AND FRACTURES THAT
WILL REQUIRE TIME FOR SOFT TISSUES TO HEAL BEFORE DEFINITIVE FIXATION.
• • DEFINITIVE TREATMENT: EXTERNAL FIXATION MAY BE USED DEFINITIVELY FOR PERIARTICULAR FRACTURES, ARTICULAR
FRACTURES THAT CANNOT BE RECONSTRUCTED, AND SEGMENTAL FRACTURES, BUT INTERNAL FIXATION IS FAR MORE
COMMON.
• N PERIOPERATIVE COMPLICATIONS
• • THROMBOEMBOLIC DISEASE—INCIDENCE VERY HIGH IN PELVIC, SPINE, HIP, AND LOWER EXTREMITY FRACTURES.
PULMONARY EMBOLUS DEVELOPS IN AS MANY AS 5% OF THOSE WHO HAVE DEEP VENOUS THROMBOSIS (DVT).
• DIAGNOSIS OF DVT IS BY DOPPLER ULTRASOUND, MAGNETIC RESONANCE VENOGRAPHY,
OR D-DIMER TITERS.
• • TREATMENT: ALL PATIENTS WITH THESE INJURIES SHOULD RECEIVE SOME FORM OF
THROMBOEMBOLIC DISEASE PROPHYLAXIS (MECHANICAL OR PHARMACOLOGIC). RISKS
OF PHARMACOLOGIC PROPHYLAXIS INCLUDE PROLONGED BLEEDING FROM SURGICAL OR
TRAUMATIC WOUNDS OR A CEREBRAL BLEED.
• • FAT EMBOLUS SYNDROME—ASSOCIATED WITH REAMING OF LONG BONES BUT CAN
OCCUR WITH ANY LONG BONE FRACTURE. HYPOXIA, A PETECHIAL RASH ON THE CHEST,
AND TACHYCARDIA ARE THE HALLMARKS. TREATMENT IS SUPPORTIVE.
• • ARDS—PATIENTS WITH CHEST TRAUMA AND MULTIPLE FRACTURES AT HIGH RISK. IT IS
UNCLEAR WHETHER REAMED NAILING OF LONG BONE FRACTURES CAUSES IT DIRECTLY,
BUT MAY BE IMPLICATED IN THE “SECOND HIT” PHENOMENON. TREATMENT IS SUPPORTIVE
(O2, VENTILATOR).
• FRACTURE COMPLICATIONS
• • CAST TREATMENT COMPLICATIONS
• • PRESSURE SORE—CARE TO PAD BONY PROMINENCES AND PERFORM MORE FREQUENT SKIN
INSPECTIONS IN PATIENTS WITH DIMINISHED SENSORY CAPACITY
• • CAST BURN; CAN BE MINIMIZED BY NOT DIPPING PLASTER IN HOT WATER (USE WATER
TEMPERATURE 20° TO 24°C [68° TO 75.2°F]), NOT RESTING CAST ON A PILLOW WHILE SETTING,
NOT USING EXCESSIVE LAYERS, AND NOT OVERWRAPPING WITH FIBERGLASS WHILE
PLASTER CAST IS CURING
• • DELAYED UNION—DEFINED AS NO PROGRESSION OF HEALING OVER SERIAL

RADIOGRAPHS. TREATMENT MAY INCLUDE BONE GRAFTING AND EXTERNAL BONE
STIMULATION.
• FIGURE 11-1 SOFT TISSUE DEFECT LADDER OF RECONSTRUCTION. COMPLEXITY OF THE
TREATMENT AND EXPERTISE REQUIRED INCREASE THROUGHOUT THE LADDER. FREE
TISSUE TRANSFER DISTANT TISSUE TRANSFER LOCAL TISSUE TRANSFER SKIN GRAFT
SECONDARY CLOSURE PRIMARY CLOSURE
• NONUNION
• • CLASSIFICATION (FIGURE 11-2)
• • BIOLOGIC TREATMENTS—MANY NEW TREATMENTS, BUT SCANTY LITERATURE TO
SUPPORT ANY ONE OVER THE OTHERS
• • BONE MORPHOGENETIC PROTEIN—EXPENSIVE, INDICATED IN SOME ACUTE TIBIA FRACTURES,
AND POSSIBLY USEFUL IN NONUNIONS
• • TRADITIONAL TREATMENT
• • IDENTIFY INFECTION AND TREAT APPROPRIATELY.
• • ADDRESS PATIENT FACTORS INCLUDING VITAMIN D DEFICIENCY AND NUTRITION.
• • CORRECT ANY DEFORMITY.
• • PROVIDE STABILITY FOR HYPERTROPHIC NONUNIONS.
• • PROVIDE IMPROVED BIOLOGY (AUTOGENOUS BONE GRAFT, MUSCLE FLAP) FOR ATROPHIC
NONUNIONS.
• • PRESERVE NATIVE BIOLOGY

• NONUNION
• • CLASSIFICATION (FIGURE 11-2)
• • BIOLOGIC TREATMENTS—MANY NEW TREATMENTS, BUT SCANTY LITERATURE TO
SUPPORT ANY ONE OVER THE OTHERS
• • BONE MORPHOGENETIC PROTEIN—EXPENSIVE, INDICATED IN SOME ACUTE TIBIA FRACTURES,
AND POSSIBLY USEFUL IN NONUNIONS
• • TRADITIONAL TREATMENT
• • IDENTIFY INFECTION AND TREAT APPROPRIATELY.
• • ADDRESS PATIENT FACTORS INCLUDING VITAMIN D DEFICIENCY AND NUTRITION.
• • CORRECT ANY DEFORMITY.
• • PROVIDE STABILITY FOR HYPERTROPHIC NONUNIONS.
• • PROVIDE IMPROVED BIOLOGY (AUTOGENOUS BONE GRAFT, MUSCLE FLAP) FOR ATROPHIC
NONUNIONS.
• • PRESERVE NATIVE BIOLOGY

• BONE STIMULATOR—NO STRONG EVIDENCE FOR EFFECTIVENESS OF ONE METHOD OVER
ANOTHER
• • ULTRASOUND—DELIVERS SMALL CUMULATIVE DOSES OF ULTRASOUND ENERGY;
THOUGHT TO INDUCE MICROFRACTURE AND HEALING RESPONSE; 30 MW/CM2 PULSED
WAVE ULTRASOUND HAS BEEN SHOWN EFFECTIVE FOR HEALING ACUTE FRACTURES
• • ELECTROMAGNETIC—ATTEMPTS TO PROMOTE HEALING BY DIRECTING INTEGRAL ION
FLOW AT CELLULAR LEVEL OF BONE
• • SEGMENTAL BONE LOSS—TREATMENT INCLUDES BONE GRAFT, INDUCED MEMBRANE
TECHNIQUE FOLLOWED BY BONE GRAFT, INTERPOSITION FREE TISSUE TRANSFER (FREE-
FIBULA TRANSFER), BONE TRANSPORT (RING FIXATION), AND AMPUTATION.
• • HETEROTOPIC OSSIFICATION
• DIAGNOSIS: COMMON IN HEAD-INJURED PATIENTS AND IN HIP, ELBOW, AND SHOULDER
FRACTURES. ANY FRACTURE ASSOCIATED WITH EXTENSIVE MUSCLE DAMAGE IS AT RISK.
• • PROPHYLAXIS: INDOMETHACIN 25 MG ORALLY THREE TIMES A DAY, OR INDOMETHACIN
SUSTAINED-RELEASE 75 MG ORALLY DAILY FOR 6 WEEKS HAS BEEN RECOMMENDED.
EFFICACY OF INDOMETHACIN IS DEBATABLE AND MAY INCREASE NONUNION RATE.
• • RADIATION THERAPY (600-700 CGY) GIVEN 24 HOURS BEFORE OR UP TO 72 HOURS AFTER
SURGERY; EQUAL TO INDOMETHACIN IN EFFECTIVENESS (BUT NO ISSUES WITH
COMPLIANCE WITH MEDICATION REGIMEN)
• • TREATMENT: EARLY ACTIVE RANGE OF MOTION (ROM) FOR ELBOW AND SHOULDER.
EXCISION OF PROBLEMATIC HETEROTOPIC OSSIFICATION CAN BE CONSIDERED WHEN NO
FURTHER GROWTH (CONTROVERSIAL HOW TO ASSESS—“QUIET” BONE SCAN, STABLE
DISEASE SHOWN ON RADIOGRAPHS, TIME > 1 YEAR).
• OSTEOMYELITIS
• • DIAGNOSIS
• • DEFINITIVE DIAGNOSIS—BY BONE BIOPSY. BONE CULTURE AND MICROSCOPIC PATHOLOGY.
BONE CULTURE MAY HAVE HIGH FALSE-NEGATIVE RATE. MICROSCOPIC PATHOLOGY TO
EVALUATE FOR INFLAMMATORY CHANGES CONSISTENT WITH INFECTION.
• • OTHER TESTS—MAY BE USED IN COMBINATION WITH PHYSICAL EXAMINATION (DRAINING
WOUND, PAIN) TO CONFIRM DIAGNOSIS
• • CHRONIC DRAINING WOUNDS CAN DIFFERENTIATE INTO SQUAMOUS CELL CARCINOMA AND
SHOULD UNDERGO HISTOLOGIC ANALYSIS WHEN EXCISED.
• • MAGNETIC RESONANCE IMAGING (MRI)—95% SENSITIVE AND 90% SPECIFIC
• • TECHNETIUM 99M (99MTC) STUDY—85% SENSITIVE AND 80% SPECIFIC
• • INDIUM STUDY—95% SENSITIVE AND 85% TO 90% SPECIFIC

• TREATMENT—BASED ON GRADE AND HOST TYPE (CIERNY/MADER)
• • GRADE
• • GRADE I—INTRAMEDULLARY; DÉBRIDEMENT BY INTRAMEDULLARY REAMING
• • GRADE II—SUPERFICIAL, INVOLVES CORTEX, OFTEN SEEN IN DIABETIC WOUNDS; CURETTAGE
• • GRADE III—LOCALIZED, INVOLVES CORTICAL LESION WITH EXTENSION INTO MEDULLARY
CANAL; REQUIRES WIDE EXCISION, BONE GRAFTING, AND PERHAPS STABILIZATION
• • GRADE IV—DIFFUSE, INDICATES SPREAD THROUGH CORTEX AND ALONG MEDULLARY

CANAL; WIDE SEQUESTRECTOMY, MUSCLE FLAP, BONE GRAFT, AND STABILIZATION
• HOST
• • A—NORMAL HEALTHY PATIENT
• • B—LOCALLY COMPROMISED (VASCULOPATHIC)
• • C—NOT CONSIDERED A MEDICAL CANDIDATE FOR SURGERY; MAY REQUIRE SUPPRESSIVE ANTIBIOTICS
• • FRACTURES CAUSED BY GUNSHOT WOUNDS
• • VELOCITY IS THE MOST IMPORTANT DETERMINANT OF THE ENERGY IMPARTED TO SOFT TISSUES.
• • HIGH-ENERGY GUNSHOT AND SHOTGUN WOUNDS—CONSIDERED GRADE III OPEN FRACTURES
BECAUSE THEY ARE OFTEN ASSOCIATED WITH CONSIDERABLE SOFT TISSUE INJURY (TABLE 11-7). THEY
REQUIRE EXTENSIVE SURGICAL DÉBRIDEMENT OF NECROTIC TISSUE AND REQUIRE SURGICAL
STABILIZATION OF THE FRACTURE.
• • LOW-ENERGY GUNSHOT WOUNDS—CAN BE TREATED AS A CLOSED FRACTURE BUT SHOULD GET
SINGLE-DOSE, FIRST-GENERATION CEPHALOSPORIN AND LOCAL WOUND CARE
• • BULLETS THAT PASS THROUGH COLON—MAY CONTAMINATE ANY FRACTURE CAUSED BY THE BULLET
AFTER PERFORATION (PELVIS, SPINE). BONY FRACTURES MAY BE MANAGED WITH ANTIBIOTICS ALONE
IF EXTRAARTICULAR AND THE FRACTURE PATTERN IS STABLE.
• PRINCIPLES OF LOWER EXTREMITY AMPUTATION
• • MAINTAIN KNEE JOINT AND STUMP LENGTH WHEN SOFT TISSUES PERMIT, EVEN IF FREE FLAP
IS REQUIRED FOR COVERAGE
• • LOWER EXTREMITY ASSESSMENT PROJECT (LEAP)
• • MULTICENTER PROSPECTIVE STUDY OF SEVERE LOWER EXTREMITY TRAUMA IN THE U.S. CIVILIAN
POPULATION. KEY FINDINGS AND RECOMMENDATIONS INCLUDE:
• • INJURY SEVERITY SCORING SYSTEMS DO NOT PROVIDE VALID PREDICTIVE VALUE TO GUIDE
AMPUTATION DECISION.
• • ABSENCE OF PLANTAR SENSATION ON PRESENTATION IS NOT PREDICTIVE OF EXTREMITY
FUNCTION OR RETURN OF PLANTAR SENSATION AT 2-YEAR FOLLOW-UP.
• • AT 2- AND 7-YEAR FOLLOW-UP, NO DIFFERENCE IN FUNCTIONAL OUTCOME BETWEEN PATIENTS
WHO UNDERWENT EITHER LIMB SALVAGE SURGERY OR AMPUTATION
• • OUTCOMES FOUND TO BE MORE AFFECTED BY PATIENT’S ECONOMIC, SOCIAL, AND PERSONAL
RESOURCES THAN BY THE INJURY TREATMENT METHOD
• • PATIENTS WITH MANGLED EXTREMITY INJURIES HAVE POOR OUTCOMES AT 2 YEARS.

OUTCOMES CONTINUE TO WORSEN
• BETWEEN 2 AND 7 YEARS’ FOLLOW-UP. FACTORS ASSOCIATED WITH POOR OUTCOME
INCLUDE OLDER AGE, FEMALES, NONWHITE RACE, LOWER LEVEL OF EDUCATION,
CURRENT OR PRIOR SMOKING HISTORY, POOR ECONOMIC STATUS, LOW SELF-EFFICACY,
POOR HEALTH STATUS PRIOR TO INJURY, AND INVOLVEMENT IN LEGAL SYSTEM TO OBTAIN
DISABILITY.
• • PATIENTS PRESENTING WITH MANGLED LOWER EXTREMITY INJURIES ARE LESS
AGREEABLE, MORE LIKELY TO DRINK ALCOHOL, SMOKE, BE POOR AND UNINSURED, BE
NEUROTIC AND EXTROVERTED COMPARED TO POPULATION NORMS.
• • PATIENTS WHO UNDERWENT BELOW-KNEE AMPUTATION FUNCTIONED BETTER THAN
THOSE UNDERGOING ABOVE-KNEE AMPUTATION. PATIENTS UNDERGOING THROUGH-KNEE
AMPUTATION HAD THE POOREST FUNCTION.
• OSTEOPOROTIC FRACTURES
• • WORLD HEALTH ORGANIZATION FRACTURE RISK ASSESSMENT TOOL (FRAX) CALCULATES THE 10-YEAR RISK OF HIP
FRACTURE
• • LOW-ENERGY STRESS FRACTURES ASSOCIATED WITH BISPHOSPHONATE USE IN PATIENTS TREATED FOR OSTEOPOROSIS;
FRACTURE CHARACTERIZED BY CORTICAL THICKENING, MOSTLY TRANSVERSE PATTERN, MINIMAL COMMINUTION
• • FRACTURE OF THE PROXIMAL HUMERUS CONSISTENTLY PREDICTS PATIENT’S RISK FOR A SUBSEQUENT LOW-ENERGY HIP
FRACTURE.
• BIOMECHANICS OF FRACTURE HEALING (ALSO SEE CHAPTER 1, BIOMECHANICS.)
• N STABILITY AND FRACTURE HEALING (TABLE 11-8)
• N STABILITY DETERMINES STRAIN

• • ABSOLUTE STABILITY
• • RELATIVE STABILITY
• N STRAIN DETERMINES TYPE OF HEALING (FIGURE 11-3)
• • STRAIN LESS THAN 2% RESULTS IN PRIMARY BONE HEALING (ENDOSTEAL HEALING).
• • STRAIN 2% TO 10% RESULTS IN SECONDARY BONE HEALING (ENCHONDRAL OSSIFICATION).
• • STRAIN GREATER THAN 10% DOES NOT PERMIT BONE FORMATION.
• • STRAIN IS DEFINED AS CHANGE IN FRACTURE GAP DIVIDED BY THE FRACTURE GAP (ΔL/L).
• • HIGHEST FRACTURE SITE STRAIN IS SEEN IN A SIMPLE FRACTURE THAT IS FIXED WITH A GAP (INCOMPLETELY REDUCED).
• RELATIVE STABILITY
• N MICROMOTION AT FRACTURE SITE UNDER PHYSIOLOGIC LOAD LEADS TO CALLUS
FORMATION.
• N STRAIN DECREASES AS CALLUS MATURES, LEADING TO INCREASED STABILITY.
• N IF THERE IS TOO MUCH MOTION, CALLUS BECOMES HYPERTROPHIC AS IT TRIES TO
SPREAD OUT FORCE, AND HYPERTROPHIC NONUNION CAN RESULT.
• N EXAMPLES: CASTS, EXTERNAL FIXATORS, IM NAILS, BRIDGE PLATES
• N ABSOLUTE STABILITY
• N NO MOTION AT FRACTURE SITE UNDER PHYSIOLOGIC LOAD
• N BONE HEALS THROUGH DIRECT HEALING (NO CALLUS).
• N STRAIN IS LOW OR ZERO.
• N HEALING TIMES ARE LONGER AND MORE DIFFICULT TO CONFIRM BY RADIOGRAPHY.
• N IMPLANTS MUST HAVE LONGER FATIGUE LIFE.
• EXAMPLES: SINGLE INTERFRAGMENTARY SCREW AND NEUTRALIZATION PLATE IN OBLIQUE
FRACTURE PATTERN, COMPRESSION PLATING IN TRANSVERSE FRACTURE PATTERN
• N HEALING IN DIFFERENT BONE TYPES
• N DIAPHYSEAL (CORTICAL)
• • DECREASED BLOOD SUPPLY LEADS TO LONGER HEALING TIMES.
• • BONE IS MORE AMENABLE TO COMPRESSION TECHNIQUES (IN SHORT OBLIQUE/TRANSVERSE
FRACTURES).
• • STRAIN IS CONCENTRATED OVER A SMALLER SURFACE AREA.
• N CANCELLOUS (METAPHYSEAL)
• • LARGER SURFACE AREA AND BETTER BLOOD SUPPLY
• • STRAIN IS LOWER AS FORCES SPREAD OUT OVER LARGER AREA.
• • HEALING IS MORE RAPID.
• • HOWEVER, JOINT SURFACES TOLERATE VERY LITTLE MALREDUCTION (<2 MM), SO THERE IS
OFTEN INCREASED TIME TO BEAR WEIGHT VERSUS DIAPHYSEAL FRACTURES.
• BIOMECHANICS OF OPEN REDUCTION AND INTERNAL FIXATION (ORIF [ALSO SEE CHAPTER
1, BIOMECHANICS.])
• N LAG SCREWS
• N PROVIDE RIGID INTERFRAGMENTARY COMPRESSION (ABSOLUTE STABILITY)
• N FORCE IS CONCENTRATED OVER A SMALL AREA (AROUND SCREW), SO TYPICALLY A
PLATE IS NEEDED TO PROTECT/NEUTRALIZE THE DEFORMING FORCES.
• N POSITION SCREWS
• N COMPRESS PLATE TO BONE BUT WILL NOT PROVIDE INTERFRAGMENTARY COMPRESSION
• N FRICTION BETWEEN SCREW, PLATE, AND BONE RESISTS PULLOUT OR BENDING.
• N PLATING (FIGURE 11-4)
• N PLATE LENGTH MATTERS MORE FOR BENDING STABILITY THAN NUMBER OF SCREWS IN
PLATE.
• N TORSIONAL STABILITY IS MORE AFFECTED BY POSITION OF SCREWS (NEED END HOLE
FILLED).
• TO INCREASE BENDING STIFFNESS OF A PLATE, DECREASE THE WORKING LENGTH BY PLACING
SCREWS CLOSER TO THE FRACTURE SITE (A 10-HOLE PLATE CENTERED AT A FRACTURE WITH
SCREWS IN HOLES 1, 5, 6, AND 10 HAS A HIGHER BENDING STIFFNESS THAN ONE WITH SCREWS IN
HOLES 1, 3, 8 AND 10).
• N PLATES ARE LOAD BEARING—WILL STRESS SHIELD AREA COVERED BY PLATE; IMPORTANT TO
PROTECT AREA TEMPORARILY IF PLATE REMOVED AFTER HEALING
• N COMPRESSION PLATE FUNCTION
• N PLATE DESIGN (OVAL HOLES) OR USE OF COMPRESSION DEVICE ALLOWS PLATE TO APPLY
COMPRESSIVE FORCES ACROSS FRACTURE.
• N PROVIDES ABSOLUTE STABILITY WHEN PROPERLY APPLIED
• N RELIES ON FRICTION BETWEEN PLATE AND BONE (NEEDS AT LEAST SOME NONLOCKING SCREWS)
• N MAY NEED PRE-BEND TO ACHIEVE COMPRESSION OF BOTH NEAR AND FAR CORTEX
• N INSERTION ORDER IS NEUTRAL POSITION, THEN COMPRESSION ON OPPOSITE SIDE OF FRACTURE,
THEN LAG SCREW (IF PLACING THROUGH PLATE).
• N TIGHT CONTACT OF PLATE TO BONE WHEN INITIALLY APPLIED CAUSES DECREASED PERIOSTEAL
BLOOD FLOW AND TEMPORARY OSTEOPENIA.
• PROXIMAL OR DISTAL TO FRACTURE AND AVOIDING EXPOSURE OF FRACTURE SITE.
• N TYPICALLY USED IN BRIDGE MODE, ALTHOUGH NOT EXCLUSIVE
• N ADVANTAGE: DECREASED SOFT TISSUE AND BIOLOGIC COMPROMISE
• • MEDULLARY AND PERIOSTEAL PERFUSION ARE BETTER RETAINED.
• N DISADVANTAGE: MORE PRONE TO MALREDUCTION/MALROTATION
• N LOCKED PLATING
• N SCREWS HAVE THREADS IN HEAD THAT LOCK INTO CORRESPONDING HOLES IN PLATE
• • FAIL SIMULTANEOUSLY RATHER THAN SEQUENTIALLY
• N DOES NOT DEPEND ON FRICTION BETWEEN PLATE AND BONE FOR STABILITY
• N PROVIDES FIXED-ANGLE CONSTRUCT—SIMILAR TO BLADE PLATE
• N MOST USEFUL IN UNSTABLE SHORT-SEGMENT METAPHYSEAL FRACTURES AND OSTEOPOROTIC BONE
• N FRACTURES IN WHICH LOCKING PLATE USE IS SUPPORTED BY DATA INCLUDE:
• • PERIPROSTHETIC FRACTURES
• • PROXIMAL HUMERUS FRACTURE
• • INTRAARTICULAR DISTAL FEMUR AND PROXIMAL TIBIA
• • HUMERAL SHAFT NONUNION IN THE ELDERLY
• UNICORTICAL LOCKED SCREWS
• • TYPICALLY FOR METAPHYSEAL BONE
• • SIMILAR PULLOUT STRENGTH TO BICORTICAL LOCKED SCREWS IN GOOD-QUALITY DIAPHYSEAL BONE (BUT RARE
INDICATIONS FOR USE THERE)
• • WEAKER IN TORSION COMPARED WITH BICORTICAL SCREWS
• N BICORTICAL LOCKED SCREWS: BIGGEST ADVANTAGE IS IN OSTEOPOROTIC DIAPHYSEAL BONE
• N MULTIAXIAL SCREWS
• • MAY INCREASE OPTIONS FOR FIXATION IN WORKING AROUND PERIPROSTHETIC FRACTURES

• • NO ADVANTAGE IN STRENGTH OR PULLOUT
• N “HYBRIDIZATION”
DESCRIBES THE USE OF BOTH LOCKING AND NONLOCKING SCREWS IN COMBINATION. THIS
ALLOWS FOR BOTH COMPRESSION AND FIXED-ANGLE SUPPORT.
• N IM NAILS
• N LOAD-SHARING DEVICES—RELATIVE STABILITY

• N STIFFNESS DEPENDS ON:
• • MATERIAL
• • STAINLESS IS GREATER THAN TITANIUM.
• • SIZE
• INCREASED DIAMETER LEADS TO INCREASED STIFFNESS AT A RATIO OF RADIUS TO THE POWER OF:
• • 3 IN BENDING
• • 4 IN TORSION
• • WALL THICKNESS
• • LARGER = STIFFER NAIL
• N RADIUS OF CURVATURE OF FEMORAL NAILS IS TYPICALLY LESS THAN ANATOMIC, IMPROVING
FRICTIONAL FIXATION.
• • A LARGE MISMATCH OF CURVATURE, HOWEVER, RESULTS IN DIFFICULT INSERTION, INCREASED RISK OF
INTRAOPERATIVE FRACTURE, AND MALREDUCTION IN EXTENSION.
• N NAILS RESIST BENDING VERY WELL AND REQUIRE INTERLOCKS TO RESIST TORSION OR COMPRESSION
LOADS.
• N WORKING LENGTH IS THE PORTION OF THE NAIL THAT IS UNSUPPORTED BY BONE WHEN LOADED.
• • INCREASED WORKING LENGTH PRODUCES INCREASED INTERFRAGMENTARY MOTION AND MAY DELAY
UNION.
• N ADVANTAGE OF INTRAMEDULLARY POSITION IS DECREASED LEVER ARM FOR BENDING FORCES
(ESPECIALLY USEFUL IN PERITROCHANTERIC FRACTURES VERSUS PLATE-AND-SCREW CONSTRUCT).
SECTION 2
UPPER EXTREMATION
• SHOULDER INJURIES (TABLES 11-9 AND 11-10)
• N STERNOCLAVICULAR DISLOCATION—“SERENDIPITY” VIEW OR CT SCAN REVEALS
DISLOCATION OF STERNOCLAVICULAR JOINT
• N ANTERIOR DISLOCATION—MORE COMMON, TREATED BY CLOSED REDUCTION. THE
MAJORITY WILL REMAIN UNSTABLE REGARDLESS OF INITIAL TREATMENT MODALITY,
BUT THESE ARE TYPICALLY ASYMPTOMATIC.
• POSTERIOR DISLOCATION—MORE SERIOUS—30% ASSOCIATED WITH SIGNIFICANT
COMPRESSION OF POSTERIOR STRUCTURES. MAY CAUSE DYSPHAGIA OR DIFFICULTY
BREATHING AND SENSATION OF FULLNESS IN THE THROAT. TREATED BY CLOSED
REDUCTION WITH A TOWEL CLIP IN THE OPERATING ROOM. A THORACIC SURGEON
SHOULD BE ON STANDBY.
• CHRONIC DISLOCATION—TREATED BY RESECTION OF THE MEDIAL CLAVICLE, WITH
PRESERVATION AND RECONSTRUCTION OF COSTOCLAVICULAR LIGAMENTS
• N PSEUDODISLOCATION—MEDIAL CLAVICULAR EPIPHYSIS IS THE LAST TO CLOSE (MEAN
AGE, 25 YEARS). IN PATIENTS YOUNGER THAN THIS, STERNOCLAVICULAR DISLOCATION IS
OFTEN A SALTER-HARRIS TYPE I OR II FRACTURE.
• CLAVICLE FRACTURE (FIGURE 11-5)
• CLASSIFICATION—CLASSIFIED BY THIRDS
• • MIDDLE—80%
• • DISTAL—15%
• • MEDIAL—5%
• DIAGNOSIS—AP AND 15-DEGREE CEPHALAD-OBLIQUE RADIOGRAPHIC VIEWS
• ASSOCIATED INJURIES OPEN CLAVICLE FRACTURES ASSOCIATED WITH HIGH RATES OF
PULMONARY AND CLOSED-HEAD INJURIES
• FIGURE 11-6 CLASSIFICATION OF THE LIGAMENTOUS INJURIES THAT CAN OCCUR TO THE
ACROMIOCLAVICULAR (AC) JOINT. IN A TYPE I INJURY, A MILD FORCE APPLIED TO THE
POINT OF THE SHOULDER DOES NOT DISRUPT EITHER THE AC OR CORACOCLAVICULAR (CC)
LIGAMENT. IN A TYPE II INJURY, A MODERATE TO HEAVY FORCE APPLIED TO THE POINT OF
THE SHOULDER DISRUPTS THE AC LIGAMENTS BUT THE CC LIGAMENTS REMAIN INTACT. IN
A TYPE III INJURY, WHEN A SEVERE FORCE IS APPLIED TO THE POINT OF THE SHOULDER,
BOTH THE AC AND THE CC LIGAMENTS ARE DISRUPTED. IN A TYPE IV INJURY, NOT ONLY
ARE THE LIGAMENTS DISRUPTED BUT THE DISTAL END OF THE CLAVICLE IS ALSO
DISPLACED POSTERIORLY INTO OR THROUGH THE TRAPEZIUS MUSCLE. IN A TYPE V INJURY,
A VIOLENT FORCE APPLIED TO THE POINT OF THE SHOULDER NOT ONLY RUPTURES THE AC
AND CC LIGAMENTS BUT ALSO DISRUPTS THE MUSCLE ATTACHMENTS AND CREATES A
MAJOR SEPARATION BETWEEN THE CLAVICLE AND ACROMION. A TYPE VI INJURY IS AN
INFERIOR DISLOCATION OF THE DISTAL CLAVICLE IN WHICH THE CLAVICLE IS INFERIOR TO
THE CORACOID PROCESS AND POSTERIOR TO THE BICEPS AND CORACOBRACHIALIS
TENDONS. THE AC AND CC LIGAMENTS HAVE ALSO BEEN DISRUPTED. (FROM ROCKWOOD
CA JR ET AL: DISORDERS OF THE ACROMIOCLAVICULAR JOINT. IN ROCKWOOD CA JR ET AL,
EDITORS: THE SHOULDER, ED 3, PHILADELPHIA, 2004, SAUNDERS.)
• OPERATIVE TREATMENT—INDICATED FOR INTRAARTICULAR FRACTURES THAT ARE DISPLACED MORE THAN 2 MM OR WIDELY DISPLACED
EXTRAARTICULAR FRACTURES. APPROACH IS USUALLY THROUGH A POSTERIOR PORTAL, ALTHOUGH THE NEVIASER PORTAL MAY BE
USED TO PLACE A SUPEROINFERIOR SCREW IN THE GLENOID.
• GLENOID NECK FRACTURE
• NONOPERATIVE TREATMENT—ADVOCATED BY MANY AUTHORS IN ALMOST ALL CASES.
• OPERATIVE TREATMENT—INDICATED WHEN GLENOID NECK AND HUMERAL HEAD ARE TRANSLOCATED ANTERIOR TO THE PROXIMAL
FRAGMENT OR ARE MEDIALLY DISPLACED. REDUCTION AND PLATING IS THROUGH A POSTERIOR APPROACH BETWEEN INFRASPINATUS
(SUPRASCAPULAR NERVE) AND TERES MINOR (AXILLARY NERVE). THE SUPRASCAPULAR NERVE AND ARTERY ARE AT RISK FROM
EXCESSIVE SUPERIOR RETRACTION, WHEREAS THE CIRCUMFLEX SCAPULAR ARTERY IS AT RISK DURING THE APPROACH.
• SCAPULOTHORACIC DISSOCIATION—RESULT OF SIGNIFICANT TRAUMA TO CHEST WALL, LUNG, AND HEART. SEVERE CASES ARE TREATED
ESSENTIALLY WITH A CLOSED FOREQUARTER AMPUTATION.
• ASSOCIATED WITH:
• • BRACHIAL PLEXUS AVULSION
• • SUBCLAVIAN OR AXILLARY ARTERY INJURY
• • AC DISLOCATION, CLAVICLE FRACTURE, AND STERNOCLAVICULAR DISLOCATION
• • MORTALITY RATE OF 10%
• DIAGNOSIS SHOULD BE SUSPECTED WHEN THERE IS A NEUROLOGIC AND/OR VASCULAR DEFICIT. LATERAL DISPLACEMENT OF THE
SCAPULA MORE THAN 1 CM ON A CHEST RADIOGRAPH IS ALSO SUGGESTIVE.
• MANAGEMENT
• HEMODYNAMICALLY STABLE: ANGIOGRAPHY BEFORE SURGERY. VASCULAR INJURY MAY POTENTIALLY BE TREATED NONOPERATIVELY
OWING TO THE EXTENSIVE COLLATERAL NETWORK AROUND THE SHOULDER.
• HEMODYNAMICALLY UNSTABLE: HIGH LATERAL THORACOTOMY OR MEDIAN STERNOTOMY TO CONTROL BLEEDING
• • MUSCULOSKELETAL INJURY TREATMENT IS CONTROVERSIAL BUT IS OFTEN NONOPERATIVE IF VASCULAR REPAIR
IS NOT UNDERTAKEN.
• N FUNCTIONAL OUTCOME IS BASED ON SEVERITY OF ASSOCIATED NEUROLOGIC INJURY.
• N FLOATING SHOULDER—FRACTURE OF THE GLENOID NECK AND CLAVICLE
•
NSOME AUTHORS RECOMMEND FIXATION WHEN A CLAVICLE FRACTURE IS ASSOCIATED WITH A DISPLACED GLENOID
NECK FRACTURE, WHEREAS OTHERS DO NOT CONSIDER IT NECESSARY (DEPENDS ON STABILITY OF SUPERIOR
SHOULDER SUSPENSORY COMPLEX [SSSC]).
• N PROXIMAL HUMERUS FRACTURE (FIGURE 11-7)
• N NEER CLASSIFICATION (NEER DEFINE “PART” AS DISPLACEMENT OF > 1 CM OR ANGULATION OF > 45 DEGREES);
PARTS ARE ARTICULAR SURFACE, GREATER TUBEROSITY, LESSER TUBEROSITY, SHAFT
• • ONE-PART—NONDISPLACED OR MINIMALLY DISPLACED FRACTURE (OFTEN OF THE HUMERAL NECK)
• • TWO-PART—DISPLACEMENT OF TUBEROSITY OF MORE THAN 1 CM; OR SURGICAL NECK WITH HEAD/SHAFT
ANGLED OR DISPLACED
• • THREE-PART—DISPLACEMENT OF THE GREATER OR LESSER TUBEROSITIES AND ARTICULAR SURFACE
• • FOUR-PART—DISPLACEMENT OF SHAFT, ARTICULAR SURFACE, AND BOTH TUBEROSITIES. “HEAD SPLITTING” IS A
VARIANT, WITH SPLIT THROUGH THE ARTICULAR SURFACE (USUALLY REQUIRES REPLACEMENT FOR TREATMENT).
• TREATMENT
• • ONE-PART—SLING FOR COMFORT AND EARLY MOBILIZATION
• • TWO-PART—REPAIR OF THE DISPLACED TUBEROSITY WITH SUTURES OR TENSION BAND
WIRING; SURGICAL NECK FRACTURES CAN NORMALLY BE MANAGED NONOPERATIVELY.
UNSTABLE, UNIMPACTED FRACTURES MAY BE TREATED WITH CLOSED REDUCTION WITH
PERCUTANEOUS PINNING (CRPP), ORIF WITH LOCKING PLATE FIXATION, OR IM NAILING
• • VARYING HUMERAL NAIL DESIGNS. STRAIGHT NAILS ARE PLACED THROUGH A MORE CENTRAL
ENTRY POINT (THROUGH SUPERIOR ARTICULAR CARTILAGE) THAT CAN PROVIDE ADDITIONAL
POINT OF FIXATION. NAILS WITH PROXIMAL BEND ARE PLACED THROUGH AN ENTRY POINT JUST
MEDIAL TO THE ROTATOR CUFF INSERTION.
• • IMMEDIATE PHYSICAL THERAPY DURING NONOPERATIVE MANAGEMENT RESULTS IN FASTER
RECOVERY.
• • GREATER TUBEROSITY FRACTURES ARE DISPLACED SUPERIORLY AND POSTERIORLY

OWING TO DEFORMING PULL OF SUPRASPINATUS, INFRASPINATUS, AND TERES MINOR.
HEALING IN A DISPLACED POSITION WILL BLOCK ABDUCTION AND EXTERNAL ROTATION.
SURGERY IS INDICATED FOR DISPLACEMENT GREATER THAN 5 MM. IN YOUNG PATIENTS
WITH GOOD BONE CAN FIX WITH SCREWS ALONE, BUT NONABSORBABLE SUTURE
• THREE-PART
• • ORIF FOR YOUNG PATIENTS, WITH REPAIR OF THE TUBEROSITIES OR ROTATOR CUFF
• • SCREW CUTOUT IS THE MOST COMMON COMPLICATION FOLLOWING ORIF WITH A
PERIARTICULAR LOCKING PLATE.
• • HEMIARTHROPLASTY FOR OLDER PATIENTS, WITH REPAIR OF THE ROTATOR

CUFF/TUBEROSITIES
• • FOUR-PART—SAME AS FOR THREE-PART
• • HUMERAL HEIGHT CAN BE JUDGED MOST RELIABLY USING THE SUPERIOR BORDER OF THE
PECTORALIS MAJOR INSERTION.
• • NONANATOMIC PLACEMENT OF THE TUBEROSITIES LEADS TO SIGNIFICANT IMPAIRMENT
IN EXTERNAL ROTATION
• KINEMATICS AND AN EIGHTFOLD INCREASE IN TORQUE REQUIREMENTS.
• N COMPLICATIONS
• • AVASCULAR NECROSIS (AVN)

• • FACTORS ASSOCIATED WITH HUMERAL HEAD ISCHEMIA (HERTEL CRITERIA):
• • DISRUPTION OF THE MEDIAL PERIOSTEAL HINGE

• • MEDIAL METADIAPHYSEAL EXTENSION LESS THAN 8 MM
• • INCREASING FRACTURE COMPLEXITY
• • DISPLACEMENT GREATER THAN 10 MM
• • ANGULATION GREATER THAN 45 DEGREES
• • NEUROVASCULAR INJURY
• • AXILLARY NERVE INJURY
• • LATERAL PINS PLACED DURING CRPP PLACE THE NERVE MOST AT RISK.
• • ANTERIOR PINS PLACED DURING CRPP RISK THE BICEPS TENDON, CEPHALIC VEIN, AND MUSCULOCUTANEOUS NERVE.
• • HARDWARE FAILURE
• • THE MOST COMMON COMPLICATION AFTER LOCKING PLATE FIXATION IS SCREW CUTOUT.
• • NONUNION
• • MOST COMMON AFTER TWO-PART FRACTURE OF SURGICAL NECK
• • NONUNION OF GREATER TUBEROSITY FOLLOWING ARTHROPLASTY—LOSS OF ACTIVE SHOULDER ELEVATION
• N SHOULDER DISLOCATION
• N TUBS:
TRAUMATIC, UNIDIRECTIONAL, BANKART LESION, REQUIRES SURGICAL TREATMENT. AMBRI: ATRAUMATIC, MULTIDIRECTIONAL, OFTEN
BILATERAL, REHABILITATION IS PRIMARY INITIAL TREATMENT, INFERIOR CAPSULAR SHIFT INDICATED FOR FAILED CONSERVATIVE THERAPY.
• ANTERIOR (FIGURE 11-8)—MOST COMMON SHOULDER DISLOCATION
• • MOST COMMONLY CAUSED BY FALL ON AN ABDUCTED, EXTERNALLY ROTATED SHOULDER
• • DIAGNOSIS
• • APPREHENSION SIGN
• • AXILLARY VIEW IS DIAGNOSTIC.
• • USUALLY TRAUMATIC AND UNILATERAL
• • USUALLY PAINFUL
• • TREATMENT: REDUCTION (MULTIPLE MANEUVERS AVAILABLE)

• • SLING FOR 2 WEEKS IN THE ELDERLY AND 4 WEEKS IN THE YOUNG, FOLLOWED BY ROTATOR CUFF STRENGTHENING
• HEMODYNAMICALLY UNSTABLE: HIGH LATERAL THORACOTOMY OR MEDIAN STERNOTOMY TO CONTROL BLEEDING
• • MUSCULOSKELETAL INJURY TREATMENT IS CONTROVERSIAL BUT IS OFTEN NONOPERATIVE IF VASCULAR REPAIR IS
NOT UNDERTAKEN.
• FUNCTIONAL OUTCOME IS BASED ON SEVERITY OF ASSOCIATED NEUROLOGIC INJURY.
• FLOATING SHOULDER—FRACTURE OF THE GLENOID NECK AND CLAVICLE
• SOME AUTHORS RECOMMEND FIXATION WHEN A CLAVICLE FRACTURE IS ASSOCIATED WITH A DISPLACED GLENOID
NECK FRACTURE, WHEREAS OTHERS DO NOT CONSIDER IT NECESSARY (DEPENDS ON STABILITY OF SUPERIOR
SHOULDER SUSPENSORY COMPLEX [SSSC])
• PROXIMAL HUMERUS FRACTURE (FIGURE 11-7)
• N NEER CLASSIFICATION (NEER DEFINE “PART” AS DISPLACEMENT OF > 1 CM OR ANGULATION OF > 45
DEGREES); PARTS ARE ARTICULAR SURFACE, GREATER TUBEROSITY, LESSER TUBEROSITY, SHAFT
• • ONE-PART—NONDISPLACED OR MINIMALLY DISPLACED FRACTURE (OFTEN OF THE HUMERAL NECK)
• • TWO-PART—DISPLACEMENT OF TUBEROSITY OF MORE THAN 1 CM; OR SURGICAL NECK WITH
HEAD/SHAFT ANGLED OR DISPLACED
• • THREE-PART—DISPLACEMENT OF THE GREATER OR LESSER TUBEROSITIES AND ARTICULAR SURFACE
• • FOUR-PART—DISPLACEMENT OF SHAFT, ARTICULAR SURFACE, AND BOTH TUBEROSITIES. “HEAD
SPLITTING” IS A VARIANT, WITH SPLIT THROUGH THE ARTICULAR SURFACE (USUALLY REQUIRES
REPLACEMENT FOR TREATMENT).
• N TREATMENT
• • ONE-PART—SLING FOR COMFORT AND EARLY MOBILIZATION
• • TWO-PART—REPAIR OF THE DISPLACED TUBEROSITY WITH SUTURES OR TENSION BAND WIRING;
SURGICAL NECK FRACTURES CAN NORMALLY BE MANAGED NONOPERATIVELY. UNSTABLE,
UNIMPACTED FRACTURES MAY BE TREATED WITH CLOSED REDUCTION WITH PERCUTANEOUS PINNING
(CRPP), ORIF WITH LOCKING PLATE FIXATION, OR IM NAILING
• VARYING HUMERAL NAIL DESIGNS. STRAIGHT NAILS ARE PLACED THROUGH A MORE CENTRAL ENTRY POINT
(THROUGH SUPERIOR ARTICULAR CARTILAGE) THAT CAN PROVIDE ADDITIONAL POINT OF FIXATION. NAILS WITH
PROXIMAL BEND ARE PLACED THROUGH AN ENTRY POINT JUST MEDIAL TO THE ROTATOR CUFF INSERTION.
• • IMMEDIATE PHYSICAL THERAPY DURING NONOPERATIVE MANAGEMENT RESULTS IN FASTER RECOVERY.
• • GREATER TUBEROSITY FRACTURES ARE DISPLACED SUPERIORLY AND POSTERIORLY OWING TO DEFORMING PULL
OF SUPRASPINATUS, INFRASPINATUS, AND TERES MINOR. HEALING IN A DISPLACED POSITION WILL BLOCK
ABDUCTION AND EXTERNAL ROTATION. SURGERY IS INDICATED FOR DISPLACEMENT GREATER THAN 5 MM. IN
YOUNG PATIENTS WITH GOOD BONE CAN FIX WITH SCREWS ALONE, BUT NONABSORBABLE SUTURE TECHNIQUE
SHOULD BE USED IN OLDER PATIENTS.
• • THREE-PART
• • ORIF FOR YOUNG PATIENTS, WITH REPAIR OF THE TUBEROSITIES OR ROTATOR CUFF
• • SCREW CUTOUT IS THE MOST COMMON COMPLICATION FOLLOWING ORIF WITH A PERIARTICULAR LOCKING
PLATE.
• • HEMIARTHROPLASTY FOR OLDER PATIENTS, WITH REPAIR OF THE ROTATOR CUFF/TUBEROSITIES
• • FOUR-PART—SAME AS FOR THREE-PART
• • HUMERAL HEIGHT CAN BE JUDGED MOST RELIABLY USING THE SUPERIOR BORDER OF THE PECTORALIS MAJOR
INSERTION.
• • NONANATOMIC PLACEMENT OF THE TUBEROSITIES LEADS TO SIGNIFICANT IMPAIRMENT IN EXTERNAL ROTATION
• KINEMATICS AND AN EIGHTFOLD INCREASE IN TORQUE REQUIREMENTS.
• N COMPLICATIONS
• • AVASCULAR NECROSIS (AVN)

• • FACTORS ASSOCIATED WITH HUMERAL HEAD ISCHEMIA (HERTEL CRITERIA):
• • DISRUPTION OF THE MEDIAL PERIOSTEAL HINGE

• • MEDIAL METADIAPHYSEAL EXTENSION LESS THAN 8 MM
• • INCREASING FRACTURE COMPLEXITY
• • DISPLACEMENT GREATER THAN 10 MM
• • ANGULATION GREATER THAN 45 DEGREES
• • NEUROVASCULAR INJURY
• • AXILLARY NERVE INJURY
• • LATERAL PINS PLACED DURING CRPP PLACE THE NERVE MOST AT RISK.
• • ANTERIOR PINS PLACED DURING CRPP RISK THE BICEPS TENDON, CEPHALIC VEIN, AND MUSCULOCUTANEOUS NERVE.
• • HARDWARE FAILURE
• • THE MOST COMMON COMPLICATION AFTER LOCKING PLATE FIXATION IS SCREW CUTOUT.
• • NONUNION
• • MOST COMMON AFTER TWO-PART FRACTURE OF SURGICAL NECK
• • NONUNION OF GREATER TUBEROSITY FOLLOWING ARTHROPLASTY—LOSS OF ACTIVE SHOULDER ELEVATION

• N SHOULDER DISLOCATION
• N TUBS:
TRAUMATIC, UNIDIRECTIONAL, BANKART LESION, REQUIRES SURGICAL
TREATMENT. AMBRI: ATRAUMATIC, MULTIDIRECTIONAL, OFTEN BILATERAL,
REHABILITATION IS PRIMARY INITIAL TREATMENT, INFERIOR CAPSULAR SHIFT INDICATED
FOR FAILED CONSERVATIVE THERAPY.
• N ANTERIOR (FIGURE 11-8)—MOST COMMON SHOULDER DISLOCATION
• • MOST COMMONLY CAUSED BY FALL ON AN ABDUCTED, EXTERNALLY ROTATED
SHOULDER
• • DIAGNOSIS
• • APPREHENSION SIGN
• • AXILLARY VIEW IS DIAGNOSTIC.
• • USUALLY TRAUMATIC AND UNILATERAL
• • USUALLY PAINFUL
• • TREATMENT: REDUCTION (MULTIPLE MANEUVERS AVAILABLE)

• • SLING FOR 2 WEEKS IN THE ELDERLY AND 4 WEEKS IN THE YOUNG, FOLLOWED BY
• FIGURE 11-9 ANTEROPOSTERIOR RADIOGRAPHS. A, IN THE SAGITTAL PLANE OF THE BODY (MISSED POSTERIOR DISLOCATION).
B, IN THE SAGITTAL PLANE OF THE SCAPULA, OVERLAP OF THE HEAD AND GLENOID (ARROWHEADS) INDICATES A
DISLOCATION. C, AXILLARY OR COMPUTED TOMOGRAPHY SCANS ARE THE BEST VIEWS FOR DIAGNOSING POSTERIOR DISLOCATION
OR FRACTURE-DISLOCATION. (FROM BROWNER BD ET AL, EDITORS: SKELETAL TRAUMA, ED 4, PHILADELPHIA, 2008, ELSEVIER.)
• • MAY HAVE FRACTURE OF LESSER TUBEROSITY OR REVERSE HILL-SACHS LESION
• • TREATMENT
• • IMMOBILIZATION FOR 3 TO 6 WEEKS
• • ROTATOR CUFF STRENGTHENING
• • POSSIBLE OPEN BONE GRAFTING OF HUMERAL HEAD DEFECT AND REPAIR OF POSTERIOR LABRAL TEAR
• • ALLOGRAFT, CORACOID TRANSFER, OR RESURFACING FOR LARGE DEFECTS
• N INFERIOR (LUXATIO ERECTA)
• • DIAGNOSIS
• • ASSOCIATED WITH MOTOR VEHICLE COLLISION OR SPORTING INJURY
• • ARM IS TYPICALLY ABDUCTED BETWEEN 100 AND 160 DEGREES.
• • DIMINISHED OR ABSENT PULSES
• • TREATMENT
• • CLOSED REDUCTION SUCCESSFUL IN 50%
• • CAPSULAR RECONSTRUCTION IF UNSTABLE
• HUMERAL INJURIES
• N SHAFT FRACTURE (TABLE 11-11)
• N CLASSIFICATION BY LOCATION AND FRACTURE PATTERN

• N TREATMENT
• • NONOPERATIVE TREATMENT: FUNCTIONAL BRACE IF THERE IS LESS THAN 20 DEGREES OF

ANTERIOR ANGULATION, LESS THAN 30 DEGREES OF VALGUS/VARUS ANGULATION, OR LESS
THAN 3 CM OF SHORTENING; CONTRAINDICATED IN PATIENTS WITH ASSOCIATED
BRACHIAL PLEXUS PALSY
• • OPERATIVE TREATMENT: OPEN FRACTURE, FLOATING ELBOW, POLYTRAUMA, PATHOLOGIC
FRACTURE, ASSOCIATED BRACHIAL PLEXUS INJURY
• • ORIF
• • PROBABLY THE GOLD STANDARD
• • ANTEROLATERAL APPROACH—PROXIMAL TWO THIRDS
• • DISTAL HALF—POSTERIOR APPROACH
• • NEED FOR RADIAL NERVE EXPLORATION—LATERAL APPROACH

• DISTAL LOCKING SCREW RISKS:
• • RADIAL NERVE WITH LATERAL TO MEDIAL SCREW
• • MUSCULOCUTANEOUS NERVE WITH ANTEROPOSTERIOR SCREW
• N COMPLICATIONS
• • RADIAL NERVE PALSY (5%-10%)

• • WHEN TO OBSERVE:
• • THE VAST MAJORITY (UP TO 92%) RESOLVE WITH OBSERVATION FOR 3 TO 4 MONTHS.
• • BRACHIORADIALIS FOLLOWED BY EXTENSOR CARPI RADIALIS LONGUS (WRIST EXTENSION IN RADIAL DEVIATION) ARE THE FIRST TO
RETURN, WHEREAS EXTENSOR POLLICIS LONGUS AND EXTENSOR INDICIS PROPRIUS ARE LAST TO RETURN.
• • WHEN TO EXPLORE:
• • OPEN FRACTURE
• • A HIGHER LIKELIHOOD OF TRANSECTION
• • PERFORM ORIF OF FRACTURE AT TIME OF EXPLORATION.
• • CONTROVERSIAL WHETHER TO OBSERVE OR EXPLORE:
• • SECONDARY NERVE PALSY (I.E., AFTER FRACTURE MANIPULATION)

• • SPIRAL OR OBLIQUE FRACTURE OF DISTAL THIRD (HOLSTEIN- LEWIS FRACTURE)
• • MANAGEMENT OF PALSY THAT DOES NOT RECOVER IS ALSO CONTROVERSIAL AS TO TIMING OF ELECTROMYOGRAPHY, NERVE EXPLORATION, AND TENDON
TRANSFERS.
• • NONUNION—TREAT WITH COMPRESSION PLATE WITH BONE GRAFT IF ATROPHIC.

• • SHOULDER PAIN; SOME PAPERS REPORT A HIGH INCIDENCE OF SHOULDER PAIN, WHEREAS OTHERS DO NOT. OVERALL INCIDENCE IS HIGHER
WITH IM NAILS
• SUPRACONDYLAR FRACTURE—RARE INJURY IN ADULTS
• N CLASSIFICATION
• • AO (ARBEITSGEMEINSCHAFT FÜR OSTEOSYNTHESEFRAGEN)/ OTA DISTAL HUMERUS CLASSIFICATION

• • TYPE A—EXTRAARTICULAR
• • TYPE B—INTRAARTICULAR, SINGLE COLUMN
• • TYPE C—INTRAARTICULAR, WITH BOTH COLUMNS FRACTURED AND NO PORTION OF THE JOINT CONTIGUOUS
WITH THE SHAFT
• TREATMENT: ORIF
• N COMPLICATIONS: NEUROVASCULAR INJURY, NONUNION, MALUNION, LOSS OF MOTION (CONTRACTURE,
FIBROSIS, BONY BLOCK)
• N DISTAL SINGLE-COLUMN (CONDYLE) FRACTURE
• • CLASSIFIED AS MILCH TYPES I AND II LATERAL CONDYLE FRACTURES (MORE COMMON) AND TYPES I AND II
MEDIAL CONDYLE FRACTURES. IN TYPE I LATERAL CONDYLE FRACTURES THE LATERAL TROCHLEAR RIDGE IS
INTACT, AND IN TYPE II LATERAL CONDYLE FRACTURES THERE IS A FRACTURE THROUGH LATERAL
TROCHLEAR RIDGE (FIGURE 11-10).
• • AO/OTA DISTAL HUMERUS CLASSIFICATION (SEE EARLIER)
• TREATMENT—TYPE I NONDISPLACED: IMMOBILIZE IN SUPINATION (LATERAL CONDYLE
FRACTURE) OR PRONATION (MEDIAL CONDYLE FRACTURE); OTHERWISE, CRPP OR ORIF
• N COMPLICATIONS:CUBITUS VALGUS (LATERAL) OR CUBITUS VARUS (MEDIAL), ULNAR
NERVE INJURY, AND DEGENERATIVE JOINT DISEASE (DJD)
• N DISTAL TWO-COLUMN FRACTURE
• N PRESENTATION:
FIVE MAJOR ARTICULAR FRAGMENTS IDENTIFIED: CAPITELLUM/LATERAL
TROCHLEA, LATERAL EPICONDYLE, POSTEROLATERAL EPICONDYLE, POSTERIOR
TROCHLEA, MEDIAL TROCHLEA/EPICONDYLE
• • JUPITER CLASSIFICATION
• • HIGH T—PROXIMAL OR AT LEVEL OF OLECRANON FOSSA
• • LOW T (COMMON)—TRANSVERSE COMPONENT JUST PROXIMAL TO THE TROCHLEA
• • Y—OBLIQUE PORTION THROUGH BOTH COLUMNS WITH DISTAL VERTICAL FRACTURE
• • H—TROCHLEA IS FREE FRAGMENT (AVN)

• BRACHIORADIALIS FOLLOWED BY EXTENSOR CARPI RADIALIS LONGUS (WRIST EXTENSION IN
RADIAL DEVIATION) ARE THE FIRST TO RETURN, WHEREAS EXTENSOR POLLICIS LONGUS
AND EXTENSOR INDICIS PROPRIUS ARE LAST TO RETURN.
• • WHEN TO EXPLORE:
• • A HIGHER LIKELIHOOD OF TRANSECTION
• • PERFORM ORIF OF FRACTURE AT TIME OF EXPLORATION.
• • CONTROVERSIAL WHETHER TO OBSERVE OR EXPLORE:

• • SECONDARY NERVE PALSY (I.E., AFTER FRACTURE MANIPULATION)
• • SPIRAL OR OBLIQUE FRACTURE OF DISTAL THIRD (HOLSTEIN- LEWIS FRACTURE)
• • MANAGEMENT OF PALSY THAT DOES NOT RECOVER IS ALSO CONTROVERSIAL AS TO TIMING
OF ELECTROMYOGRAPHY, NERVE EXPLORATION, AND TENDON TRANSFERS.
• • NONUNION—TREAT WITH COMPRESSION PLATE WITH BONE GRAFT IF ATROPHIC.
• • SHOULDER PAIN; SOME PAPERS REPORT A HIGH INCIDENCE OF SHOULDER PAIN, WHEREAS
OTHERS DO NOT. OVERALL INCIDENCE IS HIGHER WITH IM NAILS.
• SUPRACONDYLAR FRACTURE—RARE INJURY IN ADULTS
• • AO (ARBEITSGEMEINSCHAFT FÜR OSTEOSYNTHESEFRAGEN)/ OTA DISTAL HUMERUS CLASSIFICATION

• • TYPE A—EXTRAARTICULAR
• • TYPE B—INTRAARTICULAR, SINGLE COLUMN
• • TYPE C—INTRAARTICULAR, WITH BOTH COLUMNS FRACTURED AND NO PORTION OF THE JOINT CONTIGUOUS WITH THE SHAFT
• TREATMENT: ORIF
• N COMPLICATIONS: NEUROVASCULAR INJURY, NONUNION, MALUNION, LOSS OF MOTION (CONTRACTURE, FIBROSIS, BONY
BLOCK)
• N DISTAL SINGLE-COLUMN (CONDYLE) FRACTURE
• • CLASSIFIED AS MILCH TYPES I AND II LATERAL CONDYLE FRACTURES (MORE COMMON) AND TYPES I AND II MEDIAL
CONDYLE FRACTURES. IN TYPE I LATERAL CONDYLE FRACTURES THE LATERAL TROCHLEAR RIDGE IS INTACT, AND IN TYPE
II LATERAL CONDYLE FRACTURES THERE IS A FRACTURE THROUGH LATERAL TROCHLEAR RIDGE (FIGURE 11-10).
• N TREATMENT—TYPE I NONDISPLACED: IMMOBILIZE IN SUPINATION (LATERAL CONDYLE FRACTURE) OR PRONATION
(MEDIAL CONDYLE FRACTURE); OTHERWISE, CRPP OR ORIF
• N COMPLICATIONS: CUBITUS VALGUS (LATERAL) OR CUBITUS VARUS (MEDIAL), ULNAR NERVE INJURY, AND DEGENERATIVE
JOINT DISEASE (DJD)
• DISTAL TWO-COLUMN FRACTURE
• N PRESENTATION:
FIVE MAJOR ARTICULAR FRAGMENTS IDENTIFIED: CAPITELLUM/LATERAL
TROCHLEA, LATERAL EPICONDYLE, POSTEROLATERAL EPICONDYLE, POSTERIOR
TROCHLEA, MEDIAL TROCHLEA/EPICONDYLE
• • JUPITER CLASSIFICATION
• • HIGH T—PROXIMAL OR AT LEVEL OF OLECRANON FOSSA
• • LOW T (COMMON)—TRANSVERSE COMPONENT JUST PROXIMAL TO THE TROCHLEA
• • Y—OBLIQUE PORTION THROUGH BOTH COLUMNS WITH DISTAL VERTICAL FRACTURE
• • H—TROCHLEA IS FREE FRAGMENT (AVN)

• MEDIAL LAMBDA—PROXIMAL FRACTURE EXITS MEDIALLY
• • LATERAL LAMBDA—PROXIMAL FRACTURE EXITS LATERALLY
• • MULTIPLANE—T TYPE WITH ADDITIONAL FRACTURE IN CORONAL PLANE
• N TREATMENT (GOAL IS EARLY ROM WITH < 3 WEEKS OF IMMOBILIZATION)
• • ORIF USING A POSTERIOR APPROACH WITH TWO PLATES APPLIED TO EITHER COLUMN
• • BIOMECHANICAL STUDIES SUPPORT BOTH PARALLEL PLACEMENT (ONE PLATE MEDIAL, ONE
PLATE LATERAL) AND PERPENDICULAR PLACEMENT (ONE PLATE MEDIAL, ONE PLATE
POSTEROLATERAL) CONFIGURATIONS
• • USED WITH OLECRANON OSTEOTOMY OR TRICEPS SPLIT/PEEL (FINAL MUSCLE STRENGTH
SIMILAR WITH BOTH)
• • IN AN OPEN FRACTURE, USE ORIF BY MEANS OF A TRICEPS SPLIT THROUGH THE DEFECT,
PRODUCING BETTER RESULTS THAN OSTEOTOMY.
• • LOW-T FRACTURES ARE MORE DIFFICULT AND FREQUENTLY REQUIRE REOPERATION (ALMOST
50%) FOR STIFFNESS, BUT THEY CAN HAVE GOOD RESULTS.
• NO BENEFIT FROM ULNAR NERVE TRANSPOSITION DURING ORIF
• • “BAG-OF-BONES” TECHNIQUE—REASONABLE FOR DEMENTED PATIENTS AND THOSE WHO HAVE SEVERE MEDICAL
COMORBIDITIES THAT PREVENT SURGICAL TREATMENT
• • TOTAL ELBOW ARTHROPLASTY—USEFUL FOR COMMINUTED FRACTURES IN LOW-DEMAND PATIENTS OLDER THAN 65
YEARS, PARTICULARLY WITH OSTEOPOROSIS OR RHEUMATOID ARTHRITIS
• N COMPLICATIONS
• • STIFFNESS
• • MOST COMMON COMPLICATION
• • INITIALLY TREAT WITH STATIC-PROGRESSIVE SPLINTING
• • LOSS OF ELBOW MUSCLE STRENGTH OF 25%
• • ULNAR NERVE INJURY
• • TREAT WITH ANTERIOR TRANSPOSITION
• • HETEROTOPIC OSSIFICATION (4%)
• • INFECTION
• N CAPITELLUM FRACTURE
• • BRYAN-MORREY (FIGURE 11-11)
• • TYPE I—HAHN-STEINTHAL; COMPLETE FRACTURE OF CAPITELLUM
• 787 TRAUMA • TYPE II—KOCHER-LORENZ; SHEAR FRACTURE OF ARTICULAR CARTILAGE
• • TYPE III—COMMINUTED
• • MCKEE MODIFICATION
• • TYPE IV—CORONAL SHEAR FRACTURE INCLUDING CAPITELLUM AND TROCHLEA
• N TREATMENT
• • TYPE I—IF NONDISPLACED, SPLINT FOR 2 TO 3 WEEKS AND THEN ALLOW MOTION; IF
DISPLACED MORE THAN 2 MM, USE ORIF.
• • TYPE II—IF NONDISPLACED, SPLINT FOR 2 TO 3 WEEKS AND THEN ALLOW MOTION; IF
DISPLACED, EXCISE FRAGMENTS.
• • TYPE III—IF DISPLACED, EXCISE FRAGMENTS.
• • TYPE IV—ORIF; LATERAL APPROACH RECOMMENDED
• N COMPLICATIONS: NONUNION (1%-11% WITH ORIF), OLECRANON OSTEOTOMY NONUNION,
ULNAR NERVE INJURY, HETEROTOPIC OSSIFICATION (4% WITH ORIF), AND AVN OF
CAPITELLUM
• ELBOW INJURIES (TABLE 11-12)
• N OLECRANON FRACTURE
• N CLASSIFICATION—COLTON (FIGURE 11-12)

• • TYPE I—AVULSION
• • TYPES IIA TO IID—OBLIQUE FRACTURES WITH INCREASING COMPLEXITY
• • TYPE III—FRACTURE-DISLOCATION
• • TYPE IV—ATYPICAL, HIGH-ENERGY, COMMINUTED FRACTURES
• N TREATMENT
• • LESS THAN 1 TO 2 MM DISPLACED—SPLINT AT 60 TO 90 DEGREES FOR 7 TO 10 DAYS, FOLLOWED BY GENTLE

ACTIVE ROM EXERCISES.
• • TENSION BAND—USE STAINLESS STEEL WIRE OR BRAIDED CABLE, NOT BRAIDED SUTURE MATERIAL.
• • THE WIRE LOOP SHOULD BE DORSAL TO THE MIDAXIS OF THE ULNA, THUS TRANSFORMING TENSILE FORCES AT
THE FRACTURE SITE INTO COMPRESSIVE FORCES AT THE ARTICULAR SURFACE.
• • BURY KIRSCHNER WIRES IN ANTERIOR CORTEX FOR INCREASED STABILITY. PROTRUSION THROUGH THE
ANTERIOR CORTEX, HOWEVER, IS ASSOCIATED WITH REDUCED FOREARM ROTATION.
• • MIGRATION OF KIRSCHNER WIRES AND PROMINENT OR PAINFUL HARDWARE OCCURS IN 71%

• CORONOID FRACTURE
• • REGAN AND MORREY CLASSIFICATION

• • TYPE I—FRACTURE OF THE TIP OF THE CORONOID PROCESS
• • TYPE II—FRACTURE OF 50% OR LESS OF CORONOID
• • TYPE III—FRACTURE OF > 50% OF CORONOID
• • O’DRISCOLL CLASSIFICATION
• • TIP
• • ANTEROMEDIAL PROCESS—CAUSED BY A VARUS POSTEROMEDIAL ROTATORY FORCE

AND MAY BE ASSOCIATED
• TRAUMA WITH POSTEROMEDIAL INSTABILITY. INJURY IS AT THE ATTACHMENT SITE OF THE ANTERIOR BUNDLE
OF THE MEDIAL COLLATERAL LIGAMENT.
• • BASAL
• N TREATMENT
• • TYPE I—ASSOCIATED WITH EPISODES OF ELBOW INSTABILITY. IF INSTABILITY PERSISTS, APPLY CERCLAGE WIRE OR
NO. 5 SUTURE THROUGH DRILL HOLES; IF INSTABILITY DOES NOT PERSIST, NO OPERATION.
• • TYPES II AND III—ORIF HELPS RESTORE ELBOW STABILITY; MUST CONFIRM STABILITY BEFORE NONOPERATIVE
TREATMENT BEGINS
• N COMPLICATIONS: INSTABILITY (PARTICULARLY MEDIAL) AND DJD
• N RADIAL HEAD FRACTURE
• N CLASSIFICATION (FIGURE 11-13)
• • TYPE I—NONDISPLACED
• • TYPE II—PARTIAL ARTICULATION WITH DISPLACEMENT
• • TYPE III—COMMINUTED FRACTURES INVOLVING THE ENTIRE HEAD OF THE RADIUS
• • TYPE IV—FRACTURES ASSOCIATED WITH LIGAMENTOUS INJURY OR OTHER ASSOCIATED FRACTURES
• N TREATMENT
• • TYPE I—SPLINT FOR NO MORE THAN 7 DAYS, AND THEN ALLOW MOTION.
• TYPE II—NONSURGICAL TREATMENT WITH ANALGESICS AND ACTIVE ROM AS SYMPTOMS
RESOLVE IF ELBOW IS STABLE AND THERE IS NO BLOCK TO MOTION WITH GOOD REDUCTION.
OTHERWISE, USE ORIF. SURGERY PROVIDES BETTER RESULTS (90%-100% GOOD OR
EXCELLENT).
• • TYPE III—REPLACE THE RADIAL HEAD, USUALLY WITH A METAL IMPLANT. USE ORIF IF
FEWER THAN THREE PIECES. EXCISE ONLY IN ELDERLY PATIENTS WITH LOW FUNCTIONAL
DEMANDS.
• • TYPE IV—REQUIRES SURGICAL REPAIR: MUST USE EITHER ORIF OR METALLIC RADIAL HEAD
REPLACEMENT. DO NOT EXCISE WITHOUT ADDING RADIAL HEAD IMPLANT.
• • SAFE ZONE FOR ORIF OF RADIAL HEAD/NECK IS 110-DEGREE ARC (I.E., 25%) ALONG LATERAL
SIDE, DEFINED BY RADIAL STYLOID AND LISTER TUBERCLE.
• N COMPLICATIONS
• • LOSS OF MOTION
• • POSTERIOR INTEROSSEOUS NERVE INJURY
• • PRONATE ARM TO AVOID INJURY.
• • RADIAL SHORTENING IF ESSEX-LOPRESTI INJURY
• • SYNOVITIS IF A SILASTIC RADIAL HEAD IMPLANT IS USED
• HETEROTOPIC OSSIFICATION (COLLATERAL LIGAMENTS)
• • ULNAR OR MEDIAN NERVE INJURY
• • BRACHIAL ARTERY INJURY
• N “TERRIBLE TRIAD” OF THE ELBOW
• N ELBOW DISLOCATION WITH LATERAL COLLATERAL LIGAMENT INJURY, RADIAL
HEAD FRACTURE, AND CORONOID FRACTURE
• • THE LATERAL COLLATERAL LIGAMENT INJURY IS TYPICALLY A LIGAMENTOUS
AVULSION FROM THE ORIGIN ON THE DISTAL HUMERUS.
• N ALWAYS UNSTABLE AND REQUIRES TREATMENT
• N TREATMENT
• • CORONOID ORIF
• • RADIAL HEAD ORIF OR REPLACEMENT
• • LATERAL COLLATERAL LIGAMENT REPAIR (TYPICALLY TO DISTAL HUMERUS)
• • POSSIBLE MEDIAL COLLATERAL LIGAMENT REPAIR DEPENDING ON STABILITY
• FOREARM FRACTURES (TABLE 11-13)
• N MONTEGGIA FRACTURES
• N DIAGNOSIS/CLASSIFICATION
• • BADO CLASSIFICATION (FIGURE 11-14)

• • TYPE 1 (60%)—ANTERIOR RADIAL HEAD DISLOCATION AND APEX ANTERIOR
PROXIMAL-THIRD ULNA FRACTURE
• • TYPE 2 (15%)—POSTERIOR RADIAL HEAD DISLOCATION AND APEX POSTERIOR
PROXIMAL-THIRD ULNA FRACTURE. ANNULAR LIGAMENT IS DISRUPTED IN
POSTERIOR MONTEGGIA FRACTURE DISLOCATIONS.
• • TYPE 3—LATERAL RADIAL HEAD DISLOCATION AND PROXIMAL ULNAR
METAPHYSEAL FRACTURE
• • TYPE 4—ANTERIOR RADIAL HEAD DISLOCATION AND PROXIMAL-THIRD RADIUS AND
ULNA FRACTURES
• • “MONTEGGIA-EQUIVALENT OR VARIANT”—RADIAL HEAD FRACTURE INSTEAD

OF DISLOCATION
• FIGURE 11-14 MONTEGGIA FRACTURE-DISLOCATIONS. A, TYPE 1. B, TYPE 2. C,
TYPE 3. D, TYPE 4. (FROM CRENSHAW AH: ADULT FRACTURES AND COMPLEX
JOINT INJURIES OF THE ELBOW. IN STANLEY D, KAY NRM, EDITORS: SURGERY OF
THE ELBOW: PRACTICAL AND SCIENTIFIC ASPECTS, LONDON, 1998, ARNOLD.)
• INTEROSSEOUS MEMBRANE EVALUATION IS IMPORTANT WITH MONTEGGIA AND
MONTEGGIA-EQUIVALENT INJURIES.
• • PHYSICAL EXAMINATION—CONSIDERED ABNORMAL IF GREATER THAN 3-MM
INSTABILITY IS NOTED WHEN THE RADIUS PULLED PROXIMALLY, INDICATING
INJURY. IF INJURY IS GREATER THAN 6 MM, BOTH THE INTEROSSEOUS
MEMBRANE AND THE TRIANGULAR FIBROCARTILAGE COMPLEX ARE INJURED.
• • CONFIRM DIAGNOSIS WITH FINDINGS ON MRI OR ULTRASONOGRAPHY.
• • MIDDLE THIRD IS STRONGEST AND MOST IMPORTANT FOR STABILITY.
• TREATMENT—ALL MONTEGGIA FRACTURES IN ADULTS SHOULD BE TREATED WITH ORIF.
• • THE RADIAL HEAD WILL NORMALLY REDUCE AND BE STABLE. IF NOT, THE MOST COMMON CAUSE IS A
NONANATOMIC REDUCTION OF THE ULNA.
• • IF THE ULNA IS ANATOMIC AND THE RADIAL HEAD DOES NOT REDUCE, AN OPEN REDUCTION WITH A
SEPARATE APPROACH IS REQUIRED TO ADDRESS THE ANNULAR LIGAMENT.
• N COMPLICATIONS
• • THE COMPLICATION RATE IS HIGHER FOR MONTEGGIA-EQUIVALENT AND BADO TYPE II INJURIES.
• • PIN INJURY
• • USUALLY RESOLVES SPONTANEOUSLY AND SHOULD BE OBSERVED FOR 3 MONTHS
• • REDISLOCATION/SUBLUXATION, SYNOSTOSIS, AND LOSS OF MOTION

• N BOTH-BONE FOREARM FRACTURES
• N CLASSIFICATION—DISPLACED VERSUS NONDISPLACED

• N TREATMENT
• • ORIF IN ADULTS
• • ORIF WITH CANCELLOUS BONE GRAFT
• • SIGNIFICANT SEGMENTAL BONE LOSS
• • BONE LOSS ASSOCIATED WITH OPEN INJURY

• ROUTINE USE OF BONE GRAFT FOR CLOSED, COMMINUTED FRACTURES IS NO LONGER INDICATED.
• N COMPLICATIONS
• • MALUNION (STIFFNESS/DEFORMITY)
• • RESTORATION OF THE RADIAL BOW IS DIRECTLY RELATED TO FUNCTIONAL OUTCOME.
• • NONUNION
• • TYPICALLY DUE TO TECHNICAL ERROR OR USE OF IM FIXATION
• • TREAT WITH ORIF AND BONE GRAFTING.
• • REFRACTURE AFTER PLATE REMOVAL
• • ASSOCIATED WITH PREMATURE PLATE REMOVAL AT LESS THAN 12 TO 18 MONTHS
• • AFTER PLATE REMOVAL, A FUNCTIONAL FOREARM BRACE SHOULD BE WORN FOR 6 WEEKS AND ACTIVITY
PROTECTED FOR 3 MONTHS.
• • SYNOSTOSIS
• • ASSOCIATED WITH SINGLE-INCISION APPROACH TO ORIF
• • TREATED WITH EARLY EXCISION, IRRADIATION, AND INDOMETHACIN
• • POSTERIOR INTEROSSEOUS NERVE INJURY
• • HENRY (VOLAR) APPROACH TO THE MIDDLE AND UPPER THIRD OF RADIAL DIAPHYSIS
• • VASCULAR INJURY
• ULNA “NIGHTSTICK” FRACTURES
• N CLASSIFICATION: STABLE (TRADITIONAL DEFINITION IS < 50% DISPLACEMENT)
VERSUS UNSTABLE (NEWER LITERATURE SUGGESTS THAT 25%-50%
DISPLACEMENT OR 10-15 DEGREES ANGULATION IS UNSTABLE)
• N TREATMENT
• • DISTAL TWO THIRDS, LESS THAN 50% DISPLACED, AND LESS THAN 10 DEGREES
ANGULATION—SHORT ARM CAST OR FUNCTIONAL FRACTURE BRACE WITH
GOOD INTEROSSEOUS MOLD
• • PROXIMAL THIRD, VERY DISTAL SHAFT/HEAD, OVER 50% DISPLACED, OR OVER
10 DEGREES ANGULATION—ORIF
• CRPP, CLOSED REDUCTION WITH PERCUTANEOUS PINNING; CRPS, COMPLEX REGIONAL PAIN
SYNDROME; DISI, DORSAL INTERCALATED SEGMENT INSTABILITY; ORIF, OPEN REDUCTION AND
INTERNAL FIXATION; TFCC, TRIANGULAR FIBROCARTILAGE COMPLEX.
• FOR NONDISPLACED FRACTURES, THERE IS NO DIFFERENCE IN OUTCOME BETWEEN
SURGICAL AND NONSURGICAL TREATMENT.
• N COMPLICATIONS: MALUNION/NONUNION
• N DISTAL-THIRD RADIUS FRACTURE WITH RADIOULNAR DISLOCATION (GALEAZZI)
• N DIAGNOSIS/CLASSIFICATION:
FRACTURE OF THE RADIUS (USUALLY AT JUNCTION OF
MIDDLE AND DISTAL THIRDS), WITH DISTAL RADIOULNAR JOINT (DRUJ) INSTABILITY
• • DRUJ INSTABILITY
• • DRUJ IS UNSTABLE IN 55% OF PATIENTS WHEN THE RADIAL FRACTURE IS LESS THAN 7.5 CM FROM
THE ARTICULAR SURFACE.
• • DRUJ IS UNSTABLE IN 6% OF PATIENTS WHEN THE RADIAL FRACTURE IS MORE THAN 7.5 CM AWAY
FROM THE ARTICULAR SURFACE.
• • SIGNS OF DRUJ INSTABILITY INCLUDE ULNAR STYLOID FRACTURE, WIDENED DRUJ ON

POSTEROANTERIOR VIEW, DISLOCATION ON LATERAL VIEW, AND 5 MM OR MORE OF RADIAL
SHORTENING.
• TREATMENT
• • PERFORM ORIF OF THE RADIUS AND THEN SUPINATE THE FOREARM AND ASSESS DRUJ.
• • REDUCED AND STABLE: PROTECTIVE SPLINT AND EARLY MOTION
• • REDUCED AND UNSTABLE
• • LARGE ULNAR STYLOID FRAGMENT: PERFORM ORIF OF STYLOID AND IMMOBILIZE IN SUPINATION.
• • NO FRAGMENT: PIN ULNA TO RADIUS AND IMMOBILIZE IN SUPINATION.
• • IRREDUCIBLE
• • MOST COMMONLY DUE TO INTERPOSITION OF EXTENSOR CARPI ULNARIS TENDON
• • APPROACH DRUJ VIA DORSAL INCISION AND REMOVE BLOCK.

• COMPLICATIONS: MALUNION/NONUNION AND DRUJ SUBLUXATION
• WRIST FRACTURES (TABLE 11-14)
• N DISTAL RADIUS FRACTURES
• • FRYKMAN CLASSIFICATION—TYPES I TO VIII (FIGURE 11-15)

• • TYPES II, IV, VI, AND VIII—INCLUDE THE ULNAR STYLOID
• • TYPE I—EXTRAARTICULAR
• • TYPE III—ENTERS RADIOCARPAL JOINT
• • TYPE V—ENTERS RADIOULNAR JOINT
• • TYPE VII—ENTERS BOTH JOINTS

• MELONE CLASSIFICATION (FIGURE 11-16)—DESCRIBES RADIOCARPAL JOINT AS FOUR FRAGMENTS:
• • RADIAL STYLOID
• • SHAFT
• • VOLAR MEDIAL
• • DORSAL MEDIAL
• • TYPES I TO IV REPRESENT INCREASINGLY COMMINUTED FRACTURES OF THE AFOREMENTIONED
FOUR ANATOMIC REGIONS AND THEIR PARTS.
• • TYPE V IS AN EXTREMELY COMMINUTED UNSTABLE FRACTURE WITHOUT LARGE IDENTIFIABLE
FACET FRAGMENTS.
• • FERNANDEZ CLASSIFICATION (FIGURE 11-17)—BASED ON THE MECHANISM OF INJURY AND
DESIGNED TO GUIDE TREATMENT DECISION MAKING
• • TYPE I—BENDING FRACTURES
• • TYPE II—ARTICULAR SHEAR FRACTURES
• • TYPE III—COMPRESSION FRACTURES
• • TYPE IV—FRACTURE-DISLOCATIONS (ASSOCIATED WITH LIGAMENTOUS INJURY)
• • TYPE V—COMBINED MECHANISMS
• FIGURE 11-15 THE FRYKMAN CLASSIFICATION OF DISTAL RADIUS FRACTURES.
NOTE EVEN NUMBERS WITH ULNAR STYLOID INVOLVEMENT. (FROM KOZIN SH,
BERLET AC: HANDBOOK OF COMMON ORTHOPAEDIC FRACTURES, WEST CHESTER,
PA, 1989, MEDICAL SURVEILLANCE, PP 17, 19.)
• LAFONTAINE PREDICTORS OF INSTABILITY—PATIENTS WITH THREE OR MORE
FACTORS HAVE HIGH CHANCE OF LOSS OF REDUCTION. AMONG THESE
VARIABLES, RADIAL SHORTENING IS THE MOST PREDICTIVE OF INSTABILITY,
FOLLOWED BY DORSAL COMMINUTION.
• • DORSAL ANGULATION GREATER THAN 20°
• • DORSAL COMMINUTION GREATER THAN 50%, PALMAR COMMINUTION,
INTRAARTICULAR COMMINUTION
• • INITIAL DISPLACEMENT GREATER THAN 1 CM
• • INITIAL RADIAL SHORTENING GREATER THAN 5 MM
• • ASSOCIATED ULNAR FRACTURE
• • SEVERE OSTEOPOROSIS
• FIGURE 11-16 THE MELONE CLASSIFICATION OF DISTAL RADIUS FRACTURES. (FROM MELONE CP JR:
OPEN TREATMENT FOR DISPLACED ARTICULAR FRACTURES OF THE DISTAL RADIUS, CLIN ORTHOP
RELAT RES 202:104, 1986, REPRINTED BY PERMISSION.)
• TREATMENT—BASED ON FERNANDEZ CLASSIFICATION
• • TYPE I—USUALLY AN EXTRAARTICULAR METAPHYSEAL FRACTURE. COMMINUTION DETERMINES
STABILITY. THE VOLARLY DISPLACED RADIAL FRACTURE IS MUCH MORE UNSTABLE. USE
CONSERVATIVE TREATMENT WITH REDUCTION AND CASTING IF STABLE AND CRPP VERSUS
INTERNAL/EXTERNAL FIXATION IF UNSTABLE. AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
CLINICAL PRACTICE GUIDELINES GIVES A MODERATE STRENGTH OF RECOMMENDATION FOR
SURGICAL FIXATION OF DISTAL RADIUS FRACTURES.
• • TYPE II—SHEARING INJURY OF THE JOINT SURFACE (VOLAR OR DORSAL LIP OR RADIAL STYLOID).
THIS TYPE IS USUALLY UNSTABLE, AND CARPAL SUBLUXATION FREQUENTLY OCCURS. TREATMENT IS
WITH ORIF.
• • TYPE III—ARTICULAR COMPRESSION (DIE-PUNCH) INJURIES FOLLOW PATTERNS DESCRIBED BY
MELONE.
• • CONSERVATIVE TREATMENT IF NONDISPLACED
• • ORIF WITH DISIMPACTION OF THE ARTICULAR SURFACE IF DISPLACED. ARTHROSCOPY MAY BE ADJUNCT.
• • TYPE IV—RARE AND FOLLOWS HIGH-ENERGY TRAUMA

• • THESE ARE AVULSION FRACTURES WITH RADIOCARPAL FRACTURE DISLOCATIONS.
• SURGICAL REPAIR OF THE AVULSED STYLOID USUALLY RESTORES STABILITY.
TREAT WITH CLOSED OR (MORE FREQUENTLY) OPEN REDUCTION, PIN OR SCREW
FIXATION, OR TENSION WIRING.
• • TYPE V—COMBINATION FRACTURES OF TYPES I TO IV AFTER HIGH-ENERGY
TRAUMA. THESE ARE VERY SEVERE AND UNSTABLE FRACTURES. THERE ARE
ALWAYS ASSOCIATED INJURIES. TREATMENT IS OPEN, WITH COMBINED
METHODS.
• N OUTCOMES—RESTORATION OF ANATOMIC ALIGNMENT BEST PREDICTOR OF A
GOOD OUTCOME
• • LOSS OF RADIAL LENGTH AND VOLAR TILT IS THE MOST IMPORTANT; RADIAL
INCLINATION IS LESS IMPORTANT.
• • ARTICULAR STEP-OFFS OF MORE THAN 1 TO 2 MM ALSO PREDICT POOR
OUTCOME.
• N COMPLICATIONS—LOSS OF REDUCTION, MALUNION/NONUNION, MEDIAN
NERVE NEUROPATHY, WEAKNESS, TENDON ADHESION,
• INSTABILITY, EXTENSOR POLLICIS LONGUS RUPTURE, DORSAL INTERCALATED
SEGMENT INSTABILITY (DISI), VOLKMANN ISCHEMIC CONTRACTURE, AND
COMPLEX REGIONAL PAIN SYNDROME. SOME STUDIES HAVE SHOWN THAT
VITAMIN C CAN REDUCE THE LIKELIHOOD OF COMPLEX REGIONAL PAIN
SYNDROME FOLLOWING DISTAL RADIUS FRACTURE.
• N OTHER VARIANTS AND EPONYMS
• N DORSAL RIM RADIUS FRACTURES—DORSAL BARTON (FIGURE 11-18)
• • CLASSIFICATION—FERNANDEZ TYPE II
• • TREATMENT—ORIF WITH DORSAL APPROACH IN THE VAST MAJORITY
• • COMPLICATIONS—SAME AS FOR DISTAL RADIUS FRACTURE
• N RADIAL STYLOID FRACTURES—CHAUFFEUR FRACTURE (FIGURE 11-19)
• • DIAGNOSIS/CLASSIFICATION—FREQUENTLY HIGH-ENERGY TRAUMA IN YOUNG
ADULTS. FERNANDEZ TYPE II IS ASSOCIATED WITH PERILUNATE INJURIES.
• CARPAL INJURIES
• SEE CHAPTER 7, “HAND, UPPER EXTREMITY, AND MICROVASCULAR SURGERY.”
• SECTION
• FIGURE 11-20 THE BARTON FRACTURE (VOLAR). (FROM CONNOLLY JF, EDITOR:
DEPALMA’S THE MANAGEMENT OF FRACTURES AND DISLOCATIONS: AN ATLAS, ED 3,
PHILADELPHIA, 1981, WB SAUNDERS, P 1028, REPRINTED BY PERMISSION.)
• SECTION 3 LOWER EXTREMITY AND PELVIS
• PELVIC AND ACETABULAR INJURIES

• N PELVIC RING INJURIES (TABLE 11-15)
• N DIAGNOSIS
• • MECHANISM OF INJURY
• • OFTEN HIGH ENERGY
• • ASSOCIATED INJURIES COMMON (CHEST, HEAD, OTHER ORTHOPAEDIC)
• • NONPELVIC SOURCES OF BLEEDING MUST BE RULED OUT.
• • MORTALITY USUALLY RELATED TO NONPELVIC INJURIES
• • RADIOGRAPHS
• • ANTEROPOSTERIOR PELVIS
• • INLET—EVALUATE ANTEROPOSTERIOR DISPLACEMENT OF SACROILIAC JOINT AND INTERNAL/EXTERNAL ROTATIONAL
DEFORMITY.
• • OUTLET—EVALUATE VERTICAL DISPLACEMENT OF SACROILIAC JOINT AND FLEXION OF HEMIPELVIS.
• • CT—PARTICULARLY USEFUL TO EVALUATE POSTERIOR PELVIC INJURY PATTERNS

• • YOUNG-BURGESS (FIGURE 11-21)—BASED ON INJURY MECHANISM. THEORIZED TO PREDICT MORTALITY,

TRANSFUSION REQUIREMENTS, AND ASSOCIATED NONORTHOPAEDIC INJURIES. RECENT STUDIES QUESTION ITS
PREDICTIVE VALUE. ONE LARGE SERIES FOUND IT USEFUL FOR PREDICTING TRANSFUSION REQUIREMENTS BUT DID
NOT PREDICT MORTALITY OR ASSOCIATED NONORTHOPAEDIC INJURIES WELL.
• • LATERAL COMPRESSION (LC)—ALL HAVE ANTERIOR TRANSVERSE PUBIC RAMUS FRACTURE.
• LC I—SACRAL COMPRESSION FRACTURE
• • LC II—POSTERIOR ILIAC WING FRACTURE
• • LC III—CONTRALATERAL ANTEROPOSTERIOR COMPRESSION INJURY (“WINDSWEPT PELVIS”)
• • THOUGHT TO BE DUE TO A ROLLOVER MECHANISM
• • ANTEROPOSTERIOR COMPRESSION (APC)—ALL HAVE SYMPHYSEAL DIASTASIS.
• • APC I—SYMPHYSEAL DIASTASIS LESS THAN 2.5 CM
• • STRETCHING OF ANTERIOR SACROILIAC LIGAMENTS
• • APC II—SYMPHYSEAL DIASTASIS GREATER THAN 2.5 CM WITH WIDENING OF SACROILIAC JOINT ANTERIORLY
• • RUPTURE OF SACROTUBEROUS, SACROSPINOUS, AND ANTERIOR SACROILIAC LIGAMENTS
• • APC III—SYMPHYSEAL DIASTASIS GREATER THAN 2.5 CM WITH COMPLETE DISRUPTION OF SACROILIAC JOINT,
BOTH ANTERIORLY AND POSTERIORLY. HIGHEST TRANSFUSION REQUIREMENTS.
• • RUPTURE OF SACROTUBEROUS, SACROSPINOUS, AND ANTERIOR AND POSTERIOR SACROILIAC LIGAMENTS
• • COMPLETE SEPARATION OF HEMIPELVIS FROM PELVIC RING
• • VERTICAL SHEAR (VS)
• • USUALLY DUE TO A FALL. VERTICAL DISPLACEMENT OF HEMIPELVIS COMMONLY WITH COMPLETE DISRUPTION OF THE SI JOINT.
• • COMBINED MECHANISM
• • STABLE TYPES ARE LATERAL COMPRESSION TYPE I AND ANTEROPOSTERIOR COMPRESSION TYPE I
• APC II, APC III, LC III, AND VS MAY HAVE STRETCHING AND TEARING OF VEINS AND ARTERIES CAUSING
HEMORRHAGIC SHOCK
• • ASSOCIATED INJURIES
• • APC PATTERN HAS ASSOCIATED URETHRAL AND BLADDER INJURIES. INCIDENCE OF SPLEEN, LIVER, BOWEL,
AND PELVIC VASCULAR INJURY INCREASES FROM APC-I TO APC-III CATEGORIES.
• • LC-I AND LC-II PATTERN HAS ASSOCIATED BRAIN, LUNG, AND ABDOMINAL INJURIES.
• • LC-III PATTERN USUALLY DUE TO A CRUSH INJURY TO PELVIS, SPARING OTHER ORGANS FROM INJURY
• • VERTICAL SHEAR PATTERN HAS SIMILAR INJURY PATTERN AND MORTALITY TO APC-II AND APC-III INJURIES.
• • COMBINED MECHANISM PATTERN HAS ORGAN INJURY PATTERN SIMILAR TO LOWER-GRADE APC AND LC
PATTERNS
• • CAUSE OF DEATH IN LC PATTERN IS PRIMARILY DUE TO BRAIN INJURY, WHEREAS IN APC, PATTERN IS
PRIMARILY DUE TO SHOCK, SEPSIS, AND ARDS.
• • TILE—BASED ON FRACTURE STABILITY
• • STABLE (POSTERIOR ARCH INTACT)
• • AVULSION FRACTURES
• • ILIAC WING FRACTURES
• • TRANSVERSE SACRAL FRACTURES
• • PARTIALLY STABLE—ROTATIONALLY UNSTABLE AND VERTICALLY STABLE
• FIGURE 11-21 YOUNG-BURGESS CLASSIFICATION. A, LATERAL COMPRESSION. TYPE I: A
POSTERIORLY DIRECTED FORCE CAUSING A SACRAL CRUSHING INJURY AND HORIZONTAL
PUBIC RAMUS FRACTURES IPSILATERALLY. TYPE II: A MORE ANTERIORLY DIRECTED
FORCE CAUSING HORIZONTAL PUBIC RAMUS FRACTURES WITH AN ANTERIOR SACRAL
CRUSHING INJURY AND EITHER DISRUPTION OF THE POSTERIOR SACROILIAC JOINTS OR
FRACTURES THROUGH THE ILIAC WING. TYPE III: AN ANTERIORLY DIRECTED FORCE THAT
IS CONTINUED, CAUSING EXTERNAL ROTATION OF THE CONTRALATERAL SIDE; THE
SACROILIAC JOINT IS OPENED POSTERIORLY AND THE SACROTUBEROUS AND SPINOUS
LIGAMENTS ARE DISRUPTED. B, ANTEROPOSTERIOR COMPRESSION. TYPE I: SYMPHYSIS
DISRUPTED BUT WITH INTACT POSTERIOR LIGAMENTOUS STRUCTURES. TYPE II:
CONTINUATION OF A TYPE I FRACTURE WITH DISRUPTION OF THE SACROSPINOUS AND
POTENTIALLY THE SACROTUBEROUS LIGAMENTS AND AN ANTERIOR SACROILIAC JOINT
OPENING. TYPE III: CONTINUATION FORCE DISRUPTS THE SACROILIAC LIGAMENTS. C,
VERTICAL SHEAR: VERTICAL FRACTURES IN THE RAMI AND DISRUPTION OF ALL
POSTERIOR LIGAMENTS. THIS INJURY IS EQUIVALENT TO AN ANTEROPOSTERIOR TYPE III
OR A COMPLETELY UNSTABLE AND ROTATIONALLY UNSTABLE FRACTURE. ARROW
INDICATES THE DIRECTION OF FORCE. (REDRAWN FROM YOUNG JWR, BURGESS AR:
RADIOLOGIC MANAGEMENT OF PELVIC RING FRACTURES, BALTIMORE, 1987, URBAN &
SCHWARZENBERG.)
• EXTERNAL ROTATION
• • ANTERIOR PELVIC DISRUPTION ALONE
• • ANTERIOR SACROILIAC LIGAMENTS TOO
• • ANTERIOR AND POSTERIOR SACROILIAC LIGAMENTS
• • LATERAL COMPRESSION
• • IPSILATERAL
• • CONTRALATERAL (BUCKET HANDLE)
• • BILATERAL
• • UNSTABLE (COMPLETE DISRUPTION OF POSTERIOR ARCH)
• • UNILATERAL
• • BILATERAL BUT ONE SIDE B TYPE AND ONE SIDE C TYPE
• • BILATERAL C TYPE
• N TREATMENT
• • GENERAL PRINCIPLES
• • EMERGENT TREATMENT: CONTROL HEMORRHAGE AND PROVISIONALLY STABILIZE PELVIC RING
• • IMPORTANT TO ESTABLISH AND FOLLOW A TREATMENT PROTOCOL TO AVOID VARIATION IN TREATMENT
DECISION MAKING (FIGURE 11-22)
• 85% OF BLEEDING DUE TO VENOUS INJURY, ONLY 15% ARTERIAL SOURCE
• • VOLUME RESUSCITATION AND EARLY BLOOD TRANSFUSION
• • PELVIC BINDER OR WRAPPED SHEET. EXTERNAL ROTATIONAL DEFORMITY MAY ALSO BE
REDUCED BY TAPING FEET TOGETHER.
• • ANGIOGRAPHIC EMBOLIZATION
• • PELVIC PACKING, INITIALLY POPULARIZED IN EUROPE, PROVIDES TAMPONADE OF VENOUS
BLEEDING.
• • EXTERNAL FIXATION
• • PLACE BEFORE EMERGENT LAPAROTOMY
• • SKELETAL TRACTION—FOR VERTICALLY UNSTABLE PATTERNS
• • PELVIC C CLAMP (RARELY USED)
• • NONOPERATIVE TREATMENT
• • INDICATED FOR STABLE FRACTURE PATTERNS
• • WEIGHT BEARING AS TOLERATED FOR ISOLATED ANTERIOR INJURIES
• • PROTECTED WEIGHT BEARING FOR IPSILATERAL ANTERIOR AND POSTERIOR RING INJURIES
• OPERATIVE TREATMENT
• • INDICATIONS
• • SYMPHYSIS DIASTASIS GREATER THAN 2.5 CM. DEGREE OF ACTUAL DIASTASIS MAY NOT BE APPARENT
IN PATIENTS WHO ARE PLACED IN A PELVIC BINDER PRIOR TO INITIAL AP PELVIC X-RAY. MAY REQUIRE
INTRAOPERATIVE STRESS VIEW EXAMINATION.
• • ANTERIOR AND POSTERIOR SACROILIAC LIGAMENT DISRUPTION
• • VERTICAL INSTABILITY OF POSTERIOR HEMIPELVIS
• • SACRAL FRACTURE WITH DISPLACEMENT GREATER THAN 1 CM
• • ANTERIOR INJURIES
• • ORIF WITH PLATE FIXATION
• • EXTERNAL FIXATION VIA PINS THROUGH ANTERIOR-INFERIOR ILIAC SPINE (BIOMECHANICALLY
STRONGER THAN ILIAC WING BUT LESS WELL TOLERATED CLINICALLY) OR ILIAC WING
• • THE LATERAL FEMORAL CUTANEOUS NERVE IS MOST AT RISK.
• • POSTERIOR INJURIES
• • PERCUTANEOUS ILIOSACRAL SCREW FIXATION
• • VERTICAL SACRAL FRACTURES ARE AT HIGHER RISK FOR LOSS OF FIXATION.
• • ANTERIOR PLATE FIXATION ACROSS THE SACROILIAC JOINT
• • POSTERIOR TRANSILIAC SACRAL BARS OR SACRAL PLATING
• • SPINAL-PELVIC FIXATION CONSIDERED FOR BILATERAL SACRAL FRACTURES

• VERTICALLY UNSTABLE PATTERNS WITH ANTERIOR AND POSTERIOR DISLOCATIONS
• • ANTERIOR RING INTERNAL FIXATION AND PERCUTANEOUS SACROILIAC SCREW HAS BEEN SHOWN TO BE MOST
STABLE FIXATION CONSTRUCT
• • SPINAL-PELVIC FIXATION MAY ALSO BE CONSIDERED.
• N COMPLICATIONS
• • SEVERE LIFE-THREATENING HEMORRHAGE
• • HIGHEST RISK WITH APC II, APC III, AND LC III PATTERNS
• • NEUROLOGIC INJURY
• • UROGENITAL INJURY/DYSFUNCTION
• • URETHRAL STRICTURE MOST COMMON IN MEN
• • DYSPAREUNIA AND NEED FOR CESAREAN SECTION CHILDBIRTH COMMON IN WOMEN
• • MALUNION
• • NONUNION
• • DVT AND/OR PULMONARY EMBOLUS
• • DVT IS THE MOST COMMON COMPLICATION IF THROMBOPROPHYLAXIS IS NOT USED.
• • INFECTION—OPEN FRACTURE AND ASSOCIATED CONTAMINATED LAPAROTOMY
• • DEATH
• • RISK FACTORS FOR DEATH IDENTIFIED DURING INITIAL TREATMENT:
• • BLOOD TRANSFUSION REQUIREMENT IN FIRST 24 HOURS
• CLASSIFICATION—DENIS CLASSIFICATION (FIGURE 11-23) BASED ON FRACTURE LOCATION RELATIVE TO
FORAMEN (ZONES I, II, AND III)
• N TREATMENT
• • INDICATED FOR STABLE AND MINIMALLY DISPLACED FRACTURES
• • WEIGHT BEARING AS TOLERATED FOR INCOMPLETE FRACTURES IN WHICH THE ILIUM IS CONTIGUOUS WITH THE
INTACT SACRUM (E.G., ANTERIOR IMPACTION FRACTURES FROM LATERAL COMPRESSION MECHANISM OR ISOLATED
SACRAL ALAR FRACTURES)
• • TOUCH-TOE WEIGHT BEARING FOR COMPLETE FRACTURES
• • OPERATIVE TREATMENT
• • INDICATED FOR DISPLACED FRACTURES (>1 CM)
• • PERCUTANEOUS ILIOSACRAL SCREWS
• • APPROPRIATE FLUOROSCOPIC VISUALIZATION OF ANATOMIC LANDMARKS IS MANDATORY BEFORE SURGERY.
• • THE PELVIC OUTLET RADIOGRAPH ALLOWS OPTIMAL VISUALIZATION OF THE S1 NEURAL FORAMINA TO AVOID INJURY.
• • THE LATERAL SACRAL VIEW IDENTIFIES THE SACRAL ALAR SLOPE AND MINIMIZES RISK TO THE L5 NERVE ROOT.
• • HIGH INCIDENCE OF SACRAL DYSMORPHISM (20%-44%). SACRALIZATION OF L5 OR LUMBARIZATION OF S1. RISK OF ANTERIOR
SCREW PENETRATION CAUSING NEUROLOGIC INJURY IS MUCH HIGHER WITH ANTEROSUPERIOR SACRAL CONCAVITY. (FIGURE
11-24)
• • RADIOGRAPHIC SIGNS OF SACRAL DYSMORPHISM BEST SEEN ON OUTLET VIEW: PROMINENT MAMMILLARY
PROCESSES, LATERALLY DOWNSLOPING SACRAL ALA, RESIDUAL VESTIGIAL DISC SPACE BETWEEN S1 AND S2,
TOP OF ILIAC WING AT LEVEL OF L5/S1 INSTEAD OF AT L4/5, NONCIRCULAR S1 ANTERIOR NEURAL TUNNEL
• • PLAIN RADIOGRAPHS
• • AP PELVIS—SIX CARDINAL LINES (FIGURE 11-26)
• • OBTURATOR OBLIQUE—PROFILES ANTERIOR COLUMN AND POSTERIOR WALL. BEST VIEW TO ENSURE THAT SCREW PLACED IN ANTERIOR COLUMN DOES NOT PENETRATE
INTO HIP JOINT (FIGURE 11-27).
• • ILIAC OBLIQUE—PROFILES POSTERIOR COLUMN AND ANTERIOR WALL (FIGURE 11-28)
• • CT
• • THIN-CUT (1-2 MM) AXIAL
• • THREE-DIMENSIONAL RECONSTRUCTION WITH FEMUR SUBTRACTED
• N CLASSIFICATION—LETOURNEL CLASSIFICATION (FIGURE 11-29) BASED ON INVOLVEMENT OF ACETABULAR COLUMNS AND WALLS
• • SIMPLE TYPES
• • POSTERIOR WALL (PW)
• • MOST COMMON SIMPLE TYPE
• • POSTERIOR COLUMN (PC)

• • ANTERIOR WALL (AW)
• • ANTERIOR COLUMN (AC)
• • TRANSVERSE
• • INVOLVES BOTH THE ANTERIOR AND POSTERIOR COLUMNS
• • ASSOCIATED TYPES
• • POSTERIOR COLUMN/POSTERIOR WALL (PC/PW)
• • TRANSVERSE/POSTERIOR WALL (TPW)
• • T-TYPE
• • TRANSVERSE WITH VERTICAL LIMBS THROUGH ISCHIUM
• • ANTERIOR COLUMN/POSTERIOR HEMITRANSVERSE (ACPHT)

• • LEAST COMMON TYPE
• • ASSOCIATED BOTH COLUMN (ABC)

• • MOST COMMON ASSOCIATED TYPE
• • DISSOCIATION OF ACETABULAR DOME FROM INTACT ILIUM
• • “SPUR SIGN” SEEN ON OBTURATOR OBLIQUE VIEW REPRESENTS THE POSTERIOR ILIUM THAT IS UNDISPLACED (FIGURE 11-30).
• N RADIOGRAPHS
• • A SYSTEMATIC EVALUATION CAN BE USED TO CLASSIFY MOST ACETABULAR FRACTURES USING PLAIN RADIOGRAPHS (SEE FIGURE 11-25):
• • EXAMINE THE ILIOPECTINEAL AND ILIOISCHIAL LINES.
• IF BOTH LINES ARE INTACT:
• • POSTERIOR WALL FRACTURE
• • IF ONLY ONE LINE DISRUPTED:
• • ILIOPECTINEAL LINE
• • ANTERIOR WALL FRACTURE
• • ANTERIOR COLUMN FRACTURE
• • ILIOISCHIAL LINE
• • POSTERIOR COLUMN FRACTURE
• • POSTERIOR COLUMN AND POSTERIOR WALL FRACTURE
• • IF BOTH LINES DISRUPTED:

• • LOOK AT THE OBTURATOR RING AND DETERMINE IF IT IS INTACT.
• • OBTURATOR RING INTACT
• • TRANSVERSE FRACTURE (FIGURE 11-31)
• • TRANSVERSE/POSTERIOR WALL
• • OBTURATOR RING DISRUPTED
• • LOOK AT ILIAC WING.
• • ILIAC WING INTACT
• • T-TYPE (FIGURE 11-32)
• • ILIAC WING DISRUPTED
• • ANTERIOR COLUMN–POSTERIOR HEMITRANSVERSE
• • ASSOCIATED BOTH COLUMN FRACTURE

• CT
• • TYPICALLY USED TO EVALUATE POSTERIOR INJURIES, ARTICULAR FRAGMENTS, MARGINAL
IMPACTION, AND CONGRUENCY OF THE HIP JOINT
• • AXIAL CT MAY BE USEFUL TO AID IN FRACTURE CLASSIFICATION.
• • VERTICAL FRACTURE LINE
• • TRANSVERSE OR T-SHAPED FRACTURE
• • IF THE WALL CAN CLEARLY BE VISUALIZED, THEN ANTERIOR OR POSTERIOR WALL FRACTURE
• • HORIZONTAL FRACTURE LINE
• • COLUMN FRACTURE
• • SEQUENTIAL AXIAL CT CUTS THAT DEMONSTRATE NO INTACT SUPPORT BETWEEN THE

ACETABULAR ARTICULAR SURFACE AND AXIAL SKELETON THROUGH THE SACROILIAC JOINT
ARE ASSOCIATED BOTH-COLUMN FRACTURES
• N TREATMENT
• • RESTORE ARTICULAR CONGRUITY AND HIP STABILITY.
• • AVOID INJURY TO BLOOD SUPPLY TO FEMORAL HEAD.
• • DVT SCREENING AND PROPHYLAXIS
• DURING SURGERY, EXTEND HIP AND FLEX KNEE TO MINIMIZE TENSION ON
SCIATIC NERVE
• • PATIENTS ARE GENERALLY TOUCH-DOWN WEIGHT BEARING POSTOPERATIVELY.
GETTING UP FROM CHAIR USING THE AFFECTED LEG PRODUCES THE
GREATEST RISK OF FIXATION FAILURE BY CREATING THE HIGHEST
ACETABULAR CONTACT PRESSURES.
• • INDICATIONS
• • NONDISPLACED OR MINIMALLY DISPLACED FRACTURE (<1-MM STEP AND <2-MM
GAP)
• • ROOF ARC ANGLE GREATER THAN 45 DEGREES ON AP, ILIAC OBLIQUE, AND
OBTURATOR OBLIQUE—CT CORRELATE IS A FRACTURE GREATER THAN 10 MM FROM
THE DOME APEX.
• • POSTERIOR WALL FRACTURE WITHOUT INSTABILITY (<20%-30% OF POSTERIOR

WALL—EXACT NUMBER CONTROVERSIAL)
• OPERATIVE DYNAMIC STRESS EXAMINATION MAY BE CONSIDERED TO ASSESS
STABILITY OF POSTERIOR WALL FRACTURE.
• • FRACTURE OF BOTH COLUMNS, WITH SECONDARY CONGRUENCE
• • SEVERE COMMINUTION IN THE ELDERLY IN WHOM TOTAL HIP REPLACEMENT IS
PLANNED AFTER FRACTURE HEALING
• • PROTECTED WEIGHT BEARING FOR APPROXIMATELY 6 WEEKS
• • FOR UNSTABLE INJURIES THAT CANNOT BE OPERATED ON—FEMORAL
TRACTION FOR 2 TO 3 WEEKS, FOLLOWED BY TOE-TOUCH WEIGHT BEARING FOR
3 TO 4 WEEKS
• • EARLY SURGERY (<5 DAYS FROM INJURY) IS ASSOCIATED WITH IMPROVED
FRACTURE REDUCTION COMPARED TO LATE SURGERY (10-14 DAYS)
• • INDICATIONS
• FIGURE 11-28 A, ILIAC OBLIQUE VIEW OF PELVIS OBTAINED WITH THE PATIENT
TILTED 45 DEGREES, WITH THE AFFECTED HIP DOWN AND ADJACENT TO THE X-
RAY CASSETTE. THE X-RAY BEAM WAS CENTERED OVER THE AFFECTED HIP. B,
ILIAC OBLIQUE RADIOGRAPH PROFILES THE POSTERIOR COLUMN AND THE
ANTERIOR WALL OF THE ACETABULUM. C, ILIAC OBLIQUE–RELATED
LANDMARKS. (A AND B FROM TORNETTA P III, BAUMGAERTNER M: ORTHOPAEDIC
KNOWLEDGE UPDATE: TRAUMA 3, ROSEMONT, ILL, 2005, AMERICAN ACADEMY OF
ORTHOPAEDIC SURGEONS, P 263; C FROM SCHEMITSCH E: OPERATIVE TECHNIQUES:
ORTHOPAEDIC TRAUMA SURGERY, PHILADELPHIA, 2010, SAUNDERS.)
• CORONA MORTIS: COMMON (10%-30%) VASCULAR COMMUNICATION
BETWEEN EXTERNAL ILIAC AND THE OBTURATOR ARTERY TYPICALLY SEEN
ABOUT 5 CM MEDIALLY FROM PUBIC SYMPHYSIS. NEEDS TO BE LIGATED TO
PREVENT RETRACTION OF INADVERTENTLY INJURED VESSEL.
• • EXTENSILE APPROACHES CONSIDERED FOR FRACTURES MORE THAN 3 WEEKS
OLD, COMPLEX ASSOCIATED FRACTURES, AND NEED FOR POSTERIOR COLUMN
REDUCTION
• • COMBINED ANTERIOR AND POSTERIOR APPROACHES
• EXTENDED ILIOFEMORAL APPROACH
• • TRIRADIATE
• • POSTERIOR WITH TROCHANTERIC OSTEOTOMY
• • TREATMENT WITH ORIF AND ACUTE TOTAL HIP ARTHROPLASTY
• • RELATIVE INDICATIONS:
• • AGE OLDER THAN 60 WITH PRESENCE OF SUPEROMEDIAL DOME IMPACTION ON
RADIOGRAPH (“GULL SIGN”)
• • ASSOCIATED DISPLACED FEMORAL NECK FRACTURE
• • SIGNIFICANT PREEXISTING ARTHROSIS
• FIGURE 11-32 IMAGING OF A LEFT ACETABULUM T-TYPE FRACTURE. IN A,
ANTEROPOSTERIOR RADIOGRAPH OF THE LEFT HEMIPELVIS SHOWING A
DISRUPTION OF BOTH ILIOPECTINEAL (BLUE) AND ILIOISCHIAL (RED) LINES. NOTE
THE WHITE ARROW POINTING AT THE FRACTURE LINE EXTENDING DOWN TO THE
PUBIC RAMI (VERTICAL STEM OF THE T-TYPE FRACTURE). IN B, ILIAC OBLIQUE
RADIOGRAPH OF THE LEFT HEMIPELVIS SHOWING THE FRACTURE LINE BREACHING
THE POSTERIOR COLUMN (RED). IN C, OBTURATOR OBLIQUE RADIOGRAPH OF THE
LEFT HEMIPELVIS SHOWING THE FRACTURE EXTENDING THROUGH THE ANTERIOR
COLUMN. IN D, AXIAL CT CUT OF THE T-TYPE FRACTURE EXTENDING FROM
ANTERIOR TO POSTERIOR (TRANSVERSE STEM) WITH A BREACH IN THE
QUADRILATERAL PLATE EXTENDING DISTALLY (VERTICAL STEM).
• COMPLICATIONS
• • SOFT TISSUE DEGLOVING (MOREL-LAVALLÉE LESION) ASSOCIATED WITH HIGHER INFECTION RATES
• • DVT
• • PREOPERATIVE SCREENING AND INFERIOR VENA CAVA FILTER WHEN DVT PRESENT. POSTOPERATIVE SCREENING AND ANTICOAGULATION IF DVT IS
PRESENT.
• • PULMONARY EMBOLISM—TREATMENT SIMILAR TO THAT FOR DVT

• • HETEROTOPIC OSSIFICATION
• • HIGHEST IN EXTENDED ILIOFEMORAL APPROACH. HIGHER IN EXTENDED APPROACHES (20%-50%) THAN KOCHER-LANGENBECK (8%-25%),
THAN ANTERIOR APPROACH (2%-10%).
• • PROPHYLAXIS WITH INDOMETHACIN (DEBATABLE EFFICACY) OR EXTERNAL-BEAM RADIATION THERAPY OF 600 CGY WITHIN 48 HOURS OF SURGERY
• • NEUROLOGIC INJURY
• • SCIATIC NERVE INJURY ASSOCIATED WITH POSTERIOR DISLOCATIONS, ESPECIALLY PERONEAL DIVISION (<50% WITH FULL RECOVERY)
• • INTRAOPERATIVE MONITORING IS NOT ASSOCIATED WITH REDUCED IATROGENIC NERVE INJURY.
• • HIP EXTENSION AND KNEE FLEXION REDUCE TENSION ON SCIATIC NERVE.
• • IATROGENIC INJURY TO LATERAL FEMORAL CUTANEOUS NERVE WITH ANTERIOR APPROACH
• • OSTEONECROSIS—THE HIGHEST INCIDENCE WITH POSTERIOR FRACTURES, ESPECIALLY FRACTURE-DISLOCATIONS; IATROGENIC

DAMAGE TO MEDIAL FEMORAL CIRCUMFLEX ARTERY
• • POSTTRAUMATIC DJD
• • HIGHEST IN PATTERNS WITH POSTERIOR WALL INVOLVEMENT
• • QUALITY OF REDUCTION IS MOST IMPORTANT PREDICTOR.
• • MALREDUCTION
• • ASSOCIATED WITH GREATER DELAY TO SURGERY
• • BLEEDING—ASSOCIATED WITH SHORTER TIME TO SURGERY

• • FUNCTIONAL DEFICIT—ESPECIALLY ABDUCTOR WEAKNESS (POSTERIOR MORE THAN ANTERIOR APPROACH)
• FEMORAL AND HIP INJURIES (TABLES 11-17 AND 11-18)
• N HIP DISLOCATIONS
• N DIAGNOSIS
• • MECHANISM OF INJURY—AXIAL LOAD; POSITION OF HIP DETERMINES DIRECTION OF DISLOCATION

• • USUALLY HIGH-ENERGY MECHANISM; VERY HIGH RATE OF ASSOCIATED INJURIES EITHER SYSTEMIC OR
MUSCULOSKELETAL; 93% RATE OF MRI ABNORMALITIES OF IPSILATERAL KNEE
• • PLAIN RADIOGRAPHS—AP AND LATERAL VIEWS OF THE HIP; AP PELVIS AND JUDET VIEWS AFTER
REDUCTION TO EVALUATE ASSOCIATED ACETABULAR FRACTURES
• CT—PERFORMED AFTER REDUCTION TO EVALUATE ASSOCIATED ACETABULAR AND/OR FEMORAL
HEAD FRACTURE AND LOOSE BODIES IN JOINT
• N CLASSIFICATION—BASED
ON DIRECTION OF DISLOCATION AND PRESENCE OR ABSENCE OF
ASSOCIATED ACETABULAR OR FEMORAL HEAD FRACTURE
• • POSTERIOR DISLOCATION—MOST COMMON; ASSOCIATED WITH POSTERIOR WALL ACETABULAR
FRACTURE AND ANTERIOR FEMORAL HEAD FRACTURE—LEG FLEXED, ADDUCTED, AND INTERNALLY
ROTATED AT HIP
• • IPSILATERAL ASSOCIATED KNEE INJURY; 30% RATE OF MENISCAL TEAR
• • ANTERIOR DISLOCATION—UNCOMMON; LEG EXTENDED, ABDUCTED, AND EXTERNALLY ROTATED

AT HIP
• TREATMENT
• • EMERGENT CLOSED REDUCTION
• • EMERGENT OPEN REDUCTION IF IRREDUCIBLE AFTER CLOSED REDUCTION
• • AVN RATE 2% TO 10% IF REDUCED WITHIN 6 HOURS AND OVER 50% IF REDUCTION DELAYED MORE THAN 12
HOURS
• • ALMOST ALL CASES OF AVN APPEAR WITHIN 2 YEARS OF INJURY.
• • EVALUATE STABILITY AFTER REDUCTION.

• • TRACTION AND/OR HIP ABDUCTION PILLOW FOR UNSTABLE INJURIES PENDING DEFINITIVE
MANAGEMENT OF ASSOCIATED INJURIES (E.G., ACETABULAR FRACTURE)
• • POSTREDUCTION RADIOGRAPHS (AP PELVIS AND JUDET VIEWS) AND CT TO RULE OUT ASSOCIATED
ACETABULAR FRACTURE, FEMORAL HEAD FRACTURE, AND INTRAARTICULAR LOOSE BODIES
• • WEIGHT BEARING AS TOLERATED (IF HIP IS STABLE AND WITHOUT ASSOCIATED INJURIES)
• N COMPLICATIONS
• • OSTEONECROSIS (UP TO 15%)

• • POSTTRAUMATIC ARTHRITIS; LESS COMMON WHEN ASSOCIATED WITH PW ACETABULAR FRACTURE
• • SCIATIC NERVE INJURY (UP TO 20%); PERONEAL NERVE DIVISION USUALLY MOST AFFECTED
• • RECURRENT DISLOCATION (RARE)
• FEMORAL HEAD FRACTURES
• N DIAGNOSIS
• • PLAIN RADIOGRAPHS—AP AND LATERAL VIEWS OF HIP
• • CT—TO EVALUATE LOCATION AND SIZE OF FRAGMENT AND RULE OUT
ASSOCIATED ACETABULAR FRACTURE
• N CLASSIFICATION—PIPKIN CLASSIFICATION (FIGURE 11-33) BASED ON LOCATION
OF FRACTURE RELATIVE TO FOVEA AND PRESENCE OR ABSENCE OF ASSOCIATED
FRACTURES OF THE ACETABULUM OR FEMORAL NECK
• • TYPE I—FRACTURE BELOW FOVEA
• • TYPE II—FRACTURE ABOVE FOVEA
• • TYPE III—ASSOCIATED FEMORAL NECK FRACTURE
• • TYPE IV—ASSOCIATED ACETABULAR FRACTURE
• FIGURE 11-33 PIPKIN CLASSIFICATION SYSTEM OF POSTERIOR HIP DISLOCATIONS ASSOCIATED WITH FEMORAL HEAD
FRACTURES. (FROM BROWNER BD, ET AL, EDITORS: SKELETAL TRAUMA, ED 4, PHILADELPHIA, 2008, ELSEVIER.)
• TREATMENT
• • RESTORE ARTICULAR CONGRUITY OF WEIGHT-BEARING PORTION OF HEAD AND HIP STABILITY.
• • REMOVE ASSOCIATED LOOSE BODIES.
• • TREAT ASSOCIATED ACETABULAR FRACTURE IF UNSTABLE.
• • AVOID INJURY TO STRUCTURES INVOLVED IN BLOOD SUPPLY TO FEMORAL HEAD.
• • INDICATIONS
• • PIPKIN TYPE I—SMALL FRAGMENT AND CONGRUENT JOINT OR NONDISPLACED LARGER FRAGMENT
• • PIPKIN TYPE II—NONDISPLACED; FREQUENT (WEEKLY) RADIOGRAPHS FOR 3 TO 4 WEEKS TO RULE OUT SECONDARY DISPLACEMENT
• • PROTECTED WEIGHT BEARING FOR 4 TO 6 WEEKS
• • INDICATIONS
• • GREATER THAN 1-MM STEP-OFF (EXCEPT SMALL PIPKIN TYPE I)
• • ASSOCIATED LOOSE BODIES IN JOINT
• • ASSOCIATED NECK OR ACETABULAR FRACTURE REQUIRING SURGICAL MANAGEMENT
• • FIXATION WITH HEADLESS COUNTERSUNK LAG SCREWS
• • ANTERIOR APPROACH VIA SMITH-PETERSEN APPROACH FOR PIPKIN TYPES I AND II WITHOUT ASSOCIATED OPERATIVE POSTERIOR WALL FRACTURE
• • POSTERIOR APPROACH FOR PIPKIN TYPE IV
• • HIP ARTHROPLASTY FOR OLDER PATIENT
• N COMPLICATIONS
• • SAME AS THOSE FOR HIP DISLOCATION

• TREATMENT
• • RAPID PREOPERATIVE MEDICAL OPTIMIZATION
• • MORTALITY REDUCED IF SURGERY WITHIN 48 HOURS
• • STABLE FIXATION AND EARLY MOBILIZATION
• • INDICATIONS
• • NONDISPLACED FRACTURES IN PATIENTS ABLE TO COMPLY WITH WEIGHT-BEARING RESTRICTIONS
• • DISPLACED FRACTURES IN PATIENTS WITH EXTREMELY LIMITED FUNCTIONAL DEMANDS AND/OR THOSE WITH HIGH RISK FOR SURGERY
• • TOE-TOUCH WEIGHT BEARING FOR 6 TO 8 WEEKS
• • INDICATIONS
• • DISPLACED FRACTURES
• • MOST NONDISPLACED FRACTURES
• • INTERNAL FIXATION
• • INDICATED FOR GARDEN TYPES I, II, AND III FRACTURES IN YOUNG PATIENTS, OCCULT FRACTURES, AND DISPLACED FRACTURES IN
YOUNG PATIENTS
• • THREE PARALLEL SCREWS FOR GARDEN TYPES I AND II AND OCCULT FRACTURES
• • V PATTERN OF SCREW FIXATION
• • SINCE NECK IS DEVOID OF SUBSTANTIAL CANCELLOUS BONE, FRACTURE WILL SETTLE UNTIL SCREW ABUTS INTACT CORTICAL BONE. SCREWS
ARE IDEALLY POSITIONED SO THAT SHAFT OF SCREW ABUTS FEMORAL NECK FRACTURE INFERIORLY AND POSTERIORLY TO RESIST
DISPLACEMENT (FIGURE 11-36).
• • AVOID START POINT DISTAL TO LESSER TROCHANTER (ASSOCIATED WITH INCREASED RISK OF PERI-IMPLANT
SUBTROCHANTERIC FRACTURE)
• NONUNION—OCCURS IN 10% TO 30% OF DISPLACED FRACTURES
• • HIGHER RISK WITH MALREDUCTION (PARTICULARLY VARUS)
• • TREATMENT OPTIONS INCLUDE CONVERSION TO HIP ARTHROPLASTY (WORSE RESULTS THAN
THOSE ASSOCIATED WITH PRIMARY ARTHROPLASTY) AND VALGUS OSTEOTOMY.
• • INFECTION
• • DECREASED FUNCTIONAL STATUS
• • PREINJURY COGNITIVE FUNCTION AND MOBILITY PREDICT POSTOPERATIVE FUNCTIONAL
OUTCOME.
• • MORTALITY—1-YEAR MORTALITY IN ELDERLY PATIENTS APPROXIMATELY 30%
• • TREATMENT OF FEMORAL FRACTURES ARE ONE OF THE MOST COMMON CAUSES OF
MALPRACTICE SUITS AGAINST ORTHOPAEDIC SURGEONS.
• N INTERTROCHANTERIC FRACTURES
• N DIAGNOSIS
• • MECHANISM OF INJURY: FALL FROM STANDING HEIGHT
• • RISK FACTORS: OSTEOPOROSIS, PRIOR HIP FRACTURE, RISK OF FALLS
• • MORE COMMON THAN FEMORAL NECK FRACTURE IN PATIENTS WITH PREEXISTING HIP ARTHRITIS
• CLASSIFICATION—BASED ON THE NUMBER OF FRACTURE FRAGMENTS AND ABILITY TO RESIST
COMPRESSION LOADS ONCE THEY ARE REDUCED AND FIXED.
• • TWO-PART FRACTURES—USUALLY STABLE, WITH LITTLE RISK OF EXCESSIVE COLLAPSE
• • THREE-PART FRACTURES—INTERMEDIATE STABILITY
• • SIZE AND LOCATION OF LESSER TROCHANTERIC FRAGMENT DETERMINE STABILITY.
• • LARGE POSTERIOR MEDIAL FRAGMENTS ARE LESS STABLE.
• • FOUR-PART AND SEVERELY COMMINUTED FRACTURES ARE THE LEAST STABLE. THEY HAVE THE
HIGHEST RISK FOR EXCESSIVE SHORTENING, VARUS COLLAPSE, AND NONUNION.
• N TREATMENT
• • STABLE FIXATION TO ALLOW EARLY WEIGHT BEARING
• • MINIMIZE POTENTIAL FOR IMPLANT FAILURE
• • MODIFIABLE COMORBIDITIES SHOULD BE CORRECTED AND SURGERY PERFORMED WITHIN FIRST 48
HOURS
• • INDICATIONS
• • NONDISPLACED FRACTURES IN PATIENTS ABLE TO COMPLY WITH NON–WEIGHT-BEARING RESTRICTIONS
• • DISPLACED FRACTURES IN NONAMBULATORY INDIVIDUALS OR THOSE WITH PROHIBITIVE OPERATIVE

RISK
• LONG NAILS INDICATED FOR STANDARD OBLIQUITY, REVERSE OBLIQUITY, AND SUBTROCHANTERIC FRACTURES
• • RISK OF DISTAL ANTERIOR PERFORATION DUE TO MISMATCH OF ANTERIOR BOW BETWEEN FEMUR AND NAIL
• • HIGHER PERI-IMPLANT FRACTURE RATE THAN THAT ASSOCIATED WITH SLIDING HIP SCREW PLATE DEVICES
• • MULTIPLE SCREWS INTO HEAD FRAGMENT MAY PROVIDE IMPROVED ROTATIONAL CONTROL (ADVANTAGE
CONTROVERSIAL).
• • SINGLE LAG SCREW DESIGN SHOULD AIM FOR CENTER—CENTER IN HEAD WITH LESS THAN 25 MM TIP-APEX
DISTANCE TO MINIMIZE RISK OF SCREW CUTOUT
• • A 95-DEGREE FIXED-ANGLE PLATE DEVICE OR LOCKING PROXIMAL FEMORAL PLATE INDICATED FOR REVERSE
OBLIQUITY, COMMINUTED FRACTURE, AND NONUNION REPAIR
• N COMPLICATIONS
• • EXCESSIVE COLLAPSE—STABLE FIXATION TO ALLOW EARLY WEIGHT BEARING

• • RESULTS IN LIMB SHORTENING AND MEDIALIZATION OF SHAFT
• • REDUCED ABDUCTOR MOMENT ARM MAY CAUSE FUNCTIONAL DEFICIT.
• • ASSOCIATED WITH DISPLACEMENT OF LESSER TROCHANTER
• • MORE COLLAPSE ASSOCIATED WITH SLIDING HIP SCREW DEVICE THAN WITH IM IMPLANT
• • MAY RESULT IN PAINFUL, PROMINENT HARDWARE
• • IMPLANT FAILURE/CUTOUT—ASSOCIATED WITH TIP-APEX DISTANCE (SEE FIGURE 11-37) GREATER THAN 25 MM
• • PERI-IMPLANT FRACTURE
• SUBTROCHANTERIC FRACTURES
• N DIAGNOSIS
• • MECHANISM OF INJURY—HIGHER ENERGY THAN INTERTROCHANTERIC FRACTURES

• • AP AND LATERAL VIEWS OF HIP
• • AP AND LATERAL VIEWS OF FEMUR
• N CLASSIFICATION—RUSSELL-TAYLOR CLASSIFICATION (FIGURE 11-38) BASED ON INVOLVEMENT OF LESSER TROCHANTER

AND PIRIFORMIS FOSSA
• • TYPE IA—FRACTURE BELOW LESSER TROCHANTER
• • TYPE IB—FRACTURE INVOLVES LESSER TROCHANTER; GREATER TROCHANTER INTACT
• • TYPE IIA—GREATER TROCHANTER INVOLVED; LESSER TROCHANTER INTACT
• • TYPE IIB—GREATER AND LESSER TROCHANTER INVOLVED
• N TREATMENT
• • RESTORE LIMB LENGTH ALIGNMENT AND ROTATION.
• • INDIRECT REDUCTION TECHNIQUES OBVIATE THE NEED FOR BONE GRAFTING IN ACUTE FRACTURES.
• • NONOPERATIVE TREATMENT RARELY INDICATED
• • OPERATIVE TREATMENT: IMPLANT MUST WITHSTAND HIGH MEDIAL COMPRESSIVE LOADS AND HIGH LATERAL TENSILE LOADS.
• • INDICATIONS: MOST SUBTROCHANTERIC FRACTURES
• • IM FIXATION
• • INDIRECT REDUCTION PRESERVES BIOLOGIC ENVIRONMENT.

• FIGURE 11-38 RUSSELL-TAYLOR CLASSIFICATION OF SUBTROCHANTERIC
FRACTURES. FRACTURE LINES WITHIN RED ZONES DETERMINE THE TYPE. IN
TYPE I FRACTURES, THE PIRIFORMIS FOSSA REMAINS INTACT. INVOLVEMENT OF
THE PIRIFORMIS FOSSA INTRAMEDULLARY NAIL ENTRY SITE IS THE HALLMARK
OF TYPE II FRACTURES. SUBTYPE A FRACTURES DO NOT INVOLVE THE LESSER
TROCHANTER, BUT IN SUBTYPE B THE LESSER TROCHANTER IS A SEPARATE
FRAGMENT. A, TYPE IA SUBTROCHANTERIC FRACTURE, SUITABLE FOR FIRST-
GENERATION LOCKING NAIL. B, TYPE IB SUBTROCHANTERIC FRACTURE, WHICH
REQUIRES A CEPHALOMEDULLARY NAIL. C, TYPE IIA SUBTROCHANTERIC
FRACTURE. THE PIRIFORMIS ENTRY SITE IS INVOLVED, BUT THE LESSER
TROCHANTER IS INTACT. D, TYPE IIB SUBTROCHANTERIC FRACTURE. THE NAIL
ENTRY SITE IS INVOLVED, AND LESSER TROCHANTERIC COMMINUTION
INCREASES INSTABILITY. (MODIFIED FROM TENCER AF ET AL: ORTHOP BIOMECH
LAB REPORT #002, MEMPHIS, TENN, 1985, RICHARDS MEDICAL CO.)
• STANDARD PROXIMAL INTERLOCKING FOR FRACTURES WITH INTACT LESSER
TROCHANTER
• • RECONSTRUCTION INTERLOCKING FOR FRACTURES WITH INVOLVEMENT OF
LESSER TROCHANTER
• • PIRIFORMIS ENTRY NAIL CONTRAINDICATED FOR FRACTURES INVOLVING
PIRIFORMIS FOSSA
• • APEX ANTERIOR AND VARUS ANGULATION ARE THE MOST COMMON
DEFORMITIES.
• • THE PSOAS AND ABDUCTORS LEAD TO FLEXION, ABDUCTION, AND EXTERNAL
ROTATION OF THE PROXIMAL FRAGMENT.
• • OPEN OR PERCUTANEOUS REDUCTION INDICATED WHEN CLOSED REDUCTION
INADEQUATE (FREQUENT); UNION RATES SAME AS WITH CLOSED REDUCTION
• LATERAL POSITIONING ALLOWS EASIER ALIGNMENT OF THE DISTAL SEGMENT TO THE FLEXED PROXIMAL SEGMENT.
• • FIXED-ANGLE PLATE FIXATION/PROXIMAL FEMORAL LOCKING PLATES
• • INDICATED FOR FRACTURES WITH PROXIMAL COMMINUTION AND NONUNION
• • 95-DEGREE DEVICES
• • DEVICES OF 135 DEGREES CONTRAINDICATED
• • MUST AVOID SOFT TISSUE STRIPPING
• • ACUTE BONE GRAFTING USUALLY NOT REQUIRED WHEN BIOLOGICAL PLATING TECHNIQUES ARE USED
• N COMPLICATIONS
• • NONUNION—MINIMIZED WITH IM NAILING AND BIOLOGIC PLATING

• • MALALIGNMENT—VARUS AND APEX ANTERIOR ANGULATION WITH IM NAILING. CONSIDER ADJUNCTIVE REDUCTION AIDS AND PERCUTANEOUS
REDUCTION.
• • INFECTION—ASSOCIATED WITH INCREASED SOFT TISSUE DISSECTION
• N FEMORAL SHAFT FRACTURES (TABLE 11-19)
• N DIAGNOSIS
• • MECHANISM OF INJURY: OFTEN ASSOCIATED WITH HIGH-ENERGY MECHANISMS

• • ASSOCIATED FRACTURES AND OTHER INJURIES ARE COMMON.
• • ASSOCIATED NECK FRACTURES ARE UNCOMMON (<10%) BUT WHEN PRESENT, THEY ARE OFTEN MISSED (UP TO 50%). ANY PATIENT WHO COMPLAINS OF
HIP PAIN DURING THE EARLY POSTOPERATIVE PERIOD FOLLOWING TREATMENT OF A FEMORAL SHAFT FRACTURE SHOULD HAVE DEDICATED HIP X-
RAYS.
• • AP AND LATERAL VIEWS OF FEMUR
• • AP AND CROSS-TABLE LATERAL HIP TO RULE OUT FEMORAL NECK FRACTURE
• • CT SCAN TO RULE OUT OCCULT FEMORAL NECK FRACTURE

• • IF THE SCAN IS OBTAINED FOR ABDOMINAL OR PELVIC EVALUATION, IT SHOULD BE REVIEWED.
• • CONSIDER DEDICATED THIN-CUT CT.
• N CLASSIFICATION—WINQUIST-HANSEN CLASSIFICATION
• (FIGURE 11-39) BASED ON DEGREE OF COMMINUTION AND AMOUNT OF CORTICAL CONTINUITY
• • TYPE 0—NO COMMINUTION
• • TYPE I—COMMINUTION LESS THAN 25%
• • TYPE II—COMMINUTION 25% TO 50%
• • TYPE III—COMMINUTION GREATER THAN 50%
• • TYPE IV—COMMINUTION 100%
• N TREATMENT
• • RESTORE LIMB LENGTH, ALIGNMENT, AND ROTATION.
• • EARLY STABILIZATION REDUCES SYSTEMIC COMPLICATIONS ASSOCIATED WITH MULTIPLY INJURED PATIENTS.
• • NONOPERATIVE TREATMENT (RARELY INDICATED)

• • LONG LEG CAST OR BRACE FOR NONDISPLACED DISTAL SHAFT FRACTURE
• • PILLOW SPLINT FOR NONAMBULATORY INDIVIDUALS
• • OPERATIVE TREATMENT—INDICATED FOR MOST FRACTURES

• • IM NAIL
• • INDICATED FOR MOST FEMORAL SHAFT FRACTURES
• • HIGH UNION RATES (>95%)
• • MORE HIP PROBLEMS WITH ANTEGRADE THAN RETROGRADE INSERTION (PAIN/WEAKNESS).
• • QUADRICEPS AND ABDUCTORS ARE WEAKEST AFTER ANTEGRADE FEMORAL NAILING.

• MORE KNEE PROBLEMS RETROGRADE THAN ANTEGRADE INSERTION (PAIN AND
CHONDRAL INJURY TO PATELLA IF NAIL LEFT PROUD)
• • PIRIFORMIS AND TROCHANTERIC STARTING POINTS INDICATED WHEN THEY ARE USED
WITH APPROPRIATELY DESIGNED NAILS
• • RELATIVE INDICATIONS FOR RETROGRADE FEMORAL NAIL: MORBID OBESITY, BILATERAL
FEMORAL SHAFT FRACTURES (CAN BE DONE WITHOUT NEED TO REPOSITION
• PATIENT), PREGNANCY (REDUCED ABDOMINAL RADIATION), IPSILATERAL TIBIAL SHAFT
FRACTURE THAT WILL BE TREATED WITH AN IM NAIL, DISPLACED IPSILATERAL FEMORAL
NECK FRACTURE THAT WILL BE FIXED WITH ORIF, IPSILATERAL ACETABULAR FRACTURE
(TO AVOID CONTAMINATING ACETABULAR SURGICAL APPROACH), MULTIPLY INJURED
PATIENTS
• • PIRIFORMIS ENTRY CONTRAINDICATED WHEN FRACTURE EXTENDS TO PIRIFORMIS FOSSA
• • ANTERIOR STARTING POINT IN PIRIFORMIS FOSSA ASSOCIATED WITH INCREASED HOOP
STRESS AND RISK OF IATROGENIC COMMINUTION
• • ANTERIOR TROCHANTERIC STARTING POINT WITH MINIMAL HOOP STRESS
• • TROCHANTERIC STARTING POINT RISKS MEDIAL COMMINUTION OF SHAFT DUE TO OFF-
AXIS STARTING POINT AND VARUS IF STRAIGHT (NO TROCHANTERIC BEND) NAIL USED
• • STATIC INTERLOCKING FOR MOST FRACTURES
• • REAMED NAILING FOR MOST FRACTURES
• • HIGHER UNION RATES THAN UNREAMED NAILS
• • UNREAMED NAILS ASSOCIATED WITH DECREASED FAT EMBOLIZATION; CLINICAL
RELEVANCE UNCLEAR
• • APPROPRIATE REAMING TECHNIQUE INCLUDES SHARP REAMERS, SLOW ADVANCEMENT,
LESS HEAT GENERATION, AND LESS EMBOLIZATION.
• • MINIMUM CORTICAL REAMING PREFERRED
• • NAIL DIAMETER 1 TO 2 MM SMALLER THAN LARGEST REAMER
• • MULTIPLY INJURED PATIENTS MAY BENEFIT FROM DELAYED NAILING WITH IMMEDIATE
PROVISIONAL EXTERNAL FIXATION (DAMAGE CONTROL PRINCIPLES).
• BENEFITS INCLUDE REDUCED BLOOD LOSS, REDUCED HYPOTHERMIA, AND REDUCED
INFLAMMATORY MEDIATOR RELEASE.
• • EXTERNAL FIXATION
• • INDICATED FOR PROVISIONAL FIXATION
• • APPLICATION OF DAMAGE CONTROL PRINCIPLES
• • SEVERE CONTAMINATION REQUIRING REPEATED ACCESS TO MEDULLARY CANAL
• • VASCULAR INJURY
• • SAFELY CONVERTED TO IM NAIL IN ABSENCE OF PIN TRACT INFECTION UP TO AT LEAST

3 WEEKS WITH EQUAL UNION AND INFECTION RATES
• • PLATE FIXATION
• • INDICATED FOR PERIPROSTHETIC FRACTURES
• • INDICATED FOR NECK COMPONENT OF NECK-SHAFT FRACTURES
• • REDUCED UNION RATE, HIGHER INFECTION AND IMPLANT FAILURE RATES, AND LONGER
TIME TO WEIGHT BEARING THAN WITH USE OF IM NAIL
• COMPLICATIONS
• • INFECTION—LESS THAN 5% OF CLOSED FRACTURES
• • NONUNION—LESS THAN 5% OF CLOSED FRACTURES
• • EXCHANGE NAILING LESS SUCCESSFUL THAN REPAIR WITH PLATE AND SCREWS AND BONE GRAFTING
• • DELAYED UNION—LESS THAN 5% OF CLOSED FRACTURES

• • DYNAMIZATION LESS SUCCESSFUL THAN EXCHANGE NAILING
• • MALALIGNMENT
• • PROXIMAL FRACTURE MORE OFTEN MALALIGNED WITH RETROGRADE THAN ANTEGRADE NAILING
• • DISTAL FRACTURES MORE OFTEN MALALIGNED WITH ANTEGRADE THAN RETROGRADE NAILING
• • MALUNION (ROTATION AND LENGTH) IS THE MOST COMMON COMPLICATION FOLLOWING IM NAILING
OF HIGHLY COMMINUTED FEMORAL SHAFT FRACTURES.
• • MALROTATION DIFFICULT TO DIAGNOSE, ESPECIALLY WITH COMMINUTED FRACTURES
• • COMPARE WITH CONTRALATERAL LIMB BEFORE LEAVING OPERATING ROOM
• • SUPINE NAILING HAS A HIGHER INCIDENCE OF INTERNAL ROTATION.
• • LATERAL NAILING HAS A HIGHER INCIDENCE OF EXTERNAL ROTATION.
• • FRACTURE TABLE USE HAS A HIGHER INCIDENCE OF INTERNAL ROTATION COMPARED WITH MANUAL TRACTION.
• • LENGTH DISCREPANCY IS ASSOCIATED WITH COMMINUTED FRACTURES.

• HIP PAIN/WEAKNESS IS ASSOCIATED WITH ANTEGRADE NAILING.
• • KNEE PAIN IS ASSOCIATED WITH RETROGRADE NAILING.
• • PATELLAR CHONDRAL INJURY IS ASSOCIATED WITH RETROGRADE NAILING, WITH NAIL
LEFT PROTRUDING INTO THE KNEE JOINT.
• • PUDENDAL NERVE INJURY IS ASSOCIATED WITH EXCESSIVE TRACTION.
• • HO IS ASSOCIATED WITH ANTEGRADE NAILING (RARELY CLINICALLY RELEVANT).
• • OSTEONECROSIS IN ADOLESCENTS WITH OPEN PHYSES TREATED WITH A PIRIFORMIS-
STARTING IM NAIL
• • SIGNIFICANT SHORTENING (I.E., 4 CM) RESULTS IN MEDIAL MECHANICAL AXIS
DEVIATION.
• N SPECIAL CIRCUMSTANCES
• • OBESE PATIENTS
• • HIGHER COMPLICATION RATES WITH PIRIFORMIS NAILING
• • RELATIVE INDICATION FOR RETROGRADE NAILING

• IPSILATERAL FEMORAL NECK AND SHAFT FRACTURES
• • UNCOMMON (<10%) BUT WHEN PRESENT, MISSED IN UP TO 50% OF CASES
• • NECK FRACTURE MANAGEMENT HAS THE HIGHEST PRIORITY AND SHOULD BE FIXED FIRST,
GENERALLY FOLLOWED BY RETROGRADE FEMORAL IM NAIL OR PLATE FIXATION FOR
TREATMENT OF SHAFT FRACTURE.
• • NECK FRACTURE OFTEN NONDISPLACED, VERTICAL, AND BASICERVICAL
• • USE OF 135-DEGREE SLIDING HIP SCREW OR PARALLEL SCREWS PREFERRED FOR FEMORAL NECK
• • RECONSTRUCTION NAIL CAN BE USED FOR NONDISPLACED NECK FRACTURES OR ASSOCIATED
INTERTROCHANTERIC AND SHAFT FRACTURES
• • USE OF A CEPHALOMEDULLARY IM NAIL FOR FIXATION OF DISPLACED IPSILATERAL FEMORAL NECK AND SHAFT
FRACTURES IS ASSOCIATED WITH INCREASED RISK OF FEMORAL NECK MALREDUCTION AND AVN
• • MULTIPLY INJURED PATIENT—CONSIDER DAMAGE CONTROL PRINCIPLES.

• • PROVISIONAL EXTERNAL FIXATOR WITH CONVERSION TO IM NAIL WHEN STABLE (WITHIN 3
WEEKS)
• • MAY BE MORE APPLICABLE WITH ASSOCIATED LUNG/CHEST INJURY
• • PERIPROSTHETIC FRACTURE (SEE CHAPTER 5, ADULT RECONSTRUCTION.)
• SUPRACONDYLAR AND INTRACONDYLAR FRACTURES
• N DIAGNOSIS
• • MECHANISM OF INJURY—HIGH ENERGY IN YOUNG PATIENTS AND LOW ENERGY IN OLDER PATIENTS
• • CT
• • IF INTRACONDYLAR EXTENSION
• • CORONAL FRACTURE (HOFFA FRACTURE) INCIDENCE—40%
• • LATERAL FEMORAL CONDYLE FRACTURE INCIDENCE—80%
• • PLAIN RADIOGRAPHS FREQUENTLY MISS THIS INJURY.
• N CLASSIFICATION—OTA CLASSIFICATION (FIGURE 11-40) BASED ON DEGREE OF COMMINUTION AND ARTICULAR

INVOLVEMENT
• • 33-A—EXTRAARTICULAR
• • 33-B—SIMPLE ARTICULAR (UNICONDYLAR)
• • 33-C—COMPLEX ARTICULAR
•
• TREATMENT
• • RESTORE ARTICULAR CONGRUITY.
• • RIGID STABILIZATION OF ARTICULAR FRACTURE
• • INDIRECT REDUCTION OF METAPHYSEAL COMPONENT TO PRESERVE VASCULARITY TO FRACTURE FRAGMENTS
• • STABLE (NOT NECESSARILY RIGID) FIXATION OF ARTICULAR BLOCK TO SHAFT
• • EARLY KNEE ROM
• • NONOPERATIVE TREATMENT—INDICATED FOR NONDISPLACED FRACTURES

• • BRACE OR KNEE IMMOBILIZED
• • FULL-TIME BRACING FOR 6 TO 8 WEEKS
• • CLOSED-CHAIN ROM AT 3 TO 4 WEEKS
• • OPERATIVE TREATMENT—INDICATED FOR MOST DISPLACED FRACTURES

• • PLATE FIXATION—INDICATED FOR MOST FRACTURES
• • FIXED-ANGLE PLATES REQUIRED WHEN METAPHYSEAL COMMINUTION EXISTS
• • TRADITIONAL 95-DEGREE DEVICES LIMITED BY NUMBER AND LOCATION OF DISTAL FIXATION AND ARE CONTRAINDICATED IN
CASES OF ASSOCIATED HOFFA FRACTURES
• LOCKED PLATES OFFER MULTIPLE FIXED-ANGLE POINTS OF FIXATION IN DISTAL
FRAGMENT IN MULTIPLE PLANES AND OFFER THE ADVANTAGE OF USE IN CASES
WITH ASSOCIATED CORONAL (HOFFA) FRACTURES
• • NON–FIXED-ANGLE PLATES PRONE TO VARUS COLLAPSE, ESPECIALLY IN
METAPHYSEAL COMMINUTION
• • HIGH UNION RATES (>80%) WITH INDIRECT REDUCTION TECHNIQUE WITHOUT BONE
GRAFT
• • LATERAL APPROACH—INDIRECT REDUCTION OF METAPHYSEAL FRACTURE AND
ARTHROTOMY WITH DIRECT REDUCTION OF ARTICULAR COMPONENT
• • SAGITTAL INTRAARTICULAR SPLIT MOST COMMON
• • CONDYLES ARE MALROTATED IN SAGITTAL PLANE WITH RESPECT TO EACH OTHER.
• FIGURE
• CORONAL (HOFFA) FRACTURES REQUIRE INTERFRAGMENTARY LAG SCREWS.
• • LATERALLY APPLIED CONDYLAR PLATE SPANS FRACTURE (LOCKED PLATE PREFERRED).
• • RETROGRADE IM NAIL
• • INDICATED FOR EXTRAARTICULAR FRACTURES AND SIMPLE INTRAARTICULAR
FRACTURES
• • REDUCED STABILITY COMPARED WITH PLATE FIXATION FOR OSTEOPOROTIC FRACTURES,
ESPECIALLY THOSE WITH WIDE METAPHYSEAL FLARES
• • BLOCKING SCREWS CAN HELP PROVIDE REDUCTION AND IMPROVED STABILITY.
• • FIXED-ANGLE DISTAL INTERLOCKING SCREWS MAY PROVIDE IMPROVED STABILITY.
• LONG NAILS THAT CROSS THE FEMORAL ISTHMUS ARE PREFERRED TO SHORT “SUPRACONDYLAR” NAILS.
• • ARTHROPLASTY
• • INDICATED WHEN ASSOCIATED WITH PREEXISTING JOINT ARTHROPATHY AND SELECTED CASES WHEN STABLE
INTERNAL FIXATION NOT ACHIEVABLE
• • USUALLY REQUIRES DISTAL FEMORAL REPLACEMENT PROSTHESIS
• • REDUCED LONGEVITY COMPARED WITH INTERNAL FIXATION
• • ALLOWS IMMEDIATE WEIGHT BEARING
• N COMPLICATIONS
• • NONUNION—ASSOCIATED WITH SOFT TISSUE STRIPPING IN METAPHYSEAL REGION
• • MALALIGNMENT
• • VALGUS MALREDUCTION MOST COMMON (PLATE FIXATION) IN CORONAL PLANE; HYPEREXTENSION MALREDUCTION
MOST COMMON IN SAGITTAL PLANE
• • MALALIGNMENT MORE COMMON WITH IM NAILS
• • LOSS OF FIXATION
• • VARUS COLLAPSE MOST COMMON
• • PLATE FIXATION ASSOCIATED WITH TOGGLE OF DISTAL NON–FIXED-ANGLE SCREWS USED FOR COMMINUTED
METAPHYSEAL FRACTURES
• • IM NAIL FIXATION
• PROXIMAL (DIAPHYSEAL) SCREW FAILURE ASSOCIATED WITH SHORT PLATES AND NONLOCKED
DIAPHYSEAL FIXATION. PLATE FIXATION IS ASSOCIATED WITH TOGGLE OF DISTAL NON–FIXED-
ANGLE SCREWS USED FOR COMMINUTED METAPHYSEAL FRACTURES.
• • INFECTION—OCCURS IN DIABETIC PATIENTS, ESPECIALLY THOSE WITH ACTIVE FOOT ULCERS
• • KNEE PAIN/STIFFNESS
• • PAINFUL HARDWARE—AVOID PROMINENT MEDIAL SCREWS.
• KNEE INJURIES (TABLE 11-20)
• N DISLOCATION
• • DIRECTION (KENNEDY)—ANTERIOR (30%-40%), POSTERIOR (30%-40%), MEDIAL, LATERAL, AND
ROTATORY (POSTEROLATERAL THE MOST COMMON) (FIGURE 11-41)
• • SCHENCK ANATOMIC CLASSIFICATION OF KNEE DISLOCATION (KD)
• • KD I—DISLOCATION WITH EITHER ANTERIOR CRUCIATE LIGAMENT (ACL) OR POSTERIOR CRUCIATE
LIGAMENT (PCL) STILL INTACT (VARIABLE COLLATERAL INVOLVEMENT)
• • KD II—TORN ACL/PCL
• KD III—MOST COMMON
• • TORN ACL/PCL AND EITHER POSTEROLATERAL CORNER (PLC-KD IIIL) OR
POSTEROMEDIAL CORNER (PMC-KD IIIM)
• • KD IV—TORN ACL/PCL/PLC/PMC
• • KD V—FRACTURE-DISLOCATION
• • MORE THAN 50% PRESENT REDUCED (EASILY MISSED DIAGNOSIS)
• • VASCULAR INJURY—5% TO 15% IN RECENT STUDIES
• • SELECTIVE ARTERIOGRAPHY WITH USE OF A PHYSICAL EXAMINATION (INCLUDING ABI)
RATHER THAN AN IMMEDIATE ARTERIOGRAM IS NOW THE STANDARD OF CARE.
• • MOST COMMON FINDING IN PATIENTS WITH VASCULAR INJURY IS A DIMINISHED OR
ABSENT PEDAL PULSE.
• • SIGNIFICANT SOFT TISSUE INJURIES
• TREATMENT
• • EMERGENT REDUCTION IF PATIENT DID NOT PRESENT WITH FRACTURE REDUCED
• • REVASCULARIZE WITHIN 6 HOURS IF THERE IS SIGNIFICANT ARTERIAL INJURY.
• • CARE FOR SOFT TISSUE INJURIES (OPEN-KNEE DISLOCATIONS).
• • LIGAMENT REPAIR OR RECONSTRUCTION
• • RECONSTRUCTION WITH ALLOGRAFT BECOMING THE MOST COMMON
• • ACUTE RECONSTRUCTION MAY BE BETTER THAN CHRONIC RECONSTRUCTION.
• • EARLY MOTION REHABILITATION
• • POSSIBLE ROLE FOR HINGED EXTERNAL FIXATOR

• COMPLICATIONS
• • VASCULAR INJURY—HIGHEST WITH KD IV; ABI OF GREATER THAN 0.9 ASSOCIATED WITH
AN INTACT ARTERY
• • NEUROLOGIC INJURY—PERONEAL NERVE INJURY COMMON (≈25%), BUT UP TO 50%
RECOVER AT LEAST PARTIALLY; MAY BENEFIT FROM NEUROLYSIS.
• • STIFFNESS/ARTHROFIBROSIS—MOST COMMON COMPLICATION (38%)
• • LIGAMENTOUS LAXITY ALSO VERY COMMON (37%)
• N PATELLA FRACTURES
• • DESCRIPTIVE—TRANSVERSE, VERTICAL (RARELY REQUIRES SURGICAL TREATMENT),
COMMINUTED, PROXIMAL OR DISTAL (30%) POLE, AND NONDISPLACED
• • INABILITY TO EXTEND KNEE OR DO A STRAIGHT-LEG RAISE DEMONSTRATES AN
INCOMPETENT EXTENSOR MECHANISM.
• • DISPLACED FRACTURE IS 3 MM FRAGMENT SEPARATION OR 2 MM STEP-OFF.
• TREATMENT: PRESERVE PATELLA WHENEVER POSSIBLE (MAINTAINS LEVER ARM FOR
QUADRICEPS FUNCTION).
• • NONOPERATIVE TREATMENT: NONDISPLACED WITH INTACT EXTENSOR MECHANISM,
HINGED KNEE BRACE IN EXTENSION, AND PROGRESS IN FLEXION AFTER 2 TO 3 WEEKS
• • TENSION BAND WIRING: SIMPLE FRACTURE PATTERNS, MOST COMMON TECHNIQUE; CAN
BE DONE WITH K WIRES OR CANNULATED SCREWS (BIOMECHANICALLY STRONGER); MAY
USE WIRE OR BRAIDED NONABSORBABLE SUTURE (LESS HARDWARE IRRITATION)
• CERCLAGE AND TENSION BAND WIRING: MINIMALLY DISPLACED STELLATE FRACTURES
WITH SIGNIFICANT COMMINUTION
• • PARTIAL PATELLECTOMY: USEFUL WITH EXTRAARTICULAR DISTAL POLE FRACTURES
AND ALSO USED WITH SEVERELY COMMINUTED FRACTURES; PRESERVE THE LARGEST
PIECES AND REATTACH PATELLA LIGAMENT (FIGURE 11-42).
• • ORIF, WHEN POSSIBLE, IS ASSOCIATED WITH BETTER OUTCOMES THAN PARTIAL
PATELLECTOMY IN COMMINUTED AND DISPLACED FRACTURE OF THE INFERIOR
POLE OF THE PATELLA.
• N COMPLICATIONS: SYMPTOMATIC HARDWARE (VERY COMMON), LOSS OF REDUCTION
(22%), NONUNION (<5%), INFECTION, ARTHROFIBROSIS/STIFFNESS
• PATELLA DISLOCATIONS
• N DIAGNOSIS: FREQUENTLY INVOLVES YOUNG ADULTS OR ADOLESCENTS, USUALLY LATERALLY,
AND INVOLVES INJURY TO THE MEDIAL PATELLOFEMORAL LIGAMENT
• N TREATMENT: REDUCE AND IMMOBILIZE WITH CONTROLLED MOTION FOR 6 WEEKS.
• N COMPLICATIONS: REDISLOCATION
• N PATELLA LIGAMENT RUPTURE
• N DIAGNOSIS/CLASSIFICATION: OCCURS IN PATIENTS YOUNGER THAN 40 WITH OVERLOAD OF
EXTENSOR MECHANISM DURING ATHLETIC ACTIVITY
• • INCREASED RISK WITH METABOLIC DISORDERS, RHEUMATOLOGIC DISEASE, RENAL FAILURE,
CORTICOSTEROID INJECTION, PATELLAR
• TENDINITIS, AND INFECTION. DIAGNOSIS IS FREQUENTLY MISSED.
• N TREATMENT: DIRECT PRIMARY REPAIR WITH A NONABSORBABLE SUTURE AND LOCKING
(KRACKOW) STITCH THROUGH PATELLAR DRILL HOLES; CAN SUPPLEMENT WITH SEMITENDINOSUS
GRAFT AND/OR CERCLAGE WIRE/SUTURE TO PROTECT REPAIR
• N COMPLICATIONS: STIFFNESS AND EXTENSOR WEAKNESS
• QUADRICEPS TENDON RUPTURE
• N DIAGNOSIS: PATIENTS MAY BE YOUNGER THAN 40, BUT THIS CONDITION MOST COMMONLY OCCURS IN
OLDER PATIENTS WITH MEDICAL PROBLEMS.
• • ASSOCIATION WITH RENAL FAILURE, DIABETES, RHEUMATOID ARTHRITIS, HYPERPARATHYROIDISM,
CONNECTIVE TISSUE DISORDERS, STEROID USE, AND INTRAARTICULAR INJECTIONS IN 20% TO 33%
• • MALES ARE AFFECTED MORE OFTEN (UP TO 8 : 1); NONDOMINANT LIMB AFFECTED TWO TIMES MORE OFTEN
THAN DOMINANT LIMB
• N TREATMENT
• • INCOMPLETE RUPTURE: NONOPERATIVE MANAGEMENT; WARN OF RISK FOR FUTURE RUPTURE.
• • ACUTE UNILATERAL RUPTURE: REPAIR THROUGH OSSEOUS DRILL HOLES OR SUTURE ANCHORS; REPAIR
ACUTELY. RUPTURES MORE THAN 2 WEEKS OLD MAY BE RETRACTED 5 CM.
• • BILATERAL RUPTURES: IDENTIFY UNDERLYING MEDICAL PROBLEM; OTHERWISE, TREAT SAME AS A
UNILATERAL RUPTURE. NON–WEIGHT BEARING AND DVT PROPHYLAXIS ARE REQUIRED.
• • CHRONIC TENDON RUPTURES—LESS SUCCESSFUL THAN ACUTE ONES; MAY REQUIRE CODIVILLA
PROCEDURE (V-Y LENGTHENING) OR QUADRICEPS TENDON LENGTHENING
• N COMPLICATIONS: STRENGTH DEFICIT (33%-50% OF PATIENTS), STIFFNESS, INABILITY TO RESUME PRIOR
LEVEL OF ATHLETIC/RECREATIONAL ACTIVITY (50%)
• TYPE III—PURE DEPRESSION (RARE)
• • TYPE IV—MEDIAL TIBIAL (HIGHEST RISK OF ASSOCIATED
• VASCULAR INJURY)
• • TYPE V—BICONDYLAR WITH INTACT METAPHYSIS
• • TYPE VI—BICONDYLAR WITH METAPHYSEAL/DIAPHYSEAL
• DISSOCIATION
• • AO/OTA CLASSIFICATION
• • 41-A—EXTRAARTICULAR FRACTURE
• • 41-B—PARTIAL ARTICULAR FRACTURE (SCHATZKER I-IV)
• • 41-C—COMPLETE ARTICULAR/BICONDYLAR (SCHATZKER V
• AND VI)
• • MRI CHANGES TREATMENT OR CLASSIFICATION IN MOST CASES.
• • SOFT TISSUE INJURY IS DEMONSTRATED (50%-90%

• INCIDENCE).
• • MCL AND ACL INJURIES IN 30% TO 50%
• • MENISCUS TEARS IN OVER 50% OF CASES
• • LATERAL TEARS MORE COMMON MEDIAL TEARS
• • TYPE II—LATERAL MENISCAL PATHOLOGY
• • TYPE IV—MEDIAL MENISCAL PATHOLOGY
• • PERIPHERAL TEARS MOST COMMON TYPE
• • ORDER OF FREQUENCY—LATERAL GREATER THAN BICONDYLAR
• GREATER THAN MEDIAL (THINK KNEE DISLOCATION WITH
• MEDIAL PLATEAU FRACTURES)
• ELDERLY OSTEOPOROTIC PATIENTS ARE LESS LIKELY TO SUFFER
• ASSOCIATED LIGAMENTOUS INJURY, SINCE THEIR BONE FAILS
• PRIOR TO THE LIGAMENT.
• • THE LATERAL PLATEAU IS MORE CONVEX-SHAPED AND SITUATED
• MORE PROXIMAL THAN THE MEDIAL PLATEAU, WHICH IS MORE
• CONCAVE-SHAPED.
• TREATMENT
• • NONOPERATIVE TREATMENT INDICATED IN STABLE KNEES (<10
• DEGREES CORONAL PLANE INSTABILITY WITH THE KNEE IN FULL
• EXTENSION) WITH LESS THAN 3 MM ARTICULAR STEP-OFF. CAST
• BRACE, EARLY ROM, AND DELAYED WEIGHT BEARING FOR AT
• LEAST 4 TO 6 WEEKS.
• • OPERATIVE TREATMENT INDICATED WITH ARTICULAR STEP-OFF
• GREATER THAN 3 MM, CONDYLAR WIDENING GREATER THAN
• 5 MM, INSTABILITY OF THE KNEE, AND ALL MEDIAL AND
• BICONDYLAR PLATEAU FRACTURES. THE GOAL OF TREATMENT IS
• RESTORATION OF NORMAL ALIGNMENT. MAINTENANCE OF
• MECHANICAL AXIS CORRELATES MOST WITH A SATISFACTORY
• CLINICAL OUTCOME. DEVELOPMENT OF ARTHRITIS DOES NOT
• CORRELATE WITH ARTICULAR STEP-OFF.
• ORIF
• • PLATE FIXATION WITH EARLY MOTION
• • PERCUTANEOUS LOCKED PLATING FOR POOR-QUALITY BONE
• IN BICONDYLAR FRACTURES; NO STRIPPING
• • POSTEROMEDIAL CORONAL FRAGMENT MAY NOT BE
• CAPTURED VIA A LATERAL PLATE. USE A SEPARATE
• POSTEROMEDIAL INCISION AND POSTEROMEDIAL
• PLATE.
• • USE OF BONE VOID FILLERS
• • CALCIUM PHOSPHATE CEMENT HAS HIGHEST
• COMPRESSIVE STRENGTH
• • LOWER RATE OF SUBSIDENCE COMPARED WITH
• AUTOGENOUS ILIAC BONE GRAFT
• • BEST TREATMENT TO PREVENT ARTICULAR REDUCTION LOSS
• IN A SPLIT DEPRESSION TIBIAL PLATEAU FRACTURE IS A
• LATERAL PLATE RAFTING SCREWS AND CALCIUM
• PHOSPHATE CEMENT
• • EXTERNAL FIXATION—RING FIXATION USEFUL FOR BICONDYLAR
• FRACTURES WITH SEVERE SOFT TISSUE INJURIES. KEEP SMALL
• WIRES AT LEAST 15 MM FROM THE JOINT TO AVOID SEPTIC
• JOINT.
• • SPANNING EXTERNAL FIXATORS—USED TEMPORARILY WITH
• SELECTED HIGH-ENERGY INJURIES TO ALLOW FOR A REDUCTION
• IN SOFT TISSUE SWELLING BEFORE DEFINITIVE FIXATION
• COMPLICATIONS: DEGENERATIVE JOINT DISEASE (DJD),
• INFECTION (SURGICAL APPROACH THE MOST IMPORTANT FACTOR),
• MALUNION (VARUS COLLAPSE WITH NONOPERATIVE OR
• CONVENTIONAL PLATES IN SEVERE BICONDYLAR FRACTURES),
• LIGAMENT INSTABILITY (LEFT UNTREATED, HAS AN ADVERSE IMPACT
• ON OUTCOME), PERONEAL NERVE INJURY
• • COMPARTMENT SYNDROME—INCREASED RISK WITH MORE
• PROXIMAL FRACTURES. ANTERIOR AND LATERAL COMPARTMENTS
• ARE AT HIGHEST RISK.
• SHAFT FRACTURES
• DIAGNOSIS
• • MECHANISM OF INJURY
• • LOW ENERGY
• • SPIRAL OBLIQUE FRACTURE
• • TIBIA AND FIBULA AT DIFFERENT LEVELS
• • CLOSED FRACTURE WITH MINOR SOFT TISSUE TRAUMA
• • THERE IS A HIGH ASSOCIATION OF POSTERIOR
• MALLEOLUS FRACTURES WITH SPIRAL DISTAL TIBIA
• FRACTURES.
• IGH ENERGY
• • COMMINUTED FRACTURE
• • TIBIA AND FIBULA AT SAME LEVEL
• • TRANSVERSE FRACTURE PATTERN
• • DIASTASIS BETWEEN TIBIA AND FIBULA
• • SEGMENTAL FRACTURE
• • OPEN FRACTURE OR CLOSED WITH SIGNIFICANT SOFT TISSUE
• TRAUMA
• • MOST COMMON LONG BONE FRACTURE
• • OFTEN ASSOCIATED WITH SOFT TISSUE INJURIES
• • SOFT TISSUE MANAGEMENT CRITICAL TO OUTCOME
• • OPEN FRACTURES MAY REQUIRE REPEATED INCISION AND
• DRAINAGE.
• • NUMBER OF INSTANCES OF DÉBRIDEMENT, TYPE OF
• IRRIGATION, AND PRESSURE OF IRRIGANT CONTROVERSIAL
• • SHARP DÉBRIDEMENT OF NONVIABLE SOFT TISSUE AND
• BONE THE MOST IMPORTANT ASPECT OF INCISION AND
• DRAINAGE
• • SEVERITY OF MUSCLE INJURY HAS THE HIGHEST
• IMPACT ON NEED FOR AMPUTATION.
• CLASSIFICATION
• • OTA CLASSIFICATION (FIGURE 11-44)—BASED ON
• COMMINUTION
• • 42-A—SIMPLE (TWO PARTS)
• • 42-B—BUTTERFLY COMMINUTION
• • 42-C—COMMINUTED, NO DIRECT CONTACT BETWEEN
• PROXIMAL AND DISTAL FRAGMENTS
• • HIGH INCIDENCE OF OPEN FRACTURE OR ASSOCIATED SEVERE
• SOFT TISSUE INJURY WITH CLOSED FRACTURES
• (SEE TABLE 11-5.)
• TREATMENT
• • DEGREE OF SHORTENING AND TRANSLATION SEEN ON INJURY
• RADIOGRAPHS CAN BE EXPECTED TO BE PRESENT AT UNION
• WITH NONOPERATIVE MANAGEMENT.
• • ANGULAR AND ROTATIONAL ALIGNMENT WELL CONTROLLED
• WITH CAST
• • SHORTENING IS MOST DIFFICULT TO CONTROL IN OBLIQUE
• AND COMMINUTED FRACTURES INVOLVING BOTH TIBIA
• AND FIBULA.
• • TIMELY AND THOROUGH SOFT TISSUE MANAGEMENT CRITICAL
• TO OUTCOME
• RESTORE LIMB LENGTH, ALIGNMENT, AND ROTATION.
• • STABLE FIXATION
• • EARLY ROM OF KNEE AND ANKLE
• • PROMPT ADMINISTRATION (WITHIN 3 HOURS OF INJURY) OF ANTIBIOTICS FOR OPEN FRACTURES IS THE MOST
IMPORTANT FACTOR IN MINIMIZING THE RISK OF INFECTION.
• • BMP-2 IS APPROVED FOR USE IN OPEN TIBIA FRACTURES TREATED WITH IM FIXATION AND HAS BEEN SHOWN TO
LEAD TO FEWER REOPERATIONS IN ACUTE OPEN TIBIA FRACTURES.
• • BMP-7 IS APPROVED FOR TREATMENT OF TIBIAL NONUNION IN CASES WHERE AUTOGENOUS BONE GRAFT IS NOT FEASIBLE.
• • INDICATIONS
• • LOW-ENERGY FRACTURES
• • SHORTENING LESS THAN 1 TO 2 CM
• • CORTICAL APPOSITION GREATER THAN 50%
• • ANGULATION MAINTAINED WITH CAST
• • VARUS—VALGUS LESS THAN 5 DEGREES
• • FLEXION—EXTENSION LESS THAN 10 DEGREES
• • LONG LEG CAST

• • CAN CONTROL VARUS/VALGUS, FLEXION/EXTENSION, AND ROTATION
• • SHORTENING AND CORTICAL APPOSITION SEEN ON INJURY RADIOGRAPH ARE EQUIVALENT TO SHORTENING AT UNION.
• CONVERT TO FUNCTIONAL BRACE AT 4 TO 6 WEEKS.
• • NON–WEIGHT BEARING FOR 4 TO 6 WEEKS
• • INDICATIONS
• • OPEN FRACTURES
• • CRITERIA FOR NONOPERATIVE MANAGEMENT NOT MET OR FAILED NONOPERATIVE MANAGEMENT
• • SOFT TISSUE INJURY NOT AMENABLE TO CAST
• • IPSILATERAL FEMORAL FRACTURE
• • POLYTRAUMA
• • MORBID OBESITY
• • IM NAILING
• • REDUCED TIME OF IMMOBILIZATION COMPARED WITH CAST MANAGEMENT
• • EARLIER WEIGHT BEARING THAN THAT ACHIEVED WITH CAST
• • UNION RATE GREATER THAN 80% FOR CLOSED INJURIES
• • REAMED NAILING ASSOCIATED WITH HIGHER UNION RATES THAN THOSE ACHIEVED WITH NONREAMED NAILING
• • REAMED NAILING SAFE FOR OPEN FRACTURES
• • SEVERITY OF SOFT TISSUE INJURY MORE PROGNOSTIC THAN REAMING STATUS
• • STATIC INTERLOCKING INDICATED FOR STABLE AND UNSTABLE FRACTURES

• • DYNAMIC INTERLOCKING INDICATED ONLY FOR STABLE FRACTURE (WINQUIST I OR II)
• • GAPS AT FRACTURE SITE ASSOCIATED WITH NONUNION
• PROXIMAL-THIRD TIBIAL FRACTURES ASSOCIATED WITH VALGUS AND APEX
ANTERIOR ANGULATION
• • AVOIDANCE OF MALREDUCTION OF PROXIMAL-THIRD FRACTURES ACHIEVED BY THE
FOLLOWING:
• • ENSURING A LATERALLY BASED STARTING POINT AND ANTERIOR INSERTION ANGLE;
ENTRY SITE SHOULD BE IN LINE WITH MEDIAL BORDER OF LATERAL TIBIAL EMINENCE
• • BLOCKING SCREWS PLACED IN THE METAPHYSEAL SEGMENT AT THE CONCAVE SIDE
OF THE DEFORMITY NARROW THE AVAILABLE INTRAMEDULLARY SPACE AND DIRECT
THE NAIL TOWARD A MORE CENTRALIZED POSITION (FIGURE 11-45).
• • TO PREVENT AN APEX ANTERIOR DEFORMITY, A BLOCKING SCREW CAN BE PLACED
POSTERIOR TO THE NAIL IN THE PROXIMAL FRACTURE.
• • PROVISIONAL UNICORTICAL PLATES
• • SEMIEXTENDED POSITION FOR NAILING
• EXTERNAL FIXATION
• • TEMPORARY DURING APPLICATION OF DAMAGE CONTROL PRINCIPLES
• • TEMPORARY OR DEFINITIVE FOR HIGHLY CONTAMINATED FRACTURES
• • DEFINITIVE FIXATION WITH EXTERNAL FIXATION FOR TYPE III OPEN TIBIA FRACTURES HAVE
SIGNIFICANTLY LONGER TIME TO UNION AND POORER FUNCTIONAL OUTCOMES COMPARED WITH
IM NAILING.
• • HIGHER INCIDENCE OF MALALIGNMENT THAN IM NAILS

• • CIRCULAR FRAMES INDICATED FOR VERY PROXIMAL AND DISTAL SHAFT FRACTURES AND
WHEN THESE FRACTURES ARE ASSOCIATED WITH SEVERE SOFT TISSUE INJURY
• • CAN BE SAFELY CONVERTED TO IM NAIL WITHIN 7 TO 21 DAYS (NEWER STUDIES SHOW
LONGER THAN 7-DAY DELAY ACCEPTABLE, BUT EXACT SAFE TIMING UNKNOWN)
• PLATE FIXATION
• • FOR EXTREME PROXIMAL AND DISTAL SHAFT FRACTURES
• • HIGHER INFECTION RISK THAN THAT FOR IM NAILING IN OPEN FRACTURES
• • USE OF A LONG 13-HOLE PERCUTANEOUS PLATE, SUCH AS A LESS INVASIVE STABILIZATION SYSTEM (LISS) PLATE, PLACES THE SUPERFICIAL
PERONEAL NERVE AT RISK DURING PERCUTANEOUS SCREW INSERTION FOR HOLES 11, 12, AND 13. A LARGER INCISION WITH BLUNT
DISSECTION SHOULD BE USED FOR INSERTION OF SCREWS IN THIS REGION.
• N COMPLICATIONS
• • NONUNION
• • RULE OUT INFECTION.
• • DYNAMIZATION IF AXIALLY STABLE
• • REAMED-EXCHANGE NAILING IS PREFERRED TREATMENT FOR MID-DIAPHYSEAL TIBIAL NONUNIONS.
• • BONE GRAFT FOR BONE DEFECTS
• • MALUNION
• • MOST COMMON WITH PROXIMAL-THIRD FRACTURES
• • VALGUS AND APEX ANTERIOR
• • MAY INCREASE LONG-TERM RISK OF ARTHROSIS, PARTICULARLY IN THE ANKLE
• • MORE COMMON WITH VARUS DEFORMITY
• • ROTATIONAL MALALIGNMENT IS COMMON WITH DISTAL-THIRD FRACTURES.
• • DELAYED UNION
• • RISK FACTORS FOR REOPERATION TO ACHIEVE BONY UNION WITHIN FIRST POSTINJURY YEAR:
• • TRANSVERSE FRACTURE PATTERN
• • CORTICAL CONTACT LESS THAN 50%
• INFECTION
• • RISK INCREASES WITH INCREASED SEVERITY OF SOFT TISSUE INJURY AND TIME TO SOFT TISSUE COVERAGE
• • USE OF VACUUM-ASSISTED CLOSURE FOR WOUND DOES NOT ALTER RISK OF INFECTION.
• • COMPARTMENT SYNDROME
• • DIAGNOSED BY COMPARTMENT PRESSURE WITHIN 30 MM HG OF DIASTOLIC BLOOD PRESSURE (ΔP)
• • EMERGENT FASCIOTOMY INDICATED
• • CAN OCCUR EVEN WITH OPEN FRACTURES
• INFECTION
• • RISK INCREASES WITH INCREASED SEVERITY OF SOFT TISSUE INJURY AND TIME TO SOFT TISSUE COVERAGE
• • USE OF VACUUM-ASSISTED CLOSURE FOR WOUND DOES NOT ALTER RISK OF INFECTION.
• • COMPARTMENT SYNDROME
• • DIAGNOSED BY COMPARTMENT PRESSURE WITHIN 30 MM HG OF DIASTOLIC BLOOD PRESSURE (ΔP)
• • EMERGENT FASCIOTOMY INDICATED
• • CAN OCCUR EVEN WITH OPEN FRACTURES
SECTION 4
PEDIATRIC TRAUMA
• SEVERAL FEATURES OF FRACTURES AND DISLOCATIONS IN CHILDREN ARE NOT FOUND IN ADULTS
(SEE TABLES 11-22 THROUGH 11-32 AND FIGURES 11-46 THROUGH 11-64.)
• N CHILDREN’S BONES ARE MORE DUCTILE THAN ADULTS’ BONES, AND BOWING IS THUS UNIQUE TO
CHILDREN.
• N THE TERMS GREENSTICK AND TORUS IMPLY A PARTIAL FRACTURE WITH SOME PART OF THE BONE
INTACT.
• N THE PERIOSTEUM IN CHILDREN IS MUCH THICKER AND OFTEN REMAINS INTACT ON THE CONCAVE
(COMPRESSION) SIDE, ALLOWING FOR LESS DISPLACEMENT AND BETTER REDUCTION OF FRACTURES.
• N CHILDREN’S FRACTURES HEAL MORE QUICKLY AND WITH LESS IMMOBILIZATION THAN ADULTS’
FRACTURES. CONTRACTURES ARE ALSO LESS LIKELY.
• N BECAUSE BONES ARE ACTIVELY GROWING IN PEDIATRIC FRACTURES, MALUNION AND GROWTH
PLATE INJURIES ARE IMPORTANT CONCERNS. REMODELING IS MORE THOROUGH; THUS,
DISPLACEMENT AND ANGULATION THAT WOULD NOT BE ACCEPTABLE IN AN ADULT ARE OFTEN
ACCEPTABLE IN CHILDREN.
• N THE EXCEPTION TO THIS RULE IS AN INTRAARTICULAR FRACTURE, IN WHICH THE SAME AXIOMS
APPLY. HOWEVER, THE PRESENCE OF NEARBY PHYSEAL STRUCTURES CAN AFFECT FIXATION OPTIONS.
• CHILD ABUSE
• N INTRODUCTION
• N ONE MUST ALWAYS BE ALERT FOR THE “BATTERED CHILD.”
• N ALL STATES NOW REQUIRE PHYSICIANS TO REPORT SUSPECTED CHILD ABUSE. IF CHILD ABUSE IS NOT DIAGNOSED
AND REPORTED THERE IS A 30% TO 50% CHANCE OF REPEAT ABUSE AND A 5% TO 10% CHANCE OF DEATH FROM
SUBSEQUENT ABUSE.
• N SUSPICION SHOULD BE RAISED WHEN FRACTURES ARE SEEN IN CHILDREN YOUNGER THAN AGE 5 YEARS (90% OF
FRACTURES DUE TO ABUSE OCCUR IN CHILDREN < 5), WITH MULTIPLE HEALING BRUISES, SKIN MARKS, BURNS,
UNREASONABLE HISTORIES, AND SIGNS OF NEGLECT, AMONG OTHER INDICATIONS.
• N ABUSE ACCOUNTS FOR 50% OF FRACTURES IN CHILDREN YOUNGER THAN AGE 1 YEAR AND 30% OF FRACTURES IN
CHILDREN YOUNGER THAN AGE 3.
• N THE MOST COMMON CAUSE OF FEMUR FRACTURES IN NONAMBULATORY CHILDREN IS ABUSE.
• N OSTEOGENESIS IMPERFECTA IS OFTEN IN THE DIFFERENTIAL DIAGNOSIS IN A CHILD WITH MULTIPLE FRACTURES.
• N FRACTURE LOCATION
• N THE MOST COMMON LOCATIONS OF FRACTURES IN CHILDREN OF ABUSE ARE THE HUMERUS, TIBIA, AND FEMUR,
IN THAT ORDER.
• • SPIRAL HUMERUS FRACTURES AND DISTAL HUMERAL PHYSEAL SEPARATIONS ARE HIGHLY SUGGESTIVE OF CHILD
ABUSE.
• SPIRAL FEMUR FRACTURES IN NONAMBULATORY CHILDREN ARE ALSO HIGHLY SUSPICIOUS.
• N IF SUSPICION IS HIGH, SKELETAL SURVEYS ARE APPROPRIATE IN CHILDREN WITH DELAYED
DEVELOPMENT AND IN SOME METAPHYSEAL AND SPIRAL FRACTURES.
• N CORNER FRACTURES (AT JUNCTION OF METAPHYSIS AND PHYSIS) AND POSTERIOR RIB
FRACTURES ARE DESCRIBED AS PATHOGNOMONIC FOR ABUSE (FIGURE 11-46).
• N HOWEVER, DIAPHYSEAL FRACTURES ARE MORE COMMON IN ABUSE CASES (FOUR TIMES AS
LIKELY AS METAPHYSEAL FRACTURES).
• N SKELETAL SURVEYS ARE NOT AS HELPFUL IN CHILDREN OLDER THAN 5 YEARS. INSTEAD, A
BONE SCAN MAY BE DONE AS AN ALTERNATIVE OR ADJUNCTIVE STUDY.
• N NONORTHOPAEDIC INJURIES FOUND IN ABUSE INCLUDE SKIN INJURIES, HEAD INJURIES,
BURNS, AND BLUNT ABDOMINAL VISCERAL INJURIES.
• N TREATMENT
• N IN ADDITION TO NORMAL FRACTURE CARE, EARLY INVOLVEMENT OF SOCIAL WORKERS
AND PEDIATRICIANS IS ESSENTIAL TO EVALUATE FOR POSSIBILITY OF CHILD ABUSE AND
INITIATE NECESSARY PROTECTIVE ACTIONS.
• PHYSEAL FRACTURES
• N INTRODUCTION
• N FRACTUREOF THE PHYSIS, OR GROWTH PLATE, IS MORE LIKELY THAN INJURY TO ATTACHED LIGAMENTS; THUS,
ASSUME THAT THERE IS A FRACTURE OF THE PHYSIS UNTIL EVIDENCE PROVES OTHERWISE (YOUNG CHILDREN RARELY
GET SPRAINS).
• N CHARACTERISTICS
• N ALTHOUGH PHYSEAL FRACTURES ARE CLASSICALLY THOUGHT TO BE THROUGH THE ZONE OF PROVISIONAL
CALCIFICATION (WITHIN THE ZONE OF HYPERTROPHY) OF THE GROWTH PLATE, THE FRACTURE CAN BE THROUGH MANY
DIFFERENT LAYERS.
• N BLOODSUPPLY OF EPIPHYSIS IS TENUOUS, AND INJURIES CAN DISRUPT SMALL PHYSEAL VESSELS SUPPLYING THE
GROWTH CENTER. THIS CAN LEAD TO MANY COMPLICATIONS ASSOCIATED WITH THESE INJURIES (E.G., LIMB-LENGTH
DISCREPANCIES, MALUNION, BONY BARS).
• N MOST COMMON PHYSEAL INJURIES OCCUR IN DISTAL RADIUS, FOLLOWED BY DISTAL TIBIA
• N THE
SALTER-HARRIS (SH) CLASSIFICATION MODIFIED BY RANG IS THE GOLD STANDARD FOR PHYSEAL INJURIES
(FIGURE 11-47; TABLE 11-22).
• • IT CAN BE RECALLED USING THE MNEMONIC SALTR
• • I—SLIPPED—SEPARATION PHYSIS
• • II—ABOVE—METAPHYSIS AND PHYSIS

• III—LOWER—EPIPHYSIS AND PHYSIS
• • IV—THROUGH—METAPHYSIS, PHYSIS, EPIPHYSIS
• • V—RUINED—CRUSHED PHYSIS
• • SH TYPE I FRACTURE IS THROUGH THE ZONE OF HYPERTROPHIC CELLS OF THE PHYSIS.
• N TREATMENT AND RESULTS
• N GENTLE REDUCTION SHOULD BE ATTEMPTED INITIALLY FOR SH I AND II FRACTURES,
SOMETIMES USING CONSCIOUS SEDATION PROTOCOLS. WITH REDUCTION AND
IMMOBILIZATION, THESE FRACTURES WILL DO WELL WITHOUT A SIGNIFICANT AMOUNT
OF GROWTH ARREST (EXCEPT IN THE DISTAL FEMUR).
• N SH III AND IV FRACTURES ARE INTRAARTICULAR BY DEFINITION AND USUALLY REQUIRE
ORIF. FOLLOW-UP RADIOGRAPHS ARE REQUIRED FOR ALL PHYSEAL INJURIES.
• N REMODELING IS ALSO COMMON IN PEDIATRIC FRACTURES (UP TO 20 DEGREES). THIS
DEPENDS ON THE LOCATION AND AGE OF THE PATIENT.
• N HARRIS-PARK GROWTH ARREST LINES (TRANSVERSE RADIODENSE LINES) MAY BE THE
ONLY EVIDENCE OF A PHYSEAL INJURY ON FOLLOW-UP RADIOGRAPHS.
• PARTIAL GROWTH ARREST
• N PHYSEAL BARS OR BRIDGES RESULT FROM GROWTH PLATE INJURIES THAT ARREST A
PART OF THE PHYSIS AND LEAVE THE UNINJURED PHYSIS TO GROW NORMALLY. THIS
RESULTS IN ANGULAR GROWTH AND DEFORMITY.
• N PHYSEAL BRIDGE RESECTION WITH INTERPOSITION OF A FAT GRAFT OR ARTIFICIAL
MATERIAL IS RESERVED FOR PATIENTS WITH OVER 2 CM OF GROWTH REMAINING AND LESS
THAN 50% PHYSEAL INVOLVEMENT.
• N TREATMENT OF SMALLER PERIPHERAL BARS IN YOUNG PATIENTS HAVE THE HIGHEST
SUCCESS RATE.
• N MRI AND CT CAN HELP DEFINE THE LOCATION AND AMOUNT OF PHYSEAL CLOSURE.
• N ARREST INVOLVING MORE THAN 50% OF THE PHYSIS SHOULD BE TREATED WITH
IPSILATERAL COMPLETION OF THE ARREST AND CONTRALATERAL EPIPHYSIODESIS OR
IPSILATERAL LIMB LENGTHENING.
• PEDIATRIC POLYTRAUMA
• N INTRODUCTION
• N TRAUMA IS THE MOST COMMON CAUSE OF DEATH IN CHILDREN OLDER THAN AGE 1 YEAR.
• • DEATH AND LONG-TERM MORBIDITY ARE MOST CLOSELY ASSOCIATED WITH THE SEVERITY OF TRAUMATIC BRAIN
INJURY.
• N MOST COMMON CAUSES OF POLYTRAUMA ARE FALL FROM HEIGHT AND MOTOR VEHICLE COLLISION
• N TREATMENT
• N CHILDREN MAY REMAIN HEMODYNAMICALLY STABLE FOR SOME TIME DESPITE SIGNIFICANT BLOOD LOSS.
INTRAOSSEOUS INFUSION MAY BE NEEDED OWING TO DIFFICULTY IN QUICKLY OBTAINING IV ACCESS.
CRYSTALLOID FLUID BOLUS 20 ML/KG. IF HEMODYNAMIC STABILITY RECURS OR PERSISTS DESPITE 2 OR 3
• BOLUSES, SHOULD BEGIN BLOOD TRANSFUSION (10 ML/KG). ESTIMATE OF PEDIATRIC BLOOD VOLUME IS 75 TO 80
ML/KG.
• N CERVICAL SPINE IMMOBILIZATION FOR CHILDREN YOUNGER THAN AGE 6 YEARS REQUIRES USE OF A
BACKBOARD WITH OCCIPITAL CUTOUT BECAUSE OF THE LARGE HEAD SIZE OF CHILDREN.
• • ADULT BACKBOARD USE CAN RESULT IN NECK FLEXION.
• N TIMING OF ORTHOPAEDIC MANAGEMENT
• • EARLY OPERATIVE FIXATION (WITHIN 2-3 DAYS) DECREASES INTENSIVE CARE UNIT AND OVERALL HOSPITAL STAY.
• SHOULDER AND ARM INJURIES (TABLE 11-23)
• N CLAVICLE FRACTURES
• N PRINCIPLES AND PRESENTATION

• • MOST FREQUENT FRACTURE IN CHILDREN
• • 90% OF OBSTETRIC FRACTURES; OFTEN ASSOCIATED WITH BRACHIAL PLEXUS PALSIES
• • BIRTH INJURY MECHANISM—DIRECT PRESSURE FROM SYMPHYSIS PUBIS
• • OLDER CHILDREN MECHANISM—FALL ON AN OUTSTRETCHED HAND; DIRECT TRAUMA TO CLAVICLE OR ACROMION
• N DIAGNOSIS AND RADIOGRAPHS
• • ULTRASOUND FOR OBSTETRIC FRACTURES
• • CEPHALIC TILT VIEWS (CEPHALIC TILT OF 35-40 DEGREES)
• • APICAL OBLIQUE VIEW (IPSILATERAL SIDE ROTATED 45 DEGREES AND CEPHALIC TILT OF 20 DEGREES TOWARD BEAM)
• • CT AXIAL IMAGING FOR MEDIAL CLAVICLE FRACTURES AND PHYSEAL SEPARATION EVALUATIONS
• N CLASSIFICATION—ALLMAN
• • MIDDLE THIRD (80%)

• • LATERAL THIRD (10%-15%)
• • DISTAL TO CORACOCLAVICULAR LIGAMENTS
• • MEDIAL THIRD (5%-10%)

• N
• TREATMENT
• • NEWBORN: NONOPERATIVE TREATMENT
• • ADOLESCENTS: NONOPERATIVE TREATMENT (STANDARD OF CARE)
• • STERNOCLAVICULAR PHYSEAL FRACTURE-DISLOCATIONS
• • ANTERIOR: CLOSED REDUCTION, OFTEN UNSTABLE BUT CAN REMODEL
• • POSTERIOR: REDUCTION WITH CT SURGERY BACKUP AFTER CT SCAN TO EVALUATE FOR
MEDIASTINAL IMPINGEMENT
• • OPERATIVE TREATMENT CONTROVERSIAL FOR MIDDLE-THIRD CLAVICLE FRACTURES

• • ABSOLUTE INDICATIONS: OPEN FRACTURES, NEUROVASCULAR COMPROMISE
• • RELATIVE INDICATIONS: NONUNION, MALUNION, DISPLACEMENT GREATER THAN 2.0 CM
• • PIN FIXATION SHOULD BE AVOIDED.
• • PLATE FIXATION OR INTRAMEDULLARY NAILING ACCEPTABLE OPERATIVE OPTIONS

• COMPLICATIONS
• • NONUNION (1%-3%)—RARE IN CHILDREN; BEWARE OF CONGENITAL PSEUDARTHROSIS
• • MALUNION—RARE IN YOUNGER POPULATIONS; RATES INCREASE AS AGE INCREASES.
• • NEUROVASCULAR COMPROMISE
• • PNEUMOTHORAX
• N PROXIMAL HUMERUS FRACTURES

• • IN 80% TO 90% HUMERAL GROWTH OCCURS AT PROXIMAL PHYSIS; INCREASED REMODELING POTENTIAL (FIGURE 11-48)
• • LESS THAN 5% OF PEDIATRIC FRACTURES
• • THREE OSSIFICATION CENTERS (HUMERAL HEAD, GREATER AND LESSER TUBEROSITIES) COALESCE AT AGES 6 TO 7.
• • PROXIMAL FRAGMENTS ROTATED INTO ABDUCTION AND EXTERNAL ROTATION BY ROTATOR CUFF MUSCLES
• • DISTAL FRAGMENTS PULLED INTO ADDUCTION AND SHORTENED BY THE PECTORALIS MAJOR AND DELTOID
• • ACCORDINGLY, GRAVITY CAN BE A USEFUL REDUCTION AID.
• • BLOCKS TO CLOSED REDUCTION CAN INCLUDE LONG HEAD OF BICEPS TENDON, JOINT CAPSULE, AND PERIOSTEUM
• • AP, SCAPULAR Y, AND AXILLARY VIEWS
• • SH CLASSIFICATION COMMONLY APPLIED TO THESE FRACTURES

• • SH I FRACTURES MOST COMMON IN CHILDREN YOUNGER THAN AGE 5
• • SH II FRACTURES MOST COMMON IN CHILDREN OLDER THAN AGE 12
• • METAPHYSEAL FRACTURES COMMON IN CHILDREN BETWEEN AGES 5 AND 12
• • “LITTLE LEAGUER SHOULDER” REPRESENTS AN SH I FRACTURE.
• TREATMENT
• • NONOPERATIVE TREATMENT WITH TEMPORARY IMMOBILIZATION IS USUAL TREATMENT OWING TO REMODELING POTENTIAL (SEE FIGURE 11-48)
• • OPERATIVE INDICATIONS
• • ABSOLUTE: OPEN FRACTURES, NEUROVASCULAR INJURIES, INTRAARTICULAR EXTENSION
• • RELATIVE: YOUNG CHILDREN (<12 YEARS); 70 DEGREES AND 100% DISPLACEMENT ACCEPTABLE
• • AGE OLDER THAN 12 YEARS, CONTROVERSIAL, 30 TO 40 DEGREES, AND 50% DISPLACEMENT
• N COMPLICATIONS
• • MALUNION—VARUS DEFORMITY WELL TOLERATED OWING TO SHOULDER MOTION

• N DIAPHYSEAL HUMERUS FRACTURES
• • UNCOMMON IN CHILDREN
• • RADIAL NERVE PALSY CAN ACCOMPANY MIDDLE- OR DISTAL-THIRD FRACTURES; USUALLY NEURAPRAXIA AND TRANSIENT
• • AP AND LATERAL RADIOGRAPHS OF HUMERUS
• • ALWAYS EVALUATE ELBOW AND SHOULDER APPROPRIATELY.
• N TREATMENT
• • NONOPERATIVE TREATMENT WITH SLING OR CLAM-SHELL TYPE SPLINT IMMOBILIZATION

• • OPERATIVE INDICATIONS: OPEN FRACTURES, VASCULAR COMPROMISE AFTER REDUCTION
• N COMPLICATIONS
• • RADIAL NERVE PALSY—USUALLY TRANSIENT; EXPLORATION RARELY INDICATED

• ELBOW INJURIES (TABLE 11-24)
• N PRINCIPLES OF ELBOW FRACTURES
• N SKELETAL ANATOMY (FIGURE 11-49)

• • SECONDARY OSSIFICATION CENTERS IN ORDER OF OSSIFICATION CAN BE RECALLED
USING THE MNEMONIC CRITOE, AND AGE AT OSSIFICATION CAN BE ROUGHLY
ESTIMATED BASED ON ODD NUMBERS 1, 3, 5, 7, 9, 11:
• • CAPITELLUM
• • RADIAL HEAD
• • INTERNAL (MEDIAL) EPICONDYLE
• • TROCHLEA
• • OLECRANON
• • EXTERNAL (LATERAL) EPICONDYLE
• • RADIAL HEAD, TROCHLEA, AND OLECRANON MAY APPEAR AS MULTIPLE OSSIFICATION

SITES.
• RADIOGRAPHIC ANATOMY
• • A FIVE-PART SYSTEMATIC APPROACH IS KEY TO AVOIDING MISSING INJURY (FIGURE 11-50):
• • PROXIMAL RADIUS SHOULD ALIGN WITH CAPITELLUM IN ALL VIEWS.
• • LONG AXIS OF ULNA SHOULD ALIGN AND BE SLIGHTLY MEDIAL TO HUMERUS ON AP
RADIOGRAPH.
• • ANTERIOR HUMERAL LINE SHOULD BISECT CAPITELLUM ON TRUE LATERAL RADIOGRAPH.
• • HUMERAL-CAPITELLAR (BAUMANN) ANGLE SHOULD BE IN VALGUS AND FALL BETWEEN 9 AND
26 DEGREES.
• • SOFT TISSUE SHADOWS MAY DEMONSTRATE AN ANATOMIC ANTERIOR FAT PAD.
• • ABNORMALITIES IN RADIOGRAPHIC ANATOMY (BOX 11-1)

• COMPLICATIONS
• • FISHTAIL DEFORMITY OF DISTAL HUMERUS MAY RESULT FROM MALUNION,
OSTEONECROSIS, GROWTH ARREST, OR SOME COMBINATION OF THESE FACTORS.
UNCOMMON BUT CHALLENGING COMPLICATION TO TREAT THAT MAY BE SEEN FOLLOWING
BOTH SUPRACONDYLAR AND LATERAL CONDYLAR FRACTURES. RESULTS IN LOSS OF
MOTION WITH PROXIMAL FOREARM MIGRATION, ULNOTROCHLEAR INCONGRUITY, AND
RADIAL HEAD DISLOCATION.
• N DISTAL HUMERUS FRACTURES
• N DISTAL HUMERAL PHYSEAL SEPARATION (FIGURE 11-51)
• • PRINCIPLES AND PRESENTATION
• • USUALLY OCCUR IN PEDIATRIC PATIENTS YOUNGER THAN AGE 6 TO 7 YEARS
• CONSIDER EVALUATION FOR CHILD ABUSE IN YOUNG PATIENTS WITH QUESTIONABLE PRESENTATION.
• • YOUNG PATIENTS MAY PRESENT WITH PSEUDOPARALYSIS.
• • OFTEN CONFUSED FOR ELBOW DISLOCATIONS (WHICH ARE RARE IN YOUNG CHILDREN)
• • DIAGNOSIS AND RADIOGRAPHS
• • RADIOGRAPHS DEMONSTRATE INTACT RELATIONSHIP BETWEEN RADIUS AND CAPITELLUM. RADIUS AND
ULNA LOSE NORMAL RELATIONSHIP WITH DISTAL END OF HUMERUS.
• • ULTRASOUND OR MRI EVALUATION MAY BE NECESSARY FOR YOUNG CHILDREN.
• • ARTHROGRAPHY CAN BE USED TO EVALUATE FOR INTRAARTICULAR EXTENSION.
• • TREATMENT
• • CLOSED REDUCTION AND PERCUTANEOUS PINNING
• • AVOID CLOSED REDUCTION IF DIAGNOSIS IS MADE LATE TO AVOID IATROGENIC INJURY TO THE PHYSIS.
• • COMPLICATIONS
• • MISDIAGNOSIS IS MOST COMMON, AND THESE INJURIES CAN BE MISTAKEN FOR ELBOW DISLOCATIONS OR
SOFT TISSUE INJURIES.
• • PHYSEAL SEPARATIONS ARE TYPICALLY MEDIAL, WHEREAS ELBOW DISLOCATIONS ARE TYPICALLY LATERAL.
• SUPRACONDYLAR HUMERUS FRACTURES
• • PRINCIPLES AND PRESENTATION
• • 50% TO 60% OF FRACTURES
• • 95% TO 98% EXTENSION TYPE; TYPICALLY OCCUR FROM A FALL ON OUTSTRETCHED HAND WITH ELBOW IN EXTENSION OR HYPEREXTENSION
• • 2% TO 5% FLEXION TYPE; TYPICALLY OCCUR FROM A FALL ONTO THE FLEXED ELBOW
• • PEAK INCIDENCE IN CHILDREN BETWEEN AGES 5 AND 8
• • 1% ASSOCIATED WITH VASCULAR INJURIES
• • ANTERIOR INTEROSSEOUS NERVE (AIN) INJURY MOST COMMON FOR EXTENSION-TYPE FRACTURES; USUALLY NEURAPRAXIA
• • ULNAR NERVE INJURY USUALLY IATROGENIC FROM MEDIAL PINNING AND ALSO THE MOST COMMON NERVE INJURY FROM FLEXION TYPE
• • POSTEROMEDIAL ANGULATION ASSOCIATED WITH RADIAL NERVE INJURY (THE SECOND MOST COMMON NEUROPRAXIA AFTER AIN PALSY)
• • POSTEROLATERAL ANGULATION ASSOCIATED WITH BRACHIAL ARTERY AND MEDIAN NERVE INJURY
• • IMMEDIATE SURGERY INDICATED IN PRESENCE OF VASCULAR COMPROMISE (PALE, COOL HAND)
• • MOST INJURIES CAN BE SPLINTED IN A NONFLEXED POSITION AND TREATED THE FOLLOWING DAY WITH NO ADVERSE IMPACT ON OUTCOME.
• • DIAGNOSIS AND RADIOGRAPHS

• • AP AND LATERAL RADIOGRAPHS ESSENTIAL
• • AP VIEW SHOULD BE EXAMINED FOR BAUMANN ANGLE; MAY NEED TO COMPARE WITH CONTRALATERAL ARM
• • LATERAL RADIOGRAPH SHOULD BE EXAMINED TO SEE IF THE ANTERIOR HUMERAL LINE INTERSECTS THE MIDDLE THIRD OF THE CAPITELLAR
OSSIFICATION CENTER.
• • ANTERIOR AND POSTERIOR FAT PAD SIGNS SHOULD BE EXAMINED.
• • ANTERIOR FAT PAD DISPLACEMENT HAS LOW SPECIFICITY AND CAN BE NORMAL.
• • POSTERIOR FAT PAD DISPLACEMENT IS ALWAYS PATHOLOGIC AND CAN INDICATE A NONDISPLACED FRACTURE.
• • CLASSIFICATION AND TREATMENT—GARTLAND CLASSIFICATION (FIGURE 11-52)

• TYPE I—NONDISPLACED
• • TREATED CLOSED IN A LONG-ARM CAST FOR 2 TO 3 WEEKS
• • TYPE II—DISPLACED WITH INTACT POSTERIOR CORTEX
• • CLOSED TREATMENT FOR TYPE II FRACTURES IS APPROPRIATE IF ALL OF THE FOLLOWING CRITERIA
ARE MET:
• • NO SIGNIFICANT SWELLING
• • ANTERIOR HUMERAL LINE INTERSECTS THE CAPITELLUM
• • NO MEDIAL DISTAL HUMERAL CORTICAL IMPACTION
• • OTHERWISE, CLOSED REDUCTION AND PERCUTANEOUS PINNING IS APPROPRIATE FOR TYPE II

FRACTURES WITH POSTOPERATIVE LONG-ARM IMMOBILIZATION AT 90 DEGREES OF FLEXION.
• • TYPE III—COMPLETELY DISPLACED; CAN BE DISPLACED POSTEROMEDIALLY OR POSTEROLATERALLY
• • TREATED WITH CLOSED REDUCTION AND PERCUTANEOUS PINNING
• • ORIF RARELY NEEDED
• • ROTATIONALLY UNSTABLE FRACTURES, OPEN FRACTURES, OR THOSE ASSOCIATED WITH NEUROVASCULAR
INJURIES
• • ANTERIOR APPROACH PREFERRED

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CARE OF THE MULTIPLY

• PRIMARY ASSESSMENT—BEGINS WITH THE PRIMARY SURVEY, WHICH SEEKS TO IDENTIFY

• AGGRESSIVE FLUID RESUSCITATION SHOULD BEGIN IMMEDIATELY IN MOST CASES WITH

• • TYPICALLY AVAILABLE WITHIN 10 MINUTES

• • THE MOST COMMON COMPLICATION OF MASSIVE TRANSFUSION IS A DILUTIONAL

• • HEMORRHAGIC (TABLE 11-1)

• • CARDIOVASCULAR COLLAPSE UNRESPONSIVE TO FLUIDS OR PRESSORS

• • MOTOR RECOVERY POTENTIAL AFTER REPAIR

• • RADIAL, MUSCULOCUTANEOUS, FEMORAL

• • BURNS—GENERALLY TREATED BY BURN SURGEONS, BUT EXTREMITY BURNS MAY BE

• N DISLOCATIONS—ORTHOPAEDIC EMERGENCIES THAT SHOULD BE REDUCED AS SOON AS POSSIBLE TO

• • TYPE IIIA—CONTAMINATED WOUND (HIGH-ENERGY GUNSHOT WOUND, FARM INJURY,

• • HEAVILY CONTAMINATED WOUNDS AND FARM WOUNDS—CEPHALOSPORIN,

• • PATIENTS WITH UNKNOWN TETANUS IMMUNIZATION STATES OR WHO HAVE RECEIVED

• • FULLY IMMUNIZED PATIENTS SHOULD RECEIVE TETANUS TOXOID IF THE WOUND IS

• • DELAYED UNION—DEFINED AS NO PROGRESSION OF HEALING OVER SERIAL

• • PRESERVE NATIVE BIOLOGY

• • PRESERVE NATIVE BIOLOGY

• • INDIUM STUDY—95% SENSITIVE AND 85% TO 90% SPECIFIC

• • GRADE IV—DIFFUSE, INDICATES SPREAD THROUGH CORTEX AND ALONG MEDULLARY

• • PATIENTS WITH MANGLED EXTREMITY INJURIES HAVE POOR OUTCOMES AT 2 YEARS.

• N STABILITY DETERMINES STRAIN

• • MAY INCREASE OPTIONS FOR FIXATION IN WORKING AROUND PERIPROSTHETIC FRACTURES

• N LOAD-SHARING DEVICES—RELATIVE STABILITY

• • GREATER TUBEROSITY FRACTURES ARE DISPLACED SUPERIORLY AND POSTERIORLY

• • HEMIARTHROPLASTY FOR OLDER PATIENTS, WITH REPAIR OF THE ROTATOR

• • AVASCULAR NECROSIS (AVN)

• • DISRUPTION OF THE MEDIAL PERIOSTEAL HINGE

• • TREATMENT: REDUCTION (MULTIPLE MANEUVERS AVAILABLE)

• • AVASCULAR NECROSIS (AVN)

• • DISRUPTION OF THE MEDIAL PERIOSTEAL HINGE

• • NONUNION OF GREATER TUBEROSITY FOLLOWING ARTHROPLASTY—LOSS OF ACTIVE SHOULDER ELEVATION

• • TREATMENT: REDUCTION (MULTIPLE MANEUVERS AVAILABLE)

• N CLASSIFICATION BY LOCATION AND FRACTURE PATTERN

• • NONOPERATIVE TREATMENT: FUNCTIONAL BRACE IF THERE IS LESS THAN 20 DEGREES OF

• • NEED FOR RADIAL NERVE EXPLORATION—LATERAL APPROACH

• • RADIAL NERVE PALSY (5%-10%)

• • SECONDARY NERVE PALSY (I.E., AFTER FRACTURE MANIPULATION)

• • NONUNION—TREAT WITH COMPRESSION PLATE WITH BONE GRAFT IF ATROPHIC.

• • AO (ARBEITSGEMEINSCHAFT FÜR OSTEOSYNTHESEFRAGEN)/ OTA DISTAL HUMERUS CLASSIFICATION

• • H—TROCHLEA IS FREE FRAGMENT (AVN)

• • CONTROVERSIAL WHETHER TO OBSERVE OR EXPLORE:

• • AO (ARBEITSGEMEINSCHAFT FÜR OSTEOSYNTHESEFRAGEN)/ OTA DISTAL HUMERUS CLASSIFICATION

• • H—TROCHLEA IS FREE FRAGMENT (AVN)

• N CLASSIFICATION—COLTON (FIGURE 11-12)

• • LESS THAN 1 TO 2 MM DISPLACED—SPLINT AT 60 TO 90 DEGREES FOR 7 TO 10 DAYS, FOLLOWED BY GENTLE

• • MIGRATION OF KIRSCHNER WIRES AND PROMINENT OR PAINFUL HARDWARE OCCURS IN 71%

• • REGAN AND MORREY CLASSIFICATION

• • ANTEROMEDIAL PROCESS—CAUSED BY A VARUS POSTEROMEDIAL ROTATORY FORCE

• • BADO CLASSIFICATION (FIGURE 11-14)

• • “MONTEGGIA-EQUIVALENT OR VARIANT”—RADIAL HEAD FRACTURE INSTEAD

• • REDISLOCATION/SUBLUXATION, SYNOSTOSIS, AND LOSS OF MOTION

• N CLASSIFICATION—DISPLACED VERSUS NONDISPLACED

• • BONE LOSS ASSOCIATED WITH OPEN INJURY

• • SIGNS OF DRUJ INSTABILITY INCLUDE ULNAR STYLOID FRACTURE, WIDENED DRUJ ON

• • APPROACH DRUJ VIA DORSAL INCISION AND REMOVE BLOCK.

• • FRYKMAN CLASSIFICATION—TYPES I TO VIII (FIGURE 11-15)

• • TYPE VII—ENTERS BOTH JOINTS