Escolar Documentos
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ORTHO BULLETS
Volume
One
Trauma
2017
Collected By : Dr AbdulRahman AbdulNasser
drxabdulrahman@gmail.com
Preface
Orthobullets.com is an educational resource for
orthopaedic surgeons designed to improve
training through the communal efforts of those
who use it as a learning resource. It is a simple but
powerful concept. All of our topics, technique
guides, cases, and user-generated videos are
free, and will stay that way.
3. Humeral Shaft Fractures ....... 152 4. Hamate Body Fracture .......... 241
IV. Hand Trauma .......................... 210 2. Dog and Cat Bites ................. 271
3. Nail Bed Injury ...................... 274 1. Ankle Fractures .................... 377
4. High-Pressure Injection Injuries 2. Talar Neck Fractures ............ 387
................................................ 276 3. Talus Fracture (other than neck)
5. Frostbite............................... 278 ................................................ 390
V. Pelvis Trauma .......................... 284 4. Subtalar Dislocations ............ 394
A. Pelvis ................................... 285 5. Calcaneus Fractures............. 396
1. Pelvic Ring Fractures............ 285 VII. Foot & Ankle Trauma ............ 405
2. SI Dislocation & Crescent A. Ankle Sprains ....................... 406
Fractures ................................. 294 1. High Ankle Sprain &
3. Sacral Fractures ................... 297 Syndesmosis Injury .................. 406
4. Ilium Fractures ..................... 301 2. Low Ankle Sprain .................. 410
B. Acetabulum .......................... 303 B. Mid & Forefoot Trauma ......... 414
1. Acetabular Fractures............ 303 1. Lisfranc Injury (Tarsometatarsal
2. Hip Dislocation ..................... 311 fracture-dislocation) ................. 414
VI. Lower Extremity ...................... 314 2. 5th Metatarsal Base Fracture 420
ORTHO BULLETS
I.Genaral Trauma
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Evaluation
A. Evaluation
Primary Survey
Airway
o includes cervical spine control
Breathing
Circulation
o includes hemorrhage control and resuscitation (below)
o pregnant women should be placed in the left lateral decubitus position to limit positional
hypotension
Hemorrhagic Shock Classification & Fluid Resuscitation
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OrthoBullets2017 Genaral Trauma | Evaluation
Introduction
o average adult (70 kg male) has an estimated 4.7 - 5 L of circulating blood
o average child (2-10 years old) has an estimated 75 - 80 ml/kg of circulating blood
Methods of Resuscitation
o fluids
crystalloid isotonic solution
o blood options
O negative blood (universal donor)
Type specific blood
Cross-matched blood
transfuse in 1:1:1 ratio (red blood cells: platelets: plasma)
Indicators of adequate resuscitation
o MAP > 60
o HR < 100
o urine output 0.5-1.0 ml/kg/hr (30 cc/hr)
o serum lactate levels
most sensitive indicator as to whether some circulatory beds remain inadequately
perfused (normal < 2.5 mmol/L)
o gastric mucosal ph
o base deficit
normal -2 to +2
Risk of transfusion
o risk of viral transmission following allogenic blood transfusion
hepatitis B (HBV) has highest risk: 1 in 205,000 donations
hepatitis C (HCV): 1 in 1.8 million donations
human immunodeficiency virus (HIV): 1 in 1.9 million
transfused blood is screened for
HIV-1 (cause of AIDS)
HIV-2
hepatitis B
hepatitis C
West Nile virus
syphilis
o clerical error leading to transfusion reaction (1:12,000 to 1:50,000)
o bacterial contamination leading to sepsis (1:1million)
o anaphylactic reaction (1:150,000)
Septic Shock
Septic shock vs. hypovolemic shock
o the key variable to differentiate septic shock and hypovolemic shock is that systemic
vascular resistance is decreased with septic shock and increased with hypovolemic shock
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Evaluation
Imaging
Delay of fracture diagnosis is most commonly caused by failure to image extremity
AP Chest
o mediastinal widening
o pneumothorax
Lateral C-spine
o must visualize C7 on T1
o not commonly utilized in lieu of increased sensitivity with cervical spine CT
AP Pelvis
o pelvic ring
further CT imaging should be delayed until preliminary pelvic stabilization has
been accomplished
o acetabulum
o proximal femur
CT Scan
o C spine, chest, abdomen, pelvis
o often used in initial evaluation of trauma patient to rule out life threatening injuries
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OrthoBullets2017 Genaral Trauma | Evaluation
therefore only potentially life-threatening injuries should be treated in this period
including
compartment syndrome
fractures with vascular injuries
unreduced dislocations
long bone fractures
unstable spine fractures
open fractures
Stabilization followed by staged definitive management
o to minimize trauma, initial stabilization should be performed and followed by staged
definitive management
includes initial pelvic volume reduction via sheet, pelvic packing, skeletal traction,
binder, or external fixation
if hemodynamically stable
proceed with further imaging including CT chest, abdomen, pelvis
if not hemodynamically stable
consider pelvic angiography and embolization
o definitive treatment delayed for
7-10 days for pelvic fractures
within 3 weeks for femur fractures (conversion from exfix to IMN)
7-10 days for tibia fractures (conversion from external fixation to IMN)
2. Gustilo Classification
Abridged version
Type I
o wound < 1 cm
Type II
o 1-10cm
Type III A
o > 10 cm, high energy
o adequate tissue for coverage
o includes segmental / comminuted fractures even if wound <10cm
o farm injuries are automatically Gustillo III
Type IIIB
o extensive periosteal stripping and requires free soft tissue transfer
Type IIIC
o vascular injury requiring vascular repair
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Evaluation
Complete version
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OrthoBullets2017 Genaral Trauma | Evaluation
Figure I:1 Gustillo type one Figure I:2 Gustillo type two
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Evaluation
Antibiotic Indications for Open Fractures
Gustillo Grade I and II
o 1st generation cephalosporin
Gustillo Grade III
o 1st generation cephalosporin + aminoglycoside
traditionally recommended, but there is no evidence in the literature to support its
use
With farm injury / bowel contamination
o 1st generation cephalosporin + aminoglycoside + PCN
o add PCN for clostridia
Duration
o initiate as soon as possible
increased infection rate when antibiotics are delayed > 3 hours from time of injury
o continue for 72 hours after I&D
o 48 hours after each procedure
Tetanus booster if not up to date
3. Tscherne Classification
Closed Fractures
Oestern and Tscherne classification of soft tissue injury in closed fractures
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OrthoBullets2017 Genaral Trauma | Evaluation
Open Fractures
The Oestern and Tscherne classification for open fractures uses wound size, level of
contamination, and fracture pattern to grade open fractures
Grade II Open injuries with small skin and soft tissue contusions
moderate contamination
variable fracture patterns
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Evaluation
3: >30
2: 6-9
1: 1-5
0: 0
Calculation
o Glasgow coma scale score + systolic blood pressure score + respiratory rate score
Interpretation
o lower score indicates higher severity
o RTS <4 proposed for transfer to trauma center
Pros
o useful during triage to determine which patients need to be transported to a trauma center
Cons
o can underestimate injury severity in patients injured in one system
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OrthoBullets2017 Genaral Trauma | Evaluation
5 - severe (critical, survival uncertain)
6 - maximal, possibly fatal
ISS
ISS = sum of squares for the highest AIS grades in the three most severely injured
ISS body regions
2 2 2
ISS = A + B + C
where A, B, C are the AIS scores of the three most severely injured
ISS body regions
scores range from 1 to 75
single score of 6 on any AIS region results in automatic score of 75
Interpretation
ISS > 15 associated with mortality of 10%
Pros
integrates anatomic areas of injury in formulating a prediction of outcomes
Cons
difficult to calculate during initial evaluation and resuscitation in emergency room
difficult to predict outcomes for patients with severe single body area injury
New Injury Severity Score (NISS) overcomes this deficit
Modifications
Modified Injury Severity Score (MISS)
similar to ISS but for pediatric trauma
categorizes body into 5 areas, instead of 9
sum of the squares for the highest injury score grades in the three most severely
injured body regions
New Injury Severity Score (NISS)
takes three highest scores regardless of anatomic area
more predictive of complications and mortality than ISS
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Evaluation
Sickness Impact Profile
Introduction
o evaluates the impact of disease on physical and emotional functioning
Variables
o 12 categories
sleep
eating
work
home management
recreation
physical dimension
ambulation
body care
movement
psychosocial dimension
social interaction
alertness behavior
emotional behavior
communication
Relevance to trauma
o lower extremity injuries
psychosocial subscale does not improve with time
o polytrauma
at 10 year follow-up after a major polytrauma, females have
decreased quality-of-life scores
increased PTSD rates
increased absentee sick days when compared to males
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OrthoBullets2017 Genaral Trauma | Evaluation
o respiratory rate > 20 or PaCO2 < 32mm (4.3kPa)
o temperature less than 36 degrees or greater than 38 degrees
Calculation
o each component (heart rate, WBC count, respiratory rate, temperature) is given 1 point if
it meets the above criteria
Interpretation
o score of 2 or more meets criteria for SIRS
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Evaluation
Stabilize
o splint fracture for temporary stabilization
decreases pain, further injury from bone ends, and disruption of clots
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OrthoBullets2017 Genaral Trauma | Evaluation
Tetanus Prophylaxis
Initiate in emergency room or trauma bay
Two forms of prophylaxis
o toxoid dose 0.5 mL, regardless of age
o immune globulin dosing
<5-years-old receives 75U
5-10-years-old receives 125U
>10-years-old receives 250U
o toxoid and immunoglobulin should be given intramuscularly with two different syringes in
two different locations
Guidelines for tetanus prophylaxis depend on 3 factors
o complete or incomplete vaccination history (3 doses)
o date of most recent vaccination
o severity of wound
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Specific Presentations
B. Specific Presentations
Presentation
Symptoms
o pain, deformity
Physical exam
o perform careful neurovascular exam
o clinical suspicion for compartment syndrome
secondary to increased muscle edema from higher velocity
wounds
o examine and document all associated wounds
massive bone and soft tissue injuries occur even with low
velocity weapons
I:7 This clinical photo demonstrates a
Evaluation large soft tissue wound with exposed
Radiographs tibialis anterior and bone at the level of
the ankle joint
o obtain to identify bone involvement and/or fracture pattern
CT scan
o identify potential intra-articular missile
o detect hollow viscus injury that may communicate with
fracture
high index of suspicion for pelvis or spine fractures given
increased risk of associated bowel injury
Treatment General
Nonoperative
o local wound care
indications
low velocity GSW with no bone involvement and clean
wound edges I:8 This sagittal CT image
o local wound care, tetanus +/- short course of oral antibiotics demonstrates an intra-articular
bullet in the ankle joint
indications
low-velocity injury with no bone involvement or non-
operative fractures
technique
primary closure contraindicated
antibiotic use controversial but currently recommended if wound appears contaminated
Operative
o treatment of other non-orthopedic injuries
for trans-abdominal trajectories, laparotomy takes precedence over arthrotomy
o ORIF/external fixation
indications
unstable/operative fracture pattern in low-velocity gunshot injury
technique
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Specific Presentations
treatment dictated by fracture characteristics similar to closed fracture without gunshot
wound
stabilize extremity with associated vascular or nerve injuries
stabilize soft tissues in high velocity/high energy gunshot injuries
grossly contaminated/devitalized wounds managed with aggressive debridement per
open fracture protocol
o arthrotomy
indications
intra-articular missile
may lead to local inflammation, arthritis and lead intoxication (plumbism)
transabdominal GSW
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OrthoBullets2017 Genaral Trauma | Specific Presentations
GSW to Hand/Foot
Nonoperative
o antibiotics
indications
gross contamination
joint penetration I:9 This image
demonstrates a
extent of contamination unclear comminuted femoral
Operative shaft fracture
secondary to a
o surgical debridement +/- ORIF/external fixation ballistic injury
indications
articular involvement
unstable fractures
presentation 8 or more hours after injury
tendon involvement
superficial fragments in the palm or sole
I:10 This image
GSW to Femur demonstrates immediate
Operative intramedullary nailing
of a femur fracture from
o intramedullary nailing a gun shot wound
indications
diaphyseal femur fracture secondary to low-velocity gunshot wound
superficial wound debridement and immediate reamed nailing
similar union and infection rates to closed injuries
o external fixation
indications
high-velocity gunshot wounds or close range shotgun blasts
stabilize soft tissues and debride aggressively
associated vascular injury
temporize extremity until amenable to intramedullary nailing
GSW to Spine
Nonoperative
o broad spectrum IV antibiotics for 7-14 days
indications
gunshot wounds to the spine with associated perforated viscus
bullets which pass through the alimentary canal and cause spinal cord injuries do not
require surgical removal of the bullet
Operative
o surgical decompression and bullet fragment removal
indications
when a neurologic deficit is present that correlates with
radiographic findings of neurologic compression
a retained bullet fragment within the spinal canal in patients
with incomplete motor deficits is a relative indication for
surgical excision of the fragment I:11 This axial CT image
demonstrates a retained
bullet in the spinal canal
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Specific Presentations
2. Amputations
Introduction
May be used to treat trauma
o infection
o tumor
o vascular disease
o congenital anomalies
Prognosis
o outcomes are improved with involvement of psychological counseling for coping mechanisms
o amputation vs. reconstruction
LEAP study
impact on decision to amputate limb
severe soft tissue injury
highest impact on decision-making process
absence of plantar sensation
2nd highest impact on surgeon's decision making process
not an absolute contraindication to reconstruction
plantar sensation can recover by long-term follow-up
outcome measure
SIP (sickness impact profile) and return to work not significantly different between
amputation and reconstruction at 2 years in limb-threatening injuries
most important factor to determine patient-reported outcome is the ability to return to
work
Complications
o wound healing
o neuroma
o phantom limb pain : mirror therapy is a noninvasive treatment modality
Metabolic Demand
Metabolic cost of walking
o increases with more proximal amputations
perform amputations at lowest possible level to preserve function
exception
Syme amputation is more efficient than midfoot amputation
o inversely proportional to length of remaining limb
Ranking of metabolic demand (% represents amount of increase compared to baseline)
o Syme - 15%
o transtibial
traumatic - 25% average
short BKA - 40%
long BKA - 10%
vascular - 40%
o transfemoral
traumatic - 68%
vascular - 100%
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OrthoBullets2017 Genaral Trauma | Specific Presentations
o thru-knee amputation
varies based on patient habitus but is somewhere between transtibial and transfemoral
most proximal amputation level available in children to maintain walking speeds without
increased energy expenditure compared to normal children
o bilateral amputations
Wound Healing
Dependent on
o vascular supply
o nutritional status
o immune status
Improved with
o albumin > 3.0 g/dL
o ischemic index > .5
measurement of doppler pressure at level being tested compared to brachial systolic pressure
o transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg)
o toe pressure > 40 mm Hg (will not heal if < 20 mm Hg)
o ankle-brachial index (ABI) > 0.45
o total lymphocyte count (TLC) > 1500/mm3
Hyperbaric oxygen therapy
o contraindications include
chemo or radiation therapy
pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator,
pacemaker, dorsal column stimulator, insulin pump)
undrained pneumothorax
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Specific Presentations
o transhumeral versus elbow disarticulation
elbow disarticulation advantages
indicated in children to prevent bony overgrowth seen in transhumeral amputations
Techniques
o transcarpal
transect finger flexor/extensor tendons
anchor wrist flexor/extensor tendons to carpus
o wrist disarticulation : preserve radial styloid flare to improve prosthetic suspension
o transradial amputation : middle third of forearm amputation maintains length and is ideal
o transhumeral amputation : maintain as much length as possible
o shoulder disarticulation : retain humeral head to maintain shoulder contour
Transfemoral Amputation
Maintain as much length as possible
o however, ideal cut is 12 cm above knee joint to allow for prosthetic
fitting
Technique
o 5-10 degrees of adduction is ideal for improved prosthesis function
o adductor myodesis
improves clinical outcomes
creates dynamic muscle balance
provides soft tissue envelope that enhances prosthetic fitting
I:15 Illustration showing
Through-Knee-Amputation adductor myodesis technique.
Indications
o ambulatory patients who cannot have a transtibial amputation
o non-ambulatory patients
Technique
o suture patellar tendon to cruciate ligaments in notch
o use gastrocnemius muscles for padding at end of amputation
Outcomes (based on LEAP data)
o slower self-selected walking speeds than BKA
o similar amounts of pain compared to AKA and BKA
o worse performance on the Sickness Impact Profile (SIP) than BKA and
AKA
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OrthoBullets2017 Genaral Trauma | Specific Presentations
o physicians were less satisfied with the clinical, cosmetic, and functional recovery
o require more dependence with patient transfers than BKA
Below-Knee-Amputation (BKA)
Long posterior flap
o 12-15 cm below knee joint is ideal
ensures adequate lever arm
o need approximately 8-12 cm from ground to fit most modern high-impact prostheses
o osteomyoplastic transtibial amputation (Ertl) technique
create a strut from the tibia to fibula from a piece of fibula or osteoperiosteal flap
o "dog ears"
left in place to preserve blood supply to the flap
Modified Ertl
o designed to enhance prosthetic end-bearing
o technique
the original Ertl amputation required a corticoperiosteal flap bridge
the modified Ertl uses a fibular strut graft
requires longer operative and touniquet times than standard BKA transtibial amputation
fibula is fixed in place with cortical screws, fiberwire suture with end buttons, or heavy
nonabsorbable sutures.
Ankle/Foot Amputation
Syme amputation (ankle disarticulation)
o patent tibialis posterior artery is required
o more energy efficient than midfoot even though it is more proximal
o stable heel pad is most important factor
o used successfully to treat forefoot gangrene in diabetics
Pirogoff amputation (hindfoot amputation)
o removal of the forefoot and talus followed by calcaneotibial arthrodesis
o calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal
o allows patient to mobilize independently without use of prosthetic
Chopart amputation (hindfoot amputation)
o a partial foot amputation through the talonavicular and calcaneocuboid joints
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Specific Presentations
o primary complication is equinus deformity
avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar
neck
Lisfranc amputation
o equinovarus deformity is common
caused by unopposed pull of tibialis posterior and gastroc/soleus
prevent by maintaining insertion of peroneus brevis
Pediatric Amputation
Most common complication is bone overgrowth
o prevent by performing disarticulation or using epihphyseal cap to cover medullary canal
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OrthoBullets2017 Genaral Trauma | Specific Presentations
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Specific Presentations
o risks for domestic abuse
female
19-29 years
pregnant
low-income families/low socioeconomic status
o characteristic injuries or patterns
injuries inconsistent with history
long delay between injury and treatment
repeat injuries
o characteristics of abused patient
change in affect
constantly seeking partner approval
finding excuses to stay in treatment facility for prolonged period of time
repeated visits to the emergency department
significant time missed at work or decreased productivity at work
o characteristics of the abuser
refuses to leave patient alone
overly attentive
aggressive or hostile
refuses to let the patient answer their own questions
o barrier to reporting
fear of retaliation
shame
difficulty reporting to male physicians
fear of custody conflicts
Treatment
o duty to act
health care workers should inquire into the safety environment at home in cases of suspected
abuse
emotional abuse is more difficult to discern than physical violence
reporting requirements for adult abuse is not standardized among states
a physician does not have authority to provide protection to abused spouses in most states
should encourage victim to seek protection and report case to law enforcement
physician should document encounter completely and be familiar with their state laws
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OrthoBullets2017 Genaral Trauma | Specific Presentations
infection
pancreatitis
multiple blood transfusions
lung injury
sepsis or shock
major trauma
large surface area burns
fat emboli
thromboembolism
multi-system organ failure
Prognosis : high mortality rate (50% overall) is associated with ARDS even in setting of ICU
Classification
ARDS is represented by three phases
Presentation
Symptoms
o acute onset (12-48 hours) of
dyspnea
fever
mottled or cyanotic skin
Physical exam
o resistant hypoxia
o intercostal retractions
o rales/crackles and ronchi
o tachypnea
Evaluation
Hypoxemia is refractory to O2
o 3 different categories of ARDS based on degree of hypoxemia
o PaO2 / FIO2 ratio < 300 mm Hg= mild
o PaO2 / FIO2 ratio < 200 mm Hg= moderate
o PaO2 / FIO2 ratio < 100 mm Hg= severe
Chest xray
o shows patchy pulmonary edema (air space disease)
o diffuse bilateral pulmonary infiltrates
normal sized heart
makes CHF less likely
Respiratory compliance (<40 mL/cm H20)
Positive end-expiratory pressure (>10cm H20)
Corrected expired volume per minute (>10L/min)
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Specific Presentations
Differential
Cardiogenic pulmonary edema (i.e. CHF or MI), bilateral pneumonia, SARS
Treatment
Nonoperative
o PEEP ventilation and steroids
o treat the underlying pathology/disease
Operative
o early stabilization of long bone fractures (femur)
Prevention
o closely monitor PEEP in patients at-risk of ARDS
o serial X-rays in concerning patients can assist in early identification and intervention
Complications
Pneumothorax
o secondary to ventilator with high PEEP
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OrthoBullets2017 Genaral Trauma | Compartment Syndrome
C. Compartment Syndrome
Introduction
Devastating condition where an osseofascial compartment pressure rises to a level that decreases
perfusion , may lead to irreversible muscle and nerve damage
Epidemiology
o location : compartment syndrome may occur anywhere that skeletal muscle is surrounded by
fascia, but most commonly
leg
forearm
hand
foot
thigh
buttock
shoulder
paraspinous muscles
Pathophysiology
o etiology
trauma
fractures (69% of cases)
crush injuries
contusions
gunshot wounds
tight casts, dressings, or external wrappings
extravasation of IV infusion
burns
postischemic swelling
bleeding disorders
arterial injury
o pathoanatomy
cascade of events includes
local trauma and soft tissue destruction>
bleeding and edema >
increased interstitial pressure >
vascular occlusion >
myoneural ischemia
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Compartment Syndrome
extensor hallucis longus
extensor digitorum longus
peroneus tertius
o lateral compartment
function
plantarflexion and eversion of
foot
muscles
peroneus longus
peroneus brevis
isolated lateral compartment
syndrome would only affect
superficial peroneal nerve
o deep posterior compartment
function
Presentation
Symptoms
o pain out of proportion to clinical situation is usually first symptom
may be absent in cases of nerve damage
pain is difficult to assess in a polytrauma patient and impossible to assess in a sedated patient
difficult to assess in children (unable to verbalize)
Physical exam
o pain w/ passive stretch : is most sensitive finding prior to onset of ischemia
o paresthesia and hypoesthesia
indicative of nerve ischemia in affected compartment
o paralysis
late finding
full recovery is rare in this case
o palpable swelling
o peripheral pulses absent
late finding
amputation usually inevitable in this case
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OrthoBullets2017 Genaral Trauma | Compartment Syndrome
Imaging
Radiographs
o obtain to rule-out fracture
Studies
Compartment pressure measurements
o indications
polytrauma patients
patient not alert/unreliable
inconclusive physical exam findings
o relative contraindication
unequivocally positive clinical findings should prompt emergent operative
intervention without need for compartment measurements
o technique
should be performed within 5cm of fracture site
anterior compartment
entry point
1cm lateral to anterior border of tibia within 5cm of fracture site if possible
needle should be perpendicular to skin
deep posterior compartment
entry point
just posterior to the medial border of tibia
advance needle perpendicular to skin towards fibula
lateral compartment
entry point
just anterior to the posterior border of fibula
superficial posterior
entry point
middle of calf within 5 cm of fracture site if possible
Diagnosis
o based primarily on physical exam in patient with intact mental status
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Compartment Syndrome
Treatment
Nonoperative
o observation
indications
diastolic differential pressure (delta p) is > 30
presentation not consistent with compartment syndrome
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OrthoBullets2017 Genaral Trauma | Compartment Syndrome
Special considerations
o pediatrics
children are unable to verbalize feelings
if suspicion, then perform compartment pressure measurement under sedation
o hemophiliacs : give Factor VIII replacement before measuring compartment pressures
Techniques
Emergent fasciotomy of all four compartments
o dual medial-lateral incision
approach
two 15-18cm vertical incisions separated by 8cm skin bridge
anterolateral incision
posteromedial incision
technique
anterolateral incision
identify and protect the superficial peroneal nerve
fasciotomy of anterior compartment performed 1cm in front of intermuscular
septum
fasciotomy of lateral compartment performed 1cm behind intermuscular septum
posteromedial incision
protect saphenous vein and nerve
incise superficial posterior compartment
detach soleal bridge from back of tibia to adequately decompress deep posterior
compartment
post-operative
dressing changes followed by delayed primary closure or skin grafting at 3-7 days post
decompression
pros
easy to perform
excellent exposure
cons : requires two incisions
o single lateral incision
approach: single lateral incision from head of fibula to ankle along line of fibula
technique
identify superficial peroneal nerve
perform anterior compartment fasciotomy 1cm anterior to the intermuscular septum
perform lateral compartment fasciotomy 1cm posterior to the intermuscular septum
identify and perform fasciotomy on superficial posterior compartment
enter interval between superficial posterior and lateral compartment
reach deep posterior compartment by following interosseous membrane from the
posterior aspect of fibula and releasing compartment from this membrane
common peroneal nerve at risk with proximal dissection
pros : single incision
cons : decreased exposure
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Compartment Syndrome
Anatomy
3 thigh compartments
o anterior compartment
muscles
quadriceps
sartorious
nerves
femoral nerve
o posterior compartment
muscles
hamstrings
nerves
sciatic nerve
o adductor compartment
muscles
adductors
nerves Figure I:27 Thigh Compartments
obturator nerve
Presentation
Symptoms
o pain out of proportion to clinical situation is usually first symptom
may be absent in cases of nerve damage
pain is difficult to assess in a polytrauma patient and impossible to assess in a sedated
patient
difficult to assess in children (unable to verbalize)
Physical exam
o pain with passive stretch : is most sensitive finding prior to onset of ischemia
must test each compartment separately
anterior compartment
pain with passive flexion of knee
posterior compartment
pain with passive extension of knee
medial compartment
pain with passive abduction of hip
o paraesthesia and hypoesthesia : indicative of nerve ischemia in affected compartment
o paralysis
late finding
full recovery is rare in this case
o palpable swelling
o peripheral pulses absent
late finding
amputation usually inevitable in this case
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OrthoBullets2017 Genaral Trauma | Compartment Syndrome
Evaluation
Diagnosis
o based primarily on physical exam in patient with intact mental status
Radiographs
o obtain to rule-out fracture
Compartment pressure measurements
o indications
polytrauma patients
patient not alert/unreliable
inconclusive physical exam findings
o relative contraindication
unequivocally positive clinical findings should prompt emergent operative
intervention without need for compartment measurements
o technique
should be performed within 5cm of fracture site or area of maximal swelling
must test each compartment separately
Treatment
Nonoperative
o observation
indications
delta p > 30, and
presentation not consistent with compartment syndrome
Operative
o emergent fasciotomy of all affected compartments
indications
clinical presentation consistent with compartment syndrome
compartment pressures with absolute value of 30-45 mm Hg
compartment pressures within 30 mm Hg of diastolic blood pressure (delta p)
intraoperatively, diastolic blood pressure may be decreased from anesthesia
must compare intra-operative measurement to pre-operative diastolic pressure
contraindications
missed compartment syndrome
Surgical Techniques
Thigh fasciotomies
o approach
anterolateral incision over length of thigh
o technique
single incision technique for anterior and posterior compartments
incise fascia lata
expose and decompress anterior compartment
retract vastus lateralis medially to expose lateral intermuscular septum
incise lateral intermuscular septum to decompress posterior compartment
may add medial incision for decompression of adductor compartment
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Compartment Syndrome
Complications
Associated with significant long-term morbidity
o over 50% will experience functional deficits
including
pain
decreased knee flexion
myositis ossificans
sensory deficits
decreased strength
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OrthoBullets2017 Genaral Trauma | Compartment Syndrome
Presentation
Symptoms
o pain out of proportion to clinical situation is usually first symptom
may be absent in cases of nerve damage
difficult to assess in
polytrauma
sedated patients
children
Physical exam
o pain w/ passive stretch of fingers
most sensitive finding
o paraesthesia and hypoesthesia
indicative of nerve ischemia in affected compartment
o paralysis
late finding
full recovery is rare in this case
o palpable swelling
tense hand in intrinsic minus position
most consistent clinical finding
o peripheral pulses absent
late finding
amputation usually inevitable in this case
Evaluation
Radiographs : obtain to rule-out fracture
Compartment pressure measurements
o indications
polytrauma patients
patient not alert/unreliable
inconclusive physical exam findings
o relative contraindication
unequivocally positive clinical findings should prompt emergent operative intervention
without need for compartment measurements
o threshold for decompression
controversial, but generally considered to be
absolute value of 30-45 mm Hg
within 30 mm Hg of diastolic blood pressure (delta p)
intraoperatively, diastolic blood pressure may be decreased from anesthesia
if delta p is less than 30 mmHg intraoperatively, check preoperative diastolic
pressure and follow postoperatively as intraoperative pressures may be low and
misleading
Treatment
Nonoperative
o indications
exam not consistent with compartment syndrome
delta p > 30
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Compartment Syndrome
Operative
o emergent forearm fasciotomies
indications
clinical presentation consistent with compartment syndrome
compartment measurements with absolute value of 30-45 mm Hg
compartment measurements within 30 mm Hg of diastolic blood pressure (delta p)
intraoperatively, diastolic blood pressure may be decreased from anesthesia
must compare intra-operative measurement to pre-operative diastolic pressure
o emergent hand fasciotomies
indications
clinical presentation consistent with compartment syndrome
compartment measurements with absolute value of 30-45 mm Hg
compartment measurements within 30 mm Hg of diastolic blood pressure (delta p)
intraoperatively, diastolic blood pressure may be decreased from anesthesia
must compare intra-operative measurement to pre-operative diastolic pressure
Surgical Techniques
Forearm
o emergent fasciotomies of all involved compartments
approach
volar incision
decompresses volar compartment, dorsal compartment,
carpal tunnel
incision starts just radial to FCU at wrist and extends
proximally to medial epicondyle
may extend distally to release carpal tunnel
dorsal incision
decompresses mobile wad
dorsal longitudinal incision 2cm distal to lateral
epicondyle toward midline of wrist
technique
volar incision
open lacertus fibrosus and fascia over FCU
retract FCU ulnarly, retract FDS radially
open fascia over deep muscles of forearm Figure I:31 Volar incision
dorsal incision
dissect interval between EDC and ECRB
decompress mobile wad and dorsal
compartment
post-operative
leave wounds open
wound VAC Figure I:32 Dorsal incision
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OrthoBullets2017 Genaral Trauma | Compartment Syndrome
possible delayed primary wound closure
VAC dressing when closure cannot be obtained
follow with split-thickness skin grafting at a
later time
Hand
Figure I:33 Leave the wound open
o emergent fasciotomies of all involved
compartments
approach
two longitudinal incisions over 2nd and 4th
metacarpals
decompresses volar/dorsal interossei and
adductor compartment
longitudinal incision radial side of 1st metacarpal
decompresses thenar compartment
longitudinal incision over ulnar side of 5th
metacarpal
decompresses hypothenar compartment
technique Figure I:34 Hand incisions
first volar interosseous and adductor pollicis muscles are
decompressed through blunt dissection along ulnar side of 2nd metacarpal
post-operative
wounds left open until primary closure is possible
if primary closure not possible, split-thickness skin grafting is used
Complications
Volkman's ischemic contracture
o irreversible muscle contractures in the forearm, wrist and hand that result from muscle
necrosis
o contracture positioning
elbow flexion
forearm pronation
wrist flexion
thumb adduction
MCP joints in extension
IP joints in flexion
o classification : Tsuge Classification (see table below)
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Compartment Syndrome
Presentation
Symptoms
o pain out of proportion to injury
Physical exam
o pain with dorsiflexion of toes (MTPJ)
places intrinsic muscles on stretch
o tense swollen foot
o loss of two-point discrimination
o pulses
presence of pulses does not exclude diagnosis
Evaluation
Radiographs
o obtain to rule-out fracture
Compartment pressure measurements
o indications
polytrauma patients
patient not alert/unreliable
inconclusive physical exam findings
o relative contraindication
unequivocally positive clinical findings should prompt emergent operative intervention
without need for compartment measurements
o technique
central compartment
base of first metatarsal
direct needle lateral and plantar through abductor hallucis
medial compartment
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OrthoBullets2017 Genaral Trauma | Compartment Syndrome
base of first metatarsal advancing 2cm into abductor hallucis
interosseous
second, third, and fourth webspaces
advance plantar 2cm to puncture extensor fascia
lateral
midshaft of fifth metatarsal
advance 1cm medial and plantar
o threshold for decompression
controversial, but generally considered to be
absolute value of 30-45 mm Hg
within 30 mm Hg of diastolic blood pressure (delta p)
intraoperatively, diastolic blood pressure may be decreased from anesthesia
must compare intra-operative measurement to pre-operative diastolic pressure
Treatment
Nonoperative
o observation
indications
delta p > 30
exam not consistent with compartment syndrome
Operative
o emergent foot fasciotomies
indications
clinical presentation consistent with compartment syndrome
compartment measurements with absolute value of 30-45 mm Hg
compartment measurements within 30 mm Hg of diastolic blood pressure (delta p)
intraoperatively, diastolic blood pressure may be decreased from anesthesia
must compare intra-operative measurement to pre-operative diastolic pressure
Surgical Technique
Emergent fasciotomies of all compartments
o dual dorsal incisions (gold standard)
approach
dorsal medial incision
medial to 2nd metatarsal
releases 1st and 2nd interosseous, medial, and deep central compartment
dorsal lateral incision
lateral to 4th metatarsal
releases 3rd and 4th interosseous, lateral, superficial and middle
central compartments
technique
dorsal fascia of each interosseous compartment opened longitudinally
strip muscle from medial fascia in first interosseous compartment
split adductor compartment
may add medial incision for decompression of calcaneal compartment
post-operative
delayed wound closure with possible skin grafting
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Compartment Syndrome
pros
direct access to all compartments
provides exposure for Chopart, Lisfranc, or tarsometatarsal fractures
cons
does not provide access for fixation of calcaneus fractures
o single medial incision
technique
single medial incision used to release all nine compartments
cons
technically challenging
Complications
Chronic pain and hypersensitivity
o difficult to manage
Fixed flexion deformity of digits (claw toes)
o release flexor digitorum brevis and longus at level of digits
Figure I:38 surgical approach for dual dorsal incisions Figure I:39 claw toes
Chapter of infections (adult osteomyelitis, septic arthritis, wound & hardware infections, necrotizing
fasciitis and Gas gangrene) all these topics moved from trauma to pathology volume eight.
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OrthoBullets2017 Spine Trauma | Compartment Syndrome
ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Spinal Cord Injury
History
Details of accident
o energy of accident
higher level of concern when there is a history of high energy trauma as indicated by
MVA at > 35 MPH
fall from > 10 feet
closed head injuries
neurologic deficits referable to cervical spine
pelvis and extremity fractures
o mechanism of accident
e.g., elderly person falls and hits forehead (hyperextension injury)
e.g., patient rear-ended at high speed (hyperextension injury)
o condition of patient at scene of accident
general condition
degree of consciousness
presence or absence of neurologic deficits
Identify associated conditions and comorbidities
o ankylosing spondylitis (AS)
o diffuse idiopathic skeletal hyperostosis (DISH)
o previous cervical spine fusion (congenital or acquired)
o connective tissue disorders leading to ligamentous laxity
Physical Exam
Useful for detecting major injuries
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OrthoBullets2017 Spine Trauma | Spinal Cord Injury
Primary survey
o airway
o breathing
o circulation
o visual and manual inspection of entire spine should be performed
manual inline traction should be applied whenever cervical immobilization is removed for
securing airway
seat belt sign (abdominal ecchymosis) should raise suspicion for flexion distraction injuries
of thoracolumbar spine
Secondary survey
o cervical spine exam
remove immobilization collar
examine face and scalp for evidence of direct trauma
inspect for angular or rotational deformities in the holding position of the patient's head
rotational deformity may indicate a unilateral facet dislocation
palpate posterior cervical spine looking for tenderness along the midline or paraspinal tissues
absence of posterior midline tenderness in the awake, alert patient predicts low
probability of significant cervical injury7,
log roll patient to inspect and palpate entire spinal axis
perform careful neurologic exam
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Spinal Cord Injury
II:2 standard Lat crvical spine II:3 standard open-mouth odontoid view
II:1 standard AP crvical spine radiograph radiograph radiograph
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OrthoBullets2017 Spine Trauma | Spinal Cord Injury
cons
high rate of false positives
only effective if done within 48 hours of injury
can be difficult to obtain in obtunded or intoxicated patients
o MR and CT angiography
pros : effective for evaluating vertebral artery
Treatment
Nonoperative
o cervical collar
indications : initiated at scene of injury until directed examination performed
o early active range of motion
indications
"whiplash-like" symptoms and
cleared from a serious cervical injury by exam or imaging
Complications
Delayed clearance associated with increased complication rate including
o increased risk of aspiration
o inhibition of respiratory function
o decubitus ulcers in occipital and submandibular areas
o possible increase in intracranial pressure
Relevant Anatomy
See Spinal Cord Anatomy
Classification
Descriptive
o atetrplegia
injury to the cervical spinal cord leading to impairment of function in the arms, trunk, legs,
and pelvic organs
o paraplegia
injury to the thoracic, lumbar or sacral segments leading to impairment of function in the
trunk, legs, and pelvic organs depending on the level of injury. Arm function is preserved
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OrthoBullets2017 Spine Trauma | Spinal Cord Injury
o complete injury
an injury with no spared motor or sensory function below the affected level.
patients must have recovered from spinal shock (bulbocavernosus reflex is intact) before an
injury can be determined as complete
classified as an ASIA A
o incomplete injury
an injury with some preserved motor or sensory function below the injury level
incomplete spinal cord injuries include
anterior cord syndrome
Brown-Sequard syndrome
central cord syndrome
posterior cord syndrome
conus medullaris syndromes
cauda equina syndrome
ASIA Classification
Determine if patient is in spinal shock
o check bulbocavernosus reflex
Determine neurologic level of injury
o lowest segment with intact sensation and antigravity (3 or more) muscle function strength
o in regions where there is no myotome to test, the motor level is presumed to be the same as the
sensory level.
Determine whether the injury is COMPLETE or INCOMPLETE
o COMPLETE defined as (ASIA A)
no voluntary anal contraction (sacral sparing) AND
0/5 distal motor AND
0/2 distal sensory scores (no perianal sensation) AND
bulbocavernosus reflex present (patient not in spinal shock)
o INCOMPLETE defined as
voluntary anal contraction (sacral sparing)
sacral sparing critical to determine complete vs. incomplete
OR palpable or visible muscle contraction below injury level OR
perianal sensation present
Determine ASIA Impairment Scale (AIS) Grade:
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Spinal Cord Injury
Acute Phase Conditions
Neurogenic shock
o characterized by hypotension & relative bradycardia in patient with an acute spinal cord injury
potentially fatal
o mechanism
circulatory collapse from loss of sympathetic tone
disruption of autonomic pathway within the spinal cord leads to
lack of sympathetic tone
decreased systemic vascular resistance
pooling of blood in extremities
hypotension
o treatment
Swan-Ganz monitoring for careful fluid management
pressors to treat hypotension
Spinal shock
o defined as temporary loss of spinal cord function and reflex activity below the level of a spinal
cord injury.
o characterized by
flaccid areflexic paralysis
bradycardia & hypotension (due to loss of sympathetic tone)
absent bulbocavernosus reflex
reflex characterized by anal sphincter contraction in response to squeezing the glans
penis or tugging on an indwelling Foley catheter
o timing
variable but usually resolves within 48 hours
at its conclusion spasticity, hyperreflexia, and clonus slowly progress over days to weeks
o mechanism
neurophysiologic in nature
neurons become hyperpolarized and unresponsive to stimuli from brain
o evaluation
important because one cannot evaluate neurologic deficit until spinal shock phase has
resolved
end of spinal shock indicated by return of the bulbocavernous reflex
conus or cauda equina injuries may lead to permanent loss of the bulbocavernous reflex
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OrthoBullets2017 Spine Trauma | Spinal Cord Injury
Evaluation
Field treatment
o treatment of potential spinal cord injuries begins at the accident scene with proper spinal
immobilization
o immobilization
immobilization should include rigid cervical collar and transport on firm spine board with
lateral support devices
patient should be rolled with standard log roll techniques with control of cervical spine
o athletes
in the setting of sports-related injuries helmets and shoulder pads should be left on until
arrival at hospital or until experienced personnel can perform simultaneous removal of
helmet and shoulder pads in a controlled situation
Initial evaluation
o primary survey
airway
breathing
SCI above C5 likely to require intubation
circulation
initial survey to inspect for obvious injuries of head and spine
visual and manual inspection of entire spine should be performed
seat belt sign (abdominal ecchymoses) should raise suspicion for flexion distraction
injuries of thoracolumbar spine
o secondary survey
cervical spine exam
remove immobilization collar
examine face and scalp for evidence of direct trauma
inspect for angular or rotational deformities in
the holding position of the patient's head
rotational deformity may indicate a unilateral
facet dislocation
palpate posterior cervical spine looking for
tenderness along the midline or paraspinal
tissues
absence of posterior midline tenderness in
the awake, alert patient predicts low
probability of significant cervical injury7,
log roll patient to inspect and palpate entire
spinal axis
perform careful neurologic exam
o cervical spine clearance
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Spinal Cord Injury
Acute Treatment
Nonoperative
o high dose methylprednisone
indications
nonpenetrating SCI within 8 hours of injury
recommended by NASCIS III
contraindications include
GSW
pregnancy
under 13 years
> 8 hours after injury
brachial plexus injuries
technique
load 30 mg/kg over 1st hour (2 grams for 70kg man)
drip 5.4 mg/kg/hr drip
for 23 hours if started < 3 hrs after injury
for 47 hours if started 3-8 hours after injury
outcomes
leads to improved root function at level of injury
may or may not lead to spinal cord function improvement
o monosialotetrahexosylganglioside (GM-1)
indications
remains controversial
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OrthoBullets2017 Spine Trauma | Spinal Cord Injury
large multicenter RCT did not show long term benefit
some evidence of faster recovery
o acute closed reduction with axial traction
indications
alert and oriented patient with neurologic deficits and compression due to
fracture/dislocation
bilateral facet dislocation with spinal cord injury in alert and oriented patient is most
common reason to perform acute reduction with axial traction
technique
reasons to abort
overdistraction
worsening neurologic exam
failure to obtain reduction
o DVT prophlaxis
indications
most patients
contraindications include
coagulopathy
hemorrhage
modalities
low-molecular weight heparin
rotating bed
pneumatic compression stocking
o cardiopulmonary management
careful hemodynamic monitoring and stabilization is critical in early treatment
hypotension should be avoided
implement immediate aggressive pulmonary protocols
Operative : rarely indicated in acute setting
Definitive Treatment
Nonoperative
o bracing and observation
indications
most GSWs
exceptions listed below
metastatic CA patients with < 6 mos life expectancy
presence of six variables below correspond to short life expectancy
multiple spinal mets
multiple extraspinal mets
unresectable lesions in major organs
SCI (complete or incomplete)
aggressive CA: lung, osteosarcoma, pancreas
critically ill
Operative
o surgical decompression and stabilization
indications
most incomplete SCI (except GSW)
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Spinal Cord Injury
decompress when patient hits neurologic plateau or if worsening neurologically
decompression may facilitate nerve root function return at level of injury (may
recover 1-2 levels)
most complete SCI (except GSW)
stabilize spine to facilitate rehab and minimize need for halo or orthosis
decompression may facilitate nerve root function return at level of injury (may
recover 1-2 levels)
consider for tendon transfers
e.g. Deltoid to triceps transfer for C5 or C6 SCI
metastatic CA patients with > 6 mos life expectancy
~ no for six question above
GSW with
progressive neurological deterioration with retained bullet within the spinal canal
cauda equina syndrome (considered a peripheral nerve)
retained bullet fragment within the thecal sac
CSF leads to the breakdown of lead products that may lead to lead poisoning
Complications
Skin problems
o treatment is prevention
o start in ER
do not leave on back board
start log rolling early
proper bedding
Venous Thromboembolism
o prevent with immediate DVT prophylaxis
Urosepsis
o common cause of death
o strict aseptic technique when placing catheter
o don't let bladder become overly distended
Sinus bradycardia
o most common cardiac arrhythmia in acute stage following SCI
Orthostatic hypotension
o occurs as a result of lack of sympathetic tone
Autonomic dysreflexia
o potentially fatal
o presents with headache, agitation, hypertension
o caused by unchecked visceral stimulation
check foley
disimpact patient
Major depressive disorder
o ~11% of patients with spinal cord injuries suffer from MDD
o MDD in spinal cord injury patients is highly associated with suicidal ideation in both the acute
and chronic phase.
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OrthoBullets2017 Spine Trauma | Spinal Cord Injury
Rehabilitation
Goals
o goal is to assess and identify mechanisms for reintegration into community based on functional
level and daily needs
o patients learn transfer techniques, self care retraining, mobility skills
Restoring hand function
o hand function is often limiting factor for many patients
o tendon transfers can be used to restore function to paralyzed arms and hands by giving working
muscles different jobs
Modalities
o functional electrical stimulation is a technique that uses electrical currents to stimulate and
activate muscles affected by paralysis
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Spinal Cord Injury
Classification
Clinical classification
o anterior cord syndrome (see below)
o Brown-Sequard syndrome
o central cord syndrome
o posterior cord syndrome
ASIA classification
o method to scale
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OrthoBullets2017 Spine Trauma | Spinal Cord Injury
ASIA Impairment Scale
A Complete No motor or sensory function is preserved in the sacral segments S4-S5.
B Incomplete Sensory function preserved but not motor function is preserved below the
neurological level and includes the sacral segments S4-S5.
C Incomplete Motor function is preserved below the neurological level, and more than half of
key muscles below the neurological level have a muscle grade less than 3.
D Incomplete Motor function is preserved below the neurological level, and at least half of key
muscles below the neurological level have a muscle grade of 3 or more.
E Normal Motor and sensory function are normal.
Brown-Sequard Syndrome
Caused by complete cord hemitransection
o usually seen with penetrating trauma
Exam
o ipsilateral deficit
LCS tract
motor function
dorsal columns
proprioception
vibratory sense
o contralateral deficit
LST
pain
temperature
spinothalamic tracts cross at spinal cord level (classically 2-levels below)
Prognosis
o excellent prognosis
o 99% ambulatory at final follow up
o best prognosis for function motor activity
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OrthoBullets2017 Spine Trauma | AtlantoAxial Trauma
Posterior Cord Syndrome
Introduction : very rare
Exam
o loss : proprioception
o preserved : motor, pain, light touch
B. AtlantoAxial Trauma
Anatomy
Osteology
o occipital condyles are paired prominences of the occipital bone
o oval or bean shaped structures forming lateral aspects of the foramen magnum
Joint articulations
o intrinsic relationship between occiput, atlas and axis to form the occipitoatlantoaxial complex or
CCJ
o 6 main synovial articulations
anterior and posterior median atlanto-odontoid joints
paired occipitoatloid joints
paired atlantoaxial joints
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Ligamentous structures
o intrinsic ligaments are located within the spinal canal, provide most of the ligamentous stability.
They include
transverse ligament
primary stabilizer of atlantoaxial junction
connects the posterior odontoid to the anterior atlas arch, inserting laterally on bony
tubercles.
paired alar ligaments
connect the odontoid to the occipital condyles
relatively strong and contributes to occipitalcervical stability
apical ligament
relatively weak midline structure
runs vertically between the odontoid and foramen magnum.
tectorial membrane
connects the posterior body of the axis to the anterior foramen magnum and is the
cephalad continuation of the PLL
Neurovascular considerations
o proximity of the occipital condyles to:
medulla oblongata
vertebral arteries
lower cranial nerves (CN IX - CN XII)
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OrthoBullets2017 Spine Trauma | AtlantoAxial Trauma
Classification
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Presentation
History
o clinical presentation is highly variable
o presentation is largely dependent on associated injury (eg, head injury, brainstem injury, vascular
injury)
o neurological deficits may be acute (63% of cases) or delayed (37% of cases)
Symptoms
o high cervical pain
o reduced head/neck ROM
o torticollis
o lower cranial nerve deficits
o motor paresis
Physical Examination
o lower cranial nerve deficits most commonly affect CN IX, X, and XI
Imaging
Radiographs
o recommended views
AP, lateral, open-mouth AP view
o alternative views
traction is generally not recommended
o findings
diagnosis rarely made on plain radiographs due to superimposition of structures (maxilla,
occiput) blocking view of occipital condyles
open-mouth AP view may depict occiptal condyle injuries
CT
o indications
method of choice
routine CT imaging in high-energy trauma patients
clinical criteria:
altered consciousness
occipital pain and tenderness
impaired CCJ motion
lower cranial nerve paresis
motor paresis
o views : must include cranial-cervical junction with thin-section technique
o findings : occiput fracture or CCJ instability
MRI
o indications
evaluation of soft-tissue craniocervical trauma
fractured fragment located in the vertebral canal
spinal cord or brain stem ischemia
o views
MR angiogram may be considered with suspected vascular injury
o findings
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OrthoBullets2017 Spine Trauma | AtlantoAxial Trauma
MRI better than CT for the assessment of associated brain and brain-stem injuries, although
CT still considered standard for evaluating acute subarachnoid hemorrhage
Treatment
Nonoperative
o analgesics, cervical orthosis
indications
Type 1 and 2
Type 3 without overt instability
modalities
semi-rigid or rigid cervical collar
Operative
o occipitocervical fusion
indications
Type 3 with overt instability
neural compression from displaced fracture fragment
associated occipital-atlantal or atlanto-axial injuries
technique
C0-C2/C3 occipitocervical arthrodesis using rigid segmental fixation or posterior
decompression and instrumented fusion
may require bone grafting or removal of boney fragments compressing neurovascular
structures.
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
o acquired
pathoanatomy
dueto bony dysplasia or ligament and soft-tissue laxity
Associated conditions
o atlantoaxial instability
also seen in Down syndrome patients
o neurologic deficits
o vertebral or carotid artery injuries
o Down Syndrome
Classification
Stage III Gross craniocervical misaligment (BAI or BDI > 2mm beyond normal
Unstable
limits)
Imaging
Radiographs
o recommended views
AP, lateral and odontoid views
o findings
low sensitivity in detecting injury (57%)
o measurements
used to diagnosis occipitocervical dislocation
Powers ratio = C-D/A-B
C-D: distance from basion to posterior arch
A-B: distance from anterior arch to opisthion
significance
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OrthoBullets2017 Spine Trauma | AtlantoAxial Trauma
ratio ~ 1 is normal
if > 1.0 concern for
anterior dislocation
ratio < 1.0 raises concern for
posterior atlanto-occipital dislocation
odontoid fractures
ring of atlas fractures
Harris rule of 12
basion-dens interval or basion-posterior axial interval
>12mm suggest occipitocervical dissociation
CT
o indications
II:9 Harris rule of 12: >12mm suggests
occipitocervical dissociation
considered gold standard for osseous injuries of the spine
o views
midsaggital CT reconstruction
MRI
o indications
suspected ligamentous injury with preserved alignment or occult injury
neurological deficits
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Treatment
Nonoperative
o provisional stabilization while avoiding traction
indications
traumatic instability with distraction of the occipitoatlantal joint
techniques
halo vest
tongs
prolonged cervical orthosis is not recommended due to poor stabilization of the AOJ
outcomes
use of traction should be avoided in most cases
traction may be considered in stage 2 injuries when MRI demonstates soft-tissue injury
with perserved aligment
Operative
o posterior occipitocervical fusion (C0 - C2 or lower)
indications
most traumatic cases require stabilization
acquired cases when evidence of myelpathy or significant symptomatic neck pain
invagination and atlanto-axial impaction secondary to inflammatory arthropathy (e.g.,
rheumatoid arthritis)
tumor
Technique
Posterior occipitocervical fusion
o approach
midline posterior approach to base of skull
o instrumentation
rigid occipitocervical screw-rod or plate construct
aim for 3 bicortical occipital screws on each side of the midline (total 6 screws in occiput)
extend to C2 or lower with polyaxial
pedical screws to achieve fixation
the safe zone for occipital screws is located
within an area measuring 20mm lateral to
the external occipital protuberance along the
superior nuchal line
the major dural venous sinuses are located
just below the external occipital protuberance
and are at risk of penetrative injury during
occipitocervical fusion
autogenous bone graft
Complications
Nonunion
Bleeding
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OrthoBullets2017 Spine Trauma | AtlantoAxial Trauma
3. Atlantoaxial Instability
Introduction
The atlantoaxial joint is an important "transitional zone" in the cervical spine
o prone to instability by both degenerative and traumatic processes.
Pathophysiology
o adult causes
degenerative
Down's syndrome
Rheumatoid Arthritis
Os odontoideum
traumatic
Type I odontoid fracture (very rare)
Atlas fractures
Transverse ligament injuries
o pediatric causes
degenerative
JRA
Morquio's Syndrome
lysosomal storage disorder
trauma/infection
rotatory atlantoaxial subluxation
Anatomy
Osteology
o bony articulations
C1-C2 facet joints
Ligaments
o transverse apical alar ligament complex
transverse ligament
most important stabilizer
apical ligament
single midline structure
alar ligaments
paired parasagittal ligament
Biomechanics
o the atlantoaxial joint provides ~50% of rotation in the cervical spine
this is enabled by the peg (C2)-ring(C1)
anatomy
Physical Exam
Symptoms
o symptomatic
o neck pain
o neurologic symptoms
Physical exam
o neurologic deficits
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
often appear late in disease process due to capacious nature of spinal canal at the C1 level
myelopathic symptoms
hyperreflexia (patellar tendon reflex)
muscles weakness
broad based gait
decreased hand dexterity
loss of motor milestones
bladder problems
Imaging
Radiographs
o flexion-extension xrays
atlanto-dens interval (ADI)
measurement
distance between odontoid process and the posterior border of the anterior arch of the
atlas
adult parameters
> 3.5mm considered unstable
> 10mm indicates surgery in RA
other
must get preoperative flexion-extension radiographs to clear all high-risk patients for
any type of surgery
space-available-cord (SAC) = posterior atlanto-dens-interval (PADI)
measurement
distance from posterior surface of dens to anterior surface of posterior arch of atlas
adult parameters
in adults with RA < 14 mm associated with increased risk of neurologic injury and is
an indication for surgery
o open mouth odontoid
sum of lateral mass displacement
measurement
lateral mass are connect by ring of C1, and therefore can only be displaced relative to
each other if
there is a bony fracture (disruption of the ring)
the transverse ligament is ruptured
transverse ligaments binds them together
adult parameters
if > 8.1 mm, then a transverse ligament rupture is assured and the injury pattern is
considered unstable
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Treatment
Determined by specific condition
o adult atlantoaxial instability
Down's syndrome
Rheumatoid Arthritis
Os odontoideum
Odontoid fracture
Atlas fractures
Transverse ligament injuries
o pediatric atlantoaxial instability
JRA
Morquio's Syndrome
Rotatory atlantoaxial subluxation
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
plough fracture
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Imaging
Radiographs
o lateral radiographs
atlantodens interval (ADI)
< 3 mm = normal in adult (< 5mm normal in child)
3-5 mm = injury to transverse ligament with intact alar and apical ligaments
> 5 mm = injury to transverse, alar ligament, and tectorial membrane
o open-mouth odontoid
open-mouth odontoid view important to identify atlas fractures
sum of lateral mass displacement
if sum of lateral mass displacement is > 7 mm (8.1mm with radiographic magnification)
then a transverse ligament rupture is assured and the injury pattern is considered unstable
CT
o study of choice to delineate fracture pattern and identify associated injuries in the cervical spine
MRI
o more sensitive at detecting injury to transverse ligament
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Treatment
Nonoperative
o hard collar vs. halo immobilization for 6-12 weeks
indications
stable Type I fx (intact transverse ligament)
stable Jefferson fx (Type II) (intact transverse ligament)
stable Type III (intact transverse ligament)
technique : controversy exists around optimal form of immobilization
Operative
o posterior C1-C2 fusion vs. occipitocervical fusion
indications
unstable Type II (controversial)
unstable Type III (controversial)
technique : may consider preoperative traction to reduce displaced lateral masses
Techniques
Posterior C1-C2 fusion
o preserves motion compared to occipitocervical fusion
o fixation
C1 lateral mass / C2 pedicle screw construct
may be sufficient if adequate purchase with C1 lateral mass screws
C1-2 transarticular screw placement
Occipitocervical fusion (C0-C2)
o uses when unable to obtain adequate purchase of C1 (comminuted C1 fracture)
o leads to significant loss of motion
Complications
Delayed C-spine clearance
o higher rate of complications in patients with delayed C-spine clearance so it is important to clear
expeditiously
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Pathophysiology
o mechanism
displacement may be anterior (hyperflexion) or posterior (hyperextension)
anterior displacement
is associated with transverse ligament failure and atlanto-axial instability
posterior displacement
caused by direct impact from the anterior arch of atlas during hyperextension
o biomechanics
a fracture through the base of the odontoid process severely compromises the stability of the
upper cervical spine.
Associated conditions
o Os odontoideum
appears like a type II odontoid fx on
xray
previously thought to be due to
failure of fusion at the base of the
odontoid
evidence now suggests it may
represent the residuals of an old traumatic process
treatment is observation
Anatomy
Axis Osteology
o axis has odontoid process (dens) and body
o embryology
develops from five ossification centers
subdental (basilar) synchondrosis is an initial
cartilagenous junction between the dens and vertebral
body that does not fuse until ~6 years of age
the secondary ossification center appears at ~ age 3 and fuses to the dens at ~ age 12
Axis Kinematics
o CI-C2 (atlantoaxial) articulation
is a diarthrodal joint that provides
50 (of 100) degrees of cervical rotation
10 (of 110) degrees of flexion/extension
0 (of 68) degrees of lateral bend
o C2-3 joint
participates in subaxial (C2-C7) cervical motion which
provides
50 (of 100) degrees of rotation
50 (of 110) degrees of flexion/extension
60 (of 68) degrees of lateral bend
Occipital-C1-C2 ligamentous stability
o provided by the odontoid process and its supporting ligaments
transverse ligament: limits anterior translation of the atlas
apical ligaments : limit rotation of the upper cervical spine
alar ligaments : limit rotation of the upper cervical spine
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OrthoBullets2017 Spine Trauma | AtlantoAxial Trauma
Blood Supply
oa vascular watershed exists between the apex and the base of the odontoid
apex is supplied by branches of internal carotid artery
base is supplied from branches of vertebral artery
the limited blood supply in this watershed area is thought to affect healing of type II odontoid
fractures.
Classification
Anderson and D'Alonzo Classification
Anderson and D'Alonzo Classification
Type I Oblique avulsion fx of tip of odontoid. Due to avulsion of alar ligament. Although
rare, atlantooccipital instability should be ruled out with flexion and extension
films.
Type II Fx through waist (high nonunion rate due to interruption of blood supply).
Type III Fx extends into cancellous body of C2 and involves a variable portion of the C1-C2
joint.
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Presentation
Symptoms
o neck pain worse with motion
o dysphagia may be present when associated with a large retropharyngeal hematoma
Physical exam
o myelopathy
very rare due to large cross section area of spinal canal at this level
Imaging
Radiographs
o required views
AP, lateral, open-mouth odontoid view of cervical spine
o optional views
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flexion-extension radiographs are important to diagnose occipitocervical instability in Type I
fractures and Os odontoideum
instability defined as
atlanto-dens-interval (ADI) > 10mm
< 13mm space available for cord (SAC)
o findings
fx pattern best seen on open-mouth odontoid
CT
o study of choice for fracture delineation and to assess stability of fracture pattern
CT angiogram
o required to determine location of vertebral artery prior to posterior instrumentation procedures
MRI
o indicated if neurologic symptoms present
Treatment
Treatment Overview
Os Odontoideum Observation
Type I Cervical Orthosis
Type II Young Halo if no risk factors for nonunion
Surgery if risk factors for nonunion
Type II Elderly Cervical Orthosis if not surgical candidates
Surgery if surgical candidates
Type III Cervical Orthosis
Nonoperative
o observation alone
indications
Os odontoideum
assuming no neurologic symptoms or instability
o hard cervical orthosis for 6-12 weeks
indications
Type I
Type II in elderly who are not surgical candidates
union is unlikely, however a fibrous union should provide sufficient stability except in
the case of major trauma
Type III fractures
no evidence to support Halo over hard collar
o halo vest immobilization for 6-12 weeks
indications
Type II young patient with no risk factors for nonunion
contraindications
elderly patients
do not tolerate halo (may lead to aspiration, pneumonia, and death)
Operative
o posterior C1-C2 fusion
indications
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Type II fractures with risk factors for nonunion
Type II/III fracture nonunions
Os odontoideum with neurologic deficits or instability
o anterior odontoid osteosynthesis
indications
Type II fractures with risk factors for nonunion AND
acceptable alignment and minimal displacement
oblique fracture pattern perpendicular to screw trajectory
patient body habitus must allow proper screw trajectory
outcomes
associated with higher failure rates than posterior C1-2 fusion
o transoral odontoidectomy
indications
severe posterior displacement of dens with spinal cord compression and neurologic
deficits
Surgical Techniques
Halo immobilization
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Complications
Nonunion
o increased risk in Type II fractures due to poor
blood supply
average nonunion rate 33% (up to as high as
88%)
o risk factors for nonunion include
≥ 6 mm displacement (>50% nonunion rate)
strongest reason to opt for surgery
age > 50 years
fx comminution
angulations > 10° II:16 Anterior odontoid screw osteosynthesis
delay in treatment
smoker
II:17 posterior C1 lateral mass screw and C2 pedicle screw construct II:18 posterior C1-C2 transarticular screws construct
Presentation
Symptoms
o neck pain
Physical exam
o patients are usually neurologically intact
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Imaging
Radiographs
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OrthoBullets2017 Spine Trauma | SubAxial Cervical Trauma
Treatment
Nonoperative
o rigid cervical collar x 4-6 weeks
indications
Type I fractures (< 3mm horizontal displacement)
o closed reduction followed by halo immobilization for 8-12 weeks
indications
Type II with 3-5 mm displacement
Type IIA
reduction technique
Type II use axial traction combined + extension
Type IIA use hyperextension (avoid axial traction in Type IIA)
Operative
o reduction with surgical stabilization
indications
Type II with > 5 mm displacement and severe angulation
Type III (facet dislocations)
technique
anterior C2-3 interbody fusion
posterior C1-3 fusion
bilateral C2 pars screw osteosynthesis
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By Dr, AbdulRahman AbdulNasser Spine Trauma | SubAxial Cervical Trauma
Classification
Descriptive classification (subaxial cervical spine injuries)
o includes
compression fracture
burst fraction
flexion-distraction injury
facet dislocation (unilateral or bilateral)
facet fracture
o more commonly used in clinical setting
Allen and Ferguson classification (of subaxial cervical spine injuries)
o typically used for research and not in clinical setting
o based solely on static radiographs and mechanisms of injury
Presentation
Physical exam
o monoradiculopathy
seen in patients with unilateral dislocations
C5/6 unilateral dislocation
usually presents with a C6 radiculopathy
weakness to wrist extension
numbness and tingling in the thumb
C6/7 unilateral dislocation
usually presents with a C7 radiculopathy
weakness to triceps and wrist flexion
numbness in index and middle finger
o spinal cord injury symptoms
seen with bilateral dislocations
symptoms worsen with increasing subluxation
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OrthoBullets2017 Spine Trauma | SubAxial Cervical Trauma
Imaging
Radiographs
o lateral shows subluxation of vertebral bodies
o unilateral dislocations lead to ~ 25% subluxation
o bilateral facet dislocation leads to ~ 50% subluxation on xray
o loss of disc height might indicated retropulsed disc in canal
CT scan
o essential to demonstrate
bony anatomy of the injury
malalignment or subtle subluxation of facet
facet fracture
associated fractures of the pedicle or lamina
MRI
o indications are controversial but include
acute facet dislocation in patient with altered mental status
failed closed reduction and before open reduction to look for disc herniation
any neurologic deterioration is seen during closed reduction
o timing
timing of MRI depends on severity and progression of neurologic injury
an MRI should always be performed prior to open reduction or surgical stabilization
if a disc herniation is present with compression on the spinal cord, then you must go
anterior to perform a anterior cervical diskectomy
o valuable in demonstrating
disc herniations
extent of posterior ligamentous injury
spinal cord compression or myelomalacia
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By Dr, AbdulRahman AbdulNasser Spine Trauma | SubAxial Cervical Trauma
Treatment
Nonoperative
o cervical orthosis or external immobilization (6-12 weeks)
indications
facet fractures without significant subluxation, dislocation, or kyphosis
Operative
o immediate closed reduction, then MRI, then surgical stabilization
indications
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always obtain MRI prior to open reduction and stabilization
ifdisc herniation with presence of spinal cord compression then you must use an
anterior approach and do a discectomy
Techniques
Closed reduction
o requirements
adequate anesthesia
sedation
supervision of respiratory function
serial cross table laterals
o technique
gradually increase axial traction with the addition of weights
a component of cervical flexion can facilitate reduction
perform serial neurologic exams and plain radiographs after addition of each weight
abort if neurologic exam worsens and obtain immediate MRI
Anterior open reduction & ACDF
o indications
facet dislocations reduced through closed methods with a MRI showing cervical disc
herniation with significant compression on the spinal cord
unilateral facet dislocations that fail closed reduction with a disc herniation with significant
compression on the spinal cord
o anterior open reduction techniques
can be used to reduce a unilateral facet dislocation
reduction technique involves distracting vertebral bodies with caspar pins and then rotating
the proximal pin towards the side of the dislocation
not effective for reducing bilateral facet dislocations
Posterior reduction & instrumented stabilization
o indications
when unable to reduce by closed or anterior approach
no anterior compression of spinal cord(no disc herniation)
o technique
performed with lateral mass screws
usually have to fuse two levels due to inadequate lateral mass purchase at level of dislocation
Combined anterior decompression and posterior reduction / stabilization
o indications
when disc herniation present that requires decompression in patient that can not be reduced
through closed or open anterior technique
o technique
go anterior first, perform discectomy, position plate but only fix plate to superior vertebral
body
this way the plate will prevent graft kick-out but still allows rotation during the posterior
reduction
this technique eliminates the need for a second anterior procedure
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By Dr, AbdulRahman AbdulNasser Spine Trauma | SubAxial Cervical Trauma
Classification
Kotani Classification
Kotani Classification
Fracture Type Fracture Description Rates of Anterior Rates of Anterior
Translation (same Translation
level) (adjacent level)
Type A -
2 fracture lines of unilateral lamina and
Separation 91% 20%
pedicle
fracture
Type B - Multiple fracture lines with lateral wedging
- 50%
Comminution type in coronal plane
Type C - Split type Vertical fracture line in the coronal plane,
with invagination of the superior articular 80% 0%
process of the caudal vertebra
Type D - Bilateral horizontal fracture lines of the
Traumatic pars interarticularis, leading to separation 100% 50%
spondylolysis of the anterior-posterior spinal elements
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OrthoBullets2017 Spine Trauma | SubAxial Cervical Trauma
Presentation
History
o commonest mechanisms (Allen and Ferguson classification)
extension-compression
lateral flexion : results in Type B Comminuted subtype
flexion-distraction
Symptoms
o neurologic symptoms common (up to 66%)
radicular pain, radiculopathy or spinal cord injury/myelopathy
can be classified by Frankel grade or ASIA impairment scale
Physical exam
o inspection
torticollis, paravertebral muscle spasm
o neurovascular
radicular pain and numbness
myelopathy
Imaging
Radiographs
o recommended views
AP, lateral, oblique views
o findings
disc space narrowing
often difficult to detect on plain radiographs
instability
>3.5mm displacement
>10deg kyphosis
>10deg rotation difference compared with adjacent vertebra
o sensitivity and specificity
low sensitivity
38% pickup rate on plain radiographs
CT
o indications
to further evaluate fracture morphology
fracture line extends
rostrally/caudally into adjacent superior/inferior facets
ventrally into foramen transversarium, transverse process and pedicle
dorsally into lamina
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By Dr, AbdulRahman AbdulNasser Spine Trauma | SubAxial Cervical Trauma
o findings
translationof fractured/adjacent vertebrae in sagittal and coronal planes
uncovertebral joint subluxation
degree of vertebral body destruction
MRI
o findings
disruption of ligaments
50-75% rupture of anterior longitudinal ligament (ALL)
30-35% disruption of posterior longitudinal ligament (PLL)
10-75% disruption interspinous and supraspinous ligaments (ISL and SSL)
disruption of intervertebral disc
bone bruising
Treatment
Nonoperative
o NSAIDS, rest, immobilization
indications
stable injuries without neurological deficit
hyperextension/rotation is poorly immobilized in a halo
techniques
Miami J collar
halo vest
outcomes
long term results of non-operative treatment are less desirable
may be successful in the absence of instability
surveillance is necessary to detect late instability and persistent pain
spontaneous fusion rate is only 20%
Operative
o posterior decompression and two-level instrumented fusion
indications
most cases require surgery
main injured structures are posterior, thus preferred approach is posterior
also indicated for nonoperatively managed cases with late instability and persistent pain
techniques
two-level lateral mass or pedicle screw and rod fixation
lateral mass plating
outcomes
risk of anterior disc space collapse and late kyphotic deformity
midline fusion does not control rotation
o anterior plating and interbody fusion
indications
controls anterior collapse and rotation
techniques
using iliac crest bone graft
o single posterior pedicle screw
indications
Type A Separation fracture without instability
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o anterior and posterior decompression and fusion
indications
if additional anterior column support is needed
if anterior approach is attempted initially, with unsuccessful reduction because of
complicated fracture morphology or late presentation
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By Dr, AbdulRahman AbdulNasser Spine Trauma | SubAxial Cervical Trauma
prognosis
associated with SCI
treatment
unstable and usually requires surgery
o extension teardrop avulsion fracture
characterized by
small fleck of bone is avulsed of anterior endplate
usually occur at C2
must differentiate from a true teardrop fracture
mechanism
extension
prognosis
stable injury pattern and not associated with SCI
treatment
cervical collar
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OrthoBullets2017 Spine Trauma | SubAxial Cervical Trauma
Presentation
Symtoms : incomplete vs. complete cord injury
Imaging
Must determine if there is a posterior ligamentous injury so MRI often important
Treatment
Nonoperative
o collar immobilization for 6 to 12 weeks
indications
stable mild compression fractures (intact posterior ligaments & no significant kyphosis)
anterior teardrop avulsion fracture
o external halo immobilization
indications
only if stable fracture pattern (intact posterior ligaments & no significant kyphosis)
Operative
o anterior decompression, corpectomy, strut graft, & fusion with instrumentation
indications
compression fracture with 11 degrees of angulation or 25% loss of vertebral body height
unstable burst fracture with cord compression
unstable tear-drop fracture with cord compression
minimal injury to posterior elements
o posterior decompression, & fusion with instrumentation
indications
significant injury to posterior elements
anterior decompression not required
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By Dr, AbdulRahman AbdulNasser Spine Trauma | SubAxial Cervical Trauma
Prognosis
o stable injury in isolation
o very rarely assoicated with neurological injury
o high union rate
Presentation
Symptoms
o sudden onset of pain between the shoulder blades or base of neck
o reduced head/neck ROM
Physical exam
o inspection
localized swelling and tenderness
crepitus
o motion
document flexion-extension of cervical spine
o neurovascular examination
Imaging
Radiographs
o recommended views
cervical +/- throacic xrays that should always be obtained on evaluation
o alternative views : flexion and extension views
o findings
lateral view
fracture line is usually obliquely oriented with the fragment displaced posteroinferior
AP view
double spinous process shadow is suggestive of displaced fracture
CT
o indications
method of choice
routine CT imaging in high-energy trauma patients
clinical criteria
altered consciousness
midline spinal pain or tenderness
impaired CCJ motion
lower cranial nerve paresis
motor paresis
o views : fracture is best seen on lateral view
MRI
o indications : not required in isolation
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OrthoBullets2017 Spine Trauma | Cervical Trauma Procedures
Complications
Chronic pain
Neck stiffness
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Cervical Trauma Procedures
Patient position
Preferred setting
o emergency room, operating room, ICU for close observation and frequent
fluoroscopy/radiographs
Patient position
o supine with reverse trendelenburg or use of arm and leg weights can help prevent patient
migration to the top of the bed with addition of weights.
Sedation
o small doses of diazepam can be administered to aid in muscle relaxation
o however patient must remain awake and able to converse
Pin Placement
Pin placement (Gardner-Wells pins)
o pin placement is 1 cm above pinna, in line with external auditory meatus and below the equator
of the skull.
if the pin is placed too anterior, the temporalis muscles and superficial temporal artery and
vein are at risk
an anterior pin will apply an extension moment to the cervical spine
if the pin is placed too posterior, it can apply a flexion moment to the cervical spine.
a posterior pin with a flexion moment may facilitate reduction of a facet dislocation.
Pin tightness
o On Gardner-Wells tongs, pins are tightened until spring loaded indicator protrudes 1 mm above
surface
this is the equivalent of 139 newtons (31 lbs) of force
overtightening by 0.3 mm leads to 448 newtons (100 lbs)
failure of temporal bone occurs at 965 +/- 200 newtons (216 lbs)
note Mayfield pins are tightened to 60 lbs
o overtightening of the pins can result in penetration of the
inner table of the calvarium
this may cause cerebral hemorrhage or abscess
Pin strength
o stainless steel pins have higher failure loads than titanium
and MRI-compatible graphite and should be used with
traction of > 50lbs.
Reduction with Serial Traction
Serial traction
o an initial 10lbs is added.
o weights are increased by 10lb increments every 20 minutes
o serial exams and radiographs are taken after each weight is
placed
o maximal weight is controversial
some authors recommend weight limits of 70 lbs
recent studies report that up to 140 lbs is safe
Reduction maneuvers
o reduction of a unilateral facet dislocation
reduction maneuver performed after facet is distracted to a perched position
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maintain axial load and rotate head 30-40 degrees past midline, in the direction of the
dislocation
stop once resistance is felt, and confirm with radiographs
o reduction of bilateral facet dislocation
reduction maneuver performed after facet is distracted to a perched position
palpate the stepoff in the spinal process posteriorly and apply an anterior directed force
caudal to the level of the dislocation
rotate the head 40 degrees beyond midline in one direction, and then rotate 40 degrees in the
other direction while axial traction is maintained.
Complications
Failure to reduce
o a bilateral, irreducible facet dislocation is unstable and should be treatment with urgent open
reduction after an MRI is performed..
Change in neurologic exam
o with any change in the neurologic exam the weights should be removed and an MRI should be
obtained.
Indications
Adult
o definitive treatment of cervical spine trauma including
occipital condyle fx
occipitocervical dislocation
stable Type II atlas fx (stable Jefferson fx)
type II odontoid fractures in young patients
type II and IIA hangman’s fractures
o adjunctive postoperative stabilization following cervical spine surgery
Pediatric
o definitive treatment for
atlanto-occipital dissociation
Jefferson fractures (burst fracture of C1)
atlas fractures
unstable odontoid fractures
persistent atlanto-axial rotatory subluxation
C1-C2 dissociations
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Cervical Trauma Procedures
subaxial cervical spine trauma
o preoperative reduction in the patients with spinal deformity
Contraindications
Absolute
o cranial fractures
o infection
o severe soft-tissue injury
especially near proposed pin sites
Relative
o polytrauma
o severe chest trauma
o barrel-shaped chest
o obesity
o advanced age
recent evidence demonstrates an unacceptably high mortality rate in patients aged 79
years and older (21%)
Imaging
CT scan prior to halo application
o indications
clinical suspicion for cranial fracture
children younger than 10 to determine thickness of bone
Adult Technique
Adults
o torque
tighten to 8 inch-pounds of torque
o location
total of 4 pins
2 anterior pins
safe zone is a 1 cm region just above the lateral one third of the orbit (eyebrow) at or
below the equator of the skull
this is anterior and medial to temporalis fossa/temporalis muscle
this is lateral to supraorbital nerve
2 posterior pins
placed on opposite side of ring from anterior pins
o followup care
can have patient return on day 2 to tighten again
proper pin and halo care can be done to minimize chance of infection
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Pediatric Technique
Pediatrics
o torque
best construct involves more pins with less torque
total of 6-8 pins
Complications
Higher complications in children (70%) than adults (35%)
Loosening (36%)
o can be treated with retightening
o if continues to loosen, should be treated with pin exchange
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Cervical Trauma Procedures
Infection (20%)
o can especially occur with posterior pin in temporalis fossa because
pins hidden in hairline
bone is thin
temporalis muscle moves with chewing
Collected By : Dr AbdulRahman
AbdulNasser
drxabdulrahman@gmail.com
In June 2017
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OrthoBullets2017 Spine Trauma | Thoracolumbar Trauma
E. Thoracolumbar Trauma
Anatomy
Biomechanics
o thoracic spine from T2 to T10 has increased stiffness due to
increased rigidity by articulation with ribs
ribs articulate with sternum, adding secondary stability
facet joints oriented in coronal plane
disks are thin increasing stiffness and rotational stability
kyphosis concentrates axial load on anterior column
o definitions of spinal stability
Blood supply
o "watershed area" in middle thoracic spine
is a vascular watershed area
vascular injury can lead to cord ischemia
Spinal cord
o spinal cord ends and cauda equina begins at level of L1/L2
variable so valuable to identify beginning of cauda equina on MRI in relation to pathology
injuries below L1 have a better prognosis because the nerve roots (cauda equina and nerve
roots within thecal sac) are affected as opposed to the spinal cord
Classification
Magerl classification (of thoracic spine injuries)
o Type A : compression caused by axial loading
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Thoracolumbar Trauma
o Type B
B1: ligamentous distraction injury posterior
B2: osseoligamentous distraction injury posterior
o Type C
multidirectional injuries, often fracture dislocations
very unstable with high likelihood of neurologic injury
AO classification (of thoracolumbar spinal fracture)
o Type A: Compression injuries
o Type B: Distraction injuries
o Type C: Torsional injury
each type then broken down further into
fracture morphology
bony versus ligamentous failure
direction of displacement
Imaging
Radiographs
o obtain radiographs of entire spine (concomitant spine fractures in 20%)
CT scan indications
o fracture on plain film
o neurologic deficit in lower extremity
o inadequate plain films
MRI useful to evaluate for
o injury to anterior and posterior ligament complex
o spinal cord compression by disk or osseous material
o cord edema or hemorrhage
Treatment
Treatment varies by condition, but the following should be considered
o degree of neurologic deficits seen on physical exam
o degree of spinal cord compression and imaging evidence of myelomalacia
o spinal stability
Nonoperative
o indications
most thoracic and thoracolumbar fractures (burst and compression) can be treated
nonoperatively when the patient is neurologically intact
treat in orthosis for 6 to 12 weeks depending on degree of instability
Operative
o indications for surgery
progressive neurologic deficits
myelomalacia seen on MRI
gross spinal instability
posterior osseoligamentous stability compromised
Surgical Techniques
Approaches
o surgical approach is dictated by
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site of compression (anterior or posterior)
unlike thecal sack, the spinal cord can not be manipulated or medialized
surgical window needed to restore spinal stability
often times anterior column needs to be reconstructed
o thoracic approaches used include
midline posterior approach
indicated only when spinal cord compression is posterior
costotransverse
can be open or thoracosopic
transthoracic
Anatomy
Denis three column system
o clinical relevance
only moderately reliable in determining clinical degree of stability
o definitions
anterior column
anterior longitudinal ligament (ALL)
anterior 2/3 of vertebral body and annulus
middle column
posterior longitudinal ligament (PLL)
posterior 1/3 of vertebral body and annulus
posterior column
pedicles
lamina
facets
ligamentum flavum
spinous process
posterior ligament complex (PLC)
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Thoracolumbar Trauma
instability defined by
injury to middle column
as evidenced by widening of interpedicular distance on AP radiograph
loss of height of posterior cortex of vertebral body
disruption of posterior ligament complex combined with anterior and middle column
involvement
Posterior Ligamentous Complex
o considered to be a critical predictor of spinal fracture stability
o consists of
supraspinous ligament
interspinous ligament
ligamentum flavum
facet capsule
o evaluation
determining the integrity of the PLC can be challenging
conditions where PLC is clearly ruptured
bony chance fracture
widening of interspinous distance
progressive kyphosis with nonoperative treatment
facet diastasis
conditions where integrity of PLC is indeterminant
MRI shows signal intensity between spinous process
Imaging
Radiographs
o recommended views
obtain radiographs of entire spine (concomitant spine fractures in 20%)
o AP shows
widening of pedicles
coronal deformity
o lateral shows
retropulsion of bone into canal
kyphotic deformity
CT scan
o indications
fracture on plain film
neurologic deficit in lower extremity
inadequate plain films
MRI
o useful to evaluate for
spinal cord or thecal sac compression by disk or osseous material
cord edema or hemorrhage
injury posterior ligament complex
signal intensity in PLC is concerning for instability and may warrant surgical intervention
Treatment
Nonoperative
o ambulation as tolerated with or without a thoracolumbosacral orthosis
indications
patients that are neurologically intact and mechanically stable
posterior ligament complex preserved
kyphosis < 30° (controversial)
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vertebral body has lost < 50% of body height (controversial)
TLICS score = 3 or lower
thoracolumbar orthosis
recent evidence shows no clear advantage of TLSO on outcomes
if it provides symptomatic relief, may be beneficial for patient
outcomes
retropulsed fragments resorb over time and usually do not cause neurologic deterioration
Operative
o surgical decompression & spinal stabilization
indications
neurologic deficits with radiographic evidence of cord/thecal sac compression
both complete and incomplete spinal cord injuries require decompression and
stabilization to facilitate rehabilitation
TLICS score = 5 or higher
unstable fracture pattern as defined by
injury to the Posterior Ligament Complex (PLC)
progressive kyphosis
> 30°kyphosis (controversial)
> 50% loss of vertebral body height (controversial)
> 50% canal compromise (controversial)
Techniques
Anterior decompression and stabilization (with or without posterior stabilization)
o indications
indicated when neurologic deficits caused by anterior compression (bony retropulsion)
scientific data has not shown a benefit to early decompression and stabilization
o technique
usually includes corpectomy and strut grafting followed by anterior +/- posterior
instrumentation
advantage is that you do not need to do a laminectomy which will further destabilize the
spine by compromising the posterior supporting structures
Posterior Decompression and Fusion
o indications
unstable fracture pattern with no need for neurologic decompression
complete neurologic injury (allows earlier rehab)
o neural decompression
direct decompression
retropulsed bone can be removed via transpedicular approach
indirect decompression
via ligamentotaxis may occur by restoring height and sagittal alignment with posterior
instrumentation
o arthrodesis
fusion should be performed with instrumentation
instrumentation should be under distraction to restore vertebral body height and achieve
indirect decompression
historically it was recommended to instrument three levels above and two levels below
modern pedicle screws have changes this to one level above and one level below
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avoid laminectomy if possible as it will further destabilize the spine by compromising the
posterior supporting structures
Posterior Fusion Alone (no decompression)
o indications
progression kyphosis or clear injury to posterior ligament complex, but with no significant
neurologic compression
Complications
Entrapped nerve roots and dural tear
o from associated lamina fractures
Pain
o most common
Progressive kyphosis
o common with unrecognized injury to PLL
Flat back
o leads to pain, a forward flexed posture, and easy fatigue
o post-traumatic syringomyelia
Associated injuries
o high rate of gastrointestinal injuries (50%)
Imaging
Radiographs
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MRI
o important to evaluate for injury to the posterior elements
CT
o important to evaluate degree of bone injury and retropulsion of posterior wall into canal
Treatment
Nonoperative
o immobilization in cast or TLSO
indications
neurologically intact patients with
stable injury patterns with intact posterior elements
bony Chance fracture
technique
may cast or brace (TLSO) in extension
must be followed for non-union and kyphotic deformity
Operative
o surgical decompression and stabilization
indications
patients with neurologic deficits
unstable spine with injury to the posterior ligaments (soft-tissue Chance fx)
techniques
anterior decompression and stabilization
usually with vertebrectomy and strut grafting followed by instrumentation
posterior indirect decompression and stabilization and compression fusion construct
historically three levels above and two levels below
modern pedicle screws have changed this to one level above and one level below
distraction construct in burst fractures
compression construct in Chance fractures
Complications
Pain
o most common
Deformity
o scoliosis
o progressive kyphosis
common with unrecognized injury to PLL
o flat back
leads to pain, a forward flexed posture, and easy fatigue
o post-traumatic syringomyelia
Nonunion
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4. Thoracolumbar Fracture-Dislocation
Introduction
Fractures associated with posterior facet dislocation occuring at the thoracolumbar junction (AO type
C)
Epidemiology
o incidence
approx. 4% of spinal cord injuries admitted to Level 1 trauma centres
50-60% of fracture-dislocations are associated with spinal cord injuries
o demographics
4:1 male-to-female ratio
o location
most commonly occur at the thoracolumbar junction
o risk factors
high energy injuries
motor vehicle accident (most common)
falls
sports
violence
Pathophysiology
o mechanism of injury
acceleration/deceleration injuries
resultng in hyperflexion, rotation and shearing of the spinal column
o associated injury
neurologic deficits
head injury
concomitant injuries in thorax and abdomen
Classification Systems
o Thoracolumbar Injury Classification System (TLICS)
categorizes injuries based on
morphology of injury
neurologic injury
posterior ligamentous complex integrity
treatment recommendation based on total score
nonsurgical = 3 or lower
indeterminate = 4
surgical = 5 or higher
Anatomy
Lumbothoracic junction
o Definition
T10 - L2
transition zone between thoracic spine (kyphosis) and lumbar spine (lordosis)
o Pathoanatomy
greater mobility in the lumbar spine compared to thoracic spine
results in an area of the spine that is vulnerable to shearing forces
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high risk of injury to the spinal cord, conus or cauda equina depending on the patients
anatomy and degree of dislocation
Presentation
Pre-hospital
o patients almost exclusively present as a major trauma with or without neurological deficit
o transportation to a trauma center using spine immobilization precautions with a spinal board and
cervical collar.
Clinical Approach
o ATLS
Airway, Breathing, Circulation
Neurological assessment
Inspection
open injury
deformity (e.g. kyphosis)
Palpation
point tenderness
step-off deformity
crepitus
Neurological Impairment
GCS
ASIA Impairment score
sensory, motor, or reflexes impairment
rectal examination
History
Physical examination
Imaging
Radiographs
o recommended views
AP and lateral view of thoraco-lumbar spine
o indications
suspected spinal column injury with bone tenderness
recognize stable versus unstable spine injuries
o findings
fracture type, pattern and dislocation
CT scan
o indications
better visualization of fracture pattern and type compared to plain radiographs (e.g. unilateral
facet dislocations, etc)
blunt trauma patients requiring a CT scan to screen for other injuries
o findings
cannot adequately visualize and describe the spinal canal and other associated ligaments
MRI
o indications
better visualisation of the spinal cord and supporting ligamentous structures
level of neurological deficit does not align with apparent level of spinal injury
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o findings
important to evaluate for injury to the posterior longitudinal ligament
Treatment
Operative
o posterior open reduction with instrumented fusion
indications
most patients with thoracolumbar fracture dislocation
unstable fracture patterns
disrupted supporting ligamentous structures
technique
midline incision
identify fracture-dislocation site
use pedicle screws for distraction to obtain anatomical reduction
insert posterior instrumentation two levels above and two levels below the site of injury
outcomes
early decompression and instrumentation has been shown to have better outcomes than
delayed surgery or non-operative treatment
obtain postoperative CT/MRI to see if their is any residual anterior compression
Complications
Neurological injury
Cauda equina syndrome
DVT
Non-union after spinal fusion
Post-traumatic pain
o most commoncomplication
o greater with increased kyphotic deformity
Deformity
o scoliosis
o progressive kyphosis
common with unrecognized injury to PLL
o flat back
leads to pain, a forward flexed posture, and easy fatigue
o post-traumatic syringomyelia
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Thoracolumbar Trauma
affects up to
25% people over 70 years
50% people over 80 years
o risk factors
history of 2 VCFs
is the strongest predictor of future vertebral fractures in postmenopausal women
Pathoanatomy
o osteoporosis
characteristics
bone is normal quality but decreased in quantity
cortices are thinned
cancellous bone has decreased trabecular continuity
bone mineral density in the lumbar spine (BMD)
peaks at
between 33 to 40 yrs in women
between 19 to 33 years in men
peak BMD is widely variable based on demographic factors and location in
body
decreases with age following peak mass
correlate well with bone strength and is a good predictor of fragility fracture
definition
WHO defines osteoporosis as T score below -2.5
Associated conditions
o compromised pulmonary function
increased kyphosis can affect pulmonary function
each VCF leads up to 9% reduction in FV
Prognosis
o mortality
1-year mortality ~ 15% (less than hip fx)
2-year mortality ~20% (equivalent to hip fx)
Presentation
Symptoms
o pain
25% of VCF are painful enough that patients seek medical attention
pain usually localized to area of fracture
but may wrap around rib cage if dermatomal distribution
Physical exam
o focal tenderness
pain with deep palpation of spinous process
o local kyphosis
multiple compression fractures can lead to local kyphosis
o spinal cord injury
signs of spinal cord compression are very rare
o nerve root deficits
may see nerve root deficits with compression fractures of lumbar spine that lead to severe
foraminal stenosis
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Imaging
Radiographs
o obtain radiographs of the entire spine (concomitant spine fractures in 20%)
o will see loss of anterior, middle, or posterior vertebral height by 20% or at least 4mm
CT scan
o usually not necessary for diagnosis
o indications
fracture on plain film
neurologic deficit in lower extremity
inadequate plain films
MRI
o usually not necessary for diagnosis
o useful to evaluate for
acute vs chronic nature of compression fracture
injury to anterior and posterior ligament complex
spinal cord compression by disk or osseous material
cord edema or hemorrhage
Studies
Laboratory
o a full medical workup should be performed with CBC, BMP
o ESR may help to rule out infection
o Urine and serum protein electrophoresis may help rule out multiple myeloma
Differential Diagnosis
Metastatic cancer to the spine
o must be considered and ruled out
o the following variables should raise suspicion
fractures above T5
atypical radiographic findings
failure to thrive and constitutional symptoms
younger patient with no history of fall
Treatment
Nonoperative
o observation, bracing, and medical management
indications
majority of patients can be treated with observation and gradual return to activity
PLL intact (even if > 30 degrees kyphosis or > 50% loss of vertebral body height)
technique
if the fracture is less than five days old
calcitonin can be used for four weeks to decrease pain
medical management can consist of bisphosphonates
to prevent future risk of fragility fractures
some patients may benefit from an extension orthosis
although compliance can be an issue
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Thoracolumbar Trauma
Operative
o vertebroplasty
indications
not indicated
AAOS recommends strongly against the use of vertebroplasty
outcomes
randomized, double-blind, placebo-controlled trials have shown no beneficial effect of
vertebroplasty
vertebroplasty has higher rates of cement extravasation and associated complications than
kyphoplasty
o kyphoplasty
indications
patient continues to have severe pain symptoms after 6 weeks of nonoperative treatment
AAOS recommend may be used, but recommendation strength is limited
technique
kyphoplasty is different than vertebroplasty in that a cavity is created by balloon
expansion and therefore the cement can be injected with less pressure
pain relief thought to be from elimination of micromotion
o surgical decompression and stabilization
indications
very rare in standard VCF
progressive neurologic deficit
PLL injury and unstable spines
technique
to prevent possible failure due to osteoporotic bone II:21 kyphoplasty
consider long constructs with multiple fixation points
consider combined anterior fixation
Techniques
Kyphoplasty vs. vertebroplasty
o performed under fluoroscopic guidance
o percutaneous transpedicular approach used for cannula
o vertebroplasty
PMMA injected directly into cancellous bone without cavity creation
performed when cement is more liquid
requires greater pressure because no cavity is created
increased risk of extravasation into spinal canal is greater
o kyphoplasty
cavity created with expansion device (e.g., balloon) prior to PMMA injection
performed when cement is more viscous
may be possible to obtain partial reduction of fracture with balloon expansion
Complications
Neurological injury
o can be caused by extravasation of PMMA into spinal canal
higher risk with vertebroplasty than kyphoplasty
important to consider defects in the posterior cortex of the vertebral body
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Relevant Anatomy
Spinal cord
o conus medullaris
tapered, terminal end of the spinal cord
terminates at T12 or L1 vertebral body
o filum terminale
non-neural, fibrous extension of the conus medullaris that attaches to the coccyx
o cauda equina (horse's tail)
collection of L1-S5 peripheral nerves within the lumbar canal
compression considered to cause lower motor neuron lesions
Bladder
o receives innervation from
parasympathetic nervous system (pelvic splanchnic nerves and the inferior hypogastric
plexus) and
sympathetic plexus (hypogastric plexus)
o external sphincter of the bladder is controlled by the pudendal nerve
o lower motor neuron lesions of cauda equina will interrupt the nerves forming the bladder reflex
arcs
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Thoracolumbar Trauma
Presentation
History
o two distinct clinical presentations: acute (e.g. disc herniation, trauma) and insidious (e.g. spinal
stenosis, tumor)
Symptoms
o bilateral leg pain
o saddle anesthesia
o impotence
o sensorimotor loss in lower extremity
o neurogenic bladder dysfunction
disruption of bladder contraction and sensation leads to urinary retention and eventually to
overflow incontinence
o bowel dysfunction is rare
Physical exam
o inspection
lower extremity muscle atrophy with insidious presentations (e.g. spinal stenosis)
fasciculations are rare
o palpation
lower back pain/tenderness is not a distinguishing feature
palpation of the bladder for urinary retention
o neurovascular examination
bilateral lower extremity weakness and sensory disturbances
decreased or absent lower extremity reflexes
o rectal/genital examination
reduced or absent sensation to pinprick in the perianal region (S2-S4 dermatomes), perineum,
and posterior thigh
decreased rectal tone or voluntary contracture
diminished or absent anal wink test and a
bulbocavernosus reflex
Imaging
MRI
o study of choice to evaluate neurologic compression
CT myelography
o study of choice if patient unable to undergo MRI
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Treatment
Operative
o urgent surgical decompression within 48 hours
indications
significant suspicion for CES
severity of symptoms will increase the urgency of surgical decompression
techniques
diskectomy
laminectomy
outcomes
studies have shown improved outcomes in bowel and bladder function and resolution of
motor and sensory deficits when decompression performed within 48 hours of the onset
of symptoms
Surgical Techniques
Surgical decompression of neural elements
o approach
posterior midline approach to lumbar spine
o diskectomy vs. wide laminectomy and diskectomy
no comparison studies between microdiskectomy alone and wide decompression combined
with microdiskectomy.
Complications
Delayed presentation or decompression
o sexual dysfunction
o urinary dysfunction requiring catheterization
o chronic pain
o persistent leg weakness
Collected By : Dr AbdulRahman
AbdulNasser
drxabdulrahman@gmail.com
In June 2017
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Thoracolumbar Trauma
ORTHO BULLETS
III.Upper Extremity
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OrthoBullets2017 Upper Extremity | Shoulder
A. Shoulder
Anatomy
Anatomy
o brachial plexus motor and sensory innervation
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Classification
Preganglionic vs. postganglionic
o preganglionic
avulsion proximal to dorsal root ganglion
involves CNS which does not regenerate – little potential recovery of motor function
(poor prognosis)
lesions suggesting preganglionic injury:
Horner’s syndrome
disruption of sympathetic chain
winged scapula medially
loss of serratus anterior (long thoracic nerve) rhomboids (dorsal scapular nerve) leads
to medial winging (inferior border goes medial)
presents with motor deficits (flail arm)
sensory deficits
absence of a Tinel sign or tenderness to percussion in the neck
normal histamine test (C8-T1 sympathetic ganglion)
intact triple response (redness, wheal, flare)
elevated hemidiaphragm (phrenic nerve
rhomboid paralysis (dorsal scapular nerve)
supraspinatus/infraspinatus (suprascapular nerve)
latissimus dorsi (thoracodorsal)
evaluation
EMG may show loss of innervation to cervical paraspinals
o postganglionic
involve PNS, capable of regeneration (better prognosis)
presentation
presents with motor deficit (flail arm)
sensory deficits
evaluation
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EMG shows maintained innervation to cervical paraspinals
abnormal histamine test
only redness and wheal, but NO flare
Classification based on location
Presentation
History
o high energy injury
Physical exam
o Horner's syndrome
features include
drooping of the left eyelid
pupillary constriction
anhidrosis
usually show up three days after injury
represents disruption of sympathetic chain via C8 and/or T1 root avulsions
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o severe pain in anesthetized limb
correlates with root avulsion
o important muscles to test
serratus anterior (long thoracic nerve) and rhomboids (dorsal scapular nerve)
if they are functioning then it is more likely the C5 injury is postganglionic
o pulses
check radial, ulnar and brachial pulses
arterial injuries common with complete BPIs
Imaging
Radiographs
o chest radiograph
recommended views
PA and lateral
fractures to the first or second ribs suggest damage to the overlying brachial plexus
evidence of old rib fractures can be important in case intercostal nerve is needed for nerve
transfer
inspiration and expiration can demonstrate a paralyzed diaphragm (indicates upper nerve root
injury)
o cervical spine series
recommended views
AP and lateral
transverse process fracture likely indicates a root avulsion
o scapular and shoulder series
recommended views
at least AP and axillary (or equivalent)
scapulothoracic dissociation is associated with root avulsion and major vascular injury
o clavicle
recommended views
orthogonal views
fracture may indicate brachial plexus injury
CT myelography
o indications
gold standard for defining level of nerve root injury
o avulsion of cervical root causes dural sheath to heal with meningocele
o scan should be done 3-4 weeks after injury
allows blood clot in the injured area to dissipate and meningocele to form
MRI
o indications
suspect injury is distal to nerve roots
can visualize much of the brachial plexus
CT/myelogram demonstrates only nerve root injury
o findings
traumatic neuromas and edema
mass lesions in nontraumatic neuropathy of brachial plexus and its branches
consistent with injury include
pseudomeningocele (T2 highlights water content present in a pseudomeningocele )
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empty nerve root sleeves (T1 images highlight fat content nerve roots and empty sleeves)
cord shift away from midline (T1 highlights fat of cord)
Studies
Electromyography (EMG)
o tests muscles at rest and during activity
o fibrillation potentials (denervation changes)
as early as 10-14 days following injury in proximal muscles
as late as 3-6 weeks in distal muscles
o can help distinguish preganglionic from postganglionic
examine proximally innervated muscles that are innervated by root level motor branches
rhomboids
serratus anterior
cervical paraspinals
Nerve conduction velocity (NCV)
o performed along with EMG
o measures sensory nerve action potentials (SNAPs)
distinguishes preganglionic from postganglionic
SNAPs preserved in lesions proximal to dorsal root ganglia
cell body found in dorsal root ganglia
if SNAP normal and patient insensate in ulnar nerve distribution
preganglionic injury to C8 and T1
if SNAP normal and patient insensate in median nerve distribution
preganglionic injury to C5 and C6
Nerve action potential (NAPs)
o often intraoperative
o tests a nerve across a lesion
o if NAP positive across a lesion
preserved axons
or significant regeneration
o can detect reinnervation months before EMG
NAP negative-neuropraxic lesion
NAP positive- axonotmetic lesion
Sensory and Motor Evoked Potential
o more sensitive than EMG and NCV at identifying continuity of roots with spinal cord (positive
finding)
a negative finding can not differentiate location of discontinuity (root avulsion vs.
axonotmesis)
o perform 4-6 weeks after injury to allow for Wallerian degeneration to occur
o stimulation done at Erb's point and recording done over cortex with scalp electrodes
(transcranial)
Treatment
Nonoperative
o observation alone waiting for recovery
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indications
most managed with closed observation
guns shot wounds (in absence of major vascular damage can observe for three months)
signs of neurologic recovery
advancing Tinel sign is best clinical sign of effective nerve regeneration
Operative
o immediate surgical exploration (< 1 week)
indications
sharp penetrating trauma (excluding GSWs)
iatrogenic injuries
open injuries
progressive neurologic deficits
expanding hematoma or vascular injury
techniques
nerve repair
nerve grafting
neurotization
o early surgical intervention (3-6 weeks)
indicated for near total plexus involvement and with high mechanism of energy
o delayed surgical intervention (3-6 months)
indications
partial upper plexus involvement and low energy mechanism
plateau in neurologic recovery
best not to delay surgery beyond 6 months
techniques
usually involves tendon/muscle transfers to restore function
Surgical Techniques
Direct nerve repair
o rarely possible due to traction and usually only possible for acute and sharp penetration injuries
Nerve graft
o commonly used due to traction injuries (postganglionic)
o preferable to graft lesions of upper and middle trunk
allows better chance of reinnervation of proximal muscles before irreversible changes at
motor end plate
o donor sites include sural nerve, medial brachial nerve, medial antebrachial cutaneous nerve
o vascularized nerve graft includes ulnar nerve when there is a proven C8 and T1 avulsion
(mobilized on superior ulnar collateral artery)
Neurotization (nerve transfer)
o transfer working but less important motor nerve to a nonfunctioning more important denervated
muscle
o use extraplexal source of axons
spinal accessory nerve (CN XI)
intercostal nerves
contralateral C7
hypoglossal nerve (CN XII)
o intraplexal nerves
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phrenic nerve
portion of median or ulnar nerves
pectoral nerve
Oberlin transfer
ulnar nerve used for upper trunk injury for biceps function
Muscle or tendon transfer
o indications
isolated C8-T1 injury in adult (reinervation unlikely due to distance between injury site and
hand intrinsic muscles)
o priorities of repair/reconstruction
elbow flexion (musculocutaneous nerve)
shoulder stability (suprascapular nerve)
brachial-thoracic pinch (pectoral nerve)
C6-C7 sensory (lateral cord)
wrist extension / finger flexion (lateral and posterior cords)
wrist flexion / finger extension
intrinsic function
o technique
gracilis most common free muscle transfer
2. Sternoclavicular Dislocation
Introduction
Traumatic or Atraumatic
o traumatic dislocation
direction
anterior (more common)
posterior (mediastinal structures at risk)
important to distinguish from medial clavicle physeal fracture (physis doesn't fuse until
age 20-25)
mechanism : usually high energy injury (MVA, contact sports)
o atraumatic subluxation
occurs with overhead elevation of the arm
affected patients are younger
many demonstrate signs of generalized ligamentous laxity
subluxation usually reduces with lowering the arm
treatment is reassurance and local symptomatic treatment
Anatomy
Medial clavicle
o first bone to ossify and last physis to close (age 20-25)
Sternoclavicular joint
o osteology
diarthrodial saddle joint
incongruous (~50% contact)
fibrocartilage
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o stability
stability depends on ligamentous structures
posterior capsular ligament
most important structure for anterior-posterior stability
anterior sternoclavicular ligament
primary restraint to superior displacement of medial clavicle
costoclavicular (rhomboid) ligament
anterior fasciculus resists superior rotation and lateral displacement
posterior fasciculus resists inferior rotation and medial displacement
intra-articular disk ligament
prevents medial displacement of clavicle
secondary restraint to superior clavicle displacement
Presentation
Symptoms
o anterior dislocation
deformity with palpable bump
o posterior dislocations
dyspnea or dysphagia
tachypnea and stridor worse when supine
Physical exam
o palpation
prominence that increases with
arm abduction and elevation
o ROM and instability : decreased arm ROM
o neurovascular
parasthesias in affected upper extremity
venous congestion or diminished pulse when
compared with contralateral side
o provocative maneuvers
turning head to affected side may relieve pain
Imaging
Radiographs
o recommended views
AP and serendipity views
o findings
difficult to visualize on AP
serendipity views ( beam at 40 cephalic tilt)
anterior dislocation : affected clavicle above contralateral clavicle
posterior dislocation : affected clavicle below contralateral clavicle
CT scan
o study of choice
axial views can visualize mediastinal structures and injuries
can differentiate from physeal fractures
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Shoulder
Techniques
Closed reduction under general anesthesia
o reduction technique
place patient supine with arm at edge of table and prep entire chest
abduct and extend arm while applying axial traction and direct pressure
simultaneously apply direct posterior pressure over medial clavicle
manipulate medial clavicle with towel clip or fingers
Medial clavicle excision
o approach
3. Clavicle Fractures
Introduction
Epidemiology
o incidence : clavicle fractures make up ~4% of all fractures
o demographics : often seen in young active patients
Pathophysiology
o mechanism
direct blow to lateral aspect of shoulder
fall on an outstretched arm or direct trauma
o pathoanatomy
in displaced fractures, the
sternocleidomastoid muscle pulls the
medial fragment posterosuperiorly,
while pectoralis and weight of arm pull
the lateral fragment inferomedially
open fractures buttonhole through platysma
Associated injuries
o are rare but include
ipsilateral scapular fracture
scapulothoracic dissociation
should be considered with significantly
displaced fractures
rib fracture
pneumothorax
neurovascular injury
Pediatric Clavicle fractures
o fracture patterns include
medial clavicle physeal injury
distal clavicle physeal injury
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Relevant Anatomy
Acromioclavicular Joint Anatomy
AC joint stability
o acromioclavicular ligament
provides anterior/posterior stability
has superior, inferior, anterior, and posterior components
superior ligament is strongest, followed by posterior
o coracoclavicular ligaments (trapezoid and conoid)
provides superior/inferior stability
trapezoid ligament inserts 3 cm from end of clavicle
conoid ligament inserts 4.5 cm from end of clavicle in the posterior border
conoid ligament is strongest
o capsule, deltoid and trapezius act as additional stabilizers
Classification
Allman Classification with Neer's Modification
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Group I - Middle third (80-85%)
Nondisplaced Less than 100% displacement Nonoperative
Displaced Greater than 100% displacement
Operative
Nonunion rate of 4.5%
Group II - Neer Classification of Lateral third (10-15%)
Type I Fracture occurs lateral to coracoclavicular ligaments (trapezoid,
conoid) or interligamentous Nonoperative
Usually minimally displaced
Stable because conoid and trapezoid ligaments remain intact
Type IIA Fracture occurs medial to intact conoid and trapezoid ligament
Medial clavicle unstable Operative
Up to 56% nonunion rate with nonoperative management
Type IIB Fracture occurs either between ruptured conoid and intact
trapezoid ligament or lateral to both ligaments torn Operative
Medial clavicle unstable
Up to 30-45% nonunion rate with nonoperative management
Type III Intraarticular fracture extending into AC joint
Conoid and trapezoid intact therefore stable injury Nonoperative
Patients may develop posttraumatic AC arthritis
Type IV A physeal fracture that occurs in the skeletally immature
Displacement of lateral clavicle occurs superiorly through a tear in
the thick periosteum Nonoperative
Clavicle pulls out of periosteal sleeve
Conoid and trapezoid ligaments remain attached to periosteum
and overall the fracture pattern is stable
Type V Comminuted fracture
Conoid and trapezoid ligaments remain attached to comminuted Operative
fragment
Medial clavicle unstable
Group III - Medial third (5-8%)
Anterior Most often non-operative
Nonoperative
displacement Rarely symptomatic
Posterior Rare injury (2-3%)
displacement Often physeal fracture-dislocation (age < 25)
Stability dependent on costoclavicular ligaments Operative
Must assess airway and great vessel compromise
Serendipity radiographs and CT scan to evaluate
Surgical management with thoracic surgeon on standby
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Imaging
Radiographs
o standard AP view of bilateral shoulders
to measure clavicular shortening
o 45° cephalic tilt determine superior/inferior displacement
o 45° caudal tilt determines AP displacement
CT
o may help evaluate displacement, shortening, comminution, articular extension, and nonunion
o useful for medial physeal fractures and sternoclavicular injuries
Treatment
Nonoperative
o sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10
weeks
indications
nondisplaced Group I (middle third)
stable Group II fractures (Type I, III, IV)
nondisplaced Group III (medial third)
pediatric distal clavicle fractures (skeletally immature)
outcomes
nonunion (1-5%)
risk factors for nonunion
Group II (up to 56%)
comminution
100% displacement & shortening (>2 cm)
advanced age and female gender
poorer cosmesis
decreased shoulder strength and endurance
seen with displaced midshaft clavicle fracture healed with > 2 cm of shortening
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Shoulder
Operative
o open reduction internal fixation
indications
absolute
unstable Group II fractures (Type IIA, Type IIB, Type V)
open fxs
displaced fracture with skin tenting
subclavian artery or vein injury
floating shoulder (clavicle and scapula neck fx)
symptomatic nonunion
posteriorly displaced Group III fxs
Techniques
Sling Immobilization
o technique
sling or figure-of-eight (prospective studies have not shown difference between sling and
figure-of-eight braces)
after 2-4 weeks begin gentle range of motion exercises
strengthening exercises begin at 6-10 weeks
no attempt at reduction should be made
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precontoured anatomic
plates
Superior plate Anterior plate
intramedullary screw or
3.5mm reconstruction plate hook plate nail fixation
Open Reduction Internal Fixation
o technique
plate and screw fixation
superior vs anterior (anteroinferior) plating
superior plating biomechanically higher load to failure and bending
superior plating better for inferior bony comminution
superior plating has higher risk of neurovascular injury during drilling
anteroinferior plating has longer screws
anteroinferior plating has to remove portion of deltoid attachment
limited contact dynamic compression plate
3.5mm reconstruction plate
locking plates
precontoured anatomic plates
lower profile needing less chance for removal surgery
intramedullary screw or nail fixation
higher complication rate including hardware migration
hook plate
AC joint spanning fixation
postoperative rehabilitation
sling for 7-10 days followed by active motion
strengthening at ~ 6 weeks when pain free motion and radiographic evidence of union
full activity including sports at ~ 3 month
Coracoclavicular ligament repair
o technique
coracoclavicular ligament primary repair (most common)
most add supplementary suture (mersilene tape, fiberwire, ethibond) tied around coracoid
and either into or around clavicle
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Shoulder
Coracoclavicular ligament reconstruction
o see AC separation Techniques section
techniques include
modified Weaver-Dunn
free tendon graft
Complications
Nonoperative treatment
o nonunion (1-5%)
risks
comminution
Z deformity
female
older
smoker
distal clavicle higher risk than middle third
treatment of nonunion
if asymptomatic, no treatment necessary
if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)
Operative treatment
o hardware prominence
~30% of patient request plate removal
superior plates associated with increased irritation
o neurovascular injury (3%)
superior plates associated with increased risk of subclavian artery or vein penetration
subclavian thrombosis
o nonunion (1-5%)
o infection (~4.8%)
o mechanical failure (~1.4%)
o pneumothorax
o adhesive capsulitis
4% in surgical group develop adhesive capsulitis requiring surgical intervention
Collected By : Dr AbdulRahman
AbdulNasser
drxabdulrahman@gmail.com
In June 2017
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4. Scapula Fractures
Introduction
Uncommon fracture pattern associated with high energy trauma
o 2-5% associated mortality rate
usually pulmonary or head injury
associated with Increased Injury Severity Scores
Epidemiology
incidence : less than 1% of all fractures
o location : 50% involve body and spine
Associated injuries (in 80-90%)
o orthopaedic
rib fractures (52%)
ipsilateral clavicle fracture (25%)
spine fracture (29%)
brachial plexus injury (5%) : 75% of brachial plexus
injuries resolve
o medical
pulmonary injury
pneumothorax (32%)
pulmonary contusion (41%)
head injury (34%)
vascular injury (11%) III:1 Floating Shoulder
Classification
Classification is based on the location of the fracture and includes
o coracoid fractures
o acromial fractures
o glenoid fractures
o scapular neck fractures
look for associated AC joint separation or clavicle fracture
known as "floating shoulder"
o scapular body fractures
described based on anatomic location
o scapulothoracic dissociation
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Shoulder
Ideberg Classification of Glenoid Fracture
Type Ia Anterior rim fracture
Type Ib Posterior rim fracture
Type II Fracture line through glenoid fossa exiting scapula laterally
Type III Fracture line through glenoid fossa exiting scapula superiorly
Type IV Fracture line through glenoid fossa exiting scapula medially
Type Va Combination of types II and IV
Type Vb Combination of types III and IV
Type Vc Combination of types II, III, and IV
Type VI Severe comminution
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Imaging
Radiographs
o recommended views
true AP, scapular Y and axillary lateral view
CT
o intra-articular fracture
o significant displacement
o three-dimensional reconstruction useful
Treatment
Nonoperative
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Shoulder
5. Scapulothoracic Dissociation
Introduction
A traumatic disruption of the scapulothoracic articulation often associated with
o severe neurologic injuries
o vascular injuries
o orthopaedic injuries
Mechanism
o usually caused by a lateral traction injury to the shoulder girdle
o involves significant trauma to heart, chest wall and lungs
Associated conditions
o orthopaedic
scapula fractures
clavicle fractures
AC dislocation/separation
sternoclavicular dislocation
flail extremity (52%)
complete loss of motor and sensory function rendering the extremity non-functional
o vascular injury
subclavian artery most commonly injured
axillary artery
o neurologic injury (up to 90%)
ipsilateral brachial plexus injury (often complete)
neurologic injuries more common than vascular injuries
Prognosis
o mortality rate of 10%
o functional outcome is dependent on neurologic injury
if return of neurological function is unlikely, early amputation is recommended
Anatomy
Scapulothoracic joint
o a sliding joint
o articulates with ribs 2-7
o moves into abduction at 2:1 ratio
GH joint 120°
ST joint 60°
Neurovascular anatomy
o brachial plexus
o subclavian artery
o axillary artery
Presentation
History
o history of high energy trauma
Symptoms
o pain in involved upper extremity (UE)
o numbness/tingling in involved UE
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Physical exam
o inspection
significantswelling in shoulder region
bruising around shoulder
o vascular exam
decreased or absent pulses in involved UE
o neurological exam
neurologic deficits in UE
neurological status critical part of exam
Imaging
Radiographs
o required views
AP chest III:3 Laterally displaced scapula
o recommended view
AP and lateral of shoulder as tolerated
appropriate images of suspected fracture sites
o findings
laterally displaced scapula
edge of scapula displaced > 1 cm from spinous process as compared to contralateral side
widely displaced clavicle fx
AC separation
sternoclavicular dislocation
Angiogram
o indicated to detect injury to subclavian and axillary artery
Treatment
Nonoperative
o immobilization/supportive care
indications
patients without significant vascular injury who are hemodynamically stable
patients may have adequate collateral flow to UE even with injury
Operative
o high lateral thoracotomy with vascular repair
indications : axillary artery injury in hemodynamically unstable patient
o median sternotomy with vascular repair
indications : more proximal arterial injury (i.e., subclavian artery) in a hemodynamically
unstable patient
o ORIF of the clavicle or AC joint
indications : associated clavicle and AC injuries
o forequarter amputation
indications : complete brachial plexus injury
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Shoulder
6. Flail Chest
Introduction
Defined as 3 or more ribs with segmental fractures
Epidemiology
o bimodal distribution
younger patients involved in trauma
older patients with osteopenia
Mechanism
o blunt forces
o deceleration injuries
Associated Injuries
o scapula fractures
o clavicle fractures
o hemo/pneumothorax III:4 paradoxical respiration
Prognosis
o varies depending on underlying pulmonary injury or other concomitant injuries
Anatomy
Osteology
o 12 ribs per side
the first seven pairs are connected with the sternum
the next three are each articulated with the lower border of the cartilage of the preceding rib
the last two have pointed extremities
o can have an accessory clavicular rib
o anterior ribs articulate with the sternum via the costal cartilage
Blood Supply
o derived from intercostal vessels
Presentation
Symptoms
o pain
o respiratory difficulty
o hemopneumothorax
Exam
o paradoxical respiration
area of injury "sinks in" with inspiration, and
expands with expiration (opposite of normal
chest wall mechanics) III:5 may see associated hemothorax
o chest wall deformity can be seen
o bony or soft-tissue crepitus is often noted
Imaging
Radiographs
o may be hard to distinguish non- or minimally-displaced rib fractures
o may see associated hemothorax
CT : improved accuracy of diagnosis with CT (vs. radiographs)
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Treatment
Nonoperative
o observation
indications
no respiratory compromise
no flail chest segment (>3 consecutive segmentally fractured ribs)
techniques
pain control
systemic narcotics or local anesthetics
positive pressure ventilation
Operative
o open reduction internal fixation
indications
displaced rib fractures associated with intractable pain
flail chest segment (3 or more consecutive ribs with segmental injuries)
rib fractures associated with failure to wean from a ventilator
open rib fractures
technique
approach
full thoracotomy approach
limited exposure approach
open reduction and internal fixation
plate and screw constructs
intramedullary splinting
postop
early shoulder and periscapular range of motion
Complications
Intercostal neuralgia
Periscapular muscle weakness
Pneumonia
Restrictive type pulmonary function
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B. Humerus
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Classification
Valgus impacted
o not true 4-part fractures
o have preserved posterior medial capsular vascularity to the articular segment
AO/OTA
o organizes fractures into 3 main groups and additional subgroups based on
fracture location
status of the surgical neck
presence/absence of dislocation
Neer classification
o based on anatomic relationship of 4 segments
greater tuberosity
lesser tuberosity
articular surface
shaft
o considered a separate part if
displacement of > 1 cm
45° angulation
Evaluation
Symptoms
o pain and swelling
o decreased motion
Physical exam III:6 AO/OTA of proximal humeral frx
o inspection
extensive ecchymosis of chest, arm, and forearm
o neurovascular exam
45% incidence of nerve injury (axillary most common)
distinguish from early deltoid atony and inferior subluxation of humeral head
arterial injury may be masked by extensive collateral
circulation preserving distal pulses
Imaging
Radiographs : recommended views
o complete trauma series
true AP
scapular Y
axillary
o additional views
apical oblique
Velpeau
West Point axillary
o findings
combined cortical thickness (>4 mm)
studies suggest correlation with increased lateral plate pullout strength
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
CT scan : indications
o preoperative planning
o humeral head or greater tuberosity position uncertain
o intra-articular comminution
MRI : indications
o rarely indicated
o useful to identify associated rotator cuff injury
Treatment
Nonoperative
o sling immobilization followed by progressive rehab
indications
85% of proximal humerus fractures are minimally displaced and can be treated
nonoperatively including
minimally displaced surgical neck fracture (1-, 2-, and 3-part)
greater tuberosity fracture displaced < 5mm
fractures in patients who are not surgical candidates
additional variables to consider
age
fracture type
fracture displacement
bone quality
dominance
general medical condition
concurrent injuries
technique
start early range of motion within 14 days
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Operative
o CRPP (closed reduction percutaneous pinning)
indications
2-part surgical neck fractures
3-part and valgus-impacted 4-part fractures in patients with good bone quality, minimal
metaphyseal comminution, and intact medial calcar
o ORIF
indications
greater tuberosity displaced > 5mm
2-,3-, and 4-part fractures in younger patients
head-splitting fractures in younger patients
o intramedullary rodding
indications
surgical neck fractures or 3-part greater tuberosity fractures in
younger patients
combined proximal humerus and humeral shaft fractures
outcomes
85% success rate in younger patients
o hemiarthroplasty
indications
anatomic neck fractures in elderly (initial varus malalignment >20 degrees) or those that
are severely comminuted
4-part fractures and fracture-dislocations (3-part if stable internal fixation unachievable)
rotator cuff compromise
glenoid surface is intact and healthy
chronic nonunions or malunions in the elderly
head-splitting fractures with incongruity of humeral head
humeral head impression defect of > 40% of articular surface
detachment of articular blood supply (most 3- and 4-part fractures)
outcomes
improved results if
performed within 14 days
accurate tuberosity reduction
cerclage wire passed through hole in prosthesis and tuberosities
poor results with
tuberosity malunion
proud prosthesis
retroversion of humeral component > 40°
o total shoulder arthroplasty
indications
rotator cuff intact
glenoid surface is compromised (arthritis, trauma)
o reverse shoulder arthroplasty
indications
elderly individuals with nonreconstructible tuberosities
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
Treatment by Fracture Type
One-Part Fracture (most common)
Surgical Neck fx • Most common type • if stable then early ROM
• if unstable then period of immobilization followed by ROM
once moves as a unit
Anatomic Neck fx • ORIF in young patient
• ORIF vs. hemiarthroplasty in elderly patient
• hemiarthroplasty if severely comminuted
Two-Part Fracture
Surgical Neck • Most common fx pattern (85%) Nonoperative
• Deforming forces: • Closed reduction often possible
1) pectoralis pulls shaft anterior and • Sling
medial 2) head and attached tuberosities Operative
stay neutral • indicated for >45° angulation
• Posterior angulation tolerated better • technique
than anterior and varus angulation - CRPP
- Plate fixation
- Enders rods with tension band
- IM device
Greater tuberosity • Often missed Nonoperative
• Deforming forces: GT pulled superior • indicated for GT displaced < 5 mm
and posterior by SS, IS, and TM Operative
• Can only accept minimal displacement • indicated for GT displacement > 5 mm
or else it will block ER and ABD •AP radiograph of a left shoulder demonstrates a 2-part
proximal humerus fracture at the surgical neck.
- isolated screw fixation only in young with good bone stock
- nonabsorbable suture technique for osteoporotic bone (avoid
hardware due to impingement)
- tension band wiring
Lesser tuberosity • Assume posterior dislocation until Operative
proven otherwise • ORIF if large fragment
• excision with RCR if small
Anatomic neck • Rare Operative
• ORIF in young
• ORIF vs. hemiarthroplasty in elderly patient
Three-Part Fracture
Surgical neck and GT • Subscap will internally rotate articular
segment
• Often associated with longitudinal RCT
Surgical neck and LT • Unopposed pull of external rotators lead • Trend towards nonoperative management with high
to articular surface to point anterior complications with ORIF
• Often associated with longitudinal RCT • Young patient
- percutaneous pinning (good results, protect axillary nerve)
- blade plate / fixed angle device
- IM fixation (violates cuff)
- T plate (poor results with high rate of AVN, impingement,
infection, and malunion)
• Elderly patient
- hemiarthroplasty with RCR or tuberosity repair
Four-Part Fracture
Valgus impacted 3- • Radiographically will see alignment • 74% good results with ORIF
and 4-part fracture between medial shaft and head • Low rate of AVN if posteromedial component intact thus
segments preserving intraosseous blood supply
• Surgical technique
1. raise articular surface and fill defects
2. repair tuberosities
4-part with articular • Characterized by removal of soft tissue • Young patient
surface and head- from fracture fragment leading to high - ORIF vs. hemiarthroplasty (nonreconstructible articular
splitting fracture risk of AVN (21-75%) surface, severe head split, extruded anatomic neck fracture)
• Deforming forces: 1) shaft pulled
medially by pectoralis • Elderly patient
- hemiarthroplasty
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Techniques
CRPP (closed reduction percutaneous pinning)
o approach
percutaneous
o technique
use threaded pins but do not cross cartilage
externally rotate shoulder during pin placement
engage cortex 2 cm inferior to inferior border of humeral head
o complications
with lateral pins
risk of injury to axillary nerve
with anterior pins
risk of injury to biceps tendon, musculocutaneous n., cephalic vein
ORIF
o approach
shoulder anterior approach (deltopectoral)
shoulder lateral (deltoid-splitting) approach
indicated for GT and valgus-impacted 4-part fractures
increased risk of axillary nerve injury
o technique
heavy nonabsorbable sutures
(figure-of-8 technique) should be used for greater tuberosity fx reduction and fixation
(avoid hardware due to impingement)
isolated screw
may be used for greater tuberosity fx reduction and fixation in young patients with good
bone stock
locking plate
has improved our ability to fix these fractures
screw cut-out (up to 14%) is the most common complication following fixation of 3- and
4- part proximal humeral fractures and fractures treated with locking plates
more elastic than blade plate making it a better option in osteoporotic bone
place plate lateral to the bicipital groove and pectoralis major tendon to avoid injury to the
ascending branch of anterior humeral circumflex artery
placement of an inferomedial calcar screw can prevent post-operative varus collapse,
especially in osteoporotic bone
Intramedullary rodding
o approach
superior deltoid-splitting approach
o technique
lock nail with trauma or pathologic fractures
o complications
rod migration in older patients with osteoporotic bone is a concern
shoulder pain from violating rotator cuff
nerve injury with interlocking screw placement
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
Hemiarthroplasty
o approach
shoulder anterior approach (deltopectoral)
o technique for fractures
cerclage wire or suture passed through hole in prosthesis and tuberosities improves fracture
stability
place greater tuberosity 10 mm below articular surface of humeral head (HTD = head to
tuberosity distance)
impairment in ER kinematics and 8-fold increase in torque with nonanatomic placement
of tuberosities
height of the prosthesis best determined off the superior edge of the pectoralis major tendon
post-operative passive external rotation places the most stress on the lesser tuberosity
fragment
Total shoulder arthroplasty
Reverse shoulder arthroplasty
Rehabilitation
Important part of management
Best results with guided protocols (3-phase programs)
o early passive ROM for first 6 weeks
o active ROM and progressive resistance
o advanced stretching and strengthening program
Prolonged immobilization leads to stiffness
Complications
Screw penetration
o most common complication after locked plating fixation (up to 14%)
Avascular necrosis
o risk factors
4 part fractures
head split
short calcar segments
disrupted medial hinge
o no relationship to type of fixation (plate or cerclage wires)
Nerve injury
o axillary nerve injury (up to 58%)
increased risk with anterolateral acromial approach
axillary nerve is found 7cm distal to the tip of the acromion
o suprascapular nerve (up to 48%)
Malunion
o usually varus apex-anterior or malunion of GT
o results inferior if converting from varus malunited fracture (with GT in varus necessitating
osteotomy) to TSA
use reverse TSA instead
Nonunion
o usually with surgical neck and tuberosity fx
o treatment of chronic nonunion/malunion in the elderly should include arthroplasty
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o lessertuberosity nonunion leads to weakness with lift-off testing
o greater tuberosity nonunion leads to lack of active shoulder elevation
o greatest risk factors for non-union are age and smoking
Rotator cuff injuries and dysfunction
Missed posterior dislocation
Adhesive capsulitis
Posttraumatic arthritis
Infection
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
Anatomy
Humeral head
o shape : spheroidal in 90% of individuals
o size : average diameter is 43 mm
o orientation
retroverted 30° from transepicondylar axis of the distal humerus
neck-shaft agle usually 130° to 140°
Greater tuberosity
o position important for rotator cuff muscle fuction
horizontal position : medial edge of tuberosity is 10mm lateral to humeral canal axis
vertical position : superior edge of tuberosity is 6mm inferior to upper edge of humeral head
Classification
Beredjiklian et al.
Beredjiklian
TypeI • Malposition of the greater or lesser tuberosity ( e.g. >1 cm from native anatomical
position)
Type II • Articular incongruity ( e.g. intra-articular fracture extension, osteoarthritis)
Type III • Articular surface malalignment ( e.g. >45° of deformity with respect to the humeral shaft
in the coronal, sagittal, or axial planes
Boileau et al.
Boileau
Type I • Humeral head necrosis or impaction
Type II • Chronic dislocations or fracture-dislocations
Type III • Nonunion of the surgical neck
Type IV • Severe malunion of the tuberosity
Presentation
History
o initial evaluation
date and mechanism of injury
current and prior function
handedness
treatment to date
specific goals of treatment
Symptoms
o pain and weakness
o limitations
Physical exam
III:9 Humeral head orientation
o inspection
features of systemic disease
muscle atrophy
diffuse tenderness
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o motion
active and passive shoulder range-of-motion
blocks or crepitus should be noted
rotator cuff
greater tuberosity malunion = weakness with abduction, external rotation
lesser tuberosity malunion = weakness with internal rotation
instability
humeral head malunion = apprehension test
o neurovascular
Imaging
Radiographs
o recommended views
true AP, scapular Y, axillary
o optional views
apical oblique
Velpeau
West Point axillary
o findings III:10 fracture fragment displacement
neck-shaft angle = varus or valgus
greater tuberosity = superiorly and posteriorly displaced, externally rotated
lesser tuberosity = medialized
o measurements
humeral head
> 45° of deformity in any plane
symptomatic articular incongruity
neck-shaft angle <120° or >150°
greater or lesser tuberosity
>1 cm from native anatomical position
CT scan
o indications
preoperative planning
assess bone stock, orientation and articular surface
o findings
humeral head and greater tuberosity displacement
glenoid version and glenoid bone stock
articular injury
MRI
o indications
preoperative planning
soft-tissue structures
o findings
rotator cuff or labral injury
deltoid atrophy secondary to axillary nerve injury
long-head biceps injury
osteonecrosis
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
Studies
Labs : CBC, ESR, CRP, blood cultures to rule out infection
Electrodiagnositcs : concern for nerve dysfunction
Treatment
Nonoperative
o NSAIDS, physical therapy, occasional corticosteriod injection
indications
low-demand patient
painless shoulder limitations
unable to comply with rehabilitation protocol
modalities
physical therapy
maximize ROM and strengthening program
outcomes
impacted varus and valgus fractures show good-to-excellent results
return to 90% of normal fuction
Operative
o humeral head preserving techniques
indications
symptomatic malunion following
nonoperative treatment
failed internal fixation
anatomical requirements
adequate bone stock for fixation
preserved articular surface
intact blood supply to humeral head
techniques
humeral head deformities
minor deformity techniques
open/arthroscopic tuberoplasty +/- acromioplasty +/- capsular release +/-
bursectomy
severe deformity techniques
varus/valgus osteotomy +/- rotational osteotomy and lateral plate fixation
treated with corrective osteotomy/fixation if patient is young or active
augmentation with strut allograft for poor bone stock
greater tuberosity deformities
<1.5 cm displacement
arthroscopic subacromial decompression +/- rotator cuff repair
>1.5 cm displacement
open/arthroscopic tuberosity osteotomy +/- subacromial decompression
outcomes
complication rates associated with surgical management of malunions are higher than
those associated with acute fractures
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o humeral head replacing techniques
indications
symptomatic malunion following
nonoperative treatment
failed internal fixation
anatomical requirements
inadequate bone stock for fixation techniques
articular incongruity, destruction or collapse (e.g. osteonecrosis or head-split)
compromised blood supply
chronic dislocation
techniques
hemiarthroplasty
total shoulder arthroplasty
reverse total shoulder arthroplasty
Complications
Persistent pain and weakness
Stiffness
Loss of fixation
Infection
Bleeding
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
Classification
OTA
o bone number: 1
o fracture location: 2
o fracture pattern: simple:A, wedge:B, complex:C
Descriptive
o fracture location: proximal, middle or distal third
o fracture pattern: spiral, transverse, comminuted
Holstein-Lewis fracture
o a spiral fracture of the distal one-third of the humeral shaft commonly
associated with neuropraxia of the radial nerve (22% incidence)
Presentation
Symptoms
o pain III:11 Holstein-Lewis fracture
o extremity weakness
Physical exam
o examine overall limb alignment
o preoperative or pre-reduction neurovascular exam is critical
examine and document status of radial nerve pre and post-reduction
Imaging
Radiographs : views
o AP and lateral
be sure to include joint above and below the site of injury
o transthoracic lateral
may give better appreciation of sagittal plane deformity
o traction views
may be necessary for fractures with significant shortening, proximal
or distal extension but not routinely indicated
III:12 AP radiograph fracture
Treatment humerus
Nonoperative
o coaptation splint followed by functional brace
indications
indicated in vast majority of humeral shaft fractures
criteria for acceptable alignment include:
< 20° anterior angulation
< 30° varus/valgus angulation
< 3 cm shortening
absolute contraindications
severe soft tissue injury or bone loss
vascular injury requiring repair
brachial plexus injury
relative contraindications III:13 transthoracic lateral
see relative operative indications section
radial nerve palsy is NOT a contraindication to functional bracing
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outcomes
90% union rate
increased risk with proximal third oblique or spiral fracture
varus angulation is common but rarely has functional or cosmetic sequelae
o damage control orthopaedics (DCO)
closed humerus fractures, including low velocity GSW, should be initially managed with a
splint or sling
type of fixation after trauma should be directed by acceptable fracture alignment parameters,
fracture pattern and associated injuries
Operative
o open reduction and internal fixation
absolute indications
open fracture
vascular injury requiring repair
brachial plexus injury
ipsilateral forearm fracture (floating elbow)
compartment syndrome
relative indications
bilateral humerus fracture
polytrauma or associated lower extremity fracture III:14 standard
allows early weight bearing through humerus functional brace
pathologic fractures
burns or soft tissue injury that precludes bracing
fracture characteristics
distraction at fracture site
short oblique or transverse fracture pattern
intraarticular extension
o intramedullary nailing (IMN)
relative indications
pathologic fractures
segmental fractures
severe osteoporotic bone
overlying skin compromise limits open approach
polytrauma III:15 open reduction and
internal fixation
Techniques
Coaptation Splint & Functional Bracing
o coaptation splint
applied until swelling resolves
adequately applied splint will extend up to axilla and over shoulder
common deformities include varus and extension
valgus mold to counter varus displacement
o functional bracing
extends from 2.5 cm distal to axilla to 2.5 cm proximal to humeral condyles
sling should not be used to allow for gravity-assisted fracture reduction
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shoulder extension used for more proximal fractures
Open Reduction Internal Fixation with Plating
o approaches
anterolateral approach to humerus
used for proximal third to middle third shaft fractures
distal extension of the deltopectoral approach
radial nerve identified between the brachialis and
brachioradialis distally
posterior approach to humerus
used for distal to middle third shaft fractures although
can be extensile
triceps may either be split or elevated with a lateral
paratricipital exposure III:16apply plate in bridging mode n severe
radial nerve is found medial to the long and lateral comminution
heads and 2cm proximal to the deep head of the
triceps
radial nerve exits the posterior compartment through lateral intramuscular septum 10 cm
proximal to radiocapitellar joint
lateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic
landmark leading to the radial nerve during a paratricipital approach
o techniques
plate osteosynthesis commonly with 4.5mm plate (narrow or broad)
3.5mm plates may function adequately
absolute stability with lag screw or compression plating in simple patterns
apply plate in bridging mode in the presence of significant comminution
o postoperative
full crutch weight bearing shown to have no effect on union
Closed Intramedullary Nailing (IMN)
o techniques : can be done antegrade or retrograde
o complication
nonunion
nonunion rates not shown to be different between IMN and
plating in recent meta-analyses
IM nailing associated with higher total complication rates
shoulder pain
increased rate when compared to plating (16-37%)
nerve injury
radial nerve is at risk with a lateral to medial distal locking
screw
musculocutaneous nerve is at risk with an anterior-posterior
locking screw
III:17 Closed Intramedullary
o postoperative Nailing
full weight bearing allowed and had no effect on union
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Complications
Malunion
o varus angulation is common but rarely has functional or cosmetic sequelae
o risk factors : transverse fracture patterns
Nonunion
o incidence
2 to 10% in nonoperative management
5 to 10% with surgical management
o risk factors
distraction at the fracture site on injury films
open fracture
metabolic/endocrine abnormalities (Vitamin D deficiency most common)
segmental fracture
infection
shoulder or elbow stiffness (motion directed to fracture site)
patient factors (smoking, obesity, malnutrition, noncompliance)
o treatment
compression plating with bone grafting
shown to be superior to both IM nailing with bone grafting and compression plating
alone
lateral, posterior or paratricipital (Gerwin) approach to allow exploration of the radial
nerve
Radial nerve palsy
o incidence
seen in 8-15% of closed fractures
increased incidence distal one-third fractures
neuropraxia most common injury in closed fractures and neurotomesis in open fractures
85-90% of improve with observation over 3 months
spontaneous recovery found at an average of 7 weeks, with full recovery at an average of 6
months
o treatment
observation
indicated as initial treatment in closed humerus fractures
obtain EMG at 3-4 months
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
Anatomy
Osteology
o elbow is a hinged joint
o trochlea
articulates with sigmoid notch
allows for flexion and extension
o capitellum
articulates with proximal radius : allows for forearm rotation
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Muscles
o common flexors (originate from medial epicondyle)
pronator teres
flexor carpi radialis
palmaris longus
FDS
FCU
o common extensors (originate from lateral epicondyle)
anconeus
ECRL
ECRB
extensor digitorum comminus
EDM
ECU
Ligaments
o medial collateral ligament
anterior bundle originates from distal medial epicondyle
inserts on sublime tubercle
primary restraint to valgus stress at the elbow from 30 to 120 deg
tight in pronation
o lateral collateral ligament
originates from distal lateral epicondyle
inserts on crista supinatorus
stabilizer against posterolateral rotational instability
taut in supination
Nerves
o ulnar nerve : resides in cubital tunnel in a subcutaneous position below the medial condyle
o radial nerve
resides in spiral groove 15cm proximal to distal humeral articular surface
between brachioradialis and brachialis proximal to elbow
divides into PIN and superficial radial nerve at level of radial head
Classification
Can be classified as
o supracondylar fractures
o distal single column fractures
subclassified using Milch classification system (see table)
lateral condyle more common than medial
o distal bicolumnar fractures
classified using Jupiter classification system (see table)
5 major articular fragments have been identified
capitellum/lateral trochlea
lateral epicondyle
posterolateral epicondyle
posterior trochlea
medial trochlea/epicondyle
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Presentation
Symptoms : elbow pain and swelling
Physical exam
o gross instability often present
avoid ROM due to risk of neurovascular damage
o neurovascular exam
check function of radial, ulnar, and median nerve
check distal pulses
brachial artery may be injured
if pulse decreased, obtain noninvasive vascular studies; consult vascular surgery if
abnormal
o monitor carefully for forearm compartment syndrome
Imaging
Radiographs
o recommended views
obtain AP and lateral of humerus and elbow
include entire length of humerus and forearm
o additional views
obtain wrist radiographs if elbow injury present or distal tenderness on exam
oblique radiographs may assist in surgical planning
traction radiographs may assist in surgical planning
specifically evaluate if there is continuity of the trochlear fragment to medial epicondylar
fragment, this can influence hardware choice
CT
o often obtained for surgical planning
o especially helpful when shear fractures of the capitellum and trochlea are suspected
o 3D CT scan improves the intraobserver and interobserver reliability of several classification
systems
MRI
o usually not indicated in acute injury
Treatment
Nonoperative
o cast immobilization
indications
nondisplaced Milch Type I fractures
technique
immobilize in supination for lateral condyle fractures
immobilize in pronation for medial condyle fractures
Operative
o closed reduction and percutaneous pinning
indications
displaced Mich Type I fractures
o open reduction internal fixation
indications
supracondylar fractures
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
intercondylar / bicolumnar fractures
Milch Type II fractures
o total elbow arthroplasty
indications
distal bicolumnar fractures in elderly patients
Techniques
Open Reduction Internal Fixation
o positioning
lateral decubitus position
on foam mattress with radiolucent arm board
prone position
useful in patients with spine injuries or contralateral extremity fractures
supine positioning
can be used in a polytrauma situation or with contraindications to other positioning
obtain test imaging before prepping and draping
prep entire arm from shoulder to hand
o approach
articular surface exposure
olecranon osteotomy 57%
triceps-reflecting 46%
triceps-splitting 35%
posterior superficial approach
raise full thickness medial and lateral soft tissue flaps
elevate deep fascia to identify ulnar and radial nerves
triceps splitting (Campbell)
split triceps tendon in midline down to olecranon
tricep sparing (known as paratricipital, Alonso-Llames, medial and lateral windows)
indications
extra articular fractures or fractures with simple articular split)
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can be converted to olecranon osteotomy if needed
medial side
identify ulnar nerve and dissect it 15cm proximal to elbow joint proximally, and
distally to first motor branch to FCU
elevate triceps from posterior aspect of humerus on medial side and free it from
medial intermuscular septum
posterior band of MCL is elevated and posterior joint capsule entered to visualize
trochlea
lateral side
identify radial nerve proper proximally if fracture is distal
if fracture is distal and does not require long plates, proper radial nerve does not
need to be exposed
elevate remainder of tricep from posterior aspect of humerus
anconeus may be divided or dissected on lateral side to improve exposure
olecranon osteotomy
indications : complex intra articular fragments and/or presence of coronal splint)
contraindications : total elbow arthroplasty is planned/may be required
technique
identify bare area of sigmoid notch medially and laterally
pre-drill (for 6.5mm screw) or plate prior to making bone cut
pass sponge through ulnohumeral joint to protect articular surface while making cut
fluoroscopy is used to confirm location of osteotomy
shallow chevron (apex distal) is cut down to subchondral bone (95% cut)
finish cut (remaining 5%) with osteotome
peel olecranon and triceps proximally and wrap with saline soaked sponge
fixation
screw, K wires and tension band or plate
clamp osteotomy from medial and lateral side with large pointed reduction clamps
insert 6.5, 7.0 or 7.3mm screw (or plate) in previously drilled hole
apply tension band
still preferable for posterior trochlea fx and medial epicondyle fx
complications
AIN nerve injury
check ability to flex thumb interphalangeal joint in recovery
triceps reflecting (Bryan-Morrey)
reflect triceps tendon, forearm fascia and periosteum from medial to lateral off olecranon
repair through transosseous drill holes
immobilize to protect triceps repair for 4-6wk postop
triceps-reflecting anconeous pedicle (O'Driscoll)
elevate anconeous subperiosteally from proximal ulna
medial exposure is Bryan-Morrey triceps reflecting approach
lateral muscles interval
is an alternative to visualize the articular
elevate ECRB and part of ECRL of supracondylar ridge
usually able to work anterior to and sacrifice LCL
if fx of lateral column, utilize and mobilize
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
sublux joint to assist in articular visualization
o fixation principles (O'Driscoll)
fixation in the distal fragment must be maximized
all fixation in distal fragments should contribute to stability between the distal fragments and
the shaft.
o fixation objectives (O'Driscoll)
every screw in the distal fragments should pass through a plate
engage a fragment on the opposite side that is also fixed to a plate
as many screws as possible should be placed in the distal fragments
each screw should be as long as possible
each screw should engage as many articular fragments as possible
the screws in the distal fragments should lock together by interdigitation, creating a fixed-
angle structure
this creates the architecural equivalent of an arch, which gives the most biomechanical
stability
plates should be applied such that compression is achieved at the supracondylar level for both
columns
the plates must be strong enough and stiff enough to resist breaking or bending before union
occurs at the supracondylar level.
o fixation
countersunk / headless screw to fix articular fragments 1st after provisional reduction with k-
wires
if metaphyseal injury is not comminuted, reducing one column to the metaphysis first
may be beneficial
consider using positional screws when reducing trochlea to avoid narrowing it with
compression
then address condyles and epitrochlear ridge
lateral epicondyle may be fix with tension band wire or plate
two plates in orthogonal planes used to fix articular segment to shaft
place 3.5-mm LCDC plate or one of equivalent strength on lateral side
place 2.7-mm or 3.5-mm LCDC plate on medial side
interdigitate screws if possible to increase strength
new literature supports parallel plates
if ulnar nerve contacts medial hardware during flexion/extension, can transpose however
literature does not support decreased ulnar n. symptoms with transposition
postoperative
place in splint with elbow in approx 70 degrees of flexion
remove splint at 48 hours post-operatively, initiate ROM exercises
if osteotomy performed patient may do active and active assisted flexion and
extension for 6 weeks; no active extension against gravity or resistance
if not osteotomy, permitted to do active motion against gravity without restrictions
no restrictions to rotation
start gentle strengthening program at 6 weeks, and full strengthening program at 3 months
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Complications
Elbow stiffness : most common
Heterotopic ossification
o reported rate of 8%
o routine prophylaxis is not warranted
increased rate of nonunion in patients treated with indomethacin
Nonunion
o low incidence
o avoid excessive soft-tissue stripping
Malunion
o avoided by proper surgical technique
cubitus valgus (lateral column fxs)
cubitus varus (medial column fxs)
DJD
Ulnar nerve injury
AIN Injury : can be seen with olecranon osteotomy
C. Elbow
1. Elbow Dislocation
Introduction
Epidemiology
o incidence
elbow dislocations are the most common major joint dislocation second to the shoulder
account for 10-25% of injuries to the elbow
posterolateral is the most common type of dislocation (80%)
o demographics : predominantly affects patients between age 10-20 years old
Pathophysiology
o mechanism
usually a combination of
axial loading
supination/external rotation of the forearm
posterolateral based valgus force
a varus posteromedial mechanism has also been reported
posterior dislocations may involve more than one injury mechanism
o pathoanatomy
associated with complete or near complete circular disruption of capsuloligamentous
stabilizers
pathoanatomic cascade
progression of injury is from lateral to medial
LCL fails first (primary lesion)
by avulsion of the lateral epicondylar origin
midsubstance LCL tears are less common but do occur
MCL fails last depending on degree of energy
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Anatomy
Static and dynamic stabilizers confer stability to the elbow
o static stabilizers (primary)
ulnohumeral joint
anterior bundle of the MCL
LCL complex (includes the LUCL)
o static stabilizers (secondary)
radiocapitellar joint
capsule
origins of the flexor and extensor tendons
o dynamic stabilizers : includes muscles crossing elbow joint
anconeus
brachialis
triceps
See complete Anatomy and Biomechanics of Elbow
Classification
Anatomic description
o based on anatomic location of olecranon relative to humerus
posterolateral : most common
Simple vs. complex
o simple
no associated fracture
III:19 lateral radiograph of terrible triad
account for 50-60% of elbow dislocations injury
o complex
associated fracture present
may take form of
terrible triad injury
involves a disruption of the LUCL, a radial head fracture, a coronoid tip fracture and a
dislocation of the elbow
varus posteromedial rotatory instability
the coronoid fracture may be comminuted
medial facet of the coronoid is usually involved
Presentation
Symptoms : pain may be the primary symptom
Physical exam
o important to assess
the status of the skin
presence of compartment syndrome
neurovascular status
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Imaging
Radiographs
o recommended views
AP and lateral films
need to check the status of the congruency of the joint
o optional views
oblique views
may give clearer sense of periarticular bony involvement
CT scan
o indications
suspicion of complex injury pattern
useful to identify osseous involvement
Treatment
Nonoperative
o reduction and splinting at 90° for 7-10 days, early therapy
indications
acute simple stable dislocations
o reduction splinting in hinged brace at 90° for 2-3 weeks
indications
acute simple unstable elbow dislocations (unstable with extension following reduction)
Operative
o ORIF (coronoid, radial head, olecranon) , LCL repair, +/- MCL repair
indications
acute complex elbow dislocations
persistent instability after reduction
reduction blocked by entrapped soft tissue or osteochondral fragments
outcomes
improved with use of this systematic algorithm
o open reduction, capsular release, and dynamic hinged elbow fixator
indications
chronic dislocations
postoperative
hinged external fixator indicated in chronic dislocation to protect the reconstruction and
allow early range of motion
Nonoperative Technique
Closed reduction with splinting
o reduction maneuver
inline traction to correct coronal displacement
supination to clear the coronoid beneath trochlea
flexion of elbow while placing pressure on tip of olecranon
o assess post reduction stability
elbow is often unstable in extension
if LCL is disrupted then usually more stable in pronation
if MCL is disrupted then usually more stable in supination
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o immobilize and obtain post-reduction radiographs
check for concentric reduction of joint
if concentric then immobilize (5-7 days) and start early therapy
Rehabilitation
o initial
immobilize for 5-7 days
o early
supervised (therapist) active and active assist range-of-motion exercises within stable arc
extension block brace is used for 3-4 weeks
proceed with light duty use 2 weeks from injury
o late rehabilitation
extension block is decreased such that by 6-8 weeks after the injury full stable extension is
achieved
Operative Technique
ORIF of coronoid, radial head, repair of LCL +/- MCL
o approach
posterior utility approach used
Kocher interval laterally (ECU/anconeus)
o reconstruction
coronoid
fixation can usually be completed laterally via radial head fracture
severe comminution may necessitate medial approach
radial head
ORIF
when placing fixation on the proximal radius, one must be aware of the "safe zone" (a
90° arc in the radial head that does not articulate with the proximal ulna)
the "safe zone" can be identified by its relationship to Lister's tubercle and the
radial styloid
radial head arthroplasty
indicated if radial head can not be reconstructed
if radial head is replaced the replacement should be anatomic and restore normal
length/size
this improves the varus and external rotatory stability of the elbow, but stability
isn't restored until LCL is addressed
excision of the radial head leads to varus/external rotatory instability when the
LCL function is absent
LCL
reconstructed or repaired relative to the anatomic axis of rotation
extensor origin avulsion is common and may be repaired
MCL
if instability persists following LCL repair, the MCL is repaired or reconstructed
o postoperative care
depending on stability of the elbow, active ROM exercises may commence while using a
brace
an extension block may or may not be used
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Complications
Varus Posteromedial instability
o injury to the LCL and fracture of the anteromedial facet of the coronoid
o solid fixation of the anteromedial facet is critical for functional outcome and prevention of
arthrosis
Loss of motion
o loss of terminal extension is the most common sequelae after closed treatment of a simple elbow
dislocation
o early active ROM can help prevent this from occurring
o static, progressive splinting can be utilized after inflammation has diminished
Neurovascular injuries (ulnar/median nerves)
Compartment syndrome
Damage to articular surface
Chronic instability
Heterotopic ossification
o may require excision to improve elbow range of motion
Contracture/stiffness
o correlated with immobilization beyond 3 weeks
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elbow dislocation
terrible triad (elbow dislocation, radial head fracture, coronoid fracture)
carpal fractures
scaphoid fracture
Anatomy
Osteology
o elbow joint contains two articulations
ulnohumeral (hinge)
radiocapitellar (pivot)
60% load transfer across elbow joint
o proximal radius
nonarticular portion of the radial head is a ~90 degree arc from radial styloid to Lister's
tubercle (safe zone for hardware placement)
Ligaments
o lateral collateral ligament complex
lateral ulnar collateral ligament (LUCL)
primary stabilizer to varus and external rotation stress
deficiency results in posterolateral rotatory instability
radial collateral ligament (RCL)
accessory lateral collateral ligament
annular ligament
stabilizes proximal radioulnar joint
o medial (ulnar) collateral ligament (MCL)
three bundles
anterior bundle
primary stabilizer to valgus stress
(radial head is second)
posterior bundle
transverse bundle
Biomechanics
o radial head confers two types of stability to the elbow
valgus stability
secondary restraint to valgus load at the elbow, important if MCL deficient
longitudinal stability
restraint to proximal migration of the radius
contributions from interosseous membrane and DRUJ
load-sharing from wrist to radiocapitellar joint, dependant on radiocapitellar surface area
loss of longitudinal stability occurs when
radial head fracture + DRUJ injury + interosseous membrane disruption (Essex-
Lopresti)
radial head must be fixed or replaced to restore stability, preventing proximal
migration of the radius and ulnocarpal impaction
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Classification
Mason Classification (Modified by Hotchkiss and Broberg-Morrey)
Nondisplaced or minimally displaced (<2mm), no mechanical block to
Type I
rotation
Displaced >2mm or angulated, possible mechanical block to forearm
Type II
rotation
Type III Comminuted and displaced, mechanical block to motion
Type IV Radial head fracture with associated elbow dislocation
Presentation
Symptoms
o pain and tenderness along lateral aspect of elbow
o limited elbow or forearm motion, particularly supination/pronation
Physical exam
o range of motion
evaluate for mechanical blocks to elbow motion
flexion/extension and pronation/supination
aspiration of joint hematoma and injection of local anesthesia aids in evaluation of
mechanical block
o stability
elbow
lateral pivot shift test (tests LUCL)
valgus stress test (tests MCL)
DRUJ
palpate wrist for tenderness
translation in sagittal plane > 50% compare to contralateral side is abnormal
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may be difficult to determine on exam, can get dynamic CT scan in neutral, pronation
and supination for subtle injury
interosseous membrane
palpate along interosseous membrane for tenderness
radius pull test
>3mm translation concerning for longitudinal forearm instability (Essex-Lopresti)
Imaging
Radiographs
o recommended views
AP and lateral elbow
check for fat pad sign indicating occult minimally displaced fracture
o additional views
radiocapitellar view (Greenspan view)
oblique lateral view of elbow
beam angled 45 degrees cephalad
allows visualization of the radial head without coronoid overlap
helps detect subtle fractures of the radial head
CT
o further delineate fragments in comminuted fractures
o identify associated injuries in complex fracture dislocations
III:21 The radiocapitellar (Greenspan) view is obtained by aiming the beam 45 degree cephalad,
lessening the overlap between the proximal radius and olecranon, making subtle radial head fractures easier to identify
Treatment
Nonoperative
o short period of immobilization followed by early ROM
indications
isolated minimally displaced fractures with no mechanical blocks (Mason Type I)
outcomes
elbow stiffness with prolonged immobilization
good results in 85% to 95% of patients
Operative
o ORIF
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indications
Mason Type II with mechanical block
Mason Type III where ORIF feasible
presence of other complex ipsilateral elbow injuries
outcomes
# fragments
ORIF shown to have worse outcome with 3 or more fragments compared to ORIF
with < 3 fragments
isolated vs. complex
ORIF isolated radial head fractures versus complex radial head fractures (other
associated fracture/dislocation) show no significant difference in outcomes at 4 years
isolated fractures trended towards better Patient-Rated Elbow Evaluation score, lower
complication rate and lower rate of secondary capsular release
o fragment excision (partial excision)
indications
fragments less than 25% of the surface area of the radial head or 25%-33% of capitellar
surface area
outcomes : even small fragment excision may lead to instability
o radial head arthroplasty
indications
comminuted fractures (Mason Type III) with 3 or more fragments where ORIF not
feasible and involves greater than 25% of the radial head
elbow fracture-dislocations or Essex Lopresti lesions
radial head excision will exacerbate elbow/wrist instability and may result in proximal
radial migration and ulnocarpal impingement
outcomes
radial head fractures requiring replacement have shown good clinical outcomes with
metallic implants
compared to ORIF for fracture-dislocations and Mason Type III fractures, arthroplasty
results in greater stability, lower complication rate and higher patient satisfaction
o radial head resection
indications
low demand, sedentary patients
in a delayed setting for continued pain of an isolated radial head fracture
contraindications
presence of destabilizing injuries
forearm interosseous ligament injury (>3mm translation with radius pull test)
coronoid fracture
MCL deficiency
Techniques
Approaches to Radial Head
o overview
PIN crosses the proximal radius from anterior to posterior within the supinator muscle 4cm
distal to radial head
in both Kocher and Kaplan approaches, the forearm should be pronated to protect PIN
pronation pulls the nerve anterior and away from the surgical field
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o Kocher approach
interval
between ECU (PIN) and anconeus (radial n.)
key steps
incise posterior fibers of the supinator
incise capsule in mid-radiocapitellar plane
anterior to crista supinatoris to avoid damaging LUCL
pros
less risk of PIN injury than Kaplan approach (more posterior)
cons
risk of destabilizing elbow if capsule incision is too posterior and LUCL is
violated, which lies below the equator of the capitellum
o Kaplan approach
interval
between EDC (PIN) and ECRB (radial n.)
key steps
incise mid-fibers of supinator
incise capsule anterior to mid-radiopatellar plane (have access)
pros
less risk of disrupting LUCL and destabilizing elbow than Kocher approach (more
anterior)
better visualization of the coronoid
cons
greater risk of PIN and radial nerve injury
The Kaplan approach uses the Pronation of the forearm pulls the PIN
more anterior interval between anteromedially and away from the lateral surgical
ECRB and EDC. The Kocher field.
approach uses the more
posterior interval between ECU
and anconeus.
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ORIF
o approach
Kocher or Kaplan approach
o plates
fracture involved head and neck
posterolateral plate placement
safe zone (nonarticular area) consists of 90-110 degree arc from radial styloid to Lister's
tubercle, with arm in neutral rotation to avoid impingement of ulna with forearm rotation
bicipital tuberosity is the distal limit of plate placement
anything distal to that will endanger PIN
countersink implants on articular surface
o screws
headless compression screws (Hebert) if placed in articular surface
better elbow range of motion and functional outcome scores at 1 year compared to plate
fixation
Radial head arthroplasty
o approach
Kocher or Kaplan approach
o technique
metal prostheses
loose stemmed prosthesis
that acts as a stiff spacer
bipolar prosthesis
that is cemented into the neck of the radius
silicon replacements are no longer used
III:22 Safe zone
indepedent risk factor for revision surgery
o complications
overstuffing of joint that leads to capitellar wear problems and malalignment instability
overstuffing of joint is best assessed under direct visualization
Radial head resection
o approach
Kocher or Kaplan approach
o complications after excision of the radial head include
muscle weakness
wrist pain
valgus elbow instability
heterotopic ossification
arthritis
proximal radial migration
decreased strength
cubitus valgus
Complications
Displacement of fracture
o occurs in less than 5% of fractures; serial radiographs do not change management
Posterior interosseous nerve injury (with operative management)
Loss of fixation
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Loss of forearm rotation
Elbow stiffness
o first-line management incluides supervised exercise therapy with static or dynamic progressive
elbow splinting over a 6 month period
Radiocapitellar joint arthritis
Infection
Heterotopic ossification
Hardware loosening
Complex regional pain syndrome
3. Coronoid Fractures
Introduction
Coronoid fractures are pathognomonic of an episode of elbow instability
o may be
isolated coronoid fracture : less common than previously thought
coronoid fracture + associated injuries
commonly occur with elbow dislocation
associated with recurrent instability after dislocation
Mechanism
o traumatic shear injury
typically occurs as distal humerus is driven against coronoid with an episode of severe varus
stress or posterior subluxation
not an avulsion injury as nothing inserts on tip
Pathoanatomy
o fractures at the coronoid base can amplify elbow instability given that
anterior bundle of the medial ulnar collateral ligament attaches to the sublime tubercle 18 mm
distal to tip
anterior capsule attaches 6 mm distal to the tip of the coronoid
Epidemiology
o incidence : 10-15% of elbow injuries
Associated conditions
o posteromedial rotatory instability
coronoid anteromedial facet fracture and LCL disruption III:23 anteromedial facet fracture
Anatomy
Coronoid osteology
o coronoid tip
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is an intraarticular structure
can be visualized during elbow arthroscopy
o medial facet
important for varus stability
provides insertion for the medial ulnar collateral ligament
Coronoid biomechanics
o coronoid functions as an anterior buttress of the olecranon greater sigmoid notch
important in preventing recurrent posterior subluxation
o primary resistor of elbow subluxation or dislocation
Classification
Regan and Morrey Classification
Type I coronoid process tip fracture
Type II fracture of 50% or less of height
Type III fracture of more than 50% of height
O'Driscoll Classification
Subdivides coronoid injuries based on location and number of coronoid
fragments
Recognizes anteromedial facet fractures caused by varus posteromedial rotatory
force
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Presentation
Symptoms
o elbow deformity & swelling
o elbow pain
o forearm or wrist pain may be a sign of associated injuries
Physical exam
o inspection & palpation
varus or valgus deformity
ecchymosis & swelling
diffuse tenderness
o range of motion & instability
document flexion-extension and pronation-supination
crepitus should be noted
varus/valgus instability stress test
challenging but important for an accurate diagnosis
o neurovascular exam
Imaging
Radiographs
o recommended views : AP and lateral elbow views I II:25 anteromedial facet
coronoid fracture ap and
o findings : interpretation may be difficult due to overlapping structures lateral radiographs
CT scan : useful for high grade injuries and comminuted fractures
Treatment
Nonoperative
o brief period of immobilization, followed by early range of motion
indications : Type I, II, and III that are minimally displaced with stable elbow
Operative
o ORIF with medial approach
indications
Type I, II, and III with persistent elbow instability
posteromedial rotatory instability
o ORIF with posterior approach
indications
olecranon fracture dislocation
terrible triad of elbow
o hinged external fixation
indications
large fragments
poor bone quality
difficult revision cases to help maintain stability
Techniques
ORIF with medial approach
o approach
III:26 ORIF with buttress
plate fixation and screws
medial exposure through an interval between two heads of FCU
exposure more anteriorly through a split in flexor pronator mass
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o technique
cerclage wire or No. 5 suture through ulna drill holes for Type I injuries
ORIF with retrograde cannulated screws or plate for Type II or III injuries
ORIF with buttress plate fixation or pins and lateral ligament repair for posteromedial
rotatory instability
o postoperative rehabilitation
depends on intraoperative exam following the procedure
thermoplastic resting splint
applied with elbow at 90° and forearm in neutral
restrict terminal 30° extension for 2-4 weeks
avoid shoulder abduction for 4-6 weeks
to prevent varus moment on arm
early active motion
dynamic muscle contraction may improve gapping of the ulnohumeral joint after surgical
repair
ORIF with posterior approach
o approach : posterior
o technique
mobilize olecranon fracture to access coronoid fracture for associated olecranon fracture-
dislocations
repair coronoid fragment first prior to reducing main ulnar fracture
olecranon ORIF with dorsal plate and screws
Complications
Recurrent elbow instability : especially medial-sided
Elbow stiffness
Posttraumatic arthritis
Heterotopic ossification
Early failure : associated with failure to recognize and repair underlying elbow instability
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Anatomy
Radial head
o forearm in neutral rotation, lateral portion of articular
margin devoid of cartilage
roughly between radial styloid and listers tubercle
o provides anterior and valgus buttress
Coronoid process
o provides an anterior and varus buttress
Medial collateral ligament
o anterior bundle, posterior bundle, and transverse
ligament components III:28Lateral collateral ligament
o anterior bundle most important to stability, restraint to
valgus and posteromedial rotatory instability
inserts on sublime tubercle (anteromedial facet of coronoid)
specifically inserts 18.4mm dorsal to tip of coronoid process
Lateral collateral ligament
o inserts on supinator crest distal to lesser sigmoid notch
o restraint to varus and posterolateral rotatory instability
o two components
lateral ulnar collateral ligament (most important for stability)
lateral radial collateral ligament : attaches to annular ligament
Presentation
Symptoms : patients complain of pain, clicking and locking with elbow
in extension
Physical exam
o varus instability
o may show valgus instability if injury to MCL
Imaging
Radiographs
o evaluate for concentricity of ulnohumeral and radiocapitellar joints
o line drawn through center of radial neck should intersect the center of the capitellum regardless
of radiographic projection
o evaluate lateral radiograph for coronoid fracture
CT
o better evaluation of coronoid fracture
o 3D imaging for determining fracture line propagation
Treatment
Nonoperative
o immobilize in 90 deg of flexion for 7-10 days
indications (rare)
ulnohumeral and radiocapitellar joints must be concentrically reduced
elbow should extend to at least 30 degrees before becoming unstable
CT must show insignificant radial head/neck fx, no block to motion
coronoid fx limited to tip
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technique
active motion initiated with resting splint at 90 degrees, avoiding terminal extension
static progressive extension splinting at night after 4-6 weeks
strengthening protocol after 6 weeks
Operative
o acute radial head stabilization, coronoid ORIF, and LCL reconstruction, MCL
reconstruction if needed
indications
terrible triad elbow injury that includes a unstable radial head fracture, a type III coronoid
fracture, and an associated elbow dislocation
Techniques
Acute radial head stabilization, coronoid ORIF, and LCL reconstruction, MCL reconstruction
if needed
o approach
posterior skin incision advantageous
allows access to both medial and lateral aspect of elbow
lower risk of injury to cutaneous nerves
more cosmetic
o technique
radial head ORIF vs. arthroplasty
radial head arthroplasty indicated for comminuted radial head fracture
use of modular prosthesis preferable
sizing based on fragments removed from elbow
implant should articulate 2mm distal to the tip of the coronoid process
radial head resection without replacement is NOT indicated in presence of Essex-
Lopresti lesion or in young active patient
it <25% head damaged or fragments not reconstructable and nonarticulating, can excise
fractured portion if elbow stable (rarely indicated)
radial head ORIF indicated if non comminuted with good bone stock and fracture
involves < 40% articular surface
1.5, 2.0, or 2.4mm countersunk screws
plating if necessary; 2.0 plates cause minimal loss of motion even when placed on
radial neck
coronoid ORIF
can be fixed through radial head defect laterally
fix with suture passed through 2 drill holes, or posterior to anterior lag screws if fragment
large
basal coronoid fxs (rare) fixed with anteromedial or medial plate on proximal ulna
LCL repair
usually avulsed from origin on lateral epicondyle
reattach with suture anchors or transosseous sutures
must be reattached at center of capitellar curvature on lateral epicondyle
if MCL is intact, LCL is repaired with forearm in pronation
if MCL injured, LCL is repaired with forearm in supination to avoid medial gapping due
to overtightening
repairs are performed with elbow at 90 degrees of flexion
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MCL repair
indicated if instability on exam after LCL and fracture fixation, especially with extension
beyond 30 degrees
instability after complete bone and soft tissue repair indicates need for hinged or static elbow
fixator application
postoperative
immobilize elbow in flexion with forearm pronation to provide stability against posterior
subluxation
if both MCL and LCL were repaired, splint in flexion and neutral rotation.
Complications
Instability : more common following type I or II coronoid fractures
Failure of internal fixation
o most common following repair of radial neck fractures
poor vascularity leading to osteonecrosis and nonunion
Posttraumatic stiffness
o very common
o initiate early ROM to prevent
Heterotopic ossification
o consider prophylaxis in pts with head injury or in setting of revision surgery
Posttraumatic arthritis : due to chondral damage at time of injury and/or residual instability
5. Olecranon Fractures
Introduction
Epidemiology
o bimodal distribution
high energy injuries in the young
low energy falls in the elderly
Pathophysiology
o mechanism
direct blow
usually results in comminuted fracture
indirect blow
fall onto outstretched upper extremity
usually results in transverse or oblique fracture
Anatomy
Osteology
o together with coronoid process, forms the greater sigmoid (semilunar) notch
o greater sigmoid notch articulates with trochlea
provides flexion-extension movement
adds to stability of elbow joint
Muscles
o triceps
inserts onto posterior, proximal ulna
blends with periosteum
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innervated by radial nerve (C7)
o anconeus
insertson lateral aspect of olecranon
innervate by radial nerve (C7)
Classification
Mayo Classification
Based on comminution, displacement, fracture-
dislocation
Colton Classification
Nondisplaced - Displacement does not increase with elbow flexion
Avulsion (displaced)
Oblique and Transverse (displaced)
Comminuted (displaced)
Fracture dislocation
Schatzker Classification
Type A Simple transverse fracture
Type B Transverse impacted fracture
Type C Oblique fracture
Type D Comminuted fracture
Type E More distal fracture, extra-articular
Type F Fracture-dislocation
AO Classification
Type A Extra-articular
Type B Intra-articular
Type C Intra-articular fractures of both the radial head and olecranon
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Colton Classification
Schatzker Classification
Type A Type B
Imaging
Radiographs
o recommended views
AP/lateral radiographs
true lateral essential for determination of fracture pattern
o additional views
radiocapitellar may be helpful for
radial head fracture
capitellar shear fracture
CT : may be useful for preoperative planning in comminuted fractures
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Treatment
Nonoperative
o immobilization
indications
nondisplaced fractures
displaced fracture is low demand, elderly individuals
technique
immobilization in 45-90 degrees of flexion initially
begin motion at 1 week
Operative
o tension band technique
indications
transverse fracture with no comminution
outcomes
excellent results with appropriate indications
o intramedullary fixation
indications
transverse fracture with no comminution (same as tension band technique)
o plate and screw fixation
indications
comminuted fractures
Monteggia fractures
fracture-dislocations
oblique fractures that extend distal to coronoid
o excision and triceps advancement
indications
elderly patients with osteoporotic bone
fracture must involve <50% of joint surface
nonunions
outcomes
salvage procedure that leads to decreased extension strength
may result in instability if ligamentous injury is not diagnosed before operation
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Elbow
Surgical Techniques
Tension band technique: technique
converts distraction force of triceps into a compressive force
engaging anterior cortex of ulna with Kirschner wires may prevent wire migration
avoid overpenetration of wires through anterior cortex
may injury anterior interosseous nerve (AIN)
may lead to decreased forearm rotation
use 18-gauge wire in figure-of-eight fashion through drill holes in ulna
o cons
high % of second surgeries for hardware removal (40-80%)
does not provide axial stability in comminuted fractures
Intramedullary fixation: technique
can be combined with tension banding
intramedullary screw must engage distal intramedullary canal
Plate and screw fixation
o technique
place plate on dorsal (tension) side
oblique fractures benefit from lag screws in addition to plate fixation
one-third tubular plates may not provide sufficient strength in comminuted fractures
may advance distal triceps tendon over plate to avoid hardware prominence
o pros : more stable than tension band technique
o cons : 20% need second surgery for plate removal
Excision and triceps advancement
o technique : triceps tendon reattached with nonabsorbable sutures passed through drill holes in
proximal ulna
Complications
Symptomatic hardware : most frequent reported complication
Stiffness : occurs in ~50% of patients , usually doesn't alter functional capabilities
Heterotopic ossification : more common with associated head injury
Posttraumatic arthritis
Nonunion : rare
Ulnar nerve symptoms
Anterior interosseous nerve injury
Loss of extension strength
6. Capitellum Fractures
Introduction
Coronal fracture of the distal humerus at capitellum
Epidemiology : 1% of elbow fractures
Mechanism of injury : fall on outstretched hand
Prognosis
o most patients will gain functional range of motion but have residual stiffness
o surgical treatment results are generally favorable
reoperation rates as high as 48%
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Classification
Bryan and Morrey Classification (with McKee modification)
Type I Large osseous piece of the capitellum involved
Can involve trochlea
Type II Kocher-Lorenz fracture
Shear fracture of articular cartilage
Articular cartilage separation with very little subchondral bone attached
Type III Broberg-Morrey fracture
Severely comminuted
Multifragmentary
Type IV McKee modification
Coronal shear fracture that includes the capitellum and trochlea
Type I Type II
Type III
Presentation
History : fall on outstretched arm
Symptoms : elbow pain, swelling
Physical exam : may have mechanical block to flexion and extension
Imaging
Radiographs : recommended
o AP and lateral of the elbow
best demonstrated on lateral radiograph
CT : delineates fracture anatomy and classification
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Treatment
Nonoperative
o posterior splint immobilization for < 3 weeks
indications : nondisplaced Type I and Type II fractures (<2 mm displacement)
Operative
o open reduction and internal fixation
indications
displaced Type I fractures (>2mm)
Type IV fractures
o fragment excision
indications
displaced (>2mm) Type II fractures
displaced (>2mm) Type III fractures
o total elbow arthroplasty
indications : unreconstructable capitellar fractures in elderly patients with associated medial
column instability
Technique
ORIF
o approach
lateral approach recommended for Type IV fx
posterior approach can be used if associated with other elbow injuries
o screw fixation
headless screw fixation
minifragment screw using posterior to anterior fixation
counter sink screw using anterior to posterior fixation
o avoid disruption of the blood supply that comes from the posterolateral aspect of the elbow
Complications
Elbow contracture (most common)
Nonunion (1-11% with ORIF)
Ulnar nerve injury
Heterotopic ossification (4% with ORIF)
AVN of capitellum
Nonunion of olecranon osteotomy
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D. Forearm
1. Monteggia Fractures
Introduction
Injury defined as proximal 1/3 ulnar fracture with associated radial head dislocation/instability
Epidemiology
o rare in adults
o more common in children with peak incidence between 4 and 10 years of age
different treatment protocol for children
Associated injuries
o may be part of complex injury pattern including
olecranon fracture-dislocation
radial head fx
coronoid fx
LCL injury
terrible triad of elbow
Prognosis : if diagnosis is delayed greater than 2-3 weeks complication rates increase significantly
Anatomy
Ligament : annular ligament
Classification
Bado Classification
Type I Fracture of the proximal or middle third of the ulna with anterior
60% dislocation of the radial head (most common in children and young
adults)
Type II 15% Fracture of the proximal or middle third of the ulna with posterior
dislocation of the radial head (70 to 80% of adult Monteggia fractures)
Type III Fracture of the ulnar metaphysis (distal to coronoid process) with lateral
20%
dislocation of the radial head
Type IV Fracture of the proximal or middle third of the ulna and radius with
5%
dislocation of the radial head in any direction
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Presentation
Symptoms
o pain and swelling at elbow joint
III:29 Jupiter Classification of Type II Monteggia
Physical exam Fracture-Dislocations
o inspection
may or may not be obvious dislocation at radiocapitellar joint
should evaluate skin integrity
o ROM & instability : may be loss of ROM at elbow due to dislocation
o neurovascular exam
PIN neuropathy
radial deviation of hand with wrist extension
weakness of thumb extension
weakness of MCP extension
most likely nerve injury
Imaging
Radiographs
o recommended view
AP and Lateral of elbow, wrist, and forearm
CT scan : helpful in fractures involving coronoid, olecranon, and radial head
Treatment
Nonoperative
o closed reduction
indications
more common and successful in children
must ensure stabilty and anatomic alignment of ulna fracture
technique : cast in supination for Bado I and III
Operative
o ORIF of ulna shaft fracture
indications
acute fractures which are open or unstable (long oblique)
comminuted fractures
most Monteggia fractures in adults are treated surgically
o ORIF of ulna shaft fracture, open reduction of radial head
indications
failure to reduce radial head with ORIF of ulnar shaft only
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ensure ulnar reduction is correct
complex injury pattern
o IM Nailing of ulna
indications : transverse or short oblique fracture
Techniques
ORIF of ulnar shaft fracture
o approach
lateral decubitus position with arm over padded support
midline posterior incision placed lateral to tip of olecranon
develop interval between flexor carpi ulnaris and anconeus along ulnar border proximally,
and interval between FCU and ECU distally
o techniques
with proper alignment of ulna radial head usually reduces and open reduction of radial head is
rarely needed
failure to align ulna will lead to chronic dislocation of radial head
ORIF of radial head
o approach : posterolateral (Kocher) approach
o technique
annular ligament often found interposed in radiohumeral joint preventing anatomic reduction
after ulnar ORIF
treatment based on involved components (radial head, coronoid, LCL)
Complications
PIN neuropathy
o up to 10% in acute injuries
o treatment
observation for 2-3 months
spontaneously resolves in most cases
if no improvement obtain nerve conduction studies
Malunion with radial head dislocation
o usually caused by failure to obtain anatomic alignment of ulna
o treatment
ulnar osteotomy and open reduction of the radial head
Collected By : Dr AbdulRahman
AbdulNasser
drxabdulrahman@gmail.com
In June 2017
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Forearm
Anatomy
Osteology
o axis of rotation of forearm runs through radial head (proximal) and ulna fovea (distal)
distal radius effectively rotates around the distal ulna in pronosupination
Interosseous membrane (IOM)
o occupies the space between the radius and ulna
o comprised of 5 ligaments
central band is key portion of IOM to be reconstructed
accessory band
distal oblique bundle
proximal oblique cord
dorsal oblique accessory cord
Classification
Descriptive
o closed versus open
o location
o comminuted, segmental, multifragmented
o displacement
o angulation
o rotational alignment III:30 Interosseous membrane
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OTA classification
o radial and ulna diaphyseal fractures
Type A : simple fracture of ulna (A1), radius (A2), or both bones (A3)
Type B : wedge fracture of ulna (B1), radius (B2), or both bones (B3)
Type C : complex fractures
Presentation
Symptoms
o gross deformity, pain, swelling
o loss of forearm and hand function
Physical exam
o inspection
open injuries
check for tense forearm compartments
o neurovascular exam
assess radial and ulnar pulses
document median, radial, and ulnar nerve function
o pain with passive stretch of digits
alert to impending or present compartment syndrome
Imaging
Radiographs
o recommended views
Treatment
Nonoperative
o functional fx brace with good interosseous mold
indications
isolated nondisplaced or distal 2/3 ulna shaft fx (nightstick fx) with
< 50% displacement and
< 10° of angulation
outcomes
union rates > 96%
acceptable to fix surgically due to long time to union
Operative
o ORIF without bone grafting
indications
displaced distal 2/3 isolated ulna fxs
proximal 1/3 isolated ulna fxs
all radial shaft fxs (even if nondisplaced)
both bone fxs
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Gustillo I, II, and IIIa open fractures may be treated with primary ORIF
outcomes
most important variable in functional outcome is to restore the radial bow
o ORIF with bone grafting
indications
cancellous autograft is indicated in radial and ulnar fractures with bone loss
bone loss that is segmental or associated with open injury
nonunions of the forearm
o external fixation
indications
Gustillo IIIb and IIIc open fractures
o IM nailing
indications
poor soft-tissue integrity
not preferred due to lack of rotational and axial stability and difficulty maintaining radial
bow (higher nonunion rate)
Techniques
ORIF
o approach
usually performed through separate approaches due to risk
of synostosis
radius
volar (Henry) approach to radius
best for distal 1/3 and middle 1/3 radial fx
dorsal (Thompson) approach to radius
best for middle and proximal 1/3 radial fx
ulna
subcutaneous approach to ulna shaft
o technique
3.5 mm DCP plate (AO technique) is standard
longer plates are preferred due to high torsional stress in forearm
locked plates are increasingly indicated over conventional plates in osteoporotic bone and
in bridging comminuted fractures
bone grafting
vascularized fibula grafts can be used for large defects and have a lower rate of infection
o postoperative care
early ROM unless there is an injury to proximal or distal joint
should be managed with a period of non-weight bearing due to risk of secondary
displacement of the fracture
Complications
Synostosis
o uncommon with an incidence of 3 to 9%
o associated with ORIF using a single incision approach
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o heterotopic bone excision can be performed with low recurrence risk as early as 4-6 months post-
injury when prophylactic radiation therapy and/or indomethacin are used postoperatively
Infection
o 3% incidence with ORIF
Compartment syndrome
o increased risk with
high energy crush injury
open fxs
low velocity GSWs
vascular injuries
coagulopathies (DIC)
Nonunion
o commonly result from technical error or use of IM fixation
o atrophic nonunions can be treated with 3.5 mm plates and autogenous cancellous bone grafting
Malunion
o direct correlation between restoration of radial bow and functional outcome
Neurovascular injury
o uncommon except
PIN injury with Monteggia fxs and Henry (volar) approach to middle and upper third radial
diaphysis
Type III open fxs
o observe for three months to see if nerve function returns
explore if no return of function after 3 months
Refracture
o increased risk with
removing plate too early
large plates (4.5 mm)
comminuted fx
persistent radiographic lucency
o do not remove plates before 15 mos.
o wear functional forearm brace for 6 weeks and protect activity for 3 mos. after plate removal
3. Radioulnar Synostosis
Introduction
Bony bridge which develops between radius and ulna secondary to a specific event
o must differentiate from congenital radioulnar synostosis
Epidemiology
o incidence : 3% to 9%
o risk factors
trauma related
Monteggia fracture
both bone forearm fractures at the same level
open fracture,
significant soft-tissue lesion
comminuted fracture
high energy fracture
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associated head trauma
bone fragments on the interosseous membrane
treatment related
use of one incision for both radius and ulna
delayed surgery > 2 weeks
screws that penetrate interosseous membrane
bone grafting into interosseous membrane
prolonged immobilization
Anatomy
Forearm anatomy
Presentation
History : previous trauma or surgery in forearm
Symptoms
o pain with incomplete synostosis
o no pain with complete synostosis
Physical exam : pronation and supination blocked both actively and passively
Imaging
Radiographs
o recommended views : AP and lateral of forearm, elbow, and wrist
o findings : bony bridge between radius and ulna
Treatment
Operative
o surgical resection of synostosis, irradiation, and indomethacin
indications
mature post-traumatic synostosis that impairs function
excision indicated at 4-6 months
timing is controversial
excision too early can lead to recurrence
excision too late can lead to surrounding joint contractures
results : results of resection are poor except for midshaft synostosis
o proximal radial excision
indications
reserved for patients who have a proximal radioulnar synostosis that is too extensive to
allow a safe resection, involves the articular surface, and is associated with an
anatomic deformity.
results
can provide forearm rotation
associated with radioulnar and/or elbow instability
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Classification
Fernandez: based on mechanism of injury
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Fernandez classification:
This is a mechanism-based classification system.
Type I: Metaphyseal bending fracture with the inherent problems of loss of palmar tilt and
radial shortening relative to the ulna (DRUJ injury)
Type II: Shearing fracture requiring reduction and often buttressing of the articular segment
Type III: Compression of the articular surface without the characteristic fragmentation; also the
potential for significant interosseous ligament injury
Type IV: Avulsion fracture or radiocarpal fracture dislocation
Type V: Combined injury with significant soft tissue involvement owing to high-energy injury
From Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition
Frykman: based on joint involvement (radiocarpal and/or radioulnar) +/- ulnar styloid fx
Frykman Classification
Distal Ulna Fracture
Distal Radius Fracture
Absent present
Extraarticular I II
Intraarticular involving radiocarpal joint III IV
Intraarticular involving distal radioulnar joint
V VI
(DRUJ)
Intraarticular involving radiocarpal and DRUJ VII VIII
From Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition
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Eponyms: see table for list of commonly used eponyms
Eponyms
Die-punch fxs A depressed fracture of the lunate fossa of the articular surface of the distal radius
Barton's fx Fx dislocation of radiocarpal joint with intra-articular fx involving the volar or dorsal lip
(volar Barton or dorsal Barton fx)
Chauffer's fx Radial styloid fx
Colles' fx Low energy, dorsally displaced, extra-articular fx
Smith's fx Low energy, volar displaced, extra-articular fx
AP Radial height 13 mm
<5 mm shortening
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Treatment
Successful outcomes correlate with
o accuracy of articular reduction
o restoration of anatomic relationships
o early efforts to regain motion of wrist and fingers
Nonoperative
o closed reduction and cast immobilization
indications
extra-articular
<5mm radial shortening
dorsal angulation <5° or within 20° of contralateral distal radius
technique (see below)
Operative
o surgical fixation (CRPP, External Fixation, ORIF)
indications: radiographic findings indicating instability (pre-reduction radiographs best
predictor of stability)
displaced intra-articular fx
volar or dorsal comminution
articular margins fxs
severe osteoporosis
dorsal angulation >5° or >20° of contralateral distal radius
>5mm radial shortening
comminuted and displaced extra-articular fxs (Smith's fx)
progressive loss of volar tilt and loss of radial length following closed reduction and
casting
associated ulnar styloid fractures do not require fixation
Closed reduction and cast immobilization
Indications : most extra-articular fxs
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Technique
o rehabilitation
no significant benefit of physical therapy over home exercises for simple distal radius
fractures treated with cast immobilization
Outcomes : repeat closed reductions have 50% less than satisfactory results
Complications
o acute carpal tunnel syndrome : (see complications below)
o EPL rupture : (see complications below)
Percutaneous Pinning
Indications
o can maintain sagittal length/alignment in extra-articular fxs with stable volar cortex
o cannot maintain length/alignment when unstable or comminuted volar cortex
Techniques
o Kapandji intrafocal technique
o Rayhack technique with arthroscopically assisted reduction
Outcomes : 82-90% good results if used appropriately
External Fixation
Indications
o alone cannot reliably restore 10 degree palmar tilt
therefore usually combined with percutaneous pinning technique or plate fixation
Technical considerations
o relies on ligamentotaxis to maintain reduction
o place radial shaft pins under direct visualization to avoid injury to superficial radial nerve
o nonspanning ex-fix can be useful if large articular fragment
o avoid overdistraction (carpal distraction < 5mm in neutral position) and excessive volar flexion
and ulnar deviation
o limit duration to 8 weeks and perform aggressive OT to maintain digital ROM
Outcomes : important adjunct with 80-90% good/excellent results
Complications
o malunion/nonunion
o stiffness and decreased grip strength
o pin complications (infections, fx through pin site, skin difficulties)
pin site care comprising daily showers and dry dressings recommended
o neurologic (iatrogenic injury to radial sensory nerve, median neuropathy, RSD)
ORIF
Indications
o significant articular displacement (>2mm)
o dorsal and volar Barton fxs
o volar comminution
o metaphyseal-diaphyseal extension
o associated distal ulnar shaft fxs
o die-punch fxs
Technique
o volar plating
volar plating preferred over dorsal plating
volar plating associated with irritation of both flexor and extensor tendons
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rupture of FPL is most common with volar plates
associated with plate placement distal to watershed area, the most volar margin of the
radius closest to the flexor tendons
new volar locking plates offer improved support to subchondral bone
o dorsal plating
dorsal plating historically associated with extensor tendon irritation and rupture
dorsal approach indicated for displaced intra-articular distal radius fracture with dorsal
comminution
o other technical considerations
can combine with external fixation and PCP
bone grafting if complex and comminuted
study showed improved results with arthroscopically assisted reduction
volar lunate facet fragments may require fragment specific fixation to prevent early post-
operative failure
Complications
Median nerve neuropathy (CTS)
o most frequent neurologic complication
o 1-12% in low energy fxs and 30% in high energy fxs
o prevent by avoiding immobilization in excessive wrist flexion and ulnar deviation (Cotton-Loder
Position)
o treat with acute carpal tunnel release for:
progressive paresthesias, weakness in thumb opposition
paresthesias do not respond to reduction and last > 24-48 hours
Ulnar nerve neuropathy : seen with DRUJ injuries
EPL rupture
o nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the extensor
pollicis longus tendon
extensor mechanism is felt to impinge on the tendon following a nondisplaced fracture and
causes either a mechanical attrition of the tendon or a local area of ischemia in the tendon.
o treat with transfer of extensor indicis proprius to EPL
Radiocarpal arthrosis (2-30%)
o 90% young adults will develop symptomatic arthrosis if articular stepoff > 1-2 mm
o may be nonsymptomatic
Malunion and Nonunion
o Intra-articular malunion : treat with revision at > 6 weeks
o Extra-articular angulation malunion
treat with opening wedge osteotomy with ORIF and bone grafting
o Radial shortening malunion
radial shortening associated with greatest loss of wrist function and degenerative changes in
extra-articular fxs
treat with ulnar shortening
ECU or EDM entrapment : entrapment in DRUJ injury
Compartment syndrome
RSD/CRPS
o AAOS 2010 clinical practice guidelines recommend vitamin C supplementation to prevent
incidence of RSD postoperatively
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Forearm
Anatomy
DRUJ
o arthrology
articulation occurs between the ulnar head and sigmoid notch (a shallow concavity found
along ulnar border of distal radius)
most stable in supination
o primary stabilizers
volar and dorsal radioulnar ligaments
TFCC
TFCC attaches to the fovea at the base of the ulnar styloid
components include
central articular disc
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meniscal homologue
volar
and dorsal radioulnar ligaments
ulnolunate and ulnotriquetral ligament origins
floor of the ECU tendon sheath
o biomechanics : joint motion includes both rotation and translation
Presentation
Symptoms
o pain and instability with acute DRUJ dislocation
o dorsal wrist pain and limited pronosupination with post-traumatic arthritis
Physical exam
o post-traumatic arthritis
snapping and crepitus
proximal rotation of the forearm with compression of the ulna against the radius elicits pain
decreased grip strength
Imaging
Radiographs
o AP shows widening of the DRUJ
o lateral shows dorsal displacement : instability of the DRUJ is present when the ulnar head is
subluxed from the sigmoid notch by its full width with the arm in neutral rotation
Dynamic CT
o useful in the diagnosis of subtle chronic DRUJ instability
o sequential CT scans are performed with the forearm in neutral and full supination and pronation
o >50% translation compared to the contralateral side is abnormal
MRI : useful in the identification of TFCC injuries
Treatment
Nonoperative
o closed reduction, immobilization
indications : DRUJ instability resulting from purely ligamentous
injury
techniques
closed reduction and immobilization in a position of stability III:31 MRI showig TFCC tear
for 4 weeks
dorsal instability is stable with the forearm in supination
volar instability is stable in pronation
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Forearm
outcomes : interposition of ECU may impede closed reduction
Operative
o DRUJ pinning, radioulnar ligament repair
indications : highly unstable DRUJ
techniques : pinning across joint with 0.062-inch K-wires
TFCC Tears
Mechanism of injury
o wrist extension, forearm pronation
in pronation, volar ligaments prevent dorsal subluxation
in supination, dorsal ligaments prevent volar subluxation
Classification
o type I - traumatic
o type II - degenerative (ulnocarpal impaction)
IIA - TFCC thinning III:32 Darrach procedure
IIB - IIA + lunate and/or ulnar chondromalacia
IIC - IIB + TFCC perforation
IID - IIC + LT ligament disruption
IIE - IID + ulnocarpal and DRUJ arthritis
Treatment
o nonoperative
immobilization, NSAIDS
indications : all acute traumatic TFCC tears
o operative
arthroscopic vs. open debridement and/or repair
indications
failure of nonoperative management
III:33Sauve-Kapandji procedure
persistent symptoms
techniques
type I injuries
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arthroscopic vs. open debridement and/or repair
type II injuries
TFCC pathology treated with arthroscopic or open debridement
ulnocarpal impaction treated with ulnar shortening osteotomy (in the absence of
DRUJ arthrosis) or wafer resection of the ulnar head
Ulnar Impaction Syndrome
Radial shortening leads to positive ulnar variance and altered mechanics
Sequelae includes
o lunate chondromalacia
o degenerative TFCC tears
Operative treatment
o TFCC debridement
o radial osteotomy
o ulnar shortening
o distal ulnar resection (Wafer procedure)
preserve ulnar attachment of TFCC
Essex-Lopresti Injuries
Radial head fracture with an interosseous membrane injury extending
to DRUJ
o unstable relationship between ulna and radius
o leads to proximal migration of the radius
o results in secondary DRUJ pathology and ulnocarpal abutment
Treatment
o treat bony pathology (radial head or shaft)
o pin DRUJ for 6 weeks in neutral to facilitate ligamentous healing
o if pinning fails (or the initial injury is missed) radial head
replacement may be required
Galeazzi Fractures
Distal one-third fracture of the radius and a DRUJ injury
ECU entrapment may cause DRUJ to be irreducible
Treatment
o nonoperative
splint in supination
indications : rarely indicated for stable injuries
o operative
radial ORIF and DRUJ pinning
indications : often required to achieve a stable reduction
6. Galeazzi Fractures
Introduction
Definition
o distal 1/3 radius shaft fx AND
o associated distal radioulnar joint (DRUJ) injury
Incidence of DRUJ instability
o if radial fracture is <7.5 cm from articular surface : unstable in 55%
o if radial fracture is >7.5 cm from articular surface : unstable in 6%
Mechanism
o direct wrist trauma : typically dorsolateral aspect
o fall onto outstretched hand with forearm in pronation
Anatomy
DRUJ
o sigmoid notch
found along ulnar border of distal radius
is a shallow concavity for the articulating ulnar head
o volar and dorsal radioulnar ligaments
function as the primary stabilizers of the DRUJ
o most stable in supination
Classification
OTA classification of radius/ulna
o included under subgroups and qualifications
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Presentation
Symptoms : pain, swelling, deformity
Physical exam
o point tenderness over fracture site
o ROM : test forearm supination and pronation for instability
o DRUJ stress : causes wrist or midline forearm pain
Imaging
Radiographs
o recommended views
AP and lateral views of forearm, elbow, and wrist
o findings : signs of DRUJ injury
ulnar styloid fx
widening of joint on AP view
dorsal or volar displacement on lateral view
radial shortening (≥5mm)
Treatment
Operative
o ORIF of radius with reduction and stabilization of DRUJ
indications
all cases, as anatomic reduction of DRUJ is required
acute operative treatment far superior to late reconstruction
Surgical Techniques
ORIF of radius
o approach : volar (Henry) approach to radius
o plate fixation
perform anatomic plate fixation of radial shaft
radial bow must be restored/maintained
Reduction & stabilization of DRUJ
o approach : dorsal capsulotomy
o reduction technique
immobilization in supination (6 weeks)
indicated if DRUJ stable following ORIF of radius
percutaneous pin fixation
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Forearm
indicated if DRUJ reducible but unstable following ORIF of radius
cross-pin ulna to radius : leave pins in place for 4-6 weeks
open surgical reduction
indicated if reduction is blocked
suspect interposition of ECU tendon
open reduction internal fixation
indicated if a large ulnar styloid fragment exists
fix styloid and immobilize in supination
Complications
Compartment syndrome
o increased risk with
high energy crush injury
open fractures
vascular injuries or coagulopathies
o diagnosis
pain with passive stretch is most sensitive
Neurovascular injury : uncommon except type III open fractures
Refracture
o usually occurs following plate removal
o increased risk with
removing plate too early
large plates (4.5mm)
comminuted fractures
persistent radiographic lucency
o prevention
do not remove plates before 18 months after insertion
amount of time needed for complete primary bone healing
Nonunion
Malunion
DRUJ subluxation : displaced by gravity, pronator quadratus, or brachioradialis
Collected By : Dr AbdulRahman
AbdulNasser
drxabdulrahman@gmail.com
In June 2017
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OrthoBullets2017 Hand Trauma | Forearm
ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
A. Tendon Injuries
Anatomy
Muscles
o flexor digitorum profundus (FDP)
functions as a flexor of the DIP joint
assists with PIP and MCP flexion
shares a common muscle belly in the forearm
o flexor digitorum superficialis (FDS)
functions as a flexor of the PIP joint
assists with MCP flexion
individual muscle bellies exist in the forearm
FDS to the small finger is absent in 25% of people
o flexor pollicis longus (FPL)
located within the carpal tunnel as the most radial structure
o flexor carpi radialis (FCR) IV:1 Campers chiasm
primary wrist flexor
inserts on the base of the second metacarpal
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
Classification
Presentation
Symptoms
o loss of active flexion strength or motion of the involved digit(s)
Physical exam
o inspection
observe resting posture of the hand and assess the digital cascade
evidence of malalignment or malrotation may indicate an underlying fracture
assess skin integrity to help localize potential sites of tendon injury
look for evidence of traumatic arthrotomy
o range of motion
passive wrist flexion and extension allows for assessment of the tenodesis effect
normally wrist extension causes passive flexion of the digits at the MCP, PIP, and DIP
joints
maintenance of extension at the PIP or DIP joints with wrist extension indicates flexor
tendon discontinuity
active PIP and DIP flexion is tested in isolation for each digit
o neurovascular exam
important given the close proximity of flexor tendons to the digital neurovascular bundles
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Treatment
Nonoperative
o wound care and early range of motion
indications
partial lacerations < 60% of tendon width
outcomes
may be associated with gap formation or triggering
Operative
o flexor tendon repair and controlled mobilization
indications
lacerations > 60% of tendon width
outcomes
depends on zone of injury
o flexor tendon reconstruction and intensive postoperative rehabilitation
indications
failed primary repair
chronic untreated injuries
outcomes
subsequent tenolysis is required more than 50% of the time
o FDS4 transfer to thumb
single stage procedure
indication
chronic FPL rupture
Surgical Technique
Flexor Tendon Repair of Complete Lacerations
o approach
incisions should always cross flexion creases transversely or obliquely to avoid contractures
(never longitudinal)
o timing of repair
perform repair within three weeks of injury (2 weeks ideal)
waiting longer leads to difficulty due to tendon retraction
o technique
# of suture strands that cross the repair site is more important than the number of grasping
loops
linear relationship between strength of repair and # of sutures crossing repair
4-6 strands provide adequate strength for early active motion
high-caliber suture material increases strength and stiffness and decreases gap formation
locking-loops decrease gap formation
ideal suture purchase is 10mm from cut edge
core sutures placed dorsally are stronger
meticulous atraumatic tendon handling minimizes adhesions
circumferential epitendinous suture
improves tendon gliding
improves strength of repair (adds 20% to tensile strength)
allows for less gap formation (first step in repair failure)
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
simple running suture is recommended
sheath repair is controversial
theoretically improves tendon nutrition through synovial pathway
clinical studies show no difference with or without sheath repair
most surgeons will repair if it is easy to do
pulley management
critical to preserve A2 and A4 pulleys in digits and oblique pulley in thumb
FDS repair
in zone 2 injuries, repair of one slip alone improves gliding when compared to repair of
both slips
o outcomes
repair failure
tendon repairs are weakest between postoperative day 6 and 12
repair usually fails at suture knots
Flexor Tendon Repair of Partial Lacerations
o indications
>75% laceration
≥50-60% laceration with triggering
epitendinous suture at the laceration site is sufficient
no benefit of adding core suture
Wide-Awake Flexor Tendon Repair
o performed under tumescent local anesthesia using lidocaine with epinephrine
dosing
usually epinephrine 1:100,000 and 7mg/kg lidocaine
from 1:400,000 to 1:1000 is safe
if <50cc is needed
1% lidocaine with 1:100,000 epi for a 70kg person
if 50-100cc is needed
dilute with saline (50:50) to get 0.5% lidocaine, 1:200,000 epi
if 100-200cc is needed for large fields (tendon transfer, spaghetti wrist)
dilute with 150cc saline to get 0.25% lidocaine and 1:400,000 epi
for longer surgery >2h
add 10cc of 0.5% bupivacaine with 1:200,000 epi
location
proximal and middle phalanges, use 2ml
distal phalanx, use 1ml
palm, use 10-15ml
o no tourniquet, no sedation
o 4 advantages
allows intraoperative assessment for repair gaps by getting awake patient to actively flex digit
reduces need for postop tenolysis by allowing intraoperative assessment of whether repair
will fit through pulleys
allows on-the-spot debulking of bunched repairs
allows division of A4 pulley and venting (partial division) of A2 pulleys
allows repair of tendons inside tendon sheaths as patients can demonstrate that the inside of
the sheath has not been inadvertently caught
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facilitates postop early active motion
immobilize for 3 days
begin active midrange motion after day 3 (form a partial fist with 45 degree flexion at
MP, PIP and DIP joints, or "half a fist 45/45/45 regime")
Reconstruction Technique
o requirements
supple skin
sensate digit
adequate vascularity
full passive range of motion of adjacent joints
o techniques of reconstruction involving silicone rods
Hunter-Salisbury two-stage procedure
Stage I - silicone rod is placed to create a favorable tendon bed
Stage II (3-4 months) - retrieve SR and pass a tendon graft through the mesothelium lined
pseudosheath
only perform a single-stage reconstruction if the flexor sheath is pristine and the digit has
full ROM
pulvertaft weave proximally and end-to-end tenorrhaphy distally
Paneva-Holevich two-stage technique
Stage I - SR is placed in the flexor sheath, pulleys are reconstructed (as needed), and a
loop between the proximal stumps of FDS and FDP is created in the palm
Stage II - SR is retrieved, FDS is cut proximally and reflected distally through
pseudosheath and attached directly to FDP stump/or secured with button
advantages
graft (FDS) size is known at the time of silicone rod selection
less graft diameter-rod diameter mismatch
FDS graft is intrasynovial (fewer adhesions than extrasynovial grafts)
only relying on 1 tenorrhaphy site (distal or proximal) to heal at any one time (vs
Hunter technique where 2 tennoprhaphy sites are healing simultaneously)
disadvantage
graft tensioning is at the distal end during stage II
the proximal end has already healed after stage I
o graft choices
palmaris longus (absent in 15% of population)
most common
plantaris (absent in 19%)
indicated if longer graft is needed
long toe extensor
o pulley reconstruction
one pulley should be reconstructed proximal and distal to each joint
methods include belt loop method and FDS tail method
Tenolysis
o indications
localized tendon adhesions with minimal to no joint contracture and full passive digital
motion
may be required if a discrepancy between active and passive motion exists after therapy
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
o timing of procedure
wait for soft tissue stabilization (> 3 months) and full passive motion of all joints
o technique
careful technique to preserve A2 and A4 pulleys
o postoperative care
follow with extensive therapy
Postoperative Rehabilitation
Postoperative controlled mobilization has been the major reason for improved results with tendon
repair
o especially in zone II
o leads to improved tendon healing biology
o limits restrictive adhesions and leads to increased tendon excursion
Early active motion protocols
o moderate force and potentially high excursion
o dorsal blocking splint limiting wrist extension
o perform “place and hold” exercises with digits
Early passive motion protocols
o Duran protocol
low force and low excursion
active finger extension with patient-assisted passive finger flexion
o Kleinert protocol
low force and low excursion
active finger extension, dynamic splint-assisted passive finger flexion
o Mayo synergistic splint
low force and high tendon excursion
adds active wrist motion which increases flexor tendon excursion the most
Immobilize children and noncompliant patients
o Children should be immobilized following repair
o Casts or splints are applied with the wrist and MCP joints positioned in flexion and the IP joints
in extension
Complications
Tendon adhesions : most common complication following flexor tendon repair
Rerupture
o 15-25% rerupture rate
o treatment
if <1cm of scar is present, resect the scar and perform primary repair
if >1cm of scar is present, perform tendon graft
if the sheath is intact and allows passage of a pediatric urethral catheter or vascular
dilator, perform primary tendon grafting
if the sheath is collapsed, place Hunter rod and perform staged grafting
Joint contracture : rates as high as 17%
Swan-neck deformity
Trigger finger
Lumbrical plus finger
Quadrigia
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2. Jersey Finger
Introduction
Refers to an avulsion injury of FDP from insertion at base
of distal phalanx
o a Zone I flexor tendon injury
Epidemiology
o ring finger involved in 75% of cases
during grip ring fingertip is 5 mm more prominent
than other digits in ~90% of patients
therefore ring finger exposed to greater average force than other fingers during pull-away
Pathophysiology
o FDP muscle belly in maximal contraction during forceful DIP extension
Anatomy
Muscles
o Flexor Digitorum Profundus (ulnar n. and AIN n.)
Flexor zones : zone I extends from insertion of FDS distally
Classification
Leddy and Packer classification
(based on level of tendon retraction and presence of fracture)
Type Description Treatment
Type I FDP tendon retracted to palm. Leads to disruption of Prompt surgical treatment within 7 to 10
the vascular supply days
Type II FDP retracts to level of PIP joint Attempt to repair within several weeks for
opitmal outcome
Type III Large avulsion fracture limits retraction to the level of Attempt to repair within several weeks for
the DIP joint opitmal outcome
Type IV Osseous fragment and simultaneous avulsion of the If tendon separated from fracture
tendon from the fracture fragment ("Double avulsion” fragment, first fix fracture via ORIF then
with subsequent retraction of the tendon usually into reattach tendon as for Type I/II injuries
palm)
Ruptured tendon with bone avulsion with bony
Type V comminution of the remaining distal phalanx (Va,
extraarticular; Vb, intra-articular)
Presentation
Physical exam
o pain and tenderness over volar distal finger
o finger lies in slight extension relative to other fingers in resting position
o no active flexion of DIP
o may be able to palpate flexor tendon retracted proximally along flexor sheath
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
Imaging
Radiograhs
o may see avulsion fragement
Treatment
Operative
o direct tendon repair or tendon reinsertion with dorsal button
indications
acute injury (< 3 weeks)
technique
advancement of > 1 cm carries risk of a DIP flexion contracture or quadrigia
postoperative rehab should include either
early patient assisted passive ROM (Duran) or
dynamic splint-assisted passive ROM (Kleinert)
o ORIF fracture fragment
indications
types III and IV (for type IV then repair as for Type
I/II injuries)
techniques
with K-wire, mini frag screw or pull out wire
examine for symmetric cascade once fixation
completed
o two stage flexor tendon grafting
indications
chronic injury (> 3 months) in patient with full
PROM of the DIP joint
o DIP arthrodesis
indicated as salvage procedure in chronic injury (> 3
months) with chronic stiffness
Complications
Quadrigia
o advancement of > 1 cm carries risk of a DIP flexion contracture or quadrigia
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Classification
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
Presentation
Zone I
o Inability to extend at the DIP joint
Zone III
o Elson test
flex the patient's PIP joint over a table 90 degrees and ask them to extend against resistance
if central slip is intact, DIP will remain supple
if central slip disrupted, DIP will be rigid
Zone V
o extensor lag and flexion loss common
o junctura tendinae may allow partial/temporary extension by connecting with intact adjacent
extensor tendons
o sagittal band rupture
rupture of stronger radial fibers of sagittal band may lead to extensor tendon subluxation
finger held in flexed position at MCP joint with no active extension
Imaging
Radiographs
o AP and lateral of digit to verify no bony avulsion (boney mallet)
Treatment
Nonoperative
o immobilization with early protected motion
indications
lacerations < 50% of tendon in all zones if patient can extend digit against resistance
o DIP extension splinting
indications
acute (<12 weeks) Zone 1 injury (mallet finger)
nondisplaced bony mallet
chronic mallet finger (>12 weeks) if joint supple, congruent
techniques
full-time splinting for six weeks
part-time splinting for four to six weeks
avoid hyperextension, which may cause skin necrosis
maintain PIP motion
outcomes
noncompliance is a common problem
IV:2 Mallet Finger
o PIP extension splinting
indications
closed central slip injury (zone III)
techniques
full-time splinting for six weeks
part-time splinting for four to six weeks
maintain DIP flexion
IV:3 Boutonniere deformity
o MCP extension splinting
indications
closed zone V sagittal band rupture
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techniques
full-time splinting for four to six weeks
Operative
o immediate I&D
indications
fight bite to MCP joint
techniques
close loosely or in delayed fashion
IV:4 Sagittal band rupture
treat with culture-specific antibiotics, although Eikenella corrodens is a common mouth
organism
o tendon repair
indications
laceration > 50% of tendon width in all zones
o fixation of bony avulsion
indications
boney mallet finger with P3 volar subluxation
techniques
closed reduction and percutaneous pinning through DIP joint
extension block pinning
ORIF if it involves >50% of the articular surface
o tendon reconstruction
indications
chronic tendon injury or when repair not possible
o central slip reconstruction
techniques
tendon graft
extensor turndown
lateral band mobilization
transverse retinacular ligament
FDS slip
o EIP to EPL tendon transfer
indications
chronic EPL rupture
Surgical Techniques
Tendon Repair
o incision technique
utilize laceration, when present, and extend incision as needed to gain appropriate exposure
longitudinal incision may be utilized across joints on the dorsum of digits, unlike the palmar
side
o suture technique
# of suture strands that cross the repair site is more important than the number of grasping
loops
in general strength increases with increasing number of sutures crossing the repair site,
thickness of the suture, and locking of the stitch
4-6 strands provide adequate strength for early active motion
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
o circumferential epitendinous suture
Optional for reinforcement
o repair failure
tendon repairs are weakest between postoperative day 6 and 12
repair usually fails at knots
Tendon Reconstruction
o usually done as two stage procedure
first a silicon tendon implant is placed to create a favorable tendon bed
wait 3-4 months and then place biologic tendon graft
only perform single stage reconstruction if flexor sheath is pristine and digit has full ROM
o available grafts include
palmaris longus (absent in 15% of population)
most common
plantaris (absent in 19%)
indicated if longer graft is needed
long toe extensor
o pulley reconstruction
one pulley should be reconstructed proximal and distal to each joint
methods include belt loop method and FDS tail method
Tenolysis
o indications
adhesion formation with loss of finger flexion
wait for soft tissue stabilization (> 3 months) and full passive motion of all joints
o postoperative
o follow with extensive therapy
Rehabilitation
Early active short-arc motion (SAM)
o indications
after zone III central slip repair
o advantages over static immobilization
increases total arc of motion
decrease duration of therapy
increase DIP motion
creates 4mm of tendon excursion and prevents adhesions.
Complications
Adhesion formation
o leads to loss of finger flexion
o common in zone IV and VII and older patients
o prevented with early protected ROM and dynamic splinting (zone IV)
o treatment
extensor tenolysis with early motion indicated after failure of nonoperative management,
usually 3-6 months
tenolysis contraindicated if done in conjunction with other procedures that require joint
immobilization
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Tendon rupture
o causes include poor suture material or surgical technique, aggressive therapy, and
noncompliance
o incidence
5%
most frequently during first 7 to 10 days post-op
o treatment
early recognition may allow revision repair
tendon reconstruction for late rupture or rupture with excessive scarring
Swan neck deformity
o caused by prolonged DIP flexion with dorsal subluxation of lateral bands and PIP joint
hyperextension
o treatment
Fowler central slip tenotomy
spiral oblique ligament reconstruction
Boutonniere deformity (DIP hyperextension)
o caused by central slip disruption and lateral band volar subluxation
o treatment
dynamic splinting or serial casting for maximal passive motion
terminal extensor tenotomy, PIP volar plate release
4. Mallet Finger
Introduction
A finger deformity caused by disruption of the terminal extensor
tendon distal to DIP joint
o the disruption may be bony or tendinous
Epidemiology
o risk factors
usually occur in the work environment or during participation
in sports
o demographics
common in young to middle-aged males and older females
o body location
most frequently involves long, ring and small fingers of dominant hand
Pathophysiology
o mechanism of injury
traumatic impaction blow
usually caused by a traumatic impaction blow (i.e. sudden forced flexion) to the tip of the
finger in the extended position.
forces the DIP joint into forced flexion
dorsal laceration
a less common mechanism of injury is a sharp or crushing-type laceration to the dorsal
DIP joint
Classification
Doyle's Classification
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
Doyle's Classification of Mallet Finger Injuries
Type I • Closed injury with or without small dorsal avulusion fracture
Type II • Open injury (laceration)
Type III • Open injury (deep soft tissue abrasion involving loss skin and tendon substance)
Type IV • Mallet fracture
A = distal phalanx physeal injury (pediatrics)
B = fracture fragment involving 20% to 50% of articular surface (adult)
C = fracture fragment >50% of articular surface (adult)
Presentation
Symptoms
o primary symptoms
painful and swollen DIP joint following impaction injury to finger
often in ball sports
Physical exam
o inspection
fingertip rest at ~45° of flexion
o motion
lack of active DIP extension
Imaging
Radiographs
o findings
usually see bony avulsion of distal phalanx
may be a ligamentous injury with normal bony anatomy
Treatment
Nonoperative
o extension splinting of DIP joint for 6-8 weeks
indications
acute soft tissue injury (< than 12 weeks)
nondisplaced bony mallet injury
technique Bony avulsion Ligamintous injury
maintain free movement of the PIP joint
worn for 6-8 weeks
volar splinting has less complications than dorsal splinting
avoid hyperextension
begin progressive flexion exercises at 6 weeks
Operative
o CRPP vs ORIF
indications
absolute indications
volar subluxation of distal phalanx
relative indications
>50% of articular surface involved
>2mm articular gap
o surgical reconstruction of terminal tendon
indications
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chronic injury (> 12 weeks) with healthy joint
outcomes
tendon reconstruction has a high complication rate (~ 50%)
o DIP arthrodesis
indications
painful, stiff, arthritic DIP joint
o Swan neck deformity correction
indications : Swan neck deformity present
Techniques
CRPP vs ORIF
o approach
dorsal midline incision
o fixation
simple pin fixation
dorsal blocking pin
Surgical reconstruction of terminal tendon
o repair
this may be done with direct repair/tendon advancement, tenodermodesis, or spiral oblique
retinacular ligament reconstruction
Swan neck deformity correction
o techniques to correct Swan neck deformity include
lateral band tenodesis
FDS tenodesis
Fowler central slip tenotomy
for deformities of <35° extensor lag
minimal Swan Neck deformities may correct with treatment of the DIP pathology alone
Complications
Extensor lag
o a slight residual extensor lag of < 10° may be present at completion of closed treatment
Swan neck deformities
o occurs due to
attenuation of volar plate and transverse retinacular ligament at PIP joint
dorsal subluxation of lateral bands
resulting PIP hyperextension
contracture of triangular ligament maintains deformity
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
Anatomy
Extensor mechanism comprises
o tendons
EDC/EIP/EDM
lumbricals
interossei
o retinacular system
sagittal bands
the sagittal bands are part of a closed cylindrical tube (or girdle) that surrounds the
metacarpal head and MCP along with the palmar plate
origin
volar plate and intermetacarpal ligament at the metacarpal neck
insertion
extensor mechanism (curving around radial and ulnar side of MCP joint)
retinacular ligaments
triangular ligament
Sagittal band
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o function
the SB is the primary stabilizer of the extensor tendon at the MCP joint
juncturae tendinum are the secondary stabilizers
resists ulnar deviation of the tendon, especially during MCP flexion
prevents tendon bowstringing during MCP joint hyperextension
o biomechanics
ulnar sagittal band
partial or complete sectioning does not lead to extensor tendon dislocation
radial sagittal band
distal sectioning does not produce extensor tendon instability
complete sectioning leads to extensor dislocation
sectioning of 50% of the proximal SB leads to extensor tendon subluxation
extensor tendon
instability after sectioning is greater with wrist flexion
instability after sectioning is greater in the central digits (than border digits)
the least stable tendon is the middle finger
the most stable tendon is the little finger
junctura tendinum stabilize the small finger
Classification
Rayan and Murray Classification of Closed SB Injury
Type Description
Type I SB injury without extensor tendon instability
Type II SB injury with tendon subluxation
Type III SB injury with tendon dislocation
Presentation
Symptoms
o MCP soreness
Physical exam
o tendon snapping
o ulnar deviation of the digits at the MCP joint (rheumatoid arthritis)
o inability to initiate extension
o pseudo-triggering
o extensor tendon dislocation into intermetacarpal gully
most unstable during MCP flexion with wrist flexed
least unstable during MCP flexion with wrist extended
o provocative test
pain when extending MCP joint against resistance (with both IP joints extended)
Imaging
Radiographs
o required views
hand PA, lateral, oblique
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
o optional view
Brewerton view
AP with dorsal surface of fingers touching the cassette and MCP joints flexed 45deg
stress view
to rule out collateral ligament avulsion/injury
o findings
exclude mechanical/bony pathology limiting extension, or predisposing to sagittal band
rupture
may show dropped fingers and ulnar deviation in rheumatoid arthritis
Ultrasound (dynamic)
o indications : when swelling obscures the physical exam
o findings : subluxation of EDC tendon relative to metacarpal head on MCP flexion
MRI
o indications
to establish diagnosis of SB disruption (radial or ulnar SB)
may show underlying etiology e.g. synovitis in rheumatoid arthritis
o views
axial images at the level of the long MCP
with MCP joint flexed for maximum EDC tendon displacement
o findings
poor definition, focal discontinuity and focal thickening in acute injury
subluxation of extensor tendon in radial direction due ulnar SB defect
dislocation of extensor tendon into ulnar intermetacarpal gully radial SB defect
Differentials
MCP joint collateral ligament injury
EDC tendon rupture
Trigger finger
Junctura tendinum disruption
Congenital sagittal band deficiency
MCP joint arthritis
Treatment
Nonoperative
o extension splint for 4-6 weeks
indications IV:5 extension splint IV:6 direct repair
(Kettlekamp)
acute injuries (within one week)
Operative
o direct repair (Kettlekamp)
indications
chronic injuries (more than one week) where primary repair is possible
professional athlete
o extensor centralization procedure
indications
chronic injuries (more than one week) where primary repair is NOT possible
professional athlete
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Techniques
Extensor Centralization Procedures
o various techniques described including
trapdoor flap
ulnar based partial thickness capsular flap created
tendon placed deep to flap
flap resutured to capsule
Kilgore tendon slip
IV:7 trapdoor flap
distally based slip of EDC tendon on radial side
looped around radial collateral ligament
sutured to itself after tensioning to centralize tendon
Carroll tendon slip
distally based slip of EDC tendon on ulnar side
routed deep to affected tendon and around radial collateral ligamnt
sutured to itself after tensioning to centralize tendone
McCoy tendon slip
proximally based slip of EDC tendon
looped around lumbrical insertion
sutured to itself after tensioning to centralize tendon IV:8 McCoy tendon slip
Watson EDC tendon transfer
distally based slip of EDC tendon slip
looped under deep transverse metacarpal ligament
weaved to remaining EDC tendon after tensioning to centralize tendon
Wheeldon junctural reinforcement
for a middle finger radial SB rupture, the juncturae tendinum (JT) of the ring finger
is divided close to the ring finger,
bring JT over the extensor tendon
attach JT to the torn SB
fascial strips or free tendon graft
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
B. Wrist Trauma
1. Scaphoid Fracture
Introduction
Scaphoid is most frequently fractured carpal bone
Epidemiology
o incidence : accounts for up to 15% of acute wrist injuries
o location
incidence of fracture by location
waist -65%
proximal third - 25%
distal third - 10%
distal pole is most common location in kids due to ossification sequence
Pathoanatomy
o most common mechanism of injury is axial load across hyper-extended and radially deviated
wrist
common in contact sports
o transverse fracture patterns are considered more stable than vertical or oblique oriented fractures
Associated conditions
o SNAC (Scaphoid Nonunion Advanced Collapse)
Prognosis
o incidence of AVN with fracture location
proximal 5th AVN rate of 100%
proximal 3rd AVN rate of 33%
Anatomy
Articular surface
IV:10 Blood supply of scaphoid
o > 75% of scaphoid bone is covered by articular cartilage
Blood supply
o major blood supply is dorsal carpal branch (branch of the radial artery)
enters scaphoid in a nonarticular ridge on the dorsal surface and supplies proximal 80% of
scaphoid via retrograde blood flow
o minor blood supply from superficial palmar arch (branch of volar radial artery)
enters distal tubercle and supplies distal 20% of scaphoid
Motion
o both intrinsic and extrinsic ligaments attach and surround the scaphoid
o the scaphoid flexes with wrist flexion and radial deviation and it extends during wrist extension
and ulnar deviation (same as proximal row)
Also see Wrist Ligaments and Biomechanics for more detail
Presentation
Physical exam
o anatomic snuffbox tenderness dorsally
o scaphoid tubercle tenderness volarly
o pain with resisted pronation
IV:11 scaphoid tubercle tenderness
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Imaging
Radiographs
o recommended views
AP and lateral
scaphoid view
30 degree wrist extension, 20 degree ulnar deviation
45° pronation view
o findings
if radiographs are negative and there is a high clinical suspicion
should repeat radiographs in 14-21 days
Bone scan
o effective to diagnose occult fractures at 72 hours
specificity of 98%, and sensitivity of 100%, PPV 85% to 93% when done at 72 hours
MRI
o indications
most sensitive for diagnosis occult fractures < 24 hours
immediate identification of fractures / ligamentous injuries
assessment of vascular status of bone (vascularity of proximal pole)
proximal pole AVN best determined on T1 sequences
CT scan with 1mm cuts
o less effective than bone scan and MRI to diagnose occult fracture
o can be used to evaluate location of fracture, size of fragments, extent of collapse, and progression
of nonunion or union after surgery
Treatment
Nonoperative
o thumb spica cast immobilization
indications
stable nondisplaced fracture (majority of fractures)
if patient has normal xrays but there is a high level of suspicion can immobilize in thumb
spica and reevaluate in 12 to 21 days
technique
start immobilization early (nonunion rates increase with delayed immobilization of > 4
weeks after injury)
long arm spica vs short arm casting is controversial
with no consensus
duration of casting depends on location of fracture
distal-waist for 3 months
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
mid-waist for 4 months
proximal third for 5 months
athletes should not return to play until imaging shows a healed fracture
may opt to augment with pulsed electromagnetic field (studies show beneficial in delayed
union)
outcomes
scaphoid fractures with <1mm displacement have union rate of 90%
Operative
o ORIF vs percutaneous screw fixation
indications
in unstable fractures as shown by
proximal pole fractures
displacement > 1 mm
15° scaphoid humpback deformity
radiolunate angle > 15° (DISI)
intrascaphoid angle of > 35°
scaphoid fractures associated with perilunate dislocation IV:12 screw fixation of scaphoid
comminuted fractures
unstable vertical or oblique fractures
in non-displaced waist fractures
to allow decreased time to union, faster return to work/sport, similar total costs
compared to casting
outcomes
union rates of 90-95% with operative treatment of scaphoid fractures
CT scan is helpful for evaluation of union
Technique
ORIF vs percutaneous screw fixation
o approach
dorsal approach
indicated in proximal pole fractures
care must be taken to preserve the blood supply when entering the dorsal ridge by limiting
exposure to the proximal half of the scaphoid
percutaneous has higher risk of unrecognized screw penetration of subchondral bone
volar approach
indicated in waist and distal pole fractures and fractures with humpback flexion
deformities
allows exposure of the entire scaphoid
uses the interval between the FCR and the radial artery
arthroscopic assisted approach
has also been described
o fixation
rigidity is optimized by long screw placed down the central axis of the scaphoid
o radial styloidectomy
should be performed if there is evidence of impaction osteoarthritis between radial styloid
and scaphoid
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Complications
Scaphoid Nonunion
o treatment
inlay (Russe) bone graft
indications
if minimal deformity and there is no adjacent carpal collapse or excessive flexion
deformity (humpback scaphoid)
outcomes
92% union rate
interposition (Fisk) bone graft
indications
if there is adjacent carpal collapse and excessive flexion deformity (humpback
scaphoid)
technique
an opening wedge graft that is designed to restore scaphoid length and angulation
outcomes
results show 72-95% union rates
vascular bone graft from radius
indications
gaining popularity and a good option for
proximal pole fractures with osteonecrosis
confirmed by MRI
technique
1-2 intercompartmental supraretinacular artery (branch of radial artery) is
harvested to provide vascularized graft from dorsal aspect of distal radius
vascular bone graft from medial femoral condyle
corticoperiosteal flap that provides highly osteogenic periosteum
indications
proximal pole fractures with osteonecrosis
lack of pancarpal arthritis and collapse
technique
utilize the descending genicular artery pedicle (from the superficial femoral artery)
if DGA is too small, use superomedial genicular artery (from popliteal artery)
identify and protect MCL (distal to flap)
o SNAC wrist (scaphoid nonunion advanced collapse)
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
Anatomy
Normal wrist anatomy
Osseous
o proximal row
scaphoid
lunate
triquetrum
pisiform
o distal row
trapezium
trapezoid
capitate IV:17 Normal wrist anatomy
hamate
Ligaments
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o interosseous ligaments
run between the carpal bones
scapholunate interosseous ligament
lunotriquetral interosseous ligament
major stabilizers of the proximal carpal row
o intrinsic ligaments
ligaments the both originate and insert among the carpal bones
dorsal intrinsic ligaments
volar intrinsic ligaments
o extrinsic ligaments
connect the forearm bones to the carpus
volar extrinsic carpal ligaments
dorsal extrinsic carpal ligaments
Classification
Mayfield Classification
Stage I • scapholunate dissociation
Stage II • + lunocapitate disruption
Stage III • + lunotriquetral disruption, "perilunate"
Stage IV • lunate dislocated from lunate fossa (usually volar)
• associated with median nerve compression
Presentation
Symptoms
o acute wrist swelling and pain
o median nerve symptoms may occur in ~25% of patients
most common in Mayfield stage IV where the lunate dislocates into the carpal tunnel
Imaging
Radiographs
o required views
PA/lateral wrist radiographs
o findings
AP
break in Gilula's arc
lunate and capitate overlap
lunate appears triangular "piece-of-pie sign"
IV:18 lateral xray
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
lateral
lossof colinearity of radius, lunate, and
capitate
SL angle >70 degrees
MRI
o usually not required for diagnosis
Treatment
IV:20 piece-of-pie sign IV:19 Abnormal alignment
Nonoperative
of scaphoid , lunate and
o closed reduction and casting triquetrum
indications
no indications when used as definitive management
outcomes
universally poor functional outcomes with non-operative management
recurrent dislocation is common
Operative
o emergent closed reduction/splinting followed by open reduction, ligament repair, fixation,
possible carpal tunnel release
indications
all acute injuries <8 weeks old
outcomes
emergent closed reduction leads to
decreased risk of median nerve damage
decreased risk of cartilage damage
return to full function unlikely
decreased grip strength and stiffness are common
o proximal row carpectomy
indications
chronic injury (defined as >8 weeks after initial injury)
not
uncommon, as initial diagnosis frequently missed
o total wrist arthrodesis
indications
chronic injuries with degenerative changes
Techniques
Closed Reduction
o technique
finger traps, elbow at 90 degrees of flexion
hand 5-10 lbs traction for 15 minutes
dorsal dislocations are reduced through wrist extension, traction, and flexion of wrist
apply sugar tong splint
follow with surgery
Open reduction, ligament repair and fixation +/- carpal tunnel release
o approach (controversial)
dorsal approach
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longitudinal incision centered at Lister's tubercle
excellent exposure of proximal carpal row and midcarpal joints
does not allow for carpal tunnel release
volar approach
extended carpal tunnel incision just proximal to volar wrist crease
combined dorsal/volar
pros
added exposure
easier reduction
access to distal scaphoid fractures
ability to repair volar ligaments
carpal tunnel decompression
cons
some believe volar ligament repair not necessary
increased swelling
potential carpal devascularization
difficulty regaining digital flexion and grip
o technique
fix associated fractures
repair scapholunate ligament
suture anchor fixation
protect scapholunate ligament repair
controversy of k-wire versus intraosseous cerclage wiring
repair of lunotriquetral interosseous ligament
decision to repair based on surgeon preference as no studies have shown improved results
o post-op
short arm thumb spica splint converted to short arm cast at first post-op visit
duration of casting varies, but at least 6 weeks
Proximal row carpectomy
o technique
perform via dorsal and volar incisions if median nerve compression is present
volar approach allows median nerve decompression with excision of lunate
dorsal approach facilitates excision of the scaphoid and triquetrum
Anatomy
Hamate
o one of carpal bones, distal and radial to the pisiform
o articulates with
fourth and fifth metacarpals
capitate
triquetrum
o hook of hamate
forms part of Guyon's canal, which is formed by
roof - superficial palmar carpal ligament
floor - deep flexor retinaculum, hypothenar muscles
ulnar border - pisiform and pisohamate ligament
radial border - hook of hamate
one of the palpable attachments of the flexor retinaculum
deep branch of ulnar nerve lies under the hook
Presentation
Symptoms
o hypothenar pain
o pain with activities requiring tight grip
Physical examination
o provocative maneuvers
tender to palpation over the hook of hamate
hook of hamate pull test:
hand held in ulnar deviation as patient flexes DIP joints of the ulnar 2 digits, the flexor
tendons act as a deforming force on the fracture site, positive test elicits pain
o motion and strength : decreased grip strength
o neurovascular exam
chronic cases
parasthesia in ring and small finger
motor weakness in intrinsics
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Carpal Tunnel View
Imaging
Radiographs
o recommended views
AP and carpal tunnel view
o findings
fracture best seen on carpal tunnel view
CT
o indications
establish diagnosis if radiographs are negative
Treatment
Nonoperative
o immobilization 6 weeks
indications
acute hook of hamate fractures
body of hamate fx (rare)
Operative
o excision of hamate fracture fragment
indications : chronic hook of hamate fxs with non-union
o ORIF
indications : ORIF is possible but has little benefit
Complications
Non-union
Scar sensitivity
Iatrogenic injury to ulnar nerve
Closed rupture of the flexor tendons to the small finger
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
Anatomy
Hamate Bone
o osteology
triangular shaped carpal bone
composed of hook and body
o location
most ulnar bone in the distal carpal row
o articulation
4th and 5th metacarpals
capitate
triquetrum
Classification
Milch Classification of Hamate Fractures
Milch Classification
Type I Hook of Hamate Fx (most common)
Type II Body of Hamate Fx
Presentation
Symptoms
o ulnar-sided wrist pain and swelling
Physical exam
o inspection
focal tenderness over hamate
Imaging
Radiographs
o recommended views
oblique radiographs (30°) are usually required to visualize fracture
AP and lateral radiographs are less reliable
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o additional views
carpal tunnel view radiographs
CT
o usually required to delineate fracture pattern and determine operative
plan
Treatment
Nonoperative
o immobilization
indications
IV:21 30°oblique view
rarely may be used for extra-articular nondisplaced fracture
Operative
o ORIF
indications
most fracture are intra-articular and require open reduction
technique
interfragmentary screws +/- k-wires for temporary stabilization
Surgical Techniques
Open Reduction Internal Fixation
o approach : dorsal most common approach
o fixation technique
Complications
Stiffness
Malunion
Infection
5. Pisiform Fracture
Introduction
A rare carpal fracture
Epidemiology
o incidence
<1% of carpal fractures
rare injury and often missed
Pathophysiology
o mechanism of injury
usually occurs by direct impact against a hard surface
fall on outstretched hand
Associated conditions
o 50% occur as isolated injuries
o 50% occur in association with other carpal fractures or distal radius fractures
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
Anatomy
Pisiform Bone
o osteology
pea shaped, seasmoid bone
o location
most ulnar and palmar carpal bone in proximal row
located within the FCU tendon
o function
contributes to the stability of the ulnar column by preventing triquetral subluxation
Presentation
Symptoms
o ulnar sided wrist pain after a fall
o grip weakness
Physical exam
o inspection
hypothenar tenderness and swelling
rule out associated injury to other carpal bones and distal radius
Imaging
Radiographs
o recommended views
AP and lateral views of wrist
o additional views
pronated oblique and supinated oblque views
carpal tunnel view
o findings
best seen with 30 deg of wrist supination or utilizing the carpal tunnel view
CT
o indications
may be required to delineate fracture pattern and determine treatment plan
MRI
o indications
suspected carpal fracture with negative radiographs
o findings
may show bone marrow edema within the pisiform indicating fracture
Treatment
Nonoperative
o early immobilization
indications
first line of treatment
technique
short arm cast with 30 degrees of wrist flexion and ulnar deviation for 6-8 weeks
outcomes
most often go on to heal without posttraumatic osteoarthritis
Operative
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o pisiformectomy
indications
severely displaced and symptomatic fractures
painful nonunion
outcomes
studies show a pisiformectomy is a reliable way to relieve this pain and does not impair
wrist function
Complications
Malunion
Non-union
Chronic ulnar sided pain
Decreased grip strength
6. Seymour Fracture
Introduction
Displaced distal phalangeal physeal fracture with an associated nailbed injury
Epidemiology
o incidence : 20% to 30% of phalangeal fractures involve the physis in children
o body location
middle finger injury is most common
type of the distal phalangeal physeal fracture:
metaphyseal fractures 1 to 2 mm distal to the epiphyseal plate
Salter-Harris I fractures
Salter-Harris II fractures
type of nailbed injury:
nailbed laceration
nail plate subluxation
interposition of soft tissue at fracture site (usually germinal matrix)
Pathophysiology
o mechanism of injury : direct trauma or crush injury (e.g. caught in door, heavy object or sport)
o pathoanatomy
similar mechanism to mallet finger in adults
injury causes flexed posturing of the distal phalanx
deformity results from an imbalance between the flexor and the extensor tendons at the level
of the fracture
imbalance occurs due to different insertion sites of flexor and extensor tendons
extensor tendon inserts into the epiphysis of the distal phalanx
flexor tendon inserts into metaphysis of the distal phalanx
widened physis likely to have interposed tissue in the fracture site
Prognosis
o operative intervention is warranted to ensure that there is no interposed tissue in the fracture site
o failure to recognize injury may result in:
nailplate deformity
physeal arrest
chronic osteomyelitis
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
Presentation
Physical exam
o apparent mallet deformity
o echymosis and swelling
o nail plate lying superficial to the eponychial fold
Imaging
Radiographs
o AP : may appear normal on posteroanterior view
o lateral view
widened physis or displacement between epiphysis/metaphysis
flexion deformity at fracture site
Differential Diagnosis
Mallet finger
o pediatric mallet finger is usually osseous avulsion (SH III and SH IV)
o mallet finger fracture line enters DIPJ, while Seymour fracture line traverses physis (does not
enter DIPJ)
Treatment
Nonoperative
o closed reduction and splinting
indications
minimally displaced, closed fracture
no interposition of soft tissue at fracture site
Operative
o closed reduction and pinning across DIPJ
indications
displaced, closed fracture
no interposition of soft tissue at fracture site
o antibiotics, open reduction and pinning across DIPJ, nailbed repair
open management has fewer complications than closed management
indications : open fracture
technique
hyperflexion of the digit will permit removal of the interposed soft tissue from the
fracture site
thorough irrigation and debridement
anatomical reduction and retrograde k-wire fixation crossing the fracture site and DIP
joint
nailbed injury repair
Complications
Nail dystrophy
Growth disturbance of the distal phalanx and nail
Secondary fracture displacement
Chronic osteomyelitis (failure to treat as open fracture)
Flexion deformity
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7. TFCC Injury
Introduction
Mechanism of TFCC injury
o Type 1 traumatic injury
mechanism
most common is fall on extended wrist with forearm pronation
traction injury to ulnar side of wrist
traction injury to ulnar wrist
o Type 2 degenerative injury
associated with positive ulnar variance
associated with ulnocarpal impaction
Anatomy
TFCC made up of
o dorsal and volar radioulnar ligaments
deep ligaments known as ligamentum subcruentum
o central articular disc
o meniscus homolog
o ulnar collateral ligament
o ECU subsheath
o origin of ulnolunate and ulnotriquetral ligaments
Blood supply
o periphery is well vascularized (10-40% of the periphery)
o central portion is avascular
Origin
o dorsal and volar radioulnar ligaments originate at the sigmoid notch of the radius
Insertion
o dorsal and volar radioulnar ligaments converge at the base of the ulnar styloid
Classification
Class 1 - Traumatic TFCC Injuries
1A Central perforation or tear
1B Ulnar avulsion (without ulnar styloid fx)
1C Distal avulsion (origin of UL and UT ligaments)
1D Radial avulsion
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
Class 2 - Degenerative TFCC Injuries
2A TFCC wear and thinning
2B Lunate and/or ulnar chondromalacia + 2A
2C TFCC perforation + 2B
2D Ligament disruption + 2C
2E Ulnocarpal and DRUJ arthritis + 2D
Presentation
Symptoms
o wrist pain
o turning a door key often painful
Physical exam
o positive "fovea" sign
tenderness in the soft spot between the ulnar styloid and flexor carpi ulnaris tendon, between
the volar surface of the ulnar head and the pisiform
95% sensitivity and 87% specificity for foveal disruptions of TFCC or ulnotriquetral
ligament injuries
o pain elicited with ulnar deviation (TFCC compression) or radial deviation (TFCC tension)
Imaging
Radiographs
o usually negative
o zero rotation PA view evaluates ulnar variance
o dynamic pronated PA grip view may show pathology
Arthography
o joint injection shows extravasation
MRI
o has largely replaced arthrography
o tear at ulnar part of lunate indicates ulnocarpal impaction
o sensitivity = 74-100%
Arthroscopy
o most accurate method of diagnosis
o indicated in symptomatic patients after failing several months of splinting and activity
modification
Differential
Differential for ulnar sided wrist pain
See table next page
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Treatment
Nonoperative
o immobilization, NSAIDS, steroid injections
indications
all acute Type I injuries
first line of treatment for Type 2 injuries
Operative
o arthroscopic debridement
indications
type 1A
diagnostic gold standard
o arthroscopic repair
indications
type 1B, 1C, 1D
best for ulnar and dorsal/ulnar tears
generally acute, athletic injuries more amenable to repair than chronic injuries
outcomes
patient should expect to regain 80% of motion and grip strength when injuries are
classified as acute (<3 months)
o ulnar diaphyseal shortening
indications
Type II with ulnar positive variance is > 2mm
advantage of effectively tightening the ulnocarpal ligaments and is favored when LT
instability is present
o Wafer procedure
indications
Type II with ulnar positive variance is < 2mm
type 2A-C
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
o limited ulnar head resection
indications : type 2D
o Darrach procedure
indications
contraindicated due to problems with ulnar stump instability
Techniques
Arthroscopic debridement
o approach
arthroscopic approach to the wrist
performed through combination of 3-4 and 6R portal
o technique
maintain 2 mm rim peripherally otherwise joint can become unstable
o pros & cons
not effective if patient has ulnar positive variance
80% of patients obtain good relief of pain
Arthroscopic repair
o approach
arthroscopic approach to the wrist
o technique
many techniques exist such as outside-in and inside-out
generally suture based repair
o pros & cons
only works for peripheral tears where blood supply is present
patient immobilized for 6 weeks
o complications
ECU tendonitis from suture knot
dorsal sensory nerve injury
Ulnar diaphyseal shortening
o approach
dorsal approach to the forearm
o technique
osteotomy of the diaphysis or metaphysis followed by plate fixation
o pros & cons
can address > 2 mm ulnar variance
requires immobilization and time for fracture healing
can help tension the ulnocarpal ligaments
o complications
nonunion
hardware irritation necessitating removal
Wafer procedure
o approach : dorsal approach to the forearm
o technique
ulnar cortex is not disrupted
do not extend bone removal into the DRUJ
o pros & cons
intrinsic stability of ECU, TFCC, and ulnar periosteum obviate need for plate fixation
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Limited ulnar head resection
o approach
arthroscopic approach to the wrist
o technique
removal of approximately 2-4 mm of bone under the TFCC
distal ulnar burred through central TFCC defect
o pros & cons
can be technically difficult to obtain level shortening through TFCC window
only applicable when patient has < 2mm of ulnar variance
Darrach procedure
o approach
dorsal approach to the forearm
o technique
resection of the distal 1-2cm of the distal ulna
TFCC should be approximated to the wrist capsule
o pros & cons
salvage procedure for pain relief only
distal joint is unstable
o complications : ECU tendon can sublux over remaining ulna causing pain
C. Finger Trauma
1. Metacarpal Fractures
Introduction
Metacarpal fractures
o divided into fractures of metacarpal head, neck, shaft
o treatment based on which metacarpal is involved and location of fracture
o acceptable angulation varies by location
o no degree of malrotation is acceptable
Epidemiology
o incidence
metacarpal fractures account for 40% of all hand injuries
o demographics
men aged 10-29 have highest incidence of metacarpal injuries
o location
metacarpal neck is most common site of fracture
fifth metacarpal is most commonly injured
Mechanism of injury
o direct blow to hand or rotational injury with axial load
o high energy injuries (ie. automobile) may result in multiple fractures
Associated conditions
o wounds may indicate open fractures or concomitant soft tissue injury
tendon laceration
neurovascular injury
o compartment syndrome
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closed injuries with multiple fractures or dislocations
crush injuries
Anatomy
Metacarpal anatomy
o concave on palmar surface
o 1st, 4th, and 5th digits form mobile borders
o 2nd and 3rd digits form stiffer central pillar
index metacarpal is the most firmly fixed, while the thumb metacarpal articulates with the
trapezium and acts independently from the others
o three palmar and four dorsal interossei muscles arise from metacarpal shafts
Insertional anatomy
o extensor carpi radialis longus/brevis
insert on the base of metacarpal II, III (respectively); assist with wrist extension and radial
flexion of the wrist
o extensor carpi ulnaris
inserts on the base of metacarpal V; extends and fixes wrist when digits are being flexed;
assists with ulnar flexion of wrist
o abductor pollicis longus
inserts on the trapezium and base of metacarpal I; abducts thumb in frontal plane; extends
thumb at carpometacarpal joint
o opponens pollicis
inserts on metacarpal I; flexes metacarpal I to oppose the thumb to the fingertips
o opponens digiti minimi
inserts on the medial surface of metacarpal V; Flexes metacarpal V at carpometacarpal joint
when little finger is moved into opposition with tip of thumb; deepens palm of hand.
Presentation
Physical exam
o inspect for open wounds and associated injuries
fight wounds over MCP joint are open until proven otherwise
extensor tendon can be lacerated and retracted
dorsal wounds over metacarpal fractures are almost always open
fractures
o deformity indicates location
deformity at metacarpal base may indicate CMC dislocation
shortening can be assessed by comparing contralateral hand
malrotation assessed by lining up fingernail in partial flexion and full flexion if possible,
compare to contralateral side
o motor examination
typically no motor deficits unless open wounds present
check integrity of flexor/extensor tendons in presence of open wounds
o neurovascular examination
dorsal wounds may affect dorsal sensory branch of radial/ulnar nerve
volar wounds can involve digital nerves
test for radial and ulnar border two-point discrimination on the injured digit before any
regional/hematoma block or attempted reduction
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Imaging
Radiographs
o standard AP, oblique, and lateral films
o oblique radiographs
for evaluation of CMC joint and improved visualization
of affected digit
30°pronated lateral
to see 4th and 5th CMC fx/dislocation
30°supinated view
to see 2nd and 3rd CMC fx/dislocation
o Brewerton view for metacarpal head fractures
o Roberts view for thumb CMC joint
CT
o indications
inconclusive radiographs of CMC fractures/dislocations
multiple CMC dislocations
complex metacarpal head fractures
General Treatment
Nonoperative
o immobilization
indications
must be stable pattern
no rotational deformity
acceptable angulation & shortening (see table)
Operative
o operative treatment
general indications
intra-articular fxs
rotational malalignment of digit
significantly displaced fractures (see above criteria)
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Finger Trauma
Treatment - Metacarpal Head Fractures
Operative
o ORIF
indications
no degree of articular displacement acceptable
majority requires surgical fixation
o external fixation
indications
severely comminuted fractures
o MCP arthroplasty
indications
severely comminuted fractures
o MCP fusion
indications
arthritis late disease
Techniques
o ORIF
approach
dorsal incision
either centrally split extensor apparatus or release and repair sagittal band
fixation
hardware cannot protrude from joint surface
fix with multiple small screws in collateral recess, headless screws, or k-wires
ideal fixation should allow for early motion
Complications
o stiffness
most common
prevented with early motion
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Techniques
o closed reduction percutaneous pinning
place antegrade through metacarpal base or retrograde through collateral recess
remove pins at 4 weeks
o open reductions with lag screw
can use multiple lag screws for long spiral fractures
try to get at least two lag screws
o open reduction with dorsal plating
works best for transverse fractures
try to cover plate with periosteum to prevent tendon irritation
begin early motion to prevent tendon irritations
2. MCP Dislocations
Introduction
Epidemiology
o dorsal dislocations most common
o index finger most commonly involved
Mechanism
o a hyperextension injury
Classification
Simple vs. Complex
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o simple
volar plate not interposed in joint
treated with closed reduction
o complex
complex dislocations have interposition of volar plate and/or sesamoids
in index finger flexor tendon displaces ulnarly and lumbrical displaces radially which
tighten around metacarpal neck preventing reduction
in small finger flexor tendons and lumbrical displace radially and the abductor digiti
minimi and flexor digiti minimi ulnarly preventing closed reduction
may require open reduction
Kaplan's lesion (rare)
o most common in index finger
o complex dorsal dislocation of finger, irreducible
o metacarpal head buttonholes into palm (volarly)
o volar plate is interposed between base of proximal phalanx and metacarpal head
Presentation
Physical exam
o skin dimpling often seen in complex dislocations but absent in simple dislocations
Imaging
Radiographs
o lateral view best shows dislocation
o joint space widening may indicate interposition of volar plat
o useful to detect associated chip fractures
Treatment
Nonoperative
o closed reduction
indications
simple dislocations
technique
reduction technique involve applying direct pressure over proximal phalanx while the
wrist is held in flexion to take tension off the intrinsic and extrinsic flexors
avoid longitudinal traction and hyperextension during closed reduction, may pull volar
plate into joint
Operative
o open reduction
indications
complex dislocations
Surgical Techniques
Open reduction
o approach
dorsal approach
split extensor tendon to expose joint
may be able to push volar plate out with freer elevator
usually need to split volar plate to remove from joint
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use this approach for volar dislocations
volar approach
places neurovascular structures at risk
release A1 pulley to expose volar plate
3. Phalanx Fractures
Introduction
Common hand injuries that can be broken into the following injuries
o proximal phalanx
o middle phalanx
o distal phalanx
Epidemiology
o incidence
most common injuries to the skeletal system
account for 10% of all fractures
distal phalanx is most common fractured bone in the hand
Pathophysiology
o mechanism
depends on age
10-29 years of age: sports is most common
40-69 year of age: machinery is most common
>70 year of age: falls are most common
o pathoanatomy
proximal phalanx fx
deformity is usually apex volar angulation due to
IV:23 Proximal Phalynx fractures
proximal fragment in flexion (from interossei)
distal fragment in extension (from central slip)
middle phalanx
deformity is usually apex dorsal OR volar angulation
apex dorsal if fracture proximal to FDS insertion (from extension of proximal
fragment through pull of the central slip)
apex volar if fracture distal to FDS insertion (prolonged insertion from just distal to
the flare at the base to within a few mm of the neck)
a fracture through the middle third may angulate in either direction or not at all
secondary to the inherent stability provided by an intact and prolonged FDS insertion
Associated conditions
o nail bed injuries
associated with distal phalanx fractures
Presentation
Symptoms
o pain
Physical exam
o local tenderness
o deformity
o look carefully for open wounds
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Imaging
Radiographs
o finger xrays
must get true lateral of joint
o hand xrays to rule out associated fractures
30°pronated lateral to see 4th and 5th CMC x/dislocation
30°supinated view to see 2nd and 3rd CMC fx/dislocation
Complications
Loss of motion
o most common complication
o predisposing factors include prolonged immobilization, associated joint injury, and extensive
surgical dissection
o treat with rehab, and surgical release as a last resort
Malunion
o malrotation, angulation, shortening
o surgery indicated when associated with functional impairment
corrective osteotomy at malunion site (preferred)
metacarpal osteotomy (limited degree of correction)
Nonunion
o uncommon
o most are atrophic and associated with bone loss or neurovascular compromise
o surgical options
resection, bone grafting, plating
ray amputation or fusion
4. Phalanx Dislocations
Introduction
Common hand injuries can be broken into the following
o PIP joint
dorsal dislocations
dorsal fracture-dislocations
volar dislocation
volar fracture-dislocation
rotatory dislocations
o DIP joint
dorsal dislocations & fracture-dislocations
Associated conditions
o swan neck deformity
o nail bed injuries
associated with distal phalanx fractures
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Imaging
Radiographs
o finger xrays
must get true lateral of joint
o hand xrays to rule out associated fractures
30°pronated lateral to see 4th and 5th CMC x/dislocation
30°supinated view to see 2nd and 3rd CMC fx/dislocation
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Anatomy
Collateral ligaments of the digits
o located on the lateral aspect of the DIP, PIP and MCP joints
o crucial for opposing pinch stability
Presentation
Symptoms
o Pain at involved joint
o Instabilty with pinch once pain resolved
Physical exam
o inspection
swelling at involved joint
deformity of joint
o provocative tests
varus and valgus stress tests
Imaging
Radiographs
o recommended views
AP, lateral, and oblique views of digit
varus/valgus stress views may aid in diagnosis
MRI
o indicated if equivocal physical exam findings
Treatment
Nonoperative
o buddy taping for 3 weeks
indications
simple tears
o buddy taping for 6 weeks
indications
complete tears
Operative
o collateral ligament repair
indications
radial ligament injuries of index finger (ligament needed for pinch stability)
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Thumb Trauma
D. Thumb Trauma
Bennett Fracture
Intra-articular fracture/dislocation of base of 1st metacarpal characterized by
o volar lip of metacarpal based attached to volar oblique ligament
ligament holds this fragment in place
small fragment of 1st metacarpal continues to articulate with trapezium
Pathoanatomy
o lateral retraction of distal 1st metacarpal shaft by APL and
adductor pollicis
shaft pulled into adduction
metacarpal base supinated
Prognosis
o better than Rolando fx
Imaging
o radiographs
recommended views
fracture best seen with hyper-pronated thumb view
findings
minimal joint step-off considered best
Treatment
o nonoperative
closed reduction & cast immobilization
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indications
nondisplaced fractures
technique
reduction maneuver with traction, extension, pronation, and abduction
o operative
closed reduction and percutaneous pinning
indications
volar fragment is too small to hold a screw
anatomic reduction unstable
technique
can attempt reduction of shaft to trapezium to hold reduction
ORIF
indications
large fragment
2mm+ joint displacement
Complications
o post-traumatic arthritis
there is no agreement regarding the relationship of post-fixation joint incongruity and post-
traumatic arthritis
Rolando Fracture
Intra-articular fracture of base of 1st metacarpal characterized by
o intra-articular comminution
Epidemiology
o less common than Bennett's fracture
Pathoanatomy
o deforming forces are the same as Bennett's fracture
volar fragment should have volar oblique ligament
attached
shaft pulled dorsally
o typically the base is split into a volar and dorsal fragment
commonly called a 'Y' fracture
o often have more than two proximal fragments
Prognosis
o worse than Bennett fx
Treatment
o nonoperative
immobilization
indications
for severe comminution, stable
start early range of motion
o operative
external fixation, CRPP
indications
for severe comminution, unstable
technique
can approximate large fragments with k-wires
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Thumb Trauma
ORIF
indications
most common fixation method
technique
use t-plate or blade plate
can use k-wires of fragments are too small for screw purchase
Complications
o commonly results in post-traumatic osteoarthritis
Extra-articular fracture
Extra-articular fracture of base of 1st metacarpal
o can be transverse or oblique in nature
Treatment
o nonoperative
spica casting
indications
if joint is reduced and there is less than 30 degrees of angulation
o operative
CRPP
indications
if reduction cannot be held to result in less than 30 degrees of angulation
outcome
these fractures typically have the best outcome
Presentation
History
o collide onto fixed object/axial force on a flexed thumb
st
o dorsal force applied to 1 web space
e.g. handlebar driven into a motorcyclist’s thumb on impact)
Symptoms
o pain over thenar eminence
Physical exam
o swelling, bruising over thenar eminence
o unable to form a fist
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Imaging
Radiographs
o radiographs
hand AP, lateral, oblique
MRI
o indications
persistent/recurrent instability after reduction
guide to ligamentous reconstruction
Treatment
Nonoperative
o closed reduction and immobilization in extension and pronation
indications
stable on reduction (implying the AOL is intact)
Operative
o closed reduction and temporary pinning
o reconstruction of the dorsal capsuloligamentous complex with tendon autograft +
temporary pinning
recommended treatment
indications
grossly unstable joint (AOL possibly torn as well)
results
better abduction and pinch strength than closed reduction and pinning
Complications
Anterior osteophyte often visible
Low incidence of recurrent dislocation
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Anatomy
UCL is composed of
o proper collateral ligament
resists valgus load with thumb in flexion
o accessory collateral ligament and volar plate
resists valgus load with thumb in extension
valgus laxity in both flexion and extension is indicative of a complete UCL rupture
Presentation
History
o hyperabduction injury
Symptoms
o pain at ulnar aspect of thumb MCP joint
Physical exam
o inspection and palpation
mass from torn ligament and possible bony avulsion may be present
o stress joint with radial deviation both at neutral and 30° of flexion
instability in 30° of flexion indicates injury to proper UCL
instability in neutral indicates injury to accessory and proper UCL and/or volar plate
compare to uninjured thumb MCP joint
Imaging
Radiographs
o recommended views
AP, lateral and oblique of thumb
valgus stress view may aid in diagnosis if a bony avulsion has already
been ruled out
MRI
o can aid in diagnosis if exam equivocal
Treatment
Nonoperative
o immobilization for 4 to 6 weeks
indications
partial tears with < 20° side to side variation of varus/valgus instability
Operative
o ligament repair
indications
acute injuries with
> 20° side to side variation of varus/valgus instability
>35° of opening
Stener lesion
avulsed ligament with or without bony attachment is displaced above the adductor
aponeurosis
will not heal without surgical repair
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technique
can use suture, suture anchors, or small screw to repair ligament
o reconstruction of ligament with tendon graft, MCP fusion, or adductor advancement
indications
chronic injury
1. Human Bite
Introduction
Epidemiology
o incidence
third most common bite behind dog and cat
o demographics
more common in males
o location
typically dorsal aspect of 3rd or 4th MCP joint
"fight bite"
Pathophyiology
o mechanism
most often result of direct clenched-fist trauma (from tooth) after punching another individual
in the mouth
can also result from direct bite (i.e. child biting another child)
o pathoanatomy
tooth penetrates capsule of MCP joint
flora (bacteria) from mouth enter joint
bacteria become trapped within joint as fist is released from clenched position
bacteria now caught under extensor tendon and/or capsule
o microbiology
typically polymicrobial
most common organisms
alpha-hemolytic streptococcus (S. viridans) and staphylococcus aureus
eikonella corrodens in 7-29%
other gram negative organisms
Associated conditions
o extensor tendon lacerations
can be missed due to proximal tendon retraction
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Presentation
History
o direct clenched-fist trauma to another individual's mouth
often overlooked
must have high index of suspicion as patients often unwilling to reveal history
consider the injury a "fight-bite" until proven otherwise
o possible delay in presentation until symptoms become intolerable
Symptoms
o progressive development of pain, swelling, erythema, and drainage over wound
Physical exam
o fight bite
small wound over dorsal aspect of MCP joint
wound often transverse, irregular
typically 3rd and/or 4th MCPs, but can involve any digit
erythema, warmth, and/or edema overlying wound and joint
± purulent drainage
must assess for integrity of extensor tendon function
possible pain with passive ROM of MCP joint
typically no involvement of volar/flexor surface of digit
neurovascular status typically preserved
Imaging
Radiographs
o indicated to assess for foreign body (i.e. tooth fragment) and for fracture
Studies
Culture
o not routinely obtained in ED due to contamination
o deep culture obtained in OR
aerobic and anaerobic
Treatment
Operative
o I&D, IV antibiotics
indications
fight bite
joints or tendon shealths are involved
antibiotics
IV antibiotics directed at Staph, Strep, and gram-negative organisms
ampicillin/sulbactam (unasyn)
PO antibiotics upon discharge for 5 to 7 days
amoxicillin/clavulanic acid (augmentin)
debridement
debridement of wound and joint capsule
wound left open for drainage
obtain gram stain and culture
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inform lab about potential for Pasteurella
cultures require appropriate growth media and take 1wk to grow
dog bites
Pasteurella (50% of dog bite infections)
Pasteurella canis
Staphylococcus aureus
Streptococcus alpha-hemolytic
Corynebacterium
anerobes (e.g. Bacteroides)
Capnocytophaga canimorsus
rare, potentially fatal (in splenectomy patients)
causes cellulitis, sepsis, endocarditis, meningitis, DIC, ARDS and death
highest mortality in immunocompromised (30-60%)
cat bites
Pasteurella (most common, 70-80% of cat bite infections)
Pasteurella multocida and Pasteurella septica
causes intense pain, swelling in 48h
other organisms similar to dog bites
o rabies
caused by a rhabdovirus
common animal carriers include dogs, raccoons, bats, foxes
increased risk with open wounds, scratches/abrasions, mucous membranes
Prognosis
o serious and fatal bites include
large, aggressive dogs
small children
head and neck bites
Presentation
History
o important to determine
type of animal
time since injury
presence of comorbidities
Symptoms
o pain and swelling
o bleeding
o signs of local or systemic sepsis
Physical Exam
o evaluate depth of puncture wound and presence of crush injury
o check for neurovascular status
o look for joint penetration
o important to photograph wounds
Imaging
Radiographs
o indications to obtain
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crush injuries
suspected fracture
suspected foreign body
Studies
Culture
o indications
if signs of infection are present
routine culture not indicated
o technique
deep aerobic and anaerobic culture
Treatment
Noperative
o copious irrigation, prophylactic antibiotics, tetanus toxoid, +/- rabies prophylaxis
copious irrigation in emergency room
saline (>150ml) irrigation with 18-19G needle or plastic catheter
use povidone-iodine solution if high risk of rabies
indications for antibiotics
cat bites
presentation >8h
immune compromised or diabetic
hand bite
deep bites
choice of antibiotics
amoxicillin/clavulanic acid effective against Pasteurella multocida
cefuroxime
ceftriaxone
rabies prophylaxis
indicated when any suspicion for rapid animal
suspect if unprovoked attack by animal with bizarre behavior
human diploid cell vaccine and human rabies immunoglobulin
immobilization
immobilize and elevate extremity
Operative
o formal surgical debridement
indications
crush or devitalized tissue
foreign body
bites to digital pulp space, nail bed, flexor tendon sheath, deep spaces of the palm, joint
spaces
tenosynovitis
septic arthritis
abscess formation
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Anatomy
Nailbed and surrounding tissue
o perionychium
nail
nailbed
surrounding skin
o paronychium
lateral nail folds
o hyponychium
skin distal distal and palmar to the nail
o eponychium
dorsal nail fold
proximal to nail fold
o lunula : white part of the proximal nail
o matrix
sterile
soft tissue deep to nail
distal to lunula
adheres to nail
germinal
soft tissue deep to nail
proximal to sterile matrix
responsible for most of nail development
insertion of extensor tendon is approximately 1.2 to 1.4 mm proximal to germinal matrix
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Presentation
Symptoms
o pain
Physical exam
o examine for subungual hematoma
o inspect nail integrity
Imaging
Radiographs
o recommended
AP, lateral and oblique of finger
to rule out fracture of distal phalanx
Subungual Hematoma
Most commonly caused by a crushing-type injury
o causes bleeding beneath nail
Treatment
o drainage of hematoma by perforation
indications
less than 50% of nail involved
techniques
puncture nail using sterile needle
electrocautery to perforate nail
o nail removal, D&I, nail bed repair
indications
> 50 % nail involved
technique
nail bed repair (see techniques)
Avulsion Injuries
Avulsion of nail and portion of underlying nail bed
Mechanism
o usually caused by higher energy injuries
Associated conditions
o commonly associated with other injuries including
distal phalanx fracture
if present reduction is advocated
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Treatment
o nail removal, nail bed repair, +/- fx fixation
indications
avulsion injury with minimal or no loss of nail matrix, with or without fracture
technique
always give tetanus and antibiotics
fracture fixation depends on fracture type
o nail removal, nail bed repair, split thickness graft vs. nail matrix transfer, +/- fx fixation
indications
avulsion or crush injury with significant loss of nail matrix
technique
always give tetanus and antibiotics
nail matrix transfer from adjacent injured finger or nail matrix transfer from second toe
fracture fixation depends on fracture type
Techniques
Nail bed repair
o nail removal
soak nail in Betadine while repairing nail bed
o nail bed repair
IV:27 Hook nail
repair nail bed with 6-0 or smaller absorbable suture
RCT has demonstrated quicker repair time using 2-octylcyanoacrylate (Dermabond) instead
of suture with comparable cosmetic and functional results
o splint eponychial fold
splint eponychial fold with original nail, aluminum, or non-adherent gauze
Complications
Hook nail
o caused by advancement of the matrix to obtain coverage without adequate bony support
Treatment : remove nail and trim matrix to level of bone
Split nail
o caused by scarring of the matrix following injury to nail bed
Treatment
excise scar tissue and replace nail matrix
graft may be needed
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o leads to dissection along planes of least resistance (along neurovascular bundles)
o vascular occlusion may lead to local soft tissue necrosis
Prognosis
o Up to 50% amputation rate for organic solvents (paint, paint thinner, diesel fuel, jet fuel, oil)
o severity of the injury is dependent on
time from injury to treatment
force of injection
volume injected
composition of material
grease, latex, chloroflourocarbon & water based paints are less destructive
industrial solvents & oil based paints cause more soft tissue necrosis
Presentation
History
o important to document duration since event
Physical exam
o inspection
entry wound often benign looking
vascular occlusion may lead to local soft tissue necrosis
Imaging
Radiographs
o may be useful to detect spread of radio-opaque dye
Treatment
Nonoperative
o tetanus prophylaxis, parenteral antibiotics, limb elevation, early mobilization, monitoring
for compartment syndrome
indications
for injection of air and water
Operative
o irrigation & debridement, foreign body removal and broad-spectrum antibiotics
indications
most cases require immediate surgical debridement
technique
it is important to remove as much of the foreign material as possible
broad spectrum antibiotic coverage is important to reduce risk of post operative infection
outcomes
higher rates of amputation are seen when surgery is delayed greater than 10 hours after
injury
Complications
Amputation
o amputation rates approach 50% with oil-based paint injection injuries
Infection
o necrotic tissue is a good culture medium for bacterial growth
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5. Frostbite
Introduction
Definition
o extensive soft tissue damage associated with exposure to temperatures below freezing point
Epidemiology
o demographics
males (m:f = 10:1)
age 30-50 years
o risk factors
host factors
alcohol abuse
mental illness
peripheral vascular disease
peripheral neuropathy
malnutrition
chronic illness
tobacco use
race
African descent more likely to sustain frostbite than Caucasians who have better cold
induced vasodilatation
smoking
reduces nitric oxide (vasodilator)
potentiates thrombosis by increasing fibrinogen levels and platelet activity
environmental factors
degree of cold temperature
risk of frostbite is low at > -10°C
risk of frostbite is high at < -25°C
duration of exposure
windchill
tissues at -18°C freeze in 1h at windspeed of 10mph
tissues at -18°C freeze in 10min at windspeed of 40mph
altitude >17,000 feet
contact with conductive materials (water, ice, metal)
Pathophysiology
o with hypothermia (CBT <35°C) circulation shunted from periphery to maintain core body
temperature (CBT)
o cardiac effects
basal metabolic rate, HR and cardiac output drop
myocardial irritability (abnormal EKG)
o neurological effects
disorientation, coma
shivering (anaerobic) until CBT drops below 30-32°C
below 30-32°C, shivering stops and muscle rigidity ensures (like rigor mortis)
resembles death (absent respirations, dilated pupils, muscle rigidity)
must be rewarmed before pronounced dead (“no one is dead until warm and dead”)
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o limbs (4 phases)
phase I (cooling and freezing)
vasoconstriction/vasospasm followed by transient arteriovenous shunting (hunting
response) of cycles of vasodilatation/vasoconstriction every 10min
those who do not have this response are more prone to cold injury
with persistent cold, cycles cease and temperature in tissue drops to freezing point of
tissue (<-2°C)
ice crystals
extracellular ice crystals causes sludging/stasis and intracellular dehydration
(because of osmotic gradient)
intracellular ice crystals destroy cell membranes
interstitial crystallization is exothermic, maintains latent heat to keep limb above
freezing temperature
when crystallization is complete, limb temperature falls to ambient temperature
phase II (rewarming)
reverses freezing process
limb absorbs heat, intra/extracellular ice crystals melt
intracellular swelling occurs
endothelial cells of capillaries become permeable
fluid extravasation leads to blisters/edema
important to prevent re-freezing (freeze-thaw has severe effects on tissues)
phase III (progressive tissue injury)
inflammation, stasis/thrombosis, tissue necrosis
diminished prostaglandin E2 (vasodilator, antiplatelet)
elevated prostaglandin F2a and thromboxane B2 (vasoconstrictors, platelet-aggregating)
o phase IV (resolution)
complete healing with no symptoms
healing with sequelae
early tissue necrosis/gangrene
o cell biology
leads to movement of water from intracellular location to extracellular location
cellular dehydration leads to cell death
o biochemistry
o
ice crystal formation occurs within the extracellular fluid at -2 to -15°C
sensory nerve dysfunction occurs at -10°C
Associated conditions
o frostnip
mildest cold exposure injury
only affects superficial layers of skin (blanching, numbness) but no dermis damage
reversible
o chilblain (pernio)
occurs in cold, nonfreezing temperatures in dry conditions
burning sensation, with pruritus, swelling, erythema
may have blisters, ulceration
resolves in 2 weeks
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may leave chronic vasculitis esp in young/middle-aged women
o trench foot (immersion foot)
military personnel
prolonged wet nonfreezing condition <10°C
o frostbite
results in localized/extensive tissue necrosis
may require amputation
o hypothermia
when core body temperature is affected
can be fatal
Prognosis
o the severity is increased with
alcohol consumption/intoxication
contact of skin with metal or ice
elevated wind chill factor
Presentation
Physical exam
o hypothermia (mild, 32-35°C; moderate, 28-32°C; severe, <28°C)
tachycardia followed by bradycardia, decreased cardiac output, arrythymia (atrial and
ventricular fibrillation)
decreased respiratory rate
CO2 retention leads to hypoxia/respiratory acidosis
disorientation, comatose
o frostbite (similar to burns)
traditional classification
st
1 degree – central whitish area with surrounding erythema
nd
2 degree – clear/cloudy blisters within 24h
rd
3 degree – hemorrhagic blisters / hard black eschars
th
4 degree – tissue necrosis
newer classification
st nd
superficial (1 and 2 degree) has good prognosis
rd th
deep (3 and 4 degree) has poor prognosis
blisters form 6-24 hours after rewarming
superficial lesions present as clear blisters
deeper lesions form hemorrhagic blisters which may be painless
Imaging
MRI
o T2-weighted images shows enhanced signal in necrotic muscles because of disrupted cell
membranes and increased extracellular fluid
99m
Serial bone scans ( Tc)
o can be used to evaluate the severity of the soft-tissue damage
o 1st scan at 2 days after initial injury
absence of uptake has poor prognosis but may not indicate necrosis
o 2nd scan at 5 days after initial injury
normal blood/bone pool = treat expectantly
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Other Traumatic Injuries
diminished blood/bone pool = observation, with potential early debridement
absent blood/bone pool = early debridement or amputation
Treatment for Hypothermia
protect patient from further exposure to freezing temperature
rewarming
o only after confirmation that the patient can be maintained in a constant warm environment (avoid
freeze-thaw cycles)
o external-surface rewarming (for mild hyperthermia)
passive
dry clothes and warm room
active
disadvantage is too-rapid vasodilatation leads to metabolic waste rushing to core, leading
to paradoxical drop in core temperature (“afterdrop”) that can worsen arrythmia
heat lamps, radiant heaters, heating blanket, immersion in warm water with cardiac
monitoring
o internal-core rewarming (for moderate and severe hypothermia)
warmed oxygen, warm IV fluid
body cavity lavage (invasive)
cardiac bypass
requires systemic heparinization
continuous arteriovenous rewarming
blood from femoral arterial catheter into fluid heat exchanger
returns to body through subclavian venous catheter
achieves 1°C every 15min
o avoid alcohol/sedatives
dulls shivering response and further lowers CBT
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whirlpool hydrotherapy
PT and OT for preserve joint motion
Adjunctive (low molecular weight dextran, anticoagulants, tissue plasminogen activator)
o intravenous tPA within 24h reduces rate of digital amputations
indications
no blood flow on bone scan
2nd or 3rd degree (NOT superficial frostbite)
contraindications
general contraindications
alcoholic patients (risk of bleeding from concomitant head injuries)
active internal bleeding
intracranial hemorrhage/surgery within past 3 months
concurrent trauma
major surgery within previous 14 days
known aneurysm or vascular malformation
known bleeding diathesis
pregnancy
labile hypertension
cold-related contraindications
> 24 hours of cold exposure
warm ischemia times >6h
multiple freeze-thaw cycles
o hyperbaric oxygen (anecdotal evidence)
Operative
o immediate surgical escharotomy
circumferentially constrictive lesion of digit
o fasciotomy
for compartment syndrome
o debride clear blisters and apply aloe vera
reduces high levels of prostaglandin F2 and thromboxane B2
o drain/aspirate hemorrhagic blisters (represents deep injury) but leave intact
prevents dessication of underlying dermis
o late debridement/amputation for necrosis
“frostbite in January, amputate in July”
after demarcation occurs at 1-3months
o surgical sympathectomy
reduces duration of pain and time to demarcation of tissue
does not reduce extent of necrosis
Complications
Adults
o persistent pain (50%)
intolerable in 15%
o cold intolerance
o vasospastic disease (Raynauds phenomenon, cold sensitivity, persistent color changes,
hyperhidrosis)
treatment
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calcium channel blockers, vasodilators, beta blockers, surgical sympathetectomy
indications
late, persistent vasospastic disease
o neuropathy (cold/heat hypersensitivity, hypesthesia, paresthesia)
decreased motor/sensory NCV
treatment
decompression e.g. carpal tunnel release
o musculoskeletal (osteopenia)
subchondral bone loss (frostbite arthropathy), joint contractures esp in DIPJ > PIPJ of hands
and feet
treatment
joint arthroplasty, resection arthroplasty
Children
o premature growth plate closure
1-2 years after exposure
secondary to chondrocytic injury
o joint laxity, angular deformities, short digits, excess skin, degenerative joint changes
seen after age 10 in patients with prior frost bite injuries
treatment
physeal arrest, osteotomy, arthrodesis
Collected By : Dr AbdulRahman
AbdulNasser
drxabdulrahman@gmail.com
In June 2017
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ORTHO BULLETS
V. Pelvis Trauma
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Pelvis
A. Pelvis
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Ligaments
o anterior
symphyseal ligaments
resist external rotation
o pelvic floor
sacrospinous ligaments
resist external rotation
sacrotuberous ligaments
resist shear and flexion
o posterior sacroiliac complex (posterior tension band)
strongest ligaments in the body
more important than anterior structures for pelvic ring stability
anterior sacroiliac ligaments
resist external rotation after failure of pelvic floor and anterior structures
interosseous sacroiliac
resist anterior-posterior translation of pelvis
posterior sacroiliac
resist cephalad-caudad displacement of pelvis
iliolumbar
resist rotation and augment posterior SI ligaments
Physical Exam
Symptoms
o pain & inability to bear weight
Physical exam
o inspection
test stability by placing gentle rotational force on each iliac crest
low sensitivity for detecting instability
perform only once
look for abnormal lower extremity positioning
external rotation of one or both extremities
limb-length discrepancy
o skin
scrotal, labial or perineal hematoma, swelling or ecchymosis V:1 Morel-Lavallee lesion
flank hematoma
lacerations of perineum
degloving injuries (Morel-Lavallee lesion)
o neurologic exam
rule out lumbosacral plexus injuries (L5 and S1 are most common)
rectal exam to evaluate sphincter tone and perirectal sensation
o urogenital exam
most common finding is gross hematuria
more common in males (21% in males, 8% in females)
o vaginal and rectal examinations
mandatory to rule out occult open fracture
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Pelvis
Imaging
Radiographs
o AP Pelvis
part of initial ATLS evaluation
look for asymmetry, rotation or
displacement of each hemipelvis
evidence of anterior ring injury needs
further imaging
o inlet view
X-ray beam angled ~45 degrees caudad
(may be as little as 25 degrees)
adequate image when S1 overlaps S2
body
ideal for visualizing: V:2 Normal AP pelvis
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Pelvis
Young-Burgess Classification
Descriptions Treatment
Anterior Posterior Compression (APC)
APC I Symphysis widening < 2.5 cm Non-operative. Protected weight
bearing
APC II Symphysis widening > 2.5 cm. Anterior SI joint Anterior symphyseal plate or external
diastasis. Posterior SI ligaments intact. Disruption fixator +/- posterior fixation
of sacrospinous and sacrotuberous ligaments.
APC III Disruption of anterior and posterior SI ligaments Anterior symphyseal multi-hole plate or
(SI dislocation). Disruption of sacrospinous and external fixator and posterior
sacrotuberous ligaments. stabilization with SI screws or
APCIII associated with vascular injury plate/screws
Lateral Compression (LC)
LC Type I Oblique or transverse ramus fracture and Non-operative. Protected weight
ipsilateral anterior sacral ala compression bearing (complete, comminuted sacral
fracture. component. Weight bearing as
tolerated (simple, incomplete sacral
fracture).
LC Type II Rami fracture and ipsilateral posterior ilium Open reduction and internal fixation of
fracture dislocation (crescent fracture). ilium
LC Type III Ipsilateral lateral compression and contralateral Posterior stabilization with plate or SI
APC (windswept pelvis). screws as needed. Percutaneous or
Common mechanism is rollover vehicle accident open based on injury pattern and
or pedestrian vs auto. surgeon preference.
Vertical Shear
Vertical shear Posterior and superior directed force. Posterior stabilization with plate or SI
Associated with the highest risk of hypovolemic screws as needed. Percutaneous or
shock (63%); mortality rate up to 25% open based on injury pattern and
surgeon preference.
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Young-Burgess Classification
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helps to ensure pin placement within inner and outer table
AIIS pins can place the lateral femoral cutaneous nerve at risk
pedicle screws with internal subcutaneous bar may be used
superior iliac crest pin insertion
multiple half pins in the superior iliac crest
place in thickest portion of ilium (gluteal pillar)
may be placed with minimal fluoroscopy
should be placed before emergent laparotomy
o angiography / embolization
indications
controversial and based on multiple variables including:
protocol of institution, stability of patient, proximity of angiography suite , availability
and experience of IR staff
CT angiography useful for determining presence or absence of ongoing arterial
hemorrhage (98-100% negative predictive value)
contraindications
not clearly defined
technique
selective embolization of identifiable bleeding sources
in patients with uncontrolled bleeding after selective embolization, bilateral temporary
internal iliac embolization may be effective
complications include gluteal necrosis and impotence
Definitive Treatment
Nonoperative
o weight bearing as tolerated
indications
mechanically stable pelvic ring injuries including
LC1
anterior impaction fracture of sacrum and oblique ramus fractures with < 1cm of
posterior ring displacement
APC1
widening of symphysis < 2.5 cm with intact posterior pelvic ring
isolated pubic ramus fractures
parturition-induced pelvic diastasis
bedrest and pelvic binder in acute setting with diastasis less than 4cm
Operative
o ORIF
indications
symphysis diastasis > 2.5 cm
SI joint displacement > 1 cm
sacral fracture with displacement > 1 cm
displacement or rotation of hemipelvis
open fracture
chronic pain and diastasis in parturition-induced diastasis or acute setting >6cm
technique
for open fractures aggressive debridement according to open fracture principles
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Pelvis
o anterior subcutaneous pelvic fixator (INFIX)
indications : same indications as anterior external fixation and symphyseal plating
o diverting colostomy
indications
consider in open pelvic fractures
especially with extensive perineal injury or rectal involvement
Techniques
Anterior ring stabilization
o single superior plate
apply through rectus-splitting Pfannenstiel approach
may perform in conjunction with laparotomy or GU procedure
Posterior ring stabilization
o anterior SI plating
risk of L4 and L5 injury with placement of anterior sacral retractors
o iliosacral screws (percutaneous)
good for sacral fractures and SI dislocations
safe zone is in S1 vertebral body
outlet radiograph view best guides superior-inferior screw placement
inlet radiograph view best guides anterior-posterior screw placement
L5 nerve root injury complication with errors in screw placement
entry point best viewed on lateral sacral view and pelvic outlet views
risk of loss of reduction highest in vertical sacral fracture patterns
o posterior SI "tension" plating
can have prominent HW complications
Anterior and posterior ring stabilization
o necessary in vertically unstable injuries
Ipsilateral acetabular and pelvic ring fractures
o reduction and fixation of the pelvic ring should be performed first
Complications
Neurologic injury
o L5 nerve root runs over sacral ala joint
o may be injured if SI screw is placed to anterior
o anterior subcutaneous pelvic fixator may give rise to LFCN injury (most common) or femoral
nerve injury
DVT and PE
o DVT in ~ 60%, PE in ~ 27%
o prophylaxis essential
mechanical compression
pharmacologic prevention (LMWH or Lovenox)
vena caval filters (closed head injury)
Chronic instability
o rare complication; can be seen in nonoperative cases
o presents with subjective instability and mechanical symptoms
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Urogenital Injuries
Present in 12-20% of patients with pelvic fractures
o higher incidence in males (21%)
Includes
o posterior urethral tear
most common urogenital injury with pelvic ring fracture
o bladder rupture
Anatomy
Ligaments
o the SI joint is stabilized by the posterior pelvic ligaments
sacrospinous
sacrotuberous
anterior sacroiliac
posterior sacroiliac
Nerves
o the L5 nerve root crosses the sacral ala approximately 2 cm
medial to SI joint
Blood supply
o the superior gluteal artery runs across SI joint
o exits pelvis via greater sciatic notch
Classification
No classification system specifically for SI injury
o included in Young- Burgess and Tile classification of pelvic fractures
o crescent fractures described as LC-2 injury according to Young-Burgess
Presentation
Symptoms : pelvic pain
Physical Exam
o assess hemodynamic status
o perform detailed neurological exam
o abdominal assessment to look for distention
o rectal exam
o examine urethral meatus for blood
Imaging
Radiographs : recommended views
AP pelvis
inlet and outlet views
CT scan
o evaluation of sacral fractures
o posterior pelvis better delineated
Treatment
Operative
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o immediate skeletal traction
indications : vertical translation of the hemipelvis
o anterior ring ORIF
indications
incomplete SI dislocations with pubic symphyseal diastasis
o anterior and posterior ring ORIF
indications
complete SI dislocations
vertically unstable require anterior and posterior pelvic ring fixation
o ORIF of ilium
indications
crescent fracture : required to restore posterior SI ligaments and pelvic stability
Techniques
Closed Reduction and Percutaneous Fixation
o positioning
intraoperative traction may aid in reduction
small midline bump under sacrum may assist with SI screw placement
o imaging
inlet view : shows anterior-posterior position of SI joint(s) for screw placement
outlet view : shows cephalad-caudad position of SI joint(s) for screw placement
lateral sacral view
ensures safe placement of SI or sacral screws relative to the anterior cortex of the sacral
ala and the nerve root tunnel
o complications
L5 nerve root at risk with anterior perforation of iliosacral screw as nerve goes inferiorly over
sacral ala
ORIF
o approach
anterior approach : lateral window with elevation iliacus back to SI joint
posterior approach : for fixation of crescent fragment to intact ilium
o fixation
plates
iliosacral lag screws (SI screws)
Complications
DVT : 35%-50%
Neurological injury
Loss of reduction and failure of fixation
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3. Sacral Fractures
Introduction
Under-diagnosed and often mistreated fractures that may result in neurologic compromise
o common in pelvic ring injuries (30-45%)
o 25% are associated with neurologic injury
o frequently missed
75% in patients who are neurologically
intact
50% in patients who have a neurologic
deficit
Epidemiology
o young adults : as a result of high energy trauma
o elderly : as a result of low energy falls
Prognosis
o presence of a neurologic deficit is the most
important factor in predicting outcome
o mistreated fractures may result in
lower extremity deficits
urinary dysfunction
rectal dysfunction
sexual dysfunction
Anatomy
Osteology
o formed by fusion of 5 sacral vertebrae
o articulates with
5th lumbar vertebra proximally
coccyx distally
ilium laterally at sacroiliac joints
o contains 4 foramina which transmit sacral nerves
Nerves
o L5 nerve root runs on top of sacral ala
o S1-S4 nerve roots are transmitted through the sacral
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Classification
Denis classification
o zone 1
fracture lateral to foramina
characteristics
most common (50%)
nerve injury rare (5%)
usually occurs to L5 nerve root
o zone 2
fracture through foramina
characteristics
may be
stable
unstable
zone 2 fracture with shear component highly unstable
increased risk of nonunion and poor functional outcome
o zone 3
fracture medial to foramina into the spinal canal
characteristics
highest rate of neurologic deficit (60%)
bowel, bladder, and sexual dysfunction
Transverse sacral fractures
o higher incidence of nerve dysfunction
U-type sacral fractures
o results from axial loading
o represent spino-pelvic dissociation
o high incidence of neurologic complications
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Pelvis
Presentation
History
o motor vehicle accident or fall from height most common
o repetitive stress
insufficiency fracture in osteoporotic adults
Symptoms
o peripelvic pain
Physical exam
o inspection
soft tissue trauma around pelvis should raise concerns for pelvic or sacral fracture
o palpation
test pelvic ring stability by internally and externally rotating iliac wings
palpate for subcutaneous fluid mass indicative of lumbosacral fascial degloving (Morel-
Lavallee lesion)
perform vaginal exam in women to rule-out open injury
o neurologic exam
rectal exam
light touch and pinprick sensation along S2-S5 dermatomes
perianal wink
bulbocavernosus and cremasteric reflexes
o vascular exam
distal pulses
if different consider ankle-brachial index or angiogram
Imaging
Radiographs
o only show 30% of sacral fractures
o recommended views
AP pelvis
inlet view
best assessment of sacral spinal canal and superior view of S1
outlet view
provides true AP of sacrum
o additional views
cross-table lateral
effective screening tool for sacral fractures
often of poor quality
o findings
L4 or L5 transverse process fractures
asymmetric foramina
CT
o diagnostic study of choice
o recommend coronal and sagittal reconstruction views
MRI
o recommended when neural compromise is suspected V:4 Cross table lateral view
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Treatment
Nonoperative
o progressive weight bearing +/- orthosis
indications
<1 cm displacement and no neurologic deficit
insufficiency fractures
Operative
o surgical fixation
indications
displaced fractures >1 cm
soft tissue compromise
persistent pain after non-operative management
displacement of fracture after non-operative management
o surgical fixation with decompression
indications
any evidence of neurologic injury
Surgical Techniques
Percutaneous screw fixation
o screws may be placed as sacroiliac, trans-sacral or trans-iliac trans-sacral
o useful for sagittal plane fractures
o technique
screws placed percutaneously under fluoroscopy
beware of L5 nerve root
avoid overcompression of fracture
may cause iatrogenic nerve dysfunction
o cons
may result in loss of fixation or malreduction
does not allow for removal of loose bone fragments
do not use in osteoporotic bone
Posterior tension band plating
o approach : posterior two-incision approach
o technique
may use in addition to iliosacral screws
o pros : allows for direct visualization of fracture
o cons : wound healing complications
Iliosacral and lumbopelvic fixation
o approach
posterior approach to lower lumbar spine and sacrum
o technique
pedicle screw fixation in lumbar spine
iliac screws parallel to the inclination angle of outer table of ilium
longitudinal and transverse rods
o pros
shown to have greatest stiffness when used for an unstable sacral fracture
o cons
invasive
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Decompression of neural elements
o technique
indirect
reduction through axial traction
direct
posterior approach followed by laminectomy or foraminotomy
Complications
Venous thromboembolism
o often as a result of immobility
Iatrogenic nerve injury
o may result from
overcompression of fracture
improper hardware placement
Malreduction
o more common with vertically displaced fractures
4. Ilium Fractures
Introduction
Most are unstable fractures
Typically progress from iliac crest to greater sciatic notch
Iliac wing fractures have high incidence of associated injuries
o open injuries
o bowel entrapment
o soft tissue degloving
Anatomy
Osteology
o pelvic girdle is comprised of
sacrum
2 innominate (coxal) bones
each formed from the union of 3 bones: ilium, ischium, and pubis
o ilium
2 important anterior prominences
anterior-superior iliac spine (ASIS)
origin of sartorius and transverse and internal abdominal muscles
anterior-inferior iliac spine (AIIS)
origin of direct head of rectus femoris and iliofemoral ligament (Y ligament of
Bigelow)
posterior prominences
posterior-superior iliac spine (PSIS)
located 4-5 cm lateral to the S2 spinous process
posterior-inferior iliac spine (PIIS)
Imaging
Plain radiographs
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o standard set of AP pelvis, inlet/outlet, and judet views
helpful for evaluating the iliac wing in addition to pelvic stability and possible acetabular
involvement
CT scan
o carefully assess CT scan for signs of bowel entrapment
o evaluate for presence of gas or air in the soft tissues which can be associated with open injury or
bowel disruption
Classification
No specific classification for iliac wing fractures
Generally described as specific subtypes of more common classification systems
o Tile Classification
stable (intact posterior arch)
A1-1: iliac spine avulsion injury
A1-2: iliac crest avulsion
A2-1: iliac wing fractures often from a direct blow
partially stable (incomplete disruption of posterior arch)
B2-3: incomplete posterior iliac fracture
unstable (complete disruption of posterior arch)
C1-1: unilateral iliac fracture
Treatment
Nonoperative
o mobilization with an assist device
indications
nondisplaced fractures
isolated iliac wing fractures
Operative
o open reduction and internal fixation
indications
displaced fractures of ilium
Operative Techniques
Wound Management
o evaluate all wounds for
soft tissue disruption or internal degloving injury
possible soft tissue or bowel entrapment in the fracture site
o prophylactic antibiotics as appropriate
o serial debridements as necessary
Open Reduction Internal Fixation
o approach
posterior approach
ilioinguinal approach
Stoppa approach (lateral window)
o recommend early reconstruction
single pelvic reconstruction plate or lag screw along the iliac crest
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Acetabulum
supplemented with a second reconstruction plate or lag screw at the level of the pelvic brim
or sciatic buttress
o coordination with trauma team
injury to bowel may require diversion procedures
plan surgical intervention with trauma team to minimize recurrent trips to the operating room
Complications
Malunion with deformity of the iliac wing
Internal iliac artery injury
Bowel perforation
Lumbosacral plexus injury
B. Acetabulum
1. Acetabular Fractures
Introduction
Epidemiology
o demographics
bimodal distribution
high energy blunt trauma for young patients
low energy (fall from standing height) for elderly patients
o location
posterior wall fractures are most common
Pathoanatomy
o fracture pattern determined by
force vector
position of femoral head at time of injury
Associated conditions
o orthopaedic manifestations
extremity injury (36%)
nerve palsy (13%)
spine injury (4%)
o systemic injuries
head injury (19%)
chest injury (18%)
abdominal injury (8%)
genitourinary injury (6%)
Classification Systems
o Judet and Letournel
classifed as 5 elementary and 5 associated fracture patterns
o AO/OTA Classification
Anatomy
Osteology
o acetabular inclination & anteversion
mean lateral inclination of 40 to 48 degrees
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anteversion of 18 to 21 degrees
o column theory
acetabulum is supported by two columns of bone
form an "inverted Y"
connected to sacrum through sciatic buttress
posterior column
comprised of
quadrilateral surface
posterior wall and dome
ischial tuberosity
greater/lesser sciatic notches
anterior column
comprised of
anterior ilium (gluteus medius tubercle)
anterior wall and dome
iliopectineal eminence
lateral superior pubic ramus
Vascular V:5 column theory form inverted Y
o corona mortis
anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels
at risk with lateral dissection over superior pubic ramus
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Letournel Classification
Elementary
• Most common
Posterior wall • "gull sign" on obturator oblique view
Posterior column • check for injury to superior gluteal NV bundle
Anterior wall • Very rare
Anterior column • More common in elderly patients with fall from standing (most common in
elderly is "anterior column + medial wall")
Transverse • Axial CT shows anterior to posterior fx line
• Only elementary fx to involve both columns
Associated
Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone
• will see "spur sign" on obturator oblique
Transverse + Post. Wall • Most common associated fx
T Shaped • May need combined approach
Anterior column or wall + • Common in elderly patients
Post. hemitransverse
Post. column + Post. wall • Only associated fracture that does not involve both columns
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Transverse + Post. Wall CT Transverse + Post. Wall x-ray Transverse + Post. Wall CT
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Imaging
Radiographs
o recommended views
AP pelvis, Judet views, inlet and outlet if
concerned for pelvic ring involvement
o 6 radiographic landmarks of the acetabulum
iliopectineal line (anterior column)
ilioischial line (posterior column)
anterior rim
posterior rim
teardrop
weight bearing roof
o superior acetabular rim may show os acetabuli
marginalis superior which can be confused for fracture in adolescents
o Judet views (45 degree oblique views)
obturator oblique
shows profile of obturator foramen
shows anterior column and posterior wall
iliac oblique
shows profile of involved iliac wing
shows posterior column and anterior wall
o roof arc measurements
show intact weight bearing dome if > 45 degrees on
AP, obturator, and iliac oblique
not applicable for associated both column or posterior
wall pattern because no intact portion of the
acetabulum to measure
CT scan
o important to
define fragment size and orientation
identify marginal impaction
identify loose bodies
look for articular gap or step-off
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Treatment
Nonoperative
o protected weight bearing for 6-8 weeks
indications
minimally displaced fracture (< 2mm)
< 20% posterior wall fractures
treatment based on size of posterior wall is controversial
exam under anesthesia using fluoroscopy best method to test stability
femoral head remains congruent with weight bearing roof (out of traction)
both column fracture with secondary congruence (out of traction)
displaced fracture with roof arcs > 45 degrees in AP and Judet views
relative contraindications to surgery
morbid obesity
open contaminated wound
presence of DVT
technique
lowest joint reactive forces seen with toe-touch weight
bearing and passive hip abduction
greatest joint contact force seen when rising from a
chair on the affecdted extremity
close radiographic follow-up
skeletal traction rarely indicated as definitive treatment
Operative treatment
o open reduction and internal fixation
indications
displacement of roof (>2mm)
posterior wall fracture involving > 40-50%
marginal impaction
intra-articular loose bodies
irreducible fracture-dislocation
pregnancy is not contraindication to surgical fixation
outcomes
associated hip dislocations should be reduced within 12 hours for improved outcomes
clinical outcome correlates with quality of articular reduction
earlier operative treatment associated with increased chance of anatomic reduction
postoperative CT scan is most accurate way to determine posterior wall accuracy of
reduction which has greatest correlation with clinical outcome
greatest stress on acetabular repair occurs when rising from a seated position using the
affected leg, and occurs in the posterior superior portion of the acetabulum
functional outcomes most strongly correlate with hip muscle strength and restoration of
gait postoperatively
o open reduction and internal fixation with acute total hip arthroplasty
indications
significant osteopenia and/or significant comminution
outcomes
up to 78% 10-year implant survival noted
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worse outcomes in males, patients <50 years old or >80kg, or if a significant acetabular
defect remains
o percutaneous fixation with column screws
indications
anterior column screws
Techniques
Percutaneous fixation with column screws
o approach
anterograde (from iliac wing to ramus)
retrograde (from ramus to iliac wing)
posterior column screws
o imaging
obturator oblique best view to rule out joint penetration
inlet iliac oblique view best to determine anteroposterior position of screw within the pubic
ramus
obturator oblique inlet view best to determine position of a supraacetabular screw within
tables of the ilium
ORIF
o approaches
approach depends on fracture pattern
two approaches can be combined
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Approaches Indications Risks
Anterior Approach • anterior wall and anterior column • femoral nerve injury
(Ilioinguinal) • both column fracture • LFCN injury
• posterior hemitransverse • thrombosis of femoral vessels
• laceration of corona mortis in 10-15%.
Posterior Approach • posterior wall and posterior column fx • increased HO risk compared with
(Kocher-Langenbach) • most transverse and T-shaped anterior approach
• combination of above •sciatic nerve injury (2-10%)
• damage to blood supply of femoral head
(medial femoral circumflex)
Extensile Approach • only single approach that allows direct • massive heterotopic ossification
(extended iliofemoral) visualization of both columns • posterior gluteal muscle necrosis
• associated fracture pattern 21 days after
injury
• some transverse fxs and T types
• some both column fxs (if posterior
comminution is present)
Modified Stoppa • access to quadrilateral plate to buttress • Corona mortis must be exposed and
Approach comminuted medial wall fractures ligated in this approach
Complications
Post-traumatic DJD
o most common complication
o 80% survival noted at 20 years for patients s/p ORIF
o risk factors for DJD include
age >40
associated fracture patterns
concomitant femoral head injury
o treat with hip fusion or THA
Heterotopic Ossification
o highest incidence with extensile approach
treat with
indomethacin x 5 weeks post-op
low dose external radiation (no difference shown in direct comparison)
o lowest incidence with anterior ilioinguinal approach
Osteonecrosis
o 6-7% of all acetabular fractures
o 18% of posterior fracture patterns
DVT and PE
Infection
Bleeding
Neurovascular injury
Intraarticular hardware placement
Abductor muscle weakness
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Acetabulum
2. Hip Dislocation
Introduction
Epidemiology
o rare, but high incidence of associated injuries
o mechanism is usually young patients with high energy trauma
Hip joint inherently stable due to
o bony anatomy
o soft tissue constraints including
labrum
capsule
ligamentum teres V:8 Dashboard injury
Classification
Simple vs. Complex
o simple
pure dislocation without associated fracture
o complex
dislocation associated with fracture of acetabulum or
proximal femur
Anatomic classification
o posterior dislocation (90%)
occur with axial load on femur, typically with hip flexed V:9 Clinical picture of
and adducted posterior dislocation
axial load through flexed knee (dashboard injury)
position of hip determines associated acetabular injury
increasing flexion and adduction favors simple dislocation
associated with
osteonecrosis
posterior wall acetabular fracture
femoral head fractures
sciatic nerve injuries
ipsilateral knee injuries (up to 25%)
o anterior dislocation
associated with femoral head impaction or chondral injury
occurs with the hip in abduction and external rotation
inferior ("obturator") vs. superior ("pubic")
hip extension results in a superior (pubic) dislocation
Clinically hip appears in extension and external rotation
flexion results in inferior (obturator) dislocation
Clinically hip appears in flexion, abduction, and external rotation
Presentation
Symptoms
o acute pain, inability to bear weight, deformity
Physical exam
o ATLS
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95% of dislocations with associated injuries
o posterior dislocation (90%)
hip and leg in slight flexion, adduction, and internal rotation
detailed neurovascular exam (10-20% sciatic nerve injury)
examine knee for associated injury or instability
chest X-ray ATLS workup for aortic injury
o anterior dislocation
hip and leg in flexion, abduction, and external rotation
Imaging
Radiographs
o can typically see posterior dislocation on AP pelvis V:10 Anteior dislocation
femoral head smaller then contralateral side
Shenton's line broken
lesser trochanter shadow reveals internally rotated limb as compared to contralateral side
scrutinize femoral neck to rule out fracture prior to attempting closed reduction
CT
o helps to determine direction of dislocation, loose bodies, and associated fractures
anterior dislocation
posterior dislocation
o post reduction CT must be performed for all traumatic hip
dislocations to look for
femoral head fractures
loose bodies
acetabular fractures
MRI
o controversial and routine use is not currently supported
o useful to evaluate labrum, cartilage and femoral head vascularity
Loose fragment in
Anterior dislocation Posterior dislocation Associated neck fx the joint AP view posterior dislocation
Treatment
Nonoperative
o emergent closed reduction within 6 hours
indications
acute anterior and posterior dislocations
contraindications
ipsilateral displaced or non-displaced femoral neck fracture
Operative
indications
irreducible dislocation
radiographic evidence of incarcerated fragment
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Acetabulum
delayed presentation
non-concentric reduction
should be performed on urgent basis
o ORIF
indications
associated fractures of
acetabulum
femoral head
femoral neck : should be stabilized prior to reduction
o arthroscopy
indications
no current established indications
potential for removal of intra-articular fragments
evaluate intra-articular injuries to cartilage, capsule, and labrum
Techniques
Closed reduction
o perform with patient supine and apply traction in line with deformity regardless of direction of
dislocation
o must have adequate sedation and muscular relaxation to perform reduction
o assess hip stability after reduction
o post reduction CT scan required to rule out
femoral head fractures
intra-articular loose bodies/incarcerated fragments
may be present even with concentric reduction on plain films
acetabular fractures
o post-reduction : for simple dislocation, follow with protected weight bearing for 4-6 weeks
Open reduction
o approach
posterior dislocation : posterior (Kocher-Langenbeck) approach
anterior dislocation : anterior (Smith-Petersen) approach
o technique
may place patient in traction to reduce forces on cartilage due to incarcerated fragment or in
setting of unstable dislocation
repair of labral or other injuries should be done at the same time
Complications
Post-traumatic arthritis
o up to 20% for simple dislocation, markedly increased for complex dislocation
Femoral head osteonecrosis : 5-40% incidence
o Increased risk with increased time to reduction
Sciatic nerve injury : 8-20% incidence
o associated with longer time to reduction
Recurrent dislocations : less than 2%
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ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Femur
A. Femur
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Classification
Pipkin Classification
Type I Fx below fovea/ligamentum (small)
Does not involve the weightbearing portion of the femoral
head
Presentation
History
o frontal impact MVA with knee striking dashboard
o fall from height
Symptoms
o localized hip pain
o unable to bear weight
o other symptoms associated with impact
Physical exam
o inspection
shortened lower limb
with large acetabular wall fractures, little to no rotational asymmetry is seen
posterior dislocation
limb is flexed, adducted, internally rotated
anterior dislocation
limb is flexed, abducted, externally rotated
o neurovascular
may have signs of sciatic nerve injury
Imaging
Radiographs
o recommended views
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Femur
AP pelvis, lateral hip and Judet views
both pre-reduction and post-reduction
inlet and outlet views
if acetabular or pelvic ring injury suspected
CT scan
o indications
after reduction
to evaluate:
concentric reduction
loose bodies in the joint
acetabular fracture
femoral head or neck fracture
o findings
femoral head fracture
intra-articular fragments
posterior pelvic ring injury
impaction
acetabular fracture
Treatment
Nonoperative
o hip reduction
indications VI:1 Fixation of head femur by scews
acute dislocations
reduce hip dislocation within 6 hours
technique
obtain post reduction CT
o TDWB x 4-6 weeks, restrict adduction and internal rotation
indications
Pipkin I
undisplaced Pipkin II with < 1mm step off
no interposed fragments
stable hip joint
technique
perform serial radiographs to document maintained reduction
Operative
o ORIF
indications
Pipkin II with > 1mm step off
if performing removal of loose bodies in the joint
associated neck or acetabular fx (Pipkin type III and IV)
polytrauma
irreducible fracture-dislocation
Pipkin IV
treatment dictated by characteristics of acetabular fracture
small posterior wall fragments can be treated nonsurgically and suprafoveal fractures
can then be treated through an anterior approach
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outcomes
outcomes mimic those of their associated injuries (hip dislocations and femoral neck
fractures)
poorer outcomes associated with
use of posterior (Kocher-Langenbeck) approach
use of 3.0mm cannulated screws with washers
o arthroplasty
indications
Pipkin I, II (displaced), III, and IV in older patients
fractures that are significantly displaced, osteoporotic or comminuted
Surgical Techniques
ORIF of femoral head (Pipkin I, II, III)
o approach
anterior (Smith-Peterson) approach
the anterior (Smith-Peterson) and anterolateral (Watson-Jones) approaches provide the
best visualization of the head compared with the posterior approach
utilizes internervous plane between the superior gluteal and femoral nerves
no increased risk of AVN
shorter surgical time
less blood loss
ease of reduction and fixation
because femoral head fragment is commonly anteromedial
can use surgical hip dislocation if needed
anterolateral (Watson-Jones)
utilizes intermuscular plane between the tensor
fascia lata and gluteus medius (both superior
gluteal nerve)
o exposure
periacetabular capsulotomy to preserve blood supply
to femoral head
o fixation
two or more 2.7mm or 3.5mm lag screws
countersink the heads of the screws to avoid screw head
prominence
headless compression screws
bioabsorbable screws
o postop
rehabilitation
mobilization
immediate early range of motion
weightbearing
delay weight bearing for 6-8 weeks
stress strengthening of the quadriceps and abductors
radiographs
radiographs after 6 months to evaluate for AVN and osteoarthritis
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Femur
ORIF of femoral head and acetabulum (Pipkin IV)
o approach
posterior (Kocher-Langenbeck) approach with digastric osteotomy
provides the best visualization of femoral head fracture and acetabular posterior wall
fracture
preserves the medial circumflex artery supply to the femoral head
utilizes plane created by splitting of gluteus maximus (no true internervous plane
gluteus maximus is not denervated because it receives nerve supply well medial to the
split
anterior (Smith-Peterson) approach
for fixation of suprafoveal fractures (if posterior wall fragments are small, they can be
treated nonsurgically)
Arthroplasty
o approach
can use any hip approach for arthroplasty
posterior (Kocher-Langenbeck) approach provides the best visualization of
acetabular posterior wall fracture
o pros & cons
allows immediate postoperative mobilization and weightbearing
hemiarthroplasty can be utilized if no acetabular fracture present
total hip arthroplasty favored if patient physiologically younger or if acetabular fracture
present
Complications
Heterotopic ossification
o overall incidence is 6-64%
anterior approach has increased heterotopic ossification
compared with posterior approach
o treatment
administer radiation therapy if there is concern for HO
especially if there is associated head injury
AVN
o incidence is 0-23%
risk is greater with delayed reduction of dislocated hip
the impact of anterior incision on AVN is unknown
VI:2 Heterotopic ossification
Sciatic nerve neuropraxia
o incidence is 10-23%
usually peroneal division of sciatic nerve
spontaneous recovery of function in 60-70%
DJD
o incidence 8-75%
o due to joint incongruity or initial cartilage damage
o Decreased internal rotation : may not be clinically problematic or cause disability
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Classification
Garden Classification
(based on AP radiographs and does not consider lateral or sagittal plane alignment)
Type I Incomplete, ie. valgus impacted
Type II Complete fx. nondisplaced
Type III Complete, partially displaced
Type IV Complete, fully displaced
Posterior roll-off and/or angulation of femoral head leads to increased reoperation rates
Pauwels Classification
(based on vertical orientation of fracture line)
Type I < 30 deg from horizontal
Type II 30 to 50 deg from horizontal
Type III > 50 deg from horizontal (most unstable with highest risk of nonunion and AVN)
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Presentation
Symptoms
o impacted and stress fractures
slight pain in the groin or pain referred along the medial side of the thigh and knee
o displaced fractures
pain in the entire hip region
Physical exam
o impacted and stress fractures
no obvious clinical deformity
minor discomfort with active or passive hip range of motion, muscle spasms at extremes of
motion
pain with percussion over greater trochanter
o displaced fractures
leg in external rotation and abduction, with shortening
Imaging
Radiographs
o recommended views
obtain AP pelvis and cross-table lateral, and full length femur film of ipsilateral side
consider obtaining dedicated imaging of uninjured hip to use as template intraop
traction-internal rotation AP hip is best for defining fracture type
Garden classification is based on AP pelvis
CT
o helpful in determining displacement and degree of comminution in some patients
MRI
o helpful to rule out occult fracture
o not helpful in reliably assessing viability of femoral head after fracture
Bone scan
o helpful to rule out occult fracture
o not helpful in reliably assessing viability of femoral head after fracture
Duplex Scanning
o indication
rule out DVT if delayed presentation to hospital after hip fracture
Treatment
Nonoperative
o observation alone
indications
may be considered in some patients who are non-ambulators, have minimal pain, and who
are at high risk for surgical intervention
Operative
o ORIF
indications
displaced fractures in young or physiologically young patients
ORIF indicated for most pts <65 years of age
Techniques
General Surgical Consideration
o time to surgery
controversial
reduction method and quality has more pronounced effect on healing than surgical timing
elderly patients with hip fractures should be brought to surgery as soon as medically optimal
the benefits of early mobilization cannot be overemphasized
improved outcomes in medically fit patients if surgically treated less than 4 days from
injury
o treatment approach based on
degree of displacement
physiologic age of the patient (young is < than 50
ipsilateral femoral neck and shaft fractures
priority goes to fixing femoral neck because anatomic reduction is necessary to avoid
complications of AVN and nonunion
o fixation with implants that allow sliding
permit dynamic compression at fx site during axial loading
can cause shortening of femoral neck
prominent implants
affects biomechanics of hip joint
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lower physical function on SF-36
decreased quality of life
anatomic reduction with intraop compression and placement of length stable devices decrease
shortening
o open versus closed reduction
worse outcomes with displacement > 5 mm (higher rate of osteonecrosis and nonunions)
no consensus on which reduction approach is superior
multiple closed reduction attempts are associated with higher risk of osteonecrosis of the
femoral head
ORIF
o approach
limited anterior Smith-Peterson
10cm skin incision made beginning just distal to AIIS
incise deep fascia
develop interval between sartorious and TFL
external rotation of thigh accentuates dissection plane
LFCN is identified and retracted medially with sartorius
identify tendinous portion of rectus femoris, elevate off hip capsule
open capsule to identify femoral neck
Watson-Jones
used to gain improved exposure of lower femoral neck fractures
skin incision approx 2cm posterior and distal to ASIS, down toward tip of greater
trochanter
incision curved distally and extended 10cm along anterior portion of femur
incise deep fascia
develop interval between TFL and gluteus medius
anterior aspect of gluteus medius and minimus is retracted posteriorly to visualize
anterior hip capsule
capsule sharply incised with Z-shape incision
capsulotomy must remain anterior to lesser trochanter at all times to avoid injury to
medial femoral circumflex artery
reduction (method may vary)
evacuate hematoma
place A to P k-wires into femoral neck/head proximal to fracture to use as joysticks for
reduction
insert starting k-wire (for either cannulated screw or sliding hip screw) into appropriate
position laterally, up to but not across the fracture
once reduction obtained, drive starting k-wire across fracture
insert second threaded tipped k-wire if adding additional fixation
Cannulated Screw Fixation
o technique
three screws if noncomminuted (3 screw inverted triangle shown to be superior to two
screws)
order of screw placement (this varies)
1-inferior screw along calcar
2-posterior/superior screw
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3-anterior/superior screw
obtain as much screw spread as possible in femoral neck
inverted triangle along the calcar (not central in the neck) has stronger fixation and higher
load to failure
four screws considered for posterior comminution
clear advantage of additional screws not proven in literature
starting point at or above level of lesser trochanter to avoid fracture
avoid multiple cortical perforations during guide pin or screw placement to avoid
development of lateral stress riser
Hemiarthroplasty
o approach
posterior approach has increased risk of dislocations
anterolateral approach has increased abductor weakness
o technique
cemented superior to uncemented
unipolar vs. bipolar
Total Hip Replacement
o technique
should consider using the anterolateral approach and selective use of larger heads in the
setting of a femoral neck fracture
o advantages
improved functional hip scores and lower re-operation rates compared to hemiarthroplasty
o complications
higher rate of dislocation with THA (~ 10%)
about five times higher than hemiarthroplasty
Complications
Osteonecrosis
o incidence of 10-45%
o recent studies fail to demonstrate association between time to fracture reduction and subsequent
AVN
o increased risk with
increase initial displacement
AVN can still develop in nondisplaced injuries
nonanatomical reduction
o treatment
major symptoms not always present when AVN develops
young patient
> 50% involvement then treat with FVFG vs THA
older patient
prosthetic replacement (hemiarthroplasty vs THA)
Nonunion
o incidence of 5 to 30%
increased incidence in displaced fractures
no correlation between age, gender, and rate of nonunion
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o varus malreduction most closely correlates with failure of fixation after reduction and cannulated
screw fixation.
o treatment
valgus intertrochanteric osteotomy
indicated in patients after femoral neck nonunion
can be done even in presence of AVN, as long as not severely collapsed
turns vertical fx line into horizontal fx line and decreases shear forces across fx line
free vascularized fibula graft (FVFG)
indicated in young patients with a nonviable femoral head
arthroplasty
indicated in older patients or when the femoral head is not viable
also an option in younger patient with a nonviable femoral head as opposed to FVFG
revision ORIF
Dislocation
o higher rate of dislocation with THA (~ 10%)
about seven times higher than hemiarthroplasty
3. Intertrochanteric Fractures
Introduction
Extracapsular fractures of the proximal femur between the greater and lesser trochanters
Epidemiology
o incidence
roughly the same as femoral neck fractures
o demographics
female:male ratio between 2:1 and 8:1
typically older age than patients with femoral neck fractures
o risk factors
proximal humerus fractures increase risk of hip fracture for 1 year
Pathophysiology
o mechanism
elderly
low energy falls in osteoporotic patients
young
high energy trauma
Prognosis
o nonunion and malunion rates are low
o 20-30% mortality risk in the first year following fracture
o factors that increase mortality
male gender (25-30% mortality) vs female (20% mortality)
higher in intertrochanteric fracture (vs femoral neck fracture)
operative delay of >2 days
age >85 years
2 or more pre-existing medical conditions
ASA classification (ASA III and IV increases mortality)
o surgery within 48 hours decreases 1 year mortality
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o earlymedical optimization and co-management with medical hospitalists or geriatricians can
improve outcomes
Anatomy
Osteology
o intertrochanteric area exists between greater and lesser trochanters
o made of dense trabecular bone
o calcar femorale
vertical wall of dense bone that extends from posteromedial aspect of femoral shaft to
posterior portion of femoral neck
helps determine stable versus unstable fracture patterns
Classification
Stability of fracture pattern is arguably the most reliable method of classification
o stable
definition
intact posteromedial cortex
clinical significance
will resist medial compressive loads once reduced
o unstable
definition
comminution of the posteromedial cortex
clinical significance
fracture will collapse into varus and retroversion when loaded
examples
fractures with a large posteromedial fragment
i.e., lesser trochanter is displaced
subtrochanteric extension
reverse obliquity
oblique fracture line extending from medial cortex both laterally and distally
Presentation
Physical Exam
o painful, shortened, externally rotated lower extremity
Imaging
Radiographs
o recommended views
AP pelvis
AP of hip, cross table lateral
full length femur radiographs
CT or MRI
o useful if radiographs are negative but physical exam consistent with fracture
Treatment
Nonoperative
o nonweightbearing with early out of bed to chair
indications
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nonambulatory patients
patients at high risk for perioperative mortality
outcomes
high rates of pneumonia, urinary tract infections, decubiti, and DVT
Operative
o sliding hip compression screw
indications
stable intertrochanteric fractures
outcomes
equal outcomes when compared to intramedullary hip screws for stable fracture patterns
o intramedullary hip screw (cephalomedullary nail)
indications
stable fracture patterns
unstable fracture patterns
reverse obliquity fractures
56% failure when treated with sliding hip screw
subtrochanteric extension
lack of integrity of femoral wall
associated with increased displacement and collapse when treated with sliding hip
screw
outcomes
equivalent outcomes to sliding hip screw for stable fracture patterns
use has significantly increased in last decade
o arthroplasty
indications
severely comminuted fractures
preexisting symptomatic degenerative arthritis
osteoporotic bone that is unlikely to hold internal fixation
salvage for failed internal fixation
Techniques
Sliding hip compression screw
o technique
must obtain correct neck-shaft relationship
lag screw with tip-apex distance >25 mm is associated with increased failure rates
4 hole plates show no benefit clinically or biomechanically over 2 hole plates
o pros
allows dynamic interfragmentary compression
low cost
o cons
open technique
increased blood loss
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Femur
medialization of shaft
can cause anterior spike malreduction in left-sided, unstable fractures due to screw torque
Intramedullary hip screw
o technique
short implants with optional distal locking
standard obliquity fractures
long implants
standard obliquity fractures
reverse obliquity fractures
subtrochanteric extension
o pros
percutaneous approach
minimal blood loss
may be used in unstable fracture patterns
o cons
increased incidence of screw cutout
periprosthetic fracture
higher cost than sliding hip screw
Arthroplasty
o technique
calcar-replacing prosthesis often needed
must attempt fixation of greater trochanter to shaft
o pros
possible earlier return for full weight bearing
o cons
increased blood loss
may require prosthesis that some surgeons are unfamiliar with
Complications
Implant failure and cutout
o incidence
most common complication
usually occurs within first 3 months
o cause
tip-apex distance >45 mm associated with 60% failure rate
o treatment
young
corrective osteotomy and/or revision open reduction and internal fixation
elderly
total hip arthroplasty
Anterior perforation of the distal femur
o incidence
can occur following intramedullary screw fixation
o cause
mismatch of the radius of curvature of the femur (shorter) and implant (longer)
Nonunion
o incidence : <2%
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o treatment
revision ORIF with bone grafting
proximal femoral replacement
Malunion
o incidence
varus and rotational deformities are common
o treatment : corrective osteotomies
4. Subtrochanteric Fractures
Introduction
Subtrochanteric typically defined as area from lesser trochanter to 5cm distal
o fractures with an associated intertrochanteric component may be called
intertrochanteric fracture with subtrochanteric extension
peritrochanteric fracture
Epidemiology
o usually in younger patients with a high-energy mechanism
o may occur in elderly patients from a low-energy mechanism
rule out pathologic or atypical femur fracture
denosumab or bisphosphonate use, particularly
alendronate, can be risk factor
Pathoanatomy
o deforming forces on the proximal fragment are
abduction I:3 atypical subtrochanteric fracture
V
with thickening of lateral cortix
gluteus medius and gluteus minimus
(bisphosphonate use )
flexion
iliopsoas
external rotation
short external rotators
o deforming forces on distal fragment
adduction & shortening
adductors
Anatomy
Biomechanics
o weight bearing leads to net compressive forces on medial cortex
and tensile forces on lateral cortex
Classification
Russel-Taylor Classification
Type I No extension into piriformis fossa
Type II Extension into greater trochanter with involvement of piriformis fossa
• look on lateral xray to identify piriformis fossa extension
• Historically used to differentiate between fractures that would amenable to an intramedullary nail (type I) and those
that required some form of a lateral fixed angle device (type II)
• Current interlocking options with both trochanteric and piriformis entry nails allow for treatment of type II fractures
with intramedullary implants
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All major features should be present to designate a fracture as atypical; minor features may or may not be
present in individual cases
Major • Located anywhere along the femur from just distal to the lesser trochanter to just proximal to
Criteria the supracondylar flare
• Associated with no trauma or minimal trauma, as in a fall from a standing height or less
• Transverse or short oblique configuration
• Noncomminuted
• Complete fractures extend through both cortices and may be associated with a medial spike;
incomplete fractures involve only the lateral cortex
Minor • Localized periosteal reaction of the lateral cortex
Criteria • Generalized increase in cortical thickness of the diaphysis
• Prodromal symptoms such as dull or aching pain in the groin or thigh
• Bilateral fractures and symptomscomplete fractures involve only the lateral cortex
• Delayed healing
• Comorbid conditions (eg, vitamin D deficiency, rheumatoid arthritis, hypophosphatasia)
• Use of pharmaceutical agents (eg, BPs, glucocorticoids, proton pump inhibitors)
• Specifically excluded are fractures of the femoral neck, intertrochanteric fractures with spiral
subtrochanteric extension, pathological fractures associated with primary or metastatic bone
tumors, and periprosthetic fractures
Russel-Taylor Classification
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Presentation
History
o long history of bisphosphonate or denosumab
o history of thigh pain before trauma occurred
Symptoms
o hip and thigh pain
o inability to bear weight
Physical exam
o pain with motion
o typically associated with obvious deformity (shortening and varus alignment)
o flexion of proximal fragment may threaten overlying skin
Imaging
Radiographs
o required views
AP and lateral of the hip
AP pelvis
full length femur films including the knee
o additional views
traction views may assist with defining fragments in comminuted patterns but is not required
o findings
bisphosphonate-related fractures have
lateral cortical thickening
transverse fracture orientation
medial spike
lack of comminution
Treatment
Nonoperative
o observation with pain management
indications
non-ambulatory patients with medical co-morbidities that would not allow them to
tolerate surgery
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limited role due to strong muscular forces displacing fracture and inability to mobilize
patients without surgical intervention
Operative
o intramedullary nailing (usually cephalomedullary)
indications
historically Russel-Taylor type I fractures
newer design of intramedullary nails has expanded indications
most subtrochanteric fractures treated with IM nail
o fixed angle plate
indications
surgeon preference
associated femoral neck fracture
narrow medullary canal
pre-existing femoral shaft deformity
Techniques
Intramedullary Nailing
o position
lateral positioning
advantages
allows for easier reduction of the distal fragment to the flexed proximal fragment
allows for easier access to entry portal, especially for piriformis nail
supine positioning
advantages
protective to the injured spine
address other injuries in polytrauma patients
easier to assess rotation
o techniques
1st generation nail (rarely used)
2nd generation reconstruction nail
cephalomedullary nail
trochanteric or piriformis entry portal
piriformis nail may mitigate risk of iatrogenic malreduction from proximal valgus bend of
trochanteric entry nail
o pros
preserves vascularity
load-sharing implant
stronger construct in unstable fracture patterns
o cons
reduction technically difficult
nail can not be used to aid reduction
fracture must be reduced prior to and during passage of nail
may require percutaneous reduction aids or open clamp placement to achieve and
maintain reduction
mismatch of the radius of curvature
nails with a larger radius of curvature (straighter) can lead to perforation of the anterior
cortex of the distal femur
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o complications
varus malreduction (see complications
below)
Fixed angle plate
o approach
lateral approach to proximal femur
may split or elevate vastus lateralis
off later intermuscular septum
dangers include perforating branches of profunda femoris
o technique
95 degree blade plate or condylar screw
sliding hip screw is contraindicated due to high rate of malunion and failure
blade plate may function as a tension band construct
femur eccentrically loaded with tensile force on the lateral cortex converted to
compressive force on medial cortex
o cons
compromise vascularity of fragments
inferior strength in unstable fracture patterns
Complications
Varus/ procurvatum malunion
o the most frequent intraoperative complication with antegrade nailing of a subtrochanteric femur
fracture is varus and procurvatum (or flexion) malreduction
Nonunion : can be treated with plating : allows correction of varus malalignment
Bisphosphonate fractures
o nail fixation
increased risk of iatrogenic fracture : because of brittle bone and cortical thickening
increased risk of nonunion with nail fixation resulting in increased need for revision surgery
o plate fixation : increased risk of plate hardware failure
because of varus collapse and dependence on intramembranous healing inhibited by
bisphosphonates
Anatomy
Osteology
o largest and strongest bone in the body
o femur has an anterior bow
o linea aspera
rough crest of bone running down middle third of posterior femur
attachment site for various muscles and fascia
acts as a compressive strut to accommodate anterior bow to femur
Muscles
o 3 compartments of the thigh
anterior
sartorius
quadriceps
posterior
biceps femoris
semitendinosus
semimembranosus
adductor
gracilis
adductor longus
adductor brevis
adductor magnus
Biomechanics
o musculature acts as a deforming force after fracture
proximal fragment
abducted
gluteus medius and minimus abduct as they insert on
greater trochanter
flexed
iliopsoas flexes fragment as it inserts on lesser trochanter
distal segment
varus
adductors inserting on medial aspect of distal femur
extension
gastrocnemius attaches on distal aspect of posterior femur
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Classification
Winquist and Hansen Classification
Type 0 • No comminution
Type I • Insignificant amount of comminution
Type II • Greater than 50% cortical contact
Type III • Less than 50% cortical contact
Type IV • Segmental fracture with no contact between proximal and distal fragment
OTA Classification
32A - Simple • A1 - Spiral
• A2 - Oblique, angle > 30 degrees
• A3 - Transverse, angle < 30 degrees
32B - Wedge • B1 - Spiral wedge
• B2 - Bending wedge
• B3 - Fragmented wedge
32C - Complex • C1 - Spiral
• C2 - Segmental
• C3 - Irregular
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Presentation
Initial evaluation
o Advanced Trauma Life Support (ATLS) should be initiated VI:5 OTA classification
Symptoms
o pain in thigh
Physical exam
o inspection
tense, swollen thigh
blood loss in closed femoral shaft fractures is 1000-1500ml
for closed tibial shaft fractures, 500-1000ml
blood loss in open fractures may be double that of closed fractures
affected leg often shortened
tenderness about thigh
o motion
examination for ipsilateral femoral neck fracture often difficult secondary to pain from
fracture
o neurovascular : must record and document distal neurovascular status
Imaging
Radiographs
o recommended views
AP and lateral views of entire femur
AP and lateral views of ipsilateral hip
important to rule-out coexisting femoral neck fracture
AP and lateral views of ipsilateral knee
CT
o indications
may be considered in midshaft femur fractures to rule-out associated femoral neck fracture
Treatment
Nonoperative
o long leg cast
indications
nondisplaced femoral shaft fractures in patients with multiple medical comorbidities
Operative
o antegrade intramedullary nail with reamed technique
indications
gold standard for treatment of diaphyseal femur fractures
outcomes
stabilization within 24 hours is associated with
decreased pulmonary complications (ARDS)
decreased thromboembolic events
improved rehabilitation
decreased length of stay and cost of hospitalization
exception is a patient with a closed head injury I:6 A piriformis entry B trochanteric entry
V
critical to avoid hypotension and hypoxemia
consider provisional fixation (damage control)
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o retrograde intramedullary nail with reamed technique
indications
ipsilateral femoral neck fracture
floating knee (ipsilateral tibial shaft fracture)
use same incision for tibial nail
ipsilateral acetabular fracture
does not compromise surgical approach to acetabulum
multiple system trauma
bilateral femur fractures
avoids repositioning
morbid obesity
outcomes
results are comparable to antegrade femoral nails
immediate retrograde or antegrade nailing is safe for early treatment of gunshot femur
fractures
o external fixation with conversion to intramedullary nail within 2-3 weeks
indications
unstable polytrauma victim
vascular injury
severe open fracture
o ORIF with plate
indications
ipsilateral neck fracture requiring screw fixation
fracture at distal metaphyseal-diaphyseal junction
inability to access medullary canal
outcomes
inferior when compared to IM nailing due to increased rates of:
infection
nonunion
I:7 piriformis entry
V
hardware failure
Surgical Techniques
Antegrade intramedullary nailing
o approach
3 cm incision proximal to the greater trochanter in line with the femoral canal
o technique
starting points
piriformis entry
pros
colinear trajectory with long axis of femoral shaft
cons
starting point more difficult to access, especially in obese patients
causes the most significant damage to
abductor muscles and tendons
may result in abductor limp
blood supply to the femoral head
may result in AVN in pediatric patients
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Femur
trochanteric entry
pros
minimizes soft tissue injury to abductors
easier starting point than piriformis entry nail
cons
not colinear with the long axis of femoral shaft
must use nail specifically designed for trochanteric entry
use of a straight nail may lead to varus malalignment
reaming
reamed nailing superior to unreamed nailing, with:
increased union rates
decreased time to union
no increase in pulmonary complications
indications for unreamed nail
consider for patient with bilateral pulmonary injuries VI:8 trochanteric entry
interlocking screws
technique
computer-assisted navigation for screw placement decreases
radiation exposure
widening/overlap of the interlocking hole in the proximal-
distal direction
correct with adjustment in the abduction/adduction plane
widening/overlap of the interlocking hole in the anterior-
posterior plane
correct with adjustment in the internal/external rotation
plane
o postoperative care
weight-bearing as tolerated
range of motion of knee and hip is encouraged
o pros
98-99% union rate
low complication rate
infection risk 2%
o cons
not indicated for use with ipsilateral femoral neck fracture
increased rate of HO in hip abductors with antegrade nailing
increased rate of hip pain compared with retrograde nailing
mismatch of the radius of curvature of the femoral shaft and intramedullary nails can lead to
anterior perforation of the distal femur
Retrograde intramedullary nailing
o approach
2 cm incision starting at distal pole of patella
medial parapatellar versus transtendinous approaches
nail inserted with knee flexed to 30-50 degrees
o technique
entry point
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center of intercondylar notch on AP view
extension of Blumensaat's line on lateral
posterior to Blumensaat's line risks damage to
cruciate ligaments
o postoperative care
weight-bearing as tolerated
range of motion of knee and hip is encouraged
o pros
technically easier
union rates comparable to those of antegrade nailing
VI:9 entry point of retrogade nail
no increased rate of septic knee with retrograde nailing
of open femur fractures
o cons
knee pain
increased rate of interlocking screw irritation
cartilage injury
cruciate ligament injury with improper starting point
External fixation with conversion to intramedullary nail within 2-3 weeks
o technique
safest pin location sites are anterolateral and direct lateral regions of the femur
2 pins should be used on each side of the fracture line
o pros
prevents further pulmonary insult without exposing patient to risk of major surgery
may be converted to IM fixation within 2-3 weeks as a single stage procedure
o cons
pin tract infection
knee stiffness
due to binding/scarring of quadriceps mechanism
Special considerations
o ipsilateral femoral neck fracture
priority goes to fixing femoral neck because anatomic reduction is necessary to avoid
complications of AVN and nonunion
technique
preferred methods
screws for neck with retrograde nail for shaft
screws for neck and plate for shaft
compression hip screw for neck with retrograde nail for shaft
less preferred methods
antegrade nail with screws anterior to nail
technically challenging
Complications
Heterotopic ossification
o incidence
25%
o treatment
rarely clinically significant VI:10 ipsilateral femoral neck fracture
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Pudendal nerve injury
o incidence
10% when using fracture table with traction
Femoral artery or nerve injury
o incidence
rare
o cause
can occur when inserting proximal interlocking screws during a retrograde nail
Malunion and rotational malalignment
o most accurately determined by the Jeanmart method
angle between a line drawn tangential to the femoral condyles and a line drawn through the
axis of the femoral neck
o incidence
proximal fractures 30%
distal fractures 10%
o risk factors
use of a fracture table increases risk of internal rotation deformities when compared to
manual traction
fracture comminution
night-time surgery
o treatment
if noticed intraoperatively, remove distal interlocking screws and manually correct rotation
if noticed after union, osteotomy is required
Delayed union
o treatment
dynamization of nail with or without bone grafting
Nonunion
o incidence
<10%
o risk factors
postoperative use of nonsteroidal anti-inflammatory drugs
smoking is known to decrease bone healing in reamed antegrade exchange nailing for
atrophic non-unions
o treatment
reamed exchange nailing
Infection
o incidence
< 1%
o treatment
removal of nail and reaming of canal
external fixation used if fracture not healed
Weakness
o quadriceps and hip abductors are expected to be weaker than contralateral side
Iatrogenic fracture etiologies
o risk factors
antegrade starting point 6mm or more anterior to the intramedullary axis
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however, anterior starting point improves position of screws into femoral head
failure to overream canal by at least .5mm
Mechanical axis deviation (MAD)
o lengthening along the anatomical axis of the femur leads to lateral MAD
o shortening along the anatomical axis of the femur leads to medial MAD
Anterior cortical penetration.
Classification
Descriptive
o supracondylar
o intercondylar
OTA: 33
o A: extraarticular
o B: partial articular
portion of articular surface remains in continuity with shaft
33B3 is in coronal plane (Hoffa fragment)
o C: complete articular
articular fragment separated from shaft
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Presentation
Physical exam
o pain, deformity, swelling localizing to distal thigh/knee
o evaluate skin integrity
o vascular evaluation
potential for injury to popliteal artery if significant displacement
if no pulse after gross alignment restored then angiography is indicated
Full trauma evaluation if high energy mechanism
Imaging
Radiographs
o obtain standard AP and Lateral
o traction views
AP, Lateral, and oblique traction views can help characterize
injury but are painful for patient
in elderly patients, evaluate for any pre-existing knee DJD
consider views of the remainder of the extremity to rule out
VI:11 vascular evaluation
associated injuries
consider views of contralateral femur for pre-operative planning and templating
CT
o obtain with frontal and sagittal reconstructions
o useful for
establishing intra-articular involvement
identifying separate osteochondral fragments in the area of the intercondylar notch
identifying coronal plane fx (Hoffa fx): 38% incidence of Hoffa fractures in Type C fractures
preoperative planning
o if temporizing external fixation required, CT obtained after external
fixation
Angiography
o indicated when diminished distal pulses after gross alignment restored
o consider if associated with knee dislocation
Treatment
Nonoperative
o hinged knee brace with immediate ROM, NWB for 6 weeks
indications (rare)
nondisplaced fractures
nonambulatory patient
patient with significant comorbidities presenting unacceptably high degree of
surgical/anesthetic risk
Operative
o external fixation
temporizing measure until soft tissues permit internal fixation, or until patient is stable
avoid pin placement in area of planned plate placement if possible
o open reduction internal fixation
indications
displaced fracture
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intra-articular fracture
nonunion
goals
need anatomic reduction of joint
stable fixation of articular component to shaft to permit early motion
preserve vascularity
technique (see below)
postoperative
early ROM of knee important
non-weight bearing or toe touch
weight-bearing for 6-8 weeks, up
to 10-12 weeks if comminuted
quadriceps and hamstring
strength exercises
o retrograde IM nail VI:12 retrograde nail
indications
good for supracondylar fx without significant comminution
preferred implant in osteoporotic bone
traditionally, 4 cm of intact distal femur needed but newer implants with very distal
interlocking options may decrease this number, can perform independent screw
stabilization of intercondylar component of fracture around nail
o distal femoral replacement
indications
unreconstructable fracture
fracture around prior total knee arthroplasty with loose component
Surgical Techniques
ORIF Approaches
o anterolateral
fractures without articular involvement or with simple articular extension
incision from tibial tubercle to anterior 1/3 of distal femoral condyle
extend up midlateral femoral shaft as needed
minimally invasive plate osteosynthesis: small lateral incision, slide plate proximally, use
stab incisions for proximal screw placement
o lateral parapatellar
fractures with complex articular extension
extend incision into quad tendon to evert patella
can be used for Hoffa fracture
o medial parapatellar
typical TKA approach
used for complex medial femoral condyle fractures
o medial/lateral posterior
used for very posterior Hoffa fragment fixation
patient placed in prone position
midline incision over popliteal fossa
develop plane between medial and lateral gastrocnemius m.
capsulotomy to visualize fracture
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Blade Plate Fixation
o indications
not commonly used, technically difficult
contraindicated in type C3 fractures
o technique
placed 1.5 cm from articular surface
Dynamic Condylar Screw Placement VI:13 Blade plate
o indications : identical to 95 degree angled blade plate
o technique
precise sagittal plane alignment is not necessary
placed 2.0 cm from articular surface
o cons VI:14 DCS
large amount of bone removed with DCS
difficult to place
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preferred implant in osteoporotic bone
short nail rarely indicated, implant should at least reach lesser trochanter
o approach
medial parapatellar
no articular extension present
2.5 cm incision parallel to medial aspect of patellar tendon
stay inferior to patella
no attempt to visualize articular surface
articular extension present
continue approach 2-8 cm cephalad
incise extensor mechanism 10 mm medial to
patella
eversion of patella not typically necessary
need to stabilize articular segments prior to
nail placement
o pros : requires minimal dissection of soft tissue
o cons
less axial and rotational stability
postoperative knee pain
Complications
Symptomatic hardware
VI:15 Distal femur malunion
o lateral plate
pain with knee flexion/extension due to IT band contact with plate
o medial screw irritation
excessively long screws can irritate medial soft tissues
determine appropriate intercondylar screw length by obtaining an
AP radiograph of the knee with the leg internally rotated 30 degrees
Malunions
o most commonly associated with plating, usually valgus
o functional results satisfactory if malalignment is within 5 degrees in
any plane
Nonunions
o up to 19%, most commonly in metaphyseal area, with articular portion
healed (comminution, bone loss and open fractures more likely in
metaphysis)
o decreasing with less invasive techniques
o treatment with revision ORIF and autograft indicated
o consider changing fixation technique to improve biomechanics
Infection
o treat with debridement, culture-specific antibiotics, hardware removal
if fracture stability permits I:16 Non union
V
Implant failure
o up to 9%
o titanium plates may be superior to stainless steel
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B. Knee
Meniscal tears and ligamintous injuries of knee discussed in Volume 3 (Sport)
1. Patella Fracture
Introduction
Patella fractures account for 1% of all skeletal injuries
o occur either by direct impact injury or indirect eccentric contraction
o male to female 2:1
o most fractures occur in 20-50 year olds
Patella sleeve fracture
o seen in pediatric population (8-10 year olds)
o high index of suspicion required
Bipartite patella
o may be mistaken for patella fracture
o affects 8% of population
o characteristic superolateral position
I:17 Bipartite patella
V
Anatomy
Patella is largest sesamoid bone in body
Articular cartilage thickest in body (up to 1cm)
Most important blood supply to the patella is located at the inferior pole
Classification
Can be described based on fracture pattern
o nondisplaced
o transverse
o pole or sleeve (upper or lower)
o vertical
o marginal
o osteochondral
o comminuted (stellate)
Presentation
Physical exam
o palpable patellar defect
o significant hemarthrosis
o unable to perform straight leg raise indicates failure of extensor mechanism
retinaculum disrupted
Imaging
Radiographs
o patella alta
o fracture displacement
best evaluated on lateral x-ray
VI:18 palpable patellar defect
degree of fracture displacement correlates with degree of retinacular disruption
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MRI
o obtain MRI if child has normal xrays but is unable to straight leg
raise
Treatment
Nonoperative
o knee immobilized in extension (brace or cylinder cast) and full
weight bearing
indications
intact extensor mechanism (patient able to perform straight
leg raise)
VI:19 Patela alta with
nondisplaced or minimally displaced fractures avulsion fracture of lower
vertical fracture patterns pole
early active ROM with hinged knee brace
early WBAT in full extension
progress in flexion after 2-3 weeks
Operative
o ORIF with tension band construct
indications
preserve patella whenever possible
extensor mechanism failure (unable to perform straight leg raise)
open fractures
fracture articular displacement >2mm
displaced patella fracture >3mm
patella sleeve fractures in children
techniques
minifrag lag screw fixation for independent fragments
tension bands
0.062 K wires with figure of 8 wire
longitudinal cannulated screws combined with tension band wires shown to be
biomechanically superior
circumferential cerclage wiring
good for comminuted fractures
interfragmentary screw compression supplemented by cerclage wiring
o partial patellectomy
indications
comminuted superior or inferior pole fracture measuring <50% patellar height ONLY if
ORIF is not possible
techniques
quadricep or patellar tendon re-attachment
reattachment close to articular surface prevents patellar tilt
medial and lateral retinacular repair essential
o total patellectomy
indications
reserved for severe and extensive comminution not amenable to salvage
quadriceps torque reduced by 50%
medial and lateral retinacular repair essential
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Knee
Complications
Weakness and anterior knee pain
Symptomatic hardware
o most common
Loss of reduction (22%)
o increased in osteoporotic bone
Nonunion (<5%)
o can consider partial patellectomy
Osteonecrosis (proximal fragment)
o thought to be due to excessive initial fracture displacement
o can observe these, as most spontaneously revascularize by 2 years
Infection
Stiffness
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2. Knee Dislocation
Introduction
Devastating injury resulting from high or low energy
o high-energy
usually from MVC or fall from height
commonly a dashboard injury resulting in axial load to flexed knee
o low-energy
often from athletic injury
generally has a rotational component
morbid obesity is a risk-factor
Pathoanatomy
o associated with significant soft tissue disruption
o 3/4 of ligaments generally disrupted
Associated injuries
o vascular injury
5-15% in all dislocations
40-50% in anterior/posterior dislocations I:20 Knee recurvatum when held in extension
V
(knee dislocation-clinical instability)
due to tethering at the popliteal fossa
proximal - fibrous tunnel at the adductor hiatus
distal - fibrous tunnel at soleus muscle
o nerve injury
usually common peroneal nerve injury (25%)
tibial nerve injury is less common
o fractures
present in 60%
tibia and femur most common
Prognosis
o complications frequent and rarely does knee return to pre-injury state
Classification
Descriptive
o Kennedy classification based on direction of displacement of the tibia
anterior (30-50%)
most common
due to hyperextension injury
usually involves tear of PCL
arterial injury is generally an intimal tear due to traction
posterior (25%)
2nd most common
due to axial load to flexed knee (dashboard injury)
highest rate of vascular injury (25%) based on Kennedy classification (direction of
dislocation)
highest rate of complete tear of popliteal artery
lateral (13%)
due to varus or valgus force
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usually involves tears of both ACL and PCL
highest rate of peroneal nerve injury
medial (3%)
varus or valgus force
usually disrupted PLC and PCL
rotational (4%)
posterolateral is most common rotational dislocation
usually irreducible
buttonholding of femoral condyle through capsule
Schenck Classification
o based on pattern of multiligamentous injury of knee dislocation (KD)
Presentation
Symptoms
o history of trauma and deformity of the knee
o knee pain & instability
Physical exam
o appearance
no obvious deformity
50% spontaneously reduce before arrival to ED (therefore underdiagnosed)
may present with subtle signs of trauma (swelling, effusion, abrasions)
obvious deformity
do not wait for radiographs, reduce immediately, especially if absent pulses
"dimple sign" - buttonholing of medial femoral condyle through medial capsule
indicative of an irreducible posterolateral dislocation
a contraindication to closed reduction due to risks of skin necrosis
o stability
diagnosis based on instability on exam (radiographs and gross appearance may be normal)
may see recurvatum when held in extension
assess ACL, PCL, MCL, LCL, and PLC
o vascular exam
priority is to rule out vascular injury on exam both before and after reduction
serial examinations are mandatory
palpate the dorsalis pedis and posterior tibial pulses
if pulses are present and normal
does not indicate absence of arterial injury
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collateral circulation can mask a complete popliteal artery occlusion
measure Ankle-Brachial Index (ABI)
if ABI >0.
then monitor with serial examination (100% Negative Predictive Value)
if ABI <0.9
perform arterial duplex ultrasound or CT angiography
if arterial injury confirmed then consult vascular surgery
If pulses are absent or diminished
confirm that the knee joint is reduced or perform immediate reduction and reassessment
immediate surgical exploration if pulses are still absent following reduction
ischemia time >8 hours has amputation rates as high as 86%
if pulses present after reduction then measure ABI then consider observation vs.
angiography
Imaging
Radiographs
Treatment
Initial Treatment
o reduce knee and re-examine vascular status
considered an orthopedic emergency
splint in 20-30° flexion
confirm reduction is held with repeat radiographs in brace/splint
vascular consult indicated if
if arterial injury confirmed by arterial duplex ultrasound or CT angiography
pulses are absent or diminished following reduction
Nonoperative
o indications : limited and most cases require surgical stabilization
Operative
o emergent surgical intervention with external fixation
indications
vascular repair (takes precedence)
open fx and open dislocation
irreducible dislocation
compartment syndrome
obese
multi trauma patient
technique
vascular intervention
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Knee
perform external fixation first
excision of damaged segment and repair with reverse saphenous vein graft
always perform fasciotomies after vascular repair
o delayed ligamentous reconstruction/repair
indications
generally instability will require some kind of ligamentous repair or fixation
patients can be placed in a knee immobilizer for 6 weeks for initial stabilization
improved outcomes with early treatment (within 3 weeks)
technique
PLC
early reconstruction before ACL reconstruction
postoperative
recommend early mobilization and functional bracing
Complications
Stiffness (arthrofibrosis)
o is most common complication (38%)
o more common with delayed mobilization
Laxity and instability (37%)
Peroneal nerve injury (25%)
o most common in posterolateral dislocations
o poor results with acute, subacute, and delayed (>3 months) nerve exploration
o neurolysis and tendon transfers are the mainstay of treatment
o Dynamic tendon transfer involves transferring the posterior tibial tendon (PTT) to the lateral
cuneiform.
Vascular compromise
o in addition to vessel damage, claudication, skin changes, and muscle atrophy can occur
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C. Leg
Anatomy
Osteology
o lateral tibial plateau
convex in shape
proximal to the medial plateau
o medial tibial plateau
concave in shape
distal to the lateral tibial plateau
Muscles
o anterior compartment musculature : attaches to anterolateral tibia
o pes anserine : attaches to anteromedial tibia
Biomechanics
o medial tibial plateau bears 60% of knee's load
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Leg
Classification
Schatzker Classification
Type I Lateral split fracture
Type II Lateral Split-depressed fracture
Type III Lateral Pure depression fracture
Type IV Medial plateau fracture
Type V Bicondylar fracture
Type VI Metaphyseal-diaphyseal disassociation
Schatzker Classification
Type I
Type II
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Presentation
History
o high-energy trauma in young patients
o low-energy falls in elderly
Physical exam
o inspection
look circumferentially to rule-out an open injury
o palpation
consider compartment syndrome when compartments are firm and not compressible
o varus/valgus stress testing
any laxity >10 degrees indicates instability
often difficult to perform given pain
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o neurovascular exam
any differences in pulse exam between extremities should be further investigated with anke-
brachial index measurement
Imaging
Radiographs
o recommended views
AP, lateral, oblique
oblique is helpful to determine amount of depression
o optional views
plateau view
10 degree caudal tilt
o findings
posteromedial fracture lines must be recognized
CT scan
o important to identify articular depression and comminution
o findings
lipohemarthrosis indicates an occult fracture
fracture fragment orientation and surgical planning
MRI
o indications
not well established
o findings
useful to determine meniscal and ligamentous pathology
Treatment
Nonoperative
o hinged knee brace, PWB for 8-12 weeks, and immediate passive ROM
indications
minimally displaced split or depressed fractures
low energy fracture stable to varus/valgus alignment
nonambulatory patients
Operative
o temporizing bridging external fixation w/ delayed ORIF
indications
significant soft tissue injury
polytrauma
o external fixation with limited open/percutaneous fixation of articular segment
indications
severe open fracture with marked contamination
highly comminuted fractures where internal fixation not possible
outcomes
similar to open reduction, internal fixation
o open reduction, internal fixation
indications
articular stepoff > 3mm
condylar widening > 5mm
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varus/valgus instability
all medial plateau fxs
all bicondylar fxs
outcomes
restoration of joint stability is strongest predictor of long term outcomes
worse results with
ligamentous instability
meniscectomy
alteration of limb mechanical axis > 5 degrees
Techniques
External fixation (temporary)
o technique
two 5-mm half-pins in distal femur, two in distal tibia
axial traction applied to fixator
fixator is locked in slight flexion
o advantages
allows soft tissue swelling to decrease before definitive fixation
decreases rate of infection and wound healing complications
External fixation with limited internal fixation (definitive)
o technique
reduce articular surface either percutaneously or with small incisions
stabilize reduction with lag screws or wires
must keep wires >14mm from joint
apply external fixator or hybrid ring fixation
o post-operative care
begin weight bearing when callus is visible on
radiographs
usually remain in place 2-4 months
o pros
minimizes soft tissue insult
permits knee ROM
o cons
pin site complications
Open reduction, internal fixation
VI:21 Butress plate
o approach
lateral incision (most common)
straight or hockey stick incision anterolaterally from just proximal to joint line to just
lateral to the tibial tubercle
midline incision (if planning TKA in future)
can lead to significant soft tissue stripping and should be avoided
posteromedial incision
interval between pes anserinus and medial head of gastrocnemius
dual surgical incisions with dual plate fixation
indications
bicondylar tibial plateau fractures
posterior : can be used for posterior shearing fractures
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o reduction
restore joint surface with direct or indirect reduction
fill metaphyseal void with autogenous, allogenic bone graft, or bone graft substitutes
calcium phosphate cement has high compressive strength for filling metaphyseal void
o internal fixation
absolute stability constructs should be used to maintain the joint reduction
screws
may be used alone for
simple split fractures
depression fractures that were elevated percutaneously
plate fixation
non-locked plates
non-locked buttress plates best indicated for simple partial articular fractures in
healthy bone
locked plates
advantages
fixed-angle construct
less compression of periosteum and soft tissue
o postoperative
hinged knee brace with early passive ROM
gentle mechanical compression on repaired osteoarticular segments improves
chondrocyte survival
NWB or PWB for 8 to 12 weeks
Complications
Post-traumatic arthritis
o rate increases with
meniscectomy during surgery
axial malalignment
intra-articular infection
joint instability
Anatomy
Osteology
o proximal tibia
triangular
wide metaphyseal region
narrow distally
Muscles
o deforming forces
patellar tendon
proximal fragment into extension
fracture into apex anterior, or procurvatum
hamstring tendons
distal fragment into flexion
pes anserinus
proximal fragment into varus
valgus deforming force of the fracture
anterior compartment musculature
valgus deforming force of the fracture
Classification
AO Classification - 42
Type A Simple fracture pattern
Type B Wedge fracture pattern
Type C Comminuted fracture pattern
Presentation
Symptoms
o pain, inability to bear weight
Physical exam
o inspection and palpation
contusions
blisters
open wounds
compartments
palpation
passive motion of toes
intracompartmental pressure measurement if indicated
o neurologic
deep peroneal n.
superficial peroneal n.
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sural n.
tibial n.
saphenous n.
o pulse
dorsalis pedis
posterior tibial : be sure to check contralateral side
Imaging
Radiographs
o recommended views
full length AP and lateral views of affected tibia
AP and lateral views of ipsilateral knee
AP and lateral views of ipsilateral ankle
CT
o indications : question of intra-articular fracture extension
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o percutaneous locking plate
indications
inadequate proximal fixation for IM nailing
best suited for transverse or oblique fractures
minimal soft-tissue compromise
technique
may be used medially or laterally
better soft tissue coverage laterally makes lateral plating safer
outcomes
lateral plating with medial comminution can lead to varus collapse
long plates may place superficial peroneal nerve at risk
Surgical Technique
Intramedullary nailing
o approach
lateral parapatellar
helps maintain reduction for proximal 1/3 fractures
requires mobile patella
medial parapatellar approach may lead to valgus deformity VI:25 suprapatellar approach
suprapatellar
facilitates nailing in semiextended position
o starting point
proximal to the anterior edge of the articular margin
just medial to the lateral tibial spine
use of a more lateral starting point may decrease valgus
deformity
use of a medial starting point may create valgus
deformity
o fracture reduction techniques VI:26 medial starting point may
blocking (Poller) screws create valgus deformity
coronal blocking screw
prevents apex anterior (procurvatum) deformity
place in posterior half of proximal fragment
sagittal blocking screw
prevents valgus deformity
place on lateral concave side of proximal fragment
enhance construct stability if not removed
unicortical plating
short one-third tubular plate placed anteriorly, anteromedially, or
posteromedially across fracture I:27 coronal blocking screw
V
Complications
Malunion VI:28 sagittal blocking screw
o incidence : 20-60% rate of malunion following intramedullary nailing (valgus/procurvatum)
o treatment
revision intramedullary nailing
osteotomy if fracture has healed
o prevention
blocking screws
temporary plating
VI:29 unicortical
universal distractors plating
nailing in semiextended position
Presentation
Symptoms
o pain, inability to bear weight, deformity
Physical exam
o inspection and palpation
deformity / angulation / malrotation
contusions
blisters
open wounds
compartments
palpation
pain
passive motion of toes
intracompartmental pressure measurement if indicated
o neurologic
deep peroneal n.
superficial peroneal n.
sural n.
tibial n.
saphenous n.
o pulse
dorsalis pedis
posterior tibial : be sure to check contralateral side
Imaging
Radiographs
o recommended views
full length AP and lateral views of affected tibia
AP, lateral and oblique views of ipsilateral knee and ankle
CT : indications
intra-articular fracture extension or suspicion of joint involvement
CT ankle for spiral distal third tibia fracture
to exclude posterior malleolar fracture
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Treatment of Closed Tibia Fractures
Nonoperative
o closed reduction / cast immobilization
indications
closed low energy fxs with acceptable alignment
< 5 degrees varus-valgus angulation
< 10 degrees anterior/posterior angulation
> 50% cortical apposition
< 1 cm shortening
< 10 degrees rotational malalignment
if displaced perform closed reduction under general anesthesia
certain patients who may be non-ambulatory (ie. paralyzed), or those unfit for surgery
technique
place in long leg cast and convert to functional brace at 4 weeks
outcomes
high success rate if acceptable alignment maintained
risk of shortening with oblique fracture patterns
risk of varus malunion with midshaft tibia fractures and an intact fibula
non-union occurs in 1.1% of patients treated with closed reduction
Operative
o external fixation
indications
can be useful for proximal or distal metaphyseal fxs
complications
pin tract infections common
outcomes : higher incidence of malalignment compared to IM nailing
o IM Nailing
indications
unacceptable alignment with closed reduction and casting
soft tissue injury that will not tolerate casting
segmental fx
comminuted fx
ipsilateral limb injury (i.e., floating knee)
polytrauma
bilateral tibia fx
morbid obesity
contraindications
pre-existing tibial shaft deformity that may preclude passage of IM nail
previous TKA or tibial plateau ORIF (not strict contraindication)
outcomes
IM nailing leads to (versus external fixation)
decreased malalignment
IM nailing leads to (versus closed treatment)
decrease time to union
decreased time to weight bearing
reamed vs. unreamed nails
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reamed possibly superior to unreamed nails for treatment of closed tibia fxs for
decrease in future bone grafting or implant exchange (SPRINT trial)
recent studies show no adverse effects of reaming (infection, nonunion)
reaming with use of a tourniquet is NOT associated with thermal necrosis of the tibial
shaft
o percutaneous locking plate
indications
proximal tibia fractures with inadequate proximal fixation from IM nailing
distal tibia fractures with inadequate
distal fixation from IM nail
complications
non-union
wound infection and dehiscence
long plates may place superficial peroneal
nerve at risk
Percutaneous plate shown to have (versus
infrapatellar IMN)
Equivalent time to union
Greater radiation exposrure
Longer surgical duration
Lower postoperative pain scores
More difficulty in hardware removal
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Technique
IM nailing of shaft fractures
o preparation
anesthesia : general anesthesia recommended
positioning
patient positioned supine on radiolucent table
bring fluoro in from opposite, non-injured, side
bump placed under ipsilateral hip
leave full access to foot and ankle to help judge intraoperative length, rotation, and
alignment of extremity
tourniquet
tourniquet placed on proximal thigh
not typically inflated
use in patients with vascular injury or significant bleeding associated with extensive soft
tissue injuries
deflate during reaming or nail insertion (weak data to support this)
o approach
options include
medial parapatellar
most common starting point
can lead to valgus malalignment when used to treat proximal fractures
lateral parapatellar
helps maintain reduction when nailing proximal 1/3 fractures
requires mobile patella
patellar tendon splitting
gives direct access to start point
can damage patellar tendon or lead to patella baja (minimal data to support this)
semiextended medial or lateral parapatellar
used for proximal and distal tibial fractures
suprapatellar (transquadriceps tendon)
requires special instruments
can damage patellofemoral joint
starting point
medial parapatellar tendon approach with knee flexed
incision from inferior pole of patella to just above tibial tubercle
identify medial edge of patellar tendon, incise
peel fat pad off back of patellar tendon
starting guidewire is placed in line with medial aspect of lateral tibial spine on AP
radiograph, just below articular margin on lateral view
insert starting guide wire, ream
semiextended lateral or medial parapatellar approach
skin incision made along medial or lateral border of patella from superior pole of
patella to upper 1/3 of patellar tendon
knee should be in 5-30 degrees of flexion
choice to go medial or lateral is based of mobility of patella in either direction
open retinaculum and joint capsule to level of synovium
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free retropatellar fat pad from posterior surface of patellar tendon
identify starting point as mentioned previously
o fracture reduction techniques
spanning external fixation (ie. traveling traction)
clamps
femoral distractor
small fragment plates/screws
intra-cortical screws
o reaming
reamed nails superior to unreamed nails in closed fractures
be sure tourniquet is released
advance reamers slowly at high speed
overream by 1.0-1.5mm to facilitate nail insertion
confirm guide wire is appropriately placed prior to reaming
o nail insertion
insert nail in slight external rotation to move distal interlocking screws anteriorly decreasing
risk of NVS injury
if nail does not pass, remove and ream 0.5-1.0mm more
o locking screws
statically lock proximal and distally for rotational stability
no indication for dynamic locking acutely
number of interlocking screws is controversial
two proximal and two distal screws in presence of <50% cortical contact
consider 3 interlock screws in short segment of distal or proximal shaft fracture
Complications
Knee pain
o >50% anterior knee pain with IM nailing
occurs with patellar tendon splitting and paratendon approach
pain relief unpredictable with nail removal
o lateral radiograph is best radiographic views to make sure nail is not too proud proximally
Malunion
o high incidence of valgus and procurvatum (apex anterior) malalignment in proximal third
fractures
o varus malunion leads to ipsilateral ankle pain and stiffness
o chronic angular deformity is defined by the proximal and distal anatomical/mechanical axis of
each segment
center of rotation of angulation is intersection of proximal and distal axes
Nonunion
o definition
delayed union if union at 6-9 mos.
nonunion if no healing after 9 mos.
o treatment
nail dynamization if axially stable
exchange nailing if not axially stable
reamed exchange nailing most appropriate for aseptic, diaphyseal tibial nonunions with
less than 30% cortical bone loss.
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consider revision with plating in metaphyseal nonunions
posterolateral bone grafting if significant bone loss
non-invasive techniques (electrical stimulation, US)
BMP-7 (OP-1) has been shown equivalent to autograft
often used in cases of recalcitrant non-unions
compression plating has been shown to have 92-96% union rate after open tibial fractures
initially treated with external fixation
Malrotation
o most commonly occurs after IM nailing of distal 1/3 fractures
o can assess tibial rotation by obtaining perfect lateral fluoroscopic image of knee, then rotating c-
arm 105-110 degrees to obtain mortise view of ipsilateral ankle
o reduced risk with adjunctive fibular plating
Compartment syndrome
o incidence 1-9% : can occur in both closed and open tibia shaft fxs
o diagnosis
high index of clinical suspicion
pain out of proportion
pain with passive stretch
compartment pressure within 30mm Hg of diastolic BP is most sensitive diagnostic test
o treatment
emergent four compartment fasciotomy
o outcome
failure to recognize and treat compartment syndrome is most common reason for successful
malpractice litigation against orthopaedic surgeons
o prevention
increased compartment pressure found with
traction (calcaneal)
leg positioning
Nerve injury
o LISS plate application without opening for distal screw fixation near plate holes 11-13 put
superficial peroneal nerve at risk of injury due to close proximity
o saphenous nerve can be injured during placement of locking screws
o transient peroneal nerve palsy can be seen after closed nailing
EHL weakness and 1st dorsal webspace decreased sensation
treated nonoperatively; variable recovery is expected
Anatomy
Osteology
o tibia
distal tibia forms an inferior quadrilateral surface and pyramid-shaped medial malleolus
articulates with the talus and fibula laterally via the fibula notch
Vascular anatomy
o anterior tibial artery
first branch of popliteal artery
passes between 2 heads of tibialis posterior and interosseous membrane (IOM)
lies anterior to IOM between tibialis anterior and EHL
terminates as dorsalis pedis artery
o posterior tibial artery
continues in deep posterior compartment of leg
courses obliquely to pass behind medial malleolus
terminates by dividing into medial and lateral plantar arteries
o peroneal artery
main branch takes off 2.5 cm distal to popliteal fossa
continues in deep posterior compartment between tibialis posterior and FHL
terminates as calcaneal branches
Nerves
o tibial nerve (L4-S3)
crosses over popliteus from the popliteal fossa and splits 2 heads of gastrocnemius
passes deep to soleus coursing to the posterior aspect of the medial malleolus
terminates as medial and lateral plantar nerves
muscular branches supply posterior leg (superficial and deep posterior compartments)
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o common peroneal nerve (L4-S2)
winds around neck of fibula and runs deep to peroneus longus
divides into superficial and deep peroneal nerves
o superficial peroneal nerve
courses along border between lateral and anterior compartments of leg
supplies muscular branches to peroneus longus and brevis (lateral compartment)
terminates as medial dorsal and intermediate dorsal cutaneous nerves
o deep peroneal nerve
courses along anterior surface of IOM
supplies musculature of anterior compartment and sensation to first web space
o saphenous nerve (L3-L4)
continuation of femoral nerve of the thigh
becomes subcutaneous on medial aspect of knee between sartorius and gracilis
supplies sensation to medial aspect of leg and foot
o sural nerve (S1-S2)
formed by cutaneous branches of tibial (medial sural cutaneous) and common peroneal
(lateral sural cutaneous) nerves
lies on lateral aspect of leg and foot
Classification
AO/OTA Classification
43-A Extra-articular
43-B Partial articular
43-C Complete articular
Each category is further subdivided based on amount and degree of comminution
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Presentation
Symptoms
o ankle pain, inability to bear weight, deformity
Physical exam
o inspection
examine soft tissue integrity
swelling, abrasions, ecchymosis, fracture blisters, open wounds
examine for associated musculoskeletal injuries
o ROM & stability
examine stability and alignment of the ankle joint
o neurovascular
check DP and PT pulses
look for neurologic compromise
check for signs of compartment syndrome
Imaging
Radiographs
o recommended views
AP, lateral, mortise views of ankle
full-length tibia/fibula and foot x-rays performed for fracture extension
CT scan
o delineate articular involvement
o surgical planning
o most useful after ligamentotaxis is provided by a spanning external fixator
Treatment
Nonoperative
o immobilization
indications
stable fracture patterns without articular surface displacement
critically ill or nonambulatory patients
significant risk of skin problems (diabetes, vascular disease, neuropathy)
technique
long leg cast for 6 weeks followed by fracture brace and ROM exercises
alternative treatment is with early ROM
outcomes
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intra-articular fragments are unlikely to reduce with manipulation of displaced fractures
loss of reduction is common
inability to monitor soft tissue injuries is a major disadvantage
Operative
o temporizing spanning external fixation across ankle joint
indications
acute management
provides stabilization to allow for soft tissue healing
fractures with significant joint depression or displacement
leave until swelling resolves (generally 10-14 days)
o ORIF
indications
definitive fixation for majority of pilon fractures
limited or definitive ORIF can be performed acutely with low complications in certain
situations
outcomes
ability to drive
brake travel time returns to normal 6 weeks after weight bearing
o external fixation alone
indications
may be indicated in select cases
o intramedullary nailing with percutaneous screw fixation
alternative to ORIF for fractures with simple intra-articular component (AO/OTA 43 C1/C2)
Techniques
External fixation
o fixation
joint-spanning articulated vs. nonspanning hybrid ring
none have been shown to be superior with respect to ankle stiffness
2 tibial shaft half pins connected to hindfoot half pins or calcaneal transfixation pin
with hybrid fixators, thin wires may be placed within joint capsule or within zone of injury
o soft tissues
maintain soft tissue attachments of fragments
Chaput fragment - anterior inferior tibiofibular ligament
o pros
decreased incidence of wound complications and deep infections compared to ORIF
can combine with limited percutaneous fixation using lag screws
o cons
pin and wire tract infections
loss of ankle motion
injury to neurovascular structures
anatomic articular reconstruction may not be possible, especially with central depression
ORIF (AO technique)
o approach
use of multiple small incisions that can include
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Leg
Complications
Wound slough (10%)
o free flap for postoperative wound breakdown
Dehiscence (9-30%)
o wait for soft tissue edema to subside before ORIF (1-2 weeks)
Infection (5-15%)
Varus malunion
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Nonunion
o usually at metaphyseal junction
o treat with bone grafting and plate fixation
o more common with hybrid fixation
Posttraumatic arthritis
o most commonly begins 1-2 years postinjury
o arthrodesis is not commonly required until many years later
Chondrolysis
Stiffness
Collected By : Dr AbdulRahman
AbdulNasser
June 2017
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
1. Ankle Fractures
Introduction
Injury patterns
o isolated medial malleolus fracture
o isolated lateral malleolus fracture
o bimalleolar and bimalleolar-equivalent fractures
o posterior malleolus fractures
o Bosworth fracture-dislocations
o open ankle fractures
o associated syndesmotic injuries
isolated syndesmosis injury
Anatomy
Biomechanics
o deltoid ligament (deep portion)
primary restraint to anterolateral talar displacement
o fibula
acts as buttress to prevent lateral displacement of talus
Imaging
Radiographs
o external rotation stress radiograph
most appropriate stress radiograph to assess competency of deltoid ligament
a medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle
is predictive of deep deltoid disruption
more sensitive to injury than medial tenderness, ecchymosis, or edema
gravity stress radiograph is equivalent to manual stress radiograph
syndesmosis
decreased tibiofibular overlap
normal >6 mm on AP view
normal >1 mm on mortise view
increased medial clear space
normal less than or equal to 4 mm
increased tibiofibular clear space
normal <6 mm on both AP and mortise views
o radiographic measurements
talocrural angle
measured by bisection of line through tibial anatomical axis and another line through the
tips of the malleoli
shortening of lateral malleoli fractures can lead to increased talocrural angle
talocrural angle is not 100% reliable for estimating restoration of fibular length
can also utilize the realignment of the medial fibular prominence with the tibiotalar
joint
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Classification
Lauge-Hansen
o based on foot position and force of applied stress/force
o has been shown to predict the observed (via MRI) ligamentous injury in less than 50% of
operatively treated fractures
Lauge-Hansen Class Sequence
Supination - Adduction (SA) 1. Talofibular sprain or distal fibular avulsion
2. Vertical medial malleolus and impaction of anteromedial distal tibia
Supination - External Rotation (SER) 1. Anterior tibiofibular ligament sprain
2. Lateral short oblique fibula fracture (anteroinferior to
posterosuperior)
3. Posterior tibiofibular ligament rupture or avulsion of posterior
malleolus
4. Medial malleolus transverse fracture or disruption of deltoid
ligament
Pronation - Abduction (PA) 1. Medial malleolus transverse fracture or disruption of deltoid
ligament
2. Anterior tibiofibular ligament sprain
3. Transverse comminuted fracture of the fibula above the level of
the syndesmosis
Pronation - External Rotation (PER) 1. Medial malleolus transverse fracture or disruption of deltoid
ligament
2. Anterior tibiofibular ligament disruption
3. Lateral short oblique or spiral fracture of fibula (anterosuperior to
posteroinferior) above the level of the joint
4. Posterior tibiofibular ligament rupture or avulsion of posterior
malleolus
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
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VI:34 Pronation -
Abduction
I:32 Pronation -
V
External Rotation
I:33 Pronation -
V
External Rotation
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Anatomic / Descriptive
o isolated medial malleolar
o isolated lateral malleolar
o bimalleolar
o trimalleolar
o Bosworth fracture-dislocation (posterior dislocation of the fibula behind incisura fibularis)
Danis-Weber (location of fibular fracture)
o A - infrasyndesmotic (generally not associated with ankle instability)
o B - transsyndesmotic
o C - suprasyndesmotic
AO / ATA
o 44A - infrasyndesmotic
o 44B - transsyndesmotic
o 44C - suprasyndesmotic
General Treatment
Nonoperative
o short-leg walking cast/boot
indications
isolated nondisplaced medial malleolus fracture or tip avulsions
isolated lateral malleolus fracture with < 3mm displacement and no talar shift
posterior malleolar fracture with < 25% joint involvement or < 2mm step-off
Operative
o open reduction internal fixation
indications
any talar displacement
displaced isolated medial malleolar fracture
displaced isolated lateral malleolar fracture
bimalleolar fracture and bimalleolar-equivalent fracture
posterior malleolar fracture with > 25% or > 2mm step-off
Bosworth fracture-dislocations
open fractures
technique
goal of treatment is stable anatomic reduction of talus in the ankle mortise
1 mm shift of talus leads to 42% decrease in tibiotalar contact area
see fracture patterns below for specific treatment
outcomes
overall success rate of 90%
prolonged recovery expected (2 years to obtain final functional result)
significant functional impairment often noted
worse outcomes with: smoking, decreased education, alcohol use, increased age, presence
of medial malleolar fracture
ORIF superior to closed treatment of bimalleolar fractures
in Lauge-Hansen supination-adduction fractures, restoration of marginal impaction of the
anteromedial tibial plafond leads to optimal functional results after surgery
postoperative rehabilitation
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time for proper braking response time (driving) returns to baseline at nine weeks for
operatively treated ankle fractures
braking travel time is significantly increased until 6 weeks after initiation of weight
bearing in both long bone and periarticular fractures of the lower extremity
Isolated Medial Malleolus Fracture
Nonoperative
o short leg walking cast or cast boot
indications
nondisplaced fracture and tip avulsions
deep deltoid inserts on posterior colliculus
symptomatic treatment often appropriate
Operative
o ORIF
indications
any displacement or talar shift
technique
lag screw fixation
lag screw fixation stronger if placed perpendicular to fracture line
antiglide plate with lag screw
best for vertical shear fractures
tension band fixation
utilizing stainless steel wire
Isolated Lateral Malleolus Fracture
Nonoperative
o short leg walking cast vs cast boot
indications
if intact mortise, no talar shift, and < 3mm displacement
classically fractures with more than 4-5 mm of medial clear space widening on stress
radiographs have been considered unstable and need to be treated surgically
recent studies have shown the deep deltoid may be intact with up to 8-10 mm of
widening on stress radiographs
if the mortise is well reduced, results from operative and non-operative treatment are
similar
Operative
o ORIF
indications
if talar shift or > 3 mm of displacement
can be treated operatively if also treating an ipsilateral syndesmosis injury
technique
open reduction and plating
plate placement
lateral
lag screw fixation with neutralization plating
bridge plate technique
posterior
antiglide technique
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lag screw fixation with neutralization plating
most common disadvantage of using posterior antiglide plating is peroneal
irritation if the plate is placed too distally
posterior antiglide plating is biomechanically superior to lateral plate placement
intramedullary retrograde screw placement
isolated lag screw fixation
possible if fibula is a spiral pattern and screws can be placed at least 1 cm apart
post-operative care
period of immobilization usually 4-6 weeks after ORIF
duration of immobilization should be doubled in Diabetic patients
Medial and Lateral (Bimalleolar) Fracture
Nonoperative
o total contact casting
indications
elderly or unable to undergo surgical intervention
Operative
o ORIF
indications
any lateral talar shift
technique
fibula
need to fix with one of the options listed in section above
medial malleolus
fixation options
cancellous lag screws
bicortical screws
tension band wiring
antiglide plate to treat a vertical medial malleolus fracture
orient screws parallel to joint for vertical medial malleolar fracture (Lauge-Hansen
supination-adduction fracture pattern)
Functional Bimalleolar Fracture (deltoid ligament tear with fibular fracture)
Operative
o ORIF of lateral malleolus
indications
examination has been shown to be largely unreliable in predicting medial injury
can see significant lateral translation of the talus in this pattern
technique
not necessary to repair medial deltoid ligament
only need to explore medially if you are unable to reduce the mortise
see isolated fibular fracture techniques above
Posterior Malleolar Fracture
Nonoperative
o short leg walking cast vs cast boot
indications
< 25% of articular surface involved
evaluation of percentage should be done with CT, as plain radiology is unreliable
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< 2 mm articular stepoff
syndesmotic stability
Operative
o ORIF
indications
> 25% of articular surface involved
> 2 mm articular stepoff
syndesmosis injury
technique
approach
posterolateral approach
posteromedial approach
decision of approach will depend on fracture lines and need for fibular fixation
fixation
anterior to posterior lag screws to capture fragment (if nondisplaced)
posterior to anterior lag screw and buttress plate
antiglide plate
syndesmosis injury
stiffness of syndesmosis restored to 70% normal with isolated fixation of posterior
malleolus (versus 40% with isolated syndesmosis fixation)
stress examination of syndesmosis still required after posterior malleolar fixation
posteroinferior tibiofibular ligament may remain attached to posterior malleolus and
syndesmotic stability may be restored with isolated posterior malleolar fixation
Bosworth Fracture-Dislocation
Overview
o rare fracture-dislocation of the ankle where the fibula becomes entrapped behind the tibia and
becomes irreducible
o posterolateral ridge of the distal tibia hinders reduction of the fibula
Operative
o open reduction and fixation of the fibula in the incisura fibularis
indicated in most cases
Open Ankle Fracture
Operative
o emergent operative debridement and ORIF
indicated if soft tissue conditions allow
primary closure at the index procedure can be performed in appropriately-selected Gustilo-
Anderson grade I, II, and IIIA open fractures in otherwise healthy patients sustaining low-
energy injuries without gross contamination
o external fixation
indications
soft tissue conditions and overall patient characteristics
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must remain non-weight bearing, as screws are not biomechanically strong enough to
withstand forces of ambulation
controversies
number of screws
1 or 2 most commonly reported
number of cortices
3 or 4 most commonly reported
size of screws
3.5 mm or 4.5 mm screws
implant material (stainless steel screws, titanium screws,
suture, bioabsorbable materials)
need for hardware removal
no difference in outcomes seen with hardware
maintenance (breakage or loosening) or removal at 1
year
outcome may be worse with maintenance of intact screws
Diabetic Ankle Fractures (with or without Neuropathy)
Risks
o prolonged healing
o high risk of hardware failure
o high risk of infection
Enhanced fixation
o multiple quadricortical syndesmotic screws (even in the absence of syndesmotic injury)
o tibiotalar Steinmann pins or hindfoot nailing
o ankle spanning external fixation
o augment with intramedullary fibula K-wires
o stiffer, more rigid fibular plates (instead of 1/3 tubular plates)
compression plates
small fragment locking plates
Delay weightbearing
o maintain non-weightbearing postop for 8-12 weeks (instead of 4-8 weeks in normal patients
Complications
Wound problems (4-5%)
Deep infections (1-2%)
o up to 20% in diabetic patients
largest risk factor for diabetic patients is presence of peripheral neuropathy
Post-traumatic arthritis
o rare with anatomic reduction and fixation
o corrective osteotomy requires anatomic fibular and mortise correction for optimal outcomes
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
Anatomy
Articulation
o inferior surface articulates with posterior facet of calcaneus
o talar head articulates with
navicular bone
sustenaculum tali
o lateral process articulates with
posterior facet of calcaneus
lateral malleolus of fibula
o posterior process consist of medial and lateral
tubercles separated by groove for FHL
Blood supply
o talar neck supplied by three sources
posterior tibial artery
via artery of tarsal canal (dominant
supply)
supplies majority of talar body
deltoid branch of posterior tibial artery
supplies medial portion of talar body
Classification
Hawkins Classification
Type Description AVN
Hawkins I Nondisplaced 0-13% AVN
Hawkins II Subtalar dislocation 20-50%
Hawkins III Subtalar and tibiotalar dislocation 20-100%
Hawkins IV Subtalar, tibiotalar, 70-100%
and talonavicular dislocation
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Imaging
Radiographs
o recommended views
AP and lateral
Canale View
optimal view of talar neck
technique is maximum equinus, 15 degrees pronated,
Xray 75 degrees cephalad from horizontal
CT scan
o best study to determine degree of displacement, comminution and articular congruity
o CT scan also will assess for ipsilateral foot injuries (up to 89% incidence)
Treatment
Nonoperative
o emergent reduction in ER
indications
all cases require emergent closed reduction in ER
o short leg cast for 8-12 weeks (NWB for first 6 weeks)
indications
nondisplaced fractures (Hawkins I)
CT to confirm nondisplaced without articular stepoff
Operative
o open reduction and internal fixation
indications
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post-traumatic arthritis
mal-union
non-union
infection
wound dehiscence
Techniques
ORIF
o approach
two approaches recommended
visualize medial and lateral neck to assess reduction
typical areas of comminution are dorsal and medial
anteromedial
between tibialis anterior and posterior tibialis
preserve soft tissue attachments, especially deep deltoid ligament (blood supply)
medial malleolar osteotomy to preserve deltoid ligament
anterolateral
between tibia and fibula proximally, in line with 4th ray
elevate extensor digitorum brevis and remove debris from subtalar joint
o technique
anatomic reduction essential
variety of implants used including mini and small fragment screws, cannulated screws and
mini fragment plates
medial and lateral lag screws may be used in simple fracture patterns
consider mini fragment plates in comminuted fractures to buttress against varus collapse
o postoperative : non-weight-bearing for 10-12 weeks
Complications
Osteonecrosis
o 31% overall (including all subtypes)
o radiographs
hawkins sign
subchondral lucency best seen on mortise Xray at 6-8 weeks
indicates intact vascularity with resorption of subchondral bone
associated with talar neck comminution and open fractures
Posttraumatic arthritis
o subtalar arthritis (50%) is the most common complication
o tibiotalar arthritis (33%)
Varus malunion (25-30%)
o can be prevented by anatomic reduction
o treatment includes medial opening wedge osteotomy of talar neck
o leads to
decreased subtalar eversion
VI:37 hawkins sign
decreased motion with locked midfoot and hindfoot
weight bearing on the lateral border of the foot
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anterior tibial artery
supplies head and neck
perforating peroneal arteries via artery of tarsal sinus
supplies head and neck
deltoid artery (located in deep segment of deltoid ligament)
supplies body
may be only remaining blood supply with a talar neck fracture
Classification
Anatomic classification
o Lateral Process Fx
type 1 fractures do not involved the articular surface
type 2 fractures involve the subtalar and talofibular joints
type 3 fractures have comminution
o Posterior Process Fx
posteromedial tubercle fractures
result from an avulsion of the posterior talotibial ligament
or posterior deltoid ligament
posterolateral tubercle fractures
result from an avulsion of the posterior talofibular
ligament
o Talar Head Fx
o Talar Body Fx
Physical Exam
Symptoms
o pain VI:38 Lateral Process Fx
lateral process fractures often misdiagnosed as ankle sprains
Physical exam
o provocative tests
pain aggravated by FHL flexion or extension may be found with a posterolateral tubercle
fractures
Imaging
Radiographs
o recommended views
AP and lateral
lateral process fractures may be viewed on AP radiographs
Canale View
optimal view of talar neck
technique
maximum equinus
15% pronated
Xray 75 degrees cephalad from horizontal
VI:39 os trigonum
careful not to mistake os trigonum (present in up to 50%) for fracture
may be falsely negative in talar lateral process fx
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CT scan
o indicated when suspicion is high and radiographs are negative
best study for posterior process fx, lateral process fx, and posteromedial process fx
o helpful to determine degree of displacement, comminution, and articular congruity
MRI
o can be used to confirm diagnosis when radiographs are negative
Treatment
Nonoperative
o SLC for 6 weeks
indications
nondisplaced (< 2mm) lateral process fractures
nondisplaced (< 2mm) posterior process fractures
nondisplaced (< 2mm) talar head fractures
nondisplaced (< 2mm) talar body fractures
technique : cast molded to support longitudinal arch
Operative
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
o ORIF/Kirshner wire Fixation
indications
displaced (> 2mm) lateral process fractures
displaced (> 2mm) talar head fractures
displaced (> 2mm) talar body fractures
medial, lateral or posterior malleolar osteotomies may be necessary
displaced (> 2mm) posteromedial process fractures
may require osteotomies of posterior or medial malleoli to adequately reduce the
fragments
o fragment excision
indications
comminuted lateral process fractures
comminuted posterior process fractures
nonunions of posterior process fractures
Technique
ORIF/Kirshner Wires
o approaches
lateral approach
for lateral process fractures
incision over tarsal sinus, reflect EDB distally
posteromedial approach
for medial tubercle of posterior process fracture or for entire posterior process fracture
that has displaced medially
between FDL and neurovascular bundle
posterolateral approach
for lateral tubercle of posterior process fractures
between peroneal tendons and Achilles tendon (protect sural nerve)
beware when dissecting medial to FHL tendon (neurovascular bundle lies there)
combined lateral and medial approach
required for talar body fractures with more than 2 mm of displacement
Fragment excisions
o incompetence of the lateral talocalcaneal ligament is expected with excision of a 1 cm fragment
this is biomechanically tolerated and does not lead to ankle or subtalar joint instability
Complications
AVN : Hawkins sign (lucency) indications revascularization
o Lack of Hawkins sign with sclerosis is indicative of AVN
Talonavicular arthritis
o posttraumatic arthritis is common in all of these fractures
o this can be treated with an arthrodesis of the talonavicular joint
Malunion
Chronic pain from symptomatic nonunion : may have pain up to 2 years after treatment
Subtalar arthritis : found in 45% of patients with lateral process fractures, treated either non-
operatively or operatively
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4. Subtalar Dislocations
Introduction
Typically from a high-energy mechanism
o 25% may be open
lateral dislocations more likely to be open
o 65% to 80% are medial dislocations
o remaining are lateral dislocations
o case reports of anterior or posterior dislocations
Associated injuries
o associated dislocations
talonavicular
o associated fractures (up to 44%)
with medial dislocation
dorsomedial talar head
posterior process of talus
navicular
with lateral dislocation
cuboid
anterior calcaneus
lateral process of talus
fibula
I:40 assiciated with posterior process fx of talus
V
Presentation
Physical exam
o foot will be locked in supination with medial dislocation
o foot will be locked in pronation with lateral dislocation
Imaging
Radiographs
o medial subtalar dislocation
talar head will be superior to navicular on lateral image
o lateral subtalar dislocation
talar head will be colinear or inferior to navicular on lateral image
CT scan
o perform following reduction
o look for associated injuries or subtalar debris
Treatment
Nonoperative
o closed reduction and short leg non-weight bearing cast for 4-6 weeks
indications
first line of treatment
60-70% can be reduced by closed methods
technique
requires adequate sedation
typical maneuvers include knee flexion and ankle plantar flexion
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
followed by distraction and hindfoot inversion or eversion depending on direction of
dislocation
perform a post-reduction CT to look for associated injuries
Operative
o open reduction
indications
failure of closed reduction
up to 32% require open reduction
medial dislocation reduction blocked by lateral structures including
peroneal tendons
extensor digitorum brevis
talonavicular joint capsule
lateral dislocation reduction blocked by medial structures including
posterior tibialis tendon
flexor hallucis longus
flexor digitorum longus
place temporary transarticular pins as needed if joint remains unstable
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5. Calcaneus Fractures
Introduction
Epidemiology
o incidence
most frequent tarsal fracture
17% open fractures
Pathophysiology
o mechanism
traumatic axial loading is the primary mechanism of injury
fall from height
motor-vehicle accidents
o pathoanatomy
intra-articular fractures
primary fracture line results from oblique shear and leads to the following two primary
fragments
superomedial fragment (constant fragment)
includes the sustentaculum tali and is stabilized by strong ligamentous and
capsular attachments
superolateral fragment
includes an intra-articular aspect through the posterior facet
secondary fracture lines
dictate whether there is joint depression or tongue-type fracture
extra-articular fractures
strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site
on calcaneus
more common in osteopenic bone
anterior process fractures
inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament
Associated injuries
o orthopaedic
extension into the calcaneocuboid joint occurs in 63%
vertebral injuries in 10%
contralateral calcaneus in 10%
Prognosis
o poor with 40% complication rate
increased due to mechanism (fall from height), smoking, and early surgery
lateral soft tissue trauma increases the rate of complication
Anatomy
Osteology
o articular facets
superolateral fragment contains the articular facets
superior articular surface contains three facets that articulate with the talus
posterior facet is the largest and is the major weight bearing surface
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the flexor hallucis longus tendon runs just inferior to it and can be injured with errant
drills/screws that are too long
middle facet is anteromedial on sustentaculum tali
anterior facet is often confluent with middle facet
o sinus tarsi
between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that
together with the talar sulcus makes up the sinus tarsi
o sustentaculum tali
projects medially and supports the neck of talus
FHL passes beneath it
deltoid and talocalcaneal ligament connect it to the talus
contained in the anteromedial fragment, which remains "constant" due to medial
talocalcaneal and interosseous ligaments
o bifurcate ligament
connects the dorsal aspect of the anterior process to the cuboid and navicular
Classification
Extra-articular (25%)
o avulsion injury of
anterior process by bifurcate ligament
sustentaculum tali
calcaneal tuberosity (Achilles tendon avulsion)
Intra-articular (75%)
o Essex-Lopresti classification
VI:42 anterior process
the primary fracture line runs obliquely through the posterior facet
forming two fragments
the secondary fracture line runs in one of two planes
the axial plane beneath the facet exiting posteriorly in tongue-type fractures
when the superolateral fragment and posterior facet remain attached to the tuberosity
posteriorly
behind the posterior facet in joint depression fractures
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
Essex-Lopresti Classification
PRIMARY FRACTURE LINE (A, D)
The posterolateral edge of the talus splits the calcaneus obliquely through the posterior facet. The fracture line exits
anterolaterally at the crucial angle or as far distally as the calcaneocuboid joint. Posteriorly, the fracture moves from
plantar medial to dorsal lateral, producing two main fragments: the sustentacular (anteromedial) and tuberosity
(posterolateral) fragments.
The anteromedial fragment is rarely comminuted and remains attached to the talus by the deltoid and interosseous
talocalcaneal ligaments.
The posterolateral fragment usually displaces superolaterally with variable comminution, resulting in incongruity of the
posterior facet as well as heel shortening and widening.
SECONDARY FRACTURE LINE
With continued compressive forces, there is additional comminution, creating a free lateral piece of posterior facet
separate from the tuberosity fragment.
Tongue fracture: (D, E, and F) a secondary fracture line appears beneath the facet and exits posteriorly through the
tuberosity.
Joint depression fracture (A, B and C) a secondary fracture line exits just behind the posterior facet.
Continued axial force causes the sustentacular fragment to slide medially, causing heel shortening and widening. As this
occurs, the tuberosity fragment will rotate into varus. The posterolateral aspect of the talus will force the free lateral piece
of the posterior facet down into the tuberosity fragment, rotating it as much as 90 degrees. This causes lateral wall
blowout, which may extend as far anteriorly as the calcaneocuboid joint. As the lateral edge of the talus collapses further,
there will be additional comminution of the articular surface.
Source : Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition
o Sanders classification
based on the number of articular fragments seen on the coronal CT image at the widest point
of the posterior facet
Sanders Classification
Type I • Nondisplaced posterior facet (regardless of number of fracture lines)
Type II • One fracture line in the posterior facet (two fragments)
Type III • Two fracture lines in the posterior facet (three fragments)
Type • Comminuted with more than three fracture lines in the posterior facet (four or more
IV fragments)
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Presentation
Symptoms
o pain
Physical exam
o inspection
diffuse tenderness to palpation
ecchymosis and swelling
shortened, widened, heel with a varus deformity
Imaging
Radiographs
o recommended views
required
AP, lateral, and oblique foot
optional
Broden Harris view
allows visualization of posterior facet
useful for evaluation of intraoperative reduction of posterior facet
with ankle in neutral dorsiflexion take x-rays at 40, 30, 20, and 10
degrees of internal rotation
Harris view
visualizes tuberosity fragment widening, shortening, and varus positioning
place the foot in maximal dorsiflexion and angle the x-ray beam 45 degrees
AP ankle
demonstrates lateral wall extrusion causing fibular impingement
findings
reduced Bohler angle
increased angle of Gissane
calcaneal shortening
varus tuberosity deformity
o measurement
Bohler angle (normal is 20-40 degrees)
measured from lateral foot x-ray
flattening (decreased angle) represents collapse of the posterior facet
double-density highlights subtalar incongruity
angle of Gissane (normal is 130-145 degrees)
an increase represents collapse of posterior facet
CT
o indications
gold standard
o views
30-degree semicoronal
demonstrates posterior and middle facet displacement
axial
demonstrates calcaneocuboid joint involvement
sagittal : demonstrates tuberosity displacement
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
MRI
o indications
used only to diagnose calcaneal stress fractures in the presence of normal radiographs and/or
uncertain diagnosis
Treatment
Nonoperative
o cast immobilization with nonweightbearing for 6 weeks
indications
calcaneal stress fractures
o cast immobilization with nonweightbearing for 10 to 12 weeks
indications
small extra-articular fracture (<1 cm) with intact Achilles tendon and <2 mm
displacement
Sanders Type I (nondisplaced)
anterior process fracture involving <25% of calcaneocuboid joint
comorbidities that preclude good surgical outcome (smoker, diabetes, PVD)
techniques
begin early range of motion exercises once swelling allows
Operative
o closed reduction with percutaneous pinning
indications
minimally displaced tongue-type fxs or those with mild shortening
large extra-articular fractures (>1 cm)
early reduction prevents skin sloughing and need for subsequent flap coverage
techniques
lag screws from posterior superior tuberosity directed inferior and distal
o ORIF
indications
displaced tongue-type fractures
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large extra-articular fractures (>1 cm) with detachment of Achilles tendon and/or > 2 mm
displacement
urgent if skin is compromised
Sanders Type II and III
posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or varus
malalignment of the tuberosity
anterior process fracture with >25% involvement of calcaneocuboid joint
displaced sustentaculum fractures
timing
wait 10-14 days until swelling and blisters resolve and wrinkle sign present 10-14 days
no benefit to early surgery due to significant soft tissue swelling
outcomes
surgical outcome correlates with the number of intra-articular fragments and the quality
of articular reduction
factors associated with a poor outcome
age > 50
obesity
manual labor
workers comp
smokers
bilateral calcaneal fractures
multiple trauma
vasculopathies
men do worse with surgery than women
factors associated with most likely need for a secondary subtalar fusion
male worker's compensation patient who participates in heavy labor work with an
initial Böhler angle less than 0 degrees
o primary subtalar arthrodesis
indications
Sanders Type IV
techniques
combined with ORIF to restore height
Surgical Techniques
ORIF with extensile lateral or medial approach
o goals
restore congruity of subtalar joint
restore Bohler angle and calcaneal height
restore width
correct varus malalignment
o approach
extensile lateral L-shaped incision is most popular
provides access to calcaneocuboid and subtalar joints
high rate of wound complications
medial approach can also be used
full-thickness flap is created to maintain soft tissue integrity
o technique
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
place a pin in the tuberosity to assist the reduction
provisional fixation with Kirschner wires
hold reduction with low profile implants
bone grafting provides no added benefit
o postoperative care
bulky posterior U splint
early supervised subtalar range of motion exercises
nonweightbearing for 10 weeks
ORIF with sinus tarsi approach and Essex-Lopresti maneuver
o technique
manipulate the heel to increase the calcaneal varus deformity
plantarflex the forefoot
manipulate the heel to correct the varus deformity with a valgus reduction
stabilize the reduction with percutaneous K-wires or open fixation as described above
Complications
Wound complications (10-25%)
o increased risk in smokers, diabetics, and open injuries
Subtalar arthritis
o increased with nonoperative management
Lateral impingement with peroneal irritation
Damaged FHL
o at risk with placement of lateral to medial screws, especially at level of sustentaculum tali
(constant fragment)
Compartment syndrome (10%)
o results in claw toes
Malunion
o introduction
loss of height, widening, and lateral impingement
o physical exam
limited ankle dorsiflexion
due to dorsiflexed talus with talar declination angle <20
o classification (see below)
o treatment
distraction bone block subtalar arthrodesis
indications
chronic pain from subtalar joint
incongruous subtalar joint/post-traumatic DJD
loss of calcaneal height
mechanical block to ankle dorsiflexion
results from posterior talar collapse into the posterior calcaneus
technique
goal is to correct
hindfoot height
ankle impingement
subfibular impingement
subtalar arthritis
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OrthoBullets2017 Lower Extremity | Ankle and Hindfoot
Collected By : Dr AbdulRahman
AbdulNasser
June 2017
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Ankle and Hindfoot
ORTHO BULLETS
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OrthoBullets2017 Foot & Ankle Trauma | Ankle Sprains
A. Ankle Sprains
Anatomy
See complete ligament of ankle
Ligaments
o distal tibiofibular syndesmosis includes
anterior-inferior tibiofibular ligaments (AITFL)
originates from anterolateral tubercle of tibia (Chaput's)
inserts on anterior tubercle of fibula (Wagstaffe's)
posterior-inferior tibiofibular ligament (PITFL)
originates from posterior tubercle of tibia (Volkmann's)
inserts on posterior part of lateral malleolus
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Ankle Sprains
strongest component of syndesmosis
interosseous membrane
interosseous ligament (IOL)
distal continuation of the interosseous membrane
main restraint to proximal migration of the talus
inferior transverse ligament (ITL)
Syndesmosis Biomechanics
o function
maintains integrity between tibia and fibula
resists axial, rotational, and translational forces
o normal gait
syndesmosis widens 1mm during gait
o deltoid ligament
indirectly stabilizes the medial ankle mortise
Presentation
Symptoms
o anterolateral ankle pain proximal to AITFL
o may have medial sided ankle tenderness/swelling
o difficulty bearing weight
VII:2 Syndesmotic ligaments
lateral ankle sprains are often able to bear weight
Physical exam
o palpation
syndesmosis tenderness
single best predictor for return to play
o provocative tests
squeeze test (Hopkin's)
compression of tibia and fibula at midcalf level causes
pain at syndesmosis
external rotation stress test VII:3 squeeze test
pain over syndesmosis is elicited with external rotation/dorsiflexion of
the foot with knee and hip flexed to 90 degrees
Cotton
widening of the syndesmosis with lateral pull on the fibula
fibular translation
anterior and posterior drawer force to the fibula with the tibia stabilized causes increased
translation of the fibula and pain
Imaging
Radiographs
o recommended views
AP, lateral, mortise view of ankle
AP, lateral of entire tibia
may show fracture of proximal fibula
o optional views
external rotation stress radiograph
gravity stress view
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will help determine competence of deltoid ligament
contralateral ankle radiographs
may help clarify syndesmosis widening versus normal anatomic variant
o findings
decreased tibiofibular overlap
normal >6 mm on AP view
normal >1 mm on mortise view
increased medial clear space
normal less than or equal to 4 mm
increased tibiofibular clear space
normal <6 mm on both AP and mortise views
CT
o indications
clinical suspicion of syndesmotic injury with normal radiographs
useful post-operatively to assess reduction of syndesmosis after fixation
o sensitivity and specificity
more sensitive than radiographs for detecting minor degrees of syndesmotic injury
MRI
o indications
clinical suspicion of syndesmotic injury with normal radiographs
o sensitivity and specificity
highly sensitive and specific for detecting syndesmotic injury
external rotation
stress gravity stress view
Mortis &AP radiograph of entire leg radiograph CT
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Ankle Sprains
o non-weight-bearing CAM boot or cast for 2 to 3 weeks
indications
syndesmotic sprain without diastasis or ankle instability
technique
delayed weight-bearing until pain free
physical therapy program using a brace that limits external rotation
outcomes
typically display a notoriously prolonged and highly variable recovery period
recovery may extend to twice that of standard ankle sprain
Operative
o syndesmosis screw fixation
indications
syndesmotic sprain (without fracture) with instability on stress radiographs
syndesmotic sprain refractory to conservative treatment
syndesmotic injury with associated fracture that remains unstable after fixation of fracture
outcomes
excellent functional outcomes if syndesmosis is accurately reduced
requires removal
o syndesmosis fixation with suture button
indications
same as for screw fixation
technique
fiberwire suture with two buttons tensioned around the syndesmosis
may be performed in addition to a screw II:4 suture button
V
outcomes
early results promising with some showing earlier return to activity when compared to
screw fixation
does not require removal
Surgical Techniques
Syndesmotic screw fixation
o technique
two 3.5 or 4.5 mm syndesmotic screws through 3 or 4 cortices
placed 2-5 cm above the plafond
screw material
no difference between stainless-steel and titanium screws
bioabsorbable screws with similar outcomes
number of cortices
no difference between 3 or 4 cortices
number of screws
fixation with two screws is preferable
position of foot during fixation
a recent study challenges the principle of holding the ankle in maximal dorsiflexion to
avoid overtightening
o postoperative
typically non-weight-bearing for 6-12 weeks
may prolong if screw breakage is a concern
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Complications
Posttraumatic tibiofibular synostosis
o incidence
~10% after Weber C ankle fractures
o treatment
surgical excision
reserved for persistent pain that fails to respond to
nonsurgical management
ossification must be "cold" on bone scintigraphy prior to
removal
Anatomy
Ligamentous anatomy of the ankle
ATFL
o most commonly involved ligament in low ankle sprains
o mechanism is plantar flexion and inversion
o physical exam shows drawer laxity in plantar flexion
CFL
o 2nd most common ligament injury in lateral ankle sprains
o mechanism is dorsiflexion and inversion
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Ankle Sprains
o physical exam shows drawer laxity in dorsiflexion
o subtalarinstability can be difficult to differentiate from posterior ankle instability because the
CFL contributes to both
PTFL : less commonly involved
Classification
Classification of Low Ankle Sprains
Ligament disruption Ecchymosis and swelling Pain with weight bearing
Grade I none minimal normal
Grade II stretch without tear moderate mild
Grade III complete tear severe severe
Presentation
Symptoms
o pain with weight bearing
o recurrent instability
o catching or popping sensation may occur following recurrent sprains
Physical exam
o focal tenderness and swelling over involved ligament(s)
o anterior drawer test
possible laxity with anterior drawer and eversion/inversion stress testing
Imaging
Radiographs
o indications for radiographs with an ankle injury include (Ottawa ankle rules)
inability to bear weight
medial or lateral malleolus point tenderness
5MT base tenderness
navicular tenderness
o radiographic views to obtain
standard ankle series (weight bearing)
AP
lateral
mortise
II:5 varus stress view
V
ER rotation stress view
useful to diagnosis syndesmosis injury in high ankle sprain
look for asymmetric mortise widening
medial clear space widening > 4mm
tibiofibular clear space widening of 6 mm
varus stress view
used to diagnose injury to ATFL or CFL
measures ankle instability by looking at talar tilt and anterior talar translation
MRI
o indications : consider MRI if pain persists for 8 weeks following sprain
o useful to evaluate
peroneal tendon pathology
osteochondral injury
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Treatment
Nonoperative
o RICE, elastic wrap to minimize swelling, followed by therapy
indications : Grade I, II, and III injuries
technique
may require short period (approx. 1 week) of weight-bearing immobilization in a walking
boot or walking cast, but early mobilization facilitates a better recovery
therapy
once swelling and pain have subsided and patient has full range of motion begin
neuromuscular training with a focus on peroneal muscles strength and proprioception
training
a functional brace that controls inversion and eversion is typically used during the
strengthening period and used as prophylactic treatment during high risk activities
thereafter
early functional rehabilitation allows for quickest return to physical activity
Operative
o anatomic reconstruction vs. tendon transfer with tenodesis
indications
Grade I-III that continue to have pain and instability despite extensive nonoperative
management
Grade I-III with a bony avulsion
technique (see below)
o arthroscopy
indications
recurrent ankle sprains and chronic pain caused by impingement lesions
anteriorinferior tibiofibular ligament impingement
posteromedial impingement lesion of ankle
procedure : debride impinging tissue
Surgical Techniques
Gould modification of Brostrom anatomic reconstruction
o procedure
an anatomic shortening and reinsertion of the ATFL and CFL
reinforced with inferior extensor retinaculum and distal fibular periosteum
o results
good to excellent results in 90%
consider arthroscopic evaluation prior to reconstruction for intra-articular evaluation
Tendon transfer and tenodesis (Watson-Jones, Chrisman-Snook, Colville, Evans)
o procedure
a nonanatomic reconstruction using a tendon transfer
o technique
any malalignment must be corrected to achieve success during a lateral ligament
reconstruction
Coleman block testing used to distinguish between fixed and flexible hindfoot varus
o results
subtalar stiffness is a common complication
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Ankle Sprains
Rehabilitation
Return to play
o depends on, grade of sprain, syndesmosis injury, associated injuries, and compliance with rehab
Complications
Pain and instability
o up to 50% continue to experience symptoms following and acute ankle sprain
o most common cause of chronic pain is a missed injury, including
injury to the anterior process of calcaneus
injury to the lateral or posterior process of the talus
injury to the base of the 5th metatarsal
osteochondral lesion
injuries to the peroneal tendons
injury to the syndesmosis
tarsal coalition
impingement syndromes
Collected By : Dr AbdulRahman
AbdulNasser
June 2017
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Anatomy
Osteology
o Lisfranc joint complex consists of three articulations including
tarsometatarsal articulation
intermetatarsal articulation
intertarsal articulations
Ligaments
o Lisfranc ligament
critical to stabilizing the second metatarsal and maintenance
of the midfoot arch
An interosseous ligament that goes from medial cuneiform
to base of 2nd metatarsal on plantar surface
Lisfranc ligament tightens with pronation and abduction of forefoot
o plantar tarsometatarsal ligaments
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Mid & Forefoot Trauma
injury of the plantar ligament between the medial cuneiform and the second and third
metatarsals along with the Lisfranc ligament is necessary to give transverse instability.
o dorsal tarsometatarsal ligaments
dorsal ligaments are weaker and therefore bony displacement with injury is often dorsal
o intermetatarsal ligaments
between second-fifth metatarsal bases
no direct ligamentous attachment between first and second metatarsal
Biomechanics
o Lisfranc joint complex is inherently stable with little motion due to
stable osseous architecture
second metatarsal fits in mortise created by medial cuneiform and recessed middle
cuneiform, "keystone configuration"
ligamentous restraints
see individual ligaments above
Columns of the midfoot
o medial column
includes first tarsometatarsal joint
o middle column
includes second and third tarsometatarsal joints
o lateral column
includes fourth and fifth tarsometatarsal joints (most mobile)
Classification
Multiple classification schemes described
o none proven useful for determining treatment and prognosis
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Physical Exam
Symptoms
o severe pain
o inability to bear weight
Physical exam
o inspection & palpation
medial plantar bruising
swelling throughout midfoot
tenderness over tarsometatarsal joint
o motion & stability
instability test
grasp metatarsal heads and apply dorsal force to forefoot while other hand palpates the
TMT joints
dorsal subluxation suggests instability
if first and second metatarsals can be displaced medially and laterally, global
instability is present and surgery is required
when plantar ligaments are intact, dorsal subluxation does not occur with stress exam and
injury may be treated nonoperatively
o provocative tests
may reproduce pain with pronation and abduction of forefoot
o compartment syndrome
always check for compartment syndrome and take compartment pressures if high suspicion
Imaging
Radiographs
o recommended views
AP, lateral, obliques
stress radiograph
may be helpful to show instability when non-weight bearing radiographs are normal and
there is high suspicion
weight-bearing radiographs with comparison view
may be necessary to confirm diagnosis
o findings
five critical radiographic signs that indicate presence of midfoot instability
disruption of the continuity of a line drawn from the medial base of the second metatarsal
to the medial side of the middle cuneiform
widening of the interval between the first and second ray
medial side of the base of the fourth metatarsal does not line up with medial side of
cuboid on oblique view
metatarsal base dorsal subluxation on lateral view
disruption of the medial column line (line tangential to the medial aspect of the navicular
and the medial cuneiform)
lateral
non weight-bearing radiographs may show dorsal displacement of the proximal base of
the first or second metatarsal
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Mid & Forefoot Trauma
AP
malalignment of medial margin of the second metatarsal base and the medial edge of the
middle cuneiform diagnostic of Lisfranc injury
may see bony fragment (fleck sign) in first intermetatarsal space
represents avulsion of Lisfranc ligament from base of 2nd metatarsal
diagnostic of Lisfranc injury
oblique
malalignment of fourth metatarsal and cuboid
CT scan
o useful for diagnosis and preoperative planning
MRI
o can be used to confirm presence of purely ligamentous injury
AP AP Lateral CT
Treatment
Nonoperative
o cast immobilization for 8 weeks
indications
no displacement on weight-bearing and stress radiographs and no evidence of bony injury
on CT (usually dorsal sprains)
certain nonoperative candidates
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nonambulatory patients
presence of serious vascular disease
severe peripheral neuropathy
instability in only the transverse plane
Operative
o open reduction and rigid internal fixation
indications
any evidence of instability (> 2mm shift)
favored in bony fracture dislocations as opposed to purely ligamentous injuries
outcomes
anatomic reduction required for a good result
o primary arthrodesis of the first, second and third tarsometatarsal joints
indications
purely ligamentous arch injuries
delayed treatment
chronic deformity
outcomes
level 1 evidence demonstrates equivalent functional outcomes and decreased rate of
hardware removal or revision surgery compared to primary ORIF
primary arthodesis is an alternative to ORIF in patients with any evidence of instability
Complications
Posttraumatic arthritis
o most common complication
o may cause altered gait and long term disability
o treat advanced midfoot arthrosis with midfoot arthrodesis
Nonunion
o uncommon
o revision surgery indicated unless patient is elderly and low demand
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OrthoBullets2017 Foot & Ankle Trauma | Mid & Forefoot Trauma
Anatomy
Osteology and Insertions
o divided into tubercle (tuberosity), base, shaft, head and neck
o peroneus brevis and lateral band of plantar fascia insert on base
o peroneus tertius inserts on dorsal metadiaphysis
Blood supply
o blood supply provided by metaphyseal vessels and diaphyseal nutrient artery
o Zone 2 (Jones fx) represents a vascular watershed area, making these fracture prone to nonunion
Classification
Classification
Class Description
Zone 1 Proximal tubercle (rarely enters 5th tarsometatarsal joint)
(pseudo Jones Due to long plantar ligament, lateral band of the plantar fascia, or contraction of the
fx) peroneus brevis
Nonunions uncommon
Zone 2 Metaphyseal-diaphyseal junction
(Jones fx) Involves the 4th-5th metatarsal articulation
Vascular watershed area
Acute injury
Increased risk of nonunion
Zone 3 Proximal diaphyseal fracture
Distal to the 4th-5th metatarsal articulation
Stress fracture in athletes
Associated with cavovarus foot deformities or sensory neuropathies
Increased risk of nonunion
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Mid & Forefoot Trauma
Presentation
Symptoms
o pain over lateral border of forefoot, especially with
weight bearing
o look for antecedent pain in setting of stress fracture
Physical Exam
o manual palpation of area of concern
o resisted foot eversion
Imaging
Radiographs : AP, lateral and oblique foot images
CT
o not routinely obtained
o consider in setting of delayed healing or nonunion
MRI : not routinely obtained
o consider in setting of delayed healing or nonunion
Treatment
Nonoperative
o protected weight bearing in stiff soled shoe, boot or cast
indications
Zone 1
technique
advance as tolerated by pain
early return to work but symptoms may persist for up to 6 months
o non weight bearing short leg cast for 6-8 weeks
indications
Zone 2 (Jones fx) in recreational athlete
Zone 3
technique : advance with signs of radiographic healing
Operative
intramedullary screw fixation : indications
zone 2 (Jones fx) in elite or competitive athletes
minimizes possibility of nonunion or prolonged restriction from activity
zone 3 fx with sclerosis/nonunion or in athletic individual
Complications
Nonunion
o increased risk in Zone 2 (Jones fx) and Zone 3 due to vascular supply
o smaller diameter screws (<4.5mm) associated with delayed union or nonunion
Failure of fixation : higher failure rate in
elite athletes
return to sports prior to radiographic union
fracture distraction or malreduction due to screw length
screws that are too long will straighten the curved metatarsal shaft or perforate the medial
cortex
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OrthoBullets2017 Foot & Ankle Trauma | Mid & Forefoot Trauma
3. Metatarsal Fractures
Introduction
Metatarsal fractures are among the most common injuries of the foot
o goals of treatment include:
maintenance of transverse and longitudinal arch of forefoot
restore alignment to allow for normal force transmission
across metatarsal heads
Epidemiology
o 5th metatarsal most commonly fractured in adults
o 1st metatarsal most commonly fractured in children less than 4
years old
o peak incidence between 2nd and 5th decade of life
o 3rd metatarsal fractures rarely occur in isolation
68% associated with fracture of 2nd or 4th metatarsal
Mechanism
o direct crush injury
may have significant associated soft tissue injury
o indirect mechanism (most common)
occurs with forefoot fixed and hindfoot or leg rotating
Associated conditions
o Lisfranc injury
Lisfranc equivalent injuries seen with multiple proximal metatarsal fractures
o stress fracture
consider metabolic evaluation for fragility fracture
look for associated foot deformity
seen at base of 2nd metatarsal in ballet dancers
may have history of amenorrhea
Prognosis
o majority of isolated metatarsal fractures heal with conservative management
o malunion may lead to transfer metatarsalgia
Anatomy
Osteology
o shape and function similar to metacarpals of the hand
o first metatarsal has plantar crista that articulates with sesamoids
widest and shortest
bears 30-50% of weight during gait
o second metatarsal is longest
most common location of stress fracture
Muscles
o muscular balance between extrinsic and intrinsic muscles
o extrinsics include
Extensor digitorum longus (EDL)
Flexor digitorum longus (FDL)
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Mid & Forefoot Trauma
o intrinsics include
Interossei
Lumbricals
o see Layers of the Plantar Foot
Ligaments
o Metatarsals have dense proximal and distal ligamentous attachments
o 2nd-5th metatarsal have distal intermetatarsal ligaments that maintain length and alignment with
isolated fractures
implicated in formation of interdigital (Morton's) neuromas
multiple metatarsal fractures lose the stability of intermetatarsal ligaments leading to
increased displacement
Blood supply
o dorsal and plantar metatarsal arteries
Biomechanics
o see Foot and Ankle Biomechanics
Classification
Classification of metatarsal fractures is descriptive and should include
o location
o fracture pattern
o displacement
o angulation
o articular involvement
Presentation
History
o look for antecedent pain when suspicious for stress fracture
Symptoms
o pain, inability to bear weight
Physical Exam
o inspection
foot alignment (neutral, cavovarus, planovalgus)
focal areas or diffuse areas of tenderness
careful soft tissue evaluation with crush or high-energy injuries
o motion
evaluate for overlapping or malrotation with motion
o neurovascular
semmes weinstein monofilament testing if suspicious for peripheral neuropathy
Imaging
Radiographs
o recommended views
required
AP, lateral and oblique views of the foot
optional
contralateral foot views
stress or weight bearing radiographs
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CT
o not
routinely obtained
o may be of use in periarticular injuries or to rule out Lisfranc injury
MRI or bone scan
o useful in detection of occult or stress fractures
Treatment
Nonoperative
o stiff soled shoe or walking boot with weight bearing as tolerated
indications
first metatarsal
non-displaced fractures
second through fourth (central) metatarsals
isolated fractures
non-displaced or minimally displaced fractures
stress fractures
second metatarsal most common
look for metabolic bone disease
evaluate for cavovarus foot with recurrent stress fractures
Operative
o percutaneous vs open reduction and fixation
indications
open fractures
first metatarsal
any displacement
no intermetatarsal ligament support
30-50% of weight bearing with gait
central metatarsals
sagittal plane deformity more than 10 degrees
>4mm translation
multiple fractures
techniques
antegrade or retrograde pinning
lag screws or mini fragment plates in length unstable fracture patterns
maintain proper length to minimize risk of transfer metatarsalgia
outcomes
limited information available in literature
Complications
Malunion
o may lead to transfer metatarsalgia or plantar keratosis
o treat with osteotomy to correct deformity
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Mid & Forefoot Trauma
Anatomy
Articulations
o navicular bone articulates with
cuneiforms
cuboid
calcaneus
talus
Biomechanics
o navicular bone and its articulations play an important role in inversion and eversion
biomechanics and motion
Classification
Sangeorzan Classification of Navicular Body Fractures
(based on plane of fracture and degree of comminution)
Transverse fracture of dorsal fragment that involves < 50% of bone.
Type I
No associated deformity
Oblique fracture, usually from dorsal-lateral to plantar-medial.
Type II
May have forefoot aDDuction deformity.
Central or lateral comminution.
Type IIII
ABDuction deformity.
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OrthoBullets2017 Foot & Ankle Trauma | Mid & Forefoot Trauma
Imaging
Radiographs VII:8 CT
o may be difficult to see and are often missed
o oblique 45 degree radiograph
best to visualize tuberosity fractures
CT
o more sensitive to identify fracture than radiographs
MRI
o will show signal intensity on T2 image due to inflammation
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Tendon Injuries
Treatment of Traumatic Fractures
Nonoperative
o cast immobilization with no weight bearing
indications
acute avulsion fractures
most tuberosity fractures
minimally displaced Type I and II navicular body fractures
Operative
o fragment excision
indications
avulsion fractures that failed to improve with nonoperative modalities
tuberosity fractures that went on to symptomatic nonunion
o open reduction and internal fixation
indications
avulsion fractures involving > 25% of articular surface
tuberosity fractures with > 5mm diastasis or large intra-articular fragment
displaced or intra-articular Type I and II navicular body fractures
technique
medial approach
used for Type I and II navicular body fractures
o ORIF followed by external fixation VS. primary fusion
indications
Type III navicular body fractures
technique
must maintain lateral column length
C. Tendon Injuries
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OrthoBullets2017 Foot & Ankle Trauma | Tendon Injuries
sudden forced plantar flexion
violent dorsiflexion in a plantar flexed foot
Pathoanatomy
o rupture usually occurs 4-6 cm above the calcaneal insertion in hypovascular region
Anatomy
Achilles tendon
o largest tendon in body
o formed by the confluence of
soleus muscle tendon
medial and lateral gastrocnemius tendons
o blood supply from posterior tibial artery
Presentation
History
o patient usually reports a "pop"
Symptoms
o weakness and difficulty walking
o pain in heel
Physical exam
o inspection
increased resting ankle dorsiflexion in prone position with knees bent
calf atrophy may be apparent in chronic cases
o palpation
palpable gap
o motion
weakness to ankle plantar flexion
increased passive dorsiflexion
o provocative test
Thompson test
lack of plantar flexion when calf is squeezed
Imaging
Radiographs
o indications
VII:10 Partial tear U/S
used to rule out other pathology
Ultrasound
o indications
may be useful to determine complete vs. partial ruptures
MRI
o indications
equivocal physical exam findings
chronic ruptures
o findings VII:11 Complete tear U/S
will show acute rupture with retracted tendon edges
Treatment
Nonoperative
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Tendon Injuries
o functional bracing/casting in resting equinus
indications
acute injuries with surgeon or patient preference for non-
operative management
sedentary patient
medically frail patients
outcomes
decreased plantar flexion strength compared to operative
management
new studies show that this may not be true
increased risk of re-rupture compared to operative management VII:12 MRI showing rupture
new studies show that this may not be significant achilles tendon
Surgical Techniques
Functional bracing/casting in resting equinus
o technique
cast/brace in 20 degrees of plantar flexion
early functional rehab for those treated without a cast
End-to-end achilles tendon repair
o approach
make incision just medial to achilles tendon to avoid sural nerve
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OrthoBullets2017 Foot & Ankle Trauma | Tendon Injuries
o technique
incise paratenon
expose tendon edges
repair with heavy non-absorbable suture
o postoperative care
immobilize in 20° of plantar flexion to decrease
tension on skin and protect tendon repair for 4-6
weeks
Percutaneous achilles tendon repair VII:13 VY advancement
o technique
Reconstruction with VY advancement
o technique
make V cut with apex at musculotendinous junction with limbs divergent to exit the tendon
V is incised through only the superficial tendinous portion leaving the muscle fibers intact
Flexor hallucis longus transfer ± VY advancement of gastrocnemius
o technique
excise degenerative tendon edges
release FHL tendon at the Knot of Henry and transfer through the calcaneus
Complications
Re-rupture
o incidence
higher with non-operative management (~10-40% vs 2%)
new Level 1 evidence has shown no difference in re-rupture rates
o treatment
surgical repair
Wound healing complications
o incidence
5-10%
o risk factors
smoking (most common)
female gender
steroid use
open technique (versus percutaneous)
o treatment
deep infection
debridement of necrotic/infected Achilles tendon
culture-specific antibiotics for 6 weeks
Sural nerve injury
o incidence
higher when percutaneous approach is used II:14 Wound healing
V
complications
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Tendon Injuries
Anatomy
Muscles & innervation
o peroneus brevis
innervated by the superficial peroneal nerve, S1
acts as primary evertor of the foot
tendinous about 2-4cm proximal to the tip of the fibula
lies anterior and medial to the peroneus longus at the level of the lateral malleolus
o peroneus longus
innervated by superficial peroneal nerve, S1
primarily a plantar flexor and foot and first metatarsal
can have an ossicle (os peroneum) located within the tendon body
Space & compartment
o peroneal tendons contained within a common synovial sheath that splits at the level of the
peroneal tubercle
o the sheath is runs in the retromalleolar sulcus on the fibula
peroneus longus is posterior in the sulcus (longus takes the long way around)
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peroneus brevis is anterior in the sulcus (brevis is behind the bone)
deepened by a fibrocartilaginous rim (still only about 5 millimeters deep)
covered by superior peroneal retinaculum (SPR)
originates from the posterolateral ridge of the fibula and inserts onto the lateral calcaneus
(peroneal tubercle)
the inferior aspect of the SPR blends with the inferior peroneal retinaculum
is the primary restraint the peroneal tendons within the retromalleolar sulcus
o at the level of the peroneal tubercle of the calcaneus
peroneus longus is inferior
peroneus brevis is superior
both tendons covered by inferior peroneal retinaculum
Classification
Ogden Classification of Superior Peroneal Retinaculum (SPR) Tears
Grade 1 The SPR is partially elevated off of the fibula allowing for subluxation of both
tendons
Grade 2 The SPR is separated from the cartilofibrous ridge of the lateral malleolus,
allowing the tendons to sublux between the SPR and the cartilofibrous ridge
Grade 3 There is a cortical avulsion of the SPR off of the fibula, allowing the subluxed
tendons to move underneath the cortical fragment
Grade 4 The SPR is torn from the calcaneous, not the fibula
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Tendon Injuries
Presentation
History
o patients often report they felt a pop with a dorsiflexion ankle injury
Symptoms
o clicking, popping and feelings of instability or pain on the lateral aspect of the ankle
Physical exam
o inspection
swelling posterior to the lateral malleolus
tenderness over the tendons
'pseudotumor' over the peroneal tendons
voluntary subluxation of the tendons +/- a popping sound
o provocative tests
apprehension tests
the sensation of apprehension or subluxation with active dorsiflexion and eversion against
resistance cause subluxation/dislocation and apprehension
compression test
pain with passive dorsiflexion and eversion of the ankle
Imaging
Radiographs
o recommended views
best recognized on an internal rotation view
o findings
may see a cortical avulsion off the distal tip of the lateral malleolus
(fleck sign, rim fracture)
needed to evaluate for varus hindfoot
MRI
o best evaluated with axial views of a slightly flexed ankle
o can demonstrate anatomic anomalies leading to pathology
peroneus quartus muscle
low-lying peroneus brevis muscle belly
VII:15 fleck sign
Treatment
Nonoperative
o short leg cast immobilization and protected weight bearing for 6 weeks
indications
all acute injuries in nonprofessional athletes
technique
tendons must be reduced at the time of casting
outcomes
success rates for nonsurgical management are only marginally better than 50%.
Operative
o acute repair of superior peroneal retinaculum and deepening of the fibular groove
indications
acute tendon dislocations in serious athletes who desire a quick return to a sport or active
lifestyle
presence of a longitudinal tear
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OrthoBullets2017 Foot & Ankle Trauma | Tendon Injuries
o groove-deepening with soft tissue transfer and/or osteotomy
indications
chronic/recurrent dislocation
technique
less able to reconstruct SPR so treatment focuses on other aspects of peroneal stability
typically involves groove-deepening in addition to soft tissue transfers or bone block
techniques (osteotomies to further contain the tendons within the sulcus)
plantaris grafts can act to reinforce the SPR
hindfoot varus must be corrected prior to any SPR reconstructive procedure
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Tendon Injuries
indications
simple tears
debridement of the tendon with tenodesis of distal and proximal ends of the brevis
tendon to the peroneus longus or reconstruction with allograft
indications
complex tears with multiple longitudinal tears and significant tendinosis (> 50% of
the tendon involved)
Anatomy
Ankle dorsiflexion
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OrthoBullets2017 Foot & Ankle Trauma | Tendon Injuries
o primary ankle dorsiflexor (80%)
tibialis anterior
o secondary ankle dorsiflexors
extensor hallucis longus
extensor digitorum longus
Presentation
History
o acute
patient reports a 'pop' followed by anterior ankle swelling
o chronic
patient reports difficulty clearing foot during gait
Symtpoms:
o acute
pain
o chronic
may be painless
Physical exam
o acute injury
pain swelling anterior to ankle
weakness in dorsiflexion of the ankle
delay in diagnosis is common because of intact ankle dorsiflexion that occurs as a result
of secondary function of the extensor hallucis longus and extensor digitorum longus
muscles
o chronic injury
inspection and palpation
swelling may be minimal
painless mass at the anteromedial aspect of the ankle
loss of the contour of the tibialis anterior tendon over the ankle (tendon not palpable
during resisted dorsiflexion)
weakness
use of the extensor hallucis longus and extensor digitorum communis to dorsiflex the
ankle
gait
steppage gait (hip flexed more than normal in swing phase to prevent toes from catching)
foot slaps down after heel strike
Imaging
Radiographs
o three views of foot and ankle helpful to exclude any associated osseous injury
CT : not indicated
MRI
o helpful to diagnose complete versus partial tear but not to determine if interposition graft is
necessary
Differential
Lumbar radiculopathy (L4)
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Tendon Injuries
o can be differentiated from TA rupture by
intact tendon palpable
no ankle mass
may have dermatomal sensory abnormality
positive lumbar spine MRI
Common peroneal nerve compression neuropathy
o EDL, EHL also affected
o sensory abormalities
o history of compression to common peroneal nerve
Treatment
Nonoperative
o ankle-foot orthosis
indications
low demand patient
o casting
indications
partial ruptures
Operative
o direct repair
indications
acute injury (<6 week) injuries
should be attempted up to 3 months out
outcomes
surgical repair leads to improved AOFAS scores and improved levels of activity
some residual weakness of dorsiflexion is expected
o reconstruction
indications
most often required in chronic (>6 week) old injuries
Technique
Direct repair
o approach
open laceration: incorporate laceration
closed rupture: longitudinal incision centered over palpable defect
o repair technique
distal end usually accessible through laceration, proximal end may retract ~3cm
place hemostat in wound under extensor retinaculum and pull tendon into wound
primary end-to-end non-absorbable suture with Krackow, Bunnell or Kessler technique
ends oversewn with small monofilament if frayed to create smoother gliding surface
in cases of avulsion, suture anchors or bone tunnels may be used for reattachment
Tendon reconstruction
o approach
curvilinear incision over course of tibialis tendon, may need to be extensile depending needs
of reconstruction
EHL can be divided through separate small incision and tunneled proximally
o sliding tendon graft
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OrthoBullets2017 Foot & Ankle Trauma | Tendon Injuries
harvest one half width of tibialis anterior tendon proximally and turn down to span gap
repair can be strengthened by securing tibialis anterior tendon to medial cuneiform or dorsal
navicular distal to extensor retinaculum
o free tendon graft
interposition of autograft (hamstring, plantaris) or allograft
o EHL tenodesis or EHL transfer
distal EHL stump tenodesed to EHB
proximal EHL stump used as tendon graft to repair tibialis anterior insertion
proximal tibialis anterior placed under tension prior to suturing to proximal EHL stump
Complications
Failure of reconstruction/repair
Weakness of dorsiflexion
Adhesion formation
Neuroma formation
Collected By : Dr AbdulRahman
AbdulNasser
June 2017
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Tendon Injuries
ORTHO BULLETS
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OrthoBullets2017 Pediatric trauma | Introduction
A. Introduction
1. Pediatric Abuse
Introduction
Epidemiology
o incidence
>1 million children are victims of substantiated abuse or neglect in United States each year
child abuse is the second most common cause of death in children behind accidental injury.
in child abuse, head injury is the most frequent cause of long term physical morbidity in the
child
o demographics
astounding 79% of all cases of nonaccidental trauma occur in children younger than 4 years
of age
50% of fractures in children younger than 1 year of age are attributable to abuse
the most common cause of femur fractures in the nonambulatory infant is nonaccidental
trauma
o social risk factors
recent job loss of parent
children with disabilities (cerebral palsy, premature)
step children
o 4 Types (can have more than one type present):
Neglect 78%
Physical Abuse 18%
Sexual 9%
Psychological 8%
III:1 corner fxs
V
Prognosis
o If unreported, 30-50% chance of repeat abuse and 5-10% chance of death from abuse
Differential Diagnosis
o true accidental injury
o osteogenesis imperfecta
o metabolic bone disease
Presentation
History
o injury often inconsistent with history
VIII:2 posterior rib fractures
o red flags
long bone fxs in infant that is not yet walking
multiple bruises
multiple fxs in various stages of healing
corner fxs
primary spongiosa (metaphyseal)
high specificity for child abuse
posterior rib fractures
bucket handle fractures VIII:3 bucket handle fractures
same as corner fractures
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Introduction
avulsed bone fragment is seen en face as a bucket handle
transphyseal separation of the distal humerus
Symptoms
o pain related to fractures
fractures are the second most common lesion in abused children
frequency of fractures
humerus > tibia > femur
diaphyseal fractures 4 times more common than metaphyseal
Physical exam
o skin lesions
most common presenting lesion
Imaging
Radiographs
o recommended views
AP and lateral of bone or joint of suspicion
initial evaluation should include skeletal survey
Bone scan
o alternative or adjunct to the radiographic skeletal survey in selected cases, particularly for
children older than 1 year. Scintigraphy provides increased sensitivity for detecting rib fractures,
subtle shaft fractures, and areas of early periosteal elevation. Not useful in metaphyseal or
cranial fractures. Not indicated after 5 years of age
Treatment
Nonoperative
o report abuse to appropriate agency
indications
Physicians are mandated reporters, and are legally obligated to report suspected child
abuse and neglect.
Physicians are granted immunity from civil and criminal liability if they report in good
faith, but may be charged with a crime for failure to report
early involvement of social workers and pediatricians is essential
o hospital admission
indications
early multidisciplinary evaluation
admit infants with fractures to the hospital and consult child protective services
obtain social service consult
Operative
o definitive treatment as indicated for particular injury
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OrthoBullets2017 Pediatric trauma | Introduction
Transport
Occipital cut-out needed in spine board when transporting children <6 y.o.
o larger head size can flex unstable cervical spine leading to injury during transport
Help tips
o Broselow tape = estimate medication doses, size of equipment, shock voltage for defibrillator
o ETT = (age/4) + 4 or (age+16)/4 = uncuffed
o BP = 80 + (age x 2)
o Chest tube = 4 x ETT
o Blood volume = 70 x wt (kg) or 75 - 80 mL/kg
Intraosseous lines commonly needed due to difficulty obtaining venous access
o Children may remain hemodynamically stable even after significant blood loss
hypovolemic shock may result from inadequate fluid resuscitation
o "triad of death" reflects inadequate resusitation and is characterized by:
acidosis
hypothermia
coagulopathy
Airway
Smaller airway
o greater risk of airway obstruction with foreign bodies
o small amounts of swelling will result in a relatively greater reduction in airway diameter
Larger tongue, floppy epiglottis,
Larger occiput
o flexes the head forward when placed supine on a flat surface.
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Introduction
o to achieve a neutral position, it may be necessary to lift the chin or place a pad under the torso of
the infant (or head cut out)
Larynx is higher and more anterior
o sits at the level of the C2-C3 vertebrae body in the young child, compared with C6-C7 in the
adult.
positioning of the larynx makes its visualisation in the paediatric airway more difficult than
in the adult.
Breathing
Most common cause of cardiorespiratory arrest is hypoventilation
Ribs positioned more horizontally
o with inspiration the ribs only move up, and not up-and-out, like the adult rib cage.
o limits the capacity to increase tidal volumes
Diaphragmatic breathing
Fewer Type 1 fibres in respiratory muscles
o smaller number of fatigue-resistant, Type I fibres in their respiratory muscles
o exhaust more quickly than adults
Respiratory rate varies with age
o higher oxygen demand = higher respiratory rates
Circulation
Initial bolus = 20ml/kg NS
After two boluses = 10ml/kg of PRBC’s
Blood volume is relatively larger, but absolute volume is smaller
o small volumes of blood will constitute significant blood loss in small children,
example = 100ml haemorrhage experienced by a 5 kg child represents the loss of
approximately 10% of their total blood volume.
Systemic vascular resistance is lower
o increases from birth to adulthood
Hypotension is a late sign
o remain normotensive until they are loosing large intravascular volumes
25-30% of blood volume before signs of shock
Smaller vessels / more subcutaneous tissue
o difficult to obtain vascular access due to small veins and increased subcutaneous tissue
IV access more difficult – consider intraosseus
Disability
Open sutures, presence of fontanelle
Thinner cranial bones
o thinner cranial bones of children do not afford as much protection to the brain tissue
Head relatively larger
o higher centre of gravity = higher incidence of head and neck trauma
Exposure
Relatively small size
o large head and organs
Higher BMR and surface area
o greater consumption of oxygen and other metabolites
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OrthoBullets2017 Pediatric trauma | Introduction
o higher respiratory and heart rates
o larger surface-area to body-mass ratio results in greater heat loss
Increased glucose requirements but decreased glycogen stores
o higher metabolic rate
o small glycogen stores
Injuries
Head and neck
o ICP can be elevated by pain
it is possible to decrease ICP by fracture fixation
o heterotopic ossification is more common following traumatic brain injury
increase serum alkaline phosphatase heralds onset of HO
NSAID prophylaxis is indicated in these situations
Peripheral nerve injuries
o most common in closed fractures
obtain EMG if no return of function 2-3 months after injury
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Introduction
3. Physeal Considerations
Introduction
Always look to see if physis is open
Unique principals in pediatric bone
o elasticity
more elastic which leads to unique fracture patterns
buckle fractures
greenstick fractures
o remodeling potential
open physes (growth plates) can allow extensive bone
deformity remodeling potential
occurs more rapidly in plane of joint motion
sagittal plane in wrist, due to primarily extension/flexion
occurs more at the most active physes, due to most growth and
potential for remodeling
most active physes in upper extremity
proximal humerus
distal radius
most active physes in lower extremity
distal femur
proximal tibia
Same principles as adult bone
o intra-articular fractures must be reduced
VIII:4 Illustration of blood supply of the physis VIII:5 Perichondrial fibrous ring of La Croix
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OrthoBullets2017 Pediatric trauma | Introduction
Physeal Anatomy
Physis Periphery
Groove of During the first year of life, the zone spreads over Osteochondroma
Ranvier the adjacent metaphysis to form a fibrous
circumferential ring bridging from the epiphysis to
the diaphysis.
This ring increases the mechanical strength of the
physis and is responsible for appositional bone
growths
o supplies chondrocytes to periphery
Perichondrial Dense fibrous tissue that is the primary limiting
fibrous ring of membrane that anchors and supports the physis
La Croix through peripheral stability
Perichondrial artery
o major source of nutrition to physis
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Introduction
Injury Classification
Salter-Harris classification
o Type 1- physeal separation
o Type 2- fracture traverses physis and exits metaphysis
most common type
Thurston Holland fragment
o Type 3- fracture traverses physis and exits epiphysis
o Type 4- fracture passes through epiphysis, physis, metaphysis
Thurston Holland fragment
o Type 5- crush injury to physis
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OrthoBullets2017 Pediatric trauma | Shoulder & Humerus Fractures
Treatment
Closed reduction vs. CRPP vs Open reduction
o depends on injury pattern
o intra-articular fractures must be reduced
Complications
Growth arrests
o overview
complete arrest leads to shortening
see Leg Length Discrepancy
partial arrest leads to angulation
o treatment
bar resection with interposition
indications
< 50% physeal involvement
> 2 years or 2cm growth remaining VIII:6 partial arrest leads to angulation
ipsilateral completion of arrest
indications
> 50% physeal involvement
can combine with contralateral epiphysiodesis and/or ipsilateral lengthening
Anatomy
Medial clavicle ossification center
o appears during later teenage years
o last physis to close in body (20-25yrs)
sternoclavicular dislocations in
teenagers/young adults are usually
physeal fracture-dislocations
Imaging
Radiographs
o difficult to visualize on AP, and radiographs usually unreliable to assess for fracture and degree
of displacement
o obtain serendipity views ( beam at 40 deg cephalic tilt)
anterior dislocation/fxs - affected clavicle is above contralateral clavicle
posterior dislocation/fxs - affected clavicle is below contralateral clavicle
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Shoulder & Humerus Fractures
Axial CT scan
o is study of choice
o can differentiate from sternoclavicular dislocations
o can visualize mediastinal structures and injuries
Treatment
Nonoperative
o observation
controversial
most asymptomatic injuries will remodel and do not require intervention
anterior displaced physeal fracture
has good functional results treated nonoperatively
o closed reduction in operating room under anesthesia
indications
early posterior displaced physeal fx
hoarsness
blunt or direct trauma to subclavian vessels
thoracic outlet syndrome
pneumothorax
technique
approach : thoracic surgeon available
reduction
traction and abduction of arm, while applying direct pressure
posterior displaced fractures usually require sterile towel clip for manipulation
convert to open
if irreducible by closed means, consider open approach
postreduction
if stable - obtain CT to document
if unstable - open reduction with wire/suture from medial clavicle to sternum/medial
epiphysis
immobilization : figure of 8 harness or sling and swathe x 4 weeks (anterior displaced)
Operative
o open reduction
rarely needed
indications
unreducible and symptomatic in a patient > 23 yrs old
instability after reduction
Complications
Delay in reduction >48h
o reduces success of closed reduction
o because of progressive callus formation in dislocated state
Late presenting posterior displaced injuries
o do NOT attempt closed reduction because medial clavicle may be adherent to vascular structures
in mediastinum
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OrthoBullets2017 Pediatric trauma | Shoulder & Humerus Fractures
Presentation
Symptoms
o pain, dysfunction, ecchymosis in older children
Physical exam
o pseudo-paralysis of the affected ipsilateral extremity may be present in newborns
reflexes remain intact following isolated clavicle fractures, which can help differentiate from
brachial plexus injuries
Imaging
Radiographs
o obtain AP and serendipity view to help define injury
Treatment
Nonoperative
o sling management
indicated in most cases, especially if periosteum is
intact
a new clavicle will form within the intact periosteal
sleeve, and the displaced clavicle will typically
reabsorb with time and growth
Operative
o surgical reduction
indications (rarely indicated)
open fractures
severly displaced fractures in older patients with near closed physis
Anatomy
Radiographic appearance of secondary ossification centers
o proximal humeral epiphysis at 6 mos
o greater tuberosity appears at 1-3 yrs
o lesser tuberosity appears at 4-5 yrs
Growth
o Proximal humerus physis closes at 14-17 in girls, 16-18 in boys
80% of humerus growth comes from the proximal physis
highest proximal:distal ratio difference (femur is second with 30:70 proximal:distal ratio)
high remodeling potential (most fractures can be treated nonoperatively)
Classification
Neer-Horowitz Classification
Neer-Horowitz Classification
Type I • Minimally displaced (<5m)
Type II • Displaced < 1/3 of shaft width
Type III • Displaced greater than 1/3 and less than 2/3 of shaft width
Type IV • Displaced greater than 2/3 of shaft width
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Type 2 Type 4
Presentation
History
o identify any precipitating injury
Symptoms
o shoulder pain
o dysfunction
o deformity
o ecchymosis
Physical exam
o inspection of skin
o motion and tenderness of neck, ipsilateral sternoclavicular joint and
elbow VIII:8 Y view
o neurovascular examination
brachial plexus distribution
vascular examination of arm
Imaging
Radiographs
o standard views
obtain AP, lateral, and scapula Y or axillary views of
shoulder
o as needed views
hand or elbow for bone age
contralateral shoulder for comparison views VIII:9 Axillary view
o findings
stress fractures in athletes
glenohumeral dislocation (very rare with associated fracture)
assess maximum angulation of fracture displacement
identify pathologic fracture if present
Classify fracture type: newborn, acute fracture, stress fracture, pathologic fracture
Ultrasound
o ultrasound may be neccessary in newborns before secondary ossification centers are formed
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Shoulder & Humerus Fractures
Treatment
Nonoperative
o immobilization
indications
acceptable alignment for non-operative management
<10y = any degree of angulation
10-13y = up to 60° of angulation
>13y = up to 45° of angulation and 2/3 displacement
technique
immobilization modalities
sling + swathe
shoulder immobilizer
coaptation splint
o closed reduction under anesthesia/analgesia and fluoroscopy, without fixation
indications
severely displaced (>Neer-Horowitz III or >66%) with >45° angulation and <2y of
growth left
risk of loss of reduction
Operative
o open reduction and fracture fixation
indications
severely displaced fractures > 13 years old failed closed reduction
>Neer-Horowitz III (>66% displaced)
severely angulated fractures in > 9 year old failed closed reduction
open fractures in any age
fractures associated with vascular injuries
intra-articular displacement
techniques
closed reduction ± k-wire fixation
reduction maneuver
longitudinal traction
shoulder abduction to 90 degrees
external rotation
percutaneous pinning
two or three lateral threaded pins
starting point must consider branches of axillary nerve (lateral) and
musculocutaneous nerve (anterior)
ideally divergent pattern across fracture
open reduction ± k-wire fixation
indications
unacceptable closed reduction maneuver
blocks to reduction
long head of biceps tendon (most common)
joint capsule
infolded periosteum
deltoid muscle
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approach
deltopectoral interval
fixation methods
wire fixation (smooth or threaded)
cannulated screw
retrograde flexible nails
Complications
Loss of reduction
o risk factors
unstable fractures treated with closed reduction WITHOUT pinning
Axillary nerve Injuries
o occur in <1% of case due to injury alone
typically are neuropraxias
associated with a medially displaced shaft
o higher risk with percutaneous pinning
avoid lateral pin entry 5-7cm distal to acromion
Malunion
o varus malalignment, more common in younger patients
may cause glenohumeral impingement
Limb-length inequality
o fracture shortening
<3cm usually well tolerated
o growth arrest
usually rare
Hypertrophic scar
o deltopectoral approach with open reduction and fixation
Pin site infection
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Shoulder & Humerus Fractures
Associated conditions
o radial nerve palsy
associated with up to 5% of humeral shaft fractures
Prognosis
o excellent
associated with enormous remodeling potential and rarely requires surgical intervention
up to 30° of angulation is associated with excellent outcomes due to the large range of motion
of the shoulder
Presentation
Symptoms
o history of traumatic event
o pain
o upper arm deformity
Physical exam
o inspection
mid-arm swelling and deformity
open fractures rare
o palpation
tenderness to palpation
o motion
weakness or absence of wrist and digit extension if radial nerve palsy is present
pseudoparalysis
irritability or refusal to move upper limb in neonates
Imaging
Radiographs
o recommended views
full length AP, lateral views of humerus
must include joint above and below
o optional views
orthogonal views of shoulder and elbow
required to rule out associated injuries
o findings
typical fracture patterns are transverse and oblique
examine closely for pathologic lesions
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OrthoBullets2017 Pediatric trauma | Shoulder & Humerus Fractures
Treatment
Nonoperative
o analgesia, immobilization
indications
uncomplicated diaphyseal fracture without intra-articular involvement in a child of any
age
utilized for almost all pediatric humeral shaft fractures
techniques
sling and swathe or cuff and collar in young children
Coaptation splint or hanging arm cast
Sarmiento functional brace in older children/adolescents
ROM exercises can be initiated in 2-3 weeks once pain is controlled
Operative
o open reduction internal fixation
indications
open fractures
multiply injured patient
ipsilateral forearm fractures
"floating elbow"
associated shoulder injury
techniques
flexible intramedullary nail fixation
anterior, anterolateral or posterior approach with plate fixation
Complications
Radial nerve palsy
o occurs in <5%
most commonly associated with middle and distal 1/3 fractures
o typically due to a neuropraxia
o spontaneous resolution is expected
o exploration is rarely needed
if function has not returned in 3-4 months, EMGs are performed and exploration considered
Malunion
o rarely produces functional deficits, due to the wide range of motion at the shoulder
up to 30° of angulation is associated with excellent outcomes
Delayed union
o rare given the capacity to remodel
o may consider ultrasound bone stimulation
Limb length discrepancy
o commonly occurs, but rarely causes functional deficits
Physeal growth arrest
o proximal and distal humerus growth plates contributes 80:20 percent to overall humeral length
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Shoulder & Humerus Fractures
Classification
Salter Harris classification
o older children (>3y) have Salter Harris II injuries
metaphyseal piece attached to distal fragment
o younger children (<3y) have Salter Harris I injuries
pure physeal
o rare cases have intra-articular extension (Salter Harris III or IV)
Presentation
History
o birthing process (see above)
o fall from height (bed, chair, down stairs)
o another child jumps/falls on younger child's elbow
o suspect nonaccidental trauma if
unwitnessed injuries
inconsistent explanations
history of multiple injuries, burns, bites, bruising
Physical exam
o inspection
pseudoparalysis / diminished spontaneous movement
o neurovascular
rarely neurovascular compromise
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Imaging
Radiographs
o recommended views
AP and lateral centered on the elbow
"baby gram" (radiograph of entire extremity) often miss diagnosis
stress radiographs may be helpful to clarify the diagnosis
skeletal survey if child-abuse suspected
o findings
in infant only sign may be posteromedial displacement of the radial
and ulnar shafts relative to the distal humerus
forearm not aligned with humeral shaft
soft tissue swelling, joint effusion (posterior fat pad)
anterior fat pad may be absent
if capitellar ossification center is present, will be aligned with radius shaft, making diagnosis
definitive
Ultrasound
o indications
uncertain diagnosis
o advantage
no need for sedation
o findings
static exam
detect separation of epiphysis from
metaphysis by noting lack of
III:10 Magnetic resonance imaging
V
cartilage at distal humeral metaphysis demonstrates fracture through the
dynamic exam humeral physes with posterior
displacement of the cartilaginous
detect instability of epiphysis relative to metaphysis epiphysis (curved arrow) but intact
MRI articulation with radius and ulna
(arrow)
o disadvantage : requires sedation
Elbow arthrography
o indications : uncertain diagnosis
o findings
visualization of entire distal articular surface and proximal radius
o technique
posterolateral approach or direct posterior approach
direct posterior into olecranon fossa recommended in young children to prevent scuffing
of articular cartilage when posterolateral portal is used
inject equal parts saline:contrast
bring through range of motion
if pinning is needed, arthrogram aids visualization of pin starting points on capitellum
aids assessment of quality of reduction by seeing anterior humeral line intersecting
capitellum
o advantage
if performed under anesthesia in OR, can perform reduction and stabilization simultaneously
if needed
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Shoulder & Humerus Fractures
Differentials
Elbow dislocation
o almost never happens in <3 yrs because physis is weaker than bone-ligament interface,
predisposing to physeal fracture rather than ligament disruption/dislocation
Other fractures
o often misdiagnosed (or delayed diagnosis up to 1 week) as supracondylar, condyle, epicondyle
fractures
Treatment
Nonoperative
o limited role because most fractures are displaced
o posterior long arm splint then long arm casting x 2-3wk
indications
nondisplaced fractures
late presenting fractures
treat nonop initially
deformity will persist/develop, requiring osteotomy in future
Operative
o closed reduction and pinning
pinning is necessary to ensure adequate reduction, which may be lost with casting alone once
swelling subsides
indications
displaced fractures
Technique
Closed reduction and pinning
o general anesthesia
o reduction maneuver
gentle traction (very little force required)
distal fragment may sometimes be grasped between index finger and thumb and reduced
to humeral shaft
correction of translation/malrotation
elbow flexion
o use elbow arthrogram to aid
o parameters
no cubitus varus
anterior humeral line should bisect capitellum
no malrotation
o pinning
2 or 3 x 0.062inch K wires
these larger pins help prevent loss of reduction
from lateral side, retrograde fashion
divergent
engage both cortices
good spread at fracture site
o then perform live fluoroscopy through range of motion
o bend / cut pins, splint the arm
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o postop care
admit overnight 24h for IV antibiotics, observe for compartment syndrome
see 1 week postop
see 3 weeks postop with radiographs and remove pins in office
allow active ROM at that time
Complications
Cubitus varus
o up to 70% have this complication
more common than with supracondylar fractures
o cause
AVN of medial condyle
malunion (common because of missed diagnosis, or loss of reduction)
o treatment
lateral closing wedge osteotomy
Medial condyle AVN
Loss of motion
o usually no functional limitation
Growth disturbance
o progressive cubitus varus
o joint irregularities
o angular deformity
o limb-length discrepancy
o treatment
observe initially, undertake surgery when >5yo
larger extremity
child more cooperative
C. Elbow Fractures
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
the most common nerve palsy seen with supracondylar humerus fractures
radial nerve palsy
second most common neurapraxia (close second)
ulnar nerve palsy
seen with flexion-type injury patterns
nearly all cases of neurapraxia following supracondylar humerus fractures resolve
spontaneously, and therefore, further diagnostic studies are not indicated in the acute setting
o vascular injury (1%)
rich collateral circulation can maintain circulation despite vascular injury
o ipsilateral distal radius fractures
Anatomy
Ossification centers of elbow
o age of ossification/appearance and age of fusion are two independent events that must be
differentiated
e.g., internal (medial epicondyle) apophysis
ossifies/appears at age 6 years (table below)
fuses at age ~ 17 years (is the last to fuse)
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Classification
Gartland Classification
(may be extension or flexion type)
Nondisplaced, beware of subtle medial comminution leading to cubitus varus
Anterior periosteum detached from anterior humerus by up to 3cm (but not
Type I torn)
Treated with cast immobilization x 3-4wks, with radiographs at 1 wk, pull pins
at 3 wks
Displaced, posterior cortex and posterior periosteal hinge intact
IIA - no rotational deformity/fragment translation
Type II IIB - has rotational deformity/fragment translation (high risk of coronal/rotational
malalignment)
Treated with CRPP
Completely displaced, no cortical contact but has intact posterior periosteal
Type III hinge
Treated with CRPP
Complete periosteal disruption with instability in flexion and extension
Type IV*
Treated with CRPP
Collapse of medial column, loss of Baumann angle (leads to varus
Medial comminution* malunion/classic gunstock deformity)
in Type II
Treated with CRPP
Shear mechanism, oblique orientation, inherently unstable
Flexion type
Treated with CRPP
*not a part of original Gartland classification
**diagnosed intraoperatively when capitellum is anterior to AHL with elbow flexion and posterior with extension on
lateral XR
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
Presentation
Symptoms
o pain
o refusal to move the elbow
Physical exam
o inspection
gross deformity
swelling
bruising
o motion
limited active elbow motion
o neurovascular
nerve exam
AIN neurapraxia
unable to flex the interphalangeal joint of his thumb and the distal interphalangeal
joint of his index finger (can't make A-OK sign)
radial nerve neurapraxia
inability to extend wrist or digits may be present due to radial nerve injury
neurapraxia
vascular exam
vascular insufficiency at presentation is present in 5 -17%
defined as cold, pale, and pulseless hand
a warm, pink, pulseless hand does not qualify as vascular insufficiency
treat with immediate reduction and pinning in OR. Attempted closed reduction in ER first
(see treatment below)
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Imaging
Radiographs
o recommended views
AP and lateral x-ray of the elbow
o findings
posterior fat pad sign
lucency along the posterior distal humerus and olecranon fossa is highly suggestive of
occult fracture around the elbow
o measurement
displacement of the anterior humeral line
anterior humeral line should intersect the middle third of the capitellum
capitellum moves posteriorly to this reference line in extension type fracture
alteration of Baumann angle
Baumann's angle is created by drawing a line parallel to the longitudinal axis of the
humeral shaft and a line along the lateral condylar physis as viewed on the AP image
normal is 70-75°, but best judge is a comparison of the contralateral side
deviation of >5° indicates coronal plane deformity and should not be accepted
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Techniques
Closed reduction and percutanous pinning (CRPP)
o fixation
closed reduction (extension-type)
posteromedial fragments: forearm pronated with hyperflexion
posterolateral fragments: forearm supinated with hyperflexion
2 lateral pins
usually sufficient in most cases
test stability under fluoroscopy
technical pearls
maximize separation of pins at fracture site
engage both medial & lateral columns proximal to fracture
engage sufficient bone in proximal & distal segments
low threshold for 3rd lateral pin if concern about stability with 1st 2 pins
for difficult cases (type IV free floating segment)
place 2 parallel lateral pins initially in distal fragment as joysticks
rotate fluoro (not the patients arm) to obtain lateral image
after adequate reduction, advance distal pins into proximal fragment
add a 3rd pin
3 lateral pins
biomechanically stronger in bending and torsion than 2-pin constructs
indications (where 2 lateral pins are insufficient)
comminution
type IV (free floating distal fragment)
no significant difference in stability between three lateral pins and crossed pins
risk of iatrogenic nerve injury from a medial pin makes three lateral pins the construct
of choice
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
crossed pins
biomechanically strongest to torsional stress
higher risk of ulnar nerve injury (3-8%)
highest risk if placed with elbow in hyperflexion as ulnar nerve subluxates anteriorly
over medial epicondyle in some children
reduce risk of ulnar nerve injury by
placing medial pin with elbow in extension
use small medial incision (rather than percutaneous pinning)
remove pins postop at 3 weeks
these techniques reduce complication risk to equal to lateral-only pins
Complications
Pin migration
o most common complication (~2%)
Infection
o occurs in 1-2.4%
o typically superficial and treated with oral antibiotics
Cubitus valgus
o caused by fracture malunion
o can lead to tardy ulnar nerve palsy
Cubitus varus (gunstock deformity)
o caused by fracture varus malunion, especially in De Boeck medial comminution pattern
o usually a cosmetic issue with little functional limitations
Recurvatum
o common with non-operative treatment of Type II and Type III fractures
Nerve palsy from injury
o usually resolve
o extension type fractures
neuropraxia in 11%
most commonly AIN (34% of extension-type fracture nerve injuries)
mechanism = tenting of nerve on fracture, or entrapment in fracture site
o flexion type fractures
neuropraxia in 17%
most commonly cause ulnar neuropraxia (91% of flexion-type fracture nerve injuries)
Vascular Injury
o radial pulse absent on initial presentation in 7-12%
o pulseless hand after closed reduction and pinning (3-4%)
o decision to explore is based on quality of extremity perfusion, rather than absence of pulse
o arteriography is NOT indicated in isolated injuries
Volkmann ischemic contracture
o rare, but dreaded complication
o result of brachial artery compression with treatment utilizing elbow hyperflexion casting than
true arterial injury
increase in deep volar forearm compartment pressures and loss of radial pulse with elbow
flexed >90°
o rarely seen with CRPP and postoperative immobilization in less than 90°
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Postoperative stiffness
o rare after casting or after pinning procedures
remove pins and allow gentle ROM at 3 weeks postop
o resolves by 6 months
o literature does not support the use of physical therapy
Anatomy
Common flexor wad muscles of medial epicondyle include
o pronator teres
o flexor carpi radialis
o palmaris longus
o flexor digitorum superficialis
o flexor carpi ulnaris
Presentation
Symptoms
o medial elbow pain
Physical exam
o tenderness over medial epicondyle
o valgus instability
Imaging
Radiographs
o recommended views
AP and lateral of elbow
axial view is most accurate as medial epicondyle is located on the posteromedial aspect of the
distal humerus
especially because fragment displaces anteriorly
internal oblique views helpful
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
3D CT
o most accurate but radiation dose is 200x that of plain film
Treatment
Nonoperative
o brief immobilization (1 to 2 weeks) in a long arm cast or splint
indications
< 5mm displacement usually treated non-operatively, 5-15 mm remains controversial
often heal with fibrous union
fibrous union of the fragment is not associated with significant symptoms or diminished
function
Operative
o open reduction internal fixation
indications
absolute
displaced fx with entrapment of medial epicondyle fragment in joint
if medial condyle is involved (articular surface)
relative
ulnar nerve dysfunction
> 5-15mm displacement
displacement in high level athletes
Techniques
Open Reduction Internal Fixation
o approach
medial approach to elbow
incision is made directly over medial epicondyle
brachialis / triceps interval, ulnar nerve at risk
patient supine on table with arm abducted to 90 degrees and externally rotated
o technique
identify ulnar nerve and protect
reduce fracture
use cannulated screw for fixation
K-wires indicated for smaller fragments or in younger children
Complications
Nerve injury
o ulnar nerve can become entrapped
o neuropathy with dislocatoin which usually resolves
Missed incarceration
o missed incarceration of fragment in elbow joint
Elbow stiffness
o loss of elbow extension, avoid prolonged immobilization
Non-union
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OrthoBullets2017 Pediatric trauma | Elbow Fractures
Classification
Milch Classification-controversial
Type I Fracture line is lateral to trochlear groove (less common, elbow is stable as fracture
does NOT enter trochlear groove)
Type II Fracture line into trochlear groove (more common, more unstable)
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
Fracture Displacement Classification-Jakob et al.
Type 1 <2mm, indicating intact cartilaginous hinge Casting
Type 2 >2 mm < 4 displacement, intact articular cartilage on Open/closed reduction
arthrogram and fixation
Type 3 >2-4 mm, articular surface disrupted on arthrogram Open reduction and
fixation
Presentation
History
o fall onto an outstetched hand
Symptoms
o lateral elbow pain
o mild swelling
Physical exam
o inspection
exam may lack the obvious deformity often seen with supracondylar fractures
swelling and tenderness are usually limited to the lateral side
o motion
may have increased pain with resisted wrist extension/flexion
may feel crepitus at the fracture site
Imaging
Radiographs
o recommended views
AP, lateral, and oblique views of elbow
internal oblique view most accurately shows fracture displacement because fracture is
posterolateral
o optional views
contralateral elbow for comparison when ossification is not yet complete
routine elbow stress views are not recommended due to risk of fracture displacement
o findings
fracture fragment most often lies posterolateral which is best seen on internal oblique views
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Arthrogram
o indications
to assess cartilage surface when there is incomplete/absent epiphyseal ossification
allows dynamic assessment
CT scan
o indication
improved ability to assess the fracture pattern in all planes
o findings
CT has limited ability to evaluate the integrity of articular cartilage
may require sedation to perform the test
MRI
o indication
provides the ability to assess the cartilaginous integrity of the trochlea
o expensive
o require GA/sedation to perform the test
o arthrograms preferred to MRI
Differential
Pediatric Elbow Injury Frequency
Fracture Type % elbow injuries Peak Age Requires OR
Supracondylar fractures 41% 7 majority
Radial Head subluxation 28% 3 rare
Lateral condylar physeal fractures 11% 6 majority
Medial epicondylar apophyseal fracture 8% 11 minority
Radial Head and Neck fractures 5% 10 minority
Elbow dislocations 5% 13 rare
Medial condylar physeal fractures 1% 10 rare
Treatment
Nonoperative
o long arm casting x 6wks
indications
only if < 2 mm displacement (cartilaginous hinge most likely intact) (30-70% are
nondisplaced)
sub-acute presentation (>4 weeks)
technique
cast with elbow at 90 degrees and forearm supination
weekly follow up and radiographs every 3-7 days x first 3 weeks
total length of casting 6 weeks
Operative
o CRPP + 3-6 wks in above elbow cast
indications
somewhat controversial, but Weiss et al suggest fractures with < 4 mm of displacement
have intact articular cartilage and can be treated with CRPP
technique
closed reduction performed by providing a varus elbow force and pushing the fragment
anteromedial
divergent pin configuration most stable
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
third pin may be used in transverse plane to prevent fragment derotation
arthrogram used to confirm joint congruity
o open reduction and fixation + 3-6 wks in above elbow cast
open reduction (rather than closed) necessary to align joint surface
indications
if > 2-4mm of displacement
any joint incongruity
fracture non-union
technique
interval between the triceps and brachioradialis
avoid dissection of posterior aspect of lateral condyle (source of vascularization
implants
most fractures can be fixed with 2 percutaneous pins (3 if comminuted) in parallel or
divergent fashion
single screw for large fragments or non-union ± bone grafting
o supracondylar osteotomy
indications
deformity correction in late presenting cubitus valgus
Complications
Stiffness
o most common complication
Nonunion
o higher rate of nonunion than other elbow fractures
o normal radiographic union of lateral condyle fracture is 6wks
o risk
nonsurgical management
o mechanism
constant pull by extensors
intra-articular (synovial fluid impede fracture healing)
poor metaphyseal circulation to distal fragment
o prevent nonunion by
preserving soft tissue attachments to lateral condyle
stable internal fixation
o treatment
ORIF + bone grafting
AVN
o occurs 1-3 years after fracture
o posterior dissection can result in lateral condyle osteonecrosis (may also occur in the trochlea)
Malunion
o caused from delay in diagnosis and improper treatment
o 20% cubitus varus in nondisplaced/minimally displaced fractures
traumatic inflammation leads to lateral overgrowth (see spurring below)
o 10% cubitus valgus ± tardy ulnar nerve palsy
because of lateral physeal arrest as fracture is Salter Harris IV
o fishtail deformity
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area between medial ossification center and lateral condyle ossification center resorbs or fails
to develop
does NOT predispose to arthritis
may predispose to further fracture
o treatment
supracondylar osteotomy
Tardy ulnar nerve palsy
o slow, progressive ulnar nerve palsy caused by stretch in cubitus valgus
o usually late finding, presenting many years after initial fracture
Lateral overgrowth/prominence (spurring)
o up to 50% regardless of treatment, families should be counseled in advance III:11 Fishtail deformity
V
o lateral periosteal alignment will prevent this from occurring
o spurring is correlated with greater initial fracture displacement
Growth arrest with or without angular deformity
Unsatisfactory appearance of surgical scar
Late elbow presentation or deformity
o cubitus varus most common in nondisplaced and minimally displaced fractures
o cubital valgus less common, but more likely with significant deformities that cause physeal
arrest
o controversy whether to treat subacute fractures (week 3-12) nonoperatively or surgically
o most deformities can be corrected after skeletal maturation with a supracondylar osteotomy
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
Associated conditions
o osteogenesis imperfecta
olecranon fractures are highly suspicious for osteogenesis imperfecta
Anatomy
Ossification centers of elbow
o age of ossification/appearance and age of fusion are two independent events that must be
differentiated
olecranon apophysis
ossifies/appears at age 9 years
fuses at age ~ 15 -17 years
Olecranon ossification
o fusion of the epiphysis to the metaphysis of the olecranon occurs from anterior to posterior
o average age of closure is between the ages of 15-17 years old
o partial closure may be mistaken for olecranon fracture
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Presentation
History
o acute fall onto outstretched hand or direct elbow trauma
Symptoms
o pain
o swelling of posterior elbow
o inability to extend elbow
Physical exam
o inspection
swelling and deformity
contusion or abrasion over elbow may be suggestive of direct trauma
o palpation
crepitus
defect detected between fracture fragments
gapping may suggest a disruption in the posterior periosteum, which makes the fracture more
unstable
o movement
lack of active elbow extension
Imaging
Radiographs
o recommended views
AP and lateral xrays that should always be obtained on evaluation
o findings
fracture configuration (transverse, oblique, longitudinal)
intra-articular displacement
associated fracture (radial neck, medial/lateral condyle, distal radius, etc.)
Treatment
Nonoperative
o NSAIDS, rest, immobilization with avoidance of elbow resistance exercises
indications
partial stress fractures
outcomes
monitor until there is clinical improvement
convert to casting if needed
o long arm splint or casting
indications
minimally displaced fractures
integrity of posterior olecranon periosteum maintained
duration
3-4 weeks total
repeat imaging at 7-10 days to ensure no significant displacement
Operative
o ORIF
I ndications
displaced fractures
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
techniques
tension band wiring
AO technique with axial K-wires
congruent articular surface
consider early range of motion post-operatively
tension band suturing
use absorbable sutures (e.g. Number 1 polydioxanone (PDS) suture)
may combine with oblique cortical lag screw with PDS with metaphyseal fractures
plate and screws
considered with comminuted fractures with partially fused ossification centers
Complications
Nonunion
Delayed Union
Compartment syndrome
Ulnar nerve neurapraxia due to pseudarthrosis with inadequate fixation
Loss of Reduction
Elbow stiffness
Anatomy
There are 6 ossification centers around the elbow joint
o age of ossification is variable but occurs in the following order (C-R-I-T-O-E) at an average age
of (years)
Capitellum (1 yr.)
Radius (3 yr.)
Internal or medial epicondyle (5 yr.)
Trochlea (7 yr.)
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Olecranon (9 yr.)
External or lateral epicondyle (11 yr.)
Ossification center of radial head appears between and 3 and 5 years of age
o may be bipartite
o radial head fuses with radial shaft between ages of 16 and 18 years
Classification
Chambers Classification
Group 1: Primary displacement of radial Valgus Injury
head (most common) A: Salter-Harris I or II
B: Salter-Harris IV
C: metaphyseal
Elbow Dislocation
D: reduction injury
E: dislocation injury
Group 2: Primary displacement of radial neck Monteggia variant
Group 3: Stress injury Osteochondritis dissecans
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
Presentation
Symptoms
o elbow pain
o refusal to move
Physical exam
o inspection
lateral swelling
o motion
pain exacerbated by motion, especially supination and
pronation. VIII:13 AP and lateral of the elbow, radial
o must have high suspicion for forearm compartment syndrome head intersect capitellum in both views.
o pain may be referred to the wrist
Imaging
Radiographs
o recommended views
AP and lateral of the elbow
radiocapitellar (Greenspan) view
oblique lateral performed by placing the arm on the radiographic table with the elbow
flexed 90 degrees and the thumb pointing upward
The beam is directed 45 degrees proximally
o findings
nondisplaced fractures may be difficult to visualize
look for fat pads signs
a portion of the radial neck is extra-articular and
therefore an effusion and fat pads signs may be
absent.
Treatment
Nonoperative
o immobilization ± closed reduction
indications
most fractures can be treated closed
if < 30° angulation immobilize without closed reduction
if >30° angulation perform closed reduction and immobilize if angulation reduced to <
30°
followup
begin early ROM at 3-7 days to prevent stiffness
Operative
o operative percutaneous reduction
indications
> 30° of residual angulation
3-4 mm of translation
< 45° of pronation and supination
outcomes
improved outcomes with younger patients, lesser degrees of angulation, and isolated
radial neck fractures
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OrthoBullets2017 Pediatric trauma | Elbow Fractures
o open reduction
indications
fracture that cannot be adequately reduced with closed or percutaneous methods
outcomes
open reduction has been associated with a greater loss of motion, increased rates of
osteonecrosis and synostosis compared with closed reduction.
Techniques
Closed reduction
o reduction techniques
Patterson maneuver
hold the elbow in extension and apply distal traction with the forearm supinated and pull
the forearm into varus while applying direct pressure over the radial head
Israeli technique
pronate the supinated forearm while the elbow is flexed to 90° and direct pressure
stabilizes the radial head
elastic bandage technique
tight application of an elastic bandage beginning at the wrist continuing over the forearm
and elbow may lead to spontaneous reduction
Closed Reduction and Percutaneous Pinning
o reduction technique
K-wire joystick technique
Metaizeau technique
involves retrograde insertion of a pin/nail across the fracture site
fracture is reduced by rotating the pin/nail
Open reduction
o approach
performed with lateral approach (Kocher interval) to radiocapitellar joint
avoid deep branch of radial nerve
o fixation
avoid transcapitellar pins
internal fixation only used for fractures that are grossly unstable
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
Complications
Decreased range of motion
o loss of pronation more common than supination
Radial head overgrowth
o 20-40% of fractures
o usually does not affect function
Osteonecrosis
o 10-20% of fractures
o up to 70% of cases occur with open reduction
Synostosis
o most serious complication
o occurs in cases of open reduction with extensive dissection or delayed treatment
6. Nursemaid's Elbow
Introduction
Also known as subluxation of radial head
Epidemiology
o most common in children from 2 to 5 years of age.
Pathophysiology
o mechanism
caused by longitudinal traction applied to an extended arm
o pathoanatomy
caused by subluxation of the radial head and interposition of the annular (orbicular) ligament
into the radiocapitellar joint.
Presentation
Symptoms
o a child with radial head subluxation tends to hold the elbow in slight flexion and the forearm
pronated.
Physical Exam
o pain and tenderness localized to the lateral aspect of the elbow.
Imaging
Radiographs
o recommended views
not routinely indicated in presence of
classic history and physical examination
o findings
radiographs are normal
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Differential
Pediatric Elbow Injury Frequency & Treatment
Fracture Type % elbow injuries Peak Age Requires OR
Supracondylar fractures 41% 7 majority
Radial Head subluxation 28% 3 rare
Lateral condylar physeal fractures 11% 6 majority
Medial epicondylar apophyseal
fracture 8% 11 minority
Radial Head and Neck fractures 5% 10 minority
Elbow dislocations 5% 13 rare
Medial condylar physeal fractures 1% 10 rare
Treatment
Nonoperative
o closed reduction
indications
acute cases
Operative
o open reduction
indications
chronic injuries
VIII:14 reduction technique: supination > flexion > hyperpronation
Techniques
Closed reduction of radial head subluxation
o reduction techniques
reduction is performed by manually supinating the forearm and flexing the elbow past 90
degrees of flexion.
while holding the arm supinated the elbow is then maximally flexed
during this maneuver the physician’s thumb applies pressure over the radial head and a
palpable click is often heard with reduction of the radial head.
alternative technique includes hyperpronation of the forearm while in the flexed position.
o followup
immobilization is not necessary and the child may immediately resume use of the arm.
follow up is only needed if the child does not resume normal use of his arm in the following
weeks.
Complications
Recurrence
o occurs in 5% to 39% of cases, but generally ceases after 5 years of age.
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
relatively small coronoid process in children cannot resist proximal and posterior
displacement of ulna
Associated conditions
o traumatic
child abuse
high index of suspicion for child abuse
avulsion of the medial epicondyle
is the most common associated fracture
incarcerated intra-articular bone fragment may block reduction
fractures of proximal radius, olecranon and coronoid process
neurovascular injury
brachial artery and median nerve
may be stretched over displaced proximal fragment
ulnar nerve
at risk with associated medial epicondyle avulsions
most common neuropathy
o congenital
dislocation of radial head
VIII:16 avulsion of the
Classification medial epicondyle
Anatomic classification
o based on the position of the proximal radio-ulnar joint in relation to the distal humerus
o includes
posterior or posterolateral (most common)
anterior (rare)
medial
lateral
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Presentation
Symptoms
o painful and swollen elbow
o attempts at motion are painful and restricted
Physical exam
o inspection
elbow held in flexion
forearm appears to be shortened from the anterior and posterior view
o palpation
distal humerus creates a fullness within the antecubital fossa
o essential to perform neurovascular examination
Imaging
Radiographs
o required views
AP and lateral radiograph of elbow
comparison radiographs of the contralateral elbow may be helpful
o findings
look for fractures of medial epidcondyle, coronoid, proximal radius
high index of suspicion for transphyseal (distal humerus epiphyseal separation) fractures in
very young children (<3 years old)
Treatment
Nonoperative
o closed reduction, brief immobilization with early range of motion
indications
dislocation that remains stable following reduction
indicated in the majority of cases
reduction technique (see below)
brief immobilization
immobilization should be minimized to 1- 2 weeks to minimize risk of stiffness
early therapy
encourage early active range of motion
Operative
o open reduction
indications
open dislocation
incarcerated medial epicondyle or coronoid process in the joint
failure to obtain or maintain an adequate closed reduction
significant joint instability
Technique
Closed reduction technique
o closed reduction performed using gradual traction and flexion for posterior dislocations
o post-reduction films should be reviewed to rule out presence of entrapped bone fragment
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
Open reduction
o approach
depends on reason for blocked reduction
elbow medial approach
indicated if medial epicondyle avulsion with incarcerated fragment is blocking
reduction
Complications
Stiffness
o most common
due to prolonged immobilization
Heterotopic ossification
Neurologic injuries
o usually transient
o ulnar nerve most commonly affected
Loss of terminal flexion or extension
Chronic instability (recurrent dislocations)
VIII:17 incarcerated medial epicondyle in the joint
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OrthoBullets2017 Pediatric trauma | Forearm Fractures
D. Forearm Fractures
Anatomy
Normal rotational alignment
o relationship of bicipital tuberosity and radial styloid should be 180 degrees from each other on
the AP radiograph
o relationship of coronoid process and ulnar styloid should be 180 degrees from each other on the
lateral radiograph
Classification
Greenstick fractures
o are incomplete fractures
o can be described as apex volar or apex dorsal
Complete fractures
o are categorized the same as adults
Presentation
Symptoms
o forearm pain and deformity
Physical exam
o swelling and focal tenderness
o should assess for neurovascular injury
o should rule out compartment syndrome
o open fracture
can be subtle poke-holes, and can often be missed if not evaluated
by an orthopaedic surgeon
Imaging
Radiographs
o help to describe apex dorsal vs apex volar injuries
o can help judge forearm rotation deformity based on relationship of bicipital
tuberosity and radial styloid which are 180 degees apart on the AP
view
o ulnar styloid and coronoid are 180 degrees apart on the lateral view
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Forearm Fractures
Treatment
Table of Acceptable Reduction (Tolerances)
Bayonet
Age Angulation (°) Malrotation (°)
Apposition
0-9 years <15 <45 Yes, if <1cm short
≥10y, mid to distal shaft <15 <30 No
≥10y, proximal shaft <10 0 No
Approaching skeletal maturity (<2y No
0 0
growth remaining)
Nonoperative
o closed reduction and immobilization
indications
most pediatric forearm fractures can be treated without surgery
greenstick injuries
bayonet apposition ok if <10 years
followup VIII:18 example of
Bayonet Apposition
weekly radiographs for first 3-4 weeks to monitor reduction
casting for 6-12 weeks total
Short arm cast vs above elbow cast
short arm for distal 1/3 BBFA
above elbow immobilization for any fracture proximal to distal 1/3
Operative
o percutaneous vs open reduction and nancy nailing
absolute indications
unacceptable alignment following closed reduction
angulation >15°, rotation >45° in children <10y
angulation >10°, rotation >30° in children >10y
bayonet apposition in children older than 10 years
both bone forearm fractures in children> 13
relative indications
highly displaced fractures
technique
allows smaller dissection and advantage of a load-sharing device allowing rapid healing
fixation of one bone often sufficient stability
considerations
shorter surgical time than ORIF
less blood loss than ORIF
equal union rates, radial bow and rotation as ORIF
o open reduction and internal fixation
absolute indications
unacceptable alignment following closed reduction
open fractures
refractures
angulation >15° and rotation >45° in children <10y
angulation >10° and rotation >30° in children >10y
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bayonet apposition in children older than 10 years
both bone forearm fractures in children> 13
relative indications
highly displaced fractures
technique
same technique as an adult
Techniques
Closed Reduction
o steady three point bending of immobilization depending on fracture type
apex volar fractures (supination injuries)
may be treated and reduced by forearm pronation
apex dorsal fractures (pronation injuries)
may be treated and reduced by forearm supination
o greenstick both bone fractures
most pediatric greenstick both bone fractures can be temporarily reduced by placing the palm
in the direction of the deformity (pronate arm for supination injury with apex-volar
angulation of fracture)
Casting
o usually long arm cast x 6-8wks, possible conversion to short arm cast after 4wks depending on
fracture type and healing response
o no increased risk of loss of reduction with short arm vs. long arm casting
o loss of reduction is associated with increasing cast index (sagittal width/coronal width) >0.8
Complications
Refracture
o occurs in 5-10% following both bone fractures
o is an indication for an ORIF
Malunion
o loss of pronation and supination is common but mild
Compartment syndrome
o may occur due to high energy injuries
o may occur due to multiple attempts at reduction and rod passage
if unsuccessful nail passage after 2-3 attempts, open the fracture site to visualize rod passage
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Forearm Fractures
peak incidence occurring from:
10-12 years of age in girls
12-14 years of age in boys
most common fracture in children under 16 years old
Pathophysiology
o mechanism
usually fall on an outstretched hand
VIII:20 Salter-Harris I
often during sports or play
o remodeling
remodeling greatest closer to physis and in plane of joint
(wrist) motion
sagittal plane (flexion/extension)
Anatomy
Distal radius physis
o contributes 75% growth of the radius VIII:21 Salter-Harris II
o contributes 40% of entire upper extremity
o growth at a rate of ~ 5.25mm per year
Classification
Relation to distal physis
o Physeal considerations
o Salter-Harris I
o Salter-Harris II
o Salter-Harris III
o Salter-Harris IV VIII:22 Salter-
o Salter-Harris V Harris III
Metaphysis (distal) (62%)
o complete (Distal Radius fracture)
apex volar (Colles' fracture)
apex dorsal (Smith's fracture)
o incomplete (Torus/Buckle fracture)
typically unicortical
Diaphysis (20%)
o both bone forearm fracture
o isolated radial shaft fracture VIII:23 Buckle
fracture
o isolated ulnar shaft fracture
o plastic deformation
incomplete fracture with deforming force resulting in shape change of bone without clear
fracture line
thought to be due to a large number of microfractures resulting from a relatively lower force
over longer time compared to mechanism for complete fractures
o greenstick fracture
incomplete fracture resulting from failure along tension (convex) side
typically plastic deformation occurs along compression side
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Fracture with dislocation / associated injuries
o Monteggia fracture
ulnar shaft fracture with radiocapitellar dislocation
o Galeazzi fracture
radius fracture (typically distal 1/3) with associated DRUJ
injury, often dislocation
Presentation
History
o wide range of mechanism for children, often fall during play or
other activity VIII:24 Galeazzi fracture
o rule out child abuse
mechanism or history appears inconsistent with injury
multiple injuries, especially different ages
child's affect
grip marks/ecchymosis
Symptoms
o pain, swelling, and deformity
Physical exam
o gross deformity may or may not be present VIII:25 Monteggia fracture
o ecchymosis and swelling
o inspect for puncture wounds suggesting open fracture
o although uncommon, compartment syndrome and neurovascular injury should be evaluated for
in all forearm fractures.
Imaging
Radiographs
o recommended views
AP and lateral of wrist
AP and lateral of forearm
AP and lateral of elbow
o findings
in addition to fracture must evaluate for associated injuries
scapholunate joint
DRUJ
ulnar styloid
elbow injuries
CT
o indications
useful characterize fracture if intra-articular
however use sparingly in children given concerns regarding increased longitudinal effects of
radiation
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Forearm Fractures
Treatment
"Classically" Acceptable Angulation for Closed Reduction in Pediatric Forearm Radius Fractures
(controversial with ongoing discussion)
Shaft / Both bone fx Distal radius/ulna
Acceptable
Age Acceptable Angulations Malrotation* Dorsal Angulation
Bayonetting
< 9 yrs < 1 cm 15-20° 45° 30 degrees
> 9 yrs. < 1 cm 10° 30° 20 degrees
Bayonette apposition, or overlapping, of less than 1 cm, does not block rotation and is acceptable in patients less than 10
years of age.
General guidelines are that deformities in the plane of joint motion are more acceptable, and distal deformity (closer to distal
physis) more acceptable than mid shaft.
The radius and ulna function as a single rotational unit. Therefore a final angulation of 10 degrees in the diaphysis can block
20-30 degrees of rotation.
*Rotational deformities do not remodel and are increasingly being considered as not acceptable.
Nonoperative
o immobilization in short arm cast for 2-3 weeks without reduction
indications
greenstick fracture with < 10 deg of angulation
torus/buckle fracture
studies ongoing to treat minimally displaced or torus fractures with pre-fabricated
removable wrist splint, no cast
o closed reduction under conscious sedation followed by casting
indications
greenstick fracture with > 10-20 degrees of angulation
Salter-Harris I with unacceptable alignment
Salter-Harris II with unacceptable alignment
technique (see below) : reduction technique determined by fracture pattern
acceptable criteria (see table above)
acceptable angulations are controversial in the orthopedic community.
accepted angulation is defined on a case by case basis depending on
the age of the patient
location of the fracture
type of deformity (angulation, rotation, bayonetting).
outcomes
short-arm (SAC) vs long-arm casting (LAC)
good SAC (proper cast index = sagital/coronal widths) considered equal to LAC for
distal radius fractures
conservative treatment though often utilizes LAC to reduce impact of variable cast
technique/quality
no increased risk of loss of reduction with (good) short arm vs. long arm casting
cast index : loss of reduction is associated with increasing cast index
follow-up
all forearm fractures serial radiographs should be taken every 1 to 2 weeks initially to
ensure the reduction is maintained.
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Operative
o closed reduction and percutaneous pinning (CRPP)
indications
unstable patterns with loss of reduction in cast
Salter-Harris I or II fractures in the setting of NV compromise
CRPP reduces need for tight casting in setting with increased concern for
compartment syndrome
any fractures unable to reduce in ED but are successfully reduced under anesthesia in the
OR
o open reduction and internal fixation
indications
displaced Salter-Harris III and IV fractures of the distal radial physis/epiphysis unable to
be closed reduced
irreducible fracture closed
often periosteum or pronator quadratus block to reduction
Treatment Techniques
Closed Reduction
o timing
avoid delayed reduction of greater than 1 week after injury
for physeal injuries, generally limit to one attempt to reduce growth arrest
o reduction technique
gentle steady pressure for physeal reduction
for complete metaphyseal fractures re-create deformity to unlock fragments, then use
periosteal sleeve to aid reduction
traction can be counter-productive due to thick periosteum
Casting
o usually consists of a long arm cast (conservative approach) for 6 to 8 weeks with the possibility
of conversion to a short arm cast after 2-4 weeks depending on the type of fracture and healing
response.
may utilize well molded short arm cast with adequate cast index instead of long arm cast
initially
CRPP
o approach
avoid dorsal sensory branch of radial nerve, typically with small incision
o reduction
maintain closed reduction during pinning
o fixation
radial styloid pins
usually 1 or 2 radial styloid pins, entry just proximal to physis preferred
if stability demands transphyseal pin, smooth wires utilized
for intra-articular fractures, may pin distal to physis transversely across epiphysis
dorsal pins
may also utilize dorsal pin, especially to restore volar tilt
for DRUJ injuries, or severe fractures unable to stabilize with radial pins alone, pin across
ulna and DRUJ
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Forearm Fractures
o postoperative considerations
followup in clinic for repeat imaging to assess healing and position
pin removal typically in clinic once callus formation verified on radiograph
may consider sedation or removal of pins in OR for children unable to tolerate in clinic
must immobilize radio-ulnar joints in long arm cast if stabilizing DRUJ
may supplement with external fixator for severe injuries
Complications
Casting Thermal Injury
o thermal injury may occur if:
dipping water temperature is > 24C (75F)
more than 8 layers of plaster are used
during cast setting, the arm is placed on a pillow. This decreases the dissipation of heat from
the exothermic reaction
fiberglass is overwrapped over plaster
Malunion
o most common complication
Physeal arrest
o from initial injury or repeated/late reduction attempts
o isolated distal radial physeal arrest can lead to ulnocarpal impaction, TFCC injuries, DRUJ injury
o distal ulnar physis most often to arrest
Ulnocarpal impaction
o from continued growth of ulna after radial arrest
TFCC injuries
Neuropathy
o Median nerve most commonly affected
Classification
Bado Classification
Type I Apex anterior proximal ulna fracture with anterior dislocation of the radial head
Type II Apex posterior proximal ulna fracture with posterior dislocation of the radial head
Type III Apex lateral proximal ulna fracture with lateral dislocation of the radial head
Type IV Fractures of both the radius and ulna at the same level with an anterior dislocation of
the radial head (1-11% of cases)
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Bado type I
Imaging
Radiographs
o obtain elbow radiographs for all forearm fractures to evaluate for
radial head dislocation
assess radiocapitellar line on every lateral radiograph of the
elbow
a line down the radial shaft should pass through the center
of the capitellar ossification center
o obtain forearm radiographs for all radial head dislocations
Treatment
Nonoperative
o closed reduction of ulna and radial head dislocation and long
arm casting
indications
Bado Types I-III with
radial head is stable following reduction
length stable ulnar fracture pattern
reduction technique
reduction technique uses traction
radial head will reduce spontaneously with reduction of the ulna and restoration of
ulnar length
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Forearm Fractures
immobilization
immobilize in 110° of flexion and full supination for Types I and III to tighten
interosseous membrane and relax biceps tendon
Operative
o plating of ulna + reduction of radial head ± annular ligament repair/reconstruction
indications
Bado Types I-III with
radial head is not stable following reduction
ulnar length is not stable (unable to maintain ulnar length)
acute Bado Type IV
open fractures
older patients ≥ 10y
technique
annular ligament reconstruction almost never required for acute fractures
open reduction of radial head through a lateral approach if needed
o ulnar osteotomy and annular ligament reconstruction
indications
chronic (>2-3 weeks old) Monteggia fractures where radial head still retains concave
structure
symptomatic individuals (pain, loss of forearm motion, progressive valgus deformity)
who had delayed treatment or missed diagnosis
technique
reduce surgically within 6-12 months postinjury
o ORIF similar to adult treatment
indications : closed physes
Complications
Neurovascular
o posterior interosseous nerve neurapraxia (10% of acute injuries)
almost always spontaneously resolves
Delayed or missed diagnosis
o common when evaluation not performed by an orthopaedic surgeon
o complication rates and severity increase if diagnosis delayed >2-3 weeks
Anatomy
DRUJ
o osteology
possesses poor bony conformity in order to allow some translation with rotatory movements
o ligamentous
ligament structures are critical in stabilizing the radius as it rotates about the ulna during
pronation and supination
triangular fibrocartilage complex (TFCC) is a critical component to DRUJ stability
o biomechanics
the joint is most stable at the extremes of rotation
Presentation
Symptoms
o wrist and forearm pain
o radial deformity
o limitation of wrist motion
o ulnar head prominence or deformity can sometimes be seen
Physical exam
o pain with movement or palpation of the wrist
o DRUJ instability may be appreciated by local tenderness and instability to testing of the DRUJ
compare to contralateral side
o careful examination for nerve injury
Imaging
Radiographs
o required views
AP and true lateral radiographs
true lateral radiograph is essential in determining the direction of displacement
o additional views
contralateral radiographs often helpful for comparison
o findings
displaced distal radial shaft fracture
DRUJ disruption
may be subtle and radiographs must be scrutinized
additional signs of DRUJ instability include
ulnar styloid fracture
widened DRUJ on posteroanterior view
greater than or equal to 5mm radial shortening
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Forearm Fractures
Treatment
Nonoperative
o closed reduction with long arm casting
indications
indicated as first line of treatment
in younger patients (higher likelihood of successful nonoperative treatment than in
adults)
reduction
requires anatomic reduction of both the radius fracture and the DRUJ
immobilization : place in above elbow cast in supination
Operative
o open reduction internal fixation +/- DRUJ pinning
indications
unable to obtain anatomic closed reduction
irreducible DRUJ due to interposed tendon or periosteum
technique
radial fixation can be done with volar plate of flexible IMN (see below)
o ORIF, soft tissue reconstruction of DRUJ and TFCC, +/- corrective osteotomy
indications
chronic DRUJ instability (a rare consequence of a missed injury)
o corrective osteotomy with soft tissue reconstruction of DRUJ and TFCC
indications
DRUJ subluxation is caused by a radial malunion
a corrective osteotomy is also required in addition to reconstruction, otherwise a soft
tissue reconstruction of the DRUJ alone will fail
Technique
ORIF with volar plating, +/- DRUJ pinning
o approach
dorsal approach to DRUJ to remove interposed material if unable to obtain closed reduction
volar approach for ORIF(with plate)
o open reduction
irreducible DRUJ requires an open reduction to remove interposed material
reduction can be blocked by interposed
tendon
ECU most common interposed tendon
periosteum
o DRUJ stability
following fixation, test DRUJ
if unstable, pin ulna to radius in supination
if unstable with large ulnar styloid fragment, fix ulnar styloid and splint in supination
ORIF with flexbile intramedullary nailing, +/- DRUJ pinning
o approach
percutaneous (with IMN) of radius fracture
o open reduction : same as above
o DRUJ stability : same as above
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Complications
Malunion/nonunion
Chronic DRUJ instability
o chronic DRUJ instability (a rare consequence of a missed injury)
Superficial radial nerve plasy
o can be seen with IMN
Extensor pollicus longus
o can be seen with IMN
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
apparent dislocations (symphyseal, SI) may have periosteal tube that heals like
fracture
lower rate of hemmorhage secondary to
smaller vessels, which are more capable of vasoconstriction
injuries less commonly increase pelvic volume than in adult
o acetabular fractures
only 1-15% of pelvis fractures
more common after triradiate closure
differences from adult
triradiate cartilage injury can cause growth arrest and lead to deformity
fractures into triradiate cartilage occur with less force than adult acetabular fractures
transverse fracture pattern more common than both column
classified using Letournel
Associated conditions
o CNS and abdominal visceral injury
high rate (> 50%) in traumatic pelvic injuries, presumed secondary to higher energy required
to create fracture
o femoral head fractures/dislocations
associated with acetabular fractures
o GU injury
increased rate with Torode Type IV fractures
o life threatening hemmorhage
Prognosis
o complications are rare
o need for operative intervention increases after closure of triradiate cartilage
Anatomy
Pelvis undergoes endochondral ossification (like long bones) at 3 primary ossification centers
o ilium appears at 9 wks
o ischium appears at 16 wks
o pubis appears at 20 wks
all meet and fuse at 12yr in girls, 14yr in boys
Acetabular growth
o enlargement is a result of interstitial growth within triradiate cartilage
o concavity is a response to pressure from femoral head
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o depth of acetabulum results from
interstitial growth in acetabular cartilage
appositional growth in periphery of cartilage
periosteal new bone formation at acetabular margin
Puberty
o 3 secondary ossification centers of the acetabulum appear at 8-9yr and fuse at 17-18yr
os acetabuli (OA, forms anterior wall)
acetabular epiphysis (AE, forms superior acetabulum)
secondary ossification center of ischium (SCI, forms posterior wall)
o other secondary ossification centers (of the pelvis)
do not confuse with avulsion fractures
iliac crest
appears at 13-15y, fuses at 15-17y
used in Risser sign
ischial apophysis
appears at 15-17y, fuses at 19-25y
anterior inferior iliac spine
appears at 14y, fuses at 16y
pubic tubercle
angle of pubis
ischial spine
lateral wing of sacrum
Classification
Tile Classification
Type A • Stable injuries (rotationally & vertically)
Type B • Rotationally unstable
• Vertically stable
Type C • Unstable rotationally & vertically
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
Torode/Zieg Classification (pediatric pelvic ring)
Presentation
History
o pediatric pelvic ring fractures often occur secondary to motor vehicle accidents or when a
pedestrian is struck by a motor vehicle
o pelvic avulsion injuries often occur during sporting activities such as sprinting, jumping or
kicking
Physical exam
o as in all trauma patients, initial evaluation should include ABC's followed by primary and
secondary surveys
o important to thoroughly complete a rectal/genitourinary evaluation in polytrauma patient
Imaging
Radiographs
o recommended views
AP
Judet views (45 degree internal and external oblique views, to better evaluate the
acetabulum),
Inlet/Outlet views (35 degree caudal and cranial tilt views, to better evaluate integrity of the
pelvic ring)
o sensitivity
plain radiographs will miss ~50% of all pediatric pelvic fractures
CT
o indications
negative plain films with increased suspicion
preoperative evaluation
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MRI
o indications
occasionally required to detect apophyseal avulsion injuries
apophyseal avulsion injuries are usually easily detected and adequately imaged with plain
radiographs
Treatment
Nonoperative
o protected weight bearing followed by therapy
indications
pelvic ring
dislocations of symphysis and SI joint
potential for periosteal healing
Type I Avulsion Injuries with < 2 cm displacement
Type II Iliac Wing Fractures with < 2 cm displacement
Type III pelvic ring fractures without segmental instability and non-displaced
acetabulum
acetabulum
few indications for non-op treatment
results often poor, especially with comminution, joint incongruity
if non-op chosen, needs close followup for 1-2yr to detect premature triradiate closure
technique
for Type I and II
protected weight bearing for 2-4 weeks
stretching and strengthening 4-8 weeks
return to sport and activity after 8 weeks and asymptomatic
Type III
weight bearing as tolerated for 6 weeks
o bedrest
indications : Type IV pelvic ring with instability AND < 2 cm pelvic ring displacement
Operative
o ORIF
principles
physis sparing where possible
where not possible, smooth pins across physis (especially triradiate) x 4-6wks with early
removal
indications
pelvis
Type I Avulsion Injuries with > 2-3 cm displacement
Type II Iliac Wing Fractures with > 2-3 cm displacement
Type III pelvic ring with displaced acetabular fractures > 2mm
Type IV pelvic ring with instability and > 2 cm pelvic ring displacement
acetabulum
comminuted acetabular fracture when traction does not improve position of fragments
joint displacement >2mm
joint incongruity
joint instability (persistent medial subluxation or posterior subluxation)
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
central fracture dislocation
intra-articular fragments
open fractures
o temporizing external fixation followed by ORIF
indications
vertical shear with hemodynamic instability
Presentation
Symptoms
o pain, inability to bear weight
Physical exam
o posterior dislocation (most common)
slight flexion, adduction, and internal rotation of the limb
clinical limb length discrepancy
if large posterior wall acetabular fracture, can appear shortened without malalignment
o anterior dislocation
flexion, abduction, and external rotation
o neurovascular exam
check for sciatic or gluteal nerve palsy (rare)
Imaging
Radiographs
o recommended views
ap and lateral
VIII:29 post reduction xray of hip
most can be diagnosed on AP pelvis films dislocation showing medial joint space
lateral hip radiographs will confirm anterior vs posterior widening due to non concentric
reduction
dislocation
post reduction films
post-reduction radiographs are necessary to confirm concentric reduction
o findings
radiographs must be scrutinized in order to inspect for joint incongruity or nonconcentric
reduction
CT
o indications
post-reduction CT scan is utilized to further evaluate for any entrapped
osteochondral fragment
o findings
inspect for joint incongruity or nonconcentric reduction
entrapped labrum or capsule can produce a subtle asymmetry VIII:30 osteochondral
interposed soft-tissue can be difficult to appreciate on CT scan fragment
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
osteochondral fragments can be seen in older children and are easily detected by CT
a non-concentric reduction requires exploration to remove entrapped labrum, capsule,
osteochondral fragment or ligamentum teres
MRI
o best for evaluating interposed soft tissue
Treatment
Nonoperative
o closed reduction under general anesthesia with fluoroscopy
indications
urgent attempt at closed reduction is first line treatment
most are successful reduced with closed means (85%)
Operative
o open reduction
indications
nonconcentric reduction
intra-articular fragment
unstable acetabular rim fracture
irreducible by closed means
technique
surgical approach is typically performed in direction of dislocation (most commonly
posterior)
Techniques
Closed reduction technique
o reduction
adequate anesthesia or sedation during reduction is mandatory in order to decrease the risk of
displacing the proximal femoral epiphysis
reduction under fluoroscopy has been recommended to decrease risk of displacement
o post-reduction
test hip stability before weaning sedation
obtain post-reduction imaging
some advocate spica cast in younger children or bracing in older children with 6 weeks
protected weight-bearing on crutches
Complications
Osteonecrosis
o reported in 3-15%
o less frequent than in adults if there is an absence of an associated femoral neck fracture
o if present, thought to be related to delayed reduction
Coxa magna
o common radiographic finding (20%)
o not associated with functional limitation
Redislocation
o rare sequela
o treatment
prolonged immobilization
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if recurrent and recalcitrant to immobilization: capsulorrhaphy
treatment based on age of patient and time elapsed since injury
Nerve injury
o sciatic or gluteal nerve injury can occur, usually resolves with prompt reduction
Anatomy
Growth centers of the proximal femur
o proximal femoral epiphysis
accounts for 13-15% of leg length
accounts for 30% length of femur
proximal femoral physis grows 3 mm/yr
entire lower limb grows 23 mm/yr
o trochanteric apophysis
traction apophysis
contributes to femoral neck growth
disordered growth
injury to the GT apophysis leads to shortening of the GT and coxa valga
overgrowth of the GT apophysis leads to coxa vara
Vascularity
o medial femoral circumflex artery
main blood supply to the head via the posterosuperior lateral epiphyseal branch and via
posteroinferior retinacular branch
becomes main blood supply after 4 years after regression of LFCA and artery of ligamentum
teres
o lateral femoral circumflex artery
regresses in late childhood
o artery of the ligamentum teres
diminishes after 4 years old
o metaphyseal vessels
also contribute to blood supply to the head < 3 years old and after 14-17years
between 3 to 14-17 years, the physis blocks metaphyseal supply
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
after 14-17 years, anastomoses between metaphyseal-epiphyseal vessels develop
Neurovacular
o superior gluteal nerve (L5, S1, S2)
gluteus medius and gluteus minimus
Classification
Delbet Classification
Type Description Incidence AVN Nonunion
Type I Transphyseal (IA, without dislocation of <10% 38% (AVN 100%
epiphysis from acetabulum; IB, with in type IB)
dislocation of epiphysis)
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Imaging
Radiographs : AP pelvis and cross-table lateral
CT : for nondisplaced fractures and stress fractures
MRI : for nondisplaced fractures and stress fractures
Treatment
Nonoperative
o spica cast in abduction, weekly radiographs for 3wks
indications
Type IA, II, III, IV, nondisplaced, <4yrs
evaluate Type IA fractures for child abuse
Operative
o emergent ORIF, capsulotomy, or joint aspiration
indications
open hip fracture
vessel injury where large vessel repair is required
concomitant hip dislocation or significant displacement, especially type I
may decrease the rate of AVN (supporting data equivocal)
o closed reduction internal fixation (CRIF)/ percutaneous pinning (CRPP)
indications
Type II, displaced
postop spica (abduction and internal rotation) x 6-12wk
Type III and IV, displaced and older children
o open reduction and internal fixation (ORIF)
indications
Type IB
o pediatric hip screw / DHS
indications
Type IV
Techniques
Emergent reduction and capsulotomy
o timing of reduction
early reduction (<24h) may diminish risk of AVN by restoring
blood flow through kinked vessels
o reduction technique
radiolucent table for 0-10 years
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
open capsulotomy through anterior incision
Closed reduction and percutaneous pinning (CRPP)
o reduction technique : see above
o fixation
smooth or threaded pins / K wires (use 2-3 pins or wires)
indications
younger patients
transphyseal
recommended when there is little metaphyseal bone available
cannulated screws
indications
short of the physis
less stable than transphyseal
for patients <4-6yrs
transphyseal
older patients close to skeletal maturity (>12yrs old)
where crossing the physis is necessary to achieve stable fixation
it is easier to treat leg length discrepancy from premature physeal closure than
nonunion
place within 5mm of subchondral bone
avoid anterolateral quadrant of epiphysis and posterior perforation of femoral neck
to prevent injury to vasculature
Closed reduction and internal fixation (CRIF)
o indications
type IV
appropriate if immediately available
o implants
pediatric hip screws
Open reduction and internal fixation (ORIF)
o approach
anterolateral (Watson-Jones) for types I, II, III
lateral (Hardinge) for type IV
Complications
AVN
o most common complication
VIII:32 Avascular necrosis (AVN)
risks = age + fracture type
most susceptible age = 3-8 years
highest for Delbet type I (nearly 100% for Delbet type IB)
o etiology
kinking/laceration of vessels
tamponade by intracapsular hematoma
o treatment
core decompression
vascularized fibular graft
Coxa vara (neck-shaft angle <130°) VIII:33 Coxa vara
o 2nd most common complication
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o more common if fracture is treated non-operatively
o more common for types I, II and III
incidence 25% for type III
o treatment
young patients (0-3yrs) will remodel
surgical arrest of trochanteric apophysis
indication
coxa vara in <6-8yrs
only works in younger patient
subtrochanteric or intertrochanteric valgus osteotomy
indication
coxa vara + nonunion
coxa vara with severe Trendelenburg limp or FAI signs and
symptoms
for the older patient
Nonunion
o can occur together with coxa vara (see above)
o etiology
nonoperative treatment of Type II or III
occult infection at fracture site
severe AVN of proximal femur VIII:34 Nonunion
malreduced fracture
o treatment
subtrochanteric or intertrochanteric valgus osteotomy
Coxa valga
o Type IV fractures involving GT in younger patient may have
premature GT apophysis closure, leading to coxa valga
Physeal arrest
o physeal arrest alone leads to <1.5cm leg length discrepancy
only in very young children
proximal femoral physis contributes to 15% of limb length
(3mm/yr)
Limb length discrepancy
o significant LLD occurs in combined AVN + physeal arrest
o treatment
shoe lift if projected LLD at skeletal maturity <2cm
epiphysiodesis of contralateral distal femur ± proximal tibia if projected LLD at skeletal
maturity 2-5cm
Chondrolysis
o usually associated with AVN
o etiology
poor vascularity to femoral head cartilage
persistent hardware penetration of joint
o presents as restricted hip motion, hip pain, radiographic joint space narrowing
Malreduction
o common with subtrochanteric fractures
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
deforming forces on proximal fragment
displaced into flexion, abduction, and external rotation
Infection
o <1% incidence
o after ORIF or CRPP
o treatment
debridement, maintain fixation until union
o may lead to osteomyelitis, AVN, chondrolysis, premature physeal closure
Classification
Descriptive classification
o characteristics of the fracture
transverse
comminuted
spiral etc.
o integrity of soft-tissue envelope
open
closed fracture
Stability
o length stable fractures
are typically transverse or short oblique
o length unstable fractures
are spiral or comminuted fractures
Presentation
Symptoms : thigh pain, inability to walk, report of deformity or instability
Physical exam : gross deformity, shortening, swelling of the thigh
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Imaging
Radiographs
o AP and lateral of femur
typically allow complete evaluation of the fracture location, configuration and amount of
displacement
o ipsilateral AP and lateral of knee and hip
required to rule out associated injuries
Treatment
Based on age and size of patient and fracture pattern
Guidelines provided by AAOS
Treatment Guidelines
< 6 months Any fx pattern Pavlik harness
Early spica casting
7m - 5 years < 2 - 3 cm shortening Early spica casting
Surgical Technqiues
Pavlik harness
o indications
children up to 6 mos.
o technique
avoids the need for sedation or anesthesia
straps can be adjusted to manipulate fracture VIII:35 Spica cast
VIII:36 Pavlik harness
o complications
can compress femoral nerve if excessive hip flexion is used in presence of a swollen thigh
identified by decreased quadricep function
Immediate spica casting
o fewer complications than traction + later casting
o indications
children 7 m - 5 years with < 2 - 3 cm of shortening
relatively contraindicated with polytrauma, open fractures and shortening > 2-3 cm
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
o technique
applied with reduction under sedation or with GA
single-leg spica or one-and-one-half spica (to control rotation)
the exception is distal femoral buckle fracture (stable) only requires long leg cast (not
spica)
hips flexed 60-90° and approximately 30° of abduction
knees in 90° of flexion
MUST limit compression and/or traction thru popliteal fossa
external rotation is typically needed to correct rotational deformity
molds along the distal femoral condyles and buttocks help to maintain reduction
acceptable limits are based on childs age
goal of reduction should include obtaining < 10° of coronal plane and < 20° of sagittal
plane deformity with no more than 2cm of shortening or 10° of rotational malalignment
a special car seat is needed for transport
o follow-up
weekly radiographs to monitor for loss of reduction for first 2 to 3 weeks
cast wedging can be used to correct deformities
healing times vary from 4 - 8 weeks based on age
o complications
compartment syndrome
decreased with applying smooth contours around popliteal fossa, limiting knee flexion to
< 90° and avoiding excessive traction
monitored for by observing the child's neurovascular exam and level of comfort
Traction + delayed spica casting
o indications
children 7 mos. - 5 yrs. of age with > 2 - 3 cm of shortening
o technique
placed in distal femur proximal to distal femoral physis
proximal tibial traction can cause recurvatum due to damage to the tibial tubercle
apophysis
used for 2-3 weeks to allow early callus formation
spica casting then applied until fracture healing
o complications
more complications than immediate spica casting
Flexible intramedullary nails
o indications
treatment of choice for most simple, length stable fracture patterns in children 6 - 10 years
adolescent patient weighing less than 100 lbs with a length stable fracture
o technique
allows load sharing and quick moblization of the patient
nail size determined by multiplying width of narrowest portion of femoral canal by 0.4
the goal is 80% canal fill
two nails of equal size are inserted retrograde beginning approximately 2 -2.5 cm above the
distal femoral physis
o follow up : time to union is typically 10 - 12 weeks
removal of the nail can be performed at 1 year
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o complications
most common complication is pain at insertion site near the knee
in up to 40% of patients
recommended that < 25mm of nail protrusion and minimal bend of the nail outside the
femur are present
Complications
Leg-Length Discrepancy
o overgrowth
0.7 - 2 cm is common in patients between of 2 - 10 years at time of fracture
typically presents within 2 years of injury
o shortening
is acceptable if less than 2 - 3 cm because of anticipated overgrowth
can be symptomatic if greater than 2 - 3 cm
temporary traction or internal fixation used to prevent persistent shortening
Osteonecrosis (ON) of femoral head
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o reported with both piriformis and greater trochanter entry nails
o femoral nailing through the piriformis fossa is contraindicated in adolescents with open physes
because of the risk of osteonecrosis of femoral head
o main supply to femoral head is deep branch of the medial femoral circumflex artery
branches into superior retinacular vessels that supply the femoral head
vulnerable as it lies near the piriformis fossa
Nonunion
o higher risk with load bearing devices
external fixator or submuscular plates
o can occur after flexible intramedullary nailing in patients
aged over 11 years old
who weigh >49 kg (>108 lb)
Malunion
o typical deformity is varus + flexion of the distal fragment
o remodeling is greatest in sagittal plane (ie flexion/extension deformity)
o rotational malalignment does not remodel
must be corrected at the initial surgery
rarely symptomatic
Refracture
o most common after external fixator removal with varus malalignment
o highest risk in transverse and short oblique fractures
less likelihood of secondary callus formation
Anatomy
Physeal considerations of the knee
o general assumptions
leg growth continues until
16 yrs in boys
14 yrs in girls
o growth contribution
leg grows 23 mm/year, with most of that coming from the knee (15 mm/yr)
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
proximal femur - 3 mm / yr (1/8 in)
distal femur - 9 mm / yr (3/8 in)
proximal tibia - 6 mm / yr (1/4 in)
distal tibia - 5 mm / yr (3/16 in)
Presentation
Symptoms
o unable to bear weight
Physical exam
o pain and swelling
o tenderness along the physis in the presence of a knee effusion
o may see varus or valgus knee instability on exam
Imaging
MRI or ultrasound
o indications
diagnositic modality of choice to confirm physeal fracture
Radiographs
o Standard AP, lateral, and oblique radiographs of the knee should be done as initial evaluation
o indications
follow up radiographs after 2-3 weeks of casting if physeal injury is likely but not identifiable
on injury films initially
stress radiographs to look for physis opening if there was suspicion of physeal injury
have fallen out of favor due to patient discomfort and possible need for sedation in order
to properly stress the knee
Treatment
Nonoperative
o long leg casting
indications
stable nondisplaced fractures
close clinical followup is mandatory
Operative
o closed reduction and percutaneous pinning followed by casting
indications
displaced Salter-Harris I or II fractures
displaced fractures successfully reduced with closed methods should still be pinned
(undulating physis makes unstable following reduction)
technique
avoid multiple attempts at reduction
avoid physis with hardware if possible
if physis must be crossed (SH I and SH II with small Thurston-Holland fragments),
use smooth k-wires
SH II fracture, if possible, should be fixed with lag screws across the metaphyseal segment
avoiding the physis
postoperatively follow closely to monitor for deformity
o ORIF
indications
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Salter-Harris III and IV in order to anatomically reduce articular surface
irreducible SHI and SHII fractures
reduction often blocked by periosteum infolding into fracture site
techniques
If anatomic reduction cannot be obtained via closed techniques, incision over the
displaced physis to remove interposed periosteum is necessary.
Complications
Limb length discrepancy or angular deformity (most common)
o results from physeal disturbance
o correlates with fracture pattern
36% of SH 1 fractures
58% in SH 2 fractures
49% in SH 3 fractures
64% in SH 4 fractures
o prevent with
anatomic physeal alignment (critical)
close follow up following nonoperative or operative treatment
o treatment
physeal bridge excision
indication
deformity is present with a physeal bar of <50% and ≥ 2 years or 2 cm of growth
remaining
Popliteal artery injury
o rare and more common with anterior displacement of epiphysis
o most common with anterior, or posteriorly, displaced fracture patterns
Collected By : Dr AbdulRahman
AbdulNasser
June 2017
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Knee & Proximal Tibia
Anatomy
Osteology
o tibial eminence
non-articular portion of the tibia between the medial and lateral tibial plateau
Ligaments
o anterior cruciate ligament
inserts 10-14 mm behind anterior border of tibia and extends to medial and lateral tibial
eminence
Classification
Modified Meyers and McKeever Classification
Type I Nondisplaced (<3mm)
Type II Minimally displaced with intact posterior hinge
Type III Completely displaced
Type III+ Type III fracture with rotation
Type IV Completely displaced, rotated, comminuted
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OrthoBullets2017 Pediatric trauma | Knee & Proximal Tibia
Presentation
Symptoms
o pain in knee
Physical exam
o inspection
immediate knee effusion
o ROM
often limited secondary to pain
once pain is controlled, lack of motion may indicate
meniscal pathology
displaced/entrapped fracture fragment
positive anterior drawer
Imaging
Radiographs
o recommended views
standard knee radiographs
CT
o useful for pre-operative planning
MRI
o better at determining associated ligamentous/meniscal damage than CT or radiographs
Treatment
Nonoperative
o closed reduction, aspiration of hemarthrosis, immobilization in 0-20° of flexion
indications
non-displaced type I and reducible type II fractures
reduction maneuver = extend the knee to 20° short of full extension to observe for fragment
reduction
Operative
o ORIF vs. all-arthroscopic fixation
indications
Type III or Type II fractures that cannot be reduced
block to extension
Sugical Techniques
Arthroscopic fixation
o approach
standard arthroscopic portals
o technique
debride fracture
disengage entrapped meniscus or intermeniscal ligament
medial meniscus entrapment most common
reduce fracture
fracture fixation
suture fixation
pros
avoids physis
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Knee & Proximal Tibia
cons
technically demanding
screw fixation
pros
less demanding than suture fixation
possibly earlier mobilization
cons
hardware irritation
impingement from improperly placed screw
physeal damage
o post-operative care
early range of motion
length of limited weight bearing is controversial
Open fixation
o same principles as arthroscopic
Complications
Arthrofibrosis
o more common with surgical reconstruction
Growth arrest
ACL laxity
o incidence
10% of knees managed surgically
20% of knees managed non-operatively
o often not clinically significant
Anatomy
Osteology
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OrthoBullets2017 Pediatric trauma | Knee & Proximal Tibia
o proximaltibia has two ossification centers
primary ossification center (proximal tibial physis)
secondary ossification center (tibial tubercle physis or apophysis)
insertion of patellar tendon
physeal closure occurs from posterior to anterior and proximal to distal
places distal secondary center at greater risk of injury in older children
Muscles
o extensor mechanism can exert great force at secondary ossification center
Blood Supply
o recurrent anterior tibial artery can be torn with these injuries
Classification
Ogden Classification (modification of Watson-Jones)
Type I fracture of the secondary ossification center near the insertion of the patellar tendon
Type II fracture propagates proximal between primary and secondary ossification centers
Type III coronal fracture extend posteriorly to cross the primary ossification center
Modifier: A (nondisplaced), B (displaced)
Newer descriptions have been added to the original system
o Type IV is a fracture through the entire proximal tibial physis
o Type V is a periosteal sleeve avulsion of the extensor mechanism from the secondary ossification
center
Presentation
Symptoms
o sudden onset of pain
generally occurs during the initiation of jumping or sprinting
o extensor mechanism deficiency or lag with Type 2 and 3 injuries
o knee swelling
hemarthrosis with Type 3 injuries
Physical exam
o inspection & palpation
swelling at the knee
tenderness at the tibial tubercle
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Knee & Proximal Tibia
evaluate for anterior compartment firmness
o ROM & instability
extensor lag or extensor deficiency in Type 2 or 3 injuries
o neurovascular exam
monitor for increasing pain suggestive of compartment syndrome
Imaging
Radiographs
o recommended views
required
lateral of the knee
optional VIII:37 Ogden type IIIB
internal rotation view will bring the tibial tubercle into profile
consider contralateral knee views in pediatric fractures
o findings
widening or hinging open of the apophysis
fracture line may be seen extending proximally and variable distance posteriorly
anterior swelling may be the only sign in the setting of a periosteal sleeve avulsion (type 5
injury)
evaluate for possible patella alta
CT
o can be useful to evaluate for intra-articular or posterior extension
o arteriogram can be helpful if concern for anterior tibial artery injury
should not delay intervention in setting of compartment syndrome
MRI
o generally not indicated
o useful for determining fracture extension in a nondisplaced Type 2 injury
Treatment
Nonoperative
VIII:38 Ogden type IV B
o long leg cast in extension for 4-6 weeks
indications
usually Type 1 and 2 injuries
minimal displacement (< 2 mm)
acceptable displacement after closed reduction
Operative
o closed reduction and percutaneous fixation vs open reduction internal fixation
indications : Type 1, 2, and 4 fractures
o open reduction with arthrotomy and internal fixation
indications : Type 3 fractures - need to visualize joint surface for perfect reduction
o open reduction and soft tissue repair
indication
Type 5 (periosteal sleeve) fractures
Techniques
Closed reduction and percutaneous fixation
o approach
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OrthoBullets2017 Pediatric trauma | Knee & Proximal Tibia
closed reduction often done under anesthesia
percutaneous clamping
o technique
internal fixation with 4.0 cancellous partially threaded screws
larger screws can cause soft tissue irritation in the long-term
smooth K wires for younger child (>3y from skeletal maturity)
o postoperative care
immobilization
long leg cast or brace for 4-6 weeks
prolonged immobilization needed in Type 2 and 3 injuries
non-weight bearing
rehabilitation
progressive extensor mechanism strengthening
return to sports no sooner than 3 months
pros & cons
pros
no open reduction
excellent healing potential
cons
inability to clean fracture site or remove soft tissue interposition
hardware irritation can necessitate implant removal
Open reduction and internal fixation
o approach
midline incision to the fracture site
o technique
evaluate and clean fracture site
remove any soft tissue interposition (periosteum)
anatomic reduction of fracture fragments
internal fixation with 4.0 cancellous, partially threaded screws
larger screws can cause soft tissue irritation in the long-term
smooth K wires for younger child (>3y from skeletal maturity)
o postoperative care
immobilization
long leg cast or brace for 4-6 weeks
prolonged immobilization needed in Type 2 and 3 injuries
non-weight bearing
rehabilitation
progressive extensor mechanism strengthening
return to sports no sooner than 3 months
pros & cons
pros
anatomic reduction and stable fixation
excellent healing potential
may allow for earlier range of motion
cons
hardware irritation can necessitate implant removal
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Knee & Proximal Tibia
Open reduction with arthrotomy and internal fixation
o approach
midline approach or median parapatellar arthrotomy
joint surface must be visualized to assure anatomic reduction
alternatively, arthroscopy can be used to directly assess the articular reduction
o technique
same as above
evaluate for meniscal tears and repair or debride as appropriate
evacuate intraarticular hematoma
visualize joint surface to achieve anatomic reduction
o postoperative care
immobilization
long leg cast for 4-6 weeks
prolonged immobilization needed in Type 2 and 3 injuries
non-weight bearing
rehabilitation
progressive extensor mechanism strengthening
return to sports no sooner than 3 months
pros & cons
pros
addresses intraarticular extension and soft tissue injuries
cons
arthrotomy may require longer immobilization and/or rehabilitation
Open reduction and soft tissue repair
o approach
midline incision to the soft tissue injury site
o technique
evaluate soft tissue injury
remove any soft tissue interposition (periosteum)
heavy suture repair of periosteum back to the secondary ossification center
o postoperative care
immobilization
long leg cast for 8-10 weeks
prolonged immobilization needed due to soft tissue (rather than bone) healing
rehabilitation
progressive extensor mechanism strengthening
return to sports no sooner than 3 months
o pros & cons
cons
prolonged healing time due to soft tissue healing
Complications
Recurvatum deformity
o more common than leg length discrecancy
o growth arrest anteriorly as posterior growth continues leading to decrease in tibial slope
Compartment syndrome
o related to injury of anterior tibial recurrent artery
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OrthoBullets2017 Pediatric trauma | Knee & Proximal Tibia
Vascular injury
o to popliteal artery as it passes over distal metaphyseal fragment
Loss of range of motion
Bursitis
o due to prominence of screws and hardware about the knee
Anatomy
Ossification
o does not begin until 3 to 5 years of age.
o most patellar fractures occur in adolescents when ossification is nearly complete
o incomplete coalescence of a superolaterally located accessory center of ossification results in
bipartite patella (often confused with fracture)
Presentation
History
o indirect injury
o not associated with direct blow to the knee
Symptoms
o severe knee pain
Physical exam
o inspection
soft-tissue swelling
a high-riding patella implies that the extensor
mechanism has been disrupted
hemarthrosis of the knee joint is often present
o palpation
palpable gap at the lower end of the patella
o motion
active extension of the knee is difficult; especially
with resistance
inability to weightbear
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Knee & Proximal Tibia
Imaging
Radiographs
o recommended views
AP and lateral of knee
o findings
small flecks of bone adjacent to inferior pole
diagnosis may be missed because the distal bony fragment is not readily discernible on
radiographs
patella alta
for distal fractures (most common)
patella baja
for proximal fractures
MRI
o indications
may be useful for diagnosing a sleeve fracture when the diagnosis is not clear from the
clinical and plain radiographic findings
Treatment
Nonoperative
o cylinder cast for 6 weeks
indications
nondisplaced fractures with intact extensor mechanism
Operative
o open reduction and internal fixation (modified tension band technique)
indications
displacement more than 2-3mm
majority require ORIF
may be performed with sutures through drill holes
Technique
Open reduction and internal fixation
o approach
parapatellar to knee
approach the inferior pole of the patella through a 7-cm medial parapatellar incision
make incision over the distal aspect of the approach directly over the inferior pole of the
patella
o repair
repair of the torn medial and lateral retinaculum along with the use of sutures through the
cartilaginous and osseous portions of the patella often suffice
o fixation
once anatomic reduction of articular surface achieved, fracture can be stabilized using
modified tension band wiring around two longitudinally placed Kirschner wires
o post-operative care
place in cast with knee in mild degree of flexion
remove cast at ~3 weeks and start ROM exercises
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OrthoBullets2017 Pediatric trauma | Knee & Proximal Tibia
Complications
Patella alta
Extensor lag
Quadriceps atrophy
Anatomy
Physeal considerations of the knee
o general assumptions
leg growth continues until
16 yrs in boys
14 yrs in girls
o growth contribution
leg grows 23 mm/year, with most of that coming from the knee (15 mm/yr)
proximal femur - 3 mm / yr (1/8 in)
distal femur - 9 mm / yr (3/8 in)
proximal tibia - 6 mm / yr (1/4 in)
distal tibia - 5 mm / yr (3/16 in)
Presentation
Symptoms
o unable to bear weight
Physical exam
o inspection
pain and swelling
tenderness along the physis in the presence of a knee effusion
o motion
may see varus or valgus knee instability on exam
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Knee & Proximal Tibia
o neurovascular exam
physis is at same level of trifurcation of vessels and there is a risk of vascular compromise
with displacement
Imaging
Radiographs
o recommended views
AP and lateral
o optional views
oblique views
varus/valgus stress views
o findings
displacement of fracture fragments
Salter Harris classification
CT
o indications : assess fracture displacement
o findings : best modality for SH III or IV fractures
Treatment
Nonoperative
o immobilization in long leg cast
indications
non-displaced fracture
stable Salter-Harris Type I and Type II fractures
modalities
traction for fracture reduction
cast in slight flexion for 6 weeks
outcomes
redisplacement is common without internal fixation
Operative
o anatomic reduction and fixation with percutaneous pinning
indications
displaced fractures
unstable Salter-Harris Type I and Type II fractures
redisplacement following closed treatment
modalities
percutaneous pins parallel to physis
pins crossing perpendicular to physis if extra-articular fixation needed
outcomes
avoid displacement to affect trifurcation
o open reduction internal fixation
indications
displaced fractures
Salter-Harris Type III and Type IV fractures
modalities
screw parallel to physis
cast in slight flexion for 4-6 weeks
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OrthoBullets2017 Pediatric trauma | Knee & Proximal Tibia
Complications
Loss of reduction
Growth disturbances (25%)
o can lead to limb length discrepancy and/or angular deformities
Compartment syndrome
Ligamentous instability
Classification
Classification of pediatric proximal tibia metaphyseal fractures is descriptive.
o important radiographic parameters include:
complete versus incomplete fracture
majority are incomplete
displaced or nondisplaced
presence and location of associated fibula fracture
Presentation
Symptoms
o pain
o refusal to bear weight
Physical exam
o valgus deformity
o evaluate carefully for compartment syndrome
Imaging
Radiographs
o recommended views
required
AP and lateral
o findings
look for incomplete vs complete and presence of a proximal fibula fracture which may
indicate a more unstable fracture pattern
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Knee & Proximal Tibia
Treatment
Nonoperative
o long leg cast in extension with varus mold (aim for slight overcorrection)
indications
nondisplaced fracture
technique
casts are maintained for 6-8 weeks with serial radiographs
weight bearing may be allowed after 2-3 weeks.
o reduction followed by long leg cast in extension with varus mold (aim for slight
overcorrection)
indications
displaced fracture
technique
requires conscious sedation or general anesthesia
cast in near full extension (10 degrees flexion)
varus mold at fracture site
Operative
o open reduction
indications
inability to adequately reduce a displaced fracture
secondary to soft tissue interposition
technique
III:40 Valgus deformity
V
limited medial approach to proximal tibia
periosteum or tendons of pes anserinus may block reduction
internal fixation not commonly required
Complications
Valgus deformity (Cozen phenomenon)
o may be observed for 12-24 months with expectation of spontaneous correction
o parents should be counseled in advance
o etiology
incomplete reduction
concomitant injury to proximal tibia physis
infolded periosteum
injury to pes anserinus insertion, with loss of proximal tibia physeal tether, leading to
asymmetric physeal growth
o treatment
if deformity fails to resolve
medial hemi-epiphysiodesis in skeletally immature patient
corrective osteotomy in skeletally mature patient
osteotomies have significant complications
Limb length discrepancy
o affected tibia is often longer (average 9mm)
o typically does not require intervention however parents should be counseled that this does not
resolve
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OrthoBullets2017 Pediatric trauma | Leg & Ankle Fractures
Presentation
Symptoms
o pain
o bruising
o limping or refusal to bear weight
Physical exam
o warmth, swelling over fracture site
o tender over fracture site
o pain on ankle dorsiflexion
o always have high suspicion for compartment syndrome
Imaging
Radiographs
o views
AP and lateral views of the tibia and fibula are required
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Leg & Ankle Fractures
ipsilateral knee and ankle must be evaluated to rule out concomitant injury
o findings
Toddler's fracture are nondisplaced spiral tibial shaft fracture
Treatment Traumatic Tibia +/- Fibular fx
Nonoperative
o closed reduction and long leg casting
indications
almost all Toddler's fracture
most traumatic fractures
displaced with acceptable reduction
50% apposition
< 1 cm of shortening VIII:41 Toddler's fracture
< 5-10 degrees of angulation in the sagittal and coronal planes
followup
follow up xrays in 2 weeks to evaluate for callus in order to confirm diagnosis in
equivocal cases
serial radiographs are performed to monitor for developing deformity
Operative
o surgical treatment
indications (< 5% of tibia shaft fractures)
unacceptable reduction (see above)
marked soft tissue injury
open fractures
unstable fractures
compartment syndrome
neurovascular injury
multiple long bone fractures
>1cm shortening
unacceptable alignment following closed reduction (>10deg angulation)
techniques include
external fixation
plate fixation
percutaneous pinning
flexible IM nails
Techniques
Long Leg Casting
o immobilization is performed with a long leg cast with the knee flexed to provide rotational
control and prevent weight bearing.
External fixation
o open fractures with extensive soft tissue injury is most common indication
o most common complication is malunion
o nonunion (~2%)
Plate fixation
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OrthoBullets2017 Pediatric trauma | Leg & Ankle Fractures
Percutaneous pinning
o younger patients
Flexible or rigid intramedullary rods
o depending on the age of the patient and degree of soft tissue injury
o complications
nonunion (~10%)
malunion
infection
Complications
Compartment syndrome
o with both open and closed fractures
Leg-length discrepancy
Angular deformity
o varus for tibia only fractures
o valgus for tibia-fibula fractures
Associated physeal injury
o proximal or distal
Delayed union and nonunion
o usually only after external fixation
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Leg & Ankle Fractures
Anatomy
Physeal considerations
o distal tibial physis closes in predictable pattern
central to medial
anterolateral closes last
Classification
Anatomic classification
o Salter-Harris Classification
Diaz and Tachdjian classification (patterned off adult Lauge-Hansen classification)
o supination-inversion
o supination-plantar flexion
o supination-external rotation
o pronation/eversion-external rotation
Presentation
Symptoms
o ankle pain, inability to bear weight
Physical exam
o inspection : swelling, focal tenderness
Imaging
Radiographs
o recommended views
AP, mortise, and lateral
o optional views
full-length tibia, or proximal tibia, to rule out Maisonneuve-type fracture
o findings
triplane fractures
AP or mortise reveals intraarticular component
lateral reveals posterolateral metaphyseal fragment (Thurston-Holland fragment)
CT scan : indications
o assess fracture displacement
o assess articular step-off
Treatment
Nonoperative
o cast immobilization
indications
<2mm articular displacement
Operative
o CRPP vs ORIF
indications
>2mm displacement
intra-articular fractures
irreducible reduction by closed means
may have interposed periosteum, tendons, neurovascular structures
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OrthoBullets2017 Pediatric trauma | Leg & Ankle Fractures
Techniques
CRPP vs ORIF
o reduction
percutaneous manipulation with k-wires may aid reduction
open reduction may be required if interposed tissue
o fixation
transepiphyseal fixation best if at all possible
cannulated screws parallel to physis
tillaux and triplane fractures
2 parallel epiphyseal screws
medial malleolus shear fractures
transphyseal fixation
smooth wire fixation typically used
Complications
Ankle pain and degeneration
o high rate associated with articular step-off >2mm
Growth arrest
o medial malleolus SH IV have highest rate of growth disturbance of any fracture
o partial arrests can lead to angular deformity
distal fibular arrest results in valgus
medial distal tibia arrest results in varus
o complete arrests can result in leg-length discrepancy
can be addressed with contralateral epiphysiodesis
Extensor retinacular syndrome
o displaced fracture can lead to foot compartment syndrome
Rotational deformity
3. Tillaux Fractures
Introduction
Salter-Harris III fx of the distal tibia epiphysis
o caused by an avulsion of the anterior inferior tibiofibular ligament
Mechanism
o mechanism of injury is thought to be due to an external rotation force
Epidemiology
o typically occur within one year of complete distal tibia physeal closure.
older than triplane fracture age group
Pathoanatomy
o lack of fracture in the posterior distal tibial metaphysis in the coronal plane distinguishes this
fracture from a triplane injury
o transitional fractures (tillaux and triplane) occur in older children at the end of growth
variability in fracture pattern due to progression of physeal closure
a period of time exists when the lateral physis is the only portion not fused
leads to Tillaux and Triplane fractures
often associated with external rotation deformity of the ankle/foot
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Leg & Ankle Fractures
Anatomy
Ossification
o the distal tibial physis closes in the following order
central (first)
posterior
medial
anterolateral (last)
Imaging
Radiographs
o SH III fx of the anterolateral distal tibia epiphysis
CT scan
o delineate the fracture pattern
o determine degree of displacement
o identify intramalleolar or medial fracture variant patterns
Treatment
Nonoperative
o closed reduction, long leg cast x 4 weeks (control rotation), SLC x 2-3 weeks
indications
if < 2 mm of displacement (rare) following closed reduction
technique
reduction technique by internally rotating foot
CT scans sometimes needed to determine residual displacement (confirm < 2mm)
long leg cast initially to control rotational component of injury
Operative
o open reduction and internal fixation
indications
if >2 mm of displacement remains after reduction attempt
technique
closed reduction (by internal rotation) can be attempted under general anesthesia first
percutaneous screws can be placed if adequate reduction obtained
visualize joint line to optimize reduction
intra-epiphyseal screws
transphyseal screws can also be used as most patients are approaching skeletal
maturity
arthroscopically-assisted reduction has been described
Complications
Premature growth arrest
o rare as little physis remaining as closure is already occuring
o decrease risk with anatomic reduction
Early arthritis
o increase risk with articular displacement
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OrthoBullets2017 Pediatric trauma | Leg & Ankle Fractures
4. Triplane Fractures
Introduction
A complex SH IV fracture pattern with components in all three planes
o triplane fractures may be 2, 3, or 4 part fractures
epiphysis fractured in sagittal plane (same as tillaux fracture) and therefore is seen on the AP
radiograph
physis separated in axial plane
metaphysis fractured in coronal plane and therefore is seen on the lateral radiograph
Epidemiology
o Occur between ages 10-17 years, mean 13 years
juvenile ankle physis ossifies in specific order, which leads to transitional fractures such as
triplane and tillaux fractures
distal tibia physis order of
ossification
central > medial > lateral
Mechanism
o most are result of supination-external
rotation similar to tillaux fractures
(lateral triplane)
medial triplane is a result of
adduction
Classification
Parts - 2, 3, 4 part
Lateral triplane (more common) > medial triplane >> intramalleolar triplane (epiphyseal fracture
exits through medial malleolus)
Presentation
Symptoms
o ankle pain, inability to bear weight
Physical exam
o swelling, focal tenderness
Imaging
Radiographs
o AP radiograph shows Salter-Harris III
o lateral radiograph shows Salter-Harris II
CT scan
o usually required to delineate fracture pattern and access articular congruity
o fracture involvement seen in all 3 planes
Treatment
Nonoperative
o cast immobilization
indications
< 2 mm displacement
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Leg & Ankle Fractures
Operative
o CRPP vs ORIF
indications
> 2 mm displacement
techniques
epiphyseal screw placed parallel to physis
arthroscopic aided reduction can be used
Complications
Ankle pain and degeneration
o articular step-off >2mm
Collected By : Dr AbdulRahman
AbdulNasser
June 2017
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