Consultant Orthopedic Surgeon, Royal London Hospital, Barts Health NHS Trust, London, UK Pete Bates BSc, FRCS (Tr&Orth). Consultant Orthopedic Surgeon, Royal London Hospital and Gateway Surgery Centre, Barts Health NHS Trust, London, UK.
DAUD CHOU, MATTHEW BARRY AND KARIM BROHI
OVERVIEW
CLASSIFICATION
- INJURY SEVERITY SCORE
- REVISED TRAUMA SCORE (RTS)
- ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION
- TRAUMA AND INJURY SEVERITY SCORE
The Injury Severity Score (ISS) is the sum of the squares of the AIS values for the 3 most injured body systems. A score of more than 16 has been shown to have an associated mortality of 10 per cent.
INITIAL RESUSCITATION AND PRIMARY SURVEY
- AIRWAY MANAGEMENT AND CERVICAL SPINE CONTROL
- BREATHING
- CIRCULATION
- DISABILITY
- EXPOSURE
- ADJUNCTS TO PRIMARY SURVEY
In the context of acute trauma, shock can be cardiogenic, hypovolemic, or a combination of both. Pelvic fractures can be associated with life-threatening bleeding and should initially be treated with a pelvic binder at the greater trochanters.
SECONDARY AND TERTIARY SURVEYS
PHYSIOLOGICAL STAGING
- STABLE
- BORDERLINE
- UNSTABLE
- IN EXTREMIS
These patients should be monitored aggressively; although ETC can be cautiously adopted, this should be rapidly reversed if the patient becomes unstable. These patients should be managed using a damage control approach, with initial surgical intervention only for life-threatening injuries.
INVESTIGATIONS
These patients have no life-threatening injuries, shock, coagulation or hypothermia and can be managed with the ETC approach (see later). The priority is to stabilize the patient in intensive care before definitive surgical intervention to avoid a second hit phenomenon.
SURGICAL PRIORITIES AND STRATEGY
These patients have hypothermia, acidosis and coagulopathy which have been described as the deadly triad. Only life-saving procedures should be performed before attempting to provide physiologic support in intensive care.
FRACTURE MANAGEMENT
In the presence of multiple fractures, it is important to consider the need to sequentially stabilize the fractures based on their effect on the systemic response and local soft tissue. Current evidence suggests that a patient with a femoral shaft fracture should be treated with intramedullary nailing in the presence of a chest injury as long as the patient is hemodynamically stable and well oxygenated.
BASIC SCIENCE OF POLYTRAUMA
However, there is a subset of trauma patients who will not benefit from ETC due to their inability to withstand further trauma in the form of prolonged surgery. In the case of a floating knee (ipsilateral fracture of the distal femur and proximal tibia), management will include either the application of an extended external fixator or stabilization of both fractures with a retrograde femoral nail and antegrade tibial nail based on the patient's physiology .
PAEDIATRIC POLYTRAUMA
If the patient's systemic response cannot repair the damage caused by the polytrauma, an exaggerated inflammatory response occurs and immune response dysfunction may occur, leading to ARDS and multiple organ dysfunction syndrome. Further surgical intervention may enhance the overall host response, leading to an exaggerated secondary immune response known as the second hit phenomenon.
The immune system is activated to achieve hemostasis, protect against infection, and initiate the process of tissue repair. It usually involves two or more organ systems and most commonly begins with lung failure leading to liver and intestinal failure.
COMPLICATIONS
Damage to endothelial cells caused by hypoxemia is identified by the immune system, which in turn activates the coagulation system and other molecular cascades. Multiple organ dysfunction syndrome is defined as the presence of such impaired organ function that homeostasis cannot be maintained without intervention.
MCQs
Viva questions
The role of intravenous antibiotics in open fractures Administration of antibiotics at the fracture site Negative pressure wound therapy.
CHARLIE JOWETT, JOE MAY, SIMON MYERS AND PETE BATES
INTRODUCTION
PRIMARY DEBRIDEMENT
Centers that cannot provide combined plastic and orthopedic surgery for severe open tibial fractures should have protocols in place for early transfer of the patient to an appropriate specialty center. The wound, soft tissue and bone excision (debridement) is performed by senior plastic surgeons and orthopedic surgeons working together on planned trauma surgery lists, within normal working hours and within 24 hours of the injury, unless there is marine, agricultural or sewage contamination.
GUSTILO AND ANDERSON
Several classifications have gained widespread use, although none have been found, outside their center of origin, to be predictive of complications, amputation rates, or long-term functional outcome.
OTHER CLASSIFICATION SYSTEMS
For skeletal structures, a score of 4 or 5 is highly predictive of the need for limb reconstruction. In general, a score of 11-15 is highly predictive of requiring free flap, and a score greater than 15 was 100 percent predictive of amputation.
SOFT TISSUE INJURY ASSOCIATED WITH CLOSED FRACTURES
DEBRIDEMENT
DEBRIDEMENT – RADICAL VERSUS CONSERVATIVE
Skin edges are not removed unless clearly dead, and crushed bone fragments are exposed to the 'drag test'. Making small cuts near the skin edges can be helpful around bruised areas as this will reveal bleeding, implying viability.
DELAYED VERSUS IMMEDIATE PRIMARY WOUND CLOSURE
With this approach, all but the worst scars can be largely closed without the involvement of plastic surgery. However, wound exploration must be meticulous to ensure removal of all contaminants and loose bone fragments.
DEGLOVING
There may also be subfascial disruption of the perforator supply arising from the deep axial vessels. In the case of open injuries, the boundaries of the released area can be estimated by gently feeling with a finger through the open wound; care must be taken not to overextend.
COMPARTMENT SYNDROME
When nerve function is impaired, paresthesia will occur long before any motor dysfunction—the classic picture is paresthesia of the first dorsal web space indicating anterior compartment syndrome pressing on the deep peroneal nerve. Intracompartmental pressure (ICP) measuring devices can be useful in certain situations (the simplest method is to attach a needle and align with a pressure transducer on the monitor set), especially in
FASCIOTOMY INCISIONS
If the diagnosis is missed, the compartment may contain necrotic muscle and soft tissue. Controversy remains regarding ICP measurement in the awake, alert patient, and it must always be remembered that a normal pressure does not rule out compartment syndrome.
SOFT TISSUE CLOSURE
Pallor, paralysis and reduced pulses are late signs that indicate irreversible injury to muscles and nerves. Absolute values of >30 mmHg or differences between diastolic blood pressure and compartment pressure of <30 mmHg have been suggested as guidelines for decompression.
MEDIAL GASTROCNEMIUS FLAP (UPPER THIRD)
Intracompartmental pressure (ICP) measuring devices can be useful in certain situations (the simplest method is to attach a needle and align with a pressure transducer on the monitor set), especially in unconscious patient, although debate continues over what constitutes a 'high ICP'.
DISTALLY BASED FASCIOCUTANEOUS FLAP (MIDDLE THIRD)
FREE FLAP (LOWER THIRD)
FLAP AFTERCARE
In a free flap, any loss of inflow or outflow requires direct return to theater for re-exploration of the micro-anastomosis; Early intervention can often prevent loss of flap viability.
WOUND IRRIGATION
EFFECT OF IRRIGATION PRESSURE
However, there is increasing evidence that pulsatile irrigation may be detrimental to both soft tissue and bone. Early data from the ongoing multicenter fluid irrigation of open wounds (FLOW) trial compared HPPL and LPPL, showing a strong trend toward lower reoperation rates in the low-pressure group.
IRRIGATING SOLUTION
ROLE OF INTRAVENOUS ANTIBIOTICS IN OPEN FRACTURES
BRITISH ORTHOPAEDIC ASSOCIATION AND BRITISH ASSOCIATION OF
ANTIBIOTIC ADMINISTRATION AT THE FRACTURE SITE
BEAD POUCHES
ANTIBIOTIC-COATED NAILS
NEGATIVE PRESSURE WOUND THERAPY
SUMMARY OF SUGGESTED
PRACTICE FOR THE MANAGEMENT OF OPEN FRACTURES
A patient presents at 22:00 with a Gustilo and Anderson grade IIIb open fracture of the tibia caused by agricultural machinery. What are the relative advantages of early internal versus temporizing external fixation for open tibial fractures.
STEPHEN TAI, PANAGIOTIS GIKAS AND DAVID MARSH
OPTIMAL FRACTURE TREATMENT
THE ELDERLY WOMAN WITH A FRACTURED NECK OF THE FEMUR
THE YOUNG MALE PATIENT WITH A HIGH-ENERGY TIBIAL SHAFT FRACTURE
THE AMATEUR SPORTSPERSON WITH AN ISOLATED LOW-ENERGY FRACTURE
FRACTURE HEALING
The two key factors that determine whether and how a fracture will heal are the blood supply and the mechanical environment (ie, the degree of motion of the fracture ends). A small amount of micromotion at the fracture site is stimulating for angiogenesis and osteogenesis.
FRACTURE HEALING IN CANCELLOUS BONE
Absolute stability is defined as the absence of movement between fracture fragments under normal physiologic loading. Strain is defined as change in length over initial length; in the context of fracture healing, it is used to refer to the degree of movement between fragments.
PRINCIPLES OF FRACTURE TREATMENT
Preliminary stability of trabecular bone healing results in no callus formation—cortical healing lags behind cancellous healing.
REDUCTION
IMMOBILIZATION
NON-OPERATIVE FRACTURE FIXATION
CASTING
Fibreglass – knitted fibreglass is impregnated with a resin that polymerizes and hardens
Moulding
Complications of casts
FUNCTIONAL BRACING
TRACTION
Skin traction
Skeletal traction
The pin should be passed from medial to lateral 2.5 cm inferoposterior to the medial malleolus.
OPERATIVE FRACTURE FIXATION INTERNAL FIXATION
Kirschner wires
Screw fixation
This slide hole should be along the same axis as the threaded hole (which is the same diameter as the core of the screw) in the far cortex. First, create the slide hole, insert a drill sleeve for the threaded hole drill bit through this slide hole, and finally drill the far cortex.
Tension band principle
Most lag screws require an additional method of fixation to neutralize shear or torsional forces (see later). For a fully threaded screw to function in a lag state, the proximal cortex must be overbored to the size of the screw's thread diameter so that the thread does not gain purchase in the proximal cortex (Fig. 3.7a).
Plates
Static compression – pre-stressing of a plate can produce axial compression at the
To reduce this fracture distraction, the plate should be contoured to ensure a concave bend, creating compressive forces on both the distal and proximal cortex of the fracture (Fig. 3.10).
Dynamic compression – the screw holes in DCPs are oval and shaped with an angle of
Dynamic Compression - The bolt holes in the DCP are oval and angled. The brace-plate prevents compression and shearing forces that often occur in metaphyseal and epiphyseal fractures.
Intramedullary nailing
It is important to ensure that sufficient screws are used on both sides of the fracture (Table 3.5). Overgrooving the canal, relative to the size of the nail to be inserted, allows room for the endosteal blood supply to regenerate.
EXTERNAL FIXATORS
This is achieved by removing the screw from the hole without a crack and can be used in some cases of delayed union. The construct must be appropriate for the mechanical demands of the patient and the injury.
Definitive fracture fixation
Indications for the use of external fixators in the trauma setting can be broadly divided into temporizing versus definitive.
Temporary fracture fixation
Advantages of external fixators over other operative techniques
Disadvantages
External fixator constructs
This modularity of the external fixator makes it versatile and allows it to be used for both fracture reduction and fracture fixation. Two rings are placed over each major fragment, perpendicular to the long axis of the bone.
Frame types
Wire tension (typically up to 130 Nm) provides extra stiffness and stability, and addition of half pins provides additional resistance to bending and torsion. Wires placed at an angle of less than 60° to each other increase the risk of bone sliding along the wire, although this can be reduced by using olive wires to produce a buttressing effect.
NIRAV PATEL, VERONA BECKLES AND PETER CALDER
DEFINITIONS
DELAYED UNION
MALUNION
NON-UNION
BONE DEFECTS
INCIDENCE AND AETIOLOGY
DIAGNOSIS
TREATMENT
Non-operative treatment
Subsequent loading of the fracture site to stimulate healing can be achieved using muscle and weight-bearing exercises.
Operative treatment
INCIDENCE
AETIOLOGY
In the absence of pain and other symptoms, a removable splint can be used to provide support at the site of the nonunion. Excision and shortening treatment with autologous bone grafting for atrophic non-union of the femur.
SEPTIC NON-UNION
Bifocal treatment Bifocal treatment uses the principles of bone transport to manage bony defects in a "compression-distraction" process (see Figure 4.6). Ideally, this should not exceed 20 percent of the original bone length because of the risk of neurovascular damage and soft tissue compromise, with consequent instability or stiffness of the joint.
AMPUTATION
Malalignment of a nonunion of the tibia treated with dome osteotomy. a) Lateral radiograph of the malunion; (b) dome osteotomy and bone grafting; and (c) and (d) healed bone. The osteotomy can be performed at the CORA using an opening wedge, to achieve alignment of the mechanical axis without translation.
PANAGIOTIS GIKAS, MARTINA FAIMALI, STEPHEN TAI AND DAVID MARSH
AETIOLOGY AND EPIDEMIOLOGY
Only half will return to their previous level of independence, and most can expect at least some long-term hip discomfort; 50 percent will need an additional walking aid or physical aid for mobility; 10-20 percent of those hospitalized from home will move to housing or care after a hip fracture.
HIGH-QUALITY FRAGILITY FRACTURE CARE
PREOPERATIVE ASSESSMENT
Investigations such as echocardiograms should only be performed if medical and anesthesia management will significantly change as a result. Antiplatelet medications such as aspirin or clopidogrel should be stopped temporarily, but surgery should not be postponed.
PRINCIPLES OF SURGICAL MANAGEMENT
POSTOPERATIVE CARE Analgesia
Wound care
Thromboprophylaxis
Nutrition
Early rehabilitation
Orthogeriatric care
All patients with a fragility fracture should be treated in an orthopedic department with routine access to acute orthogeriatric medical support from the time of admission. Senior medical input from an orthogeriatric physician with large sessional commitments to the trauma unit is now a key component of good care for patients with fragility fractures, with improvements in preoperative assessment, medical management and coordination of early rehabilitation.
SECONDARY PREVENTION OF FRACTURES
ASSESSMENT
NATIONAL HIP FRACTURE DATABASE
Which of the following is a recognized complication of bisphosphonate therapy?
Which of the following is NOT a component of the NICE guidelines on the management
GHIAS BHATTEE, REZA MOBASHERI AND ROBERT LEE
OVERVIEW AND EPIDEMIOLOGY
SURGICAL ANATOMY
NEUROANATOMY
The efferent corticospinal tracts transmit ipsilateral motor function, the dorsal columns transmit afferent contralateral sensation to pain, temperature, and light touch, and the spinothalamic tracts transmit ipsilateral vibration and proprioception. Fractures at this level are relatively less likely to result in neurological injury, due to both Cactus Design and Illustration Ltd.
FRACTURE CLASSIFICATION
Injuries are divided into three mechanistic groups and are further subdivided into fracture morphology and degree of severity. Type A injuries affect only the anterior column, while type B and C injuries represent injuries to both columns (Table 6.1 and Fig. 6.7).
PATTERNS OF NEUROLOGICAL INJURY DEFINITIONS
SPINAL SHOCK
SPECIFIC CORD INJURY PATTERNS
NEUROGENIC SHOCK
DIAGNOSIS AND EVALUATION
While the patient is recumbent, the neurologic examination can be completed by assessing perianal sensation. The patient may then undergo a rectal examination to assess anal tone and the bulbocavernosus reflex may be examined.
IMAGING Radiographs
Once the examination is complete, the severity of the spinal injury is documented using the American Spinal Injury Association (ASIA) classification (Table 6.3). In the case of patients with an ASIA B defect (sacral sparing but no motor function), the presence of pinprick sensation increases the chance of ambulation from 11–33 percent (with perianal sensation only) to 66 percent (also with pinprick). as a perianal sensation).
Computed tomography
Magnetic resonance imaging
NON-SURGICAL TREATMENT
SURGICAL TREATMENT
Decompression
Stabilization
Fusion
Posterior Surgical Approach Usually the top of the iliac crest corresponds to the L4 level, but the image intensifier can be used before the incision is made. Anterior surgical approach The incision is in line with the rib, one or two levels, cephalad to the superior vertebra to be instrumented.
Osteoporotic vertebral compression fractures
The patient is placed in the lateral decubitus position with anterior and posterior supports and a sandbag under the surgical site. The symptomatic improvement caused by vertebral augmentation procedures appears to be sustained, at least in the short term.
Complications of surgery following lumbar spine trauma
It supplies the upper third of the spinal cord with blood via the posterior spinal artery. It supplies blood to the lower two-thirds of the spinal cord via the anterior spinal artery.
NIRAV PATEL AND ROBERT LEE
ATLAS (C1)
AXIS (C2)
SUBAXIAL SPINE (C3–C7)
EVALUATION INITIAL ASSESSMENT
Care should be taken in patients with pre-existing cervical deformity because the placement of a rigid collar may cause displacement of the fracture. Blunt injury above the clavicles or loss of consciousness requires the exclusion of cervical spine injury.
CLINICAL EXAMINATION
Cervical spine immobilization includes manual in-line stabilization in the prehospital setting; this is replaced by quadruple immobilization with a hard collar, blocks, tape, and spinal board.
RADIOGRAPHY
COMPUTED TOMOGRAPHY AND MAGNETIC RESONANCE IMAGING
Magnetic resonance imaging (MRI) is helpful in determining the extent of any spinal cord or soft tissue damage. In cases of subluxation/fracture dislocation with an incomplete spinal cord injury, MRI is essential to determine the amount of disc in the spinal canal.
PAEDIATRICS
TREATMENT PRINCIPLES
UPPER CERVICAL SPINE (C1 AND C2) INJURIES
OCCIPITAL CONDYLE FRACTURE
Low CTO – similar to high CTO, but extends to lower thorax (eg, Minerva, sternal-occipital-mandibular immobilizer [SOMI], Yale). Tongs' (Gardner-Wells) - pin inserted into each side of the external cranial table attached to forceps with traction.
Assessment
Treatment
OCCIPITOCERVICAL DISLOCATION (CRANIOVERTEBRAL DISSOCIATION)
Initial resuscitation of life-threatening injuries should be followed by immediate reduction and stabilization (avoid traction) using a halo vest, as the injury is unstable.
ATLAS (C1) FRACTURES
TRAUMATIC C1–2 LIGAMENTOUS INSTABILITY
If there is any neurologic deficit or ADI >5 mm, initial halotraction and immobilization may be continued until fusion of the avulsion fractures.
ATLANTOAXIAL ROTATORY SUBLUXATION AND DISLOCATION
ATLAS (C2) FRACTURES Dens fracture
Displaced fractures can undergo either traction reduction and immobilization in a halo vest (significant risk of nonunion) or internal fixation with anterior screws or posterior C1–2 fusion (limits rotation).
TRAUMATIC C2/3 SPONDYLOLISTHESIS
PRINCIPLES OF OPERATIVE
MANAGEMENT OF C1–C2 INJURIES
HALO VEST APPLICATION Indications
Contraindications
Consent
Planning and set-up
Anaesthesia and positioning
Surgical technique
Halo application
A key is attached to the front vest to allow emergency removal of the vest, with spare parts carried by the patient.
POSTERIOR APPROACH TO THE UPPER CERVICAL SPINE (C1–C2)
Children
Postoperative care
Surgical approach Landmarks and incision
Surgical techniques Occipitocervical fusion
LOWER CERVICAL SPINE (C3–C7) INJURIES
CENTRAL CORD SYNDROME IN THE PRESENCE OF CERVICAL SPONDYLOSIS
COMPRESSION AND BURST FRACTURES Assessment
If there is no neurological injury, nonoperative treatment is suggested with a rigid collar (C3–6) or cervicothoracic orthosis (CTO) (C7– .T1) for 6–12 weeks. In the presence of neurological injury, the SLIC score is 2 for morphology and 2, 3 or 4 depending on the neurological injury (Fig. 7.16).
HYPEREXTENSION INJURIES ± AVULSION FRACTURES (DISTRACTION INJURY)
Halo vest immobilization can be used for 3 months, or until fusion, with regular radiographic monitoring. In cases of intact intervertebral disc and posterior ligament damage, anterior or posterior decompression surgery can be performed, although posterior stabilization alone is associated with an increased incidence of long-term segmental kyphosis.
HYPERFLEXION WITH FACET
SUBLUXATION OR PERCHED FACETS
UNILATERAL OR BILATERAL FACET FRACTURE-DISLOCATION OR
OTHER C3–C7 FRACTURES
Ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis (DISH)
Laminar fractures
Transverse process fractures
C7 avulsion fracture
Facet (and pedicle) fractures without dislocation
Cervical disc herniation
MANAGEMENT OF C3–C7 INJURIES ANTERIOR APPROACH TO THE
CERVICAL SPINE (C3–T1): SMITH- ROBINSON APPROACH
Indications
Consent and risks
Planning
The interval develops between the sternocleidomastoid/anterior strap muscles laterally and the thyroid gland medially. Blunt dissection is performed between the carotid sheath laterally and the esophagus and trachea medially.
Anterior decompression and fusion
The longus colli muscles (right and left) are removed subperiosteally from the anterior surface of the vertebral bodies. Smooth-ended retractors are carefully placed under the muscles to protect the recurrent laryngeal nerve, esophagus, trachea, and carotid artery from injury.
POSTERIOR APPROACH TO THE LOWER CERVICAL SPINE (C3–C7)
The image intensifier can also be used to identify the correct plane – straight midline incision used.
Posterior interspinous wiring
Posterior cervical fixation
PEARLS AND PITFALLS
The surgical approach to subaxial cervical spine injuries: an evidence-based algorithm based on the SLIC classification system. The subaxial cervical spine injury classification system: a new approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex.
PRAKASH JAYAKUMAR AND LIVIO DI MASCIO
STERNOCLAVICULAR JOINT INJURIES OVERVIEW
ASSESSMENT AND EVALUATION
IMAGING
MANAGEMENT
Anterior sternoclavicular joint injury Non-operative treatment
Posterior sternoclavicular joint injury Non-operative treatment
Physeal injuries
POSTOPERATIVE MANAGEMENT
Mediastinal/retrosternal injury
CLAVICLE FRACTURES
Wires or pins should never be used due to the high incidence of migration and potentially catastrophic complications. Lower type II lateral third fractures may require ORIF with or without CC ligament reconstruction due to the high incidence of nonunion.
FLOATING SHOULDER (SEE SCAPULAR INJURY SECTION)
The degree of nonunion is critically dependent on the number of cortices secured; at least six are required on either side of the fracture. Avoid weight lifting and contact sports until the fracture is clinically and radiologically united (preferably 6 months).
Soft tissue injury/compromise
Anatomic locking plates and screws are popular systems used for early internal fixation of these fractures.
Neurovascular injury/compromise
Malunion
Non-union
Refracture
Neer type II lateral third fractures may require ORIF with or without CC ligament reconstruction due to the high incidence of.
ACROMIOCLAVICULAR JOINT INJURIES OVERVIEW
Surgical approach
Implants should be removed after approx. 3 months to protect the rotator cuff and acromial arch from. Repair of deltoid, trapezius, and aponeurosis attachments can be used to augment any soft tissue reconstruction.
Chronic injury
The use of wires and wire pins has been omitted due to the risks of breakage and migration. Surgery around the coracoid must be performed with care due to its proximity to important neurovascular structures.
SCAPULAR AND GLENOID FRACTURES OVERVIEW
Associated injuries are seen in 35-95 percent of scapular fractures and include injuries to the thorax, shoulder girdle, brachial plexus, head, and neck. Plain radiography, including AP, axillary or scapular lateral, Stryker notch, or Goldberg image, can identify scapular fractures.
Anatomical classification
It is important to understand morphological variations, such as an os acromiale, which is often misdiagnosed as an acromion fracture.
Glenoid fracture classification
Acromial fracture classification
Coracoid fracture classification
Stress fractures are very rare but may occur after repetitive trauma (e.g., a shotgun butt fracture) or secondary to fatigue from migration of the medial humeral head associated with cuff arthropathy.
Scapular body fractures
Glenoid fractures
Acromion fractures
Coracoid fractures
Scapulothoracic dissociation/
A superior approach or superior extension of the deltopectoral incision can be used for acromial fractures. A vertical incision is placed from the posterior aspect of the acromion to the posterior axillary fold.
PROXIMAL HUMERUS FRACTURES
The infraspinatus/teres minor interval is divided and part of the infraspinatus is taken down before exposing the posterior glenoid neck and capsule. This provides excellent direct access to the glenoid neck and the back of the glenoid fossa; however, this is not an extensive approach.
SURGICAL ANATOMY Proximal humerus
The direct posterior muscle splitting approach can be used for posterior border glenoid fractures, scapular neck fractures, and the majority of glenoid fossa fractures (types I, II–V) (Fig. 8.6). Definitive treatment of intra-articular glenoid and scapular neck fractures, particularly in the context of scapulothoracic dissociation and double dislocation of the SSSC, remains controversial.
Rotator cuff and pectoralis major
Vascular anatomy
Neural anatomy
COMPLICATIONS Malunion
Osteonecrosis
Other complications
GLENOHUMERAL JOINT DISLOCATION
Static stabilizers
Dynamic stabilizers
ASSESSMENT Clinical evaluation
Imaging
Traumatic anterior instability (about 90 percent) is caused by loading with the shoulder abducted, externally rotated, and extended. Traumatic posterior instability (2-5 percent) is caused by axial, posteriorly directed loading with the shoulder flexed, adducted, and internally rotated.
ASSOCIATED INJURIES
In anterior dislocations, the posterolateral head may be crushed against the anterior glenoid rim (Hill-Sachs lesion). In posterior dislocations, the anteromedial head may involve the posterior glenoid rim (reverse Hill-Sachs lesion; Fig. 8.9).
Emergency management
Definitive management – non-operative
Definitive management – operative
Surgical techniques
Open procedures for posterior stabilization can be performed with an incision from a point just medial from the posterolateral corner of the acromion to the axillary fold. The deltoid is split from the posterior side of the acromion to the upper border of the teres minor.
POSTOPERATIVE MANAGEMENT Anterior stabilization
Posterior stabilization
KEY PAPER SYNOPSIS
Key Paper
The trial challenges the traditional philosophy of non-operative treatment and provides evidence to support recent literature showing higher rates of non-union and malunion with non-operative treatment. The grooved defect of the humeral head: an often unrecognized complication of shoulder joint dislocations.
ADDIE MAJED AND MARK FALWORTH
ANATOMY
It descends posterior to the brachial artery until two-thirds of the way down through the humerus, it pierces the medial intermuscular septum to enter the posterior space within the triceps before running behind the medial epicondyle. The blood supply to the humeral shaft is from the nutrient vessels and from a periosteal supply related to muscle insertion.
FRACTURE BIOMECHANICS
FRACTURE TYPES AND CLASSIFICATION
HOLSTEIN-LEWIS FRACTURE
CLINICAL PRESENTATION
TREATMENT DECISION-MAKING
OPEN REDUCTION AND INTERNAL FIXATION WITH PLATING
INTRAMEDULLARY NAILING
CONSERVATIVE TREATMENT
OPEN REDUCTION AND INTERNAL FIXATION
ANTEROLATERAL APPROACH
Theatre set-up
Positioning
Procedure
LATERAL APPROACH
POSTERIOR APPROACH
Intramedullary nailing allows for less invasive surgery while achieving stable fixation of humeral shaft fractures. Preoperative preparation should therefore include assessment of humeral shaft canal length and diameter to predict nail size and avoid nerve injury.
Antegrade nailing Theatre set-up
The screw should be inserted in an anteroposterior direction to avoid damage to the radial nerve. Final image intensifier images are acquired and stored to verify fracture reduction and metal position positioning.
Retrograde nailing Theatre set-up
Distal closure is performed freehand and requires image intensification imaging using standard and recognized techniques ('perfect circles'). Rotation and reduction are checked with the image intensifier before posteroanterior distal closure with the intramedullary system jig is performed.
COMPLICATIONS OF SURGERY General complications
The distal end of the nail should be subcortically recessed to prevent irritation, damage, or impingement of the extensor mechanism.
Complications specific to intramedullary nailing
RADIAL NERVE PALSY
In the presence of an open fracture and nerve palsy, the radial nerve should be considered torn until proven otherwise. Radial nerve palsy after intramedullary nail: The management of this situation depends on the level of the fracture and placement of the locking screws.
NIEL KANG, DEBORAH HIGGS AND SIMON LAMBERT
The radial head is elliptical and articulates with the main head and the lesser sigmoid disc; therefore, articular cartilage covers the entire joint socket and most of the joint margin. Proximal radioulnar – a pivot joint between the radial head and the radial notch of the ulna, stabilized by the tough fibrous annular ligament.
OSSEOUS CONSTRAINTS
With the forearm in neutral rotation, the lateral aspect of the radial head is free of hyaline cartilage and is considered a safe area for instrumentation. The median cubital vein and the medial and lateral cutaneous nerves of the forearm all traverse the roof.
SOFT TISSUE CONSTRAINTS
Ulnohumeral - a hinged joint with an axis of rotation passing through the distal articular part of the humerus. The axis of the trochlea is in slight valgus and creates the bearing angle of the elbow.
SURGICAL APPROACHES POSTERIOR (‘UNIVERSAL’ OR
Radiocapitellar – a ball and socket between the cephalic head and the radial head that allows 75° pronation and 85° supination. The antecubital fossa is a triangular depression, bounded proximally by an imaginary line between the medial and lateral epicondyles, laterally by the brachioradialis and medially by the pronator teres.
UTILITY’) APPROACH
A supine position of the patient with the arm on a hand table can be used for anterior approaches to the distal humerus. In this position, the ulnar nerve is always on the side of the elbow that faces the patient's feet, and the radial head is toward the head.
SURGICAL APPROACHES MAINTAINING EXTENSOR CONTINUITY
At least 15 cm of the back of the hand should remain exposed for easy access. Unlike the knee, where the extensor mechanism can be mobilized to visualize the articular surfaces, the olecranon and triceps tendon are fixed, limiting visualization of the elbow joint.
PARATRICIPITAL APPROACHES
This approach uses the internal plane between the triceps and brachialis (radial and musculocutaneous nerves, respectively). This approach allows visualization of the medial column and medial aspect of the trochlea.
APPROACHES WITH DETACHMENT OF THE EXTENSOR MECHANISM
Early active motion can be initiated after triceps-to-bone repair using non-absorbable sutures. Lateral paratricipital approach with mobilization of the entire medial triceps muscle and elevation of the radial nerve.
DISSECTION FOR THE LATERAL COLUMN AND ANTERIOR
The procedure involves elevation of the insertion of the anconeus and the proximal aspects of the origin of the ECU and FCU. Unless exposure of the medial column is necessary, the ulnar nerve should be formally excised and protected before the osteotomy is performed.
COMPARTMENT: THE KOCHER AND KAPLAN-TYPE APPROACHES
The olecranon with the triceps attached is reflected proximally, separating the medial triceps from the medial intermuscular septum and the lateral triceps from the anconeus and the lateral intermuscular septum. When exposure requires triceps mobilization >10 cm proximal to the lateral epicondyle, the radial nerve should be identified and protected.
DISSECTION FOR THE MEDIAL COLUMN Superficial dissection
Deeper dissection
CAPITELLAR FRACTURES CLASSIFICATION
CORONOID FRACTURES
CLASSIFICATION Regan and Morrey
O’Driscoll
ELBOW DISLOCATIONS
CLASSIFICATION OF ELBOW INSTABILITY
TREATMENT APPROACH
ACUTE DISLOCATION Non-operative treatment
Active supination is performed to initiate dynamic congruence of the elbow due to the action of the biceps. Radial head ORIF – the surgeon must be aware of the 'safe zone' for fixation.
THE ‘TERRIBLE TRIAD’
This refers to the 90° arc in the radial head that does not articulate with the proximal ulna. Surgical treatment is practically mandatory and consists of ORIF of the radial head and coronoid, combined with LCL with or without MCL reconstruction.
Complications
When the radial fracture is significantly reduced, radial head replacement is indicated; However, ORIF is the treatment of choice if there are less than three fragments with good bone stock.
DISTAL HUMERAL FRACTURES
SINGLE COLUMN (CONDYLAR) FRACTURE
Principles of treatment
BICOLUMN FRACTURES
90–90 fixation
Arthroplasty longevity is poor in younger patients due to the high incidence of loosening, long-term risk of infection, and periprosthetic fractures.
SURGICAL PRINCIPLES
Parallel plating
TOTAL ELBOW ARTHROPLASTY
OLECRANON FRACTURES
CLASSIFICATION Colton
After fracture exposure, a longitudinal screw is advanced across the fracture from a proximal entry point through an appropriately contoured plate; this is then fixed to the posterior ulna with bicortical screws. Contraindications include the presence of a large fragment involving >50 percent of the joint and fracture dislocations where stability is likely to be a problem.
RADIAL HEAD FRACTURES
There is an increasing movement toward ORIF of the radial head when technically feasible (especially in a relatively high-demand athlete or worker). In older, undemanding patients, simple resection of the radial head may be an option, provided there is no concomitant injury to the forearm.
HINGED EXTERNAL FIXATORS
As previously mentioned, any plate should be placed on the aspect of the radius that lies most laterally when the forearm is in neutral rotation, to avoid impingement during pronation or supination. Straight excision is indicated if the fragment comprises less than one third of the head and ORIF is not technically possible.
TIPS
DISTAL BICEPS TENDON RUPTURE
Avulsion of the distal biceps brachii tendon in middle-aged population: is surgical repair advisable. The posterolateral approach to the elbow uses the internal nerve plane between which of the following muscles.
JOHN STAMMERS AND MATTHEW BARRY
KEY ANATOMY
INTEROSSEOUS MEMBRANE
DISTAL RADIOULNAR JOINT
INJURY CLASSIFICATION
DIAPHYSEAL INJURY
SURGICAL SET-UP
SURGICAL APPROACHES TO FOREARM
RADIUS
Volar approach
Dorsal approach
ULNA
MANAGEMENT PRINCIPLES CONSERVATIVE TREATMENT
OPERATIVE TREATMENT
Plate fixation
Antegrade ulnar nailing is routinely performed first using an entry point in the proximal ulna, distal to the physis. Early forearm nailing systems had a high rate of nonunion and poor performance because the nails were unable to retain and maintain the anatomical reduction required of the forearm, particularly rotational control.
External fixation
Closed reduction is attempted; where necessary, a minimal incisional exposure of the fracture can be made and percutaneous pointed reduction clamps can be used to hold the reduction. The radial nail must be inserted via an entry point immediately radial to Lister's tubercle below the extensor carpi radialis brevis tendon.
MANAGEMENT OF SPECIFIC INJURIES MONTEGGIA FRACTURES
Other investigators, however, advocate extending and debriding the wound to expose the fracture and remove contaminated bone and muscle. Complex combined elbow injuries may be associated with Monteggia-type fractures and should be considered at the time of diagnosis (see Chapter 10).
GALEAZZI FRACTURES
ESSEX-LOPRESTI LESION
External fixation and bone transport External fixation and bone transport (see Chapter 4) allow fractures with extensive bone loss to be shortened acutely, the deformities corrected, and then the bone lengthened. Antibiotic-containing bone cement can be used temporarily as spacers within the defect to maintain length and support soft tissue in the presence of bone defects that cannot be addressed primarily, either in combination with fracture stabilization of the bridge plate or fixation external.
COMPLICATIONS OF FOREARM INJURIES
LATE COMPLICATIONS
Arises from the median nerve below the supinator to supply the flexor carpi radialis, palmaris longus, and the medial half of the flexor digitorum superficialis. Arises from the median nerve below the pronator teres to supply the flexor pollicis longus, pronator quadratus, and the medial half of the flexor digitorum profundus.
DENNIS KOSUGE AND PRAMOD ACHAN
SURGICAL ANATOMY DISTAL RADIUS
This rotation of the forearm depends on the normal functioning of the proximal radioulnar joint (PRUJ) and DRUJ. The dorsal and volar peripheral radioulnar ligaments have superficial and deep components, with ulnar origins arising from the base of the styloid and the fovea, respectively.
ASSESSMENT AND EVALUATION ASSESSMENT
The external stabilizers include the extensor carpi ulnaris along with its lower sheath, the deep head of the pronator quadratus, and the interosseous membrane. Carpal alignment is another important radiographic parameter; this refers to the alignment of the head relative to the radius on a lateral radiograph.
EVALUATION
Considering the radial slope, the forearm should be inclined approximately 23° to the horizontal plane to obtain a true lateral. This teardrop represents the U-shaped volar edge of the insane facet of the distal radius on the lateral radiograph (Fig. 12.2).
Extra-articular evaluation
For a PA radiograph, the shoulder is abducted 90°, the elbow is flexed 90°, and the forearm is placed in neutral rotation. For a true lateral radiograph, the shoulder is adducted 0°, the elbow is flexed 90° with the hand positioned in the same plane as the humerus.
Intra-articular evaluation
Stability
MANAGEMENT PRINCIPLES OF DISTAL RADIUS FRACTURES
Operative management options include the use of Kirschner wires (K-wires) with plaster, open reduction and internal fixation by volar or dorsal plating, bridging or unbridged external fixation, and internal fixation with a hand bridge.
CONSENT
COMPLEX REGIONAL PAIN SYNDROME
Early phase
Late phase
Management
SET-UP AND POSITIONING
SPECIFIC SURGICAL TECHNIQUES
APPLICATION OF PLASTER CAST
Technique
Postoperative management
KIRSCHNER WIRING
Equipment and instruments
At the end of the procedure, the wires can be buried under the skin or left visible. Injury to the dorsal branches of the superficial radial nerve - minimized by ensuring adequate length of incision and blunt dissection to bone.
VOLAR PLATING
The two principles of percutaneous wiring are crossed pinning across the fracture and intrafocal pinning within the fracture. The commonly used wire configuration for crossed pins includes a radial styloid wire inserted in a radial-to-ulnar direction and another wire inserted from the ulnar corner of the dorsal distal radius in a dorsal-to-volar direction become
ARTHROSCOPICALLY ASSISTED REDUCTION
EXTERNAL FIXATION
Relevant surgical anatomy
ASSOCIATED DISTAL
RADIOULNAR JOINT INJURY
ULNAR STYLOID FRACTURES
Extensor tendon complications
Flexor tendon complications
SCREWS/PEGS
Discuss Charnley's principle of three-point fixation in the context of a distal radius fracture managed in a cast. How would you assess the vascularity of a limb before performing surgical fixation of a distal radius fracture.
NICK ARESTI AND LIVIO DI MASCIO
OVERVIEW OF ANATOMY
PROXIMAL ROW
DISTAL ROW
LIGAMENTS
RADIOLOGICAL ASSESSMENT
WRIST KINEMATICS
However, during radial deviation, the proximal row supinates and flexes, while the distal row pronates. Conversely, the proximal row pronates and extends upon ulnar deviation, while the distal row supinates.
CARPAL INSTABILITY
As previously mentioned, a much greater degree of movement is possible between the proximal carpals than in the distal row. This bending force is transmitted via the SLIL, causing the lunate to do the same.
DIRECTION OF INSTABILITY
During flexion and extension, the radiocarpal and midcarpal joint movements are simultaneous (i.e., the two carpal rows move in the same direction at approximately equal angles). In contrast, the triquetrum extends under compression and exerts a stretching force on the lunate via the LTIL.
Dorsal intercalated segment instability
Volar intercalated segment instability
Ulnar translocation
Dorsal translocation
DISSOCIATIVE/NON-DISSOCIATIVE CLASSIFICATION
Dissociative carpal instability
Non-dissociative carpal instability
Complex carpal instability
Adaptive carpal instability
LICHTMAN’S CLASSIFICATION
PERILUNATE INJURY
PERILUNATE DISLOCATIONS/
FRACTURE-DISLOCATIONS
Scaphoid fracture and/
Capitolunate dislocation and/or transcapitate fracture
Lunotriquetral dislocation/
Scapholunate dislocation
Principles of management
Reduction
