Handbook of Orthopaedic Traumatology

8/18/2019 Handbook of Orthopaedic Traumatology

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HANDBOOK OF

ORTHOPAEDIC

TRAUMATOLOGY

DEPARTMENT OF ORTHOPAEDICS AND

TRAUMATOLOGY

QUEEN MARY HOSPITAL


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Content

Trauma

Fracture

Principles of management of fractures----------------- 1

Comprehensive classification of long bone fractures 2

Principles of management of multiple trauma

patients

6

Acromioclavicular joint dislocation-------------------- 9

Fracture of clavicle--------------------------------------- 19

Fracture of scapula--------------------------------------- 31

Fracture of proximal humerus-------------------------- 41

Fracture of humeral shaft-------------------------------- 47

Supracondylar fracture of humerus--------------------- 49

Fracture of distal humerus------------------------------- 57

Fracture of capitellum------------------------------------ 63

Fracture of radial head----------------------------------- 67

Olecranon fracture--------------------------------------- 71

Fracture of shaft of radius and

ulna---------------------

77

Galeazzi fracture------------------------------------------ 78Monteggia fracture--------------------------------------- 79

Fracture of pelvis----------------------------------------- 81

Fracture of acetabulum---------------------------------- 101

Fracture of proximal femur------------------------------ 113

Fracture of femoral neck--------------------------------- 116

Intertrochanteric fracture of femur--------------------- 121

Subtrochanteric fracture of femur---------------------- 125

Fracture of femoral shaft--------------------------------- 129

Supracondylar fracture of femur------------------------ 131

Fracture of patella---------------------------------------- 137

Fracture of tibial plateau--------------------------------- 145

Fracture of proximal and distal

tibia--------------------

161

Fracture of tibial shaft------------------------------------ 165

Pilon fracture---------------------------------------------- 169

Malleolar fracture---------------------------------------- 173

Fracture calcaneum--------------------------------------- 181

Dislocation

Principle of management of dislocation--------------- 191

Shoulder dislocation------------------------------------- 193

Hip dislocation-------------------------------------------- 201

i ii


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Hand

Guidelines for hand

cases--------------------------------

219

Compound hand fractures------------------------------- 223

Phalangeal fractures-------------------------------------- 225

Fracture of distal radius---------------------------------- 227

Acute tendon injuries------------------------------------- 239

Others

Compartment syndrome--------------------------------- 250

Necrotizing fasciitis-------------------------------------- 253

Procedure

Principles of closed reduction--------------------------- 255

Principles of plaster technique-------------------------- 256

Intravenous regional block------------------------------ 259

Tourniquet usage----------------------------------------- 261

Halo traction---------------------------------------------- 263

Some useful classification

Gustilo and Anderson classification for open

fracture

267

Tscherne and Gotzen classification for soft tissueinjury------------------------------------------------------- 269

Injury Severity Score------------------------------------- 271

Hospital Trauma Index (Extremity Injury)------------ 272

Mangled extremity severity score (MESS) ----------- 273

Surgical site infection (SSI) ---------------------------- 275

Drugs

Recommended pre-operative antibiotic prophylaxis- 277

Use of methypredinisolone in traumatic acute spinal

cord compression----------------------------------------- 281

Drugs for CR under sedation---------------------------- 281

Telephone directory------------------------------------ 282

iii iv


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PRINCIPLES OF MANAGEMENT OF

FRACTURES

• Closed vs open #

•

Assessment• site of # (e.g. humerus, radius;

intra-articular vs extra-articular)

• Type of fracture (e.g. spiral vs transverse;simple vs comminuted)

• Associated neurovascular injury

• Other concommitant injury• Treatment

1. Reduction if necessary

2. Immobilization if necessary

3.

Rehabilitation always

Principle of fracture management 1


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COMPREHENSIVE CLASSIFICATION OF

LONG BONE FRACTURE (Muller, 1990)

Metaphyseal / Diaphyseal segment

Diaphyseal Fracture Type

A: Simple

B: Wedge (2 main fragments still in direct

contact)

C: Comminuted (no direct contact between 2main fragments)

Comprehensive classification of fracture 2 3 Comprehensive classification of fracture


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Metaphyseal Fracture

A: Extra-articular

B: Partial articular (part of the articular

surface is still in continuity with the

metaphysis)

C: Complete articular (no continuity

between metaphysis and articular surface)

Comprehensive classification of fracture 4 5 Comprehensive classification of fracture


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PRINCIPLES OF MANAGEMENT OF

PATIENTS WITH SEVERE AND MULTIPLE

TRAUMA

Triage• sort patients with acute life threatening injuries

and complications from those whose life are not

in danger

1. level of consciousness2. Abnormal breathing / breathing difficulties

3. Signs of shock

Priorities

1.

Support life (eg. CPR, fluid resuscitation)

2. Locate and control bleeding

3.

Prevent brainstem compression and spinal corddamage

4. Diagnose, evaluate and treat all other injuries

and complications

Basic Management Principles

1. Emergency assessment

A--Airway obstruction (eg. noisy breathing,

respiratory distress)

B--Breathing difficulty (eg. tachypnoea, mental

confusion, cyanosis, abnormal pattern of breathing)

C--Circulatory shock (eg. cold periphery, delayed

capillary refill, low BP, rapid weak pulse)

2. Fluid resuscitation

• If necessary, 2 or 3 large 14- or 16-gaugeintravenous cannula inserted

3. Oxygen therapy

• High flow oxygen by mask ventilatory support

4. Cross-match blood

5. Analgesia

6.

Urine output monitoring•

Foley unless suspected rupture urethra(eg. blood

at urinary meatus, severe fractured pelvis)

7. Evaluation of other injuries

Evaluation of injuries

1. Head Injury

• Glascow Coma scale and Neuro-observation q1h• Inspect for presence of CSF and/or blood in ears

and nose

•

SXR (3 views) +/- CT Brain2. Facial Injury

• Exclude bleeding into airway and severeoro-pharyngeal edema (eg. from caustic burn),

which may lead to airway obstruction

•

SMV and OMV view

3. Suspected spinal injury

• Immobilize until exclusion• signs of spinal cord injury (eg. paralysis,

diaphragmatic breathing, loss of vasomotor tone,lax anal tone)

•

Cervical spine fracture or dislocation need to be

excluded in all patients with head injury (Xray

cervical spine AP and lateral; lateral Xray must

include C7 / T1 junction)

6 Principle of management of multiple trauma Principle of management of multiple trauma 7


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4. Chest

• Look for haemothorax, pneumothorax, lungcontusion, flail chest

•

Clinical signs + CXR5. Abdomen

•

Rupture viscera (eg. spleen, liver, mensenteries)

haemoperitoneum and peritoneal sign for rupture

bowel

• Retroperitoneal haemorrhage (eg,. in # pelvis)• Renal injury with retroperitoneal haemorrhage,

leading to haematuria and loin pain

•

Clinical signs + AXR (E & S)

6. Pelvis #

•

Stability of Pelvis

• Look for suspected ruptured bladder and urethral bleeding

• Clinical signs + XR pelvis (AP + inlet view +outlet view)

7. Extremities

• eg. long bone fracture, associated nerve orarterial damage

8 Principle of management of multiple trauma


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ACROMIOCLAVICULAR JONT DISLOCATION

(C. Rockwook, Fractures in Adults, 4th ed., 1342-1413, 1996)

Anatomy

• Stabilizer1.

Acromioclavicular ligament

2.

Coracoclavicular ligament–conoid part and trapezoid part

3. Dynamic stabilizer—deltoid (anterior part) and trapezius(upper portion)

•

Coracoclavicular interspace—1.1 to 1.3cm (Bearden,

1973)

• Acromioclavicular ligament—horizontal(anteroposterior) stability of ACJ

• Coracoclavicular ligament—vertical stability of ACJ

Mechanism of Injury

1.

Direct force —patient falling onto the point of shoulder

with the arm at the side in an adducted position

2.

Indirect force —fall on outstretched hand

Classification (Rockwood)

Type I

• Sprain of AC ligament•

ACJ intact

•

CC ligament intact

• Deltoid and trapezoid muscle intact

Acromioclavicular joint dislocation 9 Acromioclavicular joint dislocation 10


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Type II

• ACJ disrupted

•

ACJ wider: may be a slight vertical separation whencompared with the normal shoulder

•

Sprain of CC ligament

• CC interspace might be slightly increased• Deltoid and trapezius muscles intact

Type III

•

AC ligaments disrupted

• ACJ dislocated and the shoulder complex displacedinfreriorly

• CC ligaments disrupted• CC interspace 25% to 100% greater than the normal

shoulder

• Deltoid nad trapezius muscles usually detached from thedistal end of the clavicle

Type II Variants

1.

“Pseudodislocation” through intact periosteal sleeve

2.

Physeal injury

3.

Coracoid process fracture



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Type IV

• AC ligaments disrupted

•

ACJ dislocated and clavicle anatomically displaced posteriorly into or through the trapezius muscle

• CC ligaments completely disrupted

•

CC space may be displaced, but may appear same as the

normal shoulder

•

Deltoid an trapezius muscles detached from the distal

clavicle

Type V

•


• CC ligaments disrupted

•

ACJ dislocated and grossly disparity between the clavicleand the scapula (i.e. 100% to 300% greater than

the normal shoulder)

•

Deltoid and trapezius muscles detached from the distal

half of the clavicle



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Type VI

•


• CC ligaments disrupted in subcoracoid type and intact in

subacromial type •

ACJ dislocated and clavicle displaced inferior to the

acromion or coracoid process

•

CC interspace reversed in the subcoracoid type (i.e.

clavicle inferior to the coracoid), or decreased in the

subacromial type (i.e. clavicle inferior to the acromion)

•

Deltoid and trapezius muscles detached from the distal

clavicle

Radiographical Assessment

1.

Xray both ACJ (AP)

2.

Zanca view—100 to 150 cephalic tilt



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3.

Axillary lateral view

4.

AP stress film

•

To 15 pounds are suspended from each arm with wrist

wrap

5. Lateral stress film (Alexander view)

•

Patient is positioned as if a true

scapulolateral radiograph is taken

•

Patient is asked to thrust both

shoulder forward

6.

Stryker notch view

• demonstrate fracture base of coracoid

Treatment

1.

Non-operative treatment

• Rockwood 1 and 2 (minimally displaced)

•

Arm sling x2./52; then, early and gradual

rehabilitation

• Heavy lifting or contact sports avoided for 8 to 12

weeks

2.

Operative treatment•

Rockwood 3 to 6

• ACJ debridement

•

6MM transacromial K-wires

• repair of CC ligament + Tevedek

reinforcement

o Rehabilitation—pendulum exercise x 6/52; then, r/o

K-wires at 6/52



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FRACTURE CLAVICLE

Anatomy ALLAM CLASSIFICATION

GROUP 1

• middle third clavicular fracture• 80/5 of all clavicular fracture

• Proximal fragment: pulled superiorly and

posteriorly by sternocleidomastoid

• Distal fragment: drops forward as a result of gravity

and pull of pectoralis

Fracture clavicle 19 20 Fracture clavicle


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GROUUP II

• distal third clavicular fracture

• 12% to 15 % of clavicular fracture• sub classified according to the location of

coracoclavicular ligaments relative to the fracture

fragments

Neers Classification (Type I to Type III)

Type I

• most common

• Interligamentous fracture

• occurring between the conoid and trapezoid / the

coracoclavicular and acromioclavicular ligament

• minimal displacement

Type II

Coracoclavicular ligaments are detached from the

medial/proximal segment

Proximal fragment: no ligamentous attachmentDistal fragment: retained ligamentous attachment

Type IIA

• Both conoid and trapezoid remain intact on the

distal fragment

• Proximal fragment: no ligamentous attachment

Type IIB

• Conoid ligament ruptured while trapezoid ligament

remains attached to the distal fragment (i.e. Distalfragment: partial ligamentous attachment)

• Proximal fragment: no ligamentous attachment

• Thus, displacement is similar to Allam Group I

fracture

Fracture clavicle 21 22 Fracture clavicle


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• i.e. proximal fragment: pulled superiorly and

posteriorly

• distal fragment: droops forward

Type III

• Involve the articular surface of ACJ

• No ligamentous injury

• No displacement

•

Present with late degenerative arthrosis of ACJ

Type IV (Craig)

• Occur in children


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Type V (Craig)

• Comminution

• Neither the proximal nor distal fragments has

functional coracoclavicular ligament

• Coracoclavicular ligament are intact and remain

attached to a small, third comminuted intermediate

segment

• Displacement same as Group 1 # and Type II #

distal clavicle

•

More unstable than type II # distal clavicle

GROUP III

• # medial third of clavicle• 5 % to 6% of clavicular fracture

• Craig: subdivided according to the integrity of

ligamentous structures

• Type I: minimal displacement

• Type II: significant displacement (ligaments

ruptured)

• Type III: intra-articular (sterno-clavicular joint)

• Type IV: epiphyseal separation (children and

young adult)

• Type V: comminuted

Mechanism of Injury

1. Direct blow to shoulder

2. Fall on outstretched hand

Associated Injury

1. Associated skeletal injuries

• Fracture dislocations of sternoclavicular or

acromioclavicular joints• Head and neck injuries

• Fractures of first rib (ipsilateral and contralateral)

• Floating shoulder (fracture of the clavicle and

scapula)

• Rockwood

• Treatment directed primarily at stabilization of

clavicle

• For # scapula, conservative treatment unless

grossly displaced intra-articular or fracture of

glenoid fossae2. Pneumothorax

3. Brachial plexus injury

• Considerable trauma

• Force usually come from above downward or from

the front downward

• Traction injury

• Direct injury ( with lesion directly by bone

fragments)(in direct injury, ulnar nerve is usually

involved)

4.

Vascular injury• Unusual

• Major trauma required

• Potential vascular injury: laceration, occlusion,

spasm, acute compression

Most common vessels injured: subclavian artery

subclavian vein, internal jugular vein

5Fracture clavicle 25 26 Fracture clavicle


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On admission, House Officer must examine

1. significant skin impingement

2.

neurological deficit3. vascular status (e.g. radial pulse, capillary refill)

4.

whether breath sound is symmetrical bilaterally

X-ray

1. X-ray clavicle (AP)

2. X-ray clavicle: 450 cephalic view

Treatment

• Conservative vs operative• Non-union: failure to show clinical or radiographic

progression of healing at 4 –6 months

• Conservative treatment: non-union: 0.1%

• Operative treatment: non-union: 4.4%

Predisposing factors to non-union

1. Inadequate immobilization

2. Severity of trauma (with associated soft tissue

damage)

3.

Re-fracture4. Distal third fracture

5. Marked displacement

6. Primary open reduction

Principles of non-operative treatment

1. Brace the shoulder girdle to raise the outer fragment

upward, outward and backward

2.

Depress the inner fragment3. Maintain reduction

4.

Enable ipsilateral elbow and hands to be used

Treatment

Conservative Treatment

1. Figure of eight bandage

2. Arm sling (if patient cannot tolerated figure of eight

bandage)

• Immobilization should be continued until union is

complete

• Usual healing period of # of middle third of clavicle

(Rowe)Infants: 2 weeks

Children: 3 weeks

Young adults: 4 to 6 weeks

Old adults: >6 weeks



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Operative Treatment (if)

1.

skin impingement2. open #

3.

neurovascular compromise

4. bilateral fracture clavicle

5. floating shoulder

6. multiple fracture

7. non-union

8.

cosmesis

Treatment – ORIF (PC Fix/3.5mm reconstruction

plate)



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FRACTURE OF SCAPULA

(K.P. Butters, Fractures in Adults, 4th

ed., 1996)

Anatomy

Anterior surface of scapula

Posterior surface of scapula

Fracture scapula 31 32 Fracture scapula


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Fractures

1. Body and spine

2. Glenoid neck

3.

Intra-articular glenoid4. Coracoid

5.

Acromion

Mechanism of Injury

1. Indirect injury

• through axial loading on outstretched arm(fracture scapula neck)

2. Direct injury

• From a blow or fall (# body) (often high energy

trauma)• Direct trauma to the point of shoulder (#

acromion and coracoid)

3. Shoulder dislocation

• # glenoid4.

Traction injury

• avulsion #

Associated Injury ( occur in 35% to 98% of

patients with scapular #)

1.

Pneumothorax (11% - 38%) (Delayed in onsetfrom 1 to 3 days)

2. Ipsilateral fractured ribs (27% to 54%)

3.

Pulmonary contusion (11% to 54%)

4. # clavicle (23% to 39%) (associated with #

glenoid or glenoid neck)



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5. Brachial plexus injury (5% to 13%) (usually

supraclavicular type)

6. Arterial injury (11%)

7.

Skull # (24%)8. Closed head injuries (20%)

9. Fracture of thoracic spine, cervical spine, lumbar

spine

Xray Assessment

1. True AP view of shoulder

2.

Transcapular view

3. Axillary lateral view how acromial and glenoid

rim #

4.

Stryker notch view or cephalic tilt view--showcoracoid fracture

Scapular body and spine #

• examine for associated injury• conservative treatmenty with arm sling for

comfort and early mobilization exercise

Glenoid Neck # (extra-articular)

1. Stable #

• isolated glenoid neck #

•

conservative treatment

2. Unstable #

• # glenoid neck associated with # clavicle ordisruption of coracoclavicular ligament

• ORIF of # clavicle



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Intra-articular Glenoid Fracture

Ideberg Classification

(Ideberg, Acta Orthop. Scand., 58:191-192, 1987)

Type I #

• fracture of glenoid rim• > 25 % of intra-articular involvement

•

If displaced, predispose to instability ofgleno-humeral joint

1. Type IA

• anterior type• ORIF2. Type IB

• posterior type• uncommon

Type II #

•

transverse or oblique fracture through theglenoid with inferior glenoid as a free fragment

•

humeral head may subluxate inferiorly

• If humeral subluxate ORIF

Type III #

• upper third of glenoid and includes coracoid process

• often accompanied by # acromion or clavicle oracromioclavicular separation

•

(Gross, 1995) If intra-articular step > 5mm,

ORIF



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Type IV #

• horizontal glenoid # extending all the waythrough the body to the vertebral border

•

if displaced, ORIF

Type V #

•

type II + type IV

•

If humeral head is well centred


Type VI #

• badly comminuted #• conservative treatment with early motion

Acromion #

• usually minimal displacement• DDx--os acromiale1. If undisplaced

• conservative treatment2.

If displaced with subacromial space andupward movement of humeral head

• investigate rotator cuff lesion

Coracoid #

• may occur with acromioclavicular dislocationwith coracoclavicular ligaments intact

• clinical evidence of third degreeacromioclavicular separation with a high-riding

clavicle

BUT

radiologically (AP shoulder) a normal and

symmetric coracoclavicular distance

suspect # coracoid (base or through an epiphyseal

line)• Stryker notch view• if # coracoid process + ACJ separation ORIF



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FRACTURE OF PROXIMAL HUMERUS

(J. Schatzker, The Rationale of Operative Fracture

Care, 2nd ed., 1995, 51-82)

Anatomy Four major fragments

1.

Humeral head superior to anatomical neck

2. Lesser tuberosity

3. Greater tuberosity

4. Shaft of humerus

Stable vs Unstable Fracture

Stable Fracture

• Impacted fracture• Shaft and head

moves as one piece

• resulted fromcompression force

Unstable Fracture

• movement betweenthe shaft and head

fragments• resulted from tension

or shear force

Fracture proximal humerus 41 42 Fracture proximal humerus


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CLASSIFICATION OF FRACTURE TYPE

1. Stable Fracture

2. Unstable Fracture

A. Minimally displaced (i. No segment displaced > 10 mm)

(ii.No segment angulated > 45)B Displaced

(C.S. Neer, JBJS , 52A: 1077-1089)

1. Two-part

a. Lesser tuberosity

b. Greater tuberosity

c. Surgical neck

d. Anatomical neck

2. Three-part--Surgical Necka. Plus Lesser tuberosity

b. Plus Greater tuberosity

3. Four-part--Anatomical Neck

Plus tuberosities

4. Fracture-dislocation

a. Two-part--with greater tuberosity

b. Three-part--Anterior, with greater

tuberosity

Posterior, with lesser

tuberosityc. Four-part—Anterior & Posterior

3. Articular

a. Head impaction—(Hill Sachs)

b. Articular fractures

1. Humeral head split

2. Glenoid rim



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TREATMENT

1. Stable Fracture

•

Early motion

2.

Unstable, Minimally displaced Fracture •

Collar and cuff x 3 weeks

•

then mobilization

3. 2-Part # (Displaced Unstable Fracture

Surgical Neck, Displaced Greater Tuberoisty)

& 3-Part #

•

CR + Percutaneous K-wire

•

If fail, OR + suture / wire

4. Fracture Anatomical Neck / Head Split /

4-Part #

•

Neer’s Hemiarthroplasty



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FRACTURE OF THE HUMERAL SHAFT

• most fractures can be treated successfully byclosed method

Acceptable alignment

1.

< 20 angulation2. > 50% bony overlap

To assess

• Neurological function (esp. radial nerve)• Vascular condition

FRACTURES WITH ACCEPTABLE

ALIGNMENT• U-slab x 3 weeks; then, functional brace• Check Xray humerus (AP + lat) after application

of U-stab

FRACTURES WITH UNACCEPTABLE

ALIGNMENT

•

Attempt CR under sedation

•

U-slab x 3 weeks

• Check for function of radial nerve after CR

•

Post-reduction Xray humerus to confirm

alignment

FRACTURES REQUIRING OPERATIVE

INTERVENTION

1. Fracture with unacceptable alignment despite

repeated CR (either due to failure to obtain asatisfactory reduction or failure to maintain

reduction)

2. Open fracture

3. Comminuted / unstable fracture

4. Multiple fractures

5. Pathological fracture

6. Nerve palsy after manipulation

7. Humeral fracture with asssociated vascular

lesion

METHOD OF FIXATION

1. Proximal and Middle 1/3

• Retrograde AO unreamed humeral nail2. Distal 1/3

• ORIF (plating)3. Open #

• AO nail / External fixator

Fracture shaft of humerus 47 48 Fracture shaft of humerus


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SUPRACONDYLAR FRACTURE OF HUMERUS

(J. Schaztker, The Rationale of Operative Fracture

Treatment , 2nd ed., 1995, 103-111)

Anatomy

1.

Articular Surface

• Capitellum •

covered by articular cartilage on its anterior

and inferior surface (not posterior)

•

articulate with radial head•

Elbow in flexion: radial head articulate with

anterior surface of capitellum

• Elbow in extension: radial head articulateswith inferior surface of capitellum

• Trochlea•

covered completely with articular cartilage

•

articulates with the trochlear notch of ulna

• Elbow in Flexion

• trochlear notch of ulna articulate with the

anterior aspect of trochlea• coronoid process of ulna rests in coronoid

fossa of humerus

•

radial head rests in radial fossa of humerus

• Elbow in Extension

• ulna articulates with inferior and posterior

aspect of trochlea

• tip of olecranon lodges within the olecranon

fossa of humerus

•

Trochlea: corresponds the physiological

valgus tendency of elbow in full extension (ie.Carrying angle, 170)

Supracondylar fracture of humerus 49 50 Supracondylar fracture of humerus


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2. At the level of olecranon fossa, the two columns of

bone on either side of the fossa

bone for fixation of implants

3. Longitudinal axis of lateral condyle makes a 60 angle

with the longitudinal axis of the shaft reconstruction plate applied to the level of lateral

condyle must be bend to angle forward

• Otherwise, extension deformity of distal fragment will

result

CLASSIFICATION

Riseborough and Radin Classification

(E.J. Riseborough and EL Radin, JBJS , 51A:130-141)

Type I Non-displaced fracture

between capitellum and

trochlea

Type II

Separation of capitellum

and trochlea without

appreciable rotation of the

fragments in frontal plane

Type III

Separation of

the fragments

with rotational

deformity

Type IV

Severe

comminution

of the articular

surface with

wide separation

of the humeral

condyles



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Comprehensive Classification Mechanism of Injury

• fall on the point of elbow

P/E

1.

Closed vs Open2. Associated vascular injury (Feel for radial pulse)

3. Associated compartment syndrome

4. Associated neurological complications

5. Associated fracture of humerus or radius and ulna

6.

Concomitant injury

Aim of treatment

1.

Accurate anatomical reduction of joint surfaces

2.

Stable internal fixation

3.

Early active motion

Recommended Treatment

1.

Undisplaced

Conservative

2. Displaced and intra-articular

ORIF (+ olecranon osteotomy if intra-

articular)



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Immediate management

1. Exclude need for emergency operation (eg. open #,

associated vascular injury)

2. Long arm backslab for temporary immobilization

3.

Elevation

Factors which influence success of surgical treatment

1.

Patient’s age and degree of osteoporosis

2.

Type of #

3.

Degree of displacement

4. Degree of joint comminution

5. Whether trochlea can be reconstructed

6. If trochlea can be reconstructed

ORIF

7.

If trochlea is beyond surgical reconstruction

conservative treatment (traction with early

mobilization); or

total elbow replacement (in active elderly

patients)

Rehabilitation

1. CPM

2. Indomethacin x 1/12

3. Hinged elbow brace



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FRACTURE OF DISTAL END OF HUMERUS

Anatomy

FRACTURE OF EPICONDYLE


Treatment , 2nd ed., 1995, 95-97)

Fracture of Lateral Epicondyle

•

avulsion #

• Adult

• Rare

• associated with posterolateral or posteriordislocation of elbow(may be associated with #

medial epiconyle)

• Children

• lateral epicondyle is avulsed with varying

portion of capitellum

• may turn no itself by 180

•

risk of non-union and deformity• When elbow is reduced, epicondylar fragment reduces

and heals in place

• Prognosis: good

Fracture of Medial Epiconyle

• most common in children• may be seen in adult1. Direct injury

2.

AvulsionTreatment

1. Small and undisplaced

•


2. Displaced

•

ORIF to prevent ulnar nerve palsy

•

ORIF {4.0mm cancellous screw

{medial approach

{ulnar nerve protected +/- anterior

transposition

•

Prognosis: good

Fracture distal humerus 57 58 Fracture distal humerus


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FRACTURE OF CONDYLES

(R.N. Hotchkiss, Fracture in Adults, 4th

ed., 1996,

953-958)

• capitellotrochlear sulcus divides the capitellar andtrochlear articular surfaces

• lateral trochlear ridge: key to analyse humeralcondyle #

Milch Classification

(H. Milch, JAMA, 160: 529-539, 1956)

1. Type I #

• lateral trochlear ridge remains with the intact condyle elbow stable (medial to lateral)

2. Type II #

• lateral trochlear ridge is involved in the fractured

condyle elbow unstable (medial to lateral)

Fracture of Lateral Condyle

1.

Type I #

•

lateral trochlear ridge remains intact

preventing dislocation of radius and ulna

2. Type II #

• lateral trochlear ridge is a part of the fractured lateralcondyle

• If + medial capsuloligamentous disruption radius and ulna may dislocate

• always extends medially and involve part of thetrochlea

Treatment

• ORIF, then early mobilization

•

Lateral approach, 2 x 3.5mm cancellous screwsPrognosis

• good



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Fracture of Medial Condyle

1. Type I #

•

Lateral trochlear ridge intact

elbow stable2. Type II #

• lateral trochlear ridge is a part of fractured medialcondyle

• If + lateral capsuloligamentous disruption radius and ulna may dislocate medially on

humerus

Treatment

• ORIF, then early mobilization



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FRACTURE OF CAPITELLUM

(J. Schatzker, The Rationale of Operative Fracture Care,

2nd ed., 1995, 97-102)

Anatomy

•

smooth, rounded, knob-like portion of lateral condyleof humerus

• covered with articular surface only on anterior and

inferior surface (but not on posterior surface)

• Elbow in Flexion

Head of radius articulated with the anterior surface of

capitellum (radial fossa, a depression on anterior

humerus just above the capitellum, accomodates the

margin of radial head when the elbow is acutely

flexed. Thus, radial fossa must be cleared of all #

fragments for the elbow to regain a FROM)• Elbow in ExtensionRadial head articulates with the inferior surface of

capitellum

1.

Isolated injury

2.

Part of comminuted supracondylar fracture

Isolated Injury

Mechanism

1. As the head of radius is forcibly driven against the

capitellum with the elbow in flexion2. Direct blow to elbow when it is fully flexed

•

Becomes a free intra-articular osteochondral body

• Always displaced antero-superiorly into the radial

fossa

limit elbow flexion

•

Occasionally, displaced posteriorly

limit elbow extension

Classification

Type I (Hahn-Steinthal) Capitellar #

Type II (Kocher-Lorenz) Capitellar #

Fracture capitellum 63 64 Fracture capitellum


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•

closed manipulation always fail

•

attempts at internal fixation five poor results

•

If the fragment is small excision

•

If the fragment is sufficient large to allow stable

fixation

ORIF

1. Lateral approach

• posterior fixation• capitellum held in place with a small hook; then,

provisionally fixed with K-wire; then,

3.5 mm cancellous screw from back to front

2.

Fix the capitellum transarticularly

•

(head of screw must be countersunk below the level of

articular cartilage)

Fracture capitellum 65 66 Fracture capitellum


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FRACTURE OF RADIAL HEAD

(J. Schtazker, The Rationale of Operative Fracture Care,

2nd ed., 121-125)

Aim

•

preservation of elbow flexion and extension, pronation and supination of forearm

Mechanism of injury

• Fall on outstretched hand(majority)(may be associated with # capitellum)

• Valgus force to elbow(occasionally)(may be associated with fracture olecranon and torn

medial collateral ligament of elbow elbow

instability)

Permanent loss of motion

1.

Bony block(due to displaced piece of bone)

•

Treatment: removal of block

•

confirm bony block by infiltration of the joint with 2%

lignocaine and test motion

2.

Capsular and pericapsular scarring

•

Prevention: early mobilization

Conservative treatment

1. Displacement < 2mm

2.

Fragment < 1/3 of radial head3. In comminuted #, no associated elbow dislocation

4.

No bony block

Treatment

Early active mobilization as pain allow

Otherwise,

1.

OR + Bone wedge elevation + mini-screw; or2. Radial head excision and spacer (if elbow is unstable)

Type I #

• simple split wedge #• displaced vs undisplaced

Treatment

• OR + lag screw

Type II #

•

impaction #• part of the head and neck remain intact

Fracture radial head 67 68 Fracture radial head


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(usually the medial portion is intact because the injury

is usually the result of a valgus force with forearm in

supination)

• variable comminution

Treatment•

OR + Bone wedge elevation + mini-screws

Type III #

• severely comminuted #•

no portion of head and neck is in continuity

•

severe comminution

•

may be associated with torn medial collateral ligamentof elbow and fracture olecranon

1. If possible(esp. young patient)

• OR + Bone wedge elevation + mini-screws2. If irreconstructable,

• excision of radial head (except with elbowdislocation)

• excision + prosthetic replacement (if elbow isunstable)

Fracture radial head 69 70 Fracture radial head


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OLECRANON FRACTURE


Treatment , 2nd ed., 1995, 113-119)

Fracture of olecranon with displacement

disruption of triceps mechanism loss of active extension of elbow

Assesment and Initial Management

1. Xray

• Simple # vs comminuted #•

Undisplaced vs displaced

2. For undisplaced fracture

• test for ability to actively extend elbow against gravity3. Long arm backslab for displaced fracture or with loss

of extensor mechanism

4.

Elevation


1. Minimally displaced with intact extensor mechanism

Free mobilization

2.

Displaced # +/- Ipsilateral elbow dislocation

ORIF

CLASSIFICATION

• Intra-articular Fracture1. Simple Transverse Fracture

Mechanism of injury

• avulsion fracture and results from a sudden pull of both the triceps and brachialis muscle

• Direct fall on olecranonTreatment

• OR + TBW + K-wires2.

Complex Transverse #

Mechanism of injury

•

Direct force, such as a fall

•

comminution and depression of articular surface

Treatment

•

TBW + K-wire / Plate (in severe comminution) +/-

bone grafting

Olecranon fracture 71 72 Olecranon fracture


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c. Fracture or Dislocation of Radial head

• associated with disruption of medial collateralligament

• Treatment

• ORIF of # (TBW + K-wires)• Repair of ligament• Radial head is reduced and fixed or replaced

by a prosthesis

Olecranon fracture 75 76 Olecranon fracture


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MONTEGGIA FRACTURE

(R.R. Richards, Fracture in Adults, 4th

ed., 1996,

914-925)

•

Fracture shaft of ulna + dislocation of radial head

•

< 5% of an forearm fracture

Bado’s Classification

(J.L. Bado, Clin. Orthop., 50: 71-86, 1967)

Type I (most common)

•

anterior dislocation of radial head + anterior angulated

fracture of ulna shaft

Type II #

•

posterior dislocation of radial head + posterior

angulated fracture of ulna shaft

Type III #

•

lateral or anterolateral dislocation of radial head +

fracture of ulnar metaphysis

Type IV # (rare)

•

anterior dislocation of radial head + fracture of proximal one third of both radius and ulna

For Monteggia #,

must look for neurological injury, esp. radial nerve

(PIN), ulnar nerve injury has also been reported

Monteggia fracture 79 80 Monteggia fracture


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FRACTURE OF SHAFTS OF RADIUS AND ULNA

Aim of Treatment

1. Anatomical reduction

2. Stable fixation

Patients requiring operative treatment

1.

All displaced #

2.

Monteggia fracture and Galeazzi # with persistent

subluxed / dislocated proximal / distal radio-ulnar

joint

On admission

1. make sure Xray whole forearm(including both elbow

and wrist joint) is well taken(to rule out Monteggia

and Galeazzi #)

2.

For undisplaced # long arm pop

3. For displaced #

long arm backslab for temporary immobilization; and

work-up for OT

Operative Choice

1.

Closed #

•

ORIF (PC Fix / LCDCP)

2.

Open #

•

ORIF vs External Fixator

GALEAZZI FRACTURE

• fracture of radius (junction of middle third and distalthird) + Dislocation / Subluxation of distal radio-ulnar

joint

• Dislocation of DRUJ may occur at

1.

initial injury2.

progressively during conservative treatment

• Treatment must include reduction of DRUJ

Fracture shaft of radius and ulna 77 78 Galezzi fracture


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PELVIC FRACTURE

On admission

1.

Follow principle of management of patients with

severe trauma

2.

Assessment•

Haemodynamic condition

•

Associated potential life threatening injuries (esp. in

high enery trauma, eg. severe RTA, fell from height,

etc)

• eg. Head injuries•

Cervical spine injuries

•

Chest injuries (eg. haemothorax,

pneumothorax)

•

Abdominal injuries (eg. haemoperitoneum,

torn abdominal viscera)• Torn vessels3. Other associated injuries

• eg. ruptured bladder• ruptured urethra•

ruptured pelvic organ (eg. vagina, rectum)

•

peripheral nerve injuries

4. Fracture pelvis

•

Type and stability

•

Close vs open

5. Other associated muscoloskeletal injuries

Haemodynamic instability due to

1.

Bleeding from fracture site

•

Pelvis fracture: 1500 - 2000 ml

•

Fracture femur: 1000 ml

2.

Torn pelvic vessels (arterial or veins), withretroperitoneal haemorrhage

3. Other injuries(eg. rupture abdominal viscera,

haemothorax, etc)

For patients with haemodynamic instability / Associated

life threatening condition

1.

NPO

2.

Start Fluid resuscitation, as indicated

3.

Start oxygen therapy (high flow oxygen +/-

intubation)

4.

Insert 2 large bore iv line +/- CVP

5. Foley to BSB (uless suspect urethral injury)

6. Blood x cross-match

7. Routine blood test

8.

Must examine patient’s neurology(to r/o severe head

injury and spinal injury), chest (for pneumothorax,

haemothorax) and abdomen (for haemoperitoneum )

9. Analgesics

Fracture pelvis 81 82 Fracture pelvis


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PELVIC FRACTURE

(M. Tiles, The Rationale of Operative Fracture Care, 2nd

ed., 1995, 221-270)

Anatomy

•

Pelvic ring•

3 bones

•

Sacrum + 2 inominate bones (each consists of

ilium, ischium and pubis)

•

Stability

•

ability of pelvis to withstand physiological

force without significant displacement

•

depends mainly on surrounding soft tissues

1.

Symphysis pubis

2.

Posterior sacroiliac complex

3.

Pelvic floor



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SACROILIAC COMPLEX

Posterior sacroiliac complex(work like a suspension

bridge)

• transfer weight bearing forces from the spine to the

lower extremities1. Posterior sacroiliac interosseous ligaments

(strongest ligament in the whole body)

(maintain sacrum in position with pelvic ring)

2. Iliolumbar ligament

(from transverse process of L5 to iliac crest)

3. Interosseous ligament

Anterior sacroiliac ligament

• resists external rotation and shearing force

PELVIC FLOOR

• muscular layer covered by investing fascia•

contains 2 major ligaments: sacrospinous ligament

and sacrotuberous ligament

1.

Sacrospinous ligament •

resists external rotation of the pelvis

2. Sacrotuber

ous

ligament

• resistsvertical

shearing

force



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TYPES OF INJURIES FORCE

1. External rotation force

2.

Internal rotation force (lateral compression force)

3.

Vertical shearing force

4.

Complex force (as in high energy trauma)

External Rotation Force

1.

Direct blow to the PSIS

2. Forced external rotation through hip joints unilaterally

or bilaterally

External rotation force ( open book injury)

symphysis pubis disrupts

sacrospinous ligament and anterior sacroiliac

ligament open

impingement of the posterior ilium on sacrum

Internal Rotation Force (Lateral Compression)

1.

Direct blow to iliac crest

upward rotation of the hemipelvis (bucket handle

injury)

1. Through the femoral head, by a direct force against the

greater trochanter, often causing an ipsilateral injury

Internal rotation force / lateral compression



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anterior structures, usually the rami, break and then

hemipelvis rotates internally

If the posterior ligament remain intact

anterior sacrum will compress

If the posterior ligament is torn, stability is maintained by pelvic floor

Vertical Shearing Force

Vertical shearing force

marked displacement of bone gross disruption of soft

tissue structures

unstable pelvic ring with major anterior and posterior

displacement

Effects of Force on Soft Tissue

1. External rotation and Vertical Shear force

Tearing of viscera and arteries

Traction injuries to nerves

2.

Internal rotation

puncture visceracompress nerve

CLASSIFICATION

Type A

•

Stable #

•

pelvic ring not displaced

Type B

• Partially stable• retain posterior stability• cannot translate vertically ie. stable in vertical plane1.

Open book injury (external rotation force)

• (Unstable in external rotation)2. Lateral compression injury(internal rotation)

• either unstable in internal rotation; or• rigidly impactedType C

• Unstable•

complete disruption of posterior arch, pelvic floor and

usually the anterior arch

•

Type A + B : 70 %• Type C : 30 %



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CLASSIFICATION OF PELVIC RING

DISRUPTION

Type A: Stable pelvic ring injury

A1: Avulsion of the innominate bone

A2: Stable iliac wing fracture or stableminimally displaced ring fracture

A3: Transverse fractures of the sacrum and

coccyx

Type B: Partially stable

B1: Open book injury

B2: Lateral compression injury

B2.1: Ipsilateral type

B2.2: Contralateral type (bucket-

handle)

B3: Bilateral B injuries

Type C: Unstable (vertical shear)

C1: Unilateral

C1.1: Ilium

C1.2: Sacroiliac dislocation or fracture

dislocation

C1.3: Sacrum

C2: Bilateral, one side B, one side C

C3: Bilateral C lesions

TYPE A--STABLE FRACTURES

• pelvic ring is stable and cannot be disrupted by physiological force

Type A1

•

avulsion # of innominate bone• not involve pelvic ring• usually in adolescentType A2

• involve the iliac ring; or• anterir arch• no posterior injury•

rare

Type A3

• transverse # sacrum and coccyx

TYPE B--PARTIALLY STABLE FRACTURE

Open Book Fracture (External Rotation)

First stage

•

disruption of symphysis pubis(< 2.5cm opening of

symphysis pubis)



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Second stage

• continuation of external rotation force will tear thesacrospinous ligament and anterior sacroiliac

ligament

Signified by1.

Opening of pubis symphysis > 2.5cm

2.

Avulsion fracture fo ischial spine

• strong posterior sacroiliac ligament remain intact( stable in vertical force)

Third stage

• external rotation force go beyond the yield point of

posterior ligament

posterior complex ruptures

unstable Type C # now (avulsion fracture of L 5

transverse process)

Lateral Compression Fracture (Internal Rotation)

Ipsilateral Injury

• anterior and posterior lesion on the same side

•

direct blow to greater trochanter• superior and inferior pubic rami break + crush at

anterior part of SIJ

• posterior ligamentous structures are intact• possible rupture of bladder +/- blood vessels• elastic recoil



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Contralateral Injury (Bucket-handle injury)

• anterior fracture on the opposite side of posteriorlesion

• (or all four rami may fracture anteriorly but the

anterior displacement is on the side opposite the posterior lesion)

• usually has major leg length discrepency (shorteningof the side of posterior lesion because of marked

internal rotation of hemipelvis)

• posterior structures are firmly impacted

• reduction require derotation of hemipelvis rather than pure vertical traction

TYPE C--UNSTABLE FRACTURE

• complete disruption of posterior sacroiliac arch +rupture of pelvic floor(including the sacrospinous and

sacrotuberous ligaments)

Radiographic signs of Instability1. Avulsion fracture of the transverse process of L5

vertebrae

• (indicating rupture of ilio-lumbar ligament)

2.

Avulsion fracture of ischial spine or avulsion of sacral

attachment of sacrospinous ligament (indicating

rupture of ischiospinous ligament)

3. > 1cm posterior or vertical translation

MANAGEMENT FO PELVIC #

Depends on

1.

“Personality” of injury2. Associated injuries

Management

• Assessment

• Resuscitation• Provisional stabilization• Definite stabilization



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ASSESSMENT

General assessment

•

general assessment and management of a

polytraumatised patient

Specific Musculoskeletal assessment•

Aim: Determine the stability of pelvic ring

Clinical Assessment

1.

History

•

High-energy injury(eg.RTA, fell from height) vs

low-energy injury

2. P/E

• Major bruising or bleeding from urethral meatus,vagina, rectum (may signify an open fracture)

• Rotatory deformity or limb shortening (may implyunstable pelvic injury)

•

Test pelvic stability

• apply both hands to ASIS and move the affectedhemi-pelvis (external rotation vs internal rotation)

• apply one hand to the pelvic iliac crest and usingthe other to apply traction to the leg (displacement

in vertical plane)

Radiological Assessment

• Plain Xray

• Xray pelvis (AP)• Xray Pelvis (inlet view)

•

direct Xray beam 60 from head to midpelvis• demonstrate posterior displacement

• Xray pelvis (outlet view)

• Xray beam from the foot of patient to thesymphysis at an angle of 45

• demonstrate superior or inferior migration• CT scan

Diagnosis of Pelvic Stability

1. Type C (Completely unstable)

• Clinically, lack of a firm end-point in rotation ortraction

• Radiologically,• displacement / gap (vertical displacement or

antero-posterior displacement)on Xray or CT >

1cm

• Avulsion # of ischial spine or sacrum

2.

Type B (Partially stable)• Clinically, firm end-point on palpation



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RESUSCITATION

• Pelvic # hamorrhage (arterial, venous, bony)•

Risk in unstable # > stable #

1. Massive fluid replacement, as indicated

2.

Pneumatic antishock garment3. Application of anterior external frame / Pelvic C

Clamp

• in hypotensive patients / unstable #• pelvic volume tamponade effect• help to stop venous and bony bleeding4. Embolization of pelvic vessels

• usually only help to control bleeding from asmall-bore artery

• Small-bore artery bleeding may be asssumed if,although the patient can be well controlled using the

above methods of fluid replacement, PASG, an

fracture stabilization, he or she goes into a shocked

state each time the fluid is slow down

5. Direct surgical control

•

rarely indicated and usually unsuccessful

PROVISIONAL STABILIZATION

Provisional stabilization by Anterior External Fixator

/ Pelvic C Clamp

Indications

• those fractures with potential increase in pelvic

volume and patients with unstable haemodynamecondition

• Wide open book injury (B1, B3)

• Unstable pelvic fracture C

• rarely required for lateral compression injuries (B2)

Anterior External Fixator

• 2 pins percutaneously place in each ilium, atapproximately 45 to each other

• one pin in ASIS

•

one in iliac tubercle• joined by an anterior rectangular configurationPelvic C Clamp

• point of entry• 4 finger breadth from PSIS on a line joining ASIS and

PSIS

Provisional stabilization with Skeletal traction

•

for patient with no haemodynamic instability

•

temporary skeletal traction pin in distal femur

•

5 - 20 kg of traction to prevent hemipelvis from

shortening



55/145

ACETABULAR FRACTURE

(M. Tile, The Rationale of Operative Fracture

Treatment , 2nd ed., 1995, 271-324)

Aim of Treatment

•

anatomical reduction of hip joint without

operative complication

Major factors affecting prognosis

1. Degree of initial displacement

2. Damage to superior weight bearing surface of

acetabulum or femoral head

3. Degree of joint instability caused by posterior

wall fracture

4. Adequacy of reduction, either open or closed

5.

Late complications

• AVN of femoral head• Heterotropic ossification• Chondrolysis• Sciatic or femoral nerve injury

Anatomy

Mechanism of injury

• pathological anatomy of the fracture depends onthe position of the femoral head at the moment of

impact

1.

External rotation

of hip

• anterior column #2. Internal rotation

of hip

• posterior column#

3. Abduction of hip

• Low transverse #

4.

Adduction of hip• high transverse #

1. Direct blow on the acetabulum / upon the greater

trochanter

usually a transverse acetabular #

2. Dashboard injury (Flexed knee joint strikes the

dashboard of a motor vehicle, driving the femur

posteriorly on the acetabulum)

posterior wall or posterior column fracture or

fracture dislocation of hip joint

Fracture acetabulum 101 102 Fracture acetabulum


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ASSESSMENT

•

Follow principles of assessment of polytrauma

patient

• Specific assessment of # acetabulumXray pelvis (AP)

Important landmarks

1. iliopectineal line

• denoting limit of anterior column2. ilioischial line

• denoting limit of posterior column3. Anterior lip of acetabulum

4. Posterior lip of acetabulum

5.

Tear drop

6.

Superior dome

Iliac oblique view

• 45 external rotation of the affected pelvis• by elevating the uninjuried side on a wedge foam• Landmarks1.

best depicits the extent of posterior column

2.

anterior lip of acetabulum

3. entire iliac crest



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Obturator Oblique View

• 45 internal rotation of the affected hemipelvis• by placing a foam wedge under the affected hip• Landmarks1.

best shows the anterior column

2.

posterior lip of acetabulum

3. best show displacement of iliac wing in the

coronal plane (because iliac crest is seen

perpendicular to its normal plane)

Classification

• acetabulum consistsof 4 basic

anatomical areas

1.

Anterior column

2. Posterior column

3. Anterior wall of lip

4. Posterior wall of lip

Fracture Types

1. Isolated Anterior

Column fractures

2. Isolated Posterior

Column fractures

3. Combined anterior

column and anterior

lip fracture

4. Combined posterior

column and

posterior lip

fracture

5.

Transverse fracture

• both anterior and posterior columns are broken



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6. T Fracture

• both columns are broken and

separated from

each other

• both transverse orT fracture may be

associated with an

anterior or

posterior lip #

•

Transverse / T

fracture, a portion

of acetabular

dome is always

attached to the intact ilium

7. Both Column Fractures

• both anterior and posterior columns

are fractured and

separated from

each other

• but the fracture inthe columns is

proximal to theacetabulum in the

ilium

• true floatingacetabulum

• no portion of theweight-bearing

surface of the acetabulum remain attached to the

acetabulum

Management (Depends on)

1.

Fracture factor

2.

Patient’s factor (age and bone quality, general

medical status, associated injuries)

Fracture factor

Non-operative management if

Hip stable and Congrous

Undisplaced fractures (all types)

require no skeletal traction

Minimally displaced # (displacement < 2mm)

Low anterior column # (# not involve major weight

bearing area)

Low transverse #

• through theacetabular

fossa area

(infratectal)

• skeletaltraction

•

Low transverse# (infratectal)

• main portion ofthe weight

bearing dome is intact



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• medial portion of the dome act as a buttress to the

femoral head, preventing redisplacement

c.f. High transverse

# (Supratectal,

tanstectal)

divides the

mid-portion of the

superior

weight-bearing

dome

medial fragment

remains displaced

and the femoral

head is congrous with that portion rather than the

dome portion

Both column fractures without major posterior

column displacement

• true floating acetabulum• no portion of the weight bearing dome attached

to the axial skeleton

• exhibit secondary congruence (Letournel, 1980)• skeletal traction

Operative management

• indicated for unstable and/or incongruous hip joint

Instability

• hip dislocation associated with1. Posterior wall or column displacement (posterior

instability)

2.

Anterior wall or column displacement (anterior

instability)

Incongruity

1. Fractures through the roof of the dome

• displaced dome fragement•

High transverse or T types # (transtectal)

• Both-column types with incongruity (displaced posterior column)

2. Retained bone fragments

3. Displaced fractures of femoral head

4. Soft tissue interposition (usually posterior

capsule)

Other operative indications

1.

development of a sciatic or femoral nerve palsyafter reduction of the acetabular # (possible

entrapment of the nerve)

2. Presence of a femoral artery injury associated

with an anterior column fracture of the

acetabulum



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3. Fracture of the ipsilateral femur / disruption of

ipsilateral knee, which makes closed treatment of

acetabulum virtually impossible



61/145

FRACTURE OF PROXIMAL FEMUR

*For patients < 60 years old presenting with acute

intracapsular fracture neck of femur (both displaced

and undisplaced), need EOT x CR + IF (AO screw)

(J. Schaztker, The Rationale of Operative FractureCare, 2nd ed., 1995, 323-340)

Anatomy

• Neck shaft angle: 125 - 135

Blood Supply of Femoral Head

1. Via retinacular vessels in the posterior capsule of

hip joint

• Common femoral artery

medial circumflex femoral artery

posterior superior retinacular vessels and

posterior inferior retinacular vessels posterior superior retinacular artery gives rise

to lateral superior epiphyseal vessels

Femoral artery

(Lateral femoral circumflex artery

anterior retinacular vessels

not contribute to blood supply of head

Fracture proximal part of femur 113 114 Fracture proximal part of femur


62/145

2. Via ligamentous teres (supply a small portion of

head close to their site of entry)3.

Intraosseous blood supply

Attachment of capsule of hip joint

1. Front

• along the intertrochanteric line2. Back

• attach to the neck only halfway to theintertrochanteric crest

Fracture Proximal Part of Femur

1. Intracapsular

• Subcapital # neck of femur• Transcervical # neck of femur

•

In these fractures, capsule may be torn

blood supply of femoral head is at risk

2.

Extracapsular

•

Fracture basal neck of femur

•

Intertrochanteric fracture of femur

• Subtrochanteric fracture of femur• In these fractures, capsule is intact Femoral head is not at risk of AVN

Intracapsular Fracture Neck of FemurGarden Classification (1964)

• use the relationship of medial trabeculae(compression trabeculae) in the head and pelvis

as an index of displacement

• undisplaced # (Garden I and II) vs displaced #(Garden III and IV)

1. Undisplaced Fracture

• capsule is less likely to be injuried lower incidence of AVN

2.

Displaced Fracture• capsule is likely to be torn higher incidence of AVN and higher

incidence of failure of fixation and nonunion

Fracture proximal part of femur 115 116 Fracture neck of femur


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Garden I

• head impacted invalgus

Garden II

•

undisplaced #

Garden III

• partially displaced#

Garden IV

• completelydisplaced #

History

• simple fall with pain over groin +/- inability towalk

P/E

• R/O concomittant injury (eg. head injury, # distalradius)

• Affected leg shortened and externally rotated• Pain on manipulation of the affected leg

Treatment

1. For all young patients (< 60 years) with

intracapsular fracture neck of femur (both

displaced and undisplaced #) need EOT x CR + IF

2.

For patients > 60 years

• for elective OT uless medically unfit• Undisplaced intracapsular Fracture (Garden I

and II)

AO screws +/- AMA

Fracture neck of femur 117 118 Fracture neck of femur


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• Displaced intracapsular fracture (Garden III

and IV)

AMA / Cemented Thompson

CR of intracapsular fracture neck of femur

• Femoral head usually displaces into varus andretroversion

• femoral shaft externally rotates

Methods of CR (under Image Intensifier)

1. Longitudinal traction (bring the head out of varus

position)

2. Gentle internal rotation of the limb (correct

retroversion)

Acceptable alignment(Schatzker)

1. Anatomical reduction or one with the head in

slight valgus position

2. Head in neutral version or minimally anteverted

• repeated attempts of CR increase risk of AVN

Fracture neck of femur 119 120 Fracture neck of femur


65/145


66/145

Kyle’s III

•

unstable and has a large postero-medial

comminuted area

Kyle’s IV

• fracture with subtrochanteric extension• highly unstable

Treatment

• all #TOF require elective OT for internal fixationwith DHS (dynamic hip screw)

• look for assicated injuries (eg. head injury,fracture distal radius)

•

work-up for OT

Intertrochanteric fracture of femur 123 124 Intertrochanteric fracture of femur


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SUBTROCHANTERIC FRACTURE


Care, 2nd ed., 1995, 349-366)

•

Subtrochanteric segment--extends from lesser

trochanter to the junction of proximal and middlethird of the diaphysis

Biomechanical

consideration

• subtrochantericregion is

subjected to:

1. axial load

2. bending force

because of

eccentric load

application to

the femoral head

• medialcortex--loaded

in compression

• lateralcortex--loaded

in tension

Factors important for stability (in order of

importance)

1. Degree of comminution

2.

Level of fracture3. Pattern of fracture

Degree of comminution

1. irreconstructable medial cortex comminution

(shattered medial cortex)

2. irreconstructable segmental comminution

Level of fracture

1.

Closer the fracture to the lesser trochanter

shorter the lever arm and the lower the bending moment

2. Involvement of greater trochanter

• difficult to keep the intramedullary nail withinthe proximal fragment

• better to fix the fracture with an angled device(eg. angled blade plate)

3. Involvement of lesser trochanter

• lock proximally within the femoral neck andhead (eg. AO unreamed femoral nail + spiral

blade locking)

Pattern of fracture

• determine the mode of internal fixation

Subtrochanteric fracture of femur 125 126 Subtrochanteric fracture of femur


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Comprehensive Classification of Fractures

(Muller, 1990)

Type A #

•

simple

•

transverse / oblique / spiral

Type B #

• wedge #• can still be reconstructed to yield a stable

structure

lateral wedge medial wedge

Type C #

•

comminution to a degree that a stable unit cannot

be achieved

Indications for surgery

• all subtrochanteric fracture of femur needsoperative treatment

On admission

1. r/o associated injury

2. skeletal traction

3.

work-up for OT

Surgery

• AO unreamed intramedullary nail with spiral blade locking

Subtrochanteric fracture of femur 127 128 Subtrochanteric fracture of femur


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FRACTURE SHAFT OF FEMUR

• result of high energy trauma• rule out associated injury• follow management of polytrauma patient

Comprehensive Classification of Fracture

(Muller, 1990)

Type A

• simple #• A1--long oblique• A2--short oblique• A3--transverse

Type B

•

wedge fracture

Type C

• complex #• C1--spiral• C2--segmental•

C3--irregular

Treatment

• All adult femoral fracture• Closed #O unreamed femoral nail• Open #xternal fixator

On admission

•

Follow management of polytrauma patient (if

applicable)

• Skeletal traction•

work-up for operation

Fracture shaft of femur 129 130 Fracture shaft of femur


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SUPRACONDYLAR FRACTURE OF FEMUR


Care, 2nd ed., 1995, 387-413)

1. Younger patient

•

high energy trauma• severe fracture with greater intra-articular

disruption or segmental comminution

• possible association with open wound, multiplefractures, ligamentous injury

2. Older patients

• low energy trauma (eg. slip an fell)• associated with severe osteoporosis

Aim of treatment

1.

accurate anatomical reduction of Joint surface

2. Stable internal fixation of the articular surface

3.

Restoration of normal axial alignment and

length

4. Buttressing of metaphysis

5. Early mobilization

6. thus, operaive treatment for all patients

On admission

•

Follow management of polytrauma patient (ifapplicable)

•

Skeletal traction

•

work-up for OT

Comprehensive Classification of Fractures

(Muller, 1990)

Type A

•

extra-articular• A1--extra-articular, simple• A2--extra-articular, metaphyseal wedge• A3--extra-articular, metaphyseal complex

Type B

• partial articular• part of the articular surface intact and in contact

with the diaphysis

• B1--partial articular, lateral condyle, sagittal

•

B2--partial articular, medial condyle, sagittal• B3--partial articualr, frontal

Supracondylar fracture of femur 131 132 Supracondylar fracture of femur


71/145

Type C

• complete articular• articular surfaces are fractured and have lost

continuity with the diaphysis• C1--cmplete articular #, articular simple,

metaphyseal simple

• C2--complete articular #, articular simple,metaphyseal multifragmentary

• C3--complete articular #, multifragmentary

Treatment

• ORIF (May plate +/- Bone grafting +/- Cementaugmentation)

Surgical Anatomy

1.

Anatomical axis:• in valgus• with sagittal plane• (79 to 82) with the

knee joint axis

(parallel to ground)

2. Mechanical axis:

• line projectedthrough the centre

of femoral head,

knee joint an ankle

joint

•

with sagittal plane

• with anatomical axisof femur



72/145

Lateral view

• when posterior cortex of the shaft is projecteddistally, it divides the epiphysis into an anterior

and posterior half

•

Anterior position of condyles appear as acontinuation of shaft

• thus, blade of a condylar plate / screw of a DCSshould be placed into the anterior part of

condyle; or the plate will not fit the femur

Cross Section

• distal femur appear as a trapezoid• anterior and posterior surfaces are not parallel• medial and lateral walls are inclined (medial wall

inclined at 25 to the vertical)• important in selecting the length of compression

screw



73/145

FRACTURE PATELLA


Care, 2nd ed., 1995, 415-418)

Anatomy

•

seasmoid bone within the tendon of quadricepsmuscle

• displacement with disruption of quadricepsmechanism

loss of active extension of knee and loss of ability

to lock the knee in extension

• Patella is bound1.

proximally to quadriceps tendon

2. distally to infrapatellar tendon

3. on either side to retinacular expansion which are

adherent to the capsule

Classification

Transverse fracture

• result from sudden, violent contraction of thequadriceps (eg. when a person tries to stop a fall)

• may disrupt quadriceps mechanism• may result in avulsion of quadriceps tendon, or

infrapatellar tendon, or transverse fracture of patella

• associated with a tear into retinacular expansion•

If undisplaced # with intact extensor mechanism

long leg cylinder x 6 weeks and FWB walking

• For all displaced fracture open reduction + TBW / Cerclage wiring

Fracture patella 137 138 Fracture patella


74/145


75/145


76/145

Partial patellectomy

Fracture patella 143 144 Fracture patella


77/145

TIBIAL PLATEAU FRACTURE


Care, 2nd ed., 1995, 419-438)

History• Mechanism of injury(S/F, RTA, Fell from

height)

• High velocity injury vs Low velocity injury• Direction of force• Patient’s expectation and level of function

required

P/E

• Soft tissue condition (open wound, swelling, bruising, etc)

• Site of Local tenderness (may indicate possibledisruption of collateral ligament)

• Neurological deficit• Vascular deficit• Compartment syndrome

Management

1.

Rule out concomitant injury

2.

Rule out patients requiring EOT (eg. openfracture, vascular injury, acute compartment

syndrome)

3. Long leg backslab for temporary immobilization

Tibial Plateau Fracture

• about 50 % patients get satisfactory results (bothclosed and open treatment)

Causes of failure of treatment

1. Residual pain

2. Stiffness

3. Instability of knee joint

4. Deformity

5. Recurrent effusions

6. Giving way

Mechanism of Injury

•

usually a combination of vertical thrust and bending

Aims of Treatment

1. Stable Joint

2. Congruent articular surface

3. Correct axial alignment

4. Satisfactory range of movement

Fracture tibial plateau 145 146 Fracture tibial plateau


78/145

Schatzker Classification of Tibial Plateau

Fracture

TREATMENT

1. Undisplaced Fracture (< 5mm depression, no

splaying of condyles)

hinged knee brace x 6 weeks

+ protected weight bearing(NWB walking x 6/52

PWB walking x 6/52

FWB walking)

2. All others / Open Fracture / Fracture

associated with acute compartment syndrome

/ Fracture associated with vascular or

neurological injury (vascular injury is most

often associated with type IV tibial plateau

injury)

i. OR + Buttress Plate + Bone Graftii. CR + Ilizarov +/- Mini-open technique + bone

graft

Rehabilitation

• early mobilization



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Type I Fracture

• wedge fracture of lateral tibial plateau1. Undisplaced

2. Displaced with lateral wedge fragment

• spread apart from the metaphysis broadening of joint surface

• Depressed• Both spread and depressed

• (For fracture with significant displacement,

lateral meniscus may be trapped in the #)Mechanism

• result of bending and shearing forceAge

• usually young people < 30 years (because ofdense cancellous bone of lateral tibial plateau)

Treatment

1. Undisplaced

• Hinged knee brace x 6/52; protected weight bearing

2. Displaced

•

ORIF +/- bone graft(Young people: lag screw

Old people : lag screw + buttress plate)

3. Minor displacement

• may need arthroscopy to make sure that themeniscus is not trapped in the fracture

Prognosis

• excellent if the joint is carefully reconstructed



80/145

Type II Fracture

• wedge fracture + depression adjacent weight bearing portion of lateral tibial plateau

• Depressed fragment may be anterior, central, posterior, or a combination of all three

Mechanism

• result of bending and shearing force

Age

•

> 50 years

Treatment

1. Undisplaced and Depression < 5mm

• Hinged knee brace x 6/52• Protected weight bearing2. Displaced fracture

•

ORIF (buttress plate) + Bone graft3.

Displaced Fracture with contraindication to

surgery

• CR + Hinged knee brace x 6/52 + Protectedweight bearing

Prognosis

1. Poor results if residual joint depression,

incongruity, joint instability

2.

Significant knee stiffness if prolonged

immobilization



81/145

Type III Fracture

•

most common but least serious tibial plateaufracture

• Depression of articular surface of the lateraltibial plateau without an associated lateral wedge

fracture

Mechanism

• result of smaller force exerting its effect onweaker bone

Age

• > 55 years

Treatment

1. Depression < 5mm and No knee instability

• Hinged knee brace x 6/52 + Protected weight bearing

2.

Depression > 5mm• ORIF (Buttress plate + Lag screw below the

elevated portion of tibial plateau + Bone graft)

Prognosis

• excellent



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Type IV Fracture

• fracture medial tibial plateau• carry worst prognosis

1.

High velocity injury

•

Younger individual

• medial plateau splits as a simple wedge with anassociated fracture of the intercondylar eminence

and adjacent bone with the attached cruciate

ligament

•

may be associated with a posterior split wedge ofmedial plateau

femoral condyle subluxate posteroirly on

flexion

• frequently a concomitant disruption of the lateralcollateral ligament complex (tear through the

substance of ligament or avulsion of bone, such

as the proximal fibula)

• possible stretching or rupture of the peronealnerve (as a result of traction)

•

occasionally, damage to popliteal vessels•

represents a subluxation or a dislocation of knee

which has been reduced

• Poor prognosis--because of associated soft tissueinjury and other complications, such as

compartment syndrome, Volkmans’ contracture,

footdrop

2. Trivial Low Velocity Injury

• elderly with marked osteoporotic bone•

medial tibial plateau crumbles into an

irreconstructable mass of fragments

• Poor prognosis--because of joint incongruity andinstability



83/145

Treatment

1. Undisplaced with No significant soft tissue

injury

• Hinged knee brace x 6/52 + Protected weight

bearing2. Displaced and/or associated ligamentous or

neurovascular lesion

• Open repair of ligamentous injury• ORIF--buttress plate to medial plateau + BG

Avulsed intercondylar #:

Fixed with lag screw or wire loop

Posterior split wedge fracture

2nd buttress plate posterio-meduially

• CR + Ilizarov External Fixator +/- Mini-opentechnique + bone grafting

Type V Fracture

•

bicondylar fracture, which consists of a wedge

fracture of the medial and lateral tibial plateau

•

Documents

Handbook of Orthopaedic Traumatology