OPERATIVE

TECH N IQUES IN
ORTHOPAEDIC
TRAUMA SURGERY
A LS O A VA IL A B LE IN T H IS S E R IE S

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 OPERATIVE
TECH N IQUES IN
ORTHOPAEDIC
TRAUMA SURGERY
EDITORS
Paull T
P To rn ett t a III,
III MMD
D Mat t h ew L. Ram sey, MD
Pro fe sso r a n d Vice Ch a irm a n Sh o uld e r a n d Elb o w Se r vice
De p a r t m e n t o f Or t h o p ae d ic Surg e r y Th e Rot h m a n In st it ute
Dire cto r o f Or t h o p ae d ic Traum a Asso ciate Pro fe sso r o f Or t h o p ae d ic Surg e r y
Bosto n Un ive rsit y Me d ica l Ce n te r Je ffe rso n Me d ica l Co lle g e, Th o m as
Bosto n , Massach uset t s Je ffe rso n Un ive rsit y
Ph ilad e lp h ia, Pe n n sylva n ia
Ge rald R. William s, MD
Pro fe sso r o f Or t h o p ae d ic Surg e r y
Th o m as R. Hun t III, MD
Ch ie f, Sh o uld e r a n d Elb o w Se r vice Pro fe sso r o f Surg e r y
Th e Rot h m a n In st it ute Jo h n D. Sh e rrill En d o we d Ch a ir o f
Je ffe rso n Me d ica l Co lle g e, Th o m as Ort h o p ae d ic Surg e r y
Je ffe rso n Un ive rsit y Un ive rsit y o f Ala b a m a Sch o o l o f Me d icin e
Ph ila d e lp h ia , Pe n n sylva n ia Birm in g h am , Alab am a

Sam W. Wie se l, MD
EDITOR-IN-CHIEF
Pro fe sso r a n d Ch a ir
De p a r t m e n t o f Or t h o p ae d ic Surg e r y
Ge o rg eto wn Un ive rsit y Me d ica l Sch o o l
Wash in g to n , DC
Acquisitions Editor: Robert A. H urley
Developmental Editor: Grace Caputo, Dovetail Content Solutions
Product M anager: Dave M urphy
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Compositor: M aryland Composition /ASI
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Library of Congress Cataloging-in-Publication Data

O perative techniques in orthopaedic trauma / editors, Paul Tornetta III ... [et al.].
p. ; cm.
Includes bibliographical references and index.
Summary: “ O perative Techniques in O rthopaedic Trauma Surgery provides full-color, step-by-step explanations
of all operative procedures in orthopaedic trauma surgery. It contains the chapters on trauma from Sam W. Wiesel’s
O perative Techniques in O rthopaedic Surgery. Written by experts from leading institutions around the world, this
superbly illustrated volume focuses on mastery of operative techniques and also provides a thorough understanding of
how to select the best procedure, how to avoid complications, and what outcomes to expect. The user-friendly format
is ideal for quick preoperative review of the steps of a procedure. Each procedure is broken down step by step, with
full-color intraoperative photographs and drawings that demonstrate how to perform each technique. Extensive use of
bulleted points and tables allows quick and easy reference. Each clinical problem is discussed in the same format:
definition, anatomy, physical exams, pathogenesis, natural history, physical findings, imaging and diagnostic studies,
differential diagnosis, non-operative management, surgical management, pearls and pitfalls, postoperative care,
outcomes, and complications. To ensure that the material fully meets residents' needs, the text was reviewed by a
Residency Advisory Board” --Provided by publisher.
ISBN 978-1-4511-0260-4
1. O rthopedic surgery. 2. Bones--Wounds and injuries--Surgery. I. Tornetta, Paul.
[DN LM : 1. Fractures, Bone--surgery. 2. Bone and Bones--surgery. 3. Dislocations--surgery. 4. O rthopedic
Procedures--methods. 5. Surgical Procedures, O perative--methods. WE 175 O 61 2011]
RD732.O 64 2011
617.4'7--dc22
2010023506

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10 9 8 7 6 5 4 3 2 1
De d ica t io n

To my mother, Phyllis, who found the best in people, had compassion for all, and whose insight, guid-
ance, and love have always made me believe that anything is possible. —PT

To my cherished wife Teri and our four extraordinary children, Thomas, William, Caitlin, and
Christopher, for their love and understanding, and especially for their endless supply of smiles,
laughter, and fun!—TRH

To our wives, Robin and Nancy, and our children, Mark and Alexis and Chelsea, Alex, and Julia.
—GRW and MLR
CONTENTS
Pr e f a ce xiii
Re s id e n cy Ad v is o r y Bo a r d xv
SECTION I HAND, WRIST AND FOREARM
1 Op e r a t iv e Tr e a t m e n t o f Fin g e r Ca r p o m e t a ca r p a l
Jo in t Fra ct u r e -Dis lo ca t io n s
Jo h n J. W alsh IV 1
2 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
Dia p h y s e a l Fo r e a r m Fr a ct u r e s
M ich ae l R. Bo lan d 8
3 Re d u ct io n a n d St a b iliza t io n o f t h e Dis t a l
Ra d io u ln a r Jo in t Fo llo w in g Ga le a zzi Fr a ct u r e s
M ich ae l R. Bo lan d 2 0
4 K-Wir e Fix a t io n o f Dis t a l Ra d iu s Fr a ct u r e s Wit h
a n d Wit h o u t Ex t e r n a l Fix a t io n
Ch rist o p h e r Do u m as an d David J. Bo z e n t k a 3 0
5 Ar t h r o s co p ic Re d u ct io n a n d Fix a t io n o f Dis t a l
Ra d iu s a n d Uln a r St y lo id Fr a ct u r e s
W illiam B. Ge issle r 4 0
6 Vo la r Pla t in g o f Dis t a l Ra d iu s Fr a ct u r e s
Jo h n J. Fe rn an d e z 5 1
7 In t r a m e d u lla r y a n d Do r s a l Pla t e Fix a t io n o f
Dis t a l Ra d iu s Fr a ct u r e s
Pe d ro K. Be re d jik lian an d Ch rist o p h e r Do u m as 6 3
8 Fr a g m e n t -Sp e cif ic Fix a t io n o f Dis t a l Ra d iu s
Fr a ct u r e s
Ro b e rt J. M e d o f f 7 1
9 Br id g e Pla t in g o f Dis t a l Ra d iu s Fr a ct u r e s
Pau l A . M art in e au , Ke vin J. M alo n e ,
an d Do u g las P. Han e l 8 6
1 0 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f Uln a r
St y lo id , He a d , a n d M e t a d ia p h y s e a l Fr a ct u r e s
To m m y Lin d au an d A n d re w J. Lo g an 92
1 1 Pe r cu t a n e o u s Fix a t io n o f Acu t e Sca p h o id
Fr a ct u r e s
Pe t e r J. L. Je b so n , Jan e S. Tan , an d A n d re w W o n g 102
1 2 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
Sca p h o id Fr a ct u r e s
A sh e e sh Be d i an d Pe t e r J. L. Je b so n 109
1 3 Co r r e ct iv e Os t e o t o m y f o r Ra d iu s a n d Uln a
Dia p h y s e a l M a lu n io n s
Vim ala Ram ach an d ran an d Th o m as F. Vare ck a 117
1 4 Op e r a t iv e Tr e a t m e n t o f Ra d iu s a n d Uln a
Dia p h y s e a l No n u n io n s
Re n a L. St e w art 124
1 5 Co r r e ct iv e Os t e o t o m y f o r Dis t a l Ra d iu s
M a lu n io n
David Rin g , Die g o Fe rn an d e z , an d Je sse B. Ju p it e r 130
SECTION II SHOULDER AND ELBOW
1 6 Pla t e Fix a t io n o f Cla v icle Fr a ct u r e s
David Rin g an d Je sse B. Ju p it e r 140
1 7 In t r a m e d u lla r y Fix a t io n o f Cla v icle Fr a ct u r e s
Brad f o rd S. Tu ck e r, Carl Basam an ia,
an d M at t h e w D. Pe p e 144
1 8 Pe r cu t a n e o u s Pin n in g f o r Pr o x im a l Hu m e r u s
Fr a ct u r e s
Le e sa M . Galat z 154
1 9 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
Pr o x im a l Hu m e r u s Fr a ct u r e s
M ark T. Dillo n an d David L. Glase r 163
2 0 In t r a m e d u lla r y Fix a t io n o f Pr o x im a l Hu m e r u s
Fr a ct u r e s
J. De an Co le 172
2 1 He m ia r t h r o p la s t y f o r Pr o x im a l Hu m e r u s
Fr a ct u r e s
Kam al I. Bo h sali, M ich ae l A . W irt h ,
an d St e ve n B. Lip p it t 180
2 2 Pla t e Fix a t io n o f Hu m e r a l Sh a f t Fr a ct u r e s
M at t h e w J. Garb e rin a an d Ch arle s L. Ge t z 189
2 3 In t r a m e d u lla r y Fix a t io n o f Hu m e r a l Sh a f t
Fr a ct u r e s
Ph illip Lan g e r an d Ch rist o p h e r T. Bo rn 197
2 4 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
No n a r t icu la r Sca p u la r Fr a ct u r e s
Bre t t D. Ow e n s an d Th o m as P. Go ss 206
2 5 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
In t r a -a r t icu la r Sca p u la r Fr a ct u r e s
Bre t t D. Ow e n s, Jo an n a G. Bran st e t t e r,
an d Th o m as P. Go ss 212
2 6 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
Su p r a co n d y la r a n d In t e r co n d y la r Dis t a l
Hu m e r u s Fr a ct u r e s
Jo aq u in San ch e z -So t e lo 219
2 7 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
Ca p it e llu m a n d Ca p it e lla r –Tr o ch le a r Sh e a r
Fr a ct u r e s
A sif M . Ilyas an d Je sse B. Ju p it e r 227
2 8 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f Ra d ia l
He a d a n d Ne ck Fr a ct u r e s
A n sh u Sin g h , Ge o rg e Fre d e rick Hat ch III,
an d Jo h n M . It am u ra 233
2 9 Ra d ia l He a d Re p la ce m e n t
Y ish ai Ro se n b lat t an d Grah am J. W . Kin g 242
3 0 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
Ole cr a n o n Fr a ct u r e s
David Rin g 252
v ii
v iii CONTENTS

3 1 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
Fr a ct u r e -Dis lo ca t io n s o f t h e Elb o w w it h
Co m p le x In s t a b ilit y
Ju b in B. Payan d e h an d M ich ae l D. M cKe e 259
3 2 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
M o n t e g g ia Fr a ct u r e s in Ad u lt s
M at t h e w L. Ram se y 267
SECTION III PELVIS AND HIP
4 4 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f t h e
Pa t e lla
J. Be n jam in Sm u ck e r an d Jo h n K. So n t ich 416
4 5 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
Bico n d y la r Tib ia l Pla t e a u Fr a ct u r e s
To b y M . Risk o an d W illiam M . Ricci 425
4 6 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
La t e r a l Tib ia l Pla t e a u Fr a ct u r e s
Ph ilip p Ko b b e an d Han s Ch rist o p h Pap e 434

3 3 Ex t e r n a l Fix a t io n o f t h e Pe lv is
St e p h e n Ko t t m e ie r, Jo h n C. P. Flo yd ,
SECTION V LEG
an d Nich o las Divaris 274
4 7 Ex t e r n a l Fix a t io n o f t h e Tib ia
3 4 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f t h e J. Tracy W at so n 441
Sy m p h y s is
4 8 In t r a m e d u lla r y Na ilin g o f t h e Tib ia
M ich ae l S. H. Kain an d Pau l To rn e t t a III 288
M ark A . Le e an d Bre t t D. Crist 454
3 5 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f t h e
4 9 Fa s cio t o m y o f t h e Le g f o r Acu t e
Sa cr o ilia c Jo in t a n d Sa cr u m
Co m p a r t m e n t Sy n d r o m e
He n ry Clau d e Sag i 299
Ge o rg e Part al, A n d re w Fu re y, an d Ro b e rt O’To o le 472
3 6 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f t h e
Po s t e r io r Wa ll o f t h e Ace t a b u lu m
Jo d i Sie g e l an d David C. Te m p le m an 315 SECTION VI FOOT AND ANKLE
3 7 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f 5 0 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
Fe m o r a l He a d Fr a ct u r e s Pilo n Fr a ct u r e s
Darin Frie ss an d Th o m as Ellis 326 Co ry Co llin g e an d M ich ae l Prayso n 483
3 8 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n a n d 5 1 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
Clo s e d Re d u ct io n a n d Pe r cu t a n e o u s Fix a t io n o f In d ir e ct An k le Fr a ct u r e s
Fe m o r a l Ne ck Fr a ct u r e s Ke n n e t h A . Eg o l 499
Brian M u llis an d Je f f A n g le n 333
5 2 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
Ta lu s Fr a ct u r e s
SECTION IV FEM UR AND KNEE David E. Karg e s 509
5 3 Su r g ica l Tr e a t m e n t o f Ca lca n e a l Fr a ct u r e s
3 9 Ce p h a lo m e d u lla r y Na ilin g o f t h e
Jam e s B. Carr 524
Pr o x im a l Fe m u r
Th o m as A . Ru sse ll 345 5 4 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
Lis f r a n c In ju r ie s
4 0 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
M ich ae l P. Clare an d Ro y W . San d e rs 536
Pe r it r o ch a n t e r ic Hip Fr a ct u r e s
M at t h e w E. Oe t g e n an d M ich ae l R. Bau m g ae rt n e r 359 5 5 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f
Jo n e s Fr a ct u r e s
4 1 Re t r o g r a d e In t r a m e d u lla r y Na ilin g o f t h e
W illiam Cre e vy an d Se t h Le vit z 546
Fe m u r
Lau ra S. Ph ie f f e r an d Ro n ald Lak at o s 370
4 2 An t e r o g r a d e In t r a m e d u lla r y Na ilin g
o f t h e Fe m u r EXA M TA B LE 1
Bru ce H. Ziran , Nat alie L. Talb o o , an d Navid M . Ziran 381
4 3 Op e n Re d u ct io n a n d In t e r n a l Fix a t io n o f t h e IN D E X I -1
Dis t a l Fe m u r
A n im e sh A g arw al 394
CONTRIBUTORS

Animesh Agarwal, MD James B. Carr, MD Thomas Ellis, MD

Associate Professor of O rthopaedics Associate Clinical Professor Associate Professor of O rthopaedics
Chief, Division of O rthopaedic Trauma Department of O rthopedic Surgery The O hio State University College of
University of Texas H ealth Science Center University of South Carolina M edicine
at San Antonio Columbia, South Carolina Columbus, O hio
San Antonio, Texas
Michael P. Clare, MD Diego Fernandez, MD
Jeff Anglen, MD, FACS Director of Fellowship Education Lindenhof H ospital
Professor and Chairman of O rthopaedics Foot and Ankle Fellowship Bern, Switzerland
Indiana University School of M edicine Florida O rthopaedic Institute
Indianapolis, Indiana Tampa, Florida John J. Fernandez, MD
Assistant Professor of O rthopaedic Surgery
Carl Basamania, MD, FACS J. Dean Cole, MD Division of H and, Wrist, and Elbow
The Polyclinic First H ill M edical Director Rush University M edical Center
Seattle, Washington Florida H ospital O rthopaedic Institute Chicago, Illinois
Fracture Care Center
Michael R. Baumgaertner, MD O rlando, Florida John C. P. Floyd, MD
Professor Department of O rthopaedic Trauma
Chief, O rthopaedic Trauma Service Cory A. Collinge, MD The M edical Center of Central Georgia
Department of O rthopaedics Director of O rthopedic Trauma M acon, Georgia
Yale University School of M edicine H arris M ethodist Fort Worth H ospital
N ew H aven, Connecticut Staff Physician Darin Friess, MD
John Petter Smith O rthopedic Residency Assistant Professor of O rthopaedics &
Asheesh Bedi, MD Program Rehabilitation
Assistant Professor Fort Worth, Texas O regon H ealth & Science University
Department of O rthopaedic Surgery Portland, O regon
University of M ichigan H ealth System William R. Creevy, MD
Ann Arbor, M ichigan Vice Chairman and Associate Professor of Andrew Furey, MSc, MD, FRCSC
O rthopaedic Surgery Assistant Professor
Pedro K. Beredjiklian, MD Boston University School of M edicine Department of Surgery
Associate Professor of O rthopaedic Surgery Boston M edical Center M emorial University of N ewfoundland
Thomas Jefferson School of M edicine Boston, M assachusetts St. John’s, N ewfoundland, Canada
Chief, H and Surgery Division
The Rothman Institute Brett D. Crist, MD Leesa M. Galatz, MD
Thomas Jefferson School of M edicine Assistant Professor Associate Professor
Philadelphia, Pennsylvania Department of O rthopaedic Surgery Department of O rthopaedic Surgery
University of M issouri Washington University School of M edicine
Kamal I. Bohsali, MD Columbia, M issouri St. Louis, M issouri
Attending O rthopaedic Surgeon, Shoulder
and Elbow Reconstruction Mark T. Dillon, MD Matthew J. Garberina, MD
Department of O rthopaedics Fellow, Shoulder and Elbow Surgery Department of O rthopaedic Surgery
M emorial H ospital Department of O rthopaedic Surgery Summit M edical Group
St. Luke’s H ospital University of Pennsylvania Presbyterian Berkeley H eights, N ew Jersey
St. Vincent’s H ospital M edical Center William B. Geissler, MD
Jacksonville, Florida Philadelphia, Pennsylvania Professor and Chief
Michael R. Boland, MBChB, FRCS, FRACS N icholas Divaris, MD Division of H and and Upper Extremity
Assistant Professor of O rthopaedic Surgery Assistant Professor Surgery
University of Kentucky College of M edicine Department of O rthopaedics Chief
Lexington, Kentucky State University of N ew York at Stony Arthroscopic Surgery and Sports M edicine
Brook Department of O rthopaedic Surgery and
Christopher T. Born, MD Stony Brook, N ew York Rehabilitation
Professor of O rthopaedic Surgery University of M ississippi M edical Center
The Warren Alpert M edical School of Christopher Doumas, MD Jackson, M ississippi
Brown University Clinical Assistant Professor of O rthopaedic
Rhode Island H ospital Surgery Charles L. Getz, MD
Providence, Rhode Island Robert Wood Johnson M edical School Assistant Professor of O rthopaedic Surgery
University of M edicine and Dentistry of Thomas Jefferson University H ospital
David J. Bozentka, MD N ew Jersey Rothman Institute
Associate Professor of O rthopaedic Surgery N ew Brunswick, N ew Jersey Philadelphia, Pennsylvania
University of Pennsylvania
Chief, O rthopaedic Surgery Kenneth A. Egol, MD David L. Glaser, MD
Penn Presbyterian M edical Center Associate Professor Assistant Professor of O rthopaedic Surgery
Philadelphia, Pennsylvania Vice Chairman University of Pennsylvania
Department of O rthopaedic Surgery Chief, Shoulder and Elbow Service
Joanna G. Branstetter, MD N YU H ospital for Joint Diseases Penn Presbyterian M edical Center
O rthopaedic Surgeon N ew York, N ew York Philadelphia, Pennsylvania
M adigan Army M edical Center
San Antonio, Texas
ix
x CONTRIBUTORS
Thomas P. Goss, MD
Professor of O rthopaedic Surgery
Department of O rthopaedics and Physical
Rehabilitation
University of M assachusetts M edical
School
Worcester, M assachusetts
Douglas P. Hanel, MD
Professor of O rthopaedics and Sports
M edicine
University of Washington
H ead, Pediatric H and Surgery Program
Children’s H ospital M edical Center
Seattle, Washington
George Frederick Hatch III, MD
USC O rthopaedic Surgery Associates
Los Angeles, California
Asif M. Ilyas, MD
Director, Temple H and Center
Assistant Professor, O rthopaedic Surgery
Temple University H ospital
Philadelphia, Pennsylvania
John M. Itamura, MD
Associate Professor
Department of O rthopaedic Surgery
University of Southern California
Keck School of M edicine
Los Angeles, California
Peter J. L. Jebson, MD
Associate Professor
Chief, Division of Elbow and H and Surgery
Department of O rthopaedic Surgery
University of M ichigan H ealth System
Ann Arbor, M ichigan
Jesse B. Jupiter, MD
H anstorg Wyss/AO Professor of
O rthopaedic Surgery
H arvard M edical School
Chief, H and and Upper Limb Service
M assachusetts General H ospital
Boston, M assachusetts
Michael S. H. Kain, MD
Chief Resident, O rthopaedic Surgery
Boston University M edical Center
Boston, M assachusetts
David E. Karges, DO
Associate Professor
Department of O rthopaedic Surgery
St. Louis University
St. Louis, M issouri
Graham J. W. King, MD, MSc, FRCSC
Professor of Surgery
Division of O rthopaedic Surgery
University of Western O ntario
H and and Upper Limb Centre
St. Joseph’s H ealth Centre
London, O ntario, Canada
Philipp Kobbe, MD
Department of O rthopaedic Surgery
University of Pittsburgh M edical Center
Pittsburgh, Pennsylvania
Stephen Kottmeier, MD
Associate Professor of O rthopaedics
University H ospital and M edical Center at
Stony Brook
Stony Brook, N ew York
Ronald Lakatos, MD
Assistant Professor of O rthopaedics
The O hio State University M edical Center
Columbus, O hio
Phillip Langer, MD, MS
Assistant Team Physician and O rthopedic
Surgeon
N FL Atlanta Falcons
N H L Atlanta Thrashers
Atlanta Sports M edicine & O rthopedic
Center
Atlanta, Georgia
Mark A. Lee, MD
Associate Professor of O rthopaedic
Surgery–Trauma
University of California, San Francisco
School of M edicine
San Francisco, California
Seth P. Levitz, MD
Department of O rthopaedic Surgery
N orthShore University H ealth System
Evanston, Illinois
Tommy Lindau, MD, PhD
Assistant Professor in H and Surgery
The Pulvertaft H and Unit
Royal Derby H ospital
Derby, United Kingdom
Steven B. Lippitt, MD
Professor of O rthopaedic Surgery
N ortheastern O hio Universities College of
M edicine
Akron General M edical Center
Akron, O hio
Andrew J. Logan, MB, BCh
Department of O rthopaedics
University H ospital of Wales
Cardiff, Wales
Kevin J. Malone, MD
Assistant Professor
Department of O rthopaedic Surgery
M etroH ealth M edical Center
CWRU School of M edicine
Cleveland, O hio
Paul A. Martineau, MD, FRCSC
Assistant Professor
Section of Sport M edicine
Section of Upper Extremity Surgery
Department of O rthopaedic Surgery
M cGill University H ealth Center
M ontreal, Q uebec, Canada
Michael D. McKee, MD, FRCS(c)
Professor
Division of O rthopaedics
Department of Surgery
University of Toronto
Toronto, O ntario, Canada
Robert J. Medoff, MD
Windward O rthopedic Group
Kailua, H awaii
Brian Mullis, MD
Chief and Assistant Professor, O rthopaedic
Trauma Service
Indiana University School of M edicine
Indianapolis, Indiana
Robert O’Toole, MD
Assistant Professor
Department of O rthopaedic Surgery
University of M aryland School of M edicine
Baltimore, M aryland
Matthew E. Oetgen, MD
Clinical Instructor
Department of O rthopaedic Surgery and
Sports M edicine
Children’s N ational M edical Center
Washington, District of Columbia
Brett D. Owens, MD
Assistant Professor
Department of O rthopaedic Surgery
Service
Keller Army H ospital
West Point, N ew York
Hans Christoph Pape, MD
F. Pauwels Professor and Chairman
Department of O rthopaedic Surgery
University of Aachen M edical Center
Aachen, Germany
George Partal, MD
Department of O rthopaedics
Eastern M aine M edical Center
Bangor, M aine
Jubin B. Payandeh, MD, FRCS(c)
Staff Surgeon
Department of Surgery
Big Thunder O rthopaedics
Thunder Bay, O ntario, Canada
Matthew D. Pepe, MD
Sports M edicine Surgeon
The Rothman Institute
Voorhees, N ew Jersey
Laura S. Phieffer, MD
Assistant Professor of O rthopaedics
The O hio State University M edical Center
Columbus, O hio
Michael Prayson, MD
Associate Professor of O rthopaedic Surgery
Wright State University Boonshoft School
of M edicine
M iami Valley H ospital
Dayton, O hio
Vimala Ramachandran, MD
N orthern Arizona O rthopaedics
Flagstaff, Arizona
Matthew L. Ramsey, MD
Associate Professor of O rthopaedic Surgery
Rothman Institute Shoulder and Elbow
Surgery
Thomas Jefferson University
Philadelphia, Pennsylvania
William M. Ricci, MD
Associate Professor
Department of O rthopaedic Surgery
Washington University School of M edicine
St. Louis, M issouri
David Ring, MD, PhD
Associate Professor of O rthopaedic Surgery
H arvard M edical School
Department of O rthopaedic Surgery
M assachusetts General H ospital
Boston, M assachusetts

Toby M. Risko, MD
Assistant Professor of O rthopaedics
Texas Tech University
Lubbock, Texas
Yishai Rosenblatt, MD
O rthopaedic Surgeon
H and and Upper Limb Surgeon
The Unit of H and Surgery and
O rthopaedic Surgery
Tel-Aviv Sourasky M edical Center
The Sackler Faculty of M edicine
Tel-Aviv University
Tel-Aviv, Israel
Thomas A. Russell, BS, MD
Professor of O rthopaedic Surgery
Campbell Clinic/University of Tennessee
Department of O rthopaedics
Elvis Presley Trauma Center
University of Tennessee
Eads, Tennessee
Henry Claude Sagi, MD
Assistant Clinical Professor
Department of O rthopaedic Surgery and
O rthopaedic Trauma Service
University of South Florida
Tampa General H ospital
Tampa, Florida
Joaquin Sanchez-Sotelo, MD, PhD
Associate Professor
Department of O rthopedic Surgery
M ayo Clinic
Rochester, M innesota
Roy W. Sanders, MD
Director, O rthopaedic Trauma Service
Tampa General H ospital
Florida O rthopaedic Institute
Tampa, Florida
Jodi Siegel, MD
Assistant Professor of O rthopaedics
Department of O rthopaedics and Physical
Rehabilitation
University of M assachusetts M edical
School
University of M assachusetts M emorial
M edical Center
Worcester, M assachusetts
CONTRIBUTORS xi
Anshu Singh, MD Thomas F. Varecka, MD
Shoulder and Elbow Surgeon Assistant Professor of O rthopaedic Surgery
Kaiser Permanente University of M innesota
San Diego, California Director, H and and M icrosurgery
H ennepin County M edical Center
J. Benjamin Smucker, MD M inneapolis, M innesota
O rthopaedic Resident
M etrohealth H ospital John J. Walsh IV, MD
Cleveland, O hio Associate Professor
Department of O rthopaedics
John K. Sontich, MD University of South Carolina School of
Associate Professor of Surgery, M edicine
O rthopaedics Columbia, South Carolina
M etrohealth M edical Center
Cleveland, O hio J. Tracy Watson, MD
Professor of O rthopaedic Surgery
Rena L. Stewart, MD Chief, Division of O rthopaedic
Assistant Professor Traumatology
Department of Surgery/O rthopaedics St. Louis University School of M edicine
University H ospital (University of Alabama) St. Louis, M issouri
Birmingham, Alabama
Michael A. Wirth, MD
N atalie L. Talboo, MPAS, PA-C Professor of O rthopaedics
Department of O rthopaedic Trauma The Charles A. Rockwood, Jr., M D Chair
St. Elizabeth H ealth Center University of Texas H ealth Science Center
Youngstown, O hio San Antonio, Texas
Jane S. Tan, MD
Andrew Wong, MD
Department of O rthopaedic Surgery Private Practice
Kaiser Permanente
Arrowhead O rthopaedics
Denver, Colorado Redlands, California
David C. Templeman, MD Assistant Professor—Clinical
Associate Professor of O rthopaedic Surgery Department of O rthopaedic Surgery
University of M innesota Loma Linda University
H ennepin County M edical Center Loma Linda, California
M inneapolis, M innesota Bruce H. Ziran, MD
Paul Tornetta III, MD Associate Professor
Professor and Vice Chairman Department of O rthopaedics
Department of O rthopaedic Surgery N ortheastern O hio Universities College of
Director of O rthopaedic Trauma M edicine
Boston University M edical Center Director of O rthopaedic Trauma
Boston, M assachusetts St. Elizabeth H ealth Center
Youngstown, O hio
Bradford S. Tucker, MD
Clinical Instructor N avid M. Ziran, MD
Department of O rthopaedic Surgery Chief Resident of O rthopaedics
Thomas Jefferson University H ospital Strong M emorial H ospital of Rochester
Egg H arbor Township, N ew Jersey Rochester, N ew York
PREFACE

When a surgeon contemplates performing a procedure, there are three major questions to
consider: Why is the surgery being done? When in the course of a disease process should it
be performed? And, finally, what are the technical steps involved? The purpose of this text
is to describe in a detailed, step-by-step manner the “ how to do it” of the vast majority of
orthopaedic procedures. The “ why” and “ when” are covered in outline form at the begin-
ning of each procedure. H owever, it is assumed that the surgeon understands the basics of
“ why” and “ when,” and has made the definitive decision to undertake a specific case. This
text is designed to review and make clear the detailed steps of the anticipated operation.
O perative T echniques in O rthopaedic T raum a Surgery differs from other books be-
cause it is mainly visual. Each procedure is described in a systematic way that makes liberal
use of focused, original artwork. It is hoped that the surgeon will be able to visualize each
significant step of a procedure as it unfolds during a case.
Each chapter has been edited by a specialist who has specific expertise and experience
in the discipline. It has taken a tremendous amount of work for each editor to enlist talented
authors for each procedure and then review the final work. It has been very stimulating to
work with all of these wonderful and talented people, and I am honored to have taken part
in this rewarding experience.
Finally, I would like to thank everyone who has contributed to the development of this
book. Specifically, Grace Caputo at Dovetail Content Solutions, and Dave M urphy and
Eileen Wolfberg at Lippincott Williams & Wilkins, who have been very helpful and gener-
ous with their input. Special thanks, as well, goes to Bob H urley at LWW, who has adeptly
guided this textbook from original concept to publication.

SWW
January 1, 2010

x iii
RESIDENCY ADVISORY BOARD

The editors and the publisher would like to thank the resident reviewers who participated in the reviews of the manuscript and
page proofs. Their detailed review and analysis was invaluable in helping to make certain this text meets the needs of residents
today and in the future.

Daniel Galat, MD GautamYagnik, MD Catherine M. Robertson, MD

Dr. Galat is a graduate of O hio State Attending Physician Assistant Clinical Professor
University College of M edicine and the M ayo O rthopaedic Surgery UCSD O rthopaedic Surgery—Sports M edicine
Clinic Department of O rthopedic Surgery DRM C Sports M edicine San Diego, California
residency program. Dubois, Pennsylvania
H e is currently serving at Tenwek H ospital in Jonathan Schoenecker, MD
Kenya as an orthopedic surgeon. Gregg T. N icandri, M.D. Assistant Professor
Assistant Professor Departments of O rthopaedics, Pharmacology
Lawrence V. Gulotta, MD Department of O rthopaedics (SM D) and Pediatrics
Fellow in Sports M edicine/Shoulder Surgery University of Rochester Vanderbilt University
H ospital for Special Surgery School of M edicine and Dentistry N ashville, Tennessee
N ew York, N ew York Rochester, N ew York

Dara Chafik, MD, PhD

Southwest Shoulder, Elbow and H and Center
PC
Tuscon, Arizona

xv
 OPERATIVE
TECH N IQUES IN
ORTHOPAEDIC
TRAUMA SURGERY
 Op e r a t iv e Tre a t m e n t o f Fin g e r
Ch a p t e r 1 Ca r p o m e t a ca r p a l Jo in t
Fr a ct u re -Dis lo ca t io n s
Jo h n J. W alsh IV

DEFIN ITION
■ Fractures and dislocations of the carpometacarpal (CM C)
joints of the index through small fingers involve intra-articular
fractures at the base of the metacarpals or pure dislocations
between the metacarpals and carpus. The fracture can involve
the base of the metacarpal or the trapezoid, capitate, or ha-
mate articular surface.
■ These fractures and dislocations can result in instability and
articular incongruity (FIG 1 ).
AN ATOMY
■ The CM C joints connect the metacarpals and the distal
carpal row.
■ The shape and degree of constraint present in the joints
differ from finger to finger.
■ The index and middle fingers have highly constrained ar-
ticulations due to the shape of the index CM C articulation
and supporting soft tissues.4 These include the flexor carpi
radialis tendon, extensor carpi radialis longus and brevis
tendons, and very strong capsular insertions. This provides
for a strong radial column for the hand, and efficient force
transfer to the radius (FIG 2 A).
■ The ring and small fingers have a gliding articulation on the
hamate, which allows for the closure of the hand around ob-
jects and is very important in power grip. This mobility makes
them more susceptible to injury. The extensor carpi ulnaris
tendon attaches to the base of the small finger metacarpal.4
■ The deep motor branch of the ulnar nerve crosses around
the base of the hamate hook and runs along the volar surface
of the CM C joints (FIG 2 B). It is vulnerable at the time of
injury or during fixation.
PATHOGEN ESIS
■ Injuries of the CM C joints may be divided into two broad
categories.
■ The first, involving a load applied to a flexed metacarpal,
is by far the most common mechanism. This injury usually
involves the ring and small fingers displacing dorsally as a
unit relative to the hamate. This may occur as a dislocation
only or include a marginal fracture of the hamate.8
■ The second mechanism involves an axially directed force
that creates a comminuted fracture of the articular surface
(FIG 3 A). Severe crushing injuries can cause multiple disloca-
tions and fractures diffusely throughout the CMC region 1,7
(FIG 3 B,C).
N ATURAL HISTORY
■ The natural result of an untreated fixation dislocation is
progressive arthritis of the involved joints.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ The patient’s history is important to assess the mechanism
of injury, which provides further clues regarding concomitant
injuries in the extremity.

A B

FIG 1 • Mu lt ip le d o rsa l ca rp o m e t a ca rp a l (CMC) d islo ca t io n s in vo lvin g t h e in d e x t h ro u g h sm a ll fin g e rs.

1
2 Se ct io n I HAND, WRIST AND FOREARM
A B
■ Examine the hand for tenderness and local swelling.
■ Assess neurovascular integrity, especially function of the deep
branch of the ulnar nerve (first dorsal interosseous contraction).
■ Examine the limb for other injuries.
■ Associated injuries should be detected by examination and
verified by radiographs.
■ Preoperative notation of nerve function is important when
comparing function following reduction and fixation.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Radiographs of the CM C joints require careful positioning
to assess each joint.
A B
FIG 3 • A. Co m m in u t e d fra ct u re o f t h e fift h m e t a ca rp a l b a se . B,C. Mu lt ip le fra ct u re s a n d d islo ca t io n s in vo lvin g t h e
u ln a r sid e o f t h e h a n d .
FIG 2 • A. Va ria b le a rt icu la r co n g ru it y o f t h e va rio u s CMC
jo in t s. B. De e p m o t o r b ra n ch o f t h e u ln a r n e rve a d ja ce n t t o
t h e m e t a ca rp a l b a se s.
■ The transverse metacarpal arch causes the CMC joints of
the index and middle fingers to appear in an oblique projec-
tion when a standard PA radiograph is obtained of the ring
and small finger CM C joints, and vice versa (FIG 4 A).
■ A true frontal radiograph is most easily obtained by posi-
tioning the hand in an AP projection with the dorsum of the
hand placed flat on the cassette (or image intensifier, if using
fluoroscopy). The base of the affected metacarpal should lie on
the cassette (FIG 4 B). This will result in a far more accurate
portrayal of the joint, essential for assessing the fracture as
well as checking hardware position after fixation.
■ Visualization of the joint surfaces at the base of the ring and
small fingers differs in a typical PA projection (FIG 4 C) and a
properly positioned film of the same patient (FIG 4 D).
C
 Ch a p t e r 1 OPERATIVE TREATM ENT OF FINGER CARPOM ETACARPAL JOINT FRACTURE-DISLOCATIONS 3

A C D

B E

FIG 4 • A. A co n ven t io n a l PA view o f t h e h a n d cre at es an o b liq u e view o f t h e rin g an d sma ll fin g e r b ases. B.
Ha n d p ro p e rly p o sitio n e d fo r AP vie w o f t h e rin g a n d sm a ll fin g e r CMC jo in t s. C. Po st operat ive PA film afte r
o pen re d u ct io n w it h in t e rna l fixa t io n o f th e rin g an d sma ll fin g e r CMC jo in ts. D. AP p ro ject io n clearly sh o ws
th e joint re d uction in t h e sa m e pa t ie n t sho w n in C. E. CT scan o f the fra ct u re of t h e do rsa l lip o f t h e h am ate .

■ The same principle holds for obtaining lateral radiographs. metacarpophalangeal (M CP) joints can develop relatively
A semisupinated lateral view will best visualize the base of the rapidly in hands with the MCP joints immobilized in extension.
index and middle CM C joints,5 and a semipronated lateral ■ Radiographs following cast immobilization should be

view will best show the bases of the ring and small finger checked carefully to ensure that no dorsal subluxation is pres-
CM C joints.2 ent and should be repeated at weekly intervals for the first
■ A CT scan should be obtained in most cases to assess for ar- 2 weeks to prevent healing in a displaced position.
ticular injury. CT also is especially helpful for visualizing im- ■ These injuries, especially those involving a dislocation, have

pacted articular surface fragments. The best visualization and a known propensity for recurrent dorsal subluxation following
determination of fracture patterns will be possible if the scan reduction. M ost will require operative fixation.2,4,9 Some au-
is obtained after preliminary reduction of any displaced frac- thors believe nonoperative management does have a role
tures or dislocations associated with a fracture (FIG 4 E).10 despite intra-articular displacement and shortening.4,13

DIFFEREN TIAL DIAGN OSIS SURGICAL MAN AGEMEN T

■ M etacarpal fracture Preoperative Planning
■ Carpal bone fracture ■ Careful review of all imaging studies will facilitate planning
■ Carpometacarpal fracture/dislocation of fracture fragment exposure and identify sites for internal
■ Fracture associated with neurovascular injury fixation.
N ON OPERATIVE MAN AGEMEN T Positioning
■ N ondisplaced fractures can be treated in a below-elbow cast ■ The patient is positioned supine on the operating table with
that incorporates the affected digit or digits and one adjacent a standard arm table.
digit.5,9 Special attention should be paid to positioning the hand ■ The surgeon often is more comfortable seated on the head

in an intrinsic-plus position. Capsular contractures of the side of the arm table. This avoids the neck strain that may
 4 Se ct io n I HAND, WRIST AND FOREARM

A B

FIG 5 • A. Po sit io n in g o f t h e su rg e o n (o n le ft ) a n d a ssist a n t (rig h t ). B. Skin in cisio n m a rke d w it h p ro b a b le co u rse

o f n e rve .

result from looking “ over the top” that happens when the arm ■ Incisions placed between metacarpals allow access to two
externally rotates and the surgeon is seated on the axilla side adjacent joints.
of the table (FIG 5 A). ■ Cross the wrist with oblique extensions if necessary.

■ M arking out the anticipated locations of nearby nerve

Approach branches can be helpful (FIG 5 B).
■ A dorsal extensile approach provides satisfactory exposure
of any of the CM C joints.
TECHNIQUES

DORSAL EXPOSURE
■ Fo llo w in g in cisio n o f t h e skin , ca re fu l sp re a d in g d isse c-
t io n sh o u ld b e u se d t o lo ca t e a n d p ro t e ct t h e d o rsa l
cu t a n e o u s n e rve b ra n ch e s in t h e o p e ra t ive fie ld .
■ Uln a r se n so ry n e rve s a re m o st co m m o n ly e n co u n -
t e re d d u rin g e xp o su re o f t h e CMC jo in t s o f t h e rin g
a n d sm a ll fin g e rs (TECH FIG 1 ), a n d ra d ia l se n so ry
n e rve s d u rin g e xp o su re o f t h e in d e x a n d m id d le
fin g e r CMC jo in t s.
■ Ext e n so r t e n d o n s a re m o b ilize d a n d re t ra ct e d .

TECH FIG 1 • Do rsa l cu t a n e o u s b ra n ch o f t h e u ln a r n e rve

cro ssin g t h e in cisio n .

FRACTURE EXPOSURE
■ Ca re fu l m o b iliza t io n o f t h e fra ct u re fra g m e n t s w it h m in - ■ Th e ro n g e u r is u se fu l b e ca u se it is h e lp fu l t o d é b rid e
im a l so ft t issu e st rip p in g is im p o rt a n t . fra ct u re ca llu s a n d h e m a t o m a .
■ Th is ca n b e fa cilit a t e d b y t h e u se o f a Be a ve r b la d e , a
d e n t a l p ick, a n d a fin e syn o via l ro n g e u r.

FRACTURE REDUCTION
■ Th e fra ct u re is t h e n re d u ce d a n d h e ld p ro visio n a lly u sin g
fin e K-w ire s (TECH FIG 2 A). Th e su rg e o n m u st b e a w a re
o f t h e p la n n e d lo ca t io n fo r d e fin it ive h a rd w a re p la ce -
m e n t , g ive n t h e lim it e d ro o m a va ila b le .
■ Pin s t e m p o ra rily d rive n a cro ss t h e b a se o f a n a rt icu la r
fra g m e n t in t o t h e co rre sp o n d in g ca rp a l b o n e ca n b e
h e lp fu l in st a b ilizin g a n y m o b ile p ie ce s o f b o n e (TECH
FIG 2 B).
■ Th e co n ve n t io n a l t e ch n iq u e o f first re co n st ru ct in g t h e
a rt icu la r su rfa ce , fo llo w e d b y se cu rin g t h e sh a ft t o t h e
re a sse m b le d jo in t su rfa ce , is u se fu l.
 Ch a p t e r 1 OPERATIVE TREATM ENT OF FINGER CARPOM ETACARPAL JOINT FRACTURE-DISLOCATIONS
B
A Fracture line
C D
■ Confirm at io n of t he p ro visio n a l re d u ct ion sh o uld b e
o bta ined w it h flu oro scop y b e fore a ny d e fin it ive scre w
p lace me nt (TECH FIG 2 C).
■ Th e co rre sp o n d in g a rt icu la r su rfa ce o n t h e u n in ju re d
b o n e is u se d a s a m o ld fo r t h e fra g m e n t s, se rvin g a s a
g u id e t o re a sse m b ly o f t h e in ju re d b o n e .
DEFINITIVE FIXATION
■ Wire s ca n b e re p la ce d b y scre w s if fra g m e n t size p e rm it s
(TECH FIG 3 A).
■ Pla cin g t h e fra g m e n t s u n d e r co m p re ssio n m a n u a lly
a n d in se rt in g scre w s so m e t im e s is p re fe ra b le t o u sin g
t h e la g scre w t e ch n iq u e , w h ich re q u ire s o ve rd rillin g
t h e n e a r sid e a n d m a y risk ia t ro g e n ic co m m in u t io n .
A B
5
TECHNIQUES
Initial K-wire
TECH FIG 2 • A. Pro visio n a l fra ct u re re d u c-
t io n u sin g t h e h a m a t e su rfa ce a s a m o ld
fo r a rt icu la r re d u ct io n o f t h e m e t a ca rp a l
b a se . B. In it ia l re d u ct io n o f t h e sh a ft a n d
st a b iliza t io n o f t h e a rt icu la r su rfa ce . C.
Flu o ro sco p ic vie w o f a rt icu la r re d u ct io n .
D. Do rsa l h a m a t e lip fixa t io n w it h t h re e
scre w s.
■ Th is t e ch n iq u e w o rks re g a rd le ss o f w h e t h e r t h e in ju ry
is in t h e m e t a ca rp a l b a se , a s p ict u re d in t h e se fig u re s,
o r in a d ist a l a rt icu la r in ju ry o f o n e o f t h e ca rp a l
b o n e s (TECH FIG 2 D).
■ Sim p le K-w ire fixa t io n is sa t isfa ct o ry fo r iso la t e d d islo ca -
t io n s w it h fra ct u re (TECH FIG 3 B).
■ Th e in se rt io n p o in t fo r a p e rcu t a n e o u s w ire o ft e n is
q u it e d ist a n t fro m t h e d islo ca t io n sit e in cru sh e d a n d
se ve re ly sw o lle n h a n d s.
TECH FIG 3 • A. Fra ct u re -d islo ca t io n o f t h e
rin g a n d sm a ll fin g e r m e t a ca rp a l b a se s u sin g
p in s a n d a scre w . B. Pe rcu t a n e o u s K-w ire
fixa t io n o f a m e t a ca rp a l sh a ft fra ct u re a n d
CMC d islo ca t io n .
 6 Se ct io n I HAND, WRIST AND FOREARM
TECHNIQUES

ADJUNCTIVE TECHNIQUES
■ Th e co n st ru ct ca n b e p ro t e ct e d b y p la cin g t h e a ffe ct e d
m e t a ca rp a l u n d e r slig h t d ist ra ct io n a n d p in n in g it t o t h e
a d ja ce n t m e t a ca rp a l.
■ Alt e rn a t ive ly, t h e p ro xim a lly d ire ct e d d e fo rm in g fo rce o f
t h e e xt e n so r ca rp i u ln a ris ca n b e re d u ce d b y d e t a ch in g it
fro m t h e b a se o f t h e sm a ll fin g e r m e t a ca rp a l a t t h e b e -
g in n in g o f t h e p ro ce d u re , a n d se cu rin g it t o t h e h a m a t e
a t t h e clo se , t h e re b y a vo id in g p ro xim a l p u ll o n t h e b a se
o f t h e sm a ll fin g e r m e t a ca rp a l.
■ I h a ve n e ve r fo u n d it n e ce ssa ry t o u se t h is a lt e rn a t ive
a p p ro a ch , b u t it m a y b e h e lp fu l in a d e la ye d p re se n -
t a t io n , w h e re m yo st a t ic co n t ra ct u re s d u e t o sh o rt e n -
in g a re p re se n t .

PEARLS AND PITFALLS

Im a g in g ■ En su re t h a t a d e q u a t e ra d io g ra p h s a re a va ila b le fo r in t ra o p e ra t ive re vie w .
■ If n e ce ssa ry, o b t a in a CT sca n .
Po sit io n in g ■ It is o ft e n e a sie r fo r t h e su rg e o n t o b e se a t e d o n t h e o u t sid e o f t h e h a n d t a b le , in st e a d o f in t h e a xilla
b e t w e e n t h e t a b le a n d p a t ie n t , d u e t o t h e lim it e d in t e rn a l ro t a t io n p re se n t in t h e sh o u ld e r, w h ich ca n m a ke
visu a liza t io n d ifficu lt fro m t h e u su a l se a t in g p o sit io n .
Exp o su re ■ Th e d o rsa l cu t a n e o u s b ra n ch o f t h e u ln a r n e rve cro sse s t h e in cisio n o b liq u e ly a n d lie s im m e d ia t e ly a cro ss t h e
o p e ra t ive fie ld fo r e xp o su re o f t h e fo u rt h a n d fift h CMC jo in t s. Cu t t in g t h is n e rve o ft e n is a sso cia t e d w it h ve ry
sym p t o m a t ic n e u ro m a s, a lt h o u g h t h e se n so ry d e ficit is w e ll t o le ra t e d .
Fra ct u re ■ Fra g m e n t s ca n b e sm a ll, a n d p e rio st e a l st rip p in g ca n re su lt in d e vit a liza t io n . Use fra ct u re lin e s fo r visu a liza t io n
management o f t h e a rt icu la r su rfa ce a s m u ch a s p o ssib le . A d e n t a l p ick, fin e K-w ire jo yst icks, a n d p ro visio n a l fixa t io n b e fo re
fin a l scre w in se rt io n ca n b e h e lp fu l. Pro visio n a l fixa t io n sh o u ld b e d o n e w it h ca re fu l a t t e n t io n t o t h e a n t ici-
p a t e d lo ca t io n o f d e fin it ive fixa t io n . Avo id m a lro t a t io n o f t h e sh a ft d u rin g re d u ct io n b y g ra sp in g it t o g e t h e r
w it h o n e o r t w o a d ja ce n t m e t a ca rp a ls w h e n a lig n in g it re la t ive t o t h e jo in t . Sm a ll d e g re e s o f m a lro t a t io n a t
t h e b a se o f t h e m e t a ca rp a l ca n re su lt in su b st a n t ia l d ist a l o ve rla p o f t h e d ig it s.
Po st o p e ra t ive ■ Co n sid e r p la cin g a t e m p o ra ry d ist ra ct io n K-w ire b e t w e e n a d ja ce n t m e t a ca rp a ls t o lim it t h e lo a d p la ce d o n t h e
p ro t e ct io n a rt icu la r su rfa ce b e fo re it h a s h e a le d .

POSTOPERATIVE CARE OUTCOMES

■ Aftercare following operative fixation falls into three general
phases: acute swelling control and wound healing (10–14 days),
fracture consolidation and maintenance of digit range of motion
(4–6 weeks), and restoration of global hand function and
strength (2–6 months).
■ Immediate measures following surgery include strict elevation
■ O pinions on outcomes vary with regard to overall success.
A dichotomy exists between recommendation for operative
and nonsurgical treatment. Kjaer-Petersen and colleagues11
found that, regardless of treatment, long-term symptoms were
present in 38% of patients at 4.3 years of follow-up.
■ Petrie and Lamb, 13 who used immediate, unrestricted mo-

and range-of-motion exercises through a full arc of motion.4 tion, reported on results at 4.5 years. Even with metacarpal
This limits swelling, reduces pain, and prevents accumulation of shortening and irregularities in the articular surface, only one
protein-rich edema fluid that will slow rehabilitation. patient had work limitations.
■ The relative speed at which the hand can be mobilized dur- ■ Another study found that pain was related to the degree of

ing the weeks after surgery depends on a number of factors, posttraumatic arthritis secondary to articular incongruity and
including the magnitude of the original injury, stability of advocated anatomic reductor and internal fixation.12
fixation, reliability of the patient, and specific occupational ■ M ultiple CM C dislocations were reviewed by Lawliss and

or athletic needs. Gunther, and poor results were noted in dislocations of

■ The radiograph in Tech Fig 2D shows the hand of a physi- the second and third CM C joints (which require higher
cian with stable fixation of a dorsal hamate injury who was energy for dislocation) and in those patients with an ulnar
mobilized and given a 1-pound lifting restriction shortly after nerve injury. 7
surgery to allow continuation of his residency training.
■ In contrast, unreliable patients require immobilization for COMPLICATION S
6 weeks in a cast (see Tech Fig 3B). ■ Complications include those common to any periarticular
■ Patients should be warned that full grip strength is the last surgery:
thing that will recover and may take months.2 It is not un- ■ Failure of wound healing

common for patients to report pain with a handshake for an ■ H ematoma formation

extended period of time. ■ N eurovascular injury

 Ch a p t e r 1 OPERATIVE TREATM ENT OF FINGER CARPOM ETACARPAL JOINT FRACTURE-DISLOCATIONS 7

REFEREN CES
1. Bergfield TG, DuPuy TE, Aulicino PL. Fracture-dislocations of all five
carpometacarpal joints: a case report. J Hand Surg Am 1985;10:76–78.
2. Bora FW Jr, Didizian NH. The treatment of injuries to the car-
pometacarpal joint of the little finger. J Bone Joint Surg Am 1974;56A:
1459–1463.
3. Gainor BJ, Stark H H , Ashworth CR, et al. Tendon arthroplasty of the
fifth carpometacarpal joint for treatment of posttraumatic arthritis.
J H and Surg Am 1991;16:520–524.
4. Glickel SZ , Barron O A, Catalano LW. Dislocations and ligament in-
juries in the digits. In Green DP, H otchkiss RN , Pederson WC, et al,
eds. Green’s O perative H and Surgery, ed 5. Philadelphia: Churchill
Livingstone, 2005:364–366.
5. H su JD, Curtis RM . Carpometacarpal dislocations on the ulnar side
FIG 6 • Ra d io g ra p h t a ke n se ve ra l m o n t h s fo llo w in g K-w ire fixa - of the hand. J Bone Joint Surg Am 1970;52:927–930.
t io n o f a fra ct u re -d islo ca t io n o f t h e fift h CMC jo in t . Fra g m e n t s 6. Kjaer-Petersen K, Jurik AG, Petersen LK. Intra-articular fractures at
w e re t o o sm a ll fo r scre w fixa t io n a n d w e re re so rb e d . the base of the fifth metacarpal: a clinical and radiographical study of
64 cases. J H and Surg Br 1992;17:144–147.
7. Lawliss JF III, Gunther SF. Carpometacarpal dislocations. J Bone
■ N euroma formation Joint Surg Am 1991;73A:52–58.
■ Tendon adhesions 8. Lilling M , Weinberg H . The mechanism of dorsal fracture dislocation
■ Posttraumatic arthritis of the fifth carpometacarpal joint. J H and Surg Am 1979;4:340–342.
■ N onunion or malunion 9. Lundeen JM , Shin AY. Clinical results of intraarticular fractures of
■ Joint stiffness
the base of the fifth metacarpal treated by closed reduction and cast
immobilization. J H and Surg Br 2000;25:258–261.
■ Weakness
10. M arck KW, Klasen HJ. Fracture-dislocation of the hamatometacarpal
■ O ccasionally small fragments may resorb, leading to col-
joint: A case report. J Hand Surg Am 1986;11:128–130.
lapse and articular incongruity (FIG 6 ). 11. N iechajev I. Dislocated intra-articular fracture of the base of the fifth
■ Long-term arthritis can be treated with fusion of the metacarpal: a clinical study of 23 patients. Plast Reconstr Surg 1985;
affected joint.4 75:406–410.
■ Alternatively, an interposition “ anchovy” using the pal-
12. Papaloizos M Y, Le M oine PH , Prues-Latour V, et al. Proximal frac-
tures of the fifth metacarpal: a retrospective analysis of 25 operated
maris longus as a biologic spacer can be inserted after cases. J H and Surg Br 2000;25:253–257.
resection of the arthritic joint surfaces, analogous to that 13. Petrie PWR, Lamb DW. Fracture-subluxation of the base of the fifth
performed for thumb basal joint arthritis. 3 metacarpal. H and 1974;6:82–86.
 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 2 Fix a t io n o f Dia p h y s e a l
Fo re a r m Fr a ct u re s
M ich ae l R. Bo lan d

DEFIN ITION ■ With rotation, the radius rotates around the ulna, and the
ulna moves in a varus–valgus direction about 9 degrees at
■ M otion in the human forearm is a complex interaction be-
the elbow. This allows the ulnar head to move out of the
tween the radius and ulna produced by the combination of
way of the rotating radius distally.
multiple muscles working coherently and hinged at the proxi- ■ At the distal radioulnar joint (DRUJ), motion between
mal and distal radioulnar joints.
■ Surgical reconstruction of diaphyseal forearm fractures re-
50 degrees pronation and 50 degrees supination is almost
pure rotation, but at the extremes the radius translates in a
quires precise realignment of both radius and ulna to minimize
dorsal direction during pronation and a palmar direction
complications and maximize function.
■ Ingenious surgical approaches have been described that
during supination.
■ M ovement at the proximal radioulnar joint (PRUJ) is pri-
allow the surgeon to follow defined internervous planes to the
marily rotation.
bones for internal fixation. The design of the forearm allows ■ The radius and ulna have two bows that assist in getting out
near 180-degree rotation combining with considerable elbow
of the other’s way. Schemitsch and Richards22 quantified the
flexion–extension and wrist circumduction. To achieve this,
importance of the distal of the two bows in the radius.
the ulna is enlarged proximally, making it a principal bone of
Restoration of this bow is the single most important step in
the elbow, and is smaller distally, while the reverse is true for
reconstruction of the forearm after diaphyseal fracture.
the radius, with the enlarged radius being the primary articu- ■ To determine whether the bow has been restored after
lation with the carpus. The result for the diaphysis of each
osteosynthesis, draw a line from the biceps tuberosity to
bone is that the proximal ulna is metaphyseal for about 25%
the sigmoid notch. A perpendicular line from the apex can
to 30% of its length but distally less than 10% , with the re-
then be measured (FIG 1 ). The normal range of bow is
verse holding true for the radius. Implant design has taken
15.3 0.3 mm at a point at 60% of the radius measured
these differences into account, with many whole systems avail-
between the bicipital tuberosity and the distal radius at the
able for metaphyseal distal radius and proximal ulna fractures.
■ The importance of maintaining the radial and ulnar heads
sigmoid notch.
■ At the apex of this bow on the convex side is the insertion
has only recently been understood. N ew developments are tak-
of the pronator teres. This provides a biomechanical advan-
ing place, therefore, for the management of distal ulna and
tage for pronation.
proximal radius fractures. ■ The biceps insertion is at the apex of a smaller proximal
■ This chapter discusses ulna fractures distal to the junction of
bow. As a result, the biceps needs to be much larger to
the proximal and middle thirds to the distal margin of the
overcome the disadvantage of insertion into a small bow for
pronator quadratus (PQ ) and radius fractures distal to the bi-
balanced supination.
ceps tuberosity down to the distal flare of the radius. ■ The arrangement in the ulna is the converse of the radius:
■ Pediatric fractures, distal radius and ulna fractures, ole-
a longer shallower proximal bow (the anconeus inserts into
cranon and radial head fractures are not covered.
■ Diaphyseal forearm fractures usually are classified accord-
the apex for valgus of the elbow), and a small distal bow for
the insertion of the PQ .
ing to the AO classification. ■ The radius and ulna are bound together essentially

AN ATOMY throughout their length, with the annular ligament at the

PRUJ, the interosseous ligament through the middle 75% ,
■ The surgical approaches to the forearm bones for fracture
and the ligaments of the triangular fibrocartilage complex
osteosynthesis involve five steps:
■ Finding an interval between longitudinally oriented super-

ficial muscles
■ Finding and preserving vessels and nerves

■ Understanding the anatomy of deeper muscles that cross

the forearm obliquely or transversely

■ Knowing where to lift these muscles to expose the bone

■ Understanding the shape of the bones themselves and

a
their relation to one another x
y
Radius and Ulna
■ M otion of the forearm involves a complex interaction be- Maximum radial bow a (mm)
x
Location of maximum radial bow (%) y− x 100
tween the radius and ulna.
■ The radius rotates around a longitudinal axis that passes
FIG 1 • Th e m e t h o d o f Sch e m it sch a n d Rich a rd s fo r q u a n t ifyin g
through the center of the radial head at the proximal radioul- t h e m a xim u m ra d ia l b o w a n d it s lo ca t io n re la t ive t o t h e le n g t h
nar joint and through the center of the ulnar head distally. o f t h e e n t ire ra d iu s.1

8
 Ch a p t e r 2 ORIF OF DIAPHYSEAL FOREARM FRACTURES
(TFCC) distally. The TFCC ligaments are the palmar and
dorsal radioulnar ligaments, which attach to the distal rim of
the sigmoid notch and the fovea of the ulna. Disruption of
these ligaments often is associated with fractures of the ra-
dius and ulna and may lead to DRUJ incongruity (ie,
Galeazzi fractures) or radial head dislocation (ie, M onteggia
fractures).
Muscles and Ligaments
■ The forearm is criss-crossed with longitudinal, oblique, and
transversely directed musculotendinous units. These muscles
are in layers, with longitudinal muscles more superficial and
crossing muscles deeper.
■ M ost activities performed by the forearm, wrist, and hand
occur from the midpronation position, with the wrist moving
into extension and radial deviation (ERD), then in an arc ac-
celerating past neutral again, to flexion and ulnar deviation
(FUD, end of deceleration) before returning to wrist neutral.
The forearm is designed to maximize the ability to perform
this motion. This wrist motion is commonly known as the
“ dart thrower’s motion” or primary wrist motion.
■ The extensor carpi radialis longus (ECRL), the cocking or
lifting muscle of primary wrist motion, originates proximal to
the lateral epicondyle on the supracondylar ridge, is positioned
“ above” the forearm, and inserts into the radial and dorsal as-
pect of the index metacarpal.
■ O n either side of the ECRL is the brachioradialis (BR),
which originates high on the lateral supracondylar ridge, in-
serting on the radial styloid deep to the first dorsal compart-
ment, and the extensor carpi radialis brevis (ECRB), which
originates more distally just above the lateral epicondyle and
inserts into the long finger metacarpal. ECRL and ECRB share
the second dorsal compartment at the wrist.
■ Together the BR, ECRL, and ECRB form a mobile wad
above the forearm (in the functional position). They are inner-
vated directly by the radial nerve and are best palpated just
distal to the elbow.
■ In a posterior approach to the radius, which is per-
formed in pronation, after incising the deep fascia, the
dissection interval is between the ECRB and the extensor
digitorum communis (EDC) muscle. The EDC originates
from the lateral epicondyle (where it shares a common ori-
gin with the extensor digiti minimi) and passes essentially
in a straight line down the forearm, then through the
fourth dorsal compartment at the wrist, just ulnar to
Lister’s tubercle.
■ In an anterior approach, which is performed in supina-
tion, the deep fascia is incised along the medial border of the
BR. The BR is then mobilized radially and the interval be-
tween it and flexor carpi radialis is developed. The FCR, like
the EDC, has a straight course in the forearm from the me-
dial epicondyle to the scaphoid tubercle (where it passes en
route to the index metacarpal).
■ The muscle of utmost importance in approaches to the ulna
is the flexor carpi ulnaris (FCU). It is the primary accelerator
of the wrist, and thus has a large tendon (equal to the me-
chanical strength of the ECRL and ECRB combined), which
originates from two heads, one from the medial epicondyle
and one from the ulna. It proceeds straight down the forearm
along the ulna border and inserts into the pisiform. From the
distal tip of the lateral epicondyle originates the extensor
carpi ulnaris, which runs down the forearm on the extensor
9
side of the subcutaneous border of the ulna, sharing a septum
with the FCU.
■ The ulna is approached along this septum. The anterior
surface and posterior aspects of the ulna can be approached
this way. The true anterior approach to the ulna is along the
radial edge of the FCU, mobilizing the ulna neurovascular
bundle and going between the FCU and the flexor digitorum
profundus (FDP). The FDP occupies the floor of most of the
flexor compartment of the forearm.
■ Crossing the forearm in its deepest parts are a series of
obliquely oriented muscles. The supinator plays a role in both
the anterior and posterior approaches to the radius. It has two
heads of origin and probably can be thought of as two muscles,
because the fibers of each head traverse in different directions.
■ The ulnar head attaches to the supinator crest on the ra-
dial side of the ulna. Its fibers are transverse (like those of
the PQ distally) and attach to the most proximal part of the
radius, deep to the posterior interosseous nerve (PIN ).
■ The humeral head attaches to the lateral epicondyle, deep
to the ECU and anconeus. Its fibers slope down the forearm
more longitudinally, and wrap over the deep or ulnar head
to attach to the radius distal to the ulnar head of the supina-
tor and proximal to the insertion of the pronator teres.
■ In an anterior approach to the radius, the forearm is
supinated, protecting the PIN , and the humeral head of the
supinator is lifted from its most ulnar attachment.
■ The pronator teres originates mainly from the medial supra-
condylar ridge, arches obliquely across the ulnar artery and me-
dian nerve, and inserts into the apex of the larger bow of the
radius. Proximally, it is superficial, but distally, where it must
be lifted from the radius, it is deep to the BR muscle (FIG 2 ). It
must be lifted from the most radial aspect of the radius in the
anterior approach.
■ Distally in the floor of the anterior compartment the PQ
muscle comes into play in anterior approaches to the radius
and ulna. It must be lifted from the radial border in an ap-
proach to the radius and the ulna border in an approach to
the ulna.
■ In a posterior approach to the radius, the abductor pollicis
longus muscle drapes across the radius just distal to its mid-
point. It can be lifted to allow plate fixation to this part of the
radius. Its ulnar origin is always left intact.
Brachioradialis Superficial radial Supinator
muscle nerve
Radial artery
Pronator teres
Flexor pollicis
longus Flexor digitorum
Flexor digitorum
superficialis profundus
FIG 2 • An t e rio r a p p ro a ch . Th e in t e rva l b e t w e e n t h e b ra ch io ra -
d ia lis a n d fle xo r ca rp i ra d ia lis is e n t e re d , a n d t h e ra d ia l a rt e ry is
re t ra ct e d la t e ra lly. Th e su p in a t o r, p ro n a t o r t e re s, fle xo r p o llicis
lo n g u s, a n d fle xo r d ig it o ru m su p e rficia lis ca n b e se e n .
10 Se c t i o n I HAND, WRIST AND FOREARM
N erves
■ The forearm is traversed longitudinally with three major
nerves plus an additional three sensory nerves, only one of
which is of surgical importance. O nce the interval between
muscles is breached, care is taken to find these nerves. Each
nerve enters the forearm from the arm in a predictable place,
and each gives off key branches that must be protected.
■ Although the radial nerve supplies all the extensor muscles of
the arm and forearm, it is an anterior structure after it pierces
the lateral intermuscular septum 10 cm above the elbow.
■ At the elbow the radial nerve lies between the BR and the
brachialis and gives off the PIN .
■ The radial sensory nerve continues deep to the BR muscle,
on its undersurface. H ere, the nerve generally lies close to
the radial artery. The anterior approach to the radius is
through the interval between the nerve and artery.
■ The posterior interosseous branch leaves the main nerve
just distal to the elbow and passes through the supinator
muscle, between its two heads, to enter the dorsal or exten-
sor compartment of the forearm.
■ As it leaves the supinator, it fans into multiple variable
branches to supply the EDC, EDM , and ECU, with the
majority of the nerve continuing distally deep to the inter-
val between EDC and ECRB.
■ The course of the ulnar nerve is represented by a line drawn
from the medial epicondyle to the pisiform. Throughout the
forearm the nerve is deep to the FCU muscle and lies deep and
slightly radial to the tendon of this muscle at the wrist.
Throughout most of the forearm the nerve is between the FCU
and the FDP.
■ The median nerve enters the forearm between the brachial
artery and the tendon of the biceps brachii. It lies deep to the
pronator teres, then passes deep to the fibrous arch of the FDS.
The nerve is closely associated with the undersurface of the
FDS as it travels distally.
Blood Supply
■ The vascular anatomy is of critical importance in the flexor
compartment.
■ The brachial artery enters the forearm deep to the lacer-
tus fibrosus, next to the median nerve. It almost immedi-
ately branches into radial and ulnar arteries.
■ The ulnar artery passes deep to the arch of origin of the
FDS to lie next to the ulnar nerve throughout the distal two
thirds of the forearm.
■ The radial artery is pushed more superficial by the bulk of
the FDS and the pronator teres lying just deep to the fascia
along the medial border of the BR muscle.
PATHOGEN ESIS
■ The degree of injury and specifics of the fracture are directly
related to the magnitude, direction, and duration of energy.
■ Both-bone forearm fractures are common in motor vehi-
cle trauma.
■ Industrial trauma often is associated with a high level of
soft tissue injury.
■ Forearm fractures occur relatively commonly in some
sports, eg, rugby in all its forms and wrestling.
■ The most common mechanism of injury is a direct blow to
the mid-forearm. If this blow is directed primarily at the ulna,
an isolated ulna shaft fracture results (“ nightstick” fracture).
■ An isolated radius fracture often is associated with a fall
onto an outstretched hand.
N ATURAL HISTORY
■ N ormal function of the human forearm requires the radius
to rotate around the ulna.
■ M atthews15 showed in a cadaveric study that 10 degrees of
angulation of one or both bones of the forearm results in a loss
of 20 degrees of pronation and supination. Thus, the natural
history is highly dependent on the position of healing of the
two forearm bones.
■ It is reasonable to consider nonoperative treatment of an
isolated ulna fracture with less than 10 degrees angulation,21
but nonoperative treatment of both-bone forearm fractures
has a poor outcome.8,13
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ In most cases, the initial presentation of a radius or ulna di-
aphyseal fracture makes the diagnosis obvious. M ost fractures
are displaced due to the high-energy nature of the traumatic
event and, therefore, deformity is common. Patients with
nondisplaced fractures usually have considerable pain and
swelling in the forearm.
■ Despite the ease of initial diagnosis, the treating physician
must be on guard for significant associated injuries and
complications, not only of the bone and joint but also of
soft tissue.
■ A systems approach to these associated injuries is as follows:
■ Sk in: Look at the skin for any evidence of laceration or
abrasion. A laceration may communicate with the fracture
site; therefore, a contaminated abrasion at the site of surgi-
cal incision should be allowed to heal before surgery.
■ Fascia: Tense tissues to palpation over the flexor or exten-
sor compartments and pain with passive finger extension are
evidence of compartment syndrome, and compartment
release must be considered.
■ V ascular: Radial and ulnar pulses distal to the site of in-
jury must be palpated and compared to the uninjured side.
These pulses can be difficult to palpate due to the proximity
of the fractures, so checking capillary refill in the digits is the
next step. In the multiply injured patient, the peripheries are
shut down, making capillary refill and pulses difficult to
perform. In such a situation, a needle stick to the digit
should reveal bright red blood.
■ N erve: Assessment of nerve injury is summarized later in
this chapter.
■ Bone: The joints above and below the fracture must be
palpated for associated joint disruption.
■ For any upper extremity injury, a history of the causative
event is essential to understand the degree of energy that the
limb has had to absorb. Given the common association with
high energy, the patient must be assessed according to an ap-
propriate trauma checklist protocol.
■ The patient must be questioned specifically regarding elbow
or wrist pain, and neurologic symptoms of numbness, tingling,
or unusual sensation in the hand. Severe pain should suggest
the possibility of compartment syndrome or vascular injury.
■ Palpation of the mid-forearm should be gentle, step by step
feeling along the radius and ulna. A tense forearm may indi-
cate a compartment syndrome.
 Ch a p t e r 2 ORIF OF DIAPHYSEAL FOREARM FRACTURES 11

■ Palpation should then proceed over the DRUJ and ulnar
head plus PRUJ and radial head. Palpation should be per-
formed of the medial and lateral epicondyles, of the scaphoid
in the snuff box, and over carpal bones and the car-
pometacarpal joints.
■ A systematic examination of the median, ulnar, and radial
nerves involves examination of sensory and motor aspects
(Table 1).
■ The sensory examination involves static two-point dis-
crimination of the digital nerves and light touch over the
■ O n a lateral radiograph of the elbow, the radial head
should align directly with the capitellum of the distal
humerus. M onteggia 17 in 1814 described a fracture of the
proximal third of the ulna with an anterior radial head dislo-
cation, and Bado 2 later subclassified these according to direc-
tion (FIG 3 ).
DIFFEREN TIAL DIAGN OSIS
■ Pathologic fracture may result from a number of causes.
■ M etabolic causes: osteoporosis, estrogen deficiency,

autogenous zones of each nerve. renal transplantation, vitamin D deficiency, parathyroid

■ M otor examination is graded by M edical Research
disease, Cushing disease, hyperthyroidism, hypogonadism,
Council (M RC) grading and is done by stressing the ap- hypophosphatasia
propriate joint and palpating the affected muscle. ■ Prim ary tum ors: osteosarcoma, Ewing sarcoma and prim-

itive neuroectodermal tumors, chondrosarcoma, myeloma,

IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ H igh-quality plain radiographs of the forearm, wrist, and
elbow are the mainstay of diagnosis of diaphyseal radius and
ulna fractures.
■ M ino 16 described a technique to interpret the lateral wrist
fibrous histiocytoma, desmoplastic fibroma, hemangioma,
intraosseous lipoma, acute myeloid leukemia, Langerhans’
cell histiocytosis, fibrous dysplasia, chondroblastoma
■ M etastatic tum ors: breast, thyroid, lung, prostate,
melanoma
■ Infection: osteomyelitis, tuberculosis

■ Congenital disorders: Turner syndrome, neurofibromato-

radiograph whereby the radial styloid is aligned with the
center of the lunate, and an assessment of the overlap of the sis pseudoarthrosis, osteogenesis imperfecta
■ Iatrogenic fracture: post–plate/screw removal; post–
radius and ulna is made. The head of the ulna should be com-
pletely obscured by the radius. If only part of the ulnar head is osteocutaneous radial forearm flap; post–elbow, forearm, and
obscured by the radius, then there is subluxation of the head; wrist manipulation
■ Stress fracture
if the ulnar head is clearly seen, there is dislocation. Any shift
in the ulnar head is a subluxation and, when combined with a
radius fracture, represents a Galeazzi fracture-dislocation.9 N ON OPERATIVE MAN AGEMEN T
■ A CT scan in neutral, pronation, and supination is useful in ■ Slight deviations in the spatial orientation of the radius and
interpreting the degree of DRUJ congruity. This is rarely used ulna will significantly decrease the forearm’s ability to rotate,
in the acute setting. impairing hand function.

Ta b le 1 M e t h o d s f o r Ne u r o lo g ic Ex a m in a t io n Af t e r Ra d iu s a n d Uln a Fr a ct u r e

Ex a m in a t io n
Median nerve autogenous zone
Ulnar nerve autogenous zone
Radial nerve autogenous zone
First dorsal interosseous
muscle test
Abductor pollicis brevis
muscle test
Extensor pollicis longus
muscle test
Flexor pollicis longus
muscle test
Passive stretch test
Te ch n iq u e
Light palpation over the palmar
aspect of the index MP joint crease
Light palpation over the palmar
aspect of the small finger MP joint
crease
Light palpation over dorsal first
interosseous space
Abduction of first dorsal
interosseous against resistance
Abduction of thumb against
resistance with palpation of
thenar space
Extend the interphalangeal joint
of the thumb against resistance
and hyperadduct thumb while
palpating the extensor pollicis
longus tendon.
Flex interphalangeal joint of thumb
against resistance.
Passively extend all fingers.
Gr a d in g
Compare sides: can be considered
normal, absent, or altered.
Compare sides: can be considered
normal, absent, or altered.
Compare sides: can be considered
normal, absent, or altered.
MRC muscle grading
MRC grading
MRC grading
MRC grading
Severe pain may indicate
compartment syndrome.
Sig n if ica n ce
If altered or absent, consider median
nerve palsy. Examine median
distribution two-point discrimination.
If altered or absent, consider ulnar
nerve palsy. Examine ulnar distribution
two-point discrimination.
If absent, consider radial nerve palsy.
If weak, consider ulnar nerve lesion.
If weak, consider median nerve lesion.
If weak, consider radial nerve palsy.
If weak, consider palsy to anterior
interosseous branch of median nerve.
Consider intracompartmental pressure
monitoring.

MRC, Medical Research Council system.

12 Se c t i o n I HAND, WRIST AND FOREARM
I II
III IV
FIG 3 • Th e Ba d o cla ssifica t io n o f Mo n t e g g ia le sio n s list s fo u r
t yp e s, d e p e n d in g o n t h e d ire ct io n o f t h e ra d ia l h e a d . In t yp e I
le sio n s t h e h e a d is a n t e rio r t o t h e d ist a l h u m e ru s. In t yp e II le -
sio n s it is p o st e rio r, a n d in t yp e III le sio n s it is la t e ra l. Typ e IV
fra ct u re -d islo ca t io n s in vo lve a d islo ca t io n o f t h e ra d ia l h e a d a s-
so cia t e d w it h a fra ct u re o f b o t h t h e ra d iu s a n d t h e u ln a .
■ Fractures of the radius and ulna can be regarded as articu-
lar fractures in the sense that functional restoration requires
anatomic reduction.
■ The only indication for nonoperative treatment is a nondis-
placed fracture of the ulna, 14,21 or if the patient’s general con-
dition makes operative treatment ill advised.
■ In the case of a displaced fracture, closed reduction and
cast immobilization sometimes is possible but is unreliable.
Loss of initial satisfactory reduction is common.3,8,12,13
■ The treatment of choice for adult diaphyseal forearm frac-
tures is open reduction and internal fixation. 1,7,20
SURGICAL MAN AGEMEN T
■ The most common scenario is fractures of the radius and
ulna in the middle third of both bones. The most common
questions confronting the surgeon are considered here.
■ Which approach should be used?
■ The anterior surface of the radius and ulna is the best
location for a plate. This surface is broad and flat on both
bones, and a plate on this surface is covered with muscle,
resulting in less plate irritation for the patient.
■ Consequently, I prefer the anterior approach to both
the radius and the ulna. In addition, the patient is posi-
tioned supine for these approaches, reducing the need to
reposition the patient during the procedure.
■ Should one or two incisions be used?
■ Use of two incisions markedly decreases the risk of syn-
ostosis, decreases the length of the incision, and reduces
tension on the skin and soft tissue by retractors.
■ Which bone should be stabilized first?
■ The fracture with the least comminution should be ap-
proached first and stabilized. This allows for length to be
restored in the forearm, allowing easier judgment of
length in the more comminuted bone.
■ Where there is equal comminution or no comminution,
the radius is generally approached first.
■ Should fixation be completed on one bone before ap-
proaching the other?
■ I recommend not completing fixation but stabilizing
one bone before proceeding to the next. This allows re-
duction of the second bone.
■ In a stable, non-comminuted fracture, “ temporary
stability” may mean a plate and one screw through
two cortices on each side of the fracture. In a comminuted
fracture, it may mean four cortices and two screws on
each side.
■ Completion of fixation should occur after the second
bone is reduced and stabilized.
■ What implant and what length of implant should be used?
■ The plate must span the fracture complex and provide
six cortices of fixation in stable bone, both proximally
and distally.
■ N on-comminuted transverse fractures require at least a
six-hole small fragment limited contact–dynamic com-
pression (LC-DC) or locking plate.
■ O blique fractures and comminuted fractures require a
longer plate. O blique fractures are treated with an inter-
fragmentary screw or screws at right angles to the fracture
line and a seven-hole plate.
■ A unicortical locked screw can be considered “ bicorti-
cal,” but practically speaking, this rule is used only for the
screw hole furthest from the fracture. In almost all situa-
tions there must be three screw holes in the plate over sta-
ble bone away from the fracture complex.
■ In distal metaphyseal, diaphyseal fractures of the ulna,
it often is impossible to get six cortices of fixation. In this
situation, two mini fragment plates (with 2.7-mm screws)
applied at a 90-degree angle to each other provides excel-
lent fixation.
■ Anterior and posterior approaches can be used to treat frac-
tures along the entire length of each bone. The anterior ap-
proach to the radius is preferred when possible.
■ This location allows for excellent soft tissue coverage, re-
ducing the need for plate removal.
■ M ost diaphyseal forearm fractures are best stabilized by
plates and screws, but other implants sometimes are indicated.
■ External fixation may be used in the following settings:
■ O pen fractures with severe soft tissue damage, as a tempo-
rizing measure until reconstruction can safely be undertaken
■ M aintenance of length in fractures with severe bone loss
(this usually occurs in open fractures)
■ Patients with multiple injuries (“ damage control”
surgery)
■ The Ilizarov technique is useful in segmental fractures, es-
pecially when the fractures are very close to the wrist and
elbow joints.
■ Intermedullary nailing is used in the following settings:
■ Young women who desire a better cosmetic result
■ Segmental fractures
■ Re-fracture at the bone plate interface in a contact athlete
or following plate removal
Preoperative Planning
■ The surgeon must develop a strategy to achieve satisfactory
alignment of the radius and ulna with congruency of the PRUJ
and DRUJ.

■ Factors that must be considered include the following:
■ O perating room time and availability (ideally within 7 days
of the injury)
■ Implant and equipment availability (eg, a distraction
device)
■ Patient factors and patient support factors (in outpatient
surgery a supportive family or friend is needed in the early
postoperative period)
■ Regional versus general anesthesia
■ Standard AO planning18 consists of drawing the fragments
on transparent paper; superimposing the transparent sheets to
align the bones; adding a chosen implant template; and draw-
ing the final outcome corresponding to the expected postoper-
ative radiograph. With experience in fracture management,
these steps are intuitive.
■ AO principles of internal fixation using plates and screws
should be reviewed by the surgeon before attempting internal
fixation.
Positioning
■ Generally, the patient is positioned supine and the hand
table is attached to the main table so the midpoint of the hand
table is directly opposite the patient’s shoulder. The shoulder
is directly over the adjoining point of the hand and main
tables. The arm is abducted to 90 degrees at the shoulder, so
the entire arm lies across the midpoint of the hand table.
■ In the case of a posterior approach to the proximal ulna, the
patient is positioned supine and a pillow is placed across his or
ANTERIOR APPROACH TO THE RADIUS
■ Th e a n t e rio r a p p ro a ch t o t h e ra d iu s, first d e scrib e d b y
He n ry,17 is o n e o f t h e cla ssic a p p ro a ch e s in o rt h o p a e d ic
su rg e ry.
■ A st ra ig h t m e t a llic in st ru m e n t is p la ce d o n t h e fo re a rm
skin , a n d a C-a rm im a g e is t a ke n t o ju d g e t h e p o sit io n o f
t h e fra ct u re . Th e skin is m a rke d (TECH FIG 1 A).
■ Th e b ice p s t e n d o n a n d ra d ia l st ylo id a re fo u n d a n d
m a rke d . Th e d ia t h e rm y co rd is e xt e n d e d b e t w e e n t h e se
p o in t s (TECH FIG 1 B), a n d t h e skin in cisio n is m a rke d
ce n t e re d o n t h e fra ct u re sit e (TECH FIG 1 C).
A ■
TECH FIG 1 • An t e rio r a p p ro a ch t o t h e ra d iu s. A. Th e p a t ie n t
is p o sit io n e d su p in e , w it h t h e fo re a rm su p in a t e d . In t h is
im a g e t h e e lb o w is t o t h e le ft a n d t h e w rist t o t h e rig h t . A
st ra ig h t m e t a l in st ru m e n t is p la ce d a cro ss t h e fo re a rm , a n d a
C-a rm flu o ro sco p ic im a g e is t a ke n t o co n firm t h e le ve l o f t h e
fra ct u re . (co n t in u e d )
Ch a p t e r 2 ORIF OF DIAPHYSEAL FOREARM FRACTURES 13
her chest and secured with broad paper tape to the operating
table. A hand table is used to rest the instruments rather than
support the upper extremity. If other forearm fractures are
present, however, the arm table may then be available.
■ A non-sterile tourniquet is applied to the upper arm before
prepping and draping the patient.
■ The surgeon usually is seated on the side of the hand table
closest to the bone being reduced and stabilized.
■ For the anterior approach to the radius, the surgeon is on
the side of the table closest to the patient’s head. The forearm
is supinated and the elbow extended. For a posterior ap-
proach to the radius, the forearm is pronated and the elbow
extended.
■ For a posterior or subcutaneous approach to the ulna, the
elbow is flexed, and the forearm is in a neutral position.
Approach
■ The anterior approach to the radius is the standard ap-
proach for a radius fracture, but the posterior approach is use-
ful when soft tissue lesions are posterior or the anterior ap-
proach is compromised in some way.
■ The posterior or subcutaneous approach to the ulna is the
common approach. I prefer an anterior approach, however,
because the anterior border of the ulna is flat, and, therefore,
the plate fits better and is buried deep to the FCU and FDP
muscles, reducing plate irritation.
■ In general, the incision is 2 cm longer than the implant to be
utilized.
TECHNIQUES
■ Th e skin is in cise d , a n d t h e su p e rficia l t issu e s a re ca re fu lly
d isse ct e d , lo o kin g fo r t h e la t e ra l a n t e b ra ch ia l cu t a n e o u s
n e rve (la t e ra l cu t a n e o u s n e rve o f t h e fo re a rm ) (TECH
FIG 1 D).
■ At t h e le ve l o f t h e d e e p fa scia , a Ra yt e ch (Ra yt e ch
In d u st rie s, Mid d le t o w n , CT) is u se d t o sw e e p t h e so ft t is-
su e s so t h a t t h e u ln a r e d g e o f t h e BR ca n b e se e n (TECH
FIG 1 E).
■ Th e d e e p fa scia is in cise d a lo n g t h e u ln a r e d g e o f t h e BR,
a n d t h e BR is m o b ilize d a n d lift e d (TECH FIG 1 F). Th e ra -
d ia l n e rve a n d ra d ia l a rt e ry a re fo u n d d e e p t o t h e BR.
■ Th e in t e rva l b e t w e e n t h e ra d ia l a rt e ry a n d n e rve is
o p e n e d (TECH FIG 1 G,H), e xp o sin g t h e ra d iu s.
■ Th e ra d ia l a sp e ct o f t h e p ro n a t o r t e re s in se rt io n is d is-
se ct e d o ff t h e ra d ia l sh a ft , in t h is ca se e xp o sin g t h e d is-
t a l fra g m e n t (TECH FIG 1 I).
■ Fo r m o re p ro xim a l e xp o su re , fo llo w t h e ra d ia l se n so ry
n e rve p ro xim a lly t o t h e p la ce w h e re it a n d t h e p o st e -
rio r in t e ro sse o u s n e rve b ifu rca t e (TECH FIG 1 J).
Th e su p in a t o r is d isse ct e d o ff t h e u ln a r a sp e ct o f t h e
ra d iu s t o p ro t e ct t h e PIN, t h u s e xp o sin g t h e p ro xim a l
fra g m e n t (TECH FIG 1 K).
■ Th e fra ct u re is t h e n re d u ce d a n d h e ld fo llo w in g AO p rin -
cip le s. I p re fe r six co rt ice s o f scre w fixa t io n o n e it h e r sid e
o f t h e fra ct u re a n d cu rre n t ly u se t h e Syn t h e s Sm a ll
Fra g m e n t Lo ckin g Co m p re ssio n Pla t e s a s fixa t io n .
 14 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES

B C

D E

F G H

I K

TECH FIG 1 • (co n t in u e d ) B. Th e e st im a t e d le ve l o f t h e fra ct u re is m a rke d . Th e ra -

d ia l st ylo id a n d b ice p s t u b e ro sit y a re m a rke d , a n d t h e d ia t h e rm y co rd is p la ce d
b e t w e e n t h e se t w o p o in t s t o a lig n t h e in cisio n . C. Th e in cisio n is ce n t e re d o n t h e
fra ct u re . Th e le n g t h o f t h e in cisio n d e p e n d s o n fra ct u re co m m in u t io n , t h e p rim a ry
d e t e rm in a n t o f im p la n t le n g t h . Th e m o st co m m o n im p la n t u se d is a se ve n -h o le 3.5-
m m sm a ll fra g m e n t p la t e , a n d t h e in cisio n is 2 cm lo n g e r t h a n t h e im p la n t . D. Th e
in cisio n is m a d e a n d t h e la t e ra l cu t a n e o u s n e rve o f t h e fo re a rm is iso la t e d in t h e su -
p e rficia l fa t a n d p re se rve d . E. Th e in cisio n is co n t in u e d t o t h e d e e p fa scia , a n d t h e
fa scia is sw e p t w it h a Ra yt e ch sp o n g e (Ra yt e ch In d u st rie s, Mid d le t o w n , CT). Th e fa s-
cia is in cise d a t t h e u ln a r e d g e o f t h e b ra ch io ra d ia lis. F. Th e b ra ch io ra d ia lis m u scle
a n d t e n d o n a re m o b ilize d . G. Th e ra d ia l a rt e ry a n d ra d ia l n e rve a re lo ca t e d , a n d t h e
d isse ct io n is co n t in u e d t h ro u g h t h e fa scia b e t w e e n t h e se st ru ct u re s. H. Th e ra d iu s is
e xp o se d o ve r t h e le n g t h o f t h e in cisio n . I. Th e p ro n a t o r t e re s in se rt io n is d isse ct e d
o ff t h e ra d ia l sh a ft fro m t h e ra d ia l a sp e ct o f t h e b o n e , in t h is ca se e xp o sin g t h e d is-
t a l fra g m e n t . J. In t h is im a g e , t h e e lb o w is a t t h e t o p . Fo r p ro xim a l e xp o su re o f t h e
ra d iu s, t h e su p e rficia l ra d ia l n e rve is t ra ce d p ro xim a lly t o t h e p o st e rio r in t e ro sse o u s
b ra n ch . K. Th e e lb o w is t o t h e rig h t in t h is im a g e . Th e su p in a t o r is d isse ct e d fro m t h e
u ln a r a sp e ct o f t h e ra d iu s t o p ro t e ct t h e p o st e rio r in t e ro sse o u s b ra n ch o f t h e ra d ia l
J n e rve , e xp o sin g t h e p ro xim a l fra ct u re fra g m e n t .
 Ch a p t e r 2 ORIF OF DIAPHYSEAL FOREARM FRACTURES 15

POSTERIOR APPROACH TO THE RADIUS
■ Th e p o st e rio r a p p ro a ch t o t h e ra d iu s a lso is kn o w n a s t h e
d o rso la t e ra l a p p ro a ch o r Th o m p so n ’s a p p ro a ch .24
■ List e r’s t u b e rcle is p a lp a t e d a t t h e d o rsa l a sp e ct o f t h e
d ist a l ra d iu s a n d m a rke d . Th e la t e ra l e p ico n d yle o f t h e
h u m e ru s is p a lp a t e d a n d m a rke d .
■ Th e d ia t h e rm y co rd is e xt e n d e d b e t w e e n t h e se b o n y
p ro m in e n ce s, a n d t h e skin in cisio n is ce n t e re d o n t h e
fra ct u re sit e .
■ A st ra ig h t m e t a l in st ru m e n t is p la ce d t ra n sve rse t o
t h e fo re a rm , a n d flu o ro sco p y is u se d t o fin d t h e le ve l
o f t h e fra ct u re sit e , w h ich is m a rke d w it h a t ra n sve rse
lin e .
■ Th e a p p ro a ch u se s t h e t h e o re t ica l in t e rn e rvo u s p la n e b e -
t w e e n t h e ECRB (ra d ia l n e rve ) a n d t h e e xt e n so r d ig it o -
ru m (PIN; TECH FIG 2 A).
TECHNIQUES
■ Th e ECRB is p a rt o f t h e m o b ile w a d o f He n ry, 10 w h ich
a lso in clu d e s t h e BR a n d t h e ECRL. Th is u su a lly ca n b e
p a lp a t e d a n d ca n h e lp g u id e p la ce m e n t o f t h e skin
in cisio n .
■ Aft e r t h e skin in cisio n a n d su p e rficia l d isse ct io n a re p e r-
fo rm e d , t h e in t e rva l b e t w e e n t h e ECRB a n d EDC is
o p e n e d d ist a lly w h e re t h e a b d u ct o r p o llicis lo n g u s t ra n s-
ve rse ly sp a n s t h e fo re a rm (TECH FIG 2 B).
■ Ext e n d in g t h e in t e rva l p ro xim a lly re ve a ls t h e PIN a s it
le a ve s t h e su p in a t o r. He re , it is a lw a ys a cco m p a n ie d b y a
le a sh o f ve sse ls, t h e p o st e rio r in t e ro sse o u s a rt e ry, a n d it s
ve n a e co m m u n ica n t e s.
■ Th e su rg e o n m u st b e ca u t io u s a t t h is st a g e , b e ca u se
a s it le a ve s t h e su p in a t o r, t h e PIN q u ickly g ive s o ff
sm a ll b ra n ch e s t o t h e EDC a n d ECU. Th e m a in n e rve a t

Extensor carpi Extensor carpi Abductor pollicis

radialis longus Extensor carpi Extensor carpi
radialis brevis longus
radialis brevis radialis longus
Abductor pollicis
longus

Extensor pollicis
A Extensor digitorum brevis B

Deep head of supinator

(split)

Posterior interosseous Abductor pollicis Posterior interosseous

Radius
C nerve longus D nerve (preserved)

TECH FIG 2 • Po st e rio r a p p ro a ch t o t h e ra d iu s. A. Aft e r in cisin g t h e d e e p fa scia , t h e in t e rva l b e t w e e n t h e e xt e n so r ca rp i

ra d ia lis b re vis a n d t h e e xt e n so r d ig it o ru m co m m u n is m u scle s is id e n t ifie d . B. Th e in t e rva l b e t w e e n t h e e xt e n so r ca rp i ra -
dia lis b re vis a n d e xt e n so r d ig it o ru m is d e ve lo p e d . C. Fu rt h e r d isse ct io n o f t h e in t e rva l p ro xim a lly w it h sp lit t in g o f t h e
a p o n e u ro t ic o rig in o f t h e e xt e n so rs re ve a ls t h e su p in a t o r a n d t h e p o st e rio r in t e ro sse o u s n e rve a s it le a ve s t h e a rca d e o f
Fro h se . D. De ve lo p m e n t o f t h e in t e rva l b e t w e e n e xt e n so r ca rp i ra d ia lis b re vis a n d e xt e n so r p o llicis lo n g u s re ve a ls t h e ra -
diu s d ist a l t o t h e e xt e n so r p o llicis b re vis. Pro xim a lly, t h e n e rve ca n b e m o b ilize d w h e re it e xit s t h e su p in a t o r if re q u ire d .
Th e p o st e rio r in t e ro sse o u s n e rve sh o u ld b e id e n t ifie d a n d p ro t e ct e d t h ro u g h o u t t h e w h o le p ro ce d u re .
 16 Se c t i o n I HAND, WRIST AND FOREARM

t h is st a g e ca n b e co m e re la t ive ly sm a ll, t a kin g o n t h e in t o t h e fie ld o ve r t h e m id d le ra d iu s, a n d d ist a lly

TECHNIQUES

a p p e a ra n ce o f a b ra n ch . t h e a b d u ct o r p o llicis lo n g u s m u st b e ca re fu lly lift e d

■ Bra n ch e s t o t h e lo n g m u scle s t o t h e t h u m b a lso ca n
co m e o ff re la t ive ly h ig h , g ivin g a fa n -like a p p e a ra n ce
t o t h e n e rve s a n d b ra n ch e s (TECH FIG 2 C).
■ Th e PIN m u st b e m o b ilize d fro m t h e d e e p h e a d o f
su p in a t o r. Th e d e e p h e a d is t h e n sp lit t o re a ch t h e ra -
d iu s p ro xim a lly. Fib e rs o f t h e p ro n a t o r t e re s e n cro a ch
fro m t h e ra d iu s t o p ro vid e ro o m fo r t h e p la t e (TECH
FIG 2 D).
■ Th e fra ct u re is t h e n re d u ce d a n d h e ld w it h a p la t e a n d
scre w s. I p re fe r a lo cke d sm a ll fra g m e n t p la t e (Syn t h e s)
w it h six co rt ice s o n e it h e r sid e o f t h e fra ct u re .
■ Th e d e e p fa scia is clo se d , fo llo w e d b y t h e skin .

ANTERIOR APPROACH TO THE ULNA

■ Th e a n t e rio r a p p ro a ch is m y p re fe rre d a p p ro a ch fo r fixa -
t io n o f t h e d ist a l t w o t h ird s o f t h e u ln a , b e ca u se t h e
p la t e is b u rie d d e e p t o t h e FCU a n d FDP m u scle s a n d t h e
a n t e rio r su rfa ce o f t h e u ln a is fla t , m u ch like t h e a n t e rio r
su rfa ce o f t h e ra d iu s. Th is a llo w s fo r m in im a l co n t o u rin g
o f t h e p la t e a n d m in im a l o ve rh a n g o f t h e p la t e o ve r t h e
b o rd e rs o f t h e b o n e .
■ Th e b o n y la n d m a rks fo r t h e in cisio n a re t h e m e d ia l e p i-
co n d yle o f t h e h u m e ru s a n d t h e u ln a r a sp e ct o f t h e p isi-
fo rm a t t h e w rist .
■ As w it h t h e ra d iu s a p p ro a ch , t h e d ia t h e rm y co rd ca n
b e e xt e n d e d b e t w e e n t h e se t w o p o in t s, a st ra ig h t
m e t a l in st ru m e n t ca n b e p la ce d o n t h e p a t ie n t t ra n s-
ve rse t o t h e lo n g a xis o f t h e fo re a rm , a n d a C-a rm
im a g e t a ke n t o co n firm t h a t t h e in cisio n is ce n t e re d
o n t h e fra ct u re sit e (TECH FIG 3 A).
■ Th e skin in cisio n sh o u ld b e t h ro u g h skin a n d d e rm is o n ly.
■ If t h e fra ct u re is re la t ive ly d ist a l, ca re sh o u ld b e t a ke n t o
a vo id in ju rin g t h e d o rsa l b ra n ch o f t h e u ln a r n e rve ,
w h ich e xit s b e t w e e n t h e FCU a n d t h e u ln a a b o u t 4 cm
p ro xim a l t o t h e u ln a r h e a d .
■ Th e d isse ct io n co n t in u e s d ire ct ly d e e p d o w n t o t h e fa scia
o ve rlyin g t h e FCU m u scle . Th e e p im ysiu m a n d fa scia a re
in cise d in t h e lin e o f t h e in cisio n (TECH FIG 3 B), a n d t h e

C D

TECH FIG 3 • An t e rio r a p p ro a ch t o t h e u ln a . A. Th e ra d ia l in cisio n h a s b e e n t e m p o ra rily clo se d w it h

st a p le s. Th e m e d ia l e p ico n d yle a n d u ln a r a sp e ct o f t h e p isifo rm a re m a rke d . Usin g a sim ila r t e ch n iq u e
t o t h a t d e scrib e d in Te ch Fig 1A, w it h C-a rm flu o ro sco p y a n d d ia t h e rm y le a d , t h e in cisio n is ce n t e re d
o n t h e fra ct u re . B. Th e d e e p fa scia a n d e p im ysiu m o f t h e fle xo r ca rp i u ln a ris a re o p e n e d . Th e fa scia is
m o b ilize d o ff t h e FCU a n d fo llo w e d a ro u n d t h e u ln a r b o rd e r o f t h e m u scle . C. Th e in t e rva l b e t w e e n
t h e fle xo r ca rp i u ln a ris a n d e xt e n so r ca rp i u ln a ris is in cise d , a n d t h e u ln a e xp o se d su b p e rio st e a lly a t
t h e le ve l o f t h e fra ct u re sit e . A Ho h m a n n re t ra ct o r lift s t h e FCU. D. Th e fle xo r d ig it o ru m p ro fu n d u s
a n d d ist a lly t h e p ro n a t o r q u a d ra t u s a re lift e d , t h e fra ct u re is re d u ce d , a n d a lo cke d sm a ll fra g m e n t
p la t e a p p lie d . (Th e e lb o w is t o t h e le ft a n d t h e w rist t o t h e rig h t .)

d isse ct io n co n t in u e s su p e rficia l t o t h e FCU m u scle u ln a rly
a ro u n d o n t o t h e u ln a (TECH FIG 3 C).
■ Disse ct io n is co n t in u e d p ro xim a lly a n d d ist a lly in t h e in -
t e rva l b e t w e e n t h e FCU a n d ECU, a n d t h e fra ct u re is re -
d u ce d a n d h e ld w it h a lo cke d sm a ll fra g m e n t p la t e
(Syn t h e s; TECH FIG 3 D).
POSTERIOR APPROACH TO THE ULNA
■ Th e p o st e rio r a p p ro a ch is p re fe rre d fo r fra ct u re s o f t h e
p ro xim a l t h ird o f t h e u ln a d ia p h ysis b u t ca n b e u se d t o
e xp o se t h e e n t ire u ln a .
■ Distally, the dorsa l branch of the ulna nerve is at risk
where it exits between the FCU and the ulna, but it usu-
ally passes distal to the head of the ulna where it crosses
the ECU tendon sheath and the extensor retinaculum.
■ Th e in t e rva l fo r t h e a p p ro a ch is b e t w e e n t h e ECU a n d
FCU, w h ich sh a re a sh o rt fa scia l se p t u m a lo n g m o st o f
t h e le n g t h o f t h e u ln a .
■ The olecrano n and u lnar h ead can be palpated o n all pa-
tients, and marked. In slim individuals, the fracture and the
FRACTURE REDUCTION AND FIXATION
■ On ce t h e b o n e is re a ch e d b y a n a n t e rio r o r p o st e rio r a p -
p ro a ch , re d u ct io n a n d fixa t io n a re p e rfo rm e d .
■ Bo n e -h o ld in g cla m p s a llo w d e live ry o f t h e fra ct u re e n d s
in t o t h e w o u n d (TECH FIG 4 A).
■ Fo r an o b liq u e fra ct u re , a lo b ste r claw b o n e re d u ct io n
cla m p is p la ce d o n e it h e r sid e o f t h e fra ct u re sit e a n d
angled ab out 30 d egrees to t he longit udinal axis of t he
b one. This allo w s con t ro l of b ot h fra ct u re fra gm en t s.
■ Th e fra ct u re fra g m e n t s a re co m p le t e ly cle a n e d o f a ll so ft
t issu e d e b ris (TECH FIG 4 B).
■ Th e fra ct u re fra g m e n t s a re re d u ce d u sin g lo n g it u d in a l
t ra ct io n a n d ro t a t io n (TECH FIG 4 C).
■ On ce t h is is acco m p lish e d p ro visio n al st ab ility is o b ta in ed
u sin g a b one clam p a cro ss th e fract u re sit e (TECH FIG 4 D).
A B
TECH FIG 4 • Re d u ct io n o f a n o b liq u e fra ct u re . A. A lo b st e r-cla w b o n e re d u ct io n cla m p is p la ce d o n
e it h e r sid e o f t h e fra ct u re sit e a n d a n g le d a b o u t 30 d e g re e s t o t h e lo n g it u d in a l a xis o f t h e b o n e . Ea ch
e n d o f t h e fra ct u re is d e live re d in t o t h e w o u n d . B. Th e fra ct u re fra g m e n t s a re co m p le t e ly cle a n e d o f
a ll so ft t issu e d e b ris. (co n t in u e d )
Ch a p t e r 2 ORIF OF DIAPHYSEAL FOREARM FRACTURES 17
■ I p re fe r t o u se six co rt ice s o f fixa t io n o n e it h e r sid e o f t h e
TECHNIQUES
fra ct u re , b u t t h is is n o t p o ssib le w it h in 3 cm o f t h e u ln a r
h e a d . In t h is sit u a t io n , t w o 2.7-m m m in i-fra g m e n t p la t e s
a re p la ce d a t rig h t a n g le s t o e a ch o t h e r.
■ Th e fa scia a n d e p im ysiu m a re clo se d t o g e t h e r, a n d skin
clo su re fo llo w s.
entire subcutaneous border of the ulna can be palpated.
The incision is centered on the fracture, over the subcuta-
neo us border or in line with the olecrano n an d ulnar head.
■ Th e in cisio n is d e e p e n e d d o w n t o t h e fa scia , a n d in
m o st ca se s t h e e p im ysiu m o ve r t h e ECU is o p e n e d . Th e
u ln a is e xp o se d in t h e in t e rva l b e t w e e n t h e ECU a n d
FCU d ist a lly a n d b e t w e e n t h e FCU a n d a n co n e u s
p ro xim a lly.
■ Th e fra ct u re is re d u ce d a n d h e ld fo llo w in g AO
p rin cip le s w it h a lo cke d sm a ll fra g m e n t p la t e . Th e
p la t e u su a lly is p la ce d o n t h e la t e ra l su rfa ce o f t h e
u ln a .
■ Th e cla m p is t h e n lift e d a n d t h e p la t e slid b e n e a t h a n d
t h e cla m p re p la ce d (TECH FIG 4 E).
■ In it s m id -p o rt io n t h e ra d iu s is b o w e d , b u t t h e p la t e is
st ra ig h t . Th e p la t e w ill a lw a ys a p p e a r t o sit o b liq u e ly
e ve n w h e n p ro p e rly a p p lie d .
■ Th e t w o scre w h o le s clo se st t o t h e fra ct u re a re fille d first ,
fo llo w e d b y p la ce m e n t o f a n in t e rfra g m e n t a ry scre w
(TECH FIG 4 F).
■ In b o t h -b o n e fra ct u re s, t h e se co n d b o n e is n o w a p -
p ro a ch e d a n d st a b ilize d in a sim ila r m a n n e r b e fo re fin a l
fixa t io n o f t h e first fra ct u re .
■ Lo ckin g (TECH FIG 4 G) o r n o n -lo ckin g scre w s a re p la ce d
in t h e re m a in in g o p e n scre w h o le s, a n d fixa t io n is co m -
p le t e (TECH FIG 4 H).
 18 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES

C D

E F

G H
TECH FIG 4 • (cont inued) C. Fractu re red u ct io n is o b t ain ed u sin g lo n g it u d in al t ra ct io n , a n d ro ta tio n ap -
p lie d t hrou g h th e lo bste r cla m p s. D. The lo bste r-cla w b o n e cla mp t e m po ra rily secu re s t h e fra ct u re sit e .
E. The clam p is lift ed a nd the plat e slid bene at h. F. One scre w on each side of th e fract ure a nd closest
to th e fra ct ure is p la ce d first, follo w e d by a n in te rfra g m en t ary screw . G. Lo ckin g g u id es a tt ach ed to t h e
p roxima l t wo ho le s allo w pla ce me n t o f the lo ckin g scre w s in th is Syn t h es p lat e . H. Fixat io n is co m p let e.

PEARLS AND PITFALLS

Pla t e irrit a t io n o n t h e su b cu t a n e o u s
b o rd e r o f t h e u ln a
Pro xim a l e xp o su re o f t h e ra d iu s
a n d t h e p o st e rio r in t e ro sse o u s n e rve
Th e w o u n d is t ig h t a n d d ifficu lt
t o clo se .
Sh o u ld t h e fa scia b e clo se d ?
Dist a l ra d io u ln a r jo in t a n d fo re a rm
ro t a t io n
Pro xim a l ra d io u ln a r jo in t
■ Use a n a n t e rio r a p p ro a ch o n t h e d ist a l h a lf t o t w o t h ird s o f t h e d ia p h ysis a n d p la ce
t h e p la t e o n t h e a n t e rio r (vo la r) su rfa ce . Be ve ry d ilig e n t a b o u t scre w le n g t h , b e ca u se
lo n g scre w s ca n b e fe lt d o rsa lly. Pla ce t h e p la t e m o re p ro xim a lly o n t h e la t e ra l su rfa ce .
■ Wh e n in d o u b t , fin d t h e n e rve . Th is is m a n d a t o ry in a p o st e rio r a p p ro a ch , b u t in a n
a n t e rio r a p p ro a ch fo llo w t h e su p e rficia l ra d ia l n e rve t o it s b ifu rca t io n p ro xim a lly.
■ Le a ve t h e w o u n d o p e n , a d m it t h e p a t ie n t t o t h e h o sp it a l fo r st rict e le va t io n , a n d re visit
t h e o p e ra t in g ro o m in 48 t o 72 h o u rs. Th e w o u n d u su a lly w ill h a ve clo se d a t t h a t t im e .
Th is sce n a rio is fa r m o re p re d ict a b le a n d e a sie r t o d e a l w it h t h a n a co m p a rt m e n t p ro b le m
a n d a w o u n d slo u g h .
■ In m o st p a t ie n t s, t h e fa scia ca n b e sa fe ly clo se d , b u t w h e n it is t e n se , le a ve o p e n a n d
co n sid e r t h e a b o ve .
■ Alw ays e xam in e th e DRUJ fo r st ab ilit y a t th e en d o f t h e case, a n d p u t t h e fo re arm th ro u g h
a ra n g e o f m o t io n . Th e n o b t a in ra d io g ra p h s o f t h e wrist .
■ DRUJ in st a b ilit y ca n b e su b t le a n d m a y n o t b e p icke d u p u n t il la t e .
■ DRUJ p ro b le m s ca n o ccu r in t h e p re se n ce o f a n u ln a fra ct u re .
■ If t h e fo re a rm is n o t a b le t o co m p le t e a fu ll ROM (co m p a re o p p o sit e fo re a rm ), t h a t u su a lly
m e a n s t h e ra d ia l b o w h a s n o t b e e n p re se rve d .
■ As w it h t h e DRUJ a n e lb o w AP a n d la t e ra l sh o u ld b e p e rfo rm e d a t t h e e n d o f t h e ca se .
 Ch a p t e r 2 ORIF OF DIAPHYSEAL FOREARM FRACTURES
POSTOPERATIVE CARE
■ The key points in immediate postoperative care are splint-
ing, pain relief, elevation of the extremity, and watching for
signs of complications.
■ The patient usually receives axillary block anesthesia,
which allows him or her to return home pain-free.
■ A sugartong splint is placed at the time of surgery and is
worn for 2 weeks, at which time the patient returns to the
office for a removal of splint and sutures.
■ N arcotic pain relief usually is ceased at 2 weeks.
■ Radiographs of the wrist, elbow, and forearm are ordered
at the 2-week visit.
■ At the 2-week visit the patient is referred for physical ther-
apy and rehabilitation to work on RO M of the elbow, fore-
arm, and wrist using active and gentle active assisted exercises.
■ From 2 to 6 weeks, the patient is given a 5-pound weight
lifting restriction and is placed on restricted work duty, includ-
ing no repetitive forearm twisting, until union occurs.
■ At 6 weeks, simple two-part fractures usually are united and
all lifting and twisting restrictions are removed. If there is no
evidence of union, the patient is placed on a 20-pound weight
restriction until union has occurred.
OUTCOMES
■ In two-part fracture of the radius and ulna, patients can ex-
pect over 95% problem-free consolidation before 6 months. In
a study by H ertel,11 out of 132 patients there were two de-
layed unions and two non-unions that required reoperation.
Plates were removed from 70 patients (53% ) at a mean of 33.1
months (range 8–122 months) after the first operation. In this
group, there were three refractures (4.3% ) occurring at a mean
of 8.7 months (range 0–14) after plate removal. In another
study by Chapman,7 98% of the fractures united, and 92% of
the patients achieved an excellent or satisfactory functional
result.
■ N onunion rates are much higher in comminuted fractures,
approximately 12% , but it has been shown that bone grafting
primarily does not lead to improved outcomes.19
COMPLICATION S
■ Complications of forearm fractures include compartment
syndrome,6 malunion,25 nonunion,5 and radioulnar synosto-
sis.4 The rate of infection is about 2% .7
■ In a study by Stern 23 of 64 adult patients with 87 diaphyseal
forearm fractures treated by plating, 18 patients (28% ) had a
major complication. There was a nonunion rate four times
higher for bones plated with four screws than six screws, and
screws loosened in three fractures, all involving the ulna.
Radioulnar synostosis occurred in seven forearms, and in five
of these the forearm injuries were associated with multiple-
system trauma involving head injury. Two patients had
osteomyelitis.
■ The surgeon must be aware of the DRUJ and PRUJ disloca-
tion associated with either an isolated or both-bone forearm
fracture.
19
■ With attention to detail, using the appropriate anatomic ap-
proach, accurate reduction, and the use of hardware that pro-
vides adequate bone stability, outcomes from diaphyseal frac-
tures of the forearm are as good as any in orthopaedic surgery.
REFEREN CES
1. Anderson LD, Sisk D, Tooms RE, et al. Compression-plate fixation
in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg
Am 1975;57:287.
2. Bado JL. The M onteggia lesion. Clin O rthop Relat Res 1967;
50:71–86.
3. Bolton H , Q uinlan AG. The conservative treatment of fractures of the
shaft of the radius and the ulna in adults. Lancet 1952;1:700.
4. Botting TD. Posttraumatic radio-ulna cross union. J Trauma 1970;
10:16–24.
5. Brakenbury H , Corea JR, Blakemore M E. N onunion of the isolated
fracture of the ulnar shafts in adults. Injury 1985;12:371.
6. Brostrom LA, Stark A, Svartengren G. Acute compartment syndrome
in forearm fractures. Acta O rthop Scand 1990;61:50–53.
7. Chapman M W, Gordon JE, Z issimos AG. Compression-plate fixa-
tion of acute fractures of the diaphyses of the radius and ulna. J Bone
Joint Surg Am 1989;71A:159–169.
8. Evans EM . Rotational deformities in the treatment of fractures of
both bones of the forearm. J Bone Joint Surg Am 1945;27A:373–379.
9. Galeazzi R. Uber ein Besonderes Syndrom bei Verltzunger im Bereich
der Unteraumknochen. Arch O rthoUnfallchir 1934;35:557–562.
10. H enry AK. Extensile Exposure, 2nd ed. Baltimore: Williams &
Wilkins, 1970.
11. H ertel R, Pisan M , Lambert S, et al. Plate osteosynthesis of diaphy-
seal fractures of the radius and ulna. Injury 1996;27:545–548.
12. H ughston JC. Fracture of the distal radial shaft: M istakes in manage-
ment. J Bone Joint Surg Am 1957;39:249–264.
13. Knight RA, Purvis GD. Fractures of both bones of the forearm in
adults. J Bone Joint Surg Am 1949;31A:755–764.
14. M ackay D, Wood L, Rangan A. The treatment of isolated ulnar frac-
tures in adults: a systematic review. Injury 2000;31:565–570.
15. M atthews LS, Kaufer H , Garver DF, et al. The effect on supination-
pronation of angular malalignment of fractures of both bones of the
forearm. J Bone Joint Surg Am 1982;64A:14–17.
16. M ino DE, Palmar AK, Levinsohn EM . The role of radiography and
computerized tomography in the diagnosis of subluxation and dislo-
cation of the distal radioulnar joint. J H and Surg Am 1983;8:23–31.
17. M onteggia GB. Instituzioni Chirurgiche Vol. 5. M ilano: M aspero,
1814.
18. M uller M E, Allgower M , Schneider R, et al. M anual of Internal
Fixation: Techniques Recommended by the AO -ASIF Group. N ew
York: Springer-Verlag, 1991.
19. Ring D, Rhim R, Carpenter C, et al. Comminuted diaphyseal frac-
tures of the radius and ulna: Does bone grafting affect nonunion rate?
J Trauma 2005;59:438–441.
20. Rosacker JA, Kopta JA. Both bone fractures of the forearm: A review
of surgical variables associated with union. O rthopaedics 1981;
4:1353–1356.
21. Sarmiento A, Latta LL, Z ych G, et al. Isolated ulnar shaft fractures
treated with functional braces. J O rthop Trauma 1998;12:420–423.
22. Schemitsch EH , Richards RR. The effect of malunion on functional
outcome after plate fixation of fractures of both bones of the forearm
in adults. J Bone Joint Surg Am 1992;74:1068–1078.
23. Stern PJ, Drury WJ. Complications of plate fixation of forearm frac-
tures. Clin O rthop Relat Res 1983;175:25–29.
24. Thompson JE. Anatomical methods of approach in operations on the
long bones of the extremities. Ann Surg 1918;68:309.
25. Trousdale RT, Linscheid RL. O perative treatment of malunited frac-
tures of the forearm. J Bone Joint Surg Am 1995;77A:894–902.
 Re d u ct io n a n d St a b iliza t io n
Ch a p t e r 3 o f t h e Dis t a l Ra d io u ln a r Jo in t
Fo llo w in g Ga le a zzi Fr a ct u re s
M ich ae l R. Bo lan d
DEFIN ITION
■ In 1934 Galeazzi7 described a fracture of the junction of the
middle and distal thirds of the radius and called attention to
the associated dislocation or subluxation of the distal radioul-
nar joint (DRUJ).
■ Garcia-Elias and Dobyns8 divided DRUJ dislocations into
three types:
■ Type I: Pure soft tissue dislocations
■ Type II: Intra-articular fracture dislocations where there is
a fracture involving the joint surface of the sigmoid notch of
the radius
■ Type III: Extra-articular DRUJ fracture dislocations for
subdivided
■ Type III fracture-dislocations can be subdivided as follows:
■ IIIa: abnormal joint surface orientation; usually involve
fractures of the distal two thirds of the radius without
complete longitudinal disruption of the forearm
■ IIIb: radioulnar length discrepancy; fractures of the dis-
tal two thirds of the radius with complete longitudinal
disruption of the forearm; also known as Essex-Lopresti
injuries
■ In this chapter, the term G aleazzi fracture-dislocation refers
to a type IIIa (extra-articular) fracture of the distal two thirds
of the radius with any disruption at all of the congruency of
the DRUJ due to soft tissue injury.
■ M anagement of the fractured radius is discussed elsewhere
(see Chaps. H A-8 to H A-13). A fracture of the ulna styloid
commonly is associated with a distal radius fracture. Reduction
and fixation of this fracture is covered in Chapter H A-14.
AN ATOMY
■ During forearm rotation a complex interaction occurs be-
tween the radius and the ulna.
■ From about 50 degrees pronation to 50 degrees supina-
tion there is a nearly pure rotation of the radius around the
ulna, with the center of rotation through the middle of the
ulna head. The ulna moves out of the way of the radius by
virtue of a 9-degree varus–valgus motion that occurs at the
elbow.
■ At 50 degrees supination or pronation, a translational
slide of the radius occurs on the ulna at the DRUJ.
■ In full pronation the radius slides volar, making the ulna
head prominent dorsally. The opposite takes place in full
supination.
■ The head of the ulna is the keystone of the DRUJ. It is flat-
tened distally adjacent to the triangular fibrocartilage disc
and rounded radially articulating with the sigmoid notch of
the radius. The sigmoid notch of the radius is only mildly
concave but is functionally deepened by a horseshoe-shaped
labrum. A flimsy, somewhat loose capsule attached to this
labrum allows the nearly 180 degrees of rotation required of
the forearm.
20
■The capsule is relevant only when it is thickened, causing
a contracture and limitation in forearm motion.12
■ Considerable incongruity exists between the curvature of
the ulna head and sigmoid notch, which, along with the
weak capsule, results in an inherently lax joint.
■ The triangular fibrocartilage is a specialized structure, part
meniscus (to allow compression accommodating the relative
shortening of the radius in pronation) and part ligament. It has
palmar and dorsal fibrous thickenings known as the palmar
and dorsal radioulnar ligaments. These attach to the distal pal-
mar and dorsal rims of the sigmoid notch as separate bundles,
and have superficial fibers that attach to the ulna styloid and
deep fibers that criss-cross to form a weave as they attach to the
foveal fossa of the distal ulna adjacent to the head. These liga-
ments, along with the distal aspect of the interosseous mem-
brane, are the most important primary stabilizers of the DRUJ.
■ During rotation, the deep interdigitating fibers create a
screw home mechanism, similar to the cruciate ligaments of
the knee.
■ In pronation the deep fibers of the dorsal radioulnar liga-
ment are taut and the superficial fibers are lax, whereas the
superficial fibers of the palmar radioulnar ligament are taut
and the deep fibers are lax.10
■ The opposite is true in supination. Avulsion of the foveal
attachment is common in Galeazzi injuries.
PATHOGEN ESIS
■ The most common mechanism of injury is an axial load in
pronation, associated with wrist hyperextension.
■ Acute dislocations of the DRUJ also can occur in supina-
tion. This usually happens after a fall with a rotating body on
an outstretched hand, but also can occur in the workplace
when the forearm is twisted by rotating machinery.8
■ The direction of force is radial to ulnar and proximal to dis-
tal, through the radius fracture down the interosseous mem-
brane, and through the DRUJ.
■ The DRUJ zone of injury includes the capsule, avulsion
of the foveal attachment of the palmar and dorsal radioul-
nar ligament, and tear of the extensor carpi ulnaris (ECU)
subsheath.
N ATURAL HISTORY
■ H ughston,9 in 1957, brought attention to the poor outcome
of these fracture-dislocations without surgical intervention.
The criteria used for a perfect result were very strict, leading
to a judgment of poor results in 92% of cases. This injury
complex has been termed “ the fracture of necessity,” meaning
open reduction and internal fixation of the radius is necessary
for a good result.22
■ M ikic15 drew attention to the significance of the DRUJ in-
jury. H e advocated reduction and percutaneous K-wire fixa-
tion, noting poor results otherwise.
 Ch a p t e r 3 REDUCTION AND STABILIZATION OF THE DRUJ FOLLOWING GALEAZZI FRACTURES 21

■ Experiments have shown that with an artificial osteotomy of
the radius, up to 5 mm of radial shortening occurs.18 Shortening
of more than 10 mm does not occur unless both the interosseous
ligament and the triangular ligament are sectioned.
■ Alexander and Lichtman 2 added another subcategory of
■ It is important to elicit information regarding the degree
of energy associated with the injury. A fall off a ladder from
a height or from a roof is associated with much greater
energy than a ground-level fall.
■ In industrial accidents, the worker will tend to use techni-

Galeazzi injury, those in which closed reduction cannot be cal jargon in referring to machinery, but the examiner must
achieved. The natural history of injuries in this subcategory obtain a layman’s description of the machinery and get an
depends on the recognition and appropriate management of accurate idea of the force the machinery will generate.
neurologic and vascular complications, in addition to the ade- ■ Any motor vehicle accident is associated with high energy.

quacy of reduction and the degree of DRUJ instability. ■ Any crushing component to the injury must be elicited.

■ The DRUJ component of Galeazzi fracture dislocations, ■ Initially, the fracture pain may overwhelm both the patient

after anatomic reduction and fixation of the radius, can be
considered simple (ie, able to be reduced closed) or complex
(ie, requiring open reduction).19 O nce reduced, the DRUJ is re-
examined and judged stable or unstable.
and the examiner. Reassessment of the patient following a
radiograph showing a radius fracture in the presence of an
intact ulna should direct the examiner to the DRUJ as a site
of pathology.
■ The patient must be asked about neurologic symptoms in

PATIEN T HISTORY AN D PHYSICAL the hand, in particular numbness and tingling in the median
FIN DIN GS nerve distribution.
■ Lister 13 stated “ nothing influences the eventual recovery of ■ Acute carpal tunnel syndrome and forearm and hand com-

hand function more than the mechanism and the force of the partment syndromes must be ruled out in the Emergency
injury.” This is certainly true for forearm injuries. Department.
■ Accurate anatomic bone anatomy is required for perfect ■ Forearm swelling and tenderness with dorsal prominence of

functioning of the forearm during rotation. the distal ulna (ie, caput ulna deformity) will be observed.
■ Patients with a Galeazzi fracture-dislocation usually present ■ The entire carpus and the elbow should be palpated to

acutely to an emergency department due to the severity of the rule out any longitudinal forearm injury (ie, Essex Lopresti
pain. injury).
■ Three common mechanisms lead to Galeazzi injuries: falls, ■ Forearm, wrist, and digital motion often are extremely lim-

industrial accidents, and motor vehicle trauma. ited due to pain.

A B C

FIG 1 • In t ra o p e ra t ive d ist a l ra d io u ln a r jo in t (DRUJ) sh u ck t e st . Th e h e a d o f t h e u ln a is h e ld w it h a ch u ck p in ch g rip , a n d t h e w rist a n d

d ist a l ra d iu s a re h e ld w it h a sp a n g ra sp w it h t h e t h u m b e xt e n d e d a cro ss t h e w rist jo in t . Th e ra d iu s is h e ld firm ly a n d t h e u ln a is m o ve d
b a ck a n d fo rt h in a p a lm a r-d o rsa l d ire ct io n . Th e t e st is d o n e first in n e u t ra l (A), t h e n in su p in a t io n (B) a n d in p ro n a t io n (C).
22 Se c t i o n I HAND, WRIST AND FOREARM
Ta b le 1 Sh u ck Te s t
Gr a d e De s cr ip t io n Pa t h o g e n e s is /Dia g n o s is
I 0.5 cm motion at extremes; Probable intrasubstance tearing of either the PRUL
firm endpoint or DRUL
II 0.5 cm motion at extremes; Usually associated with foveal avulsion of the TFCC;
soft endpoint but no can be confirmed by arthroscopy of the DRUJ and
dislocation repaired. No rupture of the distal interosseous
membrane.
III Reduced joint seen before Rupture of distal aspect of interosseous membrane
stress, with dislocation of
the DRUJ at extremes
IV Dislocated joint “Mushy” feeling on stressing joint
DRUJ, distal radioulnar joint; DRUL, distal radioulnar ligament; PRUL, proximal radioulnar ligament.
■ A sensory examination using static two-point testing is
the most reliable Emergency Department examination for sen-
sation. Vascularity is best assessed by examination of radial
and ulnar pulses together with capillary refill in the fingers.
■ O ften the fingers are pale in this situation. A needle stick
to the digital pulp should cause bright red bleeding.
■ The fingers must be passively extended to rule out a forearm
compartment syndrome. Inability to extend the fingers combined
with tense forearm swelling are the best indicators of a compart-
ment syndrome, which if present, necessitates urgent surgery.
■ Patients presenting late, in the office, usually complain of
ulnar-sided wrist pain, pain with activities requiring prono-
supination, and DRUJ instability. In these situations the radius
often is malunited or there is unrecognized bowing of the ulna.
■ The DRUJ is examined initially by direct observation, looking
for a caput ulna deformity. Palpation begins at the radial head,
along the interosseous membrane to the ulnar head. Tenderness
at the DRUJ proper is elicited by palpating the head of the ulna
with the examiner’s thumb and sliding the thumb off the head in
a radial direction. Tenderness just distal to the head dorsally is
associated with a dorsal tear of the triangular fibrocartilage com-
plex (TFCC). A volar tear of the TFCC is tender on palpation of
the ulnar head between the FCU and ECU and when the exam-
iner slides his or her thumb distally over the head.
■ DRUJ laxity is assessed with the elbow flexed 90 degrees.
A shuck test is done on the DRUJ at neutral, full pronation,
and full supination (FIG 1 ), and then compared with the un-
injured wrist.
■ At full rotation, there should be no motion of the radius
relative to the ulna. At neutral, the DRUJ ligaments are
loose and there is about 1 cm of shuck (Table 1).
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Imaging of the patient with a suspected Galeazzi injury con-
sists of plain radiographs of the elbow, forearm, and wrist.
■ The forearm views help in preoperative planning for fixa-
tion of the radius fracture.
■ The wrist views help to determine the degree of disruption
to the DRUJ. O n a posteroanterior (PA) view of the wrist,
the degree of ulna shortening has been shown to differ de-
pending on which structures are torn at the DRUJ.18 Less
than 5 mm of positive variance of the ulna indicates that
Ma n a g e m e n t
Cast in neutral rotation
Cast in midpronation
Repair foveal avulsion as for grade II; pin DRUJ
in midsupination.
Reducible with rotation, consider malposition
of radius fragments if easily dislocatable.
If truly mushy throughout forearm rotation, there is inter-
position of soft tissue, and open treatment is required.
TFCC disruption is unlikely; more than 1 cm indicates in-
terosseous membrane disruption.
■ Mino et al16 described a technique for interpreting the lat-
eral wrist radiograph whereby the radial styloid is aligned
with the center of the lunate and an assessment of the overlap
of the radius and ulna is made. The head of the ulna should
be completely obscured by the radius. If only part of the ulna
head is obscured by the radius, then there is subluxation of
the head, and if the ulnar head is clearly seen, then the joint
is dislocated. In the operating room a C-arm image in neutral
forearm rotation is obtained with the radial styloid in the
mid-lunate position to interpret DRUJ subluxation.
■ A CT scan is very useful in measuring the degree of sublux-
ation or dislocation of the DRUJ. A CT scan in the acute sit-
uation can be useful in interpreting the degree of DRUJ
congruity, but the test is more often performed in the setting
of a chronic injury.
■ This is most reliably interpreted by the radioulnar ratio
(FIG 2 ), calculated as follows:
■ The center of the ulnar head is found using concentric
circles.
■ A line similar to that used in the epicenter method is
drawn from the dorsal and volar margins of the sigmoid
notch (line A-B).
■ A line perpendicular to this line is drawn to the center
of the ulnar head (line C).
■ The AD:AB ratio is the radioulnar ratio. The normal
ratios are 0.5 to 0.71 for pronation, 0.42 to 0.58 for neu-
tral, and 0.19 to 0.55 for supination.
A
D
C
B
FIG 2 • Ra d io ulna r ra t io m et ho d to measure DRUJ su b lu xat ion
o n a CT scan . See te xt fo r d et a ils. (Ad a pt e d fro m Lo IK,
Ma cDe rmid JC, Be n n e tt JD, e t a l. Th e ra d io u ln a r ra t io : A n e w
me tho d o f q u a n tifyin g d ist al ra d io u ln ar jo in t su b luxa tion . J Hand
Su rg Am 2001;26:236–243.)
 Ch a p t e r 3 REDUCTION AND STABILIZATION OF THE DRUJ FOLLOWING GALEAZZI FRACTURES
■ M RI shows foveal avulsion injuries well and is useful for the
assessment of the TFCC.
DIFFEREN TIAL DIAGN OSIS
■ The differential diagnosis of ulnar wrist pain in the presence
of a radius fracture includes:
■ Fracture of the ulna: shaft, metaphysis, head, styloid
■ Triangular fibrocartilage complex injury. Any of the fol-
lowing structures may be injured: fibrocartilage disc, palmar
and dorsal radioulnar ligaments, ulnotriquetral ligament, ul-
nolunate ligament, ECU subsheath.
■ Lunotriquetral ligament: isolated and as part of either a
perilunate dislocation or a longitudinal wrist
■ Carpal fractures: triquetrum, hamate, lunate
■ Essex-Lopresti injury
■ M onteggia fracture-dislocation
■ Elbow fracture-dislocation
■ Stress and pathologic fractures of the radius
N ON OPERATIVE MAN AGEMEN T
■ The only time the radius is not internally fixed is when other
patient factors make such surgery unsafe.
■ In the Emergency Department, the longitudinal injury to the
forearm should be reduced and held in a splint.
■ The reduction maneuver is performed under conscious se-
dation with the thumb and index fingers placed in finger
traps and 10 pounds of traction applied.
■ A sugartong or long-arm splint with an interosseous mold
is applied.
■ Radiographs must be obtained to confirm reduction.
■ If the DRUJ is reduced, then surgery can be delayed for up
to 2 weeks. If the DRUJ remains dislocated, surgery should be
performed within 72 hours.
■ This interval allows an M RI or CT scan to be ordered and
interpreted to plan for the operative procedure.
■ O ptions for nonoperative management of the DRUJ after
fixation of the radius are discussed later in this chapter.
SURGICAL MAN AGEMEN T
■ The key to the management of a Galeazzi fracture is determi-
nation of the degree of injury to the DRUJ. It can be classified
as stable, unstable but reducible, or unstable and irreducible.
■ The following information is considered in deciding whether
the DRUJ is unstable:
■ If, on the initial pre-reduction PA radiograph, the ulna
variance is more than 5 mm positive
■ If frank dislocation remains after evaluation of the post-
reduction lateral radiograph using the M ino technique
(discussed under Imaging And O ther Diagnostic Studies)
ARTHROSCOPICALLY ASSISTED REPAIR OF FOVEAL TFCC AVULSIONS
Art h ro sco p y o f t h e Dist a l
Ra d io u ln a r Jo in t
■ A 1.9-m m sco p e a n d 2.0-m m sh a ve r a re t h e w o rkin g in -
st ru m e n t s fo r DRUJ a rt h ro sco p y.
■ Tw o p rin cip a l p o rt a ls a re u se d .
■ Th e d o rsa l-p ro xim a l DRUJ (PDRUJ) p o rt a l is lo ca t e d in
t h e a xilla o f t h e jo in t , ju st p ro xim a l t o t h e sig m o id
23
■ A foveal avulsion of the TFCC is noted on the preopera-
tive M RI scan.
■ Intraoperative fluoroscopic examination of the DRUJ
after fracture fixation
■ Intra-operative C-arm assessment includes PA and
lateral views in neutral rotation. In most cases the DRUJ
should be reduced following fixation.
■ If increased ulna variance, joint diastasis, or subluxation
of the ulna head is seen, the first possibility to consider is a
malreduction of the radius fracture.
■ M ost importantly, instability is determined by intraoper-
ative physical examination after fracture fixation.
■ Grade I: less than 0.5 cm motion at extremes, with a firm
endpoint. Probable intrasubstance tearing of either the
proximal radioulnar ligament or the DRUL. M anagement
is in a cast in neutral rotation.
■ Grade II: more than 0.5 cm motion at extremes, with a
soft endpoint but no dislocation. This injury usually is as-
sociated with foveal avulsion of the TFCC, which can
be confirmed by arthroscopy of the DRUJ and repaired.
The distal interosseous membrane is not ruptured. Cast in
midsupination.3
■ Grade III: reduced joint prior to stress with dislocation of
the DRUJ at extremes. Requires rupture of the distal aspect
of the interosseous membrane. Repair the foveal avulsion
as in grade II and pin the DRUJ in mid-supination.
■ Grade IV: dislocated joint. “ Mushy” feeling with stress-
ing joint. This joint may be reducible with rotation; con-
sider malposition of radius fragments if easily dislocatable.
If truly mushy throughout forearm rotation, then there is
interposition of soft tissue, and open treatment is required.
Positioning
■ The patient is positioned supine on the operating table with
a hand table, and the affected extremity is abducted at the
shoulder and extended across the table.
■ The hand table is positioned so that it adjoins the main
table at the level of the shoulder. When the extremity is ab-
ducted 90 degrees, it lies in the mid portion of the table.
■ A tourniquet is applied at the mid-humerus level, and a layer
of towels is placed between the humerus and the arm. A layer of
padding is placed on the upper arm just proximal to the elbow,
and the arm is taped firmly to the hand table. This allows trac-
tion to be applied along the axis of the forearm for arthroscopy.
■ Following fixation of the radius, finger traps are applied to
the long and index fingers, and 10 to 12 lb of traction is applied.
Approach
■ The DRUJ can be approached using arthroscopy,28 a mini-
open technique,6 or an open dorsal approach.22
TECHNIQUES
n o t ch o f t h e ra d iu s a n d t h e fla re o f t h e m e t a p h ysis o f
t h e u ln a . It is e a sily p a lp a t e d w it h t h e w rist su p in a t e d ,
w h ich re la xe s t h e d o rsa l ca p su le a n d fa cilit a t e s in t ro -
d u ct io n o f t h e t ro ca r a n d sco p e sh e a t h .
■ Th e jo in t is in su ffla t e d w it h a b o u t 3 m L o f sa lin e (w h ich
h e lp s a s a d ire ct io n g u id e ), t h e skin is in cise d w it h a
n o . 15 b la d e , a n d a h e m o st a t p ie rce s t h e d e e p fa scia a n d
ca p su le , fo llo w e d b y sco p e sh e a t h in se rt io n .
 24 Se c t i o n I HAND, WRIST AND FOREARM

■ Aft e r in it ia l jo in t p e n e t ra t io n , t h e sco p e is w it h d ra w n Re p a ir o f Fo ve a l TFCC Avu lsio n

TECHNIQUES

slig h t ly u n t il t h e sig m o id n o t ch a n d n e ck o f t h e u ln a a re ■ Dia g n o st ic a rt h ro sco p y o f t h e ra d io ca rp a l jo in t m a y re -

b ro u g h t in t o view .
■ Syst e m a t ica lly, t h e st e p s o f a d ia g n o st ic a rt h ro sco p y a re
a s fo llo w s
■ Eva lu a t e t h e sig m o id n o t ch w h ile in su p in a t io n .
■ Lo o k d o w n in t o t h e a xilla o f t h e jo in t (lo o se b o d ie s
so m e t im e s h id e h e re ).
■ Th e sco p e is t h e n sw e p t d ist a lly o ve r t h e h e a d o f t h e u ln a
a n d p u sh e d a n t e rio rly b e t w e e n t h e d isc o f t h e TFCC a n d
t h e se a t o f t h e h e a d w h ile re la xin g t h e ro t a t io n o f t h e
fo re a rm t o n e u t ra l.
■ Ro t a t e in t o p ro n a t io n a n d visu a lize t h e a n t e rio r co m -
p a rt m e n t o f t h e DRUJ.
■ Th e n slig h t ly w it h d ra w t h e sco p e a n d visu a lize t h e fo ve a l
re g io n .
■ Th e d ist a l DRUJ (DDRUJ) p o rt a l is lo ca t e d ju st d ist a l
t o t h e se a t o f t h e u ln a b e t w e e n t h e fift h a n d sixt h
d o rsa l co m p a rt m e n t s. It is a b o u t 5 m m p ro xim a l t o t h e
6R p o rt a l.
■ Th e DDRUJ p o rt a l a llo w s e n t ry o f t h e sco p e b e t w e e n
t h e d isc o f t h e TFCC a n d t h e h e a d o f t h e u ln a .
■ A 21-g a u g e h yp o d e rm ic n e e d le is in se rt e d a s a d ire c-
t io n fin d e r w it h t h e sco p e in t h e PDRUJ p o rt a l.
■ A p ro b e ca n b e in se rt e d t o st re ss t h e u n d e rsu rfa ce o f t h e
TFCC d isc a n d lig a m e n t in se rt io n in t o t h e fo ve a .
■ A sh a ve r a n d o t h e r in st ru m e n t s a lso ca n b e in t ro d u ce d
t h ro u g h t h e DDRUJ p o rt a l.
ve a l a p e rip h e ra l t e a r in t h e TFCC.
■ Mid -ca rp a l a rt h ro sco p y is p e rfo rm e d p rim a rily t o e va lu -
a t e t h e in t e g rit y o f t h e lu n o t riq u e t ra l lig a m e n t .
■ DRUJ a rt h ro sco p y sh o w s t h e st a t u s o f t h e p ro xim a l su r-
fa ce o f t h e TFCC a n d co n firm s a fo ve a l t e a r o f t h e TFCC
(TECH FIG 1 A).
■ A sh a ve r is in t ro d u ce d t h ro u g h t h e DDRUJ p o rt a l t o
d é b rid e t h is a re a (TECH FIG 1 B), a n d t h e m in i C-a rm is
b ro u g h t in t o co n firm p o sit io n o ve r t h e fo ve a .
■ A curette is used to freshen the ulna a t the foveal insertion.
■ Usin g a C-a rm a n d a rt h ro sco p ic g u id a n ce , a 1.8-m m d rill
h o le is m a d e (TECH FIG 1 C–E).
■ Th e DDRUJ p o rt a l is t h e n e n la rg e d t o a b o u t 1 cm in size
w it h t h e d rill b it in p la ce (TECH FIG 1 F).
■ The deep fascia and capsule are opened in line with the
incisio n. A Mit e k Min i Qu ickAnch or (Mit e k Prod uct s,
Norwood, MA) is inserted into the drill hole (TECH FIG 1 G).
■ Ea ch su t u re e n d is p la ce d t h ro u g h t h e TFCC, a n d t h e n e e -
d le is b ro u g h t o u t t h e 6R w in d o w m a d e in t h e ra d io -
ca rp a l ca p su le .
■ Th e su t u re is t h e n t ie d , p u llin g t h e TFCC b a ck t o it s
a n a t o m ic p o sit io n .
■ A DRUJ sh u ck t e st is p e rfo rm e d t o e n su re re st o ra t io n o f
st a b ilit y, t h e w o u n d s a re clo se d , a n d a lo n g -a rm sp lin t is
a d d e d in m id -su p in a t io n .

B C

D E F

TECH FIG 1 • Dia g n o st ic a rt h ro sco p y a n d d ist a l ra d io u ln a r jo in t (DRUJ) a rt h ro sco p e -a ssist e d re p a ir o f t h e t ri-

a n g u la r fib ro ca rt ila g e co m p le x (TFCC). A. Fo ve a l a vu lsio n t ea r. B. Ha n d p la ce m e n t a n d p o rt a l p o sit io n u sin g
1.9-m m sco p e a n d 2.0-m m sh a ve r. C. Ha n d p la ce m e n t fo r d rillin g b e fo re Mit e k a n ch o r in se rt io n . D. Po sit io n o f
t h e m in i–C-a rm , w h ich is b ro u g h t in t o co n firm p la ce m e n t o f t h e d rill b it in t h e fo ve a fo r in se rt io n o f t h e Mit e k
a n ch o r. E. C-a rm im a g e co n firm in g p la ce m e n t o f t h e d rill b it a t t h e fo ve a l in se rt io n o f t h e TFCC. F. Th e d ist a l
DRUJ p o rt a l is o p e n e d t o a b o u t 1 cm , a n d d isse ct io n is ca rrie d d o w n t h ro u g h t h e d e e p fa scia in lin e w it h t h e
in cisio n . Ca re is t a ke n t o a vo id t h e d o rsa l b ra n ch o f t h e u ln a r n e rve . (co n t in u e d )
 Ch a p t e r 3 REDUCTION AND STABILIZATION OF THE DRUJ FOLLOWING GALEAZZI FRACTURES 25

TECHNIQUES
TECH FIG 1 • (co n t in u e d ) G. C-a rm im a g e co n firm in g
G p la ce m e n t o f t h e Mit e k a n ch o r.

ARTHROSCOPICALLY ASSISTED REPAIR OF FOVEAL TFCC AVULSION

WITH RADIOCARPAL ARTHROSCOPY AND OPEN TECHNIQUES
Min i-Op e n Ap p ro a ch
■ In t h e m in i-o p e n a p p ro a ch , a d ia g n o st ic a rt h ro sco p y o f
t h e ra d io ca rp a l jo in t is ca rrie d o u t .
■ Th e 6R p o rt a l sh o u ld b e m a d e in a lo n g it u d in a l o rie n t a -
t io n . Th is is a g u id e fo r cre a t io n o f a lo n g it u d in a l 2- t o
3-cm in cisio n in co rp o ra t in g t h e 6R p o rt a l.
■ Th e in cisio n u su a lly is a b o u t 5 m m d ist a l t o t h e 6R
p o rt a l a n d 2 cm p ro xim a l.
■ Th e dorsal branch o f the u lnar nerve is fou nd in the soft
tissues at the d istal end of the in cision an d is p reserved .
■ Th e d e e p fa scia is in cise d in lin e w it h t h e in cisio n .
■ A 21-g a u g e n e e d le is in se rt e d t h ro u g h t h e ca p su le o f t h e
DRUJ in t o t h e in t e rva l b e t w e e n t h e h e a d a n d t h e p ro xi-
m a l e d g e o f t h e TFCC.
■ Th e jo in t ca p su le is in cise d fro m ju st p ro xim a l t o t h e TFCC
d isc t o t h e m e t a p h ysis o f t h e u ln a .
■ A 21-g a u g e n e e d le is t h e n in se rt e d ju st d ist a l t o t h e TFCC
d isc in t o t h e ra d io ca rp a l jo in t .
■ Th e ra d io ca rp a l jo in t ca p su le is in cise d t ra n sve rse ly a b o u t
6 o r 7 m m (n o t q u it e t o t h e lu n a t e ).
■ The 6R p ort al a lso can be enlarged to se e t he dist al aspect
o f t h e TFCC d isc. Th is g ive s t h e su rg e o n g o od visua liza t ion
o f b oth su rfaces o f t he TFCC disc a n d a sso cia t e d liga me nt s.
Re p a ir o f Fo ve a l TFCC Avu lsio n
■ Th e a vu lse d TFCC is id e n t ifie d a n d d é b rid e d .
■ Th e u ln a r fo ve a is ro u g h e n e d w it h a cu re t t e a n d d rille d
w it h a 1.8-m m b it , a ft e r w h ich a sin g le Mit e k Min i
Qu ickAn ch o r (Mit e k Pro d u ct s, No rw o o d , MA) is in se rt e d
in t o t h e d rill h o le .
■ Th e t o rn u ln a r b o rd e r o f t h e TFCC is t h e n a d va n ce d a n d
su t u re d d o w n t o t h e u ln a r fo ve a (TECH FIG 2 ). Th e su -
t u re o n t h e Mit e k Qu ick An ch o r is d o u b le e n d e d . Ea ch
n e e d le is p a sse d fro m a p ro xim a l t o d ist a l d ire ct io n
a b o u t 5 m m a p a rt , a n d t h e n t h e n e e d le s a re cu t o ff a n d
t h e su t u re s t ie d w it h in t h e ra d io ca rp a l jo in t . I u se a o n e -
h a n d e d su t u re -t yin g t e ch n iq u e . No a d d it io n a l su t u rin g is
n e ce ssa ry.
■ Th e ca p su le , re t in a cu lu m , a n d skin a re clo se d , a n d a st e r-
ile d re ssin g a n d lo n g -a rm sp lin t a re a p p lie d .

TFC
complex

TECH FIG 2 • So t e re a n o s t ria n g u la r fib ro ca rt ila g e co m p le x re -

p a ir. Th e t e ch n iq u e in vo lve s a 3-cm in cisio n ce n t e re d o n t h e
d ist a l a sp e ct o f t h e h e a d o f t h e u ln a . Sm a ll w in d o w s a re cre -
a t e d in t h e ca p su le o f t h e DRUJ a n d t h e ra d io ca rp a l jo in t , a n d
t h e fo ve a l t e a r o f t h e TFCC is id e n t ifie d . (co n t in u e d )
 26 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES

Drill guide

Drill

C D E

TECH FIG 2 • (co n t in u e d ) C. Th e TFCC is lift e d a n d t h e fo ve a cle a re d o f so ft t issu e d e b ris. A b o n e a n ch o r (u su a lly a 2-0 su t u re
m in i-Mit e k) is p la ce d in t h e h e a d o f t h e u ln a a t t h e fo ve a . D. Th e su t u re s a re p a sse d t h ro u g h t h e TFCC. E. Th e su t u re s a re t ie d ,
re p a irin g t h e TFCC b a ck t o it s fo ve a l in se rt io n .

OPEN DRUJ ARTHROTOMY AND TFCC REPAIR11

Tw o -Win d o w Exp o su re o f t h e DRUJ ■ At t h e le ve l o f t h e d e e p fa scia t h e so ft t issu e s a re
sw e p t o ff t h e fa scia in t h e re g io n o f t h e u ln a h e a d
■ Th e fo re a rm is p ro n a t e d a n d e xt e n d e d a t t h e e lb o w .
(TECH FIG 3 B).
■ A d o rsa l in cisio n is m a d e b e g in n in g 3 cm d ist a l t o t h e ■ Th e d ist a l a sp e ct o f t h e a n t e b ra ch ia l fa scia a n d t h e
u ln a r st ylo id .
p ro xim a l 50% o f t h e e xt e n so r re t in a cu lu m a re in cise d
■ Th e in cisio n is ca rrie d p ro xim a lly a t 45 d e g re e s t o t h e
lo n g it u d in a lly b e t w e e n t h e EDM a n d ECU t e n d o n s, a n d
lo n g a xis o f t h e fo re a rm in a ra d ia l d ire ct io n u n t il it
a n u ln a rly b a se d fla p is cre a t e d (TECH FIG 3 C).
re a ch e s t h e d o rsa l a sp e ct o f t h e ra d iu s a t t h e sig m o id ■ A 21-g a u g e n e e d le ca n b e in se rt e d t o a sse ss t h e p ro x-
n o t ch .
im a l a n d d ist a l m a rg in s o f t h e TFCC d isc.
■ At t h is p o in t it is co n t in u e d p ro xim a lly, lo n g it u d in a lly
d o w n t h e fo re a rm fo r a b o u t 7 cm (TECH FIG 3 A).
■ Th e so ft t issu e s a re sp re a d , t a kin g ca re t o p re se rve t h e
d o rsa l se n so ry b ra n ch o f t h e u ln a r n e rve , w h ich p a sse s
o n t o t h e d o rsu m o f t h e h a n d a b o u t 1 t o 2 cm d ist a l t o
t h e u ln a st ylo id .

A B

TECH FIG 3 • Op e n d o rsa l DRUJ a p p ro a ch .

A. Ma rke r o f in it ia l in cisio n . Th e in cisio n is m a d e
3 cm d ist a l t o t h e u ln a r st ylo id a t a 45-d e g re e
a n g le t o w a rd t h e sig m o id n o t ch , t h e n co n t in u e d
p a ra lle l t o t h e in t e ro sse o u s in t e rva l p ro xim a lly
u p t h e fo re a rm . B. Th e d isse ct io n is t a ke n d o w n
t o t h e d e e p fa scia . On t h e fa scia , t h e fift h co m -
p a rt m e n t is cle a rly visu a lize d . C. Th e d e e p fa scia
is o p e n e d w it h a n L sh a p e a lo n g t h e b o rd e r o f
t h e fift h co m p a rt m e n t a n d t h e p ro xim a l e d g e o f
C t h e e xt e n so r re t in a cu lu m . (co n t in u e d )
 Ch a p t e r 3 REDUCTION AND STABILIZATION OF THE DRUJ FOLLOWING GALEAZZI FRACTURES 27

TECHNIQUES
TECH FIG 3 • (co n t in u e d ) D. Th e
d o rsa l ca p su le o f t h e DRUJ a n d
p e rio st e u m o f t h e d ist a l u ln a
a re o p e n e d lo n g it u d in a lly fro m
t h e p ro xim a l e d g e o f t h e TFCC.
E. A se co n d w in d o w is cre a t e d
u ln a r t o t h e ECU t e n d o n fro m
t h e st ylo id . Th e le n g t h o f t h is
D E w in d o w u su a lly is 2 t o 3 cm .

■ Th e ca p su le o f t h e DRUJ is in cise d p ro xim a l t o t h e TFCC ■ Tw o d rill h o le s a re m a d e w it h 0.045-in ch K-w ire s a t a

d isc t o t h e p o in t w h e re it b le n d s w it h t h e p e rio st e u m
o ve r t h e m e t a p h ysis o f t h e u ln a (TECH FIG 3 D).
■ Th e u ln o ca rp a l jo in t ca p su le is o p e n e d t o t h e lu n o t ri-
q u e t ru m .
■ Bo t h ca p su la r in cisio n s a re in lin e w it h re t in a cu lu m –
fa scia l in cisio n .
■ Th e TFCC d isc a n d a sso cia t e d lig a m e n t s, t h e DRUJ, a n d
u ln a r a sp e ct o f t h e ra d io ca rp a l jo in t ca n b e in sp e ct e d .
■ A se co n d , m o re u ln a r w in d o w t o t h e d ist a l u ln a ca n b e
m a d e b y sh a rp d isse ct io n t o t h e u ln a st ylo id a n d ca rrie d
p ro xim a lly p a ra lle l w it h t h e ECU sh e a t h (TECH FIG 3 E).
■ Ca re is t a ke n t o a vo id o p e n in g t h e EDM a n d ECU
sh e a t h s.
TFCC Re p a ir
■ Th e p e rip h e ra l fo ve a l a vu lsio n is d é b rid e d , a n d t h e fo ve a
fre sh e n e d w it h a cu re t t e .
45-d e g re e a n g le a b o u t 1 cm fro m t h e a rt icu la r su rfa ce
o f t h e h e a d o f t h e u ln a , d ire ct e d fro m t h e m e d ia l co r-
t e x o f t h e u ln a a n d e xit in g a t t h e u ln a r fo ve a .
■ Th e h o le s a re p a ra lle l, b e g in n in g 1 cm a p a rt , a n d
co n ve rg e t o w a rd t h e fo ve a .
■ A t ra n sve rse a rt h ro t o m y is m a d e in t h e ra d io ca rp a l
ca p su le a t t h e d ist a l e d g e o f t h e TFCC d isc.
■ Th re e se p a ra t e lo o p s o f a 3-0 b ra id e d n ylo n su t u re a re
p a sse d t h ro u g h o n e h o le , t h ro u g h t h e p e rip h e ra l TFCC,
a n d b a ck o u t t h e o t h e r h o le , a n d t ie d in d ivid u a lly o ve r
t h e m e d ia l u ln a .
■ Th e ca p su lo t o m y in cisio n s a re clo se d first , t h e n t h e re t i-
n a cu lu m is clo se d , a n d fin a lly t h e skin is clo se d .
■ Tw o 0.062-in ch K-w ire s a re p la ce d t h ro u g h t h e u ln a a n d
in t o t h e ra d iu s in a n e u t ra l p o sit io n (TECH FIG 4 ).
■ Th e ca p su le , re t in a cu lu m –fa scia , a n d skin a re clo se d in
la ye rs.

Everted TFCC

3 3-0 sutures

Groove

3 3-0 sutures

0.062 K-wire

A B

TECH FIG 4 • Re p a ir o f t h e TFCC. A. Th re e 3-0 n o n a b so rb a b le su t u re s a re p la ce d t h ro u g h t h e re t ra ct e d m e d ia l

TFCC a n d p a sse d t h ro u g h h o le s a t t h e m e d ia l b a se o f t h e u ln a st ylo id . B. Be fo re t ig h t ly su t u rin g t h e TFC t o t h e
p re p a re d t ro u g h , t h e d ist a l ra d io u ln a r re la t io n sh ip is se cu re d b y t w o p e rcu t a n e o u s 0.062-in ch K-w ire s p la ce d
t h ro u g h t h e u ln a in t o t h e ra d iu s in n e u t ra l p o sit io n . Ca re m u st b e e xe rcise d t o a vo id in ju ry t o t h e DRUJ.

OPEN DRUJ ARTHROTOMY AND TFCC RECONSTRUCTION USING

A PALMARIS GRAFT1
■ Ra re ly, t h e TFCC ca n b e co m p le t e ly sh re d d e d is e xcise d and re co n st ru ct e d u sin g a p a lm a ris
in a h ig h -e n e rg y in ju ry. In t h is in st a n ce t h e TFCC g ra ft .
28 Se c t i o n I HAND, WRIST AND FOREARM

PEARLS AND PITFALLS

Asse ssm e n t o f DRUJ
in st a b ilit y
Irre d u cib le DRUJ a ft e r
ra d ia l fixa t io n
Difficu lt y in t e rp re t in g
DRUJ sh u ck t e st
Difficu lt y in g e t t in g in t o
t h e jo in t fo r DRUJ
a rt h ro sco p y
■ Th e in it ia l PA vie w o f t h e w rist w ill sh o w m o re t h a n 5 m m o f u ln a sh o rt e n in g . Th e in it ia l la t e ra l
ra d io g ra p h w ill sh o w d o rsa l su b lu xa t io n o f t h e u ln a . A p re o p e ra t ive MRI sca n w ill sh o w in cre a se d
sig n a l (w h it e ) in t h e TFCC a n d a n a vu lsio n o f t h e TFCC a t t h e fo ve a . A p o sit ive sh u ck t e st w ill b e
p re se n t in t ra o p e ra t ive ly (t h is is t h e m o st im p o rt a n t t e st ). A su b lu xe d u ln a w ill b e se e n in t h e la t e ra l
in t ra o p e ra t ive C-a rm vie w .
■ Co n sid e r la ck o f a n a t o m ic re d u ct io n o f t h e ra d iu s. Ra d ia l b o w w ill n o t h a ve b e e n fu lly re st o re d .
Th is is e sp e cia lly p re va le n t in t h e se g m e n t a l o r co m m in u t e d ra d iu s. If co n vin ce d t h e ra d iu s is
a n a t o m ic, t h e n e xp lo re t h e DRUJ w it h o p e n t e ch n iq u e . Th e ECU a n d t h e e xt e n so r d ig it is m in im i o f
t h e u ln a r st ylo id a re co m m o n ly in t h e jo in t .
■ En su re fo re a rm is in fu ll su p in a t io n o r p ro n a t io n . Th e re sh o u ld b e n o m o t io n a t t h e DRUJ b e t w e e n
t h e ra d iu s a n d t h e u ln a . If t h e re is a n y m o t io n t h e n t h e re is like ly t o b e in st a b ilit y, a n d a t t h e ve ry
le a st , a lo n g -a rm ca st in m id -su p in a t io n sh o u ld b e a p p lie d .
■ Re d u ce t ra ct io n t o a b o u t 5 lb . Use a 1.9-m m sco p e , a n d u se a 21-g a u g e n e e d le a n d sa lin e t o
in su ffla t e t h e jo in t . Pla ce t h e fo re a rm in su p in a t io n . Pu sh t h e t ro ca r in t o t h e n e ck o f t h e u ln a
(ie , b e t w e e n t h e ra d iu s a n d u ln a ).

POSTOPERATIVE CARE was that rigid internal fixation is necessary for the disloca-
tion as well as the fracture.
■ All of the following protocols assume that rigid and stable ■ So-called “ isolated” fractures of the radial diaphysis, where
fixation of the radius fracture has been obtained.
■ Stable DRUJ
there is less than 5 mm of positive ulna variance, are more
■ The patient is placed in a sugar-tong splint for 2 weeks,
common than true Galeazzi fractures. Fractures without iden-
tifiable radioulnar disruption can be treated without specific
and is given a Carter block arm pillow for strict elevation
treatment of the DRUJ and with immediate mobilization.23 In
and encouragement of finger and thumb motion.
■ At 2 weeks, the patient returns to the office for suture and
this situation, patients with anatomic fracture reduction have
minimal sequelae and better or equal functional results than
splint removal.
■ The patient is referred to a hand therapist for active, pas-
patients with imperfect reduction.20
■ In a series of 50 Galeazzi fracture dislocations treated by
sive, and gentle resisted motion up to 10 lbs resistance.
■ M otion of all joints from the elbow distally is encouraged.
early open reduction and internal fixation, Mohan et al17
■ Further resistance and weight bearing depend on union of
found, at 1 year, 40 good, 8 fair, and 2 poor results. Their con-
clusion was that early open reduction and rigid internal fixa-
the radius.
■ Usually, union occurs by 6 weeks and restrictions are lifted.
tion re-establishes the normal relation of the fractured frag-
■ Return to work status depends on the level of repetition
ments and the DRUJ without repair of the ligaments. Thus, in
many situations, ligament repair is unnecessary. (However, in
and lifting required by the patient’s job.
■ Rehabilitation following bone anchor fixation of a foveal
Mohan et al’s series, 1 in 5 had a less than good result.)
■ Rettig and Raskin, 21 in a more recent series, found that the
avulsion of the TFCC and full palmaris graft reconstruction
■ Long-arm splint, elbow at 90 degrees, forearm in mid-
more distal the fracture the greater the likelihood of DRUJ dis-
ruption. In this series, 12 out of 22 fractures within 7.5 cm of
supination, wrist neutral; fingers not included
■ At 2 weeks the patient returns to the office for suture re-
the midarticular surface of the distal radius had intraoperative
DRUJ instability, whereas only one of 18 more proximally
moval and the arm is placed in a cast in the same position.
■ Four weeks later (ie, 6 weeks postoperatively), the cast is
were unstable. Their conclusion was that a high index of sus-
picion, early recognition, and acute treatment of DRUJ insta-
removed and active gentle passive motion is begun to all
bility will avoid chronic problems in this complex injury.
joints from the elbow distally. ■ This high index of suspicion will lead to the recognition
■ At 12 weeks postoperatively, graduated lifting activity is
that dislocations of the DRUJ associated with fractures of the
begun, and continues for 6 more weeks.
■ At week 18 all restrictions are removed.
forearm often are irreducible. 5 These have been termed
■ O pen foveal repair and K-wire
“ complex” DRUJ dislocations: dislocations characterized by
■ At 6 weeks, K-wires are removed.
obvious irreducibility, recurrent subluxation, or “ mushy” re-
■ Begin protocol as for bone anchor fixation.
duction caused by soft tissue or bone interposition.
■ With the advent of internal fixation of the radius, most

Galeazzi fractures are predictably reduced. It is mandatory

OUTCOMES
■ The key to a successful outcome of acute Galeazzi fracture-
dislocations is accurate reduction and rigid fixation of the
radius along with recognition and appropriate repair or recon-
struction of the disrupted DRUJ. 15 Conservative management
seems to be successful only in children.
■ In a classic article by M ikic, 15 conservative management
in adults resulted in failure in 80% of cases. The results of
operative treatment were much better, and the conclusion
that the DRUJ be evaluated and managed according to the de-
gree of instability to the joint. A high index of suspicion means
the outcome is associated more with the degree of energy in-
volved in the injury than with any inability on the part of the
surgeon to care for the DRUJ appropriately.
COMPLICATION S
■The most common complication of a Galeazzi fracture is
malunion of the radius and residual DRUJ instability,9 due to
 Ch a p t e r 3 REDUCTION AND STABILIZATION OF THE DRUJ FOLLOWING GALEAZZI FRACTURES
malrotation and residual angulation of the radial shaft.8 In
most cases a DRUJ-stabilizing tenodesis cannot restore the
joint, and a corrective osteotomy is required.4
■ A preoperative three-dimensional CT reconstruction of the
bones of the entire forearm is very helpful in this situation.
■ M anagement of a missed dislocation 5 depends on the timing
of presentation.
■ If less than 10 weeks after the injury, open reduction and
repair usually is possible.
■ After 10 weeks, reconstruction with ligament grafting is
required.
■ The incidence of radius nonunion is directly related to the
number of screws used: the rate is four times higher for bones
plated with four screws compared to those plated with five or
more screws.26
■ Radioulnar synostosis may be seen, particularly in patients
with multiple system trauma involving head injury.
■ O steomyelitis may develop in open and crush injuries.
■ N erve palsies, including the anterior interosseous and ulna
nerves, have been associated with Galeazzi fractures,24,25 and
acute carpal tunnel syndrome is a common complication, par-
ticularly in crush and high-energy injuries.
■ Compartment syndrome of the forearm also is a known
complication.
■ Osteoarthritis of the DRUJ is a long-term complication and
can be managed by arthroscopy, interposition arthroplasty, ulna
shortening, ulna head replacement, or total joint arthroplasty,
depending on severity of the injury and age of the patient.
■ Complications in Galeazzi fracture-dislocations can be min-
imized with attention to detail, in particular accurate anatomic
reduction of the radius fracture, thorough assessment and re-
pair of instability of the DRUJ, and appropriate postoperative
rehabilitation.
REFEREN CES
1. Adams BD, Berger R. An anatomic reconstruction of the distal ra-
dioulnar ligaments for posttraumatic distal radioulnar joint instabil-
ity. J H and Surg 2002;27:243–251.
2. Alexander AH, Lichtman DM. Irreducible distal radioulnar joint occur-
ring in a Galeazzi fracture—case report. J Hand Surg Am 1981;6:
258–261.
3. Boland M R, Bader J, Pienkowski D. Joint reaction forces at the dis-
tal radioulnar joint: A biomechanical model presentation at the ASSH
Annual M eeting 2006, Washington, DC.
4. Bowers WH . Instability of the distal radioulnar articulation. H and
Clin 1991;7:311–327.
5. Bruckner JD, Lichtman DM , Alexander AH . Complex dislocations of
the distal radioulnar joint. Recognition and management. Clin
O rthop Relat Res 1992;275:90–103.
6. Chow KH , Sarris IK, Sotereanos DG. Suture anchor repair of ulnar-
sided triangular fibrocartilage complex tears. J H and Surg Br 2003;
28:546–550.
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7. Galeazzi R. Uber ein Besonderes Syndrom bei Verltzunger im Bereich
der Unteraumknochen. Arch O rthoUnfallchir 1934;35:557–562.
8. Garcia-Elias M , Dobyns J. Dorsal and palmar dislocations of the dis-
tal radioulnar joint. In Cooney WP, Linscheid RL, Dobyns JH , eds.
The Wrist: Diagnosis and O perative Treatment. St. Louis: M osby,
1998.
9. H ughston JC. Fracture of the distal radial shaft: M istakes in manage-
ment. J Bone Joint Surg Am 1957;39A:249–264.
10. Ishii S, Palmer AK, Werner FW, et al. An anatomic study of the liga-
mentous structure of the triangular fibrocartilage complex. J H and
Surg Am 1998;23:977–985.
11. Kleinman WB. Repair of chronic peripheral tears/avulsions of the tri-
angular fibrocartilage. In Blair W, ed. Techniques in H and Surgery.
Baltimore: Williams & Wilkins, 1996.
12. Kleinman WB, Graham TJ. The distal radioulnar joint capsule:
Clinical anatomy and role in posttraumatic limitation of forearm mo-
tion. J H and Surg Am 1998;23:588–599.
13. Lister G. The H and: Diagnosis and Indications. Edinburgh: Churchill
Livingstone, 993:2.
14. Lo IK, M acDermid JC, Bennett JD, et al. The radioulnar ratio: A new
method of quantifying distal radioulnar joint subluxation. J H and
Surg 2001;26:236–243.
15. M ikic Z D. Galeazzi Fracture-Dislocations. J Bone Joint Surg Am
1975;57A:1071–1080.
16. M ino DE, Palmar AK, Levinsohn EM . The role of radiography and
computerized tomography in the diagnosis of subluxation and
dislocation of the distal radioulnar joint. J H and Surg Am 1983;
8:23–31.
17. M ohan K, Gupta AK, Sharma J, et al. Internal fixation in 50 cases of
Galeazzi fracture. Acta O rthop Scand 1988;59:318–320.
18. M oore TM , Lester DK, Sarmiento A. The stabilizing effect of soft-
tissue constraints in artificial Galeazzi fractures. Clin O rthop Relat
Res 1985;194:189–194.
19. N icolaidis SC, H ildreth DH , Lichtman DM . Acute injuries of the dis-
tal radioulnar joint. H and Clin 2000;16:449–459.
20. Reckling FW. Unstable fracture-dislocations of the forearm (Monteggia
and Galeazzi lesions). J Bone Joint Surg Am 1982;64A:857–863.
21. Rettig M E, Raskin KB. Galeazzi fracture-dislocation: A new treatment-
oriented classification. J H and Surg Am 2001;26:228–235.
22. Richards RR, Corley FG. Fractures of the shafts of the radius and ulna.
In Rockwood CA, Green DP, Buckholz RW, et al, eds. Rockwood and
Green’s Fractures in Adults, ed 4. Philadelphia: Lippincott-Raven,
1996.
23. Ring D, Rhim R, Carpenter C, et al. Isolated radial shaft fractures
are more common than Galeazzi fractures. J H and Surg Am 2006;
31:17–21.
24. Saitoh S, Seki H , M urakami N , et al. Tardy ulnar tunnel syndrome
caused by Galeazzi fracture-dislocation: neuropathy with a new path-
omechanism. J O rthop Trauma 2000;14:66–70.
25. Stahl S, Freiman S, Volpin G. Anterior interosseous nerve palsy asso-
ciated with Galeazzi fracture. J Pediatr O rthop B 2000;9:45–46.
26. Stern PJ, Drury WJ. Complications of plate fixation of forearm
fractures. Clin O rthop Relat Res 1983;175:25–29.
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fracture-dislocations treated by open reduction and internal plate
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1994;10:589–592.
 K-Wire Fix a t io n o f Dis t a l
Ch a p t e r 4 Ra d iu s Fr a ct u re s Wit h a n d
Wit h o u t Ex t e r n a l Fix a t io n
Ch rist o p h e r Do u m as an d David J. Bo z e n t k a

DEFIN ITION
■ Distal radius fractures occur at the distal end of the bone,
originating in the metaphyseal region and often extending to
the radiocarpal and distal radioulnar joints.
■ Distal radius fractures can be classified as stable or
unstable and extra- or intra-articular to assist in treatment
decisions.
■ Fractures may angulate dorsal or volar and may have signif-
icant comminution, depending on the energy of the injury and
the quality of the bone.
■ Percutaneous pins or K-wires, typically 0.062- or 0.045-
inch, can be used for unstable intra-articular or extra-articular
fractures with mild comminution and no osteoporosis.
■ Percutaneous pins can aid reduction and stabilize the frag-
ments in a minimally invasive manner.
■ Percutaneous pins can support the subchondral area of the
distal radius and maintain the articular reduction in highly
comminuted fractures, which is useful in combined fixation
methods.
■ Smooth percutaneous pins may also be placed across the
physis to maintain a reduction in children without causing a
growth arrest.
■ H ighly comminuted fractures are more difficult to fix rigidly
and often require internal and external fixation to maintain
alignment during healing.
■ External fixators can be hinged or static, and may or may
not bridge the wrist joint.
AN ATOMY
■ The distal radius consists of three articular surfaces: the
scaphoid fossa, the lunate fossa, and the sigmoid notch.
■ Ligamentotaxis aids in the reduction of intra-articular and
■ The distal radial sensory nerve branches lie superficial to the
distal radius and should be protected during dissection and pin
placement.
■ The radial sensory nerve emerges between the brachioradi-
alis and the extensor carpi radialis longus (ECRL) muscle
bellies (FIG 1 ).
■ The terminal branches of the lateral antebrachial cutaneous
nerve lie superficial to the forearm fascia at the radial wrist.
■ There is a bare spot of bone between the first and second
dorsal compartments in the region of the radial styloid.
■ The brachioradialis tendon inserts onto the radial styloid
adjacent to the first dorsal compartment.
■ The extensor carpi radialis longus and the extensor carpi ra-
dialis brevis lie dorsal to the brachioradialis in the second dor-
sal compartment.
■ Lister’s tubercle is dorsal, with the extensor pollicis longus
(EPL) tendon on its ulnar side, in the third dorsal compartment.
■ The extensor digitorum communis tendons lie over the dorsal
ulnar half of the distal radius in the fourth dorsal compartment.
■ The extensor digiti minimi lies over the distal radioulnar
joint (DRUJ) in the fifth dorsal compartment.
PATHOGEN ESIS
■ Distal radius fractures are the most common fractures of the
upper extremity in adults, representing about 20% of all frac-
tures seen in the emergency room.17
■ M echanism of injury typically is a fall on an outstretched
hand with axial loading, but other common histories include
motor vehicle accidents or pathologic fractures.
■ H igher-energy injuries cause increased comminution, angu-
lation, and displacement.
■ O steoporosis, tumors, and metabolic bone diseases are risk

comminuted fractures. factors for sustaining pathologic distal radius fractures.

■ In children, fractures typically occur along the physis due to
■ Volar ligamentous attachments include the radioscapho-

capitate, long radiolunate, and short radiolunate ligaments. its relative weakness compared to the surrounding ligaments.
■ Dorsal ligamentous attachments include the dorsal inter-

carpal and radiocarpal ligaments. N ATURAL HISTORY

■ Dorsal and radial to the second metacarpal lie the first dor- ■ Distal radius fractures needing no reduction and those that
sal interosseous muscle and the terminal branches of the radial are stable after reduction typically recover functional range of
sensory nerve. motion with minimal long-term sequelae.

Extensor carpi Extensor pollicis

radialis brevis brevis
Extensor carpi
radialis longus

Abductor pollicis
longus Superficial branch
Extensor pollicis
of the radial nerve Brachioradialis FIG 1 • An a t o m y su rro u n d in g t h e ra d ia l
longus
muscle se n so ry n e rve b ra n ch in t h e fo re a rm .

30
 Ch a p t e r 4 K-WIRE FIXATION OF DISTAL RADIUS FRACTURES 31

■ Three parameters that affect outcome include articular con-

gruity, angulation, and shortening.16,20
■ 1 to 2 mm of articular surface incongruity of the distal ra-

dius can lead to degenerative changes, pain, and stiffness.

■ Dorsal angulation can lead to decreased range of motion

and increased load transfer to the ulna.

■ Radial shortening can lead to decreased range of motion,

pain, and ulnar impaction of the carpus.

PATIEN T HISTORY AN D PHYSICAL

FIN DIN GS
■ The history of a fall on an outstretched hand is the most com-
mon presentation for a patient with a distal radius fracture.
■ M otor vehicle or motorcycle accidents and osteoporosis ac-

count for most comminuted fractures.

■ It may be clinically indicated to implement a workup for

osteoporosis.
■ Pain, tenderness, swelling, crepitus, deformity, ecchymosis,

and decreased range of motion at the wrist are typical symp-

toms and warrant radiographic evaluation.
■ Physical examination should include the following:

■ Inspection: Evaluate the integrity of the skin, cascade of the

digits, direction of displacement, and presence of any swelling. A B

■ Identify points of maximal tenderness to differentiate be-

tween distal radius injuries and carpal or ligamentous injuries.
■ Touch or press specific areas of the wrist and hand to dif-
ferentiate distal intra-articular, DRUJ, and carpal injuries.
■ Two-point discrimination: H igher than normal (5 mm)
FIG 2 • A. La t e ra l ra d io g ra p h o f t h e w rist d e m o n st ra t in g vo la r
t ilt (b lack lin e s). B. PA ra d io g ra p h d e m o n st ra t in g ra d ia l in cli-
n a t io n (b lack lin e s), u ln a r va ria n ce (re d b rack e t ), a n d ra d ia l
h e ig h t (w h it e b rack e t ).

results in the form of progressive neurologic deficit may sig-

nify an acute carpal tunnel syndrome or ulnar neuropathy.
■ Passive finger stretch test to assist with diagnosis of com-
partment syndrome.
■ EPL tendon function should be evaluated.
■ EPL assessment: Assess the resting position of the thumb in-
terphalangeal joint and the patient’s ability to lift the thumb off
of a flat surface to determine the continuity of the EPL tendon.
■ Palpation of forearm and elbow to assess for concomitant
injury proximally.
■ The DRUJ must be assessed for displacement.
■ The bony anatomy must be carefully evaluated to avoid
missing minimally displaced fractures, which may displace
without treatment.
■ Skin should be assessed to avoid missing an open fracture.
along the radial styloid to the ulnar articular margin. The
normal angle is 22 degrees.
■ Ulnar variance, also measured on the PA view (see Fig 2B),
is the distance between the radial and ulnar articular surfaces.
Ulnar variance is compared to the contralateral side.
■ Traction radiographs help assess intra-articular involve-
ment, intercarpal ligamentous injury, and potential fracture re-
duction through ligamentotaxis.
■ CT scans are useful in fully elucidating the anatomy of the
fracture, including impaction, comminution, and size of the
fragments.
■ CT scans often significantly alter the original treatment
plan.11
■ M RI is rarely performed acutely but can diagnose concomi-

■ Swelling should be monitored to allow for early diagnosis tant ligamentous injuries, triangular fibrocartilage complex in-
of compartment syndrome. juries, and occult carpal fractures.
■ Sensory examination should be monitored for progressive

changes, which may represent acute carpal tunnel syndrome. DIFFEREN TIAL DIAGN OSIS
■ Bony contusion
IMAGIN G AN D OTHER DIAGN OSTIC ■ Radiocarpal dislocation
STUDIES ■ Scaphoid or other carpal fracture
■ Radiographic evaluation should include posteroanterior
■ Perilunate or lunate fracture dislocation
(PA), lateral, and oblique views to assess displacement, angu-
■ Distal ulna fracture
lation, comminution, and intra-articular involvement, and
■ Wrist ligament or triangular fibrocartilage complex injury
allow for radiologic measurements.14,17
■ DRUJ injury
■ Lateral articular (volar) tilt is the angle between the radial

shaft and a tangential line parallel to the articular margin as N ON OPERATIVE MAN AGEMEN T
seen on the lateral view (FIG 2 A). The normal angle is ■ Conservative treatment consists of splinting or casting for
11 degrees. stable fracture patterns using a three-point mold.
■ Radial inclination, measured on the PA view (FIG 2 B), is ■ Fractures amenable to nonoperative treatment include frac-

the angle between a line perpendicular to the shaft of the tures that are stable after reduction with minimal metaphyseal
radius at the ulnar articular margin and the tangential line comminution, shortening, angulation, and displacement.
32 Se c t i o n I HAND, WRIST AND FOREARM

■Evaluation for secondary displacement weekly for 2 to

3 weeks is critical as the swelling subsides.
■ Unstable patterns will displace if not surgically stabilized.

■ There is little role for nonoperative treatment in highly

comminuted fractures.
■ The physiologic age, medical comorbidities, and functional

level of the patient should be considered in determining the

need for surgical treatment.
■ Early range of motion of the nonimmobilized joints is essen-

tial in the nonoperative treatment of all fractures near the

wrist to prevent contracture.
■ The cast or splint must not extend past the metacar-

pophalangeal joints so as to allow digital motion.

SURGICAL MAN AGEMEN T
■ Surgical treatments are indicated to prevent malunion and
improve pain control, function, and range of motion.
■ Surgery is reserved for unstable fractures, including dis-
placed, intra-articular, comminuted, or severely angulated in-
FIG 3 • Po sit io n in g o f p a t ie n t su p in e o n t h e h a n d t a b le w it h
t o u rn iq u e t in p la ce .
■ A tourniquet is applied near the axilla with the splint still in
place (FIG 3 ).
■ Fluoroscopy should be used for reduction confirmation and

juries and fractures that displace following attempted closed fixation throughout the procedure.
management. ■ There must be enough range of motion of the shoulder and

■ Percutaneous pinning can assist in obtaining and maintain-
ing reduction of displaced fractures with limited comminution
in a minimally invasive manner.
■ External fixators maintain radius length but cannot always
control angulation and displacement; therefore, supplementa-
tion with percutaneous pins is typically performed.2
■ Conversely, external fixators may augment percutaneous pins
and plate fixation when extensive comminution is present.
■ Supplemental external fixation should be considered for
fractures with comminution of over 50% of the diameter of
elbow to allow standard AP, lateral, and oblique images.
Approach
■ Various approaches can be used in the application of exter-
nal fixators and the insertion of percutaneous pins.
■ Distal external fixator half-pins may be placed directly into
the second metacarpal or into other carpal bones (for injuries in-
cluding the second metacarpal). Wires and half-pins, which are
non-bridging fixators, may be placed in the distal radius itself.
■ Percutaneous pins can be inserted through the radial styloid

the radius on a lateral view. between the first and second dorsal compartments, through
■ External fixation may be used as a neutralization device,
Lister’s tubercle, through the interval between the fourth and
because the distraction forces decrease soon after fracture fifth dorsal compartments, and across the DRUJ (FIG 4 ).
reduction. ■ Caution is taken to avoid skewering tendons and nerves
■ External fixators also are useful for “ damage control or-
and to avoid penetrating the articular surface.
thopaedics” to temporarily stabilize wrist fractures, especially
for complex, combined, open injuries.
Compartment 5
■ For nonbridging external fixation, there must be at least
Compartment 4 Compartment 6
1 cm of volar cortex intact and adequate fragment sizes to
allow proper pin placement.
■ A relative contraindication to pin fixation with or without

external fixation is a volar shear injury, which should be re-

duced and stabilized using a volar plate and screws.

Preoperative Planning
■ All radiographs should be reviewed before surgery and
Compartment 3
brought into the operating room.
■ Analysis of the pattern and presumed stability of the frac-

ture fragments determines whether percutaneous fixation, Compartment 2

with or without external fixation, is suitable.
■ For intra-articular fractures, the specific fragments to be re-
Compartment 1
duced and fixed must be identified preoperatively to avoid in-
complete reduction of the joint surface.
■ The surgeon must be prepared to change his or her manage-
Lister’s tubercle
ment decision intraoperatively if the fracture behavior is differ-
ent than anticipated. A variety of fixation devices should be
available in the operating room. Tubercle between
4th and 5th
Positioning compartments
■ The patient is positioned supine on the operating table with
a radiolucent arm board. FIG 4 • Are a s fo r K-w ire in se rt io n a t t h e d ist a l ra d iu s.
 Ch a p t e r 4 K-WIRE FIXATION OF DISTAL RADIUS FRACTURES 33

TECHNIQUES
CLOSED REDUCTION OF A DISTAL RADIUS FRACTURE
■ Clo se d re d u ct io n sh o u ld b e p e rfo rm e d b e fo re fixa t io n
u sin g d ist ra ct io n a n d p a lm a r t ra n sla t io n o f t h e d ist a l ra -
d iu s fra g m e n t a n d ca rp u s.1
■ Use o f a p a d d e d b u m p o r t o w e l ro ll w ill a id in t h e re d u c-
t io n (TECH FIG 1 ).
■ Ove rd ist ra ct io n w ill ca u se in cre a se d d o rsa l a n g u la t io n
d u e t o t h e in t a ct sh o rt , st o u t vo la r lig a m e n t s.1
■ Exce ssive p a lm a r fle xio n o f t h e w rist ca n re st o re vo la r t ilt
b u t le a d s t o a n in cre a se d in cid e n ce o f st iffn e ss a n d
ca rp a l t u n n e l syn d ro m e . 7
■ Ove rd ist ra ct io n ca n b e a sse sse d b y m e a su rin g t h e ca rp a l
h e ig h t in d e x, m e a su rin g t h e ra d io sca p h o id a n d m id ca rp a l
jo in t sp a ce s, ch e ckin g fu ll fing e r fle xio n in t o t h e p a lm , o r TECH FIG 1 • Clo se d re d u ct io n o ve r a t o w e l b u m p u sin g t ra c-
e va lu a t in g in d e x fin g e r e xt rin sic e xt e n so r t ig h t n e ss.8 t io n a n d p a lm a r t ra n sla t io n .

KAPANDJI TECHNIQUE FOR PERCUTANEOUS PINNING

■ Clo se d re d u ct io n is o b t a in e d u sin g a b u m p , a n d t h e re -
d u ct io n is co n firm e d u sin g flu o ro sco p y.
■ Th is t e ch n iq u e sh o u ld b e e m p lo ye d in p a t ie n t s you n g e r
t h a n 55 ye a rs o f a g e w it h m in im a l co m m in u t io n . It sh o u ld
no t b e u se d in o st e o p o ro t ic, e ld e rly p a t ie n t s o r t h o se
w it h co m m in u t io n se co n d a ry t o a hig h e r lo ss o f re d u c-
t io n . Ext e rn a l fixa t io n sh o u ld b e u se d t o su p p le m e n t p in -
nin g in t h e se p o p u la t io n s.21
■ A st a b in cisio n is m a d e ra d ia lly, a n d a 0.062-in ch
p in is m a n u a lly in se rt e d in t o t h e fra ct u re sit e , t a kin g ca re
t o p ro t e ct t h e se n so ry n e rve b ra n ch e s a n d t h e first d o r-
sa l co m p a rt m e n t t e n d o n s (TECH FIG 2 A).
■ Th e p in is a n g le d d ist a l, le ve rin g t h e b o n e b a ck in t o
it s n o rm a l p o sit io n a n d re st o rin g t h e ra d ia l in clin a -
t io n (TECH FIG 2 B). Th e p in is a d va n ce d t h ro u g h t h e
fa r co rt e x u sin g p o w e r, a ct in g a s a b u t t re ss t o p re ve n t
lo ss o f ra d ia l in clin a t io n (TECH FIG 2 C).

A B C

D E F

TECH FIG 2 • A. An in cisio n is m a d e o ve r t h e ra d ia l st ylo id a n d a K-w ire is m a n u a lly in se rt e d in t o t h e fra ct u re sit e . B. Th e w ire
is le ve re d d ist a lly t o co rre ct t h e ra d ia l in clin a t io n . C. Th e w ire is a d va n ce d p ro xim a lly, u sing p o w e r, in t o co rt ica l b o n e . D. An
in cisio n is m a d e o ve r List e r’s t u b e rcle , a n d a w ire is in se rt e d in t o t h e fra ct u re sit e . E,F. Th e w ire is le ve re d d ist a lly t o co rre ct
t h e d o rsa l a n g u la t io n a n d a d va n ce d p ro xim a lly u sin g p o w e r in t o co rt ica l b o n e .
 34 Se c t i o n I HAND, WRIST AND FOREARM

■ A se co n d st a b in cisio n is p la ce d d o rsa lly, a n d a se co n d p in ce e d in g in t o t h e u ln a r co rt e x o f t h e ra d iu s p ro xim a l t o

TECHNIQUES

is m a n u a lly in se rt e d in t o t h e fra ct u re (TECH FIG 2 D). t h e fra ct u re lin e .

■ Th e p in is a n g le d d ist a l, le ve rin g t h e b o n e b a ck in t o
it s n o rm a l p o sit io n a n d re st o rin g t h e vo la r t ilt (TECH
FIG 2 E). Th e p in is a d va n ce d t h ro u g h t h e vo la r co rt e x
u sin g p o w e r, a ct in g a s a b u t t re ss t o p re ve n t lo ss o f
vo la r t ilt (TECH FIG 2 F).
■ Usin g t h e m o d ifie d t e ch n iq u e , a t h ird p in is p la ce d re t ro -
g ra d e u sin g p o w e r, st a rt in g a t t h e ra d ia l st ylo id a n d p ro -
■ Th e p in s a re b u rie d a n d cu t ju st b e lo w t h e skin , a n d t h e
skin is su t u re d .
■ Alt e rn a t ive ly, t h e p in s m a y b e b e n t u sin g t w o n e e d le
d rive rs a n d le ft o u t sid e t h e skin .
■ Th e p in s a re t h e n cu t a n d co ve re d w it h p in ca p s o r a n t ib i-
o t ic g a u ze .
■ A st e rile d re ssin g is a p p lie d , fo llo w e d b y a sp lin t .

AUTHOR’S PREFERRED TECHNIQUE FOR PERCUTANEOUS PINNING

■ Clo se d re d u ct io n is o b t a in e d u sin g a b u m p , a n d t h e re -
d u ct io n is co n firm e d u sin g flu o ro sco p y (TECH FIG 3 A,B).
■ A sm a ll in cisio n is p la ce d o ve r t h e b a re sp o t o n t h e ra d ia l
st ylo id b e t w e e n t h e first a n d se co n d d o rsa l co m p a rt -
m e n t s (TECH FIG 3 C).
■ Tw o 0.062-in ch sm o o t h K-w ire s a re p la ce d re t ro g ra d e
fro m t h e ra d ia l st ylo id a cro ss t h e re d u ce d fra ct u re , e n -
g a g in g t h e o p p o sit e co rt e x in a d ive rg e n t fa sh io n (TECH
FIG 3 D,E).
■ A sm a ll in cisio n is p la ce d o ve r t h e in t e rva l b e t w e e n t h e
fo u rt h a n d fift h d o rsa l co m p a rt m e n t s.
■ On e o r t w o K-w ire s a re p la ce d re t ro g ra d e fro m t h e d o r-
sa l u ln a r co rn e r o f t h e d ist a l ra d iu s a cro ss t h e re d u ce d
fra ct u re , e n g a g in g t h e o p p o sit e co rt e x in a d ive rg e n t
fa sh io n (TECH FIG 3 F–H).
■ Th e p in s a re cu t ju st b e n e a t h t h e skin , w h ich is clo se d
w it h a 5-0 n ylo n su t u re .
■ Alt e rn a t ive ly, t h e p in s a re b e n t a n d cu t a n d le ft o u t sid e
t h e skin (TECH FIG 3 I).
■ A d re ssin g a n d sp lin t a re t h e n a p p lie d .

A B C

D E F

TECH FIG 3 • A,B. PA and la te ra l vie ws dem onst ra ting redu ct ion of dista l ra dius fra ct ure. C. The incision is ma de
ove r th e ra d ia l stylo id. D. A p in is in se rt e d re tro g ra d e in t o th e ra d ia l st ylo id . E. PA rad io g raph d e mo n st ra tin g t h e
co u rse o f t h e ra d ia l stylo id w ire . F. Tw o radial st yloid w ires and tw o d orsoulna r wires are in place. (co n t inu e d )
 Ch a p t e r 4 K-WIRE FIXATION OF DISTAL RADIUS FRACTURES 35

TECHNIQUES
G H I

TECH FIG 3 • (co n t in u e d ) G. PA vie w sh o w in g fixa t io n a n d t h e p a t h o f t h e w ire s. H. La t e ra l vie w sh o w in g fixa -

t io n a n d p a t h o f w ire s. I. Pin s a re b e n t , cu t , a n d co ve re d a b o ve t h e skin .

BRIDGING EXTERNAL FIXATOR APPLICATION

Dist a l Pin Pla ce m e n t
■ A 3-cm in cisio n is m a d e o ve r t h e d o rsa l in d e x m e t a ca rp a l,
e xp o sin g t h e p ro xim a l t w o t h ird s.
■ Th e d ist a l se n so ry n e rve b ra n ch e s a re re t ra ct e d , a n d t h e
first d o rsa l in t e ro sse o u s m u scle is e le va t e d fro m t h e
m e t a ca rp a l t o id e n t ify t h e in se rt io n o f t h e ECRL (TECH
FIG 4 A).
■ Th e in d e x m e t a ca rp o p h a la n g e a l jo in t is fle xe d t o p ro -
t e ct t h e sa g it t a l b a n d a n d first d o rsa l in t e ro sse o u s
a p o n e u ro sis.
■ Th e m e t a ca rp a l d rill g u id e is p la ce d o n t h e ra d ia l b a se o f
t h e in d e x m e t a ca rp a l a t t h e fla re o f t h e m e t a p h ysis.
Pa rt ia lly t h re a d e d 3- t o 4-m m p in s a re u se d , w it h o r w it h -
o u t p re d rillin g .

A B

TECH FIG 4 • A. An in cisio n is m a d e o ve r t h e se co n d

m e t a ca rp a l b a se , w it h re fle ct io n o f t h e first d o rsa l in -
t e ro sse o u s m u scle a n d ra d ia l se n so ry n e rve t e rm in a l
b ra n ch e s. (Th e t h u m b is a t t h e t o p o f t h e p h o t o g ra p h .)
B. Dia g ra m sh o w in g p la ce m e n t o f fixa t o r p in s in t h e sh a ft o f
t h e in d e x a n d t h e b a se o f t h e in d e x a n d lo n g m e t a ca rp a ls.
C C. Pa ra lle l p la ce m e n t o f t w o m e t a ca rp a l p in s.
 36 Se c t i o n I HAND, WRIST AND FOREARM

■ A lo n g t h re a d e d p in is p la ce d t h ro u g h t h e in d e x a n d ■ Th e d o u b le d rill g u id e is p la ce d o n t o t h e d ia p h ysis o f t h e
TECHNIQUES

lo n g m e t a ca rp a l b a se s, o b t a in in g t h re e co rt ice s o f ra d iu s b e t w e e n t h e b ra ch io ra d ia lis a n d t h e ra d ia l w rist

fixa t io n .
■ Ca re is t a ke n n o t t o e n t e r t h e ca rp o m e t a ca rp a l jo in t .
■ Th e d o u b le d rill g u id e is t h e n p la ce d o ve r t h e first p in ,
a n d t h e d ist a l sh o rt t h re a d e d p in is p la ce d t h ro u g h b o t h
co rt ice s o f t h e in d e x m e t a ca rp a l sh a ft (TECH FIG 4 B,C).
■ Flu o ro sco p y co n firm s p la ce m e n t a n d le n g t h o f t h e p in s.
Pro xim a l Pin Pla ce m e n t a n d Fra m e
Co n st ru ct io n
■ A 4- t o 5-cm in cisio n is m a d e o ve r t h e ra d ia l fo re a rm ,
p ro xim a l t o t h e first d o rsa l co m p a rt m e n t m u scu la t u re ,
t h ro u g h skin a n d su b cu t a n e o u s t issu e , a vo id in g t h e la t -
e ra l a n t e b ra ch ia l cu t a n e o u s n e rve b ra n ch e s.
■ Th e fa scia o ve rlyin g t h e in t e rva l b e t w e e n t h e b ra ch io ra -
d ia lis a n d t h e ECRL is d ivid e d , a n d t h e ra d ia l se n so ry
n e rve is id e n t ifie d a n d re t ra ct e d (TECH FIG 5 A).
■ Th e in t e rva l b e t w e e n t h e ECRL a n d ECRB a lso m a y b e
u se d t o a vo id t h e ra d ia l se n so ry b ra n ch .
e xt e n so rs o r b e t w e e n t h e ECRL a n d ECRB (TECH FIG 5 B).
■ Th re a d e d 3- t o 4-m m p in s a re p la ce d , w it h o r w it h o u t
p re d rillin g .
■ Th e fra ct u re sh o u ld b e re d u ce d , a n d t h e p in s p la ce d
p a ra lle l t o t h e m e t a ca rp a l p in s t o fa cilit a t e a lig n m e n t
o f t h e fra ct u re .
■ Th e p ro xim a l p in sh o u ld b e p la ce d b ico rt ica lly, ju st
d ist a l t o t h e t e n d o n o f t h e p ro n a t o r t e re s.
■ Th e d ist a l p in is t h e n d rille d b ico rt ica lly t h ro u g h t h e
d o u b le d rill g u id e .
■ Pin p la ce m e n t is co n firm e d u sin g flu o ro sco p y.
■ Th e in cisio n s a re clo se d u sin g n ylo n su t u re , e n su rin g n o
t e n sio n is o n t h e skin a t t h e p in sit e s.
■ Cla m p s a n d ro d s o r a d ju st a b le fixa t o rs m a y t h e n b e a p -
p lie d t o t h e p in s t o a ch ie ve a n d m a in t a in fin a l re d u ct io n
(TECH FIG 5 C).
■ Su p p le m e n t a ry K-w ire fixa t io n is a d d e d b e fo re o r a ft e r
e xt e rn a l fixa t io n (TECH FIG 5 D).

A B

C D

TECH FIG 5 • A. In cisio n o ve r t h e ra d ia l fo re a rm d e m o n st ra t in g t h e ra d ia l se n so ry n e rve b ra n ch d e e p t o t h e

fa scia . (Th e h a n d is t o t h e rig h t .) B. Th e d o u b le d rill g u id e is p la ce d o n t o t h e ra d iu s. C. Fin a l re d u ct io n is m a in -
t a in e d b y t h e a d d it io n o f cla m p s a n d ro d s. D. K-w ire s a re u se d fo r su p p le m e n t a l fixa t io n w h e n n e ce ssa ry.

NONBRIDGING EXTERNAL FIXATOR APPLICATION

■ Fract u re red u ct io n can b e p erfo rm ed afte r in sert io n o f t h e
d ist al p in s, a llo w ing dire ct co n tro l of t he dist a l frag m en t .
■ Th e w rist is p la ce d fo r a la t e ra l flu o ro sco p ic vie w , a n d a
m a rke r is u se d t o d e t e rm in e t h e le ve l o f in cisio n h a lfw a y
b e t w e e n t h e ra d io ca rp a l jo in t a n d t h e fra ct u re . A sh o rt
t ra n sve rse skin in cisio n is m a d e ju st p ro xim a l t o t h e ra -
d io ca rp a l jo in t .
■ A lo n g it u d in a l in cisio n is t h e n m a d e t h ro u g h t h e re t in a c-
u lu m o n e it h e r sid e o f List e r’s t u b e rcle , a n d t h e EPL is
p ro t e ct e d .
■ Th e first d ist a l p in is d rille d u sin g p o w e r, p a ra lle l t o
t h e ra d io ca rp a l jo in t o n t h e la t e ra l vie w , h a lfw a y
b e t w e e n t h e fra ct u re a n d t h e jo in t su rfa ce (TECH
FIG 6 A).
 Ch a p t e r 4 K-WIRE FIXATION OF DISTAL RADIUS FRACTURES 37

TECHNIQUES
A B

TECH FIG 6 • A. Dist a l p in p la ce m e n t . B. Fin a l re d u ct io n w it h n o n b rid g e d

e xt e rn a l fixa t o r in p la ce .
■ Th e se co n d d ist a l p in is p la ce d b e t w e e n t h e se co n d a n d
t h ird d o rsa l co m p a rt m e n t s, b e t w e e n t h e ra d ia l w rist e x-
t e n so rs a n d t h e EPL t e n d o n .
■ Th is p in sh o u ld b e p la ce d p a ra lle l t o t h e first p in in b o t h
p la n e s, w it h t h e st a rt in g p o in t h a lfw a y b e t w e e n t h e ra -
d io ca rp a l jo in t a n d t h e fra ct u re .
■ Th e t w o p ro xim a l ra d iu s p in s a re p la ce d u sin g t h e t e ch -
n iq u e d e scrib e d fo r p la ce m e n t o f a b rid g in g e xt e rn a l
fixa t o r.
■ Th e in cisio n s a re clo se d , a ft e r w h ich t h e cla m p s a re a p -
p lie d b u t n o t t ig h t e n e d .
■ Re d u ct io n is a ch ie ve d b y m a n ip u la t io n o f t h e d ist a l p in s
a n d cla m p s.
■ Pu sh in g t h e p in s in t h e d o rsa l/vo la r p la n e co rre ct s
d o rsa l t ilt .
■ Ad ju st in g t h e p in cla m p ca n co rre ct ra d ia l in clin a t io n .
■ Re d u ct io n is co n firm e d u sin g flu o ro sco p y, a n d t h e
cla m p s a re t ig h t e n e d (TECH FIG 6 B).

PEARLS AND PITFALLS

In d ica t io n s
Su rg ica l a p p ro a ch
Ha rd w a re p la ce m e n t
Po st o p e ra t ive m a n a g e m e n t
■ De t e rm in e st a b ilit y.
■ De t e rm in e co m m in u t io n a n d su p p le m e n t fixa t io n w it h e xt e rn a l o r in t e rn a l fixa t io n a s n e ce ssa ry.
■ Ma ke skin in cisio n s fo r p in p la ce m e n t t o a vo id se n so ry n e rve s, t e n d o n s, a n d cro ssin g ve in s.
■ Ob t a in a d e q u a t e e xp o su re o f t h e ra d ia l se n so ry b ra n ch a t fo re a rm a n d h a n d t o a vo id in ju ry.
■ Ch o o se p in s o f a p p ro p ria t e d ia m e t e r.
■ Su p p le m e n t fixa t io n w it h p in s, u sin g e xt e rn a l o r in t e rn a l fixa t io n a s n e ce ssa ry.
■ Do n o t le a ve p in s m o re t h a n 1 t o 2 m m o u t o f t h e co rt e x, a n d ke e p a ll p in s e xt ra -a rt icu la r.
■ If p lacin g th e p ro xima l m et acarp al p in in m eta p h ysea l b o n e , e n su re th a t t h ree co rt ices are pe n etrate d .
■ Do n o t b a ck o u t co n ica l p in s, b e ca u se fixa t io n w ill b e lo st .
■ Eva lu a t e t h e DRUJ a ft e r fixa t io n t o d e t e rm in e st a b ilit y.
■ Su b cu t a n e o u s p in s a re m o re co st ly t o re m o ve , b e ca u se t h a t re q u ire s a se co n d p ro ce d u re , b u t t h e y
h a ve a lo w e r in fe ct io n ra t e . Th e re fo re , if fixa t io n is n e e d e d fo r a n e xt e n d e d p e rio d , b u ry t h e p in s.
■ Ove rd ist ra ct io n o f t h e ca rp u s m u st b e a vo id e d , b e ca u se it is a sso cia t e d w it h ch ro n ic p a in –m e d ia t e d
syn d ro m e s a n d n o n u n io n .
■ Allo w fo r a d e q u a t e im m o b iliza t io n .
■ En co u ra g e e a rly ra n g e o f m o t io n o f t h e fin g e rs, e lb o w , a n d sh o u ld e r w h e n e ve r p o ssib le .
■ Ed u ca t e t h e p a t ie n t re g a rd in g a p p ro p ria t e p in ca re .
■ Be g in st re n g t h e n in g o n ly a ft e r h e a lin g is co m p le t e a n d ra n g e o f m o t io n is m a xim ize d .

POSTOPERATIVE CARE ■ External fixation devices typically require no additional

■ After fixation with percutaneous pins, alone the wrist is im- immobilization, although a volar forearm–based O rthoplast
mobilized in a short-arm splint to allow for swelling but pro- (Johnson & Johnson, Langhorne, PA) splint may be used for
vide stability. A cast is applied after the swelling goes down. support and patient comfort.
■ Isolated radial styloid fractures fixed with pins can be ■ The splint or cast is continued for 4 to 8 weeks, until heal-

placed in a volar wrist splint. ing occurs and the pins are removed.
38 Se c t i o n I HAND, WRIST AND FOREARM
■ K-wires and half pins should be inspected and cleaned regu-
larly using either soap and water or half-strength hydrogen
peroxide and water.
■ Finger, elbow, and shoulder range of motion are begun
immediately, and wrist range of motion is begun as the frac-
ture heals.
OUTCOMES
■ A prospective randomized trial comparing percutaneous pin-
ning and casting versus external fixation with augmentation (eg,
pins, screws, bone graft) found no difference in clinical out-
comes for fractures with minimal articular displacement.9
■ In patients over 60 years of age, percutaneous pinning has
been shown to provide only marginal radiographic improve-
ment over cast immobilization alone, with no correlation with
clinical outcome.4
■ Ebraheim et al5 reported excellent outcomes for restoration
of radiographic parameters and functional outcomes with in-
trafocal pinning and trans-styloid augmentation.
■ An evaluation of percutaneous pinning outcomes found
the best results for metaphyseal fractures. Good results were
found for intra-articular fractures. The worst results were
seen in fractures with associated ulnar styloid fractures and
fractures in elderly persons. 15
■ A retrospective review of radiographic and clinical out-
comes of open reduction internal fixation (volar and dorsal)
versus external fixation revealed no significant differences, ex-
cept that palmar tilt was more effectively restored with dorsal
plating.22
■ A meta-analysis found no evidence for the use of internal
fixation over external fixation for unstable distal radius frac-
tures.12
■ Women over 55 years of age with unstable intra-articular
distal radius fractures treated with external fixation have a
high rate of secondary displacement but can have acceptable
functional outcomes.10
■ Patients over the age of 55 years have better results with ex-
ternal fixation and pinning than with pinning alone. Younger
patients with two or more sides having comminution also have
better results with supplemental external fixation. 21
■ N onbridging external fixation has been shown to maintain
volar tilt and carpal alignment better than bridging external
fixation while having significantly better function during the
first year.13
■ N onbridging external fixation was shown to have no clini-
cal advantage in patients over 60 years of age with moderately
or severely displaced distal radius fractures.3
■ A prospective, randomized comparison of bridging versus
nonbridging external fixation revealed more complications in
the nonbridging fixators and better outcomes in the bridged
fixator group.18
■ A prospective study compared unrepaired ulnar styloid frac-
tures to those without ulnar styloid fractures and found no
significant differences in clinical outcome. H owever, DRUJ in-
stability was not evaluated.19
COMPLICATION S
■ Infection (pin tract or deep). Pin tract infections occur in
10% to 30% of patients. 8,9
■ Injury to tendons, vessels, and nerves due to percutaneous
technique. Stiffness may result if tendons are inadvertently
skewered, and the radial sensory branch can be injured.
■ Loss of range of motion
■ Posttraumatic arthritis
■ Weakness in grip or pinch
■ Tenosynovitis and tendon rupture
■ M alunion or nonunion
■ Compartment syndrome
■ Carpal tunnel syndrome
■ H ardware failure
■ N onunion (associated with overdistraction with an external
fixator)
■ Complex regional pain syndrome type I (associated with
overdistraction with an external fixator)
REFEREN CES
1. Agee JM . Distal radius fractures. M ultiplanar ligamentotaxis. H and
Clin 1993;9:577–585.
2. Anderson JT, Lucas GL, Buhr BR. Complications of treating distal
radius fractures with external fixation: a community experience.
Iowa O rthop J 2004;24:53–59.
3. Atroshi I, Brogren E, Larsson GU, et al. Wrist-bridging versus non-
bridging external fixation for displaced distal radius fractures: a ran-
domized assessor-blind clinical trial of 38 patients followed for
1 year. Acta O rthop 2006;77:445–453.
4. Azzopardi T, Ehrendorfer S, Coulton T, et al. Unstable extra-articu-
lar fractures of the distal radius: a prospective, randomised study of
immobilisation in a cast versus supplementary percutaneous pinning.
J Bone Joint Surg Br 2005;87B:837–840.
5. Ebraheim N A, Ali SS, Gove N K. Fixation of unstable distal radius
fractures with intrafocal pins and trans-styloid augmentation: a ret-
rospective review and radiographic analysis. Am J O rthop 2006;
35:362–368.
6. Gupta A. The treatment of Colles’ fracture. Immobilisation with the
wrist dorsiflexed. J Bone Joint Surg Br 1991;73B:312–315.
7. Gupta R, Bozentka DJ, Bora FW. The evaluation of tension in an
experimental model of external fixation of distal radius fractures.
J H and Surg Am 1999;24:108–112.
8. H argreaves DG, Drew SJ, Eckersley R. Kirschner wire pin tract infec-
tion rates: A randomized controlled trial between percutaneous and
buried wires. J H and Surg Br 2004;29:374–376.
9. H arley BJ, Scharfenberger A, Beaupre LA, et al. Augmented external
fixation versus percutaneous pinning and casting for unstable frac-
tures of the distal radius—a prospective randomized trial. J H and
Surg Am 2004;29:815–824.
10. H egeman JH , O skam J, Vierhout PA, et al. External fixation for
unstable intra-articular distal radial fractures in women older
than 55 years. Acceptable functional end results in the majority of
the patients despite significant secondary displacement. Injury
2005;36:339–344.
11. Katz M A, Beredjiklian PK, Bozentka DJ, et al. Computed tomogra-
phy scanning of intra-articular distal radius fractures: does it influ-
ence treatment? J H and Surg Am 2001;26:412–421.
12. M argaliot Z , H aase SC, Kotsis SV, et al. M eta-analysis of outcomes
of external fixation versus plate osteosynthesis for unstable distal ra-
dius fractures. J H and Surg Am 2005;30:1185–1199.
13. M cQ ueen M M . Redisplaced unstable fractures of the distal radius.
A randomised, prospective study of bridging versus nonbridging ex-
ternal fixation. J Bone Joint Surg Br 1998;80B:665–669.
14. N ana AD, Joshi A, Lichtman DM . Plating of the distal radius. J Am
Acad O rthop Surg 2005;13:159–171.
15. Rosati M , Bertagnini S, Digrandi G, et al. Percutaneous pinning for
fractures of the distal radius. Acta O rthop Belg 2006;72:138–146.
16. Short WH , Palmer AK, Werner FW, et al. A biomechanical study of
distal radial fractures. J H and Surg Am 1987;12:529–534.
17. Simic PM , Weiland AJ. Fractures of the distal aspect of the radius:
changes in treatment over the past two decades. J Bone Joint Surg Am
2003;85A:552–564.
18. Sommerkamp TG, Seeman M , Silliman J, et al. Dynamic external fix-
ation of unstable fractures of the distal part of the radius. A prospec-
tive, randomized comparison with static external fixation. J Bone
Joint Surg Am 1994;76A:1149–1161.
 Ch a p t e r 4 K-WIRE FIXATION OF DISTAL RADIUS FRACTURES 39

19. Souer S, Ring D, M atschke S, et al. Effect of an unrepaired fracture
of the ulnar styloid base on outcome after plate and screw fixation of
a distal radius fracture. J Bone Joint Surg Am 2009;91:830–838.
20. Trumble TE, Schmitt SR, Vedder N B. Factors affecting functional
outcome of displaced intra-articular distal radius fractures. J H and
Surg Am 1994;19:325–340.
21. Trumble TE, Wagner W, H anel DP, et al. Intrafocal (Kapandji)
pinning of distal radius fractures with and without external fixation.
J H and Surg Am 1998;23:381–394.
22. Westphal T, Piatek S, Schubert S, et al. O utcome after surgery of dis-
tal radius fractures: no differences between external fixation and
O RIF. Arch O rthop Trauma Surg 2005;125:507–514.
 Ar t h ro s co p ic Re d u ct io n a n d
Ch a p t e r 5 Fix a t io n o f Dis t a l Ra d iu s a n d
Uln a r St y lo id Fr a ct u re s
W illiam B. Ge issle r
DEFIN ITION
■ A bimodal age distribution exists for patients with distal ra-
dius fractures (ie, young adults vs elderly persons), and they
frequently have a different mechanism of injury.
■ Patients 65 years of age or older have an annual incidence
of 8 to 10 fractures of the distal radius per 1000 person-years.
■ The incidence is seven times higher in women than in
men.
■ Sixteen percent of white women and 23% of white men
will sustain a fracture of the distal radius after the age of
50 years.
■ Fractures of the distal radius are one of the most common
skeletal injuries treated by orthopaedic surgeons.
■ These injuries account for one-sixth of all fractures that are
evaluated in the Emergency Department.
■ Displaced intra-articular fractures of the distal radius are a
unique subset of radius fractures.18
■ These fractures are a high-energy injury.
■ This high-energy injury results in comminuted fracture
patterns.
■ These fractures are less amenable to traditional closed
manipulation and casting.
■ The prognosis for these fractures depends on the amount of
residual radius shortening, both radiocarpal and radioulnar
articular congruity, and associated soft tissue injuries.22,24
AN ATOMY
■ The distal radius serves as a plateau to support the carpus.
■ The distal radius has three concave articular surfaces: the
scaphoid fossa, the lunate fossa, and the sigmoid notch.
■ The distal articular surface of the radius has a radial in-
clination averaging 22 degrees and palmar tilt averaging
11 degrees.
■ Radial-based volar and dorsal ligaments arise from the dis-
tal radius to support the wrist.
■ The sigmoid notch of the distal radius articulates with the
ulnar head about which it rotates.
■ The distal radioulnar joint (DRUJ) is primarily stabilized
by the triangular fibrocartilage complex (TFCC).
■ The sigmoid notch angles distally and medially at an aver-
age of 22 degrees.
PATHOGEN ESIS
■ The biomechanical characteristics of each fracture type de-
pend on the mechanism of injury.
■ Fernandez and Geissler 4 developed a classification based on
the mechanism of injury. They noted that the associated liga-
mentous lesions, subluxations, and associated carpal fractures
are related directly to the degree of energy absorbed by the dis-
tal radius.
40
■Type I fractures are bending fractures of the metaphysis in
which one cortex fails to tensile stress and the opposite one
undergoes a certain degree of comminution (eg, extra-artic-
ular Smith or Colles’ fractures).
■ Type II fractures are shearing fractures of the joint surface
(eg, radial styloid fractures, Barton’s fracture).
■ Type III fractures are compression fractures of the
joint surface with impaction of the subcondral and meta-
physeal cancellous bone (ie, intra-articular comminuted
fractures).
■ Type IV fractures are avulsion fractures of ligamen-
tous attachments, including radial styloid and ulnar styloid
fractures, and are associated with radiocarpal fracture-
dislocations.
■ Type V fractures are high-energy injuries that involve a
combination of bending, compression, shearing, and avul-
sion mechanisms or bone loss.
■ Several studies have shown that a high incidence of associ-
ated soft tissue injuries is seen with displaced intra-articular
distal radius fractures.9,11–13,17,19,20
■ Arthroscopic studies demonstrate a high incidence of in-
jury to the triangular fibrocartilage complex, followed by
the scapholunate interosseous ligament, and then the
lunotriquetral interosseous ligament (which is the least
injured).
■ A spectrum of injury occurs to the interosseous ligament
in which it attenuates and eventually tears and the degree of
rotation between the carpal bones increases.
■ Geissler et al defined an arthroscopic classification of
interosseous ligament tears that helps define the degree of
ligament injury and secondary instability as well as
proposes treatment (Table 1; see also Chap. H A-41).
N ATURAL HISTORY
■ Intra-articular fractures of the distal radius have two
pathologies: the associated global injury to the soft tissues and
the injury to the bone itself.
■ The natural history for an intra-articular fracture of the dis-
tal radius depends on restoration of anatomy as well as detec-
tion and management of any associated soft tissue injuries.1,4
■ Knirk and Jupiter 13 documented the importance of articular
restoration over extra-articular orientation in predicting out-
comes for fractures of the distal radius.
■ They showed solid evidence that the largest tolerable ar-
ticular step-off is 2 mm.
■ They demonstrate that the better the restoration of the ar-
ticular surface, the better the outcome.
■ A loss in radius length of 2.5 mm will shift the normal load
transmitted across the ulna from 20% to 42% , which may
lead to various stages of ulnar impaction syndrome.
 Ch a p t e r 5 ARTHROSCOPIC REDUCTION AND FIXATION OF DISTAL RADIUS AND ULNAR STYLOID FRACTURES 41

Ta b le 1 Ge is s le r Ar t h r o s co p ic Cla s s if ica t io n o f Ca r p a l In s t a b ilit y

Gr a d e De f in it io n
I Attenuation/hemorrhage of
interosseous ligament as seen
from the radiocarpal joint.
No incongruency of carpal
alignment in the midcarpal
space.
II Attenuation/hemorrhage
of the interosseous ligament
as seen from the radiocarpal joint.
Incongruency/step-off as
seen from the midcarpal space.
A slight gap between
the carpal bones may be present.
III Incongruency/step-off of carpal
alignment is seen in both the
radiocarpal and midcarpal spaces.
IV Incongruency/step-off of carpal
alignment is seen in both the
radiocarpal and midcarpal spaces.
Gross instability with manipulation
is noted.
Ar t h r o s co p ic Fin d in g s Ma n a g e m e n t
There is a loss of the normal concave appearance between Immobilization
the carpal bones, and the interosseous ligament attenuates
and becomes convex as seen from the radiocarpal space. In
midcarpal space, the interval between the carpal bones will
still be tight and congruent, with no step-off.
A slight gap (less than the width of a probe) between the Arthroscopic reduction and
carpal bones may be present. The interosseous ligament pinning
continues to become attenuated and is convex as seen from
the radial carpal space. In the midcarpal space, the interval
between the involved carpal bones is no longer congruent,
and a step-off is present. In scapholunate instability, palmar
flexion of the dorsal lip of the scaphoid will be seen as
compared to the lunate. In lunotriquetral instability,
increased translation between the triquetrum and lunate
will be seen when palpated with a probe.
The interosseous ligament has started to tear, usually from Arthroscopic/open reduction
volar to dorsal, and a gap is seen between the carpal bones and pinning
in the radiocarpal space. A probe often is helpful to separate
the involved carpal bones in the radiocarpal space. In the
midcarpal space, a 2-mm probe may be placed between the
carpal bones and twisted.
A 2.7-mm arthroscope may be passed through the gap Open reduction and repair
between the carpal bones. The interosseous ligament is
completely detached between the involved carpal bones. This
is the “drive-through” sign, when the arthroscope may be
freely passed from the radiocarpal space through the tear
to the midcarpal space.

■ Untreated complete tears of the scapholunate interosseous ■ Diminished sensibility, pallor, altered capillary refill, in-
ligament, which are highly associated with radial styloid creased tenseness of the soft tissues, and pain out of propor-
fractures, may progress to a wrist with scapholunate ad- tion should raise suspicion for significant soft tissue injury, in-
vanced collapse. cluding compartment syndrome.

PATIEN T HISTORY AN D PHYSICAL IMAGIN G AN D OTHER DIAGN OSTIC

FIN DIN GS STUDIES
■ A thorough history should be obtained, including the cir- ■ Posteroanterior (PA), oblique, and lateral radiographs
cumstances surrounding the injury as well as any additional are the primary radiographic workup for distal radius
injuries. fractures.
■ N eurologic basis ■ Contralateral radiographs of the uninvolved extremity are

■ Cardiac basis useful to compare radial inclination, ulnar variance, and sig-
■ Patients’ level of independence, dominant hand, status moid notch anatomy.
with assisted devices, work, activity level, and support struc- ■ PA projections are useful to evaluate the radial inclina-

ture should be determined. tion, radius height, presence of ulnar styloid fractures,
■ Physical examination, while concentrating on the wrist, widening of the DRUJ, widening of intracarpal spaces, and
should also include the hand, elbow, and shoulder to check for intra-articular involvement (FIG 1 A).
concomitant injuries. ■ Standard radiographic parameters of the distal radius

■ The hand, wrist, arm, and shoulder must be carefully in- include radial inclination of 23 degrees (range 13–30), ra-
spected for open injury so that tetanus and antibiotic pro- dius length of 12 mm (range 8–18 mm), and volar tilt of
phylaxis may be initiated if necessary. 12 degrees (range 1–21 degrees).
■ Thorough distal sensory and motor function examination ■ Ulnar variance shoulde be measured with the shoulder

should be carried out in an organized manner. in 90 degrees of abduction, the elbow at 90 degrees of
■ Vascular examination should include palpation of both flexion, and the wrist in neutral pronation-supination.
the radial and ulnar pulses and determination of capillary ■ A lateral projection is used to assess volar and dorsal tilt

refill time. of the distal fragment, dislocation or subluxation of the

■ Precise palpation is used to define areas of potential DRUJ or carpus, lunate angulation, and dorsal comminu-
trauma. tion (FIG 1 B).
 42 Se c t i o n I HAND, WRIST AND FOREARM
A B
FIG 1 • A. PA ra d io g ra p h ic vie w sh o w in g a m in im a lly d isp la ce d
ra d ia l st ylo id fra ct u re fra g m e n t . B. Th e la t e ra l vie w sh o w s a
co m p le t e fra ct u re -d islo ca t io n o f t h e w rist .
■ A modified lateral radiograph with the beam angulating
10 to 30 degrees proximally improves visualization of the
articular surface and evaluation of the volar rim of the lu-
nate facet represented by the anterior teardrop.
■ An additional 30-degree anteroposterior (AP) cephalic
projection is useful to evaluate the dorsal ulnar margin of
the distal radius.
■ O blique radiographs are very helpful, because major
fracture fragments may be rotated out of their anatomic
planes.
■ CT evaluation, particularly three-dimensional CT, can fur-
ther delineate fragment location, joint compression, and
rotation.
■ M RI evaluation is useful in assessing for associated soft tis-
sue injuries such as TFCC tears, interosseous ligament injuries,
and carpal fractures.
■ Radiographic signs that demonstrate that the distal radius
fracture is likely unstable and closed reduction would be insuf-
ficient include15 :
■ Lateral tilt greater than 20 degrees dorsal
■ Dorsal comminution greater than 50% of the width
■ Initial fragment displacement greater than 1 cm
■ Volar translation greater than 2 mm
■ Initial radius shortening more than 5 mm
■ Intra-articular step-off greater than 2 mm
■ Associated ulna fracture
■ Severe osteoporosis.
■ Age greater than 60 years
DIFFEREN TIAL DIAGN OSIS
■ Carpal bone fracture
■ M etacarpal or phalangeal fracture
■ DRUJ disruption
■ Essex-Lopresti lesion
■ Interosseous ligament tear
■ Carpal dislocation (perilunate)
N ON OPERATIVE MAN AGEMEN T
■ Displaced fractures of the distal radius are reduced using an
adequate anesthetic agent.
■Knowledge of the mechanisms of injury helps facilitate
manual reduction. Force is applied opposite the force that
caused the fracture.
■ Gentle traction is necessary to disimpact the fracture frag-
ments, followed by palmar translation of the hand and car-
pus in respect to the radius.
■ The radius articular surface will rotate around the intact
volar cortical lip to restore volar inclination with palmar
translation.
■ Care must be taken to avoid trauma to the skin during the
reduction maneuver, particularly in elderly patients where
the skin may be fragile.
■ A splint is supplied following the reduction. N o consensus
has been established regarding wrist or forearm position, long-
arm versus short-arm immobilization, or splint versus cast.
■ Extreme positions of wrist flexion and ulnar deviation
should be avoided.
■ Postreduction radiographs are taken in plaster.
■ Depending on stability of the fracture, most patients treated
nonoperatively require weekly visits for the first 3 weeks to
monitor fracture reduction.
■ In patients older than 65 years, one third of initially undis-
placed fractures subsequently collapsed to some degree.
■ O ne study of elderly patients with moderately displaced
fractures of the distal radius found that two thirds of the cor-
rection obtained by closed manipulation was lost at 5 weeks.
■ Patients with minimally displaced or nondisplaced fractures
of the distal radius treated nonoperatively must be made
aware of possible complications, including rupture of the ex-
tensor pollicis longus tendon, carpal tunnel syndrome, and
compartment syndrome.
SURGICAL MAN AGEMEN T
■ Distal radius fractures without extensive metaphyseal com-
munition are ideal candidates for arthroscopic-assisted fixa-
tion with K-wires or cannulated screws.7,8
■ Radial styloid fractures
■ Impacted fractures
■ Die punch fractures
■ Three-part T-type fractures and four-part fractures with
metaphyseal comminution are best treated with a combination
of volar plate stabilization. Wrist arthroscopy is used as an ad-
junct to fine-tune the articular reduction and evaluate for as-
sociated soft tissue lesions.
■ Distal radius fractures that may be minimally displaced, and
fractures with strongly suspected associated soft tissue injury,
also are candidates for arthroscopic-assisted fixation to stabi-
lize the fracture but, more importantly, to evaluate and treat
the acute associated soft tissue injury.
■ Stabilization of associated ulnar styloid fragments is contro-
versial.13 Wrist arthroscopy provides a rationale as to when to
stabilize an ulnar styloid fragment.
Preoperative Planning
■ All radiographic studies are reviewed.
■ Equipment needed for arthroscopic treatment and for open
stabilization is made available.
■ Small joint instrumentation is essential for arthroscopic-
assisted fixation of distal radius fractures. The small joint
arthroscope is approximately 2.7 mm in diameter, and even
 Ch a p t e r 5 ARTHROSCOPIC REDUCTION AND FIXATION OF DISTAL RADIUS AND ULNAR STYLOID FRACTURES
smaller scopes may be used if desired. In addition, a small
joint shaver (3.5 mm or less) is useful to clear fracture debris
and hematoma.
■ The ideal timing for arthroscopic-assisted fixation of distal
radius fractures is 3 to 10 days following injury.6
■ Earlier attempts at fixation may be complicated by soft
tissue swelling and troublesome bleeding, obscuring visual-
ization.
■ After 10 days, the fracture fragments start to become sticky
and more difficult to percutaneously elevate and reduce.
Positioning
■ Arthroscopic-assisted fixation of distal radius fractures may be
performed with the arm suspended vertically in a traction tower,
horizontally in a traction tower, or with finger traps applied at-
tached to weights hanging over the edge of the hand table.
■ Wrist arthroscopy in the horizontal position may make it
easier to simultaneously monitor the reduction fluoroscopi-
cally and place hardware. H owever, it does not allow for si-
multaneous volar access to the wrist.
■ Suspending the wrist in a vertical position with a traction
tower allows simultaneous access to both the volar and dor-
sal aspects of the wrist. This is particularly useful when
wrist arthroscopy is used as an adjunct to volar plate fixa-
tion of the distal radius fracture.
■ A new traction tower has been designed to allow si-
multaneous evaluatation of the intra-articular reduction of the
distal radius arthroscopically and fluoroscopically (FIG 2 A).
■ The surgeon may stabilize a comminuted fracture of the
distal radius with a plate and simultaneously evaluate the
articular reduction arthroscopically.
■ The traction tower allows for traction of the wrist in ei-
ther the vertical or horizontal planes, depending on the sur-
geon’s preference (FIG 2 B).
Approach
■ The wrist is suspended in a traction tower, and the standard
dorsal 3/4 viewing portal, 4/5 or 6R working portal, and 6U
inflow portal are made.
A B
43
■ It is difficult to palpate the normal extensor tendon land-
marks for traditional wrist arthroscopy in patients who sustain
a fracture of the distal radius because of swelling.10 H owever,
the bony landmarks usually can still be palpated. These bony
landmarks include the bases of the metacarpals, the dorsal lip
of the radius, and the ulnar head.
■ The 3/4 portal is made in line with the radial border of the
long finger. It is very useful to place a no. 18 needle into the
proposed location of the 3/4 portal before making a skin
incision.
■ If the portal is placed too proximal, the arthroscope
may be placed within the fracture pattern itself. If it is
placed too distal, it can injure the articular surface of the
carpus.
■ O nce the precise ideal location of the portal is located, the
portal is made by pulling the skin with the sugeon’s thumb
against the tip of a no. 11 blade. Blunt dissection is carried
down with a hemostat, and the arthroscope, with a blunt tro-
car, is introduced into the dorsal 3/4 portal.
■ This technique decreases potential injury to cutaneous
nerves.
■ Thorough irrigation of the joint is necessary to wash out
fracture hematoma and debris and improve visualization.
Inflow may be provided through the arthroscope cannula or
separately through a no. 14 needle into the 6U portal.
■ Use of a separate 6U inflow portal is recommended. The
small-joint arthroscopy cannula does not allow as much
space between the cannula and the arthroscope, limiting the
amount of flow through the cannula.
■ O utflow to the wrist is provided through intervenous ex-
tension tubing connected to the arthroscope cannula.
■ The 4/5 working portal is made in line with the mid-axis of
the ring metacarpal. Alternatively, the 6R working portal is
made just radial to the palpable extensor carpi ulnaris tendon.
■ A no. 18 needle is placed into the joint and should lie just
distal to the articular disc.
■ A 4/5 or 6R portal usually is located just proximal to the
3/4 portal because of the natural radial slope of the distal
radius.
FIG 2 • A. Th is t ra ct io n t o w e r (Acu m e d , Hillsb o ro ,
OR) u se s a su sp e n sio n b a r a t t h e sid e ra t h e r t h a n a t
t h e ce n t e r o f t h e w rist . Th is a llo w s e a sy flu o ro -
sco p ic e va lu a t io n o f t h e fra ct u re re d u ct io n , w it h si-
m u lt a n e o u s fu ll a cce ss t o t h e vo la r a n d d o rsa l a s-
p e ct s o f t h e w rist . B. Th e t o w e r ca n b e fle xe d in t o
a h o rizo n t a l p o sit io n fo r su rg e o n s w h o p re fe r t o
t re a t d ist a l ra d iu s fra ct u re s in t h a t p o sit io n .
 44 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES

RADIAL STYLOID FRACTURES

■ An iso la te d fra ct u re o f t h e ra d ia l stylo id is a n id e a l fra c-
tu re pat te rn t o m ana g e arth ro sco pically, e sp ecia lly fo r t h e
su rgeo n b e g in ning t o g a in e xp e rie n ce in a rt h ro sco p e-
assiste d fixat ion of d ist al radius fra ct ures.
■ In a d d it io n , ra d ia l st ylo id fra ct u re s h a ve a h ig h in cid e n ce
o f a sso cia t e d in ju ry t o t h e sca p h o lu n a t e in t e ro sse o u s lig -
a m e n t , w h ich is b e st a sse sse d a rt h ro sco p ica lly.
■ In se rt o n e o r t w o g u id e w ire s fro m a ca n n u la t e d scre w
syst e m p e rcu t a n e o u sly in t o t h e ra d ia l st ylo id —n o t a cro ss
t h e fra ct u re sit e —u sin g a w ire d rive r in o scilla t io n m o d e .
■ Eva lu a t e t h e p o sit io n o f t h e w ire s u n d e r flu o ro sco p y
t o e n su re t h e y a re ce n t e re d in t h e ra d ia l st ylo id
fra g m e n t .
■ Su sp e n d t h e w rist in a t ra ct io n t o w e r a n d e st a b lish t h e
st a n d a rd a rt h ro sco p ic p o rt a ls.
■ In se rt t h e sco p e in t h e d o rsa l 3/4 p o rt a l a n d cle a r t h e
jo in t o f d e b ris a n d h e m a t o m a .
■ Tra n sfe r t h e a rt h ro sco p e t o t h e 6R o r 4/5 p o rt a l t o lo o k
a cro ss t h e w rist a n d e ffe ct ive ly ju d g e ro t a t io n a n d re d u c-
t io n o f t h e ra d ia l st ylo id fra g m e n t .
■ Usin g t h e p re vio u sly p la ce d g u id e w ire s a s jo yst icks, m a -
n ip u la t e a n d a n a t o m ica lly re d u ce t h e fra ct u re fra g m e n t
u n d e r d ire ct a rt h ro sco p ic o b se rva t io n .
■ A t ro ca r ca n b e in se rt e d t h ro u g h t h e 3/4 p o rt a l t o
h e lp fu rt h e r g u id e t h e re d u ct io n o f t h e ra d ia l st ylo id
fra g m e n t (TECH FIG 1 A,B).
■ On ce t h e fra ct u re is ju d g e d t o b e a b so lu t e ly a n a t o m ic,
t h e g u id e w ire s a re a d va n ce d a cro ss t h e fra ct u re sit e in t o
t h e ra d iu s sh a ft a n d e va lu a t e d u n d e r flu o ro sco p y (TECH
FIG 1 C).
■ In m a n y ca se s, t h e fra ct u re re d u ct io n m a y lo o k
a n a t o m ic u n d e r flu o ro sco p y, b u t w h e n vie w e d
a rt h ro sco p ica lly, t h e ra d ia l st ylo id fra g m e n t is se e n t o
b e slig h t ly ro t a t e d . 3
■ Gu id e w ire s a lo n e ca n b e u se d t o st a b ilize t h e fra ct u re ,
b u t ca n n u la t e d scre w s (w it h o r w it h o u t h e a d s) a re re c-
o m m e n d e d (TECH FIG 1 D,E).
■ Ca n n u la t e d scre w s d e cre a se so ft t issu e irrit a t io n a n d
p o t e n t ia l p in t ra ck in fe ct io n a s co m p a re d w it h K-
w ire s.

A B

C D E

TECH FIG 1 • A. Art h ro sco p ic vie w o f t h e p a t ie n t w h o se ra d io g ra p h s a re se e n in Fig u re 1. Th e a rt h ro sco p e is in t h e 6R p o r-

t a l lo o kin g a cro ss t h e w rist , a n d a b lu n t t ro ch a r is in t h e 3/4 p o rt a l. Th e d isp la ce d ra d ia l st ylo id fra g m e n t is w e ll visu a lize d .
B. A co m b in a t io n o f jo yst icks in se rt e d in t o t h e ra d ia l st ylo id fra g m e n t a n d a t ro ch a r in se rt e d in t o t h e 3/4 p o rt a l a llo w s
a n a t o m ic re d u ct io n o f t h e d isp la ce d ra d ia l st ylo id fra g m e n t a n d ra d io ca rp a l jo in t . C. Th e ra d ia l st ylo id fra g m e n t is a n a t o m -
ica lly re d u ce d (w it h n o re sid u a l ro t a t io n ) a n d st a b ilize d . D. PA vie w d e m o n st ra t in g a n a t o m ic re d u ct io n t o t h e ra d ia l st ylo id
fra g m e n t . He a d le ss ca n n u la t e d scre w s a re u se d , if p o ssib le , t o a vo id so ft t issu e irrit a t io n . E. La t e ra l vie w sh o w in g a n a t o m ic
re st o ra t io n t o t h e ra d ia l st ylo id fra g m e n t a n d re st o ra t io n o f t h e ca rp u s in lin e w it h t h e ra d iu s.
 Ch a p t e r 5 ARTHROSCOPIC REDUCTION AND FIXATION OF DISTAL RADIUS AND ULNAR STYLOID FRACTURES 45

THREE-PART FRACTURES
■ Th re e -p a rt fra ct u re s t h a t in vo lve a d isp la ce d fra ct u re o f
t h e ra d ia l st ylo id a n d a lu n a t e fa ce t fra g m e n t w it h o u t
m e t a p h yse a l co m m u n u t io n a re id e a l fo r a rt h ro sco p ic-a s-
sist e d re d u ct io n (TECH FIG 2 A,B).
■ Re d u ce a n d p ro visio n a lly st a b ilize t h e ra d ia l
st ylo id fra g m e n t w it h g u id e w ire s u n d e r flu o ro sco p ic
g u id a n ce .
■ Th e ra d ia l st ylo id se rve s a s a la n d m a rk t o w h ich t h e
d e p re sse d lu n a t e fa ce t fra g m e n t is re d u ce d .
■ Su sp e n d t h e w rist in t h e t ra ct io n t o w e r, e st a b lish p o rt a ls,
a n d e va cu a t e t h e fra ct u re d e b ris a n d h e m a t o m a .
■ Th e d e p re sse d lu n a t e fa ce t fra g m e n t is b e st se e n w it h
t h e a rt h ro sco p e in t h e 3/4 p o rt a l (TECH FIG 2 C,D).
■ Pe rcu t a n e o u sly p la ce a n o . 18 n e e d le d ire ct ly o ve r t h e
d e p re sse d fra g m e n t a s vie w e d a rt h ro sco p ica lly.
■ In se rt a la rg e K-w ire a b o u t 2 cm p ro xim a l t o t h e p re vi-
o u sly p la ce d n o . 18 n e e d le t o p e rcu t a n e o u sly e le va t e t h e
d e p re sse d lu n a t e fa ce t fra g m e n t .
TECHNIQUES
■ Use a b o n e t e n a cu lu m t o fu rt h e r d im in ish t h e g a p b e -
t w e e n t h e ra d ia l st ylo id a n d lu n a t e fa ce t fra g m e n t s.
■ Pla ce g u id e w ire s t ra n sve rse ly u n d e r t h e su b ch o n d ra l su r-
fa ce o f t h e ra d iu s fro m t h e ra d ia l st ylo id in t o t h e
a n a t o m ica lly re d u ce d lu n a t e fa ce t fra g m e n t .
■ It is im p o rt a n t t o p ro n a t e a n d su p in a t e t h e w rist fo l-
lo w in g p la ce m e n t o f t h e t ra n sve rse p in s t o e n su re t h e
g u id e w ire s h a ve n o t vio la t e d t h e DRUJ. Th e co n ca ve
n a t u re o f t h e DRUJ m a ke s ra d io g ra p h ic a sse ssm e n t
d ifficu lt .
■ Co n sid e r in se rt io n o f b o n e g ra ft t o su p p o rt t h e re d u ce d
lu n a t e fra g m e n t a n d a vo id la t e se t t lin g .
■ Ma ke a sm a ll in cisio n b e t w e e n t h e fo u rt h a n d fift h
d o rsa l co m p a rt m e n t s.
■ Use cancellou s allog raft bo ne chips or bo ne substitutes.
■ If fe a sib le , p la ce h e a d le ss ca n n u la t e d scre w s t o st a b ilize
b o t h t h e ra d ia l st ylo id a n d t h e im p a ct e d lu n a t e fa ce t
fra g m e n t s (TECH FIG 2 E–H).

A B C

D E

TECH FIG 2 • A. PA vie w sh o w in g a im p a ct e d sca p h o id fa ce t fra ct u re fra g m e n t

w it h a n o b vio u s in ju ry t o t h e sca p h o lu n a t e in t e ro sse o u s lig a m e n t . B. La t e ra l vie w
sh o w in g a d o rsa l rim fra ct u re fra g m e n t . C. Th e a rt h ro sco p e is in t h e 6R p o rt a l,
d e m o n st ra t in g t h e im p a ct e d sca p h o id fa ce t fra ct u re fra g m e n t . Th is w o u ld b e
q u it e d ifficu lt t o vie w t h ro u g h a n o p e n a rt h ro t o m y, b u t is w e ll visu a lize d a rt h ro -
sco p ica lly u n d e r b rig h t lig h t a n d m a g n ifie d co n d it io n s. D. Th e im p a ct e d sca p h o id
fa ce t fra g m e n t is e le va t e d b a ck t o t h e vo la r rim , u sin g t h e rim a s a la n d m a rk t o
ju d g e ro t a t io n . E,F. Ge issle r g ra d e III t e a r in vo lvin g t h e sca p h o lu n a t e in -
t e ro sse o u s lig a m e n t a s se e n t h ro u g h t h e 3/4 p o rt a l (E) a n d t h e ra d ia l m id ca rp a l
F p o rt a l (F). (co n t in u e d )
 46 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES
G H
THREE- AND FOUR-PART FRACTURES WITH METAPHYSEAL COMMINUTION
■ A co m b in a t io n o f o p e n su rg e ry, u sin g a vo la r p la t e fo r
st a b ilit y, a n d a rt h ro sco p y, a s a n a d ju n ct t o a ssist t h e a r-
t icu la r re d u ct io n , is u se d if m e t a p h yse a l co m m in u t io n is
p re se n t (TECH FIG 3 ).
■ Vo la r p la t e st a b iliza t io n is ve ry st a b le a n d a llo w s fo r
e a rly ra n g e o f m o t io n a n d re h a b ilit a t io n a s co m p a re d t o
K-w ire s o r h e a d le ss scre w s a lo n e .
Op e n Re d u ct io n a n d St a b iliza t io n
■ Pe rfo rm a st a n d a rd vo la r a p p ro a ch a n d d o n o t o p e n t h e
ra d io ca rp a l jo in t ca p su le (TECH FIG 4 A).
■ Th e ra d ia l st ylo id fra g m e n t a n d t h e vo la r u ln a r fra g m e n t
a re re d u ce d t o t h e sh a ft u n d e r d ire ct visu a liza t io n . Th e
ra d ia l st ylo id fra g m e n t is p ro visio n a lly p in n e d .
■ Ap p ly a vo la r d ist a l ra d iu s lo ckin g p la t e t o st a b ilize t h e
vo la r b o n e fra g m e n t s (TECH FIG 4 B).
■ Pla ce a scre w in t h e p ro xim a l p o rt io n o f t h e p la t e
first , t o re d u ce t h e p la t e t o t h e sh a ft .
A B
TECH FIG 2 • (co n t in u e d ) G,H. PA a n d la t e ra l ra -
d io g ra p h s sh o w in g a n a t o m ic re d u ct io n t o t h e
im p a ct e d sca p h o id fa ce t fra ct u re . (Th e t e a r o f
t h e sca p h o lu n a t e in t e ro sse o u s lig a m e n t a lso w a s
a cu t e ly re p a ire d .)
■ Pro visio n a lly p in t h e d ist a l fra g m e n t s t h ro u g h t h e
p la t e .
■ Ma n ip u la t e t h e a rt icu la r fra g m e n t s u n d e r flu o ro sco p y t o
o b t a in a s a n a t o m ic a re d u ct io n a s p o ssib le (TECH FIG
4 C,D).
■ Su sp e n d t h e w rist in t h e t ra ct io n t o w e r a n d re d u ce t h e
a rt icu la r fra g m e n t s a rt h ro sco p ica lly (TECH FIG 4 E,F).
■ If a rt icu la r re d u ct io n is n o t a n a t o m ic, re m o ve t h e p in s
a n d fin e -t u n e t h e re d u ct io n .
■ On ce th e fra ct u re red u ctio n is th o u g h t t o b e an a to m ic,
p la ce t he d ist al screw s th ro u g h t h e p la t e (TECH FIG 4 G–I).
■ It is im p o rt a n t t h a t t h e fra ct u re b e re d u ce d t o t h e
p la t e , w it h n o g a p b e t w e e n t h e p la t e a n d t h e b o n e .
Th is ca n b e a ch ie ve d b y fle xio n o f t h e w rist in t h e
t o w e r a n d b y in se rt io n o f a n o n -lo ckin g scre w first ,
b e fo re t h e in se rt io n o f st a n d a rd lo ckin g scre w s.
■ Pla ce t h e re m a in in g p ro xim a l a n d d ist a l scre w s if t h e
re d u ct io n is a n a t o m ic u n d e r b o t h flu o ro sco p y a n d
a rt h ro sco p y.
TECH FIG 3 • A. Th e PA ra d io g ra p h
sh o w s a d isp la ce d fra ct u re o f t h e ra d ia l
st ylo id . B. Th is la t e ra l ra d io g ra p h sh o w s
m e t a p h yse a l co m m in u t io n a sso cia t e d
w it h t h e d isp la ce d ra d ia l st ylo id fra g -
m e n t . Be ca u se o f t h e m e t a p h yse a l co m -
m in u t io n , it w a s d e cid e d t o st a b ilize t h e
fra ct u re u sin g a vo la r p la t e .
 Ch a p t e r 5 ARTHROSCOPIC REDUCTION AND FIXATION OF DISTAL RADIUS AND ULNAR STYLOID FRACTURES 47

TECHNIQUES
A B

H
F

TECH FIG 4 • A. A st a n d a rd vo la r a p p ro a ch is m a d e , ce n t e re d o ve r t h e fle xo r ca rp i ra d ia lis t e n d o n , a n d t h e fra ct u re

sit e is e xp o se d . B. A vo la r d ist a l ra d iu s lo ckin g p la t e (Acu m e d , Hillsb o ro , OR) is a p p lie d . Th e in it ia l scre w is p la ce d
t h ro u g h t h e p ro xim a l p la t e t o se cu re t h e p la t e t o t h e sh a ft . C. Th e in t ra -a rt icu la r re d u ct io n is vie w e d u n d e r flu o ro sco p y
a n d p ro visio n a lly p in n e d . A d isp la ce d in t ra -a rt icu la r fra ct u re fra g m e n t ca n st ill b e id e n t ifie d . D. Th e a rt h ro sco p e is in
t h e 3/4 p o rt a l, sh o w in g t h e vo la r ca p su le b lo ckin g re d u ct io n o f t h e ra d ia l st ylo id fra g m e n t . E. Jo yst icks p re vio u sly in -
se rt e d in t o t h e ra d ia l st ylo id fra g m e n t a re t h e n u se d t o co n t ro l a n d a n a t o m ica lly re d u ce t h e ra d ia l st ylo id fra g m e n t .
F. Th e a rt h ro sco p e is in t h e 6R p o rt a l lo o kin g a cro ss t h e w rist . An a t o m ic re d u ct io n o f t h e ra d ia l st ylo id fra g m e n t is d o c-
u m e n t e d . G. On ce t h e a n a t o m ic re st o ra t io n o f t h e a rt icu la r su rfa ce is e va lu a t e d b o t h a rt h ro sco p ica lly a n d flu o ro sco p -
ica lly, t h e d ist a l scre w s a re p la ce d in t h e p la t e . H. Flu o ro sco p ic vie w sh o w in g a n a t o m ic re st o ra t io n t o t h e a rt icu la r su r-
fa ce o f t h e d ist a l ra d iu s. I. Th e p a t ie n t h a d a n a sso cia t e d o st e o ch o n d ra l fra ct u re o f t h e lu n a t e , n o t visib le o n p la in ra -
d io g ra p h s. Th e d isp la ce d fra g m e n t is a rt h ro sco p ica lly re m o ve d .
 48 Se c t i o n I HAND, WRIST AND FOREARM

Re d u ct io n a n d St a b iliza t io n o f a ■ Th e d o rsa l d ie p u n ch fra g m e n t is b e st se e n w it h t h e

TECHNIQUES

Do rsa l Die Pu n ch Fra g m e n t
■ It is n o t p o ssib le t o se e t h e re d u ct io n o f a d o rsa l d ie
p u n ch fra g m e n t t h ro u g h t h e vo la r a p p ro a ch w h e n st a -
b ilize d w it h a p la t e . Art h ro sco p y ca n b e h e lp fu l in t h is
sce n a rio .
■ In se rt t h e vo la r p la t e a s p re vio u sly d e scrib e d a n d p ro vi-
sio n a lly fix t h e d e vice t o t h e ra d iu s.
■ Fre q u e n t ly, t h e d o rsa l fra g m e n t m a y st ill b e slig h t ly
p ro xim a l in re la t io n t o t h e ra d ia l sh a ft .
a rt h ro sco p e in t h e 6R p o rt a l.
■ Est a b lish t h e vo la r ra d ia l p o rt a l b e t w e e n t h e ra -
d io sca p h o ca p it a t e lig a m e n t a n d t h e lo n g ra d io lu n a t e
lig m e n t , a s vie w e d d ire ct ly t h ro u g h t h e p re vio u s p e r-
fo rm e d vo la r a p p ro a ch .16
■ Pe rcu t a n e o u sly e le va t e a n d a n a t o m ica lly re d u ce t h e d o r-
sa l d ie p u n ch fra g m e n t a s vie w e d a rt h ro sco p ica lly.
■ On ce t h is h a s b e e n a ch ie ve d , p la ce t h e scre w s in t o t h e
p la t e a n d o b se rve t h e ir p a t h a rt h ro sco p ica lly t o e n su re
a d e q u a t e st a b iliza t io n o f t h e d o rsa l d ie p u n ch fra g m e n t .

ULNAR STYLOID FRACTURES

■ Fo llo w in g a n a t o m ic re d u ct io n o f t h e d ist a l ra d iu s fra c- ■ Pla ce t h e ca n n u la t e d h e a d le ss scre w o ve r t h e g u id e w ire
t u re , in se rt t h e a rt h ro sco p e in t h e d o rsa l 3/4 p o rt a l a n d a n d ve rify fra ct u re re d u ct io n w it h flu o ro sco p y.
t h e p ro b e in t h e 6R p o rt a l. Pa lp a t e t h e t e n sio n o f t h e a r- ■ In se rt t h e a rt h ro sco p e in t o t h e 3/4 p o rt a l a n d t h e p ro b e
t icu la r d isc. in t o t h e 6R p o rt a l t o d o cu m e n t re st o ra t io n o f TFCC
■ Go o d t e n sio n in d ica t e s t h a t t h e m a jo rit y o f t h e p e - t e n sio n .
rip h e ra l TFCC fib e rs a re in t a ct o r st ill a t t a ch e d t o t h e
p ro xim a l u ln a .
■ A p e rip h e ra l t e a r o f t h e a rt icu la r d isc is re p a ire d
a rt h ro sco p ica lly w h e n d e t e ct e d .21
■ St a b iliza t io n o f a la rg e u ln a r st ylo id fra g m e n t is co n sid -
e re d w h e n t h e a rt icu la r d isc is la x b y p a lp a t io n a n d n o
p e rip h e ra l TFCC is id e n t ifie d (TECH FIG 5 ).
■ In t h is in st a n ce , t h e m a jo rit y o f t h e fib e rs o f t h e TFCC
a re a t t a ch e d t o t h e d isp la ce d u ln a r st ylo id fra g m e n t .
■ Ma ke a sm a ll in cisio n b e t w e e n t h e e xt e n so r ca rp i u ln a ris
a n d t h e fle xo r ca rp i u ln a ris t e n d o n s a n d id e n t ify t h e fra c-
t u re sit e .
■ Re t rie ve t h e d ist a l fra g m e n t , w h ich o ft e n d isp la ce s in a
d ist a l a n d ra d ia l d ire ct io n .
■ Mo b ilize t h e st ylo id fra g m e n t u sin g a n o . 15 b la d e , t a k-
in g ca re t o p ro t e ct t h e TFCC in se rt io n .
■ Re d u ce t h e fra g m e n t a n a t o m ica lly, u n d e r d ire ct visu a l-
iza t io n , a n d in se rt a g u id e w ire in a re t ro g ra d e m a n n e r TECH FIG 5 • In t h is ca se , fo llo w in g re d u ct io n t o t h e d ist a l ra -
fo r p ro visio n a l st a b ilit y. d iu s fra ct u re , t h e a rt icu la r d isc w a s p a lp a t e d a n d fo u n d t o b e
■ St a b ilize t h e u ln a r st ylo id fra g m e n t u sin g e it h e r a t e n - la x b u t w it h n o p e rip h e ra l t e a r. Th e la rg e u ln a r st ylo id fra g -
sio n b a n d t e ch n iq u e (w it h w ire a n d t w o K-w ire s) o r, m e n t w a s re d u ce d w it h a m icro Acu t ra k scre w (Acu m e d ,
p re fe ra b ly, u sin g a m icro h e a d le ss ca n n u la t e d scre w . Hillsb o ro , OR).

PEARLS AND PITFALLS

Tim in g o f re d u ct io n
Art h ro sco p ic visu a liza t io n
In st ru m e n t a t io n
Fixa t io n
■ Art h ro sco p ica lly a ssist e d re d u ct io n o f d ist a l ra d iu s fra ct u re s is m o st id e a l b e t w e e n 3 a n d 10 d a ys
fo llo w in g in ju ry. Assist e d fixa t io n b e fo re 3 d a ys u su a lly is co m p lica t e d b y b le e d in g t h a t ca n o b scu re
visu a liza t io n. Pe rcu t a n e o u s fra ct u re re d u ct io n m o re t h a n 10 d a ys a ft e r t h e in ju ry is e xce e d in g ly
d ifficu lt a n d o ft e n u n su cce ssfu l.
■ It is im p o rt a n t t o t a ke t h e t im e t o t h o ro u g h ly irrig a t e a n d d é b rid e t h e jo in t o f h e m a t o m a a n d
d e b ris. Th is e sp e cia lly h e lp s visu a liza t io n o f fra g m e n t ro t a t io n . Irrig a t io n t h ro u g h a se p a rt e 6U
in flo w p o rt a l is h e lp fu l. A Co b a n w ra p (3M, St . Pa u l, MN) m a y b e w ra p p e d a ro u n d t h e fo re a rm t o
lim it flu id e xt ra va sa t io n in t o t h e so ft t issu e s.
■ La rg e -jo in t in st ru m e n t a t io n w ill d a m a g e t h e a rt icu la r ca rt ila g e a n d is n o t a p p ro p ria t e . A m o b ile
t ra ct io n t o w e r is e xt re m e ly h e lp fu l in a rt h ro sco p ic-a ssist e d m a n a g e m e n t o f d ist a l ra d iu s fra ct u re s.
■ Do n o t su b st it u t e p o o r fixa t io n fo r a n a rt h ro sco p ica lly a ssist e d p ro ce d u re . Fixa t io n sh o u ld b e
ch o se n t o fit t h e p e rso n a lit y o f t h e fra ct u re . Fo r e xa m p le , K-w ire s sh o u ld n o t b e u se d t o st a b ilize a
vo la r Ba rt o n ’s fra ct u re w h e n vo la r p la t e st a b iliza t io n is t h e o b vio u s ch o ice . Wh ile K-w ire s a re e a sy
t o in se rt , t h e y h in d e r re h a b ilit a t io n a n d h a ve t h e p o t e n t ia l fo r p in t ra ck in fe ct io n s.
 Ch a p t e r 5 ARTHROSCOPIC REDUCTION AND FIXATION OF DISTAL RADIUS AND ULNAR STYLOID FRACTURES 49

■ Ca n n u la t e d scre w s a re re co m m e n d e d w h e n a rt h ro sco p ica lly st a b ilizin g a fra ct u re o f t h e d ist a l ra -

d iu s w it h o u t m e t a p h yse a l co m m in u t io n .
■ Vo la r p la t e fixa t io n is re co m m e n d e d w h e n m e t a p h yse a l co m m in u t io n is p re se n t .
■ Arth ro sco p ic e va lua t io n o f t he wrist w hile th e d ist a l scre w s a re b e in g p la ce d o ffe rs th e ad va n ta g e of
se e ing t he scre ws p e n et rate in to th e fract ure fra gm ent s, th ereb y en su ring stab ility. Arthroscopic eval-
uation is helpful in variable-angle volar locking plat es to ensure t he screws do not violate the joint.
Ob se rva t io n ■ It is im p e ra t ive fo llo w in g a rt h ro sco p ica lly a ssist e d re d u ct io n o f t h e d ist a l ra d iu s in t h e ra d io ca rp a l
sp a ce t o e va lu a t e t h e m id ca rp a l sp a ce . Th e m id ca rp a l sp a ce is t h e m o st se n sit ive a n d id e a l lo ca t io n
t o e va lu a t e in t e rca rp a l st a b ilit y. In a d d it io n , lo o se b o d ie s fro m t h e ca p it a t e o r h a m a t e o cca sio n a lly
a re se e n , p a rt icu la rly in a sso cia t io n w it h lu n a t e d ie p u n ch fra ct u re s. Art h ro sco p ic e va lu a t io n a lso
a id s in d e t e rm in in g w h e n t o fix t h e u ln a r st ylo id .

POSTOPERATIVE CARE COMPLICATION S

■ The degree of postoperative immobilization depends on nu- ■ Failure of fixation
merous factors, including the mode of fracture stabilization, ■ Late settling of the fracture despite fixation

the quality of the bone for internal fixation, the stability of the ■ Flexor and extensor tendon irritation

fixation, and the management of any associated soft tissue in- ■ Painful metal requiring removal

juries that were addressed during the arthroscopic evaluation. ■ N euromas of the dorsal sensory branch of the radial and

■ Immediate range of motion of the digits and wrist is initi- ulnar nerves
ated in patients with volar plate fixation with good bone stock ■ Carpal tunnel syndrome

and solid fixation. ■ Reflex sympathetic dystrophy

■ In patients with soft osteopenic bone with volar plate fixa- ■ Wrist and hand stiffness

tion, digital range of motion exercises are initiated immedi-

ately, but wrist range of motion is delayed approximately 3 to
REFEREN CES
4 weeks to permit some fracture healing.
■ Soft bone may collapse around the rigid plate.
■ In patients without metaphyseal comminution treated by
arthroscopically assisted stabilization with cannulated screws,
range of motion is initiated as the patient tolerates.
■ In patients treated with percutaneous K-wires, the wrist is
immobilized until the wires are removed, usually 4 to 6 weeks
after surgery.
■ A patient with an unstable DRUJ treated by TFCC repair or
ulnar styloid reduction and fixation is restricted from prona-
tion and supination for 2 to 4 weeks.
OUTCOMES
■ The literature is relatively sparse regarding the results of
arthroscopically assisted fixation of displaced intra-articular
distal radius fractures.
■ A comparison study of 12 open and 12 arthroscopic reduc-
tions of comminuted AO type VII and VIII fractures of the dis-
tal radius found that the arthroscopic group had increased
range of motion as compared to the open stabilization
group.23
■ A second comparison study of 38 patients who underwent
arthroscopically assisted fixation compared to open reduction
found the arthroscopically assisted group had better results
and improved range of motion.2
■ O ne study compared 15 patients with arthroscopically as-
sisted fixation to 15 patients who underwent closed reduction
and external fixation.21 In this study, there were 10 tears of
the triangular fibrocartilage complex in the group that under-
went arthroscopic reduction, of which seven were peripheral
and repaired. There were no signs of distal radioulnar joint in-
stability at final follow-up visit. In the 15 patients who under-
went stabilization by external fixation alone, four patients had
continued complaints of instability of the distal radial joint,
very possibly the result of undiagnosed and untreated TFCC
tears.
1. Bradway JK, Amadio PC, Cooney WP. O pen reduction and internal
fixation of displaced comminuted intraarticular fractures of the distal
end of the radius. J Bone Joint Surg Am 1989;71A:839–847.
2. Doi K, H atturi T, O tsuka K, et al. Intraarticular fractures of the dis-
tal aspect of the radius arthroscopically assisted reduction compared
with open reduction and internal fixation. J Bone Joint Surg Am
1999;81A:1093–1110.
3. Edwards CC III, H arasztic J, M cGillivary GR, et al. Intraarticular dis-
tal radius fractures: arthroscopic assessment of radiographically as-
sisted reduction. J H and Surg Am 2001;26A:1036–1041.
4. Fernandez DL, Geissler WB. Treatment of displaced articular frac-
tures of the radius. J H and Surg Am 1991;16:375–384.
5. Geissler WB. Arthroscopically assisted reduction of intra-articular
fractures of the distal radius. H and Clin 1995;11:19–29.
6. Geissler WB. Intra-articular distal radius fractures: the role of
arthroscopy? H and Clin 2005;21:407–416.
7. Geissler WB, Freeland AE. Arthroscopically assisted reduction of
intra-articular distal radial fractures. Clin O rthop Relat Res 1996;
327:125–134.
8. Geissler WB, Freeland AE, Savoie FH , et al. Intracarpal soft-tissue le-
sions associated with an intra-articular fracture of the distal end of
the radius. J Bone Joint Surg Am 1996;78A:357–365.
9. Geissler WB, Savoie FH . Arthroscopic techniques of the wrist.
M ediguide to O rthopedics 1992;11:1–8.
10. H anker GJ. Wrist arthroscopy in distal radius fractures. Proceedings
of the Arthroscopy Association N orth America Annual M eeting,
Albuquerque, N M , O ctober 7–9, 1993.
11. H ixon M L, Fitzrandolph R, M cAndrew M , et al. Acute ligamentous
tears of the wrist associated with Colles fractures. Proceedings of the
Annual M eeting of the American Society for Surgery of the H and,
Baltimore, 1989.
12. H ollingworth R, M orris J. The importance of the ulnar side of the
wrist in fractures of the distal end of the radius. Injury 1976;7:263.
13. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the
radius in young adults. J Bone Joint Surg Am 1986;68A:647–658.
14. Lafontaine M , H ardy D, Delince P. Stability assessment of distal ra-
dius fractures. Injury 1989;20:208–210.
15. Levy H J, Glickel SZ . Arthroscopic assisted internal fixation of intra-
articular wrist fractures. Arthroscopy 1993;9:122–123.
16. Lindau T. Treatment of injuries to the ulnar side of the wrist occur-
ring with distal radial fractures. H and Clin 2005;21:417–425.
50 Se c t i o n I HAND, WRIST AND FOREARM
17. M elone CP. Articular fractures of the distal radius. O rthop Clin
N orth Am 1984;15:217–235.
18. M ohanti RC, Kar N . Study of triangular fibrocartilage of the wrist
joint in Colles fracture. Injury 1979;11:311–324.
19. M udgal CS, Jones WA. Scapholunate diastasis: a component of frac-
tures of the distal radius. J H and Surg Br 1990;15:503–505.
20. Ruch DS, Vallee J, Poehling GG, et al. Arthroscopic reduction versus
fluoroscopic reduction in the management of intra-articular distal ra-
dius fractures. Arthroscopy 2004;20:225–230.
21. Short WH , Palmer AK, Werner FW, et al. A biomechanical study of
distal radial fractures. J H and Surg Am 1987;12:529–534.
22. Stewart N J, Berger RA. Comparison study of arthroscopic as open re-
duction of comminuted distal radius fractures. Abstract. Presented at
the 53 rd Annual M eeting of the American Society for Surgery of the
H and. January 11, 1998, Scottsdale, AZ .
23. Trumble TE, Schmitt SR, Vedder N B. Factors affecting functional
outcome of displaced intra-articular distal radius fractures. J H and
Surg Am 1994;19:325–340.
 Vo la r Pla t in g o f Dis t a l
Ch a p t e r 6 Ra d iu s Fr a ct u re s
Jo h n J. Fe rn an d e z

DEFIN ITION ■ It is the floor of the fibro-osseous extensor tendon com-

partments and includes Lister’s tubercle, assisting in exten-
■ Distal radius fractures are defined by their involvement of
sor pollicis longus function (FIG 1 A).
the metaphysis of the distal radius. ■ The extensor tendons are in immediate contact with the
■ They are assessed on the basis of fracture pattern, align-
dorsal surface of the distal radius.
ment, and stability: ■ Volarly
■ Articular versus nonarticular
■ The distal radius is the origin for the extrinsic ligaments
■ Reducible versus irreducible

■ Stable versus unstable

of the carpus, including the radioscaphocapitate ligament.
■ It also is the origin of the pronator quadratus.
■ Irreducible or unstable fractures require surgical reduction
■ The flexor tendons are separated from the distal radius by
and stable fixation.
■ Volar plating historically has been the method of choice for
the pronator quadratus.
■ Ulnarly
volar shear-type fractures. ■ The distal radius is the origin for the radial triangular
■ Recently developed fixed-angle plates have now made it a
fibrocartilage (FIG 1 A).
preferred method of fixation for most types of distal radius ■ It also contains the sigmoid notch, which articulates with
fractures.
the head of the distal ulna, contributing to forearm rotation.
■ Distally

AN ATOMY ■ The surface is divided into a triangular, radioscaphoid

■ The distal radius serves as a buttress for the proximal car- fossa and a square, radiolunate fossa articulating with the
pus, transmitting 75% to 80% of its forces into the forearm. respective carpal bones (FIG 1 B).
■ The remaining 20% to 25% of force is transmitted ■ The distal articular surface is inclined approximately 22 de-

through the distal ulna and the triangular fibrocartilage grees ulnarly in the coronal plane and 11 degrees volarly in the
complex (TFCC). sagittal plane (FIG 1 C,D).
■ Dorsally ■ The metaphysis is defined by the distal radius within a

■ The distal radius is the origin for the dorsal radiocarpal length of the articular surface that is equivalent to the widest
ligament. portion of the entire wrist.

TFC
LF SF

A B C

FIG 1 • A. Axia l MR im a g e o f t h e w rist a t t h e le ve l o f t h e d ist a l ra d iu s. List e r’s t u b e rcle is

m a rke d w it h a n a st e risk. Do t t e d lin e s re p re se n t d o rsa l a n d vo la r b o rd e rs o f t h e t ria n g u la r
fib ro ca rt ila g e t h a t h e lp s st a b ilize t h e d ist a l ra d io u ln a r jo in t . Th e d o rsa l d ist a l ra d iu s a ct s a s
a n a t t a ch m e n t fo r d o rsa l e xt e n so r co m p a rt m e n t sh e a t h s. B. Th e d ist a l a rt icu la r su rfa ce o f
t h e ra d iu s is d ivid e d in t o a t ria n g u la rly sh a p e d sca p h o id fo ssa (SF) a n d a sq u a re -sh a p e d
lu n a t e fo ssa (LF). Th e d ist a l u ln a a n d t h e t ria n g u la r fib ro ca rt ila g e co m p le x (TFCC) a ct a s
u ln a r b u t t re sse s fo r t h e w rist . C. MR co ro n a l cu t o f t h e d ist a l ra d iu s. Th e a rt icu la r su rfa ce
o f t h e d ist a l ra d iu s is in clin e d a b o u t 22 d e g re e s re la t ive t o t h e fo re a rm a xis (d o t t e d lin e s).
Th e u ln a r a sp e ct o f t h e d ist a l ra d iu s (ie , t h e lu n a t e fo ssa ) u su a lly is d ist a l t o t h e e n d o f t h e
d ist a l u ln a (ie , n e g a t ive u ln a r va ria n ce ). No t e t h e so lid lin e s m a rkin g u ln a r va ria n ce . D. MR
sa g it t a l cu t o f t h e d ist a l ra d iu s. Th e a rt icu la r su rfa ce o f t h e d ist a l ra d iu s is in clin e d
a p p ro xim a t e ly 11 d e g re e s p a lm a r re la t ive t o t h e fo re a rm a xis (d o t t e d lin e s). Pro xim a lly,
D t h e re e xist s re la t ive ly t h in n e r d o rsa l co rt ica l b o n e ve rsu s t h e t h icke r vo la r b o n e .

51
52 Se c t i o n I HAND, WRIST AND FOREARM
■ The dorsal cortical bone is less substantial than the volar
cortical bone, contributing to the characteristic dorsal-bending
fracture pattern of distal radius fractures.
PATHOGEN ESIS
■ The mechanism of injury in a distal radius fracture is an
axial force across the wrist, with the pattern of injury deter-
mined by bone density, the position of the wrist, and the mag-
nitude and direction of force.
■ M ost distal radius fractures result from falls with the wrist
extended and pronated, which places a dorsal bending mo-
ment across the distal radius.
■ Relatively weaker, thinner dorsal bone collapses under
compression, whereas stronger volar bone fails under tension,
resulting in a characteristic “ triangle” of bone comminution
with the apex volar and greater comminution dorsal.
■ O ther possible mechanisms form a basis for some fracture
classifications such as the one proposed by Jupiter and
Fernandez.5
■ Bending
■ Compression
■ Shear
■ Avulsion
■ Combinations
■ Articular involvement and its severity are the basis of some
fracture classifications, such as the AO 9 and M elone8
classifications.
■ Articular involvement splits the distal radius into distinct
fragments separate from the radius shaft (FIG 2 ):
■ Scaphoid fossa fragment
■ Lunate fossa fragment. Further comminution can split the
lunate fossa fragment into dorsal and volar segments, creat-
ing the so-called four-part fracture.
N ATURAL HISTORY
■ Clinical outcome usually, but not always, correlates with
deformity.
■ Variable residual deformity can be tolerated best by indi-
viduals with fewer functional demands.
FIG 2 • Th e a rro w h e a d p o in t s t o t h e a rt icu la r sp lit . Art icu la r
d isp la ce m e n t o f t h e sca p h o id fo ssa fra g m e n t ra d ia lly a n d t h e
lu n a t e fo ssa fra g m e n t u ln a rly is a p p a re n t , a s is sig n ifica n t
sh o rt e n in g (u ln a r p o sit ive va ria n ce ) a s o u t lin e d b y t h e lin e s.
■ As wrist deformity increases, physiologic function is pro-
gressively altered.
■ Intra-articular displacement of 1 to 2 mm results in an
increased risk of osteoarthritis.3,6
■ Radial shortening of 3 to 5 mm or more results in in-
creased loading of the ulnar complex. 1,12
■ Dorsal angulation greater than 10 degrees shifts contact
forces to the dorsal scaphoid fossa and the ulnar complex,
causing increased disability.13,16
■ The incidence of associated intracarpal injuries increases
with fracture severity. Such injuries can account for poor
outcomes. These injuries often are not recognized at first,
with the result that treatment is delayed. 4,14
■ Triangular fibrocartilage (TFC) tears
■ Scapholunate and lunotriquetral ligament tears
■ Chondral injuries involving the carpal surfaces
■ Distal radioulnar joint injury
■ Distal ulna fractures
■ By predicting the stability of a distal radius fracture, defor-
mity and its complications can be minimized. Several risk
factors have been suggested by LaFontaine et al7 and others.
The presence of three or more indicates instability:
■ Dorsal angulation greater than 20 degrees
■ Dorsal comminution
■ Intra-articular extension
■ Associated ulna fracture
■ Patient age over 60 years
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ The mechanism of injury should be sought, to assist in as-
sessing the energy and level of destruction.
■ Associated injuries are not uncommon and should be care-
fully ruled out.
■ Injuries to the hand, carpus, and proximal arm, including
other fractures or dislocations
■ Injuries to other extremities or the head, neck, and torso
■ Establish the patient’s functional and occupational demands.
■ Document co-existing medical conditions that may affect
healing, such as osteoporosis or diabetes.
■ Determine possible risk factors for anesthesia and surgery,
such as cardiac disease.
■ The physical examination should document the following:
■ Condition of surrounding soft tissues (ie, skin and subcu-
taneous tissues)
■ Q uality of vascular perfusion and pulses
■ Integrity of nerve function
■ Sensory two-point discrimination or threshold sensory
testing
■ M otor function of intrinsic, thenar, and hypothenar mus-
cles of the hand
■ Examination of the distal ulna, TFCC, and distal radioulnar
joint should rule out disruption and instability.
■ Reliable physical examination of the carpus often is difficult,
making radiographic review even more critical and follow-up
examinations important.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Imaging establishes fracture severity, helps determine stabil-
ity, and guides the operative approach and choice of fixation.
 Ch a p t e r 6 VOLAR PLATING OF DISTAL RADIUS FRACTURES
A B
D E
■ Plain radiographs should be obtained before and after re-
duction: PA, lateral, and two separate oblique views.
■ O blique views, in particular, help evaluate articular in-
volvement, particularly the lunate fossa fragment (FIG 3 A,B).
■ The lateral view should be modified with the forearm in-
clined 15 to 20 degrees to best visualize the articular surface
(FIG 3 C; see Tech Fig 5BC).
■ Fluoroscopic evaluation can be useful, because it gives a
complete circumferential view of the wrist and, with traction
applied, can help evaluate injuries of the carpus.
■ CT helps define intra-articular involvement and helps detect
small or impacted fragments, which may not be apparent on
plain radiographs, particularly those involving the central por-
tion of the distal radius (FIG 3 D,E).
DIFFEREN TIAL DIAGN OSIS
■ Diagnosis is directly confirmed by radiographs.
■ Associated and contributory injuries should always be
considered.
■ Pathologic fracture (eg, related to tumor, infection)
■ Associated injuries to the carpus (eg, scaphoid fracture,
scapholunate ligament injury)
53
C
FIG 3 • A. This pronat ed view
accent uat es t he dorsa l articular su r-
fa ce irre g u la rit y (arrow h ead ) an d
th e disp lace d fra g me n t . B. Th is
su p in a te d vie w accen t u at es t he d is-
pla ced radial st yloid fragm ent . C. On
th is lat eral radio g rap h , th e a rrow -
he ad p oints t o t he articular split a nd
th e d isp la cem en t o f t h e lun at e fossa
fra gm e n t . Not e t h e d o rsa l a n gu la -
tion a n d co lla p se (d o t te d lin e).
Ob serve th e sig n ifican t ly t h icker
vo lar co rt ical b o n e in co m p a riso n t o
th e d o rsal b on e. D,E. AP an d lat eral
cu ts t a ke n fro m CT im a g e s o f a d ist a l
ra d iu s fra ct u re re ve a lin g th e e xte n t
of comm inut ion a nd cent ra l im-
pa ct ion, w hich are no t e asily
appre ciat ed on p la in radiograph s.
N ON OPERATIVE MAN AGEMEN T
■ N onoperative treatment is reserved for distal radius frac-
tures that are reducible and stable based on the criteria previ-
ously discussed.
■ The goal of nonoperative treatment is to immobilize the
wrist using a method that will maintain acceptable alignment
until the fracture is healed.
■ Radial inclination greater than 10 degrees
■ Ulnar variance less than 4 mm positive
■ Palmar tilt less than 15 degrees dorsal or 20 degrees volar
■ Articular congruity less than 2-mm gap or step-off
SURGICAL MAN AGEMEN T
■ The goal of operative treatment is to achieve acceptable
alignment and stable fixation.
■ Various methods of fixation are available: pins, external fix-
ators, dorsal plates, intramedullary devices, and volar plates.
Preoperative Planning
■ The standard preoperative medical and anesthesia evalua-
tion for concurrent medical problems is done.
 54 Se c t i o n I HAND, WRIST AND FOREARM
■ Discontinue blood thinning medications (anticoagulants
and nonsteroidal anti-inflammatory drugs).
■ Request necessary equipment, including fluoroscopic and
power equipment.
■ Confirm the plate fixation system to be used and check the
equipment before beginning surgery for completeness (ie, all
appropriate drills, plates, and screws).
■ H ave a contingency plan or additional fixation (external fix-
ator, bone graft, or bone graft substitute).
■ Review previous radiographic studies.
■ Consider use of a regional anesthetic for postoperative pain
control.
Positioning
■ Place the patient in the supine position with the affected ex-
tremity on an arm table.
■ Apply an upper arm tourniquet, preferably within the ster-
ile field.
FIG 4 • Tra ct io n is a p p lie d o ve r t h e a rm t a b le w it h fin g e r t ra p s
a n d h a n g in g w e ig h t s. Th e su rg e o n sit s o n t h e vo la r sid e , a n d
t h e a ssist a n t o n t h e d o rsa l sid e . Flu o ro sco p y ca n b e b ro u g h t in
fro m a n y d ire ct io n , b u t p re fe ra b ly fro m t h e sid e a d ja ce n t o r t h e
o p p o sit e su rg e o n .
TECHNIQUES
VOLAR FIXED-ANGLE PLATE FIXATION OF THE DISTAL RADIUS
In cisio n a n d Disse ct io n
■ Pa lp a t e t h e fle xo r ca rp i ra d ia lis t e n d o n a n d m a ke a 4- t o
8-cm lo n g it u d in a l in cisio n fro m t h e p ro xim a l w rist fle x-
io n cre a se , e xt e n d in g p ro xim a lly a lo n g t h e ra d ia l b o rd e r
o f t h e fle xo r ca rp i ra d ia lis t e n d o n .
■ If t h e in cisio n m u st cro ss t h e w rist fle xio n cre a se s, u se
a zig za g in cisio n in t h a t a re a .
■ Ca re fu lly a vo id t h e p a lm a r cu t a n e o u s b ra n ch o f t h e m e -
d ia n n e rve a lo n g t h e u ln a r sid e o f t h e fle xo r ca rp i ra d i-
a lis w it h in 10 cm o f t h e w rist fle xio n cre a se .
■ Bra nche s o f th e d o rsa l ra d ia l se nso ry ne rve an d la t era l
ant ebrach ial cu t ane o us n e rve so me tim es ap p e ar a lo n g
th e pa th o f t he in cisio n a n d a lso n e ed to b e p ro te ct e d .
■ At t h e d ist a l e n d o f t h e in cisio n , p ro t e ct t h e p a lm a r
b ra n ch o f t h e ra d ia l a rt e ry t o t h e d e e p a rch .
■ It u su a lly is n o t n e ce ssa ry t o d isse ct o u t t h e ra d ia l
a rt e ry (TECH FIG 1 A).
■ Incorporate weights or a traction system to apply distraction
across the fracture (FIG 4 ).
■ The surgeon is seated on the side, toward the patient’s head,
particularly if he or she is right-hand dominant.
■ The assistant is seated opposite the surgeon.
■ The fluoroscopy unit is brought in from the end or corner of
the table.
Approach
■ Dorsal exposure allows for direct visualization of the artic-
ular surface when necessary.
■ Fracture comminution is more severe dorsally, making over-
all alignment more difficult to judge.
■ The thicker volar cortex is less comminuted, allowing for
more precise reduction and buttressing of bone fragments.
■ Sometimes both dorsal and volar exposures may be neces-
sary to achieve articular congruency and volar reduction and
fixation, respectively.
■ An extended volar–ulnar exposure may be necessary to per-
form a carpal tunnel release if indicated.
■ The techniques described in this chapter use the volar ap-
proach to distal radius, as described by H enry (FIG 5 ).
FIG 5 • Th e vo la r in cisio n is re p re se n t e d b y t h e d o t t e d lin e ju st
p ro xim a l t o t h e w rist fle xio n cre a se s a n d ra d ia l t o t h e fle xo r
ca rp i ra d ia lis lo n g u s. Ca re is e xe rcise d t o a vo id d isse ct io n u ln a r
t o t h e fle xo r ca rp i ra d ia lis, b e ca u se t h e p a lm a r cu t a n e o u s n e rve
b ra n ch o f t h e m e d ia n n e rve (arro w ) is a t risk.
■ In cise t h e a n t e rio r sh e a t h o f t h e fle xo r ca rp i ra d ia lis t e n -
d o n a n d re t ra ct t h e t e n d o n u ln a rly t o h e lp p ro t e ct t h e
m e d ia n n e rve (TECH FIG 1 B).
■ In cise t h e p o st e rio r sh e a t h o f t h e fle xo r ca rp i ra d ia lis
tendon.
■ Th e d e e p t issu e s like ly w ill b u lg e o u t fro m t h e p re s-
su re o f sw e llin g a n d fra ct u re h e m a t o m a .
■ Th e m e d ia n n e rve lie s w it h in t h e su b cu t a n e o u s
t issu e s a lo n g t h e u ln a r p o rt io n o f t h e w o u n d
(TECH FIG 1 C,D).
■ Th e fle xo r p o llicis lo n g u s t e n d o n sit s a lo n g t h e ra d ia l
m a rg in o f t h e w o u n d .
■ Usin g b lu n t d isse ct io n w it h a g a u ze -co ve re d fin g e r,
sw e e p t h e t e n d o n s a n d t h e n e rve u ln a rly.
■ A se lf-re t a in in g re t ra ct o r is ca re fu lly p la ce d b e t w e e n
t h e ra d ia l a rt e ry ra d ia lly a n d t h e t e n d o n s a n d m e d ia n
n e rve u ln a rly.
 Ch a p t e r 6 VOLAR PLATING OF DISTAL RADIUS FRACTURES 55

TECHNIQUES
A B

C D

E F

TECH FIG 1 • A. Th e in t e rva l b e t w e e n t h e ra d ia l a rt e ry (arro w ) a n d t h e fle xo r ca rp i ra d ia lis t e n d o n

(*) is se e n . B. Th e p o st e rio r sh e a t h (*) o f t h e fle xo r ca rp i ra d ia lis is visib le a ft e r re t ra ct in g t h e fle xo r
ca rp i ra d ia lis u ln a rly (arro w ). Be ca re fu l d u rin g d e e p e r d isse ct io n , b e ca u se sw e llin g a n d h e m a t o m a
m a y d ist o rt t h e p o sit io n o f t h e m e d ia n n e rve b e n e a t h t h e sh e a t h . C. Fo llo w in g in cisio n in t h e fle xo r
ca rp i ra d ia lis p o st e rio r sh e a t h , t h e d e e p t e n d o n s a re visib le , in clu d in g t h e fle xo r p o llicis lo n g u s (FPL)
a n d t h e fle xo r d ig it o ru m su p e rficia lis o f t h e in d e x fin g e r (FDS). Th e m e d ia n n e rve a lso is visib le (*).
D. Th e p a lm a r cu t a n e o u s n e rve b ra n ch e s o f t h e m e d ia n n e rve (arro w ) a n d m e d ia n n e rve (ast e risk )
a re b o t h a t risk fo r in ju ry d u rin g t h is a p p ro a ch . Be ca re fu l re g a rd in g p la ce m e n t o f re t ra ct o rs a n d
d u rin g d isse ct io n a n d p la t e p la ce m e n t . E. Th e p ro n a t o r q u a d ra t u s (PQ) is in cise d d ist a lly, ra d ia lly,
a n d p ro xim a lly a n d t h e n re fle ct e d u ln a rly a ft e r d isse ct io n o ff t h e vo la r d ist a l ra d iu s. F. Th e b ra ch io -
ra d ia lis (arro w ) ca n b e a d e fo rm in g fo rce , e sp e cia lly in co m m in u t e d fra ct u re s a n d in t h o se fo r w h ich
t re a t m e n t h a s b e e n d e la ye d . Th is t e n d o n ca n b e re le a se d if n e ce ssa ry.

■ Th e p ro n a t o r q u a d ra t u s is n o w visu a lize d a t t h e flo o r ■ Th e ra d ia l m a rg in is in p ro xim it y t o t h e t e n d o n s

of the wound.
■ In cise t h e p ro n a t o r q u a d ra t u s a t it s ra d ia l in se rt io n , le a v-
in g fa scia l t issu e o n e it h e r sid e t o a id in clo su re . Also , d e -
t e rm in e t h e p ro xim a l a n d d ist a l e xt e n t o f t h e m u scle ,
a n d m a ke h o rizo n t a l in cisio n s a t b o t h o f t h o se p o in t s
(TECH FIG 1 E).
■ Th e d ist a l m a rg in o f t h e p ro n a t o r q u a d ra t u s a t t a ch e s
a lo n g t h e d ist a l vo la r lip o f t h e d ist a l ra d iu s, a lo n g
t h e “ t e a rd ro p .”
o f t h e first d o rsa l co m p a rt m e n t a n d t h e b ra ch io -
ra d ia lis.
■ Su b p e rio st e a lly d isse ct t h e p ro n a t o r q u a d ra t u s o ff t h e
vo la r su rfa ce o f t h e d ist a l ra d iu s a s a n u ln a rly b a se d fla p
w it h a kn ife o r e le va t o r.
■ Re t ra ct t h e p ro n a t o r u ln a rly w it h t h e fle xo r t e n d o n s a n d
m e d ia n n e rve .
■ Pa rt icu la rly if sig n ifica n t sh o rt e n in g o f ra d ia l-sid e d fra c-
t u re fra g m e n t s h a s o ccu rre d , in cise t h e b ro a d in se rt io n
 56 Se c t i o n I HAND, WRIST AND FOREARM

o f t h e b ra ch io ra d ia lis t o e lim in a t e t h e d e fo rm in g fo rce ■ Ca re fu lly cle a n t h e fra ct u re o f a n y in t e rp o se d m u scle ,

TECHNIQUES

(TECH FIG 1 F). fa scia , h e m a t o m a , o r ca llu s w h ile m a in t a in in g t h e b o n y

■ Re le a se t h e first d o rsa l co m p a rt m e n t a n d re t ra ct t h e
t e n d o n s b e fo re re le a sin g t h e b ra ch io ra d ia lis.
■ Alt e rn a t ive ly, Z-le n g t h e n t h e b ra ch io ra d ia lis t e n d o n
t o a llo w fo r re p a ir a t t h e co m p le t io n o f t h e ca se .
Fra ct u re Re d u ct io n a n d
Pro visio n a l Fixa t io n
■ Ap p ly a lo b st e r-cla w cla m p a ro u n d t h e ra d iu s sh a ft a t a
p e rp e n d icu la r a n g le t o t h e vo la r su rfa ce a t t h e m o st
p ro xim a l p o rt io n o f t h e w o u n d (TECH FIG 2 A).
■ Th is a llo w s fo r e xce lle n t co n t ro l o f t h e p ro xim a l sh a ft
fo r ro t a t io n a n d t ra n sla t io n .
■ It a lso p ro vid e s a n e xce lle n t co u n t e rfo rce w h e n co r-
re ct in g t h e d o rsa l a n g u la t io n co lla p se .
■ Wit h t h e fra ct u re n o w e xp o se d , a p p ly t ra ct io n d ist a lly t o
d ist ra ct a n d d isim p a ct t h e fra g m e n t s.
co n t o u rs.
■ In t h e ca se o f sig n ifica n t vo la r co m m in u t io n , re d u ce a n d
p ro visio n a lly st a b ilize t h e fra g m e n t s w it h K-w ire s.
■ Ta ke p la t e p o sit io n in g in t o a cco u n t w h e n p la cin g
t h e se K-w ire s.
■ Th e a rt icu la r su rfa ce is first re d u ce d , if n e ce ssa ry.
■ Un d e r flu o ro sco p ic g u id a n ce , m a n ip u la t e t h e a rt icu la r
fra g m e n t s t h ro u g h t h e fra ct u re w it h a p e rio st e a l e le va -
t o r, o st e o t o m e , o r K-w ire s (TECH FIG 2 B,C).
■ Lo n g it u d in a l t ra ct io n is im p o rt a n t d u rin g t h is re d u c-
t io n p h a se . It ca n b e p e rfo rm e d b y a n a ssist a n t o r
u sin g cro ss-t a b le w e ig h t s a n d fin g e r-t ra p s.
■ A d o rsa l e xp o su re is p e rfo rm e d a t t h is st a g e if t h e re is
sig n ifica n t im p a ct io n , p a rt icu la rly ce n t ra lly, t h a t ca n -
n o t b e co rre ct e d u sin g t h e e xt ra -a rt icu la r t e ch n iq u e
d e scrib e d h e re .

D
A

E F

TECH FIG 2 • A. A lo b st e r-cla w cla m p (d o u b le arro w ) is a p p lie d t o t h e ra d iu s sh a ft w e ll

p ro xim a l t o t h e fra ct u re . Th is in st ru m e n t h e lp s t h e su rg e o n co n t ro l t h e ra d iu s d u rin g
re d u ct io n a n d d e fin e t h e la t e ra l m a rg in s o f t h e ra d iu s. A Fre e r e le va t o r is in se rt e d in t o
t h e fra ct u re t o h e lp d isim p a ct t h e fra g m e n t s a n d a ssist in t h e ir re d u ct io n . B. Th e b ra -
ch io ra d ia lis (w h it e arro w ) is re le a se d , a n d t h e first co m p a rt m e n t e xt e n so r t e n d o n s a re
visib le in t h e b a ckg rou n d (b lack arro w ). An in st ru m e n t ca n n o w b e p la ce d t o a ssist in
t he re d u ct io n (arro w ). C. Th e Fre e r e le va t o r is u se d t o re d u ce t h e fra g m e n t s. In t h is
ca se , t h e in t ra -a rt icu la r st e p -o ff is b e in g co rre ct e d , a n d t h e ra d ia l le n g t h a n d in clin a -
t io n a re b e in g re st o re d . D. K-w ire s a re p la ce d a cro ss t h e ra d ia l st ylo id in t o t h e re d u ce d
u lna fo ssa fra g m e n t . An a ssist a n t u su a lly a p p lie s t ra ct io n , a n d t h e lo b st e r-cla w cla m p
ca n b e u se d fo r p o w e rfu l le ve ra g e . If t h e re is n o a rt icu la r in vo lve m e n t , t h is K-w ire ca n
b e p la ce d in t o t h e ra d iu s m e t a p h ysis o r d ia p h ysis p ro xim a lly. E. Th e K-w ire sh o u ld
b e p la ce d a s clo se a s p o ssib le t o t h e su b ch o n d ra l b o n e , a vo id in g a re a s o f co m m in u t io n .
C F. Th e K-w ire sh o u ld m a in t a in t h e a rt icula r re d u ct io n w it h o u t a n y su p p o rt .
 Ch a p t e r 6 VOLAR PLATING OF DISTAL RADIUS FRACTURES
■ Pla ce K-w ire s fro m t h e ra d ia l st ylo id fra g m e n t in t o t h e
lu n a t e fo ssa fra g m e n t t o m a in t a in t h e a rt icu la r re d u c-
t io n (TECH FIG 2 D).
■ Th e K-w ire s sh o u ld b e p la ce d a s clo se a s p o ssib le t o
t h e su b ch o n d ra l p la t e (TECH FIG 2 E,F).
■ On ce t h e d ist a l a rt icu la r re d u ct io n is co m p le t e , re d u ce
t h e d ist a l ra d iu s a s a sin g le u n it t o t h e ra d iu s sh a ft .
■ In se rt K-w ire s a s re q u ire d t o m a in t a in t h e p ro visio n a l re -
d u ct io n b e t w e e n t h e d ist a l fra g m e n t s a n d t h e p ro xim a l
sh a ft fra g m e n t .
■ If ra d ia l co lla p se a n d t ra n sla t io n a re p ro m in e n t , a
la rg e K-w ire ca n b e in t ro d u ce d in t o t h e ra d ia l p o rt io n
o f t h e fra ct u re a n d a d va n ce d p ro xim a lly a n d u ln a rly
t o b e h a ve like a n in t ra fo ca l p in a n d p ro vid e a ra d ia l
b u t t re ss b y p u sh in g t h e d ist a l fra g m e n t u ln a rly.
■ A sim ila r t e ch n iq u e ca n b e a p p lie d t h ro u g h t h e d o r-
sa l fra ct u re t o a ssist in m a in t a in in g t h e p a lm a r t ilt
co rre ct io n .
Pla t e Ap p lica t io n
■ Ap p ly a fixe d -a n g le vo la r p la t e t o t h e vo la r su rfa ce o f
t h e d ist a l ra d iu s a n d sh a ft . Po sit io n t h e p la t e t o a cco m -
m o d a t e fo r t h e u n iq u e d e sig n ch a ra ct e rist ics o f t h e
p la t in g syst e m a s w e ll a s t h e lo ca t io n o f t h e fra ct u re
fra g m e n t s.
■ Ea ch p la t in g syst e m h a s u n iq u e ch a ra ct e rist ics t h a t
d e t e rm in e it s o p t im a l p la ce m e n t .
■ Id e a lly, t h e p la t e sh o u ld b e p la ce d a s clo se t o t h e a r-
t icu la r m a rg in a s p o ssib le w it h o u t t h e d ist a l lo ckin g
p e g s o r scre w s p e n e t ra t in g t h e jo in t .
■ If t h e fra ct u re h a s n o t ye t b e e n fu lly re d u ce d , t h is
m u st b e t a ke n in t o a cco u n t w h e n p la cin g t h e d e vice .
■ Cla m p t h e p re vio u sly a p p lie d lo b st e r cla w t o t h e p ro xi-
m a l p o rt io n o f t h e p la t e t o ke e p t h e p la t e ce n t ra lize d o n
t h e ra d iu s sh a ft .
■ Pla ce p ro visio n a l K-w ire s t h ro u g h t h e p la t e t o m a in t a in
p o sit io n (TECH FIG 3 ). Th e n flu o ro sco p ica lly co n firm
p ro p e r p la t e p o sit io n in b o t h t h e d ist a l–p ro xim a l a n d ra -
d io u ln a r d ire ct io n s.
■ Pro p e r a lig n m e n t o f t h e p la t e ca n b e d e t e rm in e d
o n ly u sin g a t ru e a n t e ro p o st e rio r (AP) im a g e in w h ich
t h e d ist a l ra d io u ln a r jo in t is w e ll visu a lize d .
TECH FIG 3 • Ke e p t h e p la t e ce n t e re d o n t h e ra d iu s a n d a s
d ist a l a s p o ssib le . Th e lo b st e r-cla w cla m p h e lp s ke e p t h e
p la t e ce n t e re d . K-w ire s (arro w s) a re h e lp fu l a s p ro visio n fix-
a t io n u n t il a lig n m e n t ca n b e co n firm e d ra d io g ra p h ica lly a n d
scre w s p la ce d .
57
■ Th e K-w ire s a llo w fo r fin e a d ju st m e n t in p la t e p o si-
TECHNIQUES
t io n b e fo re co m m it t in g t o in se rt io n o f a scre w .
■ Drill a n d in se rt a p ro visio n a l scre w in t h e o b lo n g h o le in
t h e p la t e .
■ If t h e b o n e is o st e o p e n ic, a scre w lo n g e r t h a n t h e
in it ia l m e a su re m e n t sh o u ld b e p la ce d t o e n su re t h a t
b o t h co rt ice s a re e n g a g e d . Ot h e rw ise , t h e p la t e m a y
n o t b e h e ld se cu re ly, a n d t h e re d u ct io n w ill b e co m -
p ro m ise d . Aft e r t h e re m a in in g scre w s h a ve b e e n
se cu re d , t h is scre w ca n b e re p la ce d w it h o n e o f t h e
a p p ro p ria t e le n g t h .
■ In se rt a t le a st o n e a d d it io n a l p ro xim a l scre w a n d re m o ve
t h e p ro visio n a l K-w ire s h o ld in g t h e p la t e in p la ce .
Dist a l Fra g m e n t Re d u ct io n
■ On ce t h e p ro xim a l p la t e h a s b e e n se cu re d , e xe cu t e a n y
a d d it io n a l re d u ct io n n e e d e d .
■ A w e ll-d e sig n e d p la t e se rve s a s a n e xce lle n t b u t t re ss
fo r co rre ct io n o f t h e p a lm a r t ilt (TECH FIG 4 A).
■ Ap p ly co u n t e rfo rce t h ro u g h t h e lo b st e r-cla w cla m p in a
d o rsa l d ire ct io n w h ile t h e d ist a l h a n d a n d w rist a re t ra n s-
la t e d p a lm a rly a n d fle xe d (TECH FIG 4 B).
■ Th is m a n e u ve r re d u ce s t h e d ist a l ra d iu s t o t h e
p la t e , e ffe ct ive ly re st o rin g vo la r t ilt b y p u sh in g t h e
lu n a t e a g a in st t h e vo la r lip o f t h e d ist a l ra d iu s (TECH
FIG 4 C,D).
■ Ad d it io n a l d ist ra ct io n a n d u ln a r d e via t io n co rre ct ra d ia l
co lla p se a n d lo ss o f ra d ia l in clin a t io n .
A
TECH FIG 4 • A. Th e fin a l re d u ct io n is p e rfo rm e d w it h t ra c-
t io n o n t h e h a n d a n d w it h t h e ra d iu s h e ld p ro xim a lly w it h a
cla m p . On ce t h e re d u ct io n is co n firm e d ra d io g ra p h ica lly, t h e
a ssist a n t p la ce s t h e d ist a l scre w s o r K-w ire s. B. Th e h a n d is
t ra n sla t e d (n o t a p p re cia b ly fle xe d ) p a lm a rly w h ile t h e ra d iu s
sh a ft is h e ld w it h t h e cla m p . (co n t in u e d )
 58 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES

TECH FIG 4 • (co n t inu e d ) Pre re d u ct io n (C)

a n d p o st re d u ct io n (D) ra d io g ra p h s d e m o n -
st ra t in g t h e p a lm a r t ra n sla t io n re d u ct io n
m a n e u ve r. Th e vo la r p la t e a ct s a s a st ro n g
b u t t re ss (arro w ), a llo w in g t h e t ra n sla t e d lu -
n a t e t o p u sh o n t h e vo la r ra d iu s (*) a n d co r-
C D re ct t h e d o rsa l a n g u la t io n d e fo rm it y.

Pla t e Fixa t io n (TECH FIG 5 B,C). Th is is fa cilit a t e d b y lift in g t h e

■ Wh ile t h e re d u ct io n is h e ld , d rill t h e h o le s in t h e d ist a l
p la t e (TECH FIG 5 A).
■ So m e p la t e syst e m s a llo w fo r p ro visio n a l fixa t io n
u sin g K-w ire s p la ce d t h ro u g h t h e d ist a l p la t e .
■ Do n o t p e n e t ra t e t h e d o rsa l d ist a l ra d iu s w it h t h e
d rill, t o p ro t e ct t h e d o rsa l e xt e n so r t e n d o n s.
■ Drill a n d p la ce t h e d ist a l u ln a r scre w s first a n d t h e n p ro -
ce e d ra d ia lly a n d p ro xim a lly.
■ Ju d g e t h e p la ce m e n t o f a ll d ist a l scre w s o r p e g s p re cise ly
u sin g flu o ro sco p ic im a g in g in m u lt ip le p la n e s.
■ Pe rfo rm a “ t ru e ” la t e ra l vie w o f t h e w rist w it h t h e
x-ra y b e a m a t a 20-d e g re e a n g le t o t h e ra d iu s sh a ft
w rist o ff t h e t a b le w it h t h e e lb o w m a in t a in e d o n
t h e t a b le a n d t h e fo re a rm a t a 20-d e g re e a n g le t o
t h e t a b le (TECH FIG 5 D,E).
■ List e r’s t u b e rcle ca n b e m ist a ke n fo r t h e d o rsa l co rt e x,
re su lt in g in scre w s t h a t a re t o o lo n g .
■ Th e e xt e n so r p o llicis lo n g u s is a t g re a t e st risk o f in ju ry
fro m a p ro t ru d in g scre w .
■ Se q u e n t ia lly in se rt t h e re m a in in g d ist a l scre w s o r p e g s,
fo llo w e d b y t h e re m a in in g p ro xim a l p la t e scre w s
(TECH FIG 5 F).
■ If n e ce ssa ry, a d d b o n e g ra ft o r b o n e g ra ft su b st it u t e
a ro u n d t h e p la t e in t o t h e fra ct u re sit e o r t h ro u g h a sm a ll
d o rsa l in cisio n .

B C

TECH FIG 5 • A. Th e re m ain in g h ole s ca n no w b e d rille d a n d scre ws

p la ce d w he re n e e d ed . B. This screw (arrow ) lo oks a s t h o ug h it h a s p en -
e trat e d the jo in t wh e n in rea lit y it is simp ly th e a n g le o f t he ra di-
o g ra p h ic be am t h a t th ro w s its pro je ction in to t h e jo in t. C. A tru e late ra l
view o f t he dista l rad iu s is n ece ssary t o judge p la cem en t of th e ra dial
scre w s. D. A rad io g rap h is b ein g t ake n w it h t h e wrist p erp en d icu lar t o
t h e x-ra y b e am (arrow ). Th is is n ot a t ru e lat eral im ag e , becau se t h e d is-
D t al su rfa ce o f t h e rad iu s is in clin ed 20 d e g rees rad ia lly. (co n tinu e d)
 Ch a p t e r 6 VOLAR PLATING OF DISTAL RADIUS FRACTURES 59

TECHNIQUES
E F

TECH FIG 5 • (con tinue d) E. By lift in g t h e h a n d a n d w rist 20 d e g re e s o ff t h e t a b le , a “ t ru e ” la t e ra l

im a g e ca n b e a ch ie ve d . Th e x-ra y b e a m is n o w p e rp e n d icula r t o t h e jo in t (arro w ). F. Th e re m a in in g
scre w s h a ve b e e n p la ce d .

■ Pre cise ly a sse ss t h e st a b ilit y o f t h e co n st ru ct a ft e r t h e ■ Be fo re skin clo su re , o b t a in fin a l ra d io g ra p h s (TECH FIG

p la t e h a s b e e n a p p lie d . If a p p ro p ria t e , re m o ve t h e p ro vi-
sio n a l K-w ire s.
■ If the K-wires are deeme d critical for fracture stability,
they can be left in place and removed 4 to 8 weeks later
■ If re sid u a l in st a b ilit y e xist s, a d d a d d it io n a l fixa t io n
w it h K-w ire s, a n e xt e rn a l fixa t o r, a d o rsa l p la t e , o r a
co m b in a t io n .
Clo su re
■ Re p a ir t h e p ro n a t o r q u a d ra t u s t o it s in se rt io n sit e w it h a
se rie s o f 3-0 a b so rb a b le h o rizo n t a l m a t t re ss su t u re s
(TECH FIG 6 A).
■ In m an y ca se s it is im p ossible t o re p air t he pro na t o r
qu a dra t u s b e ca u se t h e m u scle a n d fa scia a re ext re m e ly
t h in o r t h e m u scle is d am a g ed . In t h is sit u a t io n , t h e
m u scle ca n b e d e b rid e d o r sim p ly left in p la ce .
6 B,C), a n d a sse ss st a b ilit y o f t h e d ist a l ra d io u ln a r jo in t .
■ Pla ce a d ra in o n ly if e xce ssive b le e d in g is a n t icip a t e d .
■ Co n sid e r m e t h o d s t o m in im ize p o st o p e ra t ive p a in :
■ Pe rcu t a n e o u s p la ce m e n t o f a p a in p u m p ca t h e t e r
■ In je ct io n o f a lo n g -a ct in g lo ca l a n e st h e t ic
■ Clo se t h e su b cu t a n e o u s t issu e s w it h 4-0 a b so rb a b le su -
t u re a n d re a p p ro xim a t e t h e skin w it h in t e rru p t e d 4-0 o r
5-0 n ylo n su t u re s o r a ru n n in g su b cu t icu la r st it ch .
■ Pla ce t w o la ye rs o f g a u ze a n d a n o n a d h e re n t g a u ze
o ve r t h e w o u n d , w ra p t h e w rist a n d fo re a rm w it h
t h ick We b ril (Ke n d a ll, Ma n sfie ld , MA), a n d a p p ly a
b e lo w -e lb o w sp lin t in a n e u t ra l w rist p o sit io n (TECH
FIG 6 D).
■ If t h e re is in ju ry t o t h e u ln a r w rist (e g , u ln a st ylo id
fra ct u re , d ist a l ra d io u ln a r jo in t in ju ry), im m o b ilize
t h e fo re a rm w it h a n a b o ve -e lb o w o r Mu n st e r sp lin t .

B C

TECH FIG 6 • A. Th e p ro n a t o r q u a d ra t u s h a s b e e n re p a ire d . B. AP ra d i-

o g ra p h d e m o n st ra t in g co rre ct io n o f t h e a rt icu la r su rfa ce , ra d ia l h e ig h t
(lin e s), a n d ra d ia l in clin a t io n (d o t t e d lin e ). C. La te ra l rad io g rap h d e mo n st rat -
ing correction of the palm ar t ilt (d o t ted lin e ). D. A b u lky d ressin g is a p p lied
wit h a vola r splint hold in g t he w rist in a ne utral p osit ion. A p ain pu mp
D ca t h e te r h a s b e e n in se rte d fo r a d d it io n a l p a in co n t ro l.
 60 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES

VOLAR FIXED-ANGLE PLATE USING THE PLATE AS REDUCTION TOOL

■ We d o n o t re co m m e n d u se o f t h e vo la r fixe d -a n g le p la t e
a s a re d u ct io n t o o l in t h e a cu t e se t t in g . It is b e st e m -
p lo ye d (if a t a ll) fo r a m a lu n io n , o r p e rh a p s fo r a fra ct u re
w it h m in im a l a rt icu la r co m m in u t io n .
■ Th is t e ch n iq u e is d ifficu lt , b e ca u se it h a s t o a c-
co u n t fo r t h e lo n g it u d in a l a n d t ra n sla t io n a l a lig n -
m e n t o f t h e p la t e b e fo re t h e re d u ct io n h a s b e e n
a ch ie ve d .
■ Pe rfo rm t h e su rg ica l a p p ro a ch p re vio u sly d e scrib e d .
■ Ad d re ss first a n y d ist a l a rt icu la r in vo lve m e n t w it h re d u c-
t io n a n d K-w ire fixa t io n .
■ Affix t h e p la t e t o t h e d ist a l fra g m e n t , a cco u n t in g fo r
w h e re t h e p la t e w ill sit o n t h e ra d iu s sh a ft o n ce t h e re -
d u ct io n is co m p le t e d .
■ Pla ce t h e scre w s so t h a t t h e y a re p a ra lle l t o t h e a rt icu la r
su rfa ce o n t h e la t e ra l x-ra y vie w (TECH FIG7 A,B).
■ On t h e AP ra d io g ra p h , a lig n t h e p la t e w it h t h e p e rp e n -
d icu la r o f t h e ra d ia l in clin a t io n o f t h e d ist a l ra d iu s (20
d e g re e s; TECH FIG 7 C,D).
■ On ce d ist a l fixa t io n is co m p le t e , se cure t h e p ro xim a l pla t e
t o t h e ra d iu s sh a ft , t h e re b y co m p le t in g t h e re d u ct ion .
■ Clo se a n d sp lin t a s d e scrib e d p re vio u sly.

A B

TECH FIG 7 • A. Th e vo la r p la t e is a p p lie d w it h t h e d ist a l scre w s

p la ce d first (p a ra lle l t o d ist a l a rt icu la r su rfa ce ). B. Re d u cin g t h e p la t e
t o t h e d ia p h ysis p ro xim a lly a cco m p lish e s t h e re d u ct io n . C. Th e p la t e is
a p p lie d a t a p p ro xim a t e ly a 20-d e g re e a n g le re la t ive t o t h e d ist a l a r-
t icu la r su rfa ce o r t o t h e a m o u n t o f a n g u la t io n t h a t is e st im a t e d . D. By
re d u cin g t h e p la t e t o t h e d ia p h ysis, t h e d ist a l a n g u la t io n is co rre ct e d . D

PEARLS AND PITFALLS

Pre o p e ra t ive p la n n in g
Su rg ica l a p p ro a ch
Fra ct u re re d u ct io n
Pla t e a lig n m e n t
■ Ob t a in m u lt ip le ra d io g ra p h s in d iffe re n t p o sit io n s (e g , se ve ra l o b liq u e vie w s), e sp e cia lly in t h e se t t in g
o f co m m in u t io n o r a rt icu la r in vo lve m e n t .
■ Ob t a in a CT sca n if a sse ssin g t h e p a t t e rn o f fra ct u re w h e n ra d io g ra p h s a lo n e a re d ifficu lt o r u n ce rt a in .
■ Avo id cro ssin g t h e d ist a l fle xio n cre a se s o f t h e w rist .
■ Avo id e xp o su re u ln a r t o t h e m id lin e o f t h e fle xo r ca rp i ra d ia lis.
■ Use e xt ra ca re w it h d e e p d isse ct io n in t h e p re se n ce o f h e m a t o m a o r sig n ifica n t sw e llin g .
■ Em p lo y t ra ct io n a cro ss t h e w rist w it h a d e vice o r w e ig h t s.
■ Use a lo b st e r-cla w cla m p o n t h e p ro xim a l ra d iu s sh a ft fo r co n t ro l o f t h e fo re a rm a n d a s a re fe re n ce fo r
t h e la t e ra l m a rg in s.
■ Use in st ru m e n t s t o d isim p a ct a n d re d u ce a rt icu la r fra g m e n t s t h ro u g h t h e fra ct u re it se lf, e it h e r vo la rly,
d o rsa lly, o r b o t h .
■ Em p lo y a t e m p o ra ry K-w ire t o st a b ilize t h e re d u ct io n b e fo re p la ce m e n t o f t h e p la t e .
■ Co n firm a p p ro p ria t e ra d ia l–u ln a r p o sit io n in g o f t h e p ro xim a l p la t e u sin g a t ru e AP ra d io g ra p h (ie ,
fo re a rm in su p in a t io n w it h o p e n vie w o f t h e d ist a l ra d io u ln a r jo in t ).
 Ch a p t e r 6 VOLAR PLATING OF DISTAL RADIUS FRACTURES 61

■ Co n firm p ro p e r d ist a l p la t e p o sit io n o n a t ru e la t e ra l vie w (ie , fo re a rm 20 d e g re e s o ff t h e t a b le ).

Pla t e fixa t io n
Po st o p e ra t ive
■ Pla ce t h e p la t e a s d ist a l a s p o ssib le , u p t o t h e vo la r t e a r d ro p o f t h e d ist a l ra d iu s, if p o ssib le .
■ Eva lu a t e t h e scre w s fo r p o ssib le jo in t p e n e t ra t io n u sin g 360-d e g re e flu o ro sco p ic im a g e s.
■ Use K-w ire s t o fix t h e p la t e p ro visio n a lly t o t h e p ro xim a l ra d iu s.
■ Th e in it ia l “ o b lo n g h o le ” scre w sh o u ld b e slig h t ly lo n g e r t h a n t h e m e a su re d le n g t h t o e n su re b e t t e r
in it ia l fixa t io n .
■ Clo su re o f t h e p ro n a t o r q u a d ra t u s is n o t crit ica l a n d sh o u ld b e re se rve d fo r m o re su b st a n t ia l m u scle s
w it h lim it e d t ra u m a .
■ Be g in im m e d ia t e ra n g e o f m o t io n (ROM) t o d ig it s w it h e d e m a .

POSTOPERATIVE CARE
■ The wrist is splinted in a neutral position, leaving the dig-
its free.
■ If the fracture is particularly tenuous or there is injury to
the ulnar wrist, a long-arm or M unster splint is applied.
■ The patient is instructed to perform active RO M exercises
for the digits every hour and to engage in strict elevation for at
least 3 days.
■ It is critical to emphasize edema prevention and immedi-
ate RO M of the digits.
■ At 1 week postoperatively, the splint is removed and the
wound is examined.
■ If swelling permits, the therapist fabricates a molded
O rthoplast splint (Johnson & Johnson O rthopedics, N ew
Brunswick, N J) to be worn at all times.
■ Active RO M exercises of the wrist are implemented 1 week
postoperatively.
■ At 4 to 6 weeks, putty and grip exercises are added.
■ At 6 to 8 weeks, the splint is discontinued, and progressive
strengthening exercises are advanced.
■ If necessary, progressive passive RO M can begin, including
use of dynamic splints.
■ At 10 to 12 weeks, the patient usually can be discharged to
all activities as tolerated.
■The most common sites include the dorsal wrist, when
screws have been inserted, and the radial wrist, when a plate
has been used.
■ It can be avoided with careful screw and plate placement
and radiographic verification of their position.
■ N onunion and delayed union are unusual. Consider a diag-
nosis of osteomyelitis or other risk factors such as smoking.
■ Loss of fracture reduction and fixation can occur, and is
most common in patients with osteopenic bone or commin-
uted and articular fractures.
■ This can be avoided with frequent and early follow-up
with repeat radiographs.
■ If instability is suspected, the fracture can be casted.
■ In the operating room, if instability is suspected, addi-
tional fixation should be considered (eg, external fixator,
pins, bone graft).
■ Soft tissue complications are proportional to the energy of
the initial injury.
■ O pen wounds usually can be addressed with local measures.
■ Significant swelling must be addressed with early and ag-
gressive modalities. Swelling can lead to other complications,
such as joint stiffness and tendon adhesions.
■ N erve injuries can be the result of initial trauma or subse-
quent surgical trauma.
■ Assess and document neurologic status before surgery.

■ Avoid further injury to nerves with careful placement of

OUTCOMES retractors.
■ O verall good to excellent results can be expected in over 80% ■ The palmar cutaneous branch of the median nerve can be

of patients with RO M, strength, and outcomes scoring.10,11,15,17 injured during incision and exposure.
■ Studies comparing volar fixation to other forms of fixation
■ Postoperative neuromas can cause pain and sensitivity

(eg, external fixators, pins, and dorsal plating) have revealed
similar if not superior results.
■ Results appear to be superior in the early recovery period,
with the final outcome yielding equivalent results among all
along scar.
■ Avoid the nerve with a well-placed incision radial to the
flexor carpi radialis and careful deep dissection.
■ Postoperative swelling also can lead to median neuropathy.

fixation groups. Carpal tunnel release should be performed if there is any sus-
■ Some studies suggest better maintenance in overall reduc-
pected compression neuropathy or if this is to be anticipated
tion compared to other forms of fixation. as a result of postoperative swelling.
■ Tendon complications include adhesions and ruptures.

COMPLICATION S ■ M ost tendon adhesions involve the dorsal extensor tendons

■ Complication rates as high as 27% have been reported. resulting in extrinsic extensor tightness.
■ Complications can be categorized into those involving hard- ■ Flexor tendon adhesions are uncommon and involve pri-

ware, fracture, soft tissues, nerves, and tendons.2 marily the flexor pollicis longus.
■ Failures of hardware, such as plate or screw breakage, can ■ Tendon ruptures have been described, especially involving

occur but are rare. Usually such failures are an indication of the flexor pollicis longus and the extensor pollicis longus, as a
other problems, such as nonunion. result of plate and screw prominence, respectively.
■ The hardware becomes unacceptably prominent in a minor- ■ The distal screws must not be left prominent, and caution

ity of patients. must be applied when drilling.

■ This complication may become evident only after some ■ The sagittal and coronal profiles of the plate being used

time has elapsed, as swelling of fibrous tissue subsides and must be taken into consideration—some plates are very
bone remodels. prominent and extend far radially.
62 Se c t i o n I HAND, WRIST AND FOREARM
REFEREN CES
1. Aro HT, Koivunen T. Minor axial shortening of the radius affects out-
come of Colles’ fracture treatment. J Hand Surg Am 1991;16:392–398.
2. Arora R, Lutz M , H ennerbichler A, et al. Complications following
internal fixation of unstable distal radius fracture with a palmar lock-
ing plate. J O rthop Trauma 2007;21:316–322.
3. Fernandez JJ, Gruen GS, H erndon JH . O utcome of distal radius frac-
tures using the Short Form 36 health survey. Clin O rthop Relat Res
1997;341:36–41.
4. Geissler WB, Freeland AE, Savoie FH , et al. Intracarpal soft-tissue le-
sions associated with an intra-articular fracture of the distal end of
the radius. J Bone Joint Surg Am 1996;78:357–365.
5. Jupiter JB, Fernandez DL. Comparative classification for fractures of
the distal end of the radius. J H and Surg Am 1997;22:563–571.
6. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the
radius in young adults. J Bone Joint Surg Am 1986;68:647–659.
7. LaFontaine M , H ardy D, Delince PH . Stability assessment of distal
radius fractures. Injury 1989;20:208–210.
8. M elone CP Jr. Articular fractures of the distal radius. O rthop Clin
N orth Am 1984;15:217–236.
9. M uller ME, Nazarian S, Koch P, et al. The Comprehensive Classi-
fication of Fractures of Long Bones. New York: Springer-Verlag, 1990.
10. M usgrave DS, Idler RS. Volar fixation of dorsally displaced distal
radius fractures using the 2.4-mm locking compression plates. J H and
Surg Am 2005;30:743–749.
11. O rbay JL, Fernandez DL. Volar fixed-angle plate fixation for unsta-
ble distal radius fractures in the elderly patient. J H and Surg Am
2004;29:96–102.
12. Pogue DL, Viegas SF, Patterson RM , et al. Effects of distal radius
fracture malunion on wrist joint mechanics. J H and Surg Am 1990;
15:721–727.
13. Porter M , Stockley I. Fractures of the distal radius. Intermediate and
end result in relation to radiologic parameters. Clin O rthop Relat Res
1987;220:241–252.
14. Richards RS, Bennett JD, Roth JH , et al. Arthroscopic diagnosis of
intra-articular soft tissue injuries associated with distal radius frac-
tures. J H and Surg Am 1997;22:772–776.
15. Rozental TD, Blazar PE. Functional outcome and complications after
volar plating for dorsally displaced, unstable fractures of the distal ra-
dius. J H and Surg Am 2006;31:359–365.
16. Short WH , Palmer AK, Werner FW, et al. A biomechanical study of
distal radius fractures. J H and Surg Am 1987;12:529–534.
17. Wright TW, H orodyski M , Smith DW. Functional outcome of unsta-
ble distal radius fractures: O RIF with a volar fixed-angle tine plate
versus external fixation. J H and Surg Am 2005;30:629.
 In t r a m e d u lla r y a n d Do r s a l
Ch a p t e r 7 Pla t e Fix a t io n o f Dis t a l
Ra d iu s Fr a ct u re s
Pe d ro K. Be re d jik lian an d Ch rist o p h e r Do u m as

DEFIN ITION ■ The fourth compartment, containing the extensor indicis

proprius and extensor digitorum communis, lies over the
■ Distal radius fractures typically originate in the radial meta-
dorsal-ulnar distal radius.
physis and occasionally enter the radiocarpal joint and distal ■ The fifth compartment, containing the extensor digiti
radioulnar joint.
■ These fractures may be stable or unstable, intra-articular or
minimi, lies over the distal radioulnar joint.
■ The sixth compartment, containing the extensor carpi ul-
extra-articular, and can be associated with various other bony
naris, lies over the distal ulna.
and soft tissue injuries about the wrist.
■ Distal radius fractures are most commonly dorsally dis-

placed or angulated (apex volar). PATHOGEN ESIS

■ Treatment is based on fracture stability, comminution, artic- ■ Distal radius fractures typically occur due to a fall on an
ular segment displacement, articular surface displacement, and outstretched hand.
the functional demand of the patient. ■ Fractures occur when the force of axial loading exceeds the

■ Stability is related to initial dorsal angulation, residual failure strength of cortical and trabecular bone.9
dorsal angulation after closed reduction, dorsal comminu- ■ The fracture pattern is determined by the magnitude and

tion, age of the patient, and associated distal ulna fracture direction of the force applied and the position of the hand
and intra-articular fracture extension.7,8 during impact. 3
■ Dorsally displaced or angulated fractures occur when the

AN ATOMY wrist is neutral or extended and an axial or dorsally directed

■ The distal radius has articulations at the scaphoid fossa, lu- force is applied to the carpus.
■ O steoporosis, metabolic bone diseases, and bony tumors are
nate fossa, and sigmoid notch.
■ The normal bony anatomy includes volar tilt of 10 degrees, risk factors for fracture.
radial height of 11 mm, and radial inclination of 22 degrees.
■ Ulnar variance (the length of the radius relative to the ulnar
N ATURAL HISTORY
head at the sigmoid notch) is variable and patient dependent.
■ Dorsal ligamentous structures include the dorsal intercarpal
■ Distal radius fractures are either stable or unstable.
■ Stable fractures, treated nonoperatively, historically have
ligament and the dorsal radiocarpal ligament.
■ The dorsal radiocarpal ligament originates from the dorsal
excellent outcomes in terms of range of motion, pain, strength,
and function.1
lip of the radius and attaches on the ulnar carpus. ■ N onoperative management consists of immobilization
■ The dorsal intercarpal ligament represents a capsular
with either a cast or a splint, molded to prevent dorsal
thickening on the dorsum of the carpus, with fiber alignment
displacement.
perpendicular to the long axis of the radius. ■ Displaced, unstable, and comminuted fractures often require
■ Volar ligamentous origins include the radioscaphocapitate
operative treatment.
ligament, the long radiolunate ligament, and the short radiolu- ■ The goals of surgical treatment are to provide stability and
nate ligament, among others.
■ The triangular fibrocartilage complex (TFCC) consists of
improve bony alignment in order to achieve pain control, im-
prove range of motion, and increase function.1,6
the triangular fibrocartilage and volar radioulnar and dorsal
radioulnar ligaments.
■ The volar radioulnar and dorsal radioulnar ligaments orig-
Extensor
inate form the volar and dorsal edges of the sigmoid notch Extensor digitorum communis pollicis Extensor carpi
respectively, and become confluent and insert at the base of and extensor indicis proprius longus radialis brevis
the ulnar styloid. Extensor Extensor carpi
■ The extensor retinaculum lies superficial to the extensor ten- digiti minimi radialis longus
dons and deep to the subcutaneous tissues. It has septations Extensor Extensor
creating six dorsal compartments (FIG 1 ). carpi pollicis
■ The first compartment lies over the radial styloid and con-
ulnaris brevis
tains the abductor pollicis longus and the extensor pollicis Abductor
pollicis
brevis tendons (each may have multiple slips). longus
■ The second compartment, containing the extensor carpi

radialis longus and extensor carpi radialis brevis, lies radial Ulna Extensor
Radius retinaculum
to the tubercle of Lister.
■ The third compartment, containing the extensor pollicis
FIG 1 • An a t o m y o f t h e d ist a l ra d iu s. Th e six d o rsa l e xt e n so r
longus, lies ulnar to the tubercle of Lister. co m p a rt m e n t s a t t h e le ve l o f t h e e xt e n so r re t in a cu lu m .

63
64 Se c t i o n I HAND, WRIST AND FOREARM
■ O ne to 2 mm or more of displacement of the articular sur-
face of the distal radius leads to degenerative changes in young
adults.6
■ Dorsal angulation of more than 20 degrees from normal
(10 degrees dorsal tilt) can lead to pain, decreased range of
motion, and decreased grip strength. 10
■ Radial shortening can decrease range of motion and cause
pain with ulnar impaction of the carpus.10
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ A history of trauma is the most common patient presentation.
■ Pathologic fractures may occur with minimal stress or trauma.
■ Patients complain of localized pain and present with
swelling, decreased range of motion, and ecchymosis about the
fracture.
■ A history of previous fractures in an older patient should alert
the physician to the possibility of underlying osteoporosis.
■ The skin should be carefully examined to rule out the pres-
ence of an open fracture and to assess swelling before surgery or
casting. If the wrist is markedly swollen or if swelling is antici-
pated, casting should be delayed and a splint should be placed.
■ N eurologic symptoms in the form of numbness, tingling,
and radiating pain into the digits should alert the physician to
the possibility of acute carpal tunnel syndrome. Careful neuro-
logic assessments should be performed to rule out the presence
of a progressive neurologic deficit.
■ Acute carpal tunnel syndrome represents a surgical emergency.
■ Examination:
■ Remove splints and dressings to visualize all areas of skin.
■ Palpate for areas of tenderness or deformity. Palpate
anatomic snuffbox.
■ Visualize and palpate the elbow for swelling, ecchymosis,
tenderness, crepitus, and deformity.
■ Visualize and palpate the hand and fingers for swelling,
ecchymosis, tenderness, crepitus, and deformity.
■ Use two-point tool or paper clip bent to 5 mm and touch
radial and ulnar aspects of all fingers with one or two points.
Greater than normal (5 mm) two-point testing in the form of
progressive neurologic deficit may signify an acute or chronic
carpal tunnel syndrome.
A B
FIG 2 • A. PA ra d io g ra p h d e m o n st ra t in g ra d ial in clina t io n, (b lack lin e s),
u ln a r va ria n ce (re d ), a nd rad ia l he ig ht (w h it e b racke t ). B. Lat e ra l ra di-
o g ra p h o f t h e w rist d e m o n st ra t in g vo la r t ilt (b lack lin es).
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Posteroanterior (PA), lateral, and oblique radiographic
views are critical in evaluating all suspected distal radius
fractures.
■ Consider imaging the uninjured wrist for comparison and
to serve as a template for surgical reconstruction.
■ Radiographs of the elbow should be obtained in almost
all cases, especially if any tenderness, swelling, or deformity
is detected clinically.
■ Radiographic measurements taken from the PA view
(FIG 2 A) include9,13 :
■ Radial inclination, which is the angle between a line per-
pendicular to the shaft of the radius at the articular margin
and a line along the radial articular margin
■ N ormal angle 21 degrees
■ Radial length, which is the distance from a line tan-
gential to the ulnar articular margin to a line drawn per-
pendicular to the long axis of the radius at the radial
styloid tip
■ N ormal length 11 mm
■ Ulnar variance, which is the distance from a line perpen-
dicular to the long axis of the radius at the sigmoid notch
and a line tangential to the ulnar articular surface
■ Ulnar variance is variable, so to establish a normal
value, radiographs of the normal contralateral side should
be obtained.
■ Lateral articular (volar) tilt is the angle between a line for
the articular surface of the radius and a perpendicular line to
the long axis of the radius.
■ N ormal angle 11 degrees volar tilt (FIG 2 B)9,13
■ CT scans can fully elucidate the anatomy of the fracture,
particularly articular disruption or incongruity, and also help
to determine the necessary surgical approach based on the lo-
cation and extent of comminution.
■ CT scans increase the interobserver reliability of treat-
ment plans and may actually alter the initial treatment plan
based on plain radiographs.5
■ M RI can be useful in evaluating for concomitant ligamen-
tous injuries, TFCC injuries, stress fractures, and occult carpal
fractures.
 Ch a p t e r 7 INTRAM EDULLARY AND DORSAL PLATE FIXATION OF DISTAL RADIUS FRACTURES
DIFFEREN TIAL DIAGN OSIS
■ Bony contusion
■ Wrist dislocation
■ Scaphoid or other carpal fracture
■ Carpal instability or dislocation
■ Distal ulna fracture
■ Wrist ligament or TFCC sprain or tear
N ON OPERATIVE MAN AGEMEN T
■ Closed reduction should be performed in the emergency
department with longitudinal axial traction followed by
volar displacement of the carpus. A bivalved, short-arm, well-
molded cast or sugar-tong splint should be applied.
■ Casting is the most commonly used method to definitively
treat distal radius fractures and is preferred for nondisplaced
or minimally displaced fractures and those that are stable after
a reduction maneuver (ie, restored volar tilt with minimal dor-
sal comminution). A precise three-point mold is required to
maintain fracture reduction.
■ Removable splinting can be considered when treating com-
pletely nondisplaced stable fractures in young adults.
■ If nonoperative treatment is chosen, repeat radiographs
should be taken on a weekly basis for the first 3 weeks to ensure
that the reduction is maintained. The physician should have a
low threshold for changing the cast.
■ Any sign of dorsal migration indicates instability, and oper-
ative stabilization should be considered.
■ Finger range of motion is begun immediately and wrist range
of motion can be started as the fracture heals and is managed in
a removable splint.
SURGICAL MAN AGEMEN T
■ O pen reduction and internal fixation with a dorsal plate can
be used successfully in the treatment of displaced, unstable,
comminuted fractures of the distal radius that fail to respond
to closed treatment.
■ Dorsal plating buttresses the fracture to correct deformity
and maintain fracture reduction.
■ N ew intramedullary implants have been designed to alle-
viate some of the complications associated with traditional
x Y
A B
FIG 3 • PA ra d io g ra p h (A) a n d la t e ra l ra d io g ra p h (B) o f a h e a le d d ist a l ra d iu s fra ct u re fixe d w it h a n in t ra m e d u lla ry p la t e . C,D. PA a n d
la t e ra l ra d io g ra p h s sh o w in g a n u n st a b le m e t a p h yse a l d ist a l ra d iu s fra ct u re . (C,D: co p yrig h t Th o m a s R. Hu n t III, MD.)
65
dorsal plates and allow a less invasive option for fixation of
dorsally displaced fractures (FIG 3 A,B).
■ Indications for dorsal plating include:
■ Severe initial dorsal displacement ( 20 degrees from nor-
mal, 10 degrees dorsal tilt)
■ M arked dorsal comminution (greater than or equal to
50% of the diameter of the radius shaft on the lateral
radiograph)
■ Residual (after reduction) dorsal tilt greater than 10 de-
grees past neutral
■ 10 mm of radius shortening
■ Dorsal intra-articular fragments displaced more than
1 mm 1,6
■ Stabilization using an intramedullary device is indicated for
distal radius fractures without extensive articular involvement
in which a limited incision and shorter procedure are desired
(see Tech Fig 4E).
■ Comminution of the volar metaphysis is a relative con-
traindication for the use of a dorsal intramedullary
implant.
■ The surgeon should be prepared to change management in-
traoperatively and must have additional stabilization options
available, if necessary, such as percutaneous pins or an exter-
nal fixator.
Preoperative Planning
■ All radiographic imaging must be reviewed before surgery.
■ It is helpful to compare radiographs of the injured wrist
to the uninjured wrist.
■ Displaced intra-articular fragments must be identified.
■ Dorsal comminution must be evaluated to determine frac-
ture stability and the need for bone grafting.
■ The distal extent of the fracture must be determined to
enable the buttress plate to function properly.
■ Bone should be evaluated for osteopenia, osteoporosis, and
tumors.
Positioning
■ The patient is placed supine on a regular operating table.
■ A tourniquet is placed near the axilla with the splint in place.
C D
 66 Se c t i o n I HAND, WRIST AND FOREARM

■ After anesthesia has been administered, the arm is placed on

a radiolucent hand table (FIG 4 ).
■ M otion of the shoulder and elbow should be adequate to

allow adequate reduction and positioning.

■ Image intensification using fluoroscopy should be per-

formed throughout the procedure to assess fracture reduction

and the position of the hardware.
Approach
■ The dorsal approach to the distal radius through the third
dorsal compartment with subperiosteal elevation of the com-
partments provides the exposure needed to place a dorsal plate
while protecting the extensor tendons from the plate and screws.
■ This approach helps to minimize adhesions and the risk of

tenosynovitis and tendon rupture.

■ The approach used to place an intramedullary device de-

pends on the nature of the implant and the location and extent
of the fracture.
■ Dorsal intramedullary implants are placed through a FIG 4 • Pa t ie n t is p o sit io n e d su p in e w it h a rm o n a h a n d t a b le
limited dorsal approach through the third extensor a n d t o u rn iq u e t a p p lie d o n p ro xim a l a rm .
compartment.
■ Radial intramedullary implants are placed through a

small radial incision with careful protection of the radial

sensory nerve.
TECHNIQUES

DORSAL PLATE FIXATION OF DISTAL RADIUS FRACTURES

In cisio n a n d Disse ct io n ■ Th e EPL t e n d o n ca n t h e n b e re m o ve d fro m t h e t h ird
co m p a rt m e n t a n d p ro t e ct e d fo r t h e re st o f t h e su rg ica l
■ Th e skin in cisio n is ce n t e re d o ve r t h e t u b e rcle o f List e r
p ro ce d u re .
(TECH FIG 1 A). ■ Th e e xt e n so r co m p a rt m e n t s a re su b p e rio st e a lly e le va t e d
■ Th e su b cu t a n e o u s t issu e s a re d isse ct e d d o w n t o e xt e n so r
u sin g a sca lp e l in ra d ia l a n d u ln a r d ire ct io n s t o e xp o se
re t in a cu lu m , w it h ca re t o p re se rve a n y se n so ry n e rve
t h e d o rsa l co rt e x o f t h e d ist a l ra d iu s (TECH FIG 1 E,F).
b ra n ch e s w h ile o b t a in in g h e m o st a sis w it h b ip o la r e le c- ■ If p ro p e rly m a in t a in e d , t h e p e rio st e u m o f t h e e xt e n -
t ro ca u t e ry (TECH FIG 1 B).
so r co m p a rt m e n t s ca n b e re p a ire d a ft e r p la ce m e n t o f
■ Th e e xt e n so r re t in a cu lu m is in cise d ju st u ln a r t o t h e t u -
t h e fixa t io n d e vice a n d w ill se rve a s a b a rrie r b e t w e e n
b e rcle o f List e r, e xp o sin g t h e e xt e n so r p o llicis lo n g u s
t h e d o rsa l p la t e a n d t h e e xt e n so r t e n d o n s.
(EPL) t e n d o n (TECH FIG 1 C). ■ Th e t u b e rcle o f List e r is a lm o st in va ria b ly in vo lve d in t h e
■ Th e h e m a t o m a is e va cu a t e d a n d t h e EPL t e n d o n is fre e d
fra ct u re a n d sh o u ld b e co m p le t e ly re m o ve d u sin g a
p ro xim a lly a n d d ist a lly b y in cisin g t h e se p t a o f t h e t h ird
ro n g e u r (TECH FIG 1 G).
co m p a rt m e n t (TECH FIG 1 D).

A B C

TECH FIG 1 • A. Skin in cisio n is d ra w n in re la t io n t o t h e t u b e rcle o f List e r. B. Skin in cisio n is ca rrie d d o w n t o e xt e n so r re t i-

n a cu lu m . Tu b e rcle o f List e r a n d re t in a cu la r in cisio n a re d ra w n . C. Th e re t in a cu lu m is in cise d a n d t h e EPL t e n d o n is e xp o se d .
He m a t o m a h a s a lre a d y b e e n e va cu a t e d . (co n t in u e d )
 Ch a p t e r 7 INTRAM EDULLARY AND DORSAL PLATE FIXATION OF DISTAL RADIUS FRACTURES 67

Extensor pollicis

TECHNIQUES
Empty third longus transposed
dorsal compartment

D E F Subperiosteal dissection of 2nd and 4th compartment

TECH FIG 1 • (co nt in u e d ) D. Exposing EPL by

incising the sept a of t he third d orsal com -
p a rt m e n t . E. Su b p e rio st e a l e le va t io n o f
t he seco n d an d fo u rt h d o rsa l co mp artm en t s.
F. Diag ram d em o n st rat in g th e t ran sp o sitio n
o f EPL a nd d isse ct io n d e e p t o th e e xte n so r
co m p artm en t s. G. Re mo val o f t u bercle o f
List er. H. Exp osin g t h e ra d ial sh a ft w it h a p e -
G H rio ste a l e le va t o r.

■ Th e ra d iu s sh a ft is e xp o se d w it h a p e rio st e a l e le va t o r ■ Kirsch n e r w ire s ca n b e u se d fo r t e m p o ra ry fixa t io n .

(TECH FIG 1 H).
Re d u ct io n a n d Pla t e Fixa t io n
■ Re d u ct io n is o b t a in e d a n d co n firm e d u sin g a xia l
t ra ct io n a n d p a lm a r t ra n sla t io n o f t h e h a n d (TECH
FIG 2 A).
■ If re d u ct io n o f a rt icu la r fra g m e n t s is n e e d e d , t h e ra d ia l
p o rt io n o f t h e o rig in o f t h e d o rsa l ra d io ca rp a l lig a m e n t
ca n b e e le va t e d sh a rp ly o ff t h e ra d iu s t o e va lu a t e t h e a r-
t icu la r su rfa ce s.
■ Bo n e g ra ft is in se rt e d t o su p p o rt re d u ce d a rt icu la r
fra g m e n t s.
■ Th e d o rsa l p la t e is a p p lie d d ire ct ly o n t h e ra d iu s (TECH
FIG 2 B).
■ Th e p la t e is se cu re d b e g in n in g w it h a b ico rt ica l scre w in
t h e o va l slid in g h o le .
■ Fra ct u re re d u ct io n a n d p la ce m e n t o f t h e p la t e a re co n -
firm e d u sin g flu o ro sco p y.
■ Th e p la t e is se cu re d t o t h e d ist a l fra g m e n t w it h o n e o r
t w o ca n ce llo u s scre w s. Th e su rg e o n sh o u ld a vo id p la cin g

C D

TECH FIG 2 • A. Re d u ct io n m a n e u ve r. Th e d ist a l ra d iu s is re d u ce d o ve r

a b u m p o f t o w e ls u sin g t ra ct io n a n d p a lm a r d isp la ce m e n t o f t h e ca rp u s.
B. Pla t e p la ce m e n t . Th e p la t e is p la ce d d e e p t o t h e EPL a n d a lig n e d d is-
t a lly o ve r t h e d ist a l ra d iu s. C,D. Re d u ct io n im a g in g . C. PA flu o ro sco p ic
vie w d e m o n st ra t in g fin a l re d u ct io n w it h w e ll-a lig n e d p la t e . D. La t e ra l
flu o ro sco p ic vie w d e m o n st ra t in g fin a l re d u ct io n w it h a p p ro p ria t e -
le n g t h scre w s a n d g o o d d ist a l b u t t re ssin g o f t h e fra ct u re . Vo la r t ilt h a s
B b e e n re st o re d .
 68 Se c t i o n I HAND, WRIST AND FOREARM

t h e d ist a l, u ln a r scre w if p o ssib le a s t h is m a y irrit a t e t h e

TECHNIQUES

ove rlyin g d ig it a l e xt e n so r t e n d o n s in t h e fo u rt h d o rsa l

co m p a rt m e n t .
■ Ad d it io n a l co rt ica l scre w s a re a d d e d in t h e ra d iu s sh a ft .
■ Re d u ct io n a n d st a b ilit y a re co n firm e d (TECH FIG 2 C,D).

Wo u n d Clo su re
■ Th e w o u n d is co p io u sly irrig a t e d .
■ Th e re t in a cu lu m is clo se d d e e p t o t h e t ra n sp o se d EPL
t e n d o n , in co rp o ra t in g t h e p e rio st e a l la ye r t h a t fo rm s t h e
flo o r o f t h e e xt e n so r co m p a rt m e n t s (TECH FIG 3 A). A
■ Th e skin is clo se d w it h n ylo n su t u re (TECH FIG 3 B).
■ A vo la r sp lin t is a p p lie d .

TECH FIG 3 • A. Re tin a cula r clo su re . The e xt e n sor re tin a cu lu m

is closed dee p t o t he EPL wit h a nona bsorb able sut ure. B. Skin
clo su re. Th e skin is clo se d wit h a h o rizo n ta l m at t re ss st it ch t o
e vert t he skin e d ge s. B

FIXATION OF DISTAL RADIUS FRACTURES USING A DORSAL

INTRAMEDULLARY DEVICE (TORNIER)
■ Th e fra ct u re is e xp o se d u sin g a lim it e d ve rsio n o f t h e
in cisio n d e t a ile d fo r p la ce m e n t o f a d o rsa l p la t e (TECH
FIG 4 A).
■ Th e e xt e n so r re t in a cu lu m is in cise d ju st u ln a r t o t h e
t u b e rcle o f List e r, e xp o sin g t h e EPL t e n d o n .
■ Th e EPL t e n d o n is fre e d p ro xim a lly a n d d ist a lly b y in -
cisin g t h e se p t a o f t h e t h ird co m p a rt m e n t .
■ Th e EPL t e n d o n ca n t h e n b e t ra n sp o se d fo r t h e re st o f
t h e su rg ica l p ro ce d u re .
■ A sca lp e l is u se d t o su b p e rio st e a lly e le va t e t h e fo u rt h
a n d p o rt io n s o f t h e se co n d e xt e n so r co m p a rt m e n t in ra -
d ia l a n d u ln a r d ire ct io n s.
■ Th e d o rsa l co rt e x o f t h e d ist a l ra d iu s is e xp o se d a n d
ro o m is cre a t e d fo r se a t in g o f t h e e xt ra m e d u lla ry p o r-
t io n o f t h e d e vice .
■ Th e t u b e rcle o f List e r is re m o ve d a n d a n a w l is u se d t o
cre a t e a n e n t ry p o in t in t h e d o rsa l co rt e x (TECH FIG 4 B).
■ Th is u su a lly in vo lve s a p o rt io n o f t h e fra ct u re lin e .
■ Th e ca n a l is ra sp e d u n t il t h e ra sp m a y b e fu lly se a t e d
(TECH FIG 4 C).
■ Th e im p la n t is p la ce d u sin g t h e in se rt io n d e vice t o co n -
t ro l ro t a t io n (TECH FIG 4 D).
■ Fra ct u re re d u ct io n is t yp ica lly a ch ie ve d a s t h e d e vice
is in se rt e d a n d se a t e d d u e t o it s b u t t re ss e ffe ct a n d
t h re e -p o in t fixa t io n in t h e ca n a l.
■ La g scre w s a re in se rt e d a s re q u ire d , fo llo w e d b y a co ve r
lo ck t o cre a t e fixe d a n g le st a b ilit y.
■ Re d u ct io n a n d st a b iliza t io n a re co n firm e d ra d io g ra p h i-
ca lly (TECH FIG 4 E,F).
■ Wo u n d clo su re a n d sp lin t in g a re a s d e scrib e d a b o ve .

A B

TECH FIG 4 • A. A 2.5-cm d o rsa l in cisio n is u se d fo r e xp o su re . B. Th e aw l is in se rte d t h ro ug h

t h e fractu re sit e after rem o val o f t h e tu b e rcle o f List er. (co nt inu e d)
 Ch a p t e r 7 INTRAM EDULLARY AND DORSAL PLATE FIXATION OF DISTAL RADIUS FRACTURES 69

TECHNIQUES
C

E F
TECH FIG 4 • (co n tin u e d ) C. A rasp is u sed to creat e a p at h
fo r th e imp lan t. D. The im plant is pla ced using t he inse rt ion
d evice so a s to co n t ro l ro ta tio n d uring se a tin g . E,F. An u n -
st a b le m e t a p h yse a l d ist a l ra d iu s fra ct u re h a s b e e n re d u ce d
a n d st a b ilize d u sin g a d o rsa l in t ra m e d u lla ry d e vice (To rn ie r
D Co rp ). (E,F: co p yrig h t Th o m a s R. Hu n t III, MD.)

FIXATION OF DISTAL RADIUS FRACTURES USING A RADIAL

INTRAMEDULLARY DEVICE (WRIGHT MEDICAL)
■ A 2- t o 3-cm in cisio n is m a d e o ve r t h e ra d ia l st ylo id , b e -
t w e e n t h e first a n d se co n d e xt e n so r co m p a rt m e n t s.
■ Ca re is t a ke n t o p ro t e ct b ra n ch e s o f t h e ra d ia l se n so ry
n e rve .
■ A ca n n u la t e d d rill is u se d t o p e n e t ra t e t h e co rt e x 2 t o
3 m m p ro xim a l t o t h e ra d io ca rp a l jo in t lin e t o cre a t e t h e
e n t ry p o in t .
■ Aft e r in se rt io n o f a st a rt e r a w l, t h e ca n a l is b ro a ch e d se -
q u e n t ia lly u n d e r flu o ro sco p ic g u id a n ce t o fit t h e
m e d u lla ry ca n a l.
■ Th e im p la n t is t h e n in se rt e d w it h t h e in se rt io n jig , m a k-
in g su re t h e im p la n t is co un t e rsu n k in t o t h e ra d ia l st ylo id .
■ Th e p ro xim a l in t e rlo ckin g scre w s a re t h e n p la ce d u sin g
t h e in se rt io n jig , u sin g sm a ll in cisio n s o f t h e d o rsa l a sp e ct
o f t h e fo re a rm .
■ Th e d ist a l in t e rlo ckin g scre w s a re p la ce d la st u sin g t h e in -
se rt io n jig .
■ Sm a ll a d ju st m e n t s t o ra d ia l h e ig h t a n d t ilt ca n b e
m a d e a t t h is t im e .
■ Re d u ct io n a n d st a b iliza t io n a re co n firm e d ra d io g ra p h i-
ca lly.
■ Wo u n d clo su re a n d sp lin t in g a re a s d e scrib e d a b o ve .

PEARLS AND PITFALLS

In d ica t io n s
Su rg ica l a p p ro a ch
Ha rd w a re ch o ice
a n d p la ce m e n t
Po st o p e ra t ive
management
■ De t e rm in e t h e d ire ct io n o f fra ct u re st a b ilit y.
■ De t e rm in e t h e a re a a n d e xt e n t o f co m m in u t io n .
■ En su re t h a t a n a cu t e ca rp a l t u n n e l syn d ro m e d o e s n o t e xist .
■ In cise t h e e xt e n so r re t in a cu lu m sh a rp ly t o a llo w e a sie r re p a ir.
■ Exp o se o n ly t h e t h ird d o rsa l co m p a rt m e n t .
■ Re m o ve t h e t u b e rcle o f List e r t o a llo w b e t t e r p la t e co n t o u rin g .
■ Ch o o se a lo w -p ro file im p la n t syst e m t h a t o ffe rs t h e fle xib ilit y n e e d e d t o st a b ilize t h e fra ct u re .
■ Pla ce t h e p la t e d ist a lly t o e n su re b u t t re ss e ffe ct .
■ Pla ce t h e o va l p la t e h o le scre w in it ia lly.
■ Do n o t p la ce t h e p la t e d ist a l t o t h e d o rsa l lip o f t h e d ist a l ra d iu s.
■ Avo id p la cin g t h e d ist a l, u ln a r scre w .
■ Alt h o u g h t it a n iu m im p la n t s a n d t h e ir p a rt icu la t e d e b ris h a ve b e e n im p lica t e d in t h e d e ve lo p m e n t o f
t e n o syn o vit is a n d o t h e r t e n d o n p a t h o lo g y, t h e re is n o cle a r scie n t ific e vid e n ce t o su b st a n t ia t e t h e se cla im s.
■ Avo id ca st in g fo r lo n g p e rio d s.
■ En co u ra g e e a rly a ct ive ra n g e o f m o t io n o f t h e w rist a n d fin g e rs.
■ Avo id u sin g a slin g t o p re ve n t u n n e ce ssa ry sh o u ld e r a n d e lb o w st iffn e ss.
■ Do n o t b e g in st re n g t h e n in g u n t il ra n g e o f m o t io n is re st o re d .
70 Se c t i o n I HAND, WRIST AND FOREARM
POSTOPERATIVE CARE
■ Postoperatively the patient is placed in a bulky dressing that
allows motion of the digits, elbow, and shoulder. A volar rest-
ing splint may be used to support the wrist if there is any con-
cern about fixation strength.
■ The patient is encouraged to begin finger range-of-motion
exercises immediately after surgery.
■ Seven to 10 days after surgery the sutures are removed,
Steri-Strips are applied, and the incision is allowed to get wet.
■ The patient is evaluated by an occupational therapist, who
provides a thermoplastic splint, and can start active and ac-
tive-assisted range-of-motion exercises depending on fracture
stability.
■ When the fracture heals at about 6 weeks, gentle passive
range of motion and strengthening may be started.
OUTCOMES
■ Dorsal plating has recently been shown biomechanically to
be stronger and stiffer than volar plating for dorsally unstable
fractures.12
■ Dorsal plating has been associated with a higher complica-
tion rate than other means of stabilization. 2,9,10
■ Extensor tenosynovitis and tendon rupture have been
prevalent in the past, mainly due to bulky implants.
■ There has been renewed interest in dorsal plating of the dis-
tal radius as it has been shown to have a low rate of tendon-
related complications with the use of low-profile, anatomic
implants.4,10,11
■ Clinical reports have suggested that low-profile systems are
more important in satisfactory outcomes for dorsal plating,
with a much lower rate of complications. 10
■ Fixation with low-profile dorsal plates can result in at least
80% of contralateral wrist range of motion, about 80% to
90% of grip strength, and over 90% pinch strength, with min-
imal risk of tendon rupture.4,11
COMPLICATION S
■ Infection (pin tract or deep)
■ Injury to tendons, vessels, and nerves
■ Stiffness
■ Posttraumatic arthritis
■ Weakness in grip or pinch
■ Tenosynovitis and tendon ruptures
■ M alunion or nonunion
■ Compartment syndrome
■ Carpal tunnel syndrome
■ Late tendon rupture, potentially related to implant design
and material
■ H ardware failure
■ Complex regional pain syndrome type I
DISCLOSURE
Dr. Beredjiklian is a stockholder with and consultant for
Tornier, Inc.
REFEREN CES
1. Glowacki KA, Weiss AP, Akelman E. Distal radius fractures: con-
cepts and complications. O rthopedics 1996;19:601–608.
2. Grewal R, Perey B, Wilmink M , Stothers K. A randomized prospec-
tive study on the treatment of intra-articular distal radius fractures:
open reduction and internal fixation with dorsal plating versus mini
open reduction, percutaneous fixation, and external fixation. J H and
Surg Am 2005;30A:764–772.
3. Jupiter JB, Fernandez DL. Comparative classification for fractures of
the distal end of the radius. J. H and Surg Am 1997;22A:563–571.
4. Kamath AF, Z urakowski D, Day CS. Low-profile dorsal plating for
dorsally angulated distal radius fractures: an outcomes study. J H and
Surg Am 2006;31A:1061–1067.
5. Katz M A, Beredjiklian PK, Bozentka DJ, et al. Computed tomogra-
phy scanning of intra-articular distal radius fractures: does it influ-
ence treatment? J H and Surg Am 2001;26A:412–421.
6. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the
radius in young adults. J Bone Joint Surg am 1986;68A:647–659.
7. Lafontaine M , H ardy D, Delince P. Stability assessment of distal ra-
dial fractures. Injury 1989;20:208–210.
8. M ackenney PJ, M cQ ueen M M , Elton R. Prediction of instability in
distal radial fractures. J Bone Joint Surg Am 2006;88A:1944–1951.
9. N ana AD, Joshi A, Lichtman DM . Plating of the distal radius. J Am
Acad O rthop Surg 2005;13:159–171.
10. Rozental TD, Beredjiklian PK, Bozentka DJ. Functional outcome and
complications following two types of dorsal plating for unstable frac-
tures of the distal part of the radius. J Bone Joint Surg Am 2003;85A:
1956–1960.
11. Simic PM , Robison J, Gardner M J, et al. Treatment of distal radius
fractures with a low-profile dorsal plating system: an outcomes as-
sessment. H and Surg Am 2006;31A:382–386.
12. Trease C, M cIff T, Toby EB. Locking versus nonlocking T-plates for
dorsal and volar fixation of dorsally comminuted distal radius frac-
tures: a biomechanical study. H and Surg Am 2005;30A:756–763.
13. Trumble TE, Culp R, H anel DP, et al. Intra-articular fractures of the
distal aspect of the radius. J Bone Joint Surg Am 1998;80A:582–600.
 Fr a g m e n t -Sp e cif ic Fix a t io n o f
Ch a p t e r 8 Dis t a l Ra d iu s Fr a ct u re s
Ro b e rt J. M e d o f f

DEFIN ITION ■ The goal of fragment-specific fixation is to create a multi-

■ Fragment-specific fixation is a treatment approach in which
each major fracture component is identified and fixed indepen-
dently using low-profile implants with a certain degree of
“ spring-like” elasticity.
■ Each fracture component has a unique implant specifically
designed for that particular fracture element (FIG 1 ).
■ Surgical planning is extremely important to determine
whether a single approach or a combination of surgical ap-
proaches is needed to visualize and fix each of the main frac-
ture components present in a particular injury.
■ At the start of surgery, a complete set of implants should be
available to address fractures of the radial column, ulnar cor-
ner, volar rim, dorsal wall, and free impacted articular frag-
ments. In addition, identification and treatment of distal
planar, load-sharing construct that anatomically restores the
articular surface and has enough stability to allow immediate
motion after surgery.
AN ATOMY
■ The radial column fragment is formed from the pillar of
bone along the radial border (FIG 2 ). This fracture component
is important to maintain radial length to support the carpus in
its normal spatial position. The brachioradialis inserts on the
base of the radial column and may result in shortening of the
radial column fragment, leading to impaction of the carpus
into remaining fragments. M etaphyseal comminution may
also contribute to radial column instability.
■ The volar rim of the lunate facet is a primary load-bearing

radioulnar joint (DRUJ) disruptions or unstable fractures of structure of the articular surface. Instability of the volar rim
the ulnar column may be required. occurs in two patterns:
■ As a rule, this technique avoids creating large holes in small ■ In the volar instability pattern, shortening and volar

distal fragments, with fixation based and often triangulated to translation of the volar rim result in secondary volar sublux-
the stable ipsilateral cortex of the proximal fragment. ation of the carpus.

FIG 1 • Fra g m e n t -sp e cific im p la n t s.

71
72 Se c t i o n I HAND, WRIST AND FOREARM

Radial column into the articular surface, this fragment migrates dorsally and
shortens proximally. Residual displacement of the ulnar cor-
Ulnar corner ner can result in instability of the DRUJ as well as restriction
of forearm rotation.
■ Dorsal wall fragmentation typically occurs with either dor-

sal bending injuries or axial loading injuries and may con-

tribute to fracture instability.
■ Free articular fragments may be impacted within the meta-

physeal cavity and result in incongruity of the articular surface.

PATHOGEN ESIS
■ Dorsal bending injuries result in extra-articular fractures
Dorsal wall with dorsal displacement (FIG 3 A). Comminution of the
metaphyseal cavity or dorsal wall usually suggests a dorsally
unstable fracture pattern.
■ Volar bending injuries result in extra-articular fractures with

A volar displacement (FIG 3 B). Fractures with significant volar

Intra-articular displacement are nearly always unstable and require some type
of intervention to obtain and hold a reduction until union.
■ Dorsal shearing injuries present as fractures of the dorsal

rim and are often associated with dorsal instability of the car-
pus (FIG 3 C).
■ Volar shearing injuries present as displaced fractures of the

B Volar rim
FIG 2 • Art icu la r fra ct u re co m p o n e n t s.
■ In the axial instability pattern of the volar rim, axial im-
paction of the carpus drives the volar rim into dorsiflexion,
volar rim and result in volar instability of the carpus (FIG 3 D).
O ften, this pattern is comminuted and highly unstable and not
suited to closed methods of treatment.
■ Simple three-part fractures are usually the result of low-
energy injuries that combine an axial loading and dorsal bend-
ing mechanism (FIG 3 E). This pattern is characterized by the
presence of an ulnar corner fragment that involves the dorsal
portion of the sigmoid notch, a main articular fragment, and a
proximal shaft fragment.
■ Unstable fractures with complex involvement of the articu-

resulting in secondary axial and dorsal subluxation of the lar surface to simplify complex articular fractures. In addition
carpus. to articular comminution, this pattern may often generate a
■ The ulnar corner fragment involves the dorsal half of the significant defect in the metaphyseal cavity or complete disrup-
sigmoid notch. Typically a result of impaction of the lunate tion of the DRUJ (FIG 3 F).

A B

FIG 3 • Pa t h o g e n e sis o f d o rsa l ra d iu s fra ct u re s. A.

Do rsa l b e n d in g . B. Vo la r b e n d in g . C. Do rsa l sh e a r.
C (co n t in u e d )
 Ch a p t e r 8 FRAGM ENT-SPECIFIC FIXATION OF DISTAL RADIUS FRACTURES 73

D E

F G H

FIG 3 • (co n t in u e d ) D. Vo la r sh e a r. E. Th re e -p a rt a rt icu la r. F. Co m m in u t e d a rt icu la r. G. Ca rp a l a vu lsio n . H. Hig h e n e rg y.

■ The avulsion and carpal instability pattern is primarily a lig-
amentous injury of the carpus that has associated osseous
avulsions of the distal radius (FIG 3 G).
■ Extremely high-energy injuries present as complex fractures
involving comminution of the articular surface as well as ex-
tension into the radial or ulnar shaft (FIG 3 H).
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Posteroanterior (PA), standard lateral (FIG 4 A,B), and 10-
degree lateral views are routine views for radiographic evalua-
tion of the distal radius. The 10-degree lateral view (FIG
4 C,D) clearly visualizes the ulnar two thirds of the articular
surface from the base of the scaphoid facet through the entire
lunate facet. O blique views may also be helpful for evaluating
the injury.
■ The radiographic features of distal radius fractures include
the following:
horizon identifies the volar rim. H owever, if the articular
surface is in dorsal tilt, the x-ray beam is parallel to the
subchondral bone of the dorsal half of the lunate facet and
the carpal facet horizon identifies the dorsal rim (not
shown). The carpal facet horizon is the portion of the
articular surface that is visualized on the 10-degree lateral
x-ray projection.
■ Teardrop angle (normal 70 5 degrees; FIG 5 C,D).
The teardrop angle is used to identify dorsiflexion of the
volar rim of the lunate facet. Depression of the teardrop
angle to a value less than 45 degrees indicates that the
volar rim of the lunate facet has rotated dorsally and
impacted into the metaphyseal cavity (axial instability
pattern of the volar rim). This may be associated with
axial and dorsal subluxation of the carpus. Restoration of
the teardrop angle is necessary to correct this type of
malreduction.
■ Articular concentricity (FIG 5 E,F). The subchondral

■ Carpal facet horizon (FIG 5 A,B). This is the radiodense
horizontal landmark that is used to identify the volar and
dorsal rim on the PA view. If the articular surface is in pal-
mar tilt, the x-ray beam is parallel to the subchondral bone
of the volar half of the lunate facet and the carpal facet
outline of the articular surface of the distal radius is nor-
mally congruent and concentric with the subchondral out-
line of the base of the lunate; a uniform joint interval
should be present between the radius and lunate along the
entire articular surface. When these articular surfaces are
74 Se c t i o n I HAND, WRIST AND FOREARM

A C

B D

FIG 4 • A. Positioning fo r st anda rd lat eral radiograph y. B. St an d a rd lat eral rad io g rap h . C. Posit io n in g
fo r 10-d e g re e la te ra l ra d io g ra p h y. D. Te n-d eg ree la t era l ra d io g ra ph . Not e t h e impro ve d visu a liza t io n o f
t h e articu lar su rface o f t h e b ase o f th e scap h o id facet an d th e e n tire lu n at e facet .

A B

C D

FIG 5 • A. Ca rp a l fa ce t h o rizo n (arro w s). Use d t o d iffe re n t ia t e b e t w e e n t h e vo la r a n d d o rsa l rim o n

t h e PA p ro je ct io n . B. Orig in o f ca rp a l fa ce t h o rizo n . Th e ca rp a l fa ce t h o rizo n is fo rm e d b y t h a t p a rt
o f t h e a rt icu la r su rfa ce t h a t is p a ra lle l t o t h e x-ra y b e a m a n d d e p e n d s o n w h e t h e r t h e a rt icu la r su r-
fa ce is in vo la r o r d o rsa l t ilt . C. No rm a l t e a rd ro p a n g le . D. De p re sse d t e a rd ro p a n g le , in t h is ca se
ca u se d b y a xia l in st a b ilit y o f t h e vo la r rim . (co n t in u e d )
 Ch a p t e r 8 FRAGM ENT-SPECIFIC FIXATION OF DISTAL RADIUS FRACTURES 75

E F G

H I J

FIG 5 • (con tinu e d ) E. No rm a l a rt icu la r co n ce n t ricity. F. Ab n o rm al art icu la r co n cen t ricity, in d ica tin g d isru p t io n a cro ss th e vo la r
a nd d orsal surfa ce s o f th e lun a t e fa ce t. G. AP in t erva l is th e p o in t -to -p o in t d ista n ce b e tw een t h e co rn ers o f th e d o rsal a n d
volar rim. H. Dist al rad io u ln ar jo in t in t erval. I. No rm al la te ra l ca rp a l alig n m en t . J. Do rsa l su b lu xa tio n o f th e carp u s.

not concentric, discontinuity and disruption of the lunate presence of other associated injuries that may affect the deci-
facet has occurred. sion for a particular treatment.
■ AP distance (normal: females 18 1 mm, males 20
1 mm; FIG 5 G). The AP distance is the point-to-point SURGICAL MAN AGEMEN T
distance from the dorsal corner of the lunate facet to the Operative Indications
palmar corner of the lunate facet. It is best evaluated on ■ General parameters:
the 10-degree lateral view. Elevation of the AP distance in- ■ Shortening of more than 5 mm
dicates disruption of the volar and dorsal portion of the ■ Radial inclination of less than 15 degrees
lunate facet. ■ Dorsal angulation of more than 10 degrees
■ DRUJ interval (FIG 5 H). The DRUJ interval measures the
■ Articular stepoff of more than 1 to 2 mm
apposition between the head of the ulna and the sigmoid ■ Depression of teardrop angle of less than 45 degrees
notch. Significant widening of the DRUJ interval implies dis- ■ Volar instability
ruption of the DRUJ capsule and triangular fibrocartilage ■ DRUJ instability
complex (TFCC). ■ Displaced articular fractures
■ Lateral carpal alignment (FIG 5 I,J). The center of rota-
■ Young, active patients are generally less tolerant of residual
tion of the capitate normally lines up with a line extended deformity and malposition.
from the volar surface of the radial shaft with the wrist in
neutral position. Dorsal rotation of the volar rim results in Preoperative Planning
dorsal subluxation of the carpus from this normal position, ■ Extra-articular fractures: multiple options:
placing the flexor tendons at a mechanical disadvantage, ■ Volar plating through a volar approach

which may affect grip strength. ■ Dorsal plating through a dorsal approach

■ In addition to the injury films, it is important to reassess ■ Fragment-specific fixation

postreduction views to determine the personality and specific ■ Radial pin plate (TriM ed, Inc., Valencia, CA) and volar

components of the fracture. buttress pin (TriM ed, Inc.) fixation through a limited in-
■ CT scans allow higher resolution and definition of fracture cision volar or standard volar approach
characteristics, particularly for highly comminuted fractures. ■ Radial pin plate and either an ulnar pin plate dorsally

Preferably, an attempt at closed reduction is done before a CT or a dorsal buttress pin through a dorsal or combined
scan is obtained to limit distortion of the image. CT scans are approach
particularly helpful for visualizing intra-articular fragments as ■ Intra-articular fractures: surgical approach is based on the

well as DRUJ disruption. fragmentation pattern

■ Clinical and radiographic evaluations of the carpus, in- ■ Unstable volar rim fragments require a standard volar or

terosseous membrane, and elbow are used to identify the ulnar-volar approach for adequate visualization.
 76 Se c t i o n I HAND, WRIST AND FOREARM
■ Fixation of the radial column can be done through either
a limited-incision volar-radial approach, a volar approach
with a radial extension combined with pronation of the
forearm, or a dorsal approach with radial extension com-
bined with supination of the forearm.
■ Fixation of dorsal, ulnar corner, and free intra-articular
fragments can be done through a dorsal approach.
Positioning
■ The patient is supine.
■ The affected arm is on an armboard out to the side.
■ C-arm
■ If the armboard is radiolucent, the C-arm can be brought
in from the end of the armboard and images taken directly
with the wrist on the armboard.
■ If the armboard is not radiolucent, the C-arm is brought
in along the side of the table from the foot, and the arm is
brought off the armboard for each image.
TECHNIQUES
LIMITED-INCISION VOLAR APPROACH
■ Ma ke a lo n g it u d in a l in cisio n a lo n g t h e ra d ia l sid e o f t h e
ra d ia l a rt e ry.
■ Pro xim a lly, in se rt t h e t ip o f a t e n o t o m y scisso rs o ve r t h e
su rfa ce o f t h e first d o rsa l co m p a rt m e n t sh e a t h a n d
sw e e p d ist a lly t o e le va t e a ra d ia l skin fla p .
■ Pro n a t e t h e fo re a rm a n d sh a rp ly e xp o se t h e b o n e o ve r
t h e ra d ia l st ylo id in t h e in t e rva l b e t w e e n t h e first a n d
se co n d d o rsa l co m p a rt m e n t s (TECH FIG 1 A).
■ Lea vin g t h e d ista l 1 cm o f sh eat h in t act , o p en th e first
d orsal co m partm en t p roxima lly an d m o bilize th e t en do n s.
TECH FIG 1 • Lim it e d -in cisio n vo la r a p p ro a ch . A. Sw e e p in g t e n o t o m y
scisso rs t o e le va t e ra d ia l skin fla p o ff first d o rsa l co m p a rt m e n t . B. De e p
A e xp o su re o f t h e ra d ia l co lu m n .
Operative Sequence
■ Radial column length is restored first with traction; a
transstyloid pin is inserted to hold the reduction if needed.
■ The volar rim is reduced and fixed.
■ The dorsal ulnar corner is reduced and fixed.
■ Free intra-articular fragments and the dorsal wall if needed
are reduced and stabilized.
■ Bone graft is applied if the metaphyseal defect is large.
■ Fixation is completed with a radial column plate.
Approach
■ The repair is undertaken by means of one of the following
approaches:
■ Limited-incision volar approach
■ Dorsal approach
■ Extensile volar approach
■ Volar-ulnar approach
Re fle ct th e in se rtio n o f b ra ch io ra d ia lis t o e xp o se t h e ra -
d ia l co lu m n (TECH FIG 1B).
■ If n e e d e d , t h e d isse ct io n ca n b e co n t in u e d t h ro u g h t h e
flo o r o f t h e in cisio n t o e xp o se t h e vo la r su rfa ce . De t a ch
t h e in se rt io n o f t h e p ro n a t o r q u a d ra t u s ra d ia lly a n d d is-
t a lly a n d re fle ct it t o t h e u ln a r sid e . Alt e rn a t ive ly, cre a t e
a n u ln a r skin fla p su p e rficia l t o t h e a rt e ry a n d co n t in u e
t h e e xp o su re t h ro u g h a st a n d a rd vo la r a p p ro a ch .
■ Th is a p p ro a ch ca n n o t b e u se d t o a cce ss t h e u ln a r sid e o f
t h e vo la r rim .
 Ch a p t e r 8 FRAGM ENT-SPECIFIC FIXATION OF DISTAL RADIUS FRACTURES 77

DORSAL APPROACH
■ Ma ke a lo n g it u d in a l skin in cisio n d o rsa lly a lo n g t h e u ln a r
sid e o f t h e t u b e rcle o f List e r (TECH FIG 2 A).
■ Id e n t ify t h e e xt e n so r d ig it o ru m co m m u n is (EDC) t e n d o n s
visib le p ro xim a lly t h ro u g h t h e t ra n slu ce n t e xt e n so r
sh e a t h . In cise t h e d o rsa l re t in a cu la r sh e a t h .
■ De ve lo p t h e in t e rva l b e t w e e n t h e t h ird a n d fo u rt h
co m p a rt m e n t t e n d o n s fo r a cce ss t o d o rsa l w a ll a n d fre e ,
im p a ct e d a rt icu la r fra g m e n t s. Re se ct a se g m e n t o f t h e
t e rm in a l b ra n ch o f t h e p o st e rio r in t e ro sse o u s n e rve
(TECH FIG 2 B).
■ Tra n sp o se t h e e xt e n so r p o llicis lo n g u s (EPL) fro m t h e
t u b e rcle o f List e r if re q u ire d fo r a d d it io n a l e xp o su re .
TECHNIQUES
■ Develop the interval betwe en the fourth and fifth extensor
compartments to gain access to the ulna r corner fragment.
■ A d o rsa l ca p su lo t o m y ca n b e d o n e t o visu a lize t h e a rt ic-
u la r su rfa ce a n d ca rp u s if n e ce ssa ry.
■ To g a in a cce ss t o t h e ra d ia l co lu m n t h ro u g h a d o rsa l
e xp o su re , e xt e n d t h e in cisio n a s n e e d e d a n d e le va t e a
ra d ia l su b cu t a n e o u s fla p a n d su p in a t e t h e w rist .
■ To g a in a cce ss t o t h e d ist a l u ln a , e xt e n d t h e in cisio n a s
n e e d e d a n d e le va t e a n u ln a r su b cu t a n e o u s fla p .

A B

TECH FIG 2 • Do rsa l a p p ro a ch . A. In it ia l in cisio n . B. De e p e xp o su re .

EXTENSILE VOLAR APPROACH

■ St a rt t h e skin in cisio n a t t h e d ist a l p o le o f t h e sca p h o id ■ If access t o th e rad ia l co lu mn is n eed e d , e leva te a rad ia l
a n d a n g le it t o w a rd t h e ra d ia l b o rd e r o f t h e fle xo r w rist su b cut a n eo u s fla p sup e rficial to t h e ra d ial art ery an d first
cre a se , t h e n e xt e n d it p ro xim a lly a lo n g t h e fle xo r ca rp i d o rsal co m p art me n t te n d on sh e a t h . Pro na t e th e w rist a nd
ra d ia lis (FCR) t e n d o n (TECH FIG 3 A). re t ract t h e ra d ial skin flap t o e xpo se t h e ra d ia l co lumn .
■ Op e n t h e FCR t e n d o n sh e a t h b o t h p ro xim a lly a n d d ist a lly
a n d co n t in u e in t h e p la n e b e t w e e n t h e FCR t e n d o n a n d
t h e ra d ia l a rt e ry (TECH FIG 3 B).
■ Use b lu n t d isse ct io n w it h a fin g e r o r sp o n g e t o se p a -
ra t e t h e in t e rva l b e t w e e n t h e co n t e n t s o f t h e ca rp a l
t u n n e l a n d t h e su rfa ce o f t h e p ro n a t o r q u a d ra t u s.
Re t ra ct t h e FCR, m e d ia n n e rve , a n d fle xo r t e n d o n s t o
t h e u ln a r sid e .
■ Divid e t h e ra d ia l a n d d ist a l a t t a ch m e n t o f t h e p ro n a t o r
q u a d ra t u s a n d re fle ct it t o t h e u ln a r sid e . Lim it t h e d ist a l
d isse ct io n t o n o m o re t h a n 1 o r 2 m m b e yo n d t h e d ist a l
ra d ia l rid g e t o a vo id d e t a ch m e n t o f t h e vo la r w rist ca p -
su la r lig a m e n t s (TECH FIG 3 C).
■ Re fle ct t h e b ra ch io ra d ia lis fro m it s in se rt io n o n t h e d ist a l TECH FIG 3 • Ext e n sile vo la r
fra g m e n t if n e e d e d . Bo n e g ra ft ca n b e a p p lie d t h ro u g h a p p ro a ch . A. In it ia l in cisio n .
t h e ra d ia l fra ct u re d e fe ct . A (co n t in u e d )
 78 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES
B C
VOLAR-ULNAR APPROACH
■ Ma ke a lo n g it u d in a l skin in cisio n a lo n g t h e u ln a r b o rd e r
o f t h e fle xo r ca rp i u ln a ris (FCU) t e n d o n (TECH FIG 4 A).
■ Re fle ct t h e FCU t e n d o n a n d t h e u ln a r a rt e ry a n d n e rve t o
t h e u ln a r sid e (TECH FIG 4 B).
■ With b lu nt finger or spo nge disse ct ion, develop t he pla ne
o n t h e su p e rficial su rface o f t h e p ro n at o r q u ad rat u s.
A B
TECH FIG 4 • Vo la r-u ln a r a p p ro a ch . A. In cisio n . B. In it ia l e xp o su re . C. Co m p le t e d e xp o su re .
RADIAL COLUMN FIXATION WITH RADIAL PIN PLATE
■ Exp o se t h e ra d ia l co lu m n w it h a n y o f t h e a p p ro a ch e s
p re vio u sly d e scrib e d . Sh a rp ly e xp o se t h e in t e rva l b e -
t w e e n t h e first a n d se co n d d o rsa l co m p a rt m e n t s o ve r t h e
t ip o f t h e ra d ia l st ylo id . Re le a se t h e t e n d o n sh e a t h o f t h e
TECH FIG 3 • (co n t in u e d ) B. Lin e o f in cisio n in
p ro n a t o r q u a d ra t u s. C. De e p e xp o su re .
■ Re t ra ct t h e co n t e n t s o f t h e ca rp a l t u n n e l t o t h e ra d ia l
sid e (TECH FIG 4 C).
■ Re fle ct t h e p ro n a t o r q u a d ra t u s fro m it s u ln a r a n d d ist a l
a t t a ch m e n t . Do n o t d isse ct m o re t h a n 1 t o 2 m m b e yo n d
t h e d ist a l ra d ia l rid g e t o a vo id d e t a ch in g t h e vo la r w rist
ca p su le .
C
first d o rsa l co m p a rt m e n t p ro xim a lly, le a vin g t h e la st 1
cm o f t e n d o n sh e a t h in t a ct .
■ Re t ra ct t h e t e n d o n s o f t h e first d o rsa l co m p a rt m e n t d o r-
sa lly o r vo la rly a s n e e d e d . Re le a se t h e t e rm in a l in se rt io n
 Ch a p t e r 8 FRAGM ENT-SPECIFIC FIXATION OF DISTAL RADIUS FRACTURES 79

o f t h e b ra ch io ra d ia lis t o co m p le t e e xp o su re o f t h e ra d ia l t o lim it p e n e t ra t io n o f t h e Kirsch n e r w ire t h ro u g h t h e

co lu m n .
■ Aft e r t h e in it ia l fra ct u re e xp o su re , re st o re ra d ia l le n g t h
w it h t ra ct io n a n d u ln a r d e via t io n o f t h e w rist . If n e e d e d ,
st ru ct u ra l b o n e g ra ft ca n b e in se rt e d t h ro u g h t h e ra d ia l
fra ct u re d e fe ct .
■ In se rt a 0.045-in ch t ra n sst ylo id Kirsch n e r w ire a n g le d t o
e n g a g e t h e fa r co rt e x o f t h e p ro xim a l fra g m e n t (TECH
FIG 5 A). Wh e n t h e a d va n cin g t ip o f t h e Kirsch n e r w ire
h it s t h e fa r co rt e x, p la ce a d rill sle e ve o ve r t h e Kirsch n e r
w ire t o u se a s a d rill st o p t o lim it p e n e t ra t io n o f t h e fa r
co rt e x t o 1 t o 2 m m .
■ On ce t h e ra d ia l co lu m n is t e m p o ra rily fixe d w it h a
t ra n sst ylo id Kirsch n e r w ire , re d u ce a n d st a b ilize o t h e r
vo la r, d o rsa l, a n d a rt icu la r fra ct u re e le m e n t s b e fo re co m -
p le t in g fixa t io n o f t h e ra d ia l co lu m n .
■ Se le ct a d ist a l p in h o le a n d slid e a ra d ia l p in p la t e o ve r
t h e t ra n sst ylo id Kirsch n e r w ire . Pro xim a lly, g u id e t h e
p la t e u n d e r t h e t e n d o n s o f t h e first d o rsa l co m p a rt -
m e n t a n d se cu re it in it ia lly w it h a sin g le 2.3-m m b o n e
scre w .
■ In se rt a se co n d t ra n sst ylo id Kirsch n e r w ire t h ro u g h a
n o n -a d ja ce n t d ist a l p in h o le . Use t h e p re vio u s t e ch n iq u e
TECHNIQUES
fa r co rt e x t o 1 t o 2 m m .
■ Ma rk a re fe re n ce p o in t w h e re t h e Kirsch n e r w ire cro sse s
t h e su rfa ce o f t h e p la t e . Wit h d ra w t h e Kirsch n e r w ire
1 cm a n d cu t it 1 cm o r m o re a b o ve t h e re fe re n ce m a rk
(TECH FIG 5 B).
■ Po sit io n t h e re fe re n ce m a rk b e t w e e n t h e lo w e r t w o
p o st s o f a w ire b e n d e r a n d cre a t e a h o o k (TECH FIG
5 C). Th e b e n d sh o u ld st a rt a t t h e re fe re n ce m a rk
t o m a ke a Kirsch n e r w ire o f p ro p e r le n g t h w h e n
co m p le t e d .
■ Co m p le t e t h e b e n d w it h a p in cla m p , o ve rb e n d in g
slig h t ly t o a llo w t h e h o o k t o sn a p in t o a n a d ja ce n t p in
h o le o r o ve r t h e e d g e o f t h e p la t e . Wit h a fre e 0.045-in ch
Kirsch n e r w ire , p re d rill a h o le t o a cce p t t h e e n d o f t h e
h o o k (TECH FIG 5 D).
■ Im p a ct t h e Kirsch n e r w ire w it h a p in im p a ct o r a n d fu lly
se a t t h e h o o k (TECH FIG 5 E). Re p e a t t h e p ro ce d u re w it h
t h e se co n d Kirsch n e r w ire .
■ Co m p le t e p ro xim a l fixa t io n w it h 2.3-m m co rt ica l b o n e
scre w s (TECH FIG 5 F,G).

A B D

E F G

TECH FIG 5 • Ra d ia l co lu m n fixa t io n . A. In se rt io n o f t ra n sst ylo id Kirsch n e r w ire . B,C. Cre a t io n o f p in h o o k.

D,E. Co m p le t io n a n d im p a ct io n o f p in h o o k. F,G. Co m p le t e d ra d ial co lu m n fixa t io n .
 80 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES
ULNAR CORNER AND DORSAL WALL FIXATION
Uln a r Pin Pla t e
■ Th ro u g h a d o rsa l a p p ro a ch , e xp o se a n d re d u ce t h e d o r-
sa l u ln a r co rn e r fra g m e n t , d o rsa l w a ll fra g m e n t , o r b o t h .
■ In se rt a 0.045-in ch Kirsch n e r w ire t h ro u g h t h e fra g m e n t
(TECH FIG 6 A), a n g le d p ro xim a lly a n d slig h t ly ra d ia lly t o
p u rch a se t h e fa r co rt e x o f t h e p ro xim a l fra g m e n t .
■ In se rt st ru ct u ra l b o n e g ra ft in t o t h e m e t a p h yse a l d e fe ct
if p re se n t t o su p p o rt t h e su b a rt icu la r su rfa ce .
■ If t h e p la t e is a lig n e d o ve r t h e u ln a r h a lf o f t h e sh a ft ,
a d d a 15-d e g re e t o rsio n a l b e n d t o t h e p la t e (t w ist t h e
p ro xim a l e n d o f t h e p la t e in t o slig h t su p in a t io n ). Oft e n ,
a lit t le e xt ra e xt e n sio n ca n b e co n t o u re d a t t h e d ist a l e n d
o f t h e p la t e (TECH FIG 6 B).
A C
D E
F co lu mn an d u ln ar co rn er frag me n t).
■ Slid e t h e p la t e o ve r t h e Kirsch n e r w ire a n d fix it p ro xi-
m a lly w it h a 2.3-m m b o n e scre w (TECH FIG 6 C).
■ In se rt a se co n d Kirsch n e r w ire if t h e fra g m e n t is la rg e
e n o u g h . Cre a t e a n d im p a ct h o o ks a s d e scrib e d fo r t h e ra -
d ia l p in p la t e (TECH FIG 6 D–E).
■ If t h e Kirsch n e r w ire t ip s p ro t ru d e b e yo n d t h e vo la r co r-
t e x, t h e y ca n b e cu t flu sh t o t h e b o n e su rfa ce t h ro u g h a
vo la r in cisio n .
Do rsa l Bu t t re ss Pin
■ Th ro u g h a d o rsa l a p p ro a ch , e xp o se a n d re d u ce t h e d o r-
sa l u ln a r co rn e r fra g m e n t , d o rsa l w a ll fra g m e n t , o r
both.
TECH FIG 6 • Uln ar co rn e r fixa tio n w it h an u ln a r p in
p la t e. A. Inse rt ion of t he int erfrag men ta ry Kirschn er
w ire . B. Con to u rin g th e p la te . C. Ap p lica tio n o f t h e
p la te a nd in se rt io n o f t h e in it ia l fixa tion scre w .
D. Fixat io n co m p let ed . E,F. Rad ial and uln a r p in
p la te fixa tion o f a t hre e-p a rt a rt icu la r p a t t e rn (ra d ia l
 Ch a p t e r 8 FRAGM ENT-SPECIFIC FIXATION OF DISTAL RADIUS FRACTURES 81

■ In se rt st ru ct u ra l b o n e g ra ft in t o t h e m e t a p h yse a l d e fe ct t h a n t h e ra d ia l le g so o n e le g ca n b e e n g a g e d a t a

if p re se n t t o su p p o rt t h e su b a rt icu la r su rfa ce .
■ In se rt t w o 0.045-in ch Kirsch n e r w ire s t h ro u g h t h e d o rsa l
co rt e x a n d b e h in d t h e su b ch o n d ra l b o n e ; ch e ck t h e p o si-
t io n w it h t h e C-a rm (TECH FIG 7 A). Th e Kirsch n e r w ire s
sh o u ld b e se p a ra t e d b y a b o u t 1 cm a n d sh o u ld b e t ra n s-
ve rse t o t h e lon g it u d in a l a xis o f t h e sh a ft . In it ia lly p la cin g
a d o rsa l b u t t re ss p in u p sid e -d o w n o n t h e b o n e is h e lp fu l
t o u se a s a t e m p la t e t o visu a lize t h e p ro p e r p o sit io n a n d
in se rt io n a n g le o f t h e Kirsch n e r w ire s (TECH FIG 7 B).
■ En su re t h a t t h e le a d in g t ip s o f t h e le g s o f t h e d o rsa l
b u t t re ss p in a re st ra ig h t a n d cu t t o t h e re q u ire d le n g t h
(TECH FIG 7 C). Le a ve t h e u ln a r le g 2 t o 3 m m lo n g e r
TECHNIQUES
t im e .
■ Pla ce t h e u ln a r le g o f t h e b u t t re ss p in a d ja ce n t t o t h e in -
se rt io n sit e o f t h e u ln a r Kirsch n e r w ire , a n d t h e n w it h -
d ra w t h e Kirsch n e r w ire a n d im m e d ia t e ly e n g a g e t h e le g
in t h e h o le . Re p e a t w it h t h e ra d ia l Kirsch n e r w ire t o e n -
g a g e t h e ra d ia l le g o f t h e b u t t re ss p in . Im p a ct a n d se a t
t h e b u t t re ss p in (TECH FIG 7 D).
■ Fin e -t u n e t h e re d u ct io n a n d co m p le t e t h e fixa t io n p ro x-
im a lly w it h o n e o r t w o 2.3-m m co rt ica l b o n e scre w s a n d
w a sh e rs (TECH FIG 7 E,F). If n e e d e d , a b lo ckin g scre w ca n
b e p la ce d ju st p ro xim a l t o t h e e n d o f t h e b u t t re ss p in t o
p re ve n t sh o rt e n in g o f t h e fra g m e n t .

A B C

D E F

TECH FIG 7 • Do rsa l b u t t re ss p in fixa t io n . A. Th e p o sit io n o f t h e Kirsch n e r w ire s is ch e cke d w it h a C-a rm b e fo re in se rt in g t h e

im p la n t . B. Pla cin g a n im p la n t u p sid e -d o w n o n b o n e t o t e m p la t e t h e t ra je ct o ry o f t h e Kirsch n e r w ire s. C. In se rt in g t h e d o r-
sa l b u t t re ss p in . D. Bu t t re ss p in fixa t io n co m p le t e d . E,F. Fixa t io n o f a t h re e -p a rt a rt icu la r fra ct u re w it h ra d ia l co lu m n a n d
u ln a r co rn e r fra g m e n t w it h ra d ia l co lu m n p la t e a n d d o rsa l b u t t re ss p in .

VOLAR RIM FRAGMENT

Sm a ll-Fra g m e n t Pla t e Fixa t io n a n d st re n g t h t o a llo w d ist a l lo cke d scre w p u rch a se t o o b -
t a in a n g u la r co rre ct io n o f t h e d o rsifle xio n d e fo rm it y.
■ Sm a ll-fra g m e nt vo la r p la t e fixa t io n m a y b e in d ica t e d fo r ■ An a p p ro p ria t e vo la r a p p ro a ch is u se d t o e xp o se t h e
t re a t m e n t o f a vo la r in st a b ilit y p a t t e rn o f t h e vo la r rim .
vo la r rim fra g m e n t . If a sh o rt e n e d ra d ia l co lu m n fra g -
Th e fra g m e n t m u st b e o f a d e q u a t e size t o a llo w b u t t re ss-
m e n t is p re se n t , first re st o re ra d ia l le n g t h a n d p ro visio n -
in g o n t h e vo la r su rfa ce b y t h e p la t e (TECH FIG 8 A,B).
a lly h o ld it w it h a t ra n sst ylo id Kirsch n e r w ire t o u n lo a d
■ If vo la r rim fra g m e n t a t io n is a sso cia t e d w it h a n a xia l in -
t h e lu n a t e fa ce t .
st a b ilit y p a t t e rn , t h e fra g m e n t m u st b e o f a d e q u a t e size
 82 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES
A B
C D
■ Re d u ce t h e vo la r rim fra g m e n t ; t h is sh o u ld re st o re n o r-
m a l ca rp a l a lig n m e n t .
■ Ap p ly a sm a ll-fra g m e n t vo la r p la t e a n d fix it p ro xim a lly
w it h co rt ica l b o n e scre w s. If n e e d e d , se cu re t h e d ist a l
fra g m e n t w it h st a n d a rd o r lo ckin g b o n e scre w s (TECH
FIG 8 C,D).
Vo la r Bu t t re ss Pin Fixa t io n
■ Vo la r b u t t re ss p in fixa t io n is in d ica t e d fo r u n st a b le vo la r
rim fra g m e n t s a n d ca n b e a p a rt icu la rly e ffe ct ive t e ch -
n iq u e w h e n fa ce d w it h sm a ll d ist a l fra g m e n t s o r a xia l in -
st a b ilit y p a t t e rn s o f t h e vo la r rim (d e p re sse d t e a rd ro p
a n g le ; TECH FIG 9 A,B).
■ Use a n a p p ro p ria t e vo la r a p p ro a ch t o e xp o se t h e vo la r
rim fra g m e n t . If n e ce ssa ry, re st o re ra d ia l le n g t h a n d p ro -
visio n a lly h o ld it w it h a t ra n sst ylo id Kirsch n e r w ire t o u n -
lo a d t h e lu n a t e fa ce t (TECH FIG 9 C).
■ Co n t in u e e xp o su re fo r u p t o 1 t o 2 m m b e yo n d t h e d is-
t a l ra d ia l rid g e . Re d u ce t h e vo la r rim fra g m e n t a s m u ch
A B
TECH FIG 9 • Vo la r rim fixa t io n w it h a vo la r b u t t re ss p in . A,B. Art icu la r fra ct u re w it h a xia l in st a b ilit y p a t t e rn o f
vo la r rim . C. In se rt io n o f Kirsch n e r w ire s. (co n t in u e d )
TECH FIG 8 • Vo la r rim fixa t io n
w it h sm a ll-fra g m e n t p la t e . A,B.
Sh e a r fra ct u re o f vo la r rim w it h
vo la r in st a b ilit y p a t t e rn . C,D.
Fixa t io n w it h sm a ll-fra g m e n t
p la t e .
a s p o ssib le a n d n o t e t h e o rie n t a t io n o f t h e t e a rd ro p o n
t h e 10-d e g re e la t e ra l vie w .
■ In se rt t w o 0.045-in ch Kirsch n e r w ire s t ra n sve rse t o o n e
a n o t h e r st a rt in g a t a n e n t ry sit e 1 t o 2 m m b e yo n d t h e
d ist a l ra d ia l rid g e . Th e y sh o u ld b e p la ce d w it h in t h e ce n -
t e r o f t h e t e a rd ro p o n t h e la t e ra l vie w . Co n firm t h e p o -
sit io n o f t h e Kirsch n e r w ire s w it h C-a rm .
■ If necessary, th e vo lar b uttress pin may b e con to ured with
a wire b end er to match the flare o f the volar surface of th e
distal radius. Adjust the trajectory of the legs of the im-
plant to make a 70-degree angle with the base of the wire
form. Cut the legs to appropriate length, leaving the ulnar
leg 2 to 3 mm lo nger than the rad ial leg (TECH FIG 9D,E).
■ No t in g t h e e n t ry sit e o f t h e Kirsch n e r w ire , ca re fu lly re -
m o ve t h e u ln a r Kirsch n e r w ire a n d e n g a g e t h e u ln a r le g
o f t h e vo la r b u t t re ss p in . Re p e a t t h e p ro ce d u re w it h t h e
ra d ia l le g . Im p a ct a n d se a t t h e im p la n t in t o t h e vo la r rim
fra g m e n t (TECH FIG 9 F).
■ Fin e -t u n e t h e re d u ct io n a n d fix it p ro xim a lly w it h a m in -
im u m o f t w o scre w s a n d w a sh e rs (TECH FIG 9 G,H).
C
 Ch a p t e r 8 FRAGM ENT-SPECIFIC FIXATION OF DISTAL RADIUS FRACTURES
D E
G H
FREE ARTICULAR FRAGMENT SUPPORT WITH A BUTTRESS PIN
■ Fre e a rt icu la r fra g m e n t s im p a ct e d in t o t h e m e t a p h yse a l
ca vit y re q u ire b o t h a b u t t re ss t o su p p o rt t h e su b ch o n d ra l
su rfa ce a n d circu m fe re n t ia l p e rip h e ra l co rt ica l st a b ilit y
t o p re ve n t d isp la ce m e n t (TECH FIG 1 0 A).
■ In so m e ca se s, im p a ct e d fre e a rt icu la r fra g m e n t s m a y b e
a d e q u a t e ly su p p o rt e d b y a p ro p e rly a p p lie d lo ckin g
p la t e t h a t p ro vid e s su b ch o n d ra l su p p o rt .
■ An a lt e rn a t ive m e t h o d is t o u se st ru ct u ra l b o n e g ra ft t o
su p p o rt t h e fre e a rt icu la r fra g m e n t in co m b in a t io n w it h
fra g m e n t -sp e cific fixa t io n o f t h e su rro u n d in g co rt ica l
C B
83
TECHNIQUES
F
TECH FIG 9 • (co n t in u e d ) D. Cu t t in g
a n d in se rt in g le g s. E. Re d u ct io n o f
t e a rd ro p . F. Co m p le t e d fixa t io n .
G,H. Vo la r b u t t re ss p in fixa t io n t o
co n t ro l ro t a t io n a l a lig n m e n t o f vo la r
rim fra g m e n t .
sh e ll, re su lt in g in co n t a in m e n t o f t h e g ra ft w it h in t h e
m e t a p h ysis.
■ Th e d o rsa l b u t t re ss p in ca n a lso b e u se d fo r d ire ct su b -
ch o n d ra l su p p o rt o f im p a ct e d a rt icu la r fra g m e n t s. Th e
le g s o f t h e im p la n t a re cu t t o le n g t h a n d in se rt e d
t h ro u g h t h e d o rsa l d e fe ct , slid d ist a lly d ire ct ly b e h in d
t h e a rt icu la r fra g m e n t , a n d t h e n fixe d p ro xim a lly w it h a
scre w a n d w a sh e r (TECH FIG 1 0 B). Th e a rt icu la r fra g -
m e n t is sa n d w ich e d b e t w e e n t h e b a se o f t h e lu n a t e a n d
t h e le g s o f t h e im p la n t (TECH FIG 1 0 C).
TECH FIG 1 0 • A. De p re sse d a r-
t icu la r fra g m e n t . B. Su p p o rt o f
fre e a rt icu la r fra g m e n t w it h a
b u t t re ss p in . C. Do rsa l b u t t re ss
p in t o su p p o rt fra g m e n t fro m
e n d o st e a l su rfa ce .
84 Se c t i o n I HAND, WRIST AND FOREARM
PEARLS AND PITFALLS
De t e rm in in g w h e t h e r a
fra g m e n t is vo la r o r d o rsa l o n
t h e PA vie w
Re d u ct io n o f u n st a b le fra ct u re
p a t t e rn
Wid e n in g o f t h e DRUJ o r
ca rp a l t ra n sla t io n
Sm a ll o r d o rsa lly ro t a t e d vo la r
rim fra gme nt; lo ss of fixa t io n
o f sm a ll vo la r-u ln a r fra g m e n t
Un re co g n ize d ca rp a l lig a m e n t
in ju ry
Co m p lica t io n s
Missed frag me n t: fractu re
d isp la ce m e n t a ft e r su rg e ry
Lo ss o f ra d ia l le n g t h : p ro xim a l
m ig ra t io n o f a rt icu la r su rfa ce
DRUJ d ysfu n ct io n : p a in ,
in st a b ilit y, o r lim it a t io n o f
fo re a rm ro t a t io n
St iffn ess: slo w , restrict ed re tu rn
o f mo vem en t o f w rist , fo rea rm ,
a nd fin gers, ofte n asso cia t e d
w it h p ain
Te n d in it is o r ru p t u re : p a in
w it h re sist e d m o t io n , lo ss o f
t e n d o n fu n ct io n , clickin g a n d
p a in
POSTOPERATIVE CARE
■ At the end of the surgical procedure, confirm the stability of
fixation as well as the stability of the DRUJ.
■ If stable, apply a removable wrist brace and instruct the pa-
tient to initiate gentle range-of-motion exercises of the fingers,
wrist, and forearm twice or more daily as tolerated. For non-
■ Co rre la t e t h e ca rp a l fa ce t h o rizo n w it h t h e la t e ra l vie w t o d e t e rm in e w h e t h e r a fra g m e n t is
d o rsa l o r vo la r.
■ If t h e a rt icu la r su rfa ce is t ilt e d d o rsa lly, t h e ca rp a l fa ce t h o rizo n id e n t ifie s t h e d o rsa l rim .
■ If t h e a rt icu la r su rfa ce is t ilt e d vo la rly, t h e ca rp a l fa ce t h o rizo n id e n t ifie s t h e vo la r rim .
■ Id e n t ify a n d st a rt re d u ct io n w it h t h e fra g m e n t t h a t st a b ilize s t h e ca rp u s t o it s n o rm a l sp a t ia l
re la t io n sh ip . Oft e n , in it ia l re d u ct io n o f t h e ra d ia l co lu m n w it h a p ro visio n a l t ra n sst ylo id
Kirsch n e r w ire w ill re st o re ca rp a l le n g t h . Alt e rn a t ive ly, w h e n t h is fra g m e n t is co m m in u t e d ,
fixa t io n o f t h e vo la r rim is o ft e n su cce ssfu l fo r re d u ct io n o f t h e ca rp u s.
■ Ad d in g st ru ct u ra l b o n e g ra ft , e it h e r t h ro u g h t h e fra ct u re lin e a t t h e b a se o f t h e ra d ia l co lu m n
o r t h ro u g h a d o rsa l d e fe ct , ca n h e lp st a b ilize t h e re d u ct io n d u rin g o p e ra t ive fixa t io n .
■ Ma ke su re t h e d ist a l a rt icu la r fra g m e n t s a re t ra n sla t e d t o w a rd t h e u ln a b e fo re co m p le t in g
vo la r fixa t io n .
■ An e la st ic, slig h t ly o ve rco n t o u re d ra d ia l co lu m n p la t e ca n h e lp clo se sa g it t a l fra ct u re g a p s a n d
se a t t h e sig m o id n o t ch a g a in st t h e u ln a r h e a d .
■ Asse ss t h e clin ica l st a b ilit y o f t h e DRUJ a n d co n sid e r TFCC re p a ir o r su t u re o r fixa t io n o f t h e
u ln a r st ylo id if n e e d e d .
■ En su re a d e q u a t e fixa t io n o f vo la r-u ln a r co rn e r fra g m e n t .
■ Co nsid e r vo la r b utt ress p in fixat io n for an e xtrem e ly d ist a l o r d o rsally ro ta te d vo la r rim fra gme nt .
■ Avo id re le a se o f t h e vo la r w rist ca p su le . Wh e n n e ce ssa ry, t h e le g s o f t h e im p la n t ca n b e
in se rt e d t h ro u g h t h e ca p su le .
■ If n e e d e d , t h e vo la r b u t t re ss p in ca n b e co n t o u re d a s n e e d e d t o m a t ch t h e a rc o f cu rve o f t h e
fla re o f t h e vo la r sh a ft .
■ Ma in t a in a h ig h in d e x o f su sp icio n fo r lig a m e n t o u s in ju rie s o f t h e ca rp u s. Co n sid e r a rt h ro sco p ic
e va lu a t io n , p a rt icu la rly in t h e co n t e xt o f ra d ia l o r d o rsa l sh e a r fra ct u re s, ca rp a l a vu lsio n a n d
in st a b ilit y p a t t e rn s, o r a rt icu la r fra ct u re s a sso cia t e d w it h a sig n ifica n t lo n g it u d in a l st e p o ff
b e t w e e n t h e sca p h o id a n d lu n a t e fa ce t s.
■ Ca re ful a n a lysis o f rad io g ra p h ic fe a t u re s b o t h b efo re a n d d u rin g re d u ct io n ; CT sca n w hen nee ded
■ Pre o p e ra t ive p la n n in g t o se le ct a p p ro a ch e s t h a t a llo w co m p le t e visu a liza t io n o f a ll m a jo r
fra g m e n t s
■ Co m p le t e se t o f im p la n t s a n d in st ru m e n t s a va ila b le b e fo re su rg e ry
■ Gra ft t h e m e t a p h yse a l d e fe ct w h e n n e e d e d w it h st ru ct u ra l b o n e g ra ft .
■ Use im p la n t s t h a t b u t t re ss t h e su b ch o n d ra l b o n e .
■ Asse ss clin ica l st a b ilit y o f DRUJ a t e n d o f p ro ce d u re .
■ Use ra d ia l co lu m n p la t e t o p u sh d ist a l fra g m e n t a g a in st u ln a t o se a t sig m o id n o t ch a g a in st
u ln a r h e a d .
■ Eva lu a t e a n d re p a ir TFCC a n d ca p su la r t e a rs w h e n n e ce ssa ry.
■ Re d u ce a n d fix u ln a r co rn e r a n d vo la r rim fra g m e n t s t o re st o re co n g ru it y o f sig m o id n o t ch .
■ En su re t h a t ra d ia l le n g t h is re st o re d .
■ Early rang e of m ot ion a nd m obilizat ion o f soft t issues
■ Avo id a n ce o f co n st rict in g b a n d a g e s a n d p o st o p e ra t ive sw e llin g
■ Use im p la n t s t h a t h a ve a lo w d ist a l p ro file .
■ Avo id p la cin g sh a rp , b u lky e d g e s o f h a rd w a re in p ro xim it y t o t e n d o n s.
■ Co ve r p la t e s d ist a lly w it h re t in a cu la r fla p w h e n n e e d e d .
■ Co n sid e r u se o f b u t t re ss p in s (w h ich h a ve a ve ry lo w p ro file ) w h e n p o ssib le .
■ Re m o ve a n y p in s o r h a rd w a re t h a t b a ck o u t o r b e co m e p ro m in e n t p o st o p e ra t ive ly.
■ En su re t h a t vo la r p la t e s d o n o t e xt e n d u p b e yo n d d ist a l vo la r rid g e in t o so ft t issu e s.
■ Avo id lo n g scre w s o r p in s, p a rt icu la rly w h e n p la ce d fro m vo la r t o d o rsa l. Dist a l scre w s sh o u ld
n o rm a lly b e 2 t o 4 m m sh y o f t h e d o rsa l co rt ica l m a rg in .
compliant patients or injuries with tenuous fixation, use a cast
for 2 to 3 weeks postoperatively.
■ Avoid resistive loading across the wrist until signs of radi-
ographic healing are present; typically this occurs by 4 weeks
postoperatively. Specifically instruct older patients not to push
up out of a chair or lift heavy objects after surgery.
 Ch a p t e r 8 FRAGM ENT-SPECIFIC FIXATION OF DISTAL RADIUS FRACTURES
■ If there is persistent stiffness after 4 weeks, initiate physical
and occupational therapy.
OUTCOMES
■ Konrath and Bahler 4 reported 27 patients with at least 2 years
of follow-up:
■ O ne fracture lost reduction.
■ Patient satisfaction was high (average DASH scores 17
and PRWE scores 19 at follow-up).
■ In only three cases was hardware removed; no tendon
ruptures occurred.
■ Schnall et al7 reported on two groups of patients: group I
had sustained high-energy trauma and group II had lower-
energy injuries.
■ Group I patients averaged return to work in 6 weeks, with
all fractures uniting without loss of position or deformity.
■ Two patients in group I required removal of painful
hardware.
■ Group II patients averaged 2 degrees of loss of volar tilt,
a 0.3-mm change in ulnar variance, and no loss of joint con-
gruity at follow-up.
■ Grip strength in group II patients was 67% of the con-
tralateral side.
■ Benson et al2 reported on 85 intra-articular fractures in 81
patients with a mean follow-up of 32 months.
■ There were 64 excellent and 24 good results, with an av-
erage DASH score of 9 at final follow-up.
■ Flexion and extension motion was 85% and 91% of the
opposite side at final follow-up.
■ Grip strength was 92% of the opposite side at final
follow-up.
■ Sixty-two percent of patients had a 100-degree arc of
flexion–extension and normal forearm rotation by 6 weeks
postoperatively.
■ Postoperative radiographic alignment was maintained at
follow-up.
■ There were no cases of symptomatic arthritis.
COMPLICATION S
■ Stiffness: common early, uncommon at follow-up
■ Recovery can be accelerated by anatomic fixation that is
stable enough to start motion immediately after surgery.
The relative degree of trauma to the bone and soft tissues,
combined with underlying physiologic factors, is also a crit-
ical factor that can lead to slow recovery of motion or resid-
ual stiffness.
■ M alunion or nonunion: rare
■ Loss of reduction may occur, particularly if a major frac-
ture component is missed and left untreated. In addition,
85
osteoporosis, failure to graft the metaphyseal defect, and
associated DRUJ injuries may contribute to loss of reduc-
tion or malunion.
■ Pin plates are able to resist translational displacements
but are less effective for preventing loss of length; they re-
quire osseous contact between the proximal and distal frag-
ments or additional support by a secondary implant that
will buttress the subchondral surface.
■ N onunions are extremely rare.
■ Tendinitis or tendon rupture: uncommon
■ If pins are noted postoperatively to back out, they should
be removed. Leaving the distal 1 cm of tendon sheath of the
first dorsal compartment intact helps avoid tendon contact
with hardware.
■ Using low-profile implants dorsally, covering the distal
ends with a strip of retinacular sheath, or both is also helpful.
■ The surgeon should avoid leaving screws or pins protrud-
ing from the dorsal or volar surfaces of the bone.
■ Painful hardware: rare
■ Painful hardware can be related to migration of a pin or
settling of the fracture proximally. O verbending pin hooks
and using bone graft or buttressing implants can help avoid
this problem.
■ Remove hardware when painful.
■ Late arthritis is uncommon and probably related to the
quality of the articular restoration.
■ Infections, bleeding, carpal tunnel syndrome, and other nerve
injuries are uncommon and often related to the primary injury.
■ Complex regional pain syndrome is rare and may be related
to initiation of early motion after surgery.
REFEREN CES
1. Barrie K, Wolfe S. Internal fixation for intraarticular distal radius
fractures. Tech H and Up Extrem Surg 2002;6:10–20.
2. Benson LS, M inihane KP, Stern LA, et al. The outcome of intra-
articular distal radius fractures treated with fragment-specific
fixation. J H and Surg Am 2006;31A:1333–1339.
3. Fernandez DL, Jupiter JB. Fractures of the Distal Radius, 2nd ed.
Springer, 2001:42–50.
4. Konrath G, Bahler S. O pen reduction and internal fixation of unsta-
ble distal radius fractures: results using the TriM ed system. J O rthop
Trauma 2002;16:578–585.
5. Leslie BM , M edoff RJ. Fracture-specific fixation of distal radius frac-
tures. Tech O rthop 2000;15:336–352.
6. M edoff R. Essential radiographic evaluation for distal radius frac-
tures. H and Clin 2005;21:279–288.
7. Schnall S, Kim B, Abramo A, et al. Fixation of distal radius fractures
using a fragment specific system. Clin O rthop Relat Res 2006;445:
51–57.
8. Swigart C, Wolfe S. Limited incision open techniques for distal radius
fracture management. O rthop Clin N orth Am 2001;30:317–327.
 Br id g e Pla t in g o f Dis t a l Ra d iu s
Ch a p t e r 9 Fr a ct u re s
Pau l A . M art in e au , Ke vin J. M alo n e , an d Do u g las P. Han e l
DEFIN ITION
■ H igh-energy fractures of the distal aspect of the radius with
extensive comminution of the articular surface and extension
into the diaphysis represent a major treatment challenge.
Standard plates and techniques may be inadequate for the
management of such fractures.
■ Before the introduction of the bridge plating technique,
treatment of these injuries was limited to cast immobilization
or external fixation with or without Kirschner wire augmenta-
tion. Both of these methods are associated with unacceptably
high complication rates.
AN ATOMY
■ The articular surface of the distal radius is tilted 21 degrees
in the anteroposterior plane and 5 to 11 degrees in the lateral
plane.
■ The dorsal cortex surface of the radius thickens to form the
tubercle of Lister.
■ A central ridge divides the articular surface of the radius
into a scaphoid facet and a lunate facet.
■ Because of the different areas of bone thickness and density,
fractures tend to occur in the relatively weaker metaphyseal
bone and propagate intra-articularly between the scaphoid
and lunate facets.
■ The degree, direction, and magnitude of applied load may
cause coronal or sagittal splits within the lunate or scaphoid
facets.
PATHOGEN ESIS
■ Two subsets of patients with distal radius fractures continue
to represent unique treatment challenges:
■ Patients with high-energy wrist injuries with fracture ex-
tension into the radial diaphysis
■ Patients with multiple injuries who require load bearing
through the injured wrist to assist with mobilization and
nursing care
N ATURAL HISTORY
■ Lafontaine et al13 showed that the end results of commin-
uted distal radius fractures treated by closed methods resem-
bled the prereduction radiographs more than any other radi-
ographs during treatment, even when the reduction success-
fully restored wrist anatomy.
■ A number of studies clearly show that restoration of normal
anatomy after distal radius fracture provides better func-
tion. 4,6–8,10–12,14
■ Functional outcome scores in patients without anatomic re-
duction are poor.4,15
■ M alunion of the distal radius has been associated with
pain, stiffness, weak grip strength, and carpal instability in
a substantial percentage of patients. 8 Long-term conse-
86
quences include degenerative arthritis in up to 50% of pa-
tients with even minimal displacement in the young adult
population. 16
■ As surgical treatment (plating in particular) ensures more
consistent correction of displacement and maintenance of re-
duction, there has been a trend toward operative treatment in
both the elderly and the young population.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ In the management of high-energy distal radius fractures, a
complete history should include the mechanism of injury.
These fractures are commonly the result of axial loading as
opposed to the bending forces, which are all low-velocity
fractures.
■ Examination of the soft tissue envelope of the wrist should
be performed to rule out open fractures.
■ Because of the high-energy nature of these fractures, patients
are at increased risk of neurovascular compromise. Careful ex-
amination for signs of impending compartment syndrome as
well as median nerve dysfunction from an acute carpal tunnel
syndrome should be clearly documented.
■ Associated injuries should be ruled out, and appropriate pa-
tient clearance according to advanced trauma life support
guidelines should be obtained.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Good-quality pre- and post-reduction wrist radiographs
should be obtained preoperatively to assess the fracture pat-
tern and rule out associated injuries to the carpus or distal ra-
dioulnar joint (DRUJ).
■ CT scans may be helpful to assess complex intra-articular
distal radius fractures.
N ON OPERATIVE MAN AGEMEN T
■ There is no acceptable nonoperative management for high-
energy comminuted distal radius fractures.
SURGICAL MAN AGEMEN T
■ The use of internal distraction plating or bridge plating for
distal radius fractures was introduced by Burke and Singer.3
The technique was expanded by Ruch et al,17 who described
the use of a 12- to 16-hole 3.5-mm plate dynamic compression
plate (DCP) (Synthes, Paoli, PA) placed in the floor of the
fourth dorsal extensor compartment to span from the intact
radius diaphysis to the third metacarpal.5,17
■ The bridge plating technique provides strong fixation and
allows for distraction across impacted articular segments.
■ The technique can be combined with a limited articular
fixation approach for fracture patterns with intra-articular
extension.
 Ch a p t e r 9 BRIDGE PLATING OF DISTAL RADIUS FRACTURES 87

In d ica t io n s f o r Br id g e Pla t in g
Ta b le 1 o f Dis t a l Ra d iu s Fr a ct u r e s

In d ica t io n Ex p la n a t io n
Metadiaphyseal comminution Extensive comminution in metadia-
of the radius physeal region is difficult to treat with
standard implants used for distal
radius fractures.
Need for weight bearing through Patients with associated lower limb
the upper extremity injuries may require the need for
early weight bearing through the
upper extremities.
Polytrauma Nursing care of the multiply injured
patient may be easier with spanning
internal fixation than with external
fixation.
Augmented fixation In osteoporotic bone, bridge plating
can be used to augment tenuous
fixation.
Carpal instability Carpal instability, particularly radio- FIG 1 • Se t u p fo r t h is p ro ce d u re , w it h lo n g it u d in a l t ra ct io n a p -
carpal, isolated or in combination p lie d t h ro u g h fin g e r t ra p s a n d t h e C-a rm co m in g in fro m a b o ve
with a distal radius fracture, may be o r b e lo w t h e h a n d t a b le .
held in a reduced position with the
help of spanning internal fixation.
Positioning
■ With the patient anesthetized and supine on the operating
table, the involved extremity is draped free and centered on a
■ Bridge plating of the distal radius was further refined by radiolucent hand table.
H anel et al.9 The authors described a variant of the bridge ■ Finger traps are applied to the index and middle fingers and

plating technique using 2.4-mm AO plates passed extra-artic- 4.5 kg of longitudinal traction is applied through a rope and
ularly through the second dorsal compartment and secured pulley system.
onto the dorsal-radial aspect of the radius diaphysis and the ■ A C-arm comes in from above or below the hand table

second metacarpal (Table 1). (FIG 1 ).

Preoperative Planning Approach
■ A 22-hole 2.4-mm titanium mandibular reconstruction ■ Under image intensification, the closed reduction maneuver
plate (Synthes, Paoli, PA) or a 2.4-mm stainless steel plate described by Agee1 is performed.
specifically designed for use as a distal radius bridge plate ■ Plates are passed extra-articularly through the second dorsal

(DRB plate, Synthes, Paoli, PA) is used for distal radius compartment and secured onto the dorsal-radial aspect of the
bridge plating. radius diaphysis and the second metacarpal.
■ The mandibular reconstruction plate is made of titanium ■ The interval between the extensor carpi radialis longus

and has square ends and scalloped edges and threaded holes to (ECRL) and brevis (ECRB) is developed and the diaphysis of
accept locking screws. The DRB plate that the authors cur- the radius exposed.
rently use is made of stainless steel and has tapered ends to fa- ■ The DRB plate is introduced beneath the muscle bellies of

cilitate sliding the plate within the extensor compartment; it the outcroppers extraperiosteally and advanced distally be-
also has locking screws. tween the ECRL and ECRB tendons.
TECHNIQUES
CLOSED REDUCTION MANEUVER OF AGEE
■ Lo n g it u d in a l t ra ct io n is first u se d t o re st o re le n g t h a n d
t o a sse ss t h e b e n e fit o f lig a m e n t o t a xis fo r t h e re st o ra -
t io n o f a rt icu la r st e p o ff (TECH FIG 1 A,B).
■ Ne xt , t h e h a n d is t ra n sla t e d p a lm a rly re la t ive t o t h e fo re -
a rm t o re st o re sa g it t a l t ilt a n d t o a sse ss t h e in t e g rit y o f
t h e vo la r lip o f t h e ra d iu s (TECH FIG 1 C–F).
■ Fin a lly, p ro n a t io n o f t h e h a n d re la t ive t o t h e fo re a rm is
p e rfo rm e d t o co rre ct t h e su p in a t io n d e fo rm it y.
■ On ce t h e in it ia l re d u ct io n m a n e u ve r is co m p le t e d , t h e
b rid g e p la t e is t h e n a p p lie d .

TECH FIG 1 • Ra d io g ra p h s sh o w a n AP p ro je ct io n o f t h e
w rist in ju ry b e fo re (A) a n d a ft e r (B) d ist ra ct io n is a p p lie d .
(co n t in u e d ) A B
 88 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES

C D

E F

TECH FIG 1 • (cont inued) Clin ica l p ict u re s sh o w t h e w rist d e fo rm it y b e fo re (C) a n d a ft e r (D) a p p lica t io n o f t h e Ag e e re -
d u ct io n m a n e u ve r, w h ich is a co m b in a t io n o f lo n g it u d in a l t ra ct io n a n d vo la r t ra n sla t io n o f t h e ca rp u s. Ra d io g ra p h s
sh o w t h e w rist d e fo rm it y b e fo re (E) a n d a ft e r (F) a p p lica t io n o f t h e Ag e e re d u ct io n m a n e u ve r.

APPROACH AND PLATE INSERTION

■ Th e DRB p la t e is su p e rim p o se d o n t h e skin fro m t h e ra -
d ia l d ia p h ysis t o t h e d ist a l m e t a d ia p h ysis o f t h e se co n d
m e t a ca rp a l. Th e p o sit io n o f t h e p la t e is ve rifie d w it h
im a g e in t e n sifica t io n a n d m a rkin g s a re p la ce d o n t h e
skin a t t h e le ve l o f t h e p ro xim a l a n d d ist a l fo u r scre w
h o le s o f t h e p la t e (TECH FIG 2 A–C).
■ Th e su b cu t a n e o u s t issu e s a re in filt ra t e d w it h 0.25%
b u p iva ca in e w it h e p in e p h rin e t o p ro m o t e h e m o st a sis.
■ A 5-cm in cisio n is m a d e a t t h e b a se o f th e se co n d
me t a carpa l a nd con tin u ed a lo ng t h e se con d m e t acarp al
sh a ft . In the de pth s of th is incisio n , th e in se rt io n s o f t h e
ECRL an d ECRB a re ide ntified as t hey pa ss b enea th t he dis-
ta l ed g e of t h e se con d do rsa l wrist co m p art me nt t o in se rt
o n t h e seco nd an d third m e t a ca rp a l ba se s re sp e ct ively.
■ A se co n d in cisio n is m a d e ju st p ro xim a l t o t h e o u t cro p -
p e r m u scle b e llie s (a b d u ct o r p o llicis lo n g u s a n d e xt e n -
so r p o llicis b re vis), in lin e w it h ECRL a n d ECRB t e n d o n s.
Th e in t e rva l b e t w e e n t h e ECRL a n d ECRB is d e ve lo p e d
a n d t h e d ia p h ysis o f t h e ra d iu s e xp o se d (TECH FIG
2 D,E).
■ The DRB plat e is in troduced ben eat h th e mu scle bellies o f
th e o u t cro p p e rs e xt ra p erio ste ally a n d ad va n ce d dist ally
b e t we en t he ECRL an d ECRB t e n d o n s (TECH FIG 2F).
■ So m e re sist a n ce m a y b e e n co u n t e re d a s t h e p la t e
e m e rg e s d ist a lly b u t ca n u su a lly b e e a sily o ve rco m e w it h
g e n t le m a n ip u la t io n o f t h e p la t e (TECH FIG 2G).
■ Occa sio n a lly, t h e p la t e w ill n o t p a ss t h ro u g h t h e co m -
p a rt m e n t . In t h e se ca se s, a g u id e w ire o r st o u t su t u re

A B
TECH FIG 2 • A. Th e p la t e is p la ce d
o ve r t h e fo re a rm a n d h a n d .
Ra d io g ra p h s ca n b e t a ke n t o co n firm
t h e p o sit io n o f t h e p la t e . Th e p la t e
sh o u ld b e ce n t e re d o ve r t h e se co n d
m e t a ca rp a l d ist a lly a n d t h e ra d iu s
p ro xim a lly. Th is w ill b e a lo n g t h e
co u rse o f t h e e xt e n so r ca rp i ra d ia lis
lo n g u s (ECRL). B. Ou t lin e o f t h e
p la t e . C. In cisio n s a re m a d e o ve r t h e
se co n d m e t a ca rp a l a n d t h e ra d iu s.
C (cont inued)
 Ch a p t e r 9 BRIDGE PLATING OF DISTAL RADIUS FRACTURES
D E
F
H I
re t rie ve r is p a sse d a lo n g t h e co m p a rt m e n t fro m d ist a l
t o p ro xim a l. Th e p la t e is se cu re d t o t h e d ist a l e n d o f
t h e w ire a n d d e live re d in t o t h e h a n d .
■ In th e ra re in st an ce t h at t h ese m easu res fail, a t h ird in -
cisio n is m a d e d ire ct ly o ve r t h e me ta p h ysis o f t h e ra -
PLATE FIXATION AND ARTICULAR FIXATION
■ Aft e r t h e b rid g e p la t e is p a sse d , it is t h e n se cu re d t o t h e
se co n d m e t a ca rp a l b y p la cin g a n o n lo ckin g fu lly
t h re a d e d 2.4-m m co rt ica l scre w t h ro u g h t h e m o st d ist a l
p la t e h o le . Th e p ro xim a l e n d o f t h e p la t e is t h e n id e n t i-
fie d in t h e fo re a rm .
■ If t he radial lengt h has not be en re st ored, th en the p la te ,
se cu re d to t h e se co n d m e t a ca rp a l, is p u sh e d d ist a lly u n t il
t h e len g t h is reest ab lish ed an d a fu lly th rea d ed 2.4-m m
n onlocking screw is p la ce d in t h e m o st p roxim al p la te
h ole. By using n o n lo ckin g scre w s t h e plat e is effe ct ive ly
lagge d on to the int act b one.
89
TECHNIQUES
G
TECH FIG 2 • (co n t in u e d ) D. Th e ECRL a n d e x-
t e n so r ca rp i ra d ia lis b re vis (ECRB) t e n d o n s ju st
p ro xim a l t o t h e a b d u ct o r p o llicis lo n g u s in t h e
fo re a rm . E. De ve lo p m e n t o f t h e in t e rva l b e -
t w e e n t h e ECRL a n d ECRB t e n d o n s t o g a in a c-
ce ss t o t h e ra d iu s sh a ft . F. Th e p ro xim a l a sp e ct
o f t h e p la t e o ve r t h e ra d iu s a n d in b e t w e e n t h e
ECRL a n d ECRB. It is im p o rt a n t t o e n su re t h a t
t h e p la t e ru n s w it h in t h e se co n d co m p a rt m e n t
a n d n o t su p e rficia l t o t h e first a n d t h ird co m -
p a rt m e n t t e n d o n s. G. Th e p la t e is a d va n ce d
p ro xim a l t o d ist a l a n d e m e rg e s d ist a lly o ve r t h e
se co n d m e t a ca rp a l. H. A t h ird in cisio n is m a rke d
o u t ju st u ln a r t o t h e t u b e rcle o f List e r. I. Th e e x-
t e n so r p o llicis lo n g u s t e n d o n h a s b e e n re le a se d
fro m it s co m p a rt m e n t , a n d b o n e g ra ft is in -
se rt e d t h ro u g h t h e d o rsa l fra ct u re lin e ju st
u ln a r t o t h e b rid g e p la t e .
d iu s, th e p ro xim al h alf o f t h e seco n d co m p artm en t is
incise d, and t he p la te is passed un der direct vision.
■ Th e t h ird , o r p e ria rt icu la r, in cisio n m a y a lso b e u se d t o
a sse ss t h e a rt icu la r su rfa ce , re d u ce d ie -p u n ch fra g m e n t s,
a n d in t ro d u ce b o n e g ra ft (TECH FIG 2 H,I).
■ Pla t e a lig n m e n t a lo n g t h e lo n g it u d in a l a xis o f t h e ra d iu s
is g u a ra n t e e d b y se cu rin g t h e m o st d ist a l a n d m o st p ro x-
im a l scre w h o le s first .
■ Th e re m a in in g h o le s a re se cu re d w it h fu lly t h re a d e d
lo ckin g scre w s in se rt e d w it h b ico rt ica l p u rch a se .
■ It has b een ou r exp erience th at as th e p late is p assed alo ng
th e ra dial diap hysis, th ro ugh the seco n d co mpartment and
along the second met acarpal, extra-articular alignment ,
ra d ial in clina tion , volar t ilt, a n d ra d ia l le ng th a re re store d.
■ In t ra -a rt icu la r re d u ct io n m a y b e fu rt h e r a d ju st e d b y
u sin g lim it e d p e ria rt icu la r in cisio n s t o a llo w fo r d ire ct
 90 Se c t i o n I HAND, WRIST AND FOREARM

m a n ip u la t io n o f a rt icu la r fra g m e n t s, p la ce m e n t o f su b - rig id it y is d ire ct ly p ro p o rt io n a l t o h o w clo se t h e lo n g i-

TECHNIQUES

ch o n d ra l b o n e g ra ft s, re p a ir o f in t e rca rp a l lig a m e n t in - t u d in a l fixa t o r b a r is t o t h e b o n e a n d t h e fra ct u re . A

ju rie s, a n d a u g m e n t a t io n o f fra ct u re fixa t io n w it h
Kirsch n e r w ire s a n d p e ria rt icu la r p la t e s.
■ Disp la ce d vo la r m e d ia l fra ct u re fra g m e n t s t h a t a re n o t
re d u ce d w it h t h is t e ch n iq u e re q u ire a se p a ra t e vo la r in -
cisio n a n d a p p ro p ria t e b u t t re ss su p p o rt .
■ Th e b io m e ch a n ica l st a b ilit y o f sp a n n in g p la t e s is st ro n g
a n d p re d ict a b le . Be h re n s e t a l, 2 st u d yin g t h e rig id it y o f
e xt e rn a l fixa t o r co n fig u ra t io n s, d e m o n st ra t e d t h a t
b rid g e p la t e , re st in g d ire ct ly a g a in st t h e ra d iu s p ro xi-
m a lly a n d m e t a ca rp a ls d ist a lly, t h e re fo re o p t im ize s
t h e co n d it io n s t o o b t a in t h e st ro n g e st p o ssib le fixa t o r
co n st ru ct .
■ A DRB p la t e fixe d w it h a m in im u m o f t h re e scre w s a t e i-
t h e r e n d o f t h e p la t e co n fe rs sig n ifica n t ly m o re st a b ilit y
t h a n w o u ld a n e xt e rn a l fixa t o r u se d t o st a b ilize a co m p a -
ra b le fra ct u re (TECH FIG 3 ).18

A B C

TECH FIG 3 • Fin a l AP (A), o b liq u e (B), a n d la t e ra l (C) ra d io g ra p h ic im a g e s.

DISTAL RADIOULNAR JOINT MANAGEMENT

■ DRUJ st a b ilit y is a sse sse d a ft e r ra d iu s re co n st ru ct io n . If
t h e DRUJ is st a b le , t h e lim b is im m o b ilize d in a lo n g -a rm
sp lin t w it h t h e fo re a rm in su p in a t io n fo r t h e first 10 t o
14 d a ys p o st o p e ra t ive ly.
■ If t he DRUJ is u nst able, a n d t h ere are no co n t rain dica tion s
to p rolong in g the op e rat ion , re pa ir o r re con stru ctio n o f
DRUJ a n d t ria n g u la r fib ro ca rt ila g e co m p le x is u n d e rt a ke n .
■ If h o w e ve r, t h e p a t ie n t ’s co n d it io n d o e s n o t a llo w t h e
o p e ra t io n t o b e p ro lo n g e d , t h e u ln a r h e a d is re d u ce d
m a n u a lly in t o t h e sig m o id n o t ch a n d t h e u ln a is t ra n s-
fixe d t o t h e ra d iu s w it h a m in im u m o f t w o 1.6-m m
Kirsch n e r w ire s p a sse d p ro xim a l t o t h e DRUJ.

PEARLS AND PITFALLS

Ha rd w a re re m o va l
■ At t h e t im e o f h a rd w a re e xt ra ct io n , if a m a n d ib u la r re co n st ru ct io n p la t e w a s u se d , t h e scre w s a re re -
m o ve d a n d t h e p la t e is t w ist e d a xia lly 720 d e g re e s t o b re a k u p t h e so ft t issu e a d h e sio n s a n d ca llu s t h a t
t e n d t o g ro w a ro u n d a n d o n t o t h e sca llo p e d e d g e s o f t h e t it a n iu m p la t e . Th is m a n e u ve r is n o t u su a lly
re q u ire d w h e n t h e sm o o t h -e d g e d st a in le ss st e e l DRB is u se d .
■ A re m o va b le sh o rt -a rm sp lin t is w o rn fo r 2 t o 3 w e e ks a ft e r p la t e re m o va l. Ha n d t h e ra p y a t t h is p o in t
is d ire ct e d a t re g a in in g m o t io n a n d st re n g t h .

POSTOPERATIVE CARE eratively the platform is removed and weight bearing is al-
■ Digit range-of-motion exercises start within 24 hours of lowed through the hand grip of regular crutches. Lifting and
surgery. Load bearing through the forearm and elbow is al- carrying are restricted to about 4.5 kg until fracture healing.
lowed immediately, as well as the use of a platform crutch ■ DRUJ stability and forearm motion are assessed 2 weeks

when the patient is physiologically stable. O ne month postop- after reduction. If the patient can supinate the forearm with lit-
 Ch a p t e r 9 BRIDGE PLATING OF DISTAL RADIUS FRACTURES
tle effort and the DRUJ is stable, then splinting is discontinued
and axial loading through the extremity is allowed at this
point.
■ If the patient has difficulty maintaining supination, or if the
DRUJ was reconstructed acutely, a removable long-arm splint
is fabricated.
■ If the DRUJ was transfixed with Kirschner wires, then the
wires are removed on the third postoperative week and DRUJ
stability is reassessed.
■ Supplemental Kirschner wires for articular fixation are re-
moved 6 weeks postoperatively.
■ The DRB plate and screws are removed usually no earlier
than 12 weeks after injury.
OUTCOMES
■ The bridge plating technique for distal radius fractures was
reviewed in a retrospective study consisting of 62 consecutive
patients treated in this fashion. 9 The series represents the se-
nior author’s 10-year experience with the technique at a Level
1 trauma center. Patients managed with bridge plating either
for distal radius fractures with extensive metadiaphyseal com-
minution or for distal radius fractures associated with other
injuries requiring weight bearing through the affected extrem-
ity represented 13% of distal radius fractures treated with op-
erative fixation during this period. Fracture healing occurred
in all 62 patients.
■ In each case radial length was within 5 mm of neutral
ulnar variance, radial inclination was greater than 5 degrees,
and palmar tilt was at least neutral.
■ There were also no articular gaps or stepoffs greater than
2 mm and the DRUJ was stable in all cases.
■ The plates were removed on average 112 days after
placement.
■ Forty-one of the 62 patients have returned to their previ-
ous levels of employment. O f the remaining 21 patients, 8
were unemployed at the time of injury and remain so.
■ Thirteen patients sustained multiple injuries requiring
considerable changes in occupation and lifestyle. O nly 1 of
these 13 patients considers the wrist fracture to be the lim-
iting factor in failing to return to work.
■ O verall these results compare favorably with the findings
of Burke and Singer 3 and Ruch et al.17
■ Similarly, Ruch et al17 showed that 64% of patients ob-
tained excellent radiographic and functional results and an-
other 27% of patients obtained good results in their prospec-
tive cohort of patients with comparable pathology.
■ The authors of each of these studies propose that distraction
plating allows fracture reduction and fixation over a broad
metadiaphyseal area while effectively diverting compression
forces away from the fracture site.
■ The use of bridge plating in the treatment of distal radius
fractures avoids the complications of external fixation. A
bridge plate can remain implanted for extended periods with-
out deleterious effects on functional outcome. All patients in
our series went on to heal with acceptable metadiaphyseal and
intra-articular alignment. In patients with multiple traumatic
injuries, bridge plating allowed earlier postoperative load
bearing across the affected wrist. This enabled independent
transfers and the use of ambulatory aids. Application of bridge
plates is simple and surgical time is comparable with the appli-
cation of an external fixator.
91
COMPLICATION S
■ There was one documented hardware failure in the series in
a patient who initially refused to have the implant taken out
and continued to work in heavy manual labor for 19 months
before the bridge plate failed.
■ In addition, there were no cases of excessive postoperative
finger stiffness or reflex sympathetic dystrophy.
■ This reflects the overall infrequent complications reported in
the literature for bridge plating of the distal radius. In fact,
Burke and Singer 3 reported no complications, and Ruch et al17
reported no hardware failures and only three patients who de-
veloped long finger extensor lag of 10 to 15 degrees.
REFEREN CES
1. Agee JM . Distal radius fractures: multiplanar ligamentotaxis. H and
Clin 1993;9:577–585.
2. Behrens F, Johnson W. Unilateral external fixation: methods to in-
crease and reduce frame stiffness. Clin O rthop Relat Res 1989;241:
48–56.
3. Burke EF, Singer RM . Treatment of comminuted distal radius with
the use of an internal distraction plate. Tech H and Up Extrem Surg
1998;2:248–252.
4. Drobetz H , Bryant AL, Pokorny T, et al. Volar fixed-angle plating of
distal radius extension fractures: influence of plate position on
secondary loss of reduction: a biomechanic study in a cadaveric
model. J H and Surg Am 2006;31A:615–622.
5. Ginn TA, Ruch DS, Yang CC, et al. Use of a distraction plate for dis-
tal radial fractures with metaphyseal and diaphyseal comminution: sur-
gical technique. J Bone Joint Surg Am 2006;88A(Suppl 1 Pt 1):29–36.
6. Gradl G, Jupiter JB, Gierer P, et al. Fractures of the distal radius
treated with a nonbridging external fixation technique using multi-
planar K-wires. J H and Surg Am 2005;30A:960–968.
7. Graff S, Jupiter J. Fracture of the distal radius: classification of treat-
ment and indications for external fixation. Injury 1994;25(Suppl 4):
14–25.
8. Handoll HH, M adhok R. Surgical interventions for treating distal
radial fractures in adults. Cochrane Database Syst Rev 2003(3):
CD003209.
9. H anel DP, Lu TS, Weil WM . Bridge plating of distal radius frac-
tures: the H arborview method. Clin O rthop Relat Res 2006;445:
91–99.
10. H astings H II, Leibovic SJ. Indications and techniques of open reduc-
tion: internal fixation of distal radius fractures. O rthop Clin N orth
Am 1993;24:309–326.
11. Kamath AF, Z urakowski D, Day CS. Low-profile dorsal plating for
dorsally angulated distal radius fractures: an outcomes study. J H and
Surg Am 2006;31:1061–1067.
12. Konrath GA, Bahler S. O pen reduction and internal fixation of unsta-
ble distal radius fractures: results using the Trimed fixation system.
J O rthop Trauma 2002;16:578–585.
13. Lafontaine M , H ardy D, Delince P. Stability assessment of distal ra-
dius fractures. Injury 1989;20:208–210.
14. M cQ ueen M M . N on-spanning external fixation of the distal radius.
H and Clin 2005;21:375–380.
15. M cQ ueen M M , Simpson D, Court-Brown CM . Use of the H offman
2 compact external fixator in the treatment of redisplaced unstable
distal radial fractures. J O rthop Trauma 1999;13:501–505.
16. O rbay JL, Touhami A. Current concepts in volar fixed-angle fixation
of unstable distal radius fractures. Clin O rthop Relat Res 2006;445:
58–67.
17. Ruch DS, Ginn TA, Yang CC, et al. Use of a distraction plate for dis-
tal radial fractures with metaphyseal and diaphyseal comminution. J
Bone Joint Surg Am 2005;87A:945–954.
18. Wolf JC, Weil WM , H anel DP, et al. A biomechanic comparison of
an internal radiocarpal-spanning 2.4-mm locking plate and external
fixation in a model of distal radius fractures. J H and Surg Am
2006;31:1578–1586.
 Op e n Re d u ct io n a n d In t e r n a l
Fix a t io n o f Uln a r St y lo id ,
Ch a p t e r 10 He a d , a n d M e t a d ia p h y s e a l
Fr a ct u re s
To m m y Lin d au an d A n d re w J. Lo g an

DEFIN ITION PATHOGEN ESIS

■ The distal ulna is the fixed point 3 around which the radius ■ Isolated ulnar fractures most commonly occur when the
and the hand function (FIG 1 A). forearm is struck by an object, explaining the eponym “ night-
■ Fractures of the distal ulna are often inadequately treated in stick fracture.”
comparison to its larger counterpart, the radius (FIG 1 B,C). ■ Distal ulnar fractures are most often due to a fall on an out-

■ The current literature gives little guidance as to the manage- stretched hand.
ment of these fractures and associated injuries. ■ It is a common understanding that ulnar-sided injuries are

more often caused by falls backward in which the forearm is

AN ATOMY in supination, loading the ulnar side of the distal forearm and
■ The ulnar head forms the fixed point on which the hand and wrist and causing distal ulnar fractures, triquetral chip frac-
radius rest 3 (FIG 2 A). tures, TFCC injuries, and so forth.
■ The radius rotates around the ulnar head through the distal ■ In contrast, radial-sided injuries are more often caused by

radioulnar joint (DRUJ) during forearm pronation and supina-
tion. 3,4
■ This joint is connected to the carpus by a complicated liga-
ment apparatus, the triangular fibrocartilage complex (TFCC).
■ The stability of the DRUJ is achieved through bony con-
gruity between the sigmoid notch of the radius and the ulnar
head supported by the ulnoradial ligaments1,4 (FIG 2 B).
■ The spheres of the two articular surfaces differ (FIG 2 C).
falls forward, loading the radial side of the forearm and
wrist and causing scaphoid fractures, distal radius fractures,
and so forth.
N ATURAL HISTORY
■ M any distal ulnar fractures leave only marginal long-term
problems.
■ Some distal ulnar malunions cause DRUJ incongruency with

■ Sixty percent of the joint surfaces are in contact in neutral subsequent instability or blocked forearm rotation (FIG 3 ). This
forearm position.1 is why management of these deceptive fractures is important.
■ In full pronation and supination there is only 10% bony

contact.1 IMAGIN G AN D OTHER DIAGN OSTIC

■ The ligaments run from the fovea of the ulnar head and STUDIES
the base of the ulnar styloid to the dorsal and palmar edges ■ Posteroanterior, lateral, and oblique radiographs typically
of the sigmoid notch on the distal radius1,9 (Fig 2B). reveal the pathology.

A B C

FIG 1 • A. Th e d ist a l u ln a is t h e fixe d p o in t u p o n w h ich p e rfo rm a n ce o f m o st d a ily h a n d a ct ivit ie s d e p e n d s.

B,C. Fra ct u re s o f t h e d ist a l u ln a a re o ft e n n e g le ct e d in co m p a riso n t o t h o se o f it s la rg e r co u n t e rp a rt , t h e ra d iu s,
w h ich a lw a ys a t t ra ct s a t t e n t io n a n d t re a t m e n t e ffo rt s. Th e o u t co m e a ft e r d ist a l fo re a rm fra ct u re s co u ld b e im -
p ro ve d if t h e fixe d p o in t —t h e d ist a l u ln a —is a d d re sse d su rg ica lly a t t h e sa m e t im e a s t h e ra d iu s is o p e ra t e d o n .

92
 Ch a p t e r 1 0 ORIF OF ULNAR STYLOID, HEAD, AND M ETADIAPHYSEAL FRACTURES 93

Radio-ulnar
ligament

Radius Ulna

Radius Ulna
A C

FIG 2 • A. Th e d ist a l u ln a is t h e fixe d p o in t a ro u n d w h ich t h e ra d iu s ro t a t e s in p ro n a t io n a n d su p in a -

t io n . Th ro u g h t h e u ln o ca rp a l lig a m e n t t h e d ist a l u ln a re la t e s t o t h e h a n d , a llo w in g d a ily h a n d a ct ivit ie s.
B. Th e d ist a l ra d io uln a r jo in t is st a b le b e ca u se o f b o n y co n g ru it y b e t w e e n t h e u ln a r h e a d a n d t h e sig -
m o id n o t ch o n t h e ra d iu s. Th e u ln o ra d ia l lig a m e n t in se rt s in t h e fo ve a a n d t h e b a se o f t h e u ln a r st ylo id
a n d h a s a d o rsa l a n d p a lm a r lig a m e n t a t t a ch e d t o t h e d o rsa l a n d p a lm a r p a rt o f t h e sig m o id n o t ch re -
sp e ct ive ly. Th e y a ct a s re in s in t h e p ro n a t io n a n d su p in a t io n m o t io n . C. Th e sp h e re s o f t h e t w o a rt icu la r
su rfa ce s d iffe r: t h e cu rva t u re o f t h e u ln a r h e a d h a s a sh o rt e r ra d iu s, w h e re a s t h e cu rva t u re o f t h e sig -
m o id n o t ch h a s a gre a t e r ra d iu s.

A B C

FIG 3 • A,B. Ra d io g ra p h s sh o w in g a d ist a l ra d iu s fra ct u re t o g e t h e r w it h a n u ln a r h e a d a n d st ylo id

fra ct u re . Th e co m p le xit y o f t h e u ln a r-sid e d in ju ry w a s u n d e ra p p re cia t e d . C. In t ra o p e ra t ive flu o ro -
sco p ic im a g e a ft e r fixa t io n o f t h e d ist a l ra d iu s fra ct u re , re ve a lin g d isp la ce d a n d u n st a b le u ln a r
fra ct u re s. (co n t in u e d )
 94 Se c t i o n I HAND, WRIST AND FOREARM

D E F G

FIG 3 • (co n t in u e d ) D,E. Th e d ist a l ra d iu s fra ct u re w a s st a b ilize d u sin g a vo la r lo ckin g p la t e . Th e u ln a r h e a d a n d st y-

lo id fra ct u re s w e re p a rt ia lly re d u ce d a n d fixe d w it h t w o Kirsch n e r w ire s. Th e su rg e o n a d e q u a t e ly se cu re d t h e u ln a r
st ylo id fra ct u re b u t n o t t h e u ln a r h e a d fra ct u re a n d p o st o p e ra t ive ly d id n o t re st rict fo re a rm ro t a t io n . F,G. Th e se ra -
d io g ra p h s re ve a l t h e e ve n t u a l u ln a r h e a d m a lu n io n t h a t re su lt e d in d ist a l ra d io u ln a r jo in t in st a b ilit y a n d d im in ish e d
fo re a rm ro t a t io n . Th e sit u a t io n w a s sa lva g e d u sin g a n u ln a r h e a d re p la ce m e n t p ro st h e sis.

■ CT is useful in examining articular fractures of the ulnar head. ulnoradial ligament insertion site around the fovea of the ulnar
■ M RI is sometimes needed to evaluate the integrity of the head at the base of the styloid (FIG 6 A).
TFCC. ■ Generally, ulnar styloid fractures should be operated on if

■ Arthroscopy should be considered if a radiograph leads the the fracture is at the base of the ulnar styloid and is dis-
physician to suspect DRUJ dissociation without radiographic placed more than 2 mm 11 (FIG 6 B,C).
explanations, such as a displaced ulnar styloid base fracture. ■ Radial translation of the fractured ulnar styloid is caused

by the detachment of the ulnoradial ligament. This increases

SURGICAL MAN AGEMEN T
Findings and Indications
DRUJ Dissociation
■ Radiographs occasionally reveal DRUJ dissociation in the
absence of an ulnar-sided fracture (FIG 4 ). This results from
detachment of the ulnoradial ligament 8 (FIG 5 A).
■ Such ulnoradial ligament injuries have been found to cause
DRUJ laxity and a worse outcome after distal radius frac-
tures in patients without osteoporosis7 (FIG 5 B).
■ Arthroscopically assisted repair or open repair and reat-
the indication (FIG 6 D) more than axial, distal fracture dis-
placement (detaching the ulnotriquetral collateral ligament).
■ Ulnar styloid fractures at the tip are likely to be stable
and do not require fixation, as the ulnoradial ligament re-
mains attached to the ulnar head at the base of the styloid
(FIG 6 E,F).
■ Ulnar-sided injuries associated with distal radius fractures
should be carefully assessed radiographically and clinically
after open reduction and internal fixation (O RIF) of the radius
fracture.
■ Ulnar fracture reduction and DRUJ joint stability are

tachment of the ulnoradial ligament to the fovea of the ulnar often improved after treatment of the radius fracture.
head are required to restore stability in the DRUJ (FIG 5 C) ■ Stable DRUJ means that the ulnoradial ligament is not at-

(see Chap. H A-49). tached to the fractured ulnar styloid and therefore can be
treated nonoperatively.
Ulnar Styloid Fractures ■ Unstable DRUJ indicates that the ulnoradial ligament is
■ The importance of ulnar styloid fractures and the need detached w ith the styloid fracture. The styloid should be re-
for operative intervention depends on the involvement of the duced and stabilized or the ligament reattached.

FIG 4 • A. An u n d isp la ce d d ist a l ra d iu s fra ct u re

w it h n o o b vio u s d ist a l u ln a p a t h o lo g y. B. Th e sa m e
fra ct u re w it h a st re ss t e st t o t h e d ist a l ra d io u ln a r
jo in t (DRUJ), a n d a n o b vio u s DRUJ d isso cia t io n is
se e n a s a sig n o f a co m p le t e u ln o ra d ia l lig a m e n t
d e t a ch m e n t in t h e a b se n ce o f a n u ln a r st ylo id
A B fra ct u re .
 Ch a p t e r 1 0 ORIF OF ULNAR STYLOID, HEAD, AND M ETADIAPHYSEAL FRACTURES 95

A B C

FIG 5 • A. Art h ro sco p ic vie w o f a n u ln o ra d ia l (p e rip h e ra l t ria n g u la r fib ro ca rt ila g e co m p le x) d e t a ch m e n t . Th e lu n a t e

is se e n a t t h e t o p , t h e ra d iu s b e lo w , a n d t h e d e t a ch e d su rfa ce w it h b le e d in g a t t h e rig h t sid e . B. Dist a l ra d io u ln a r
jo in t d isso cia t io n a ft e r a d ist a l ra d iu s fra ct u re w it h a co m p le t e d e t a ch m e n t o f t h e u ln o ra d ia l lig a m e n t in t h e a b se n ce
o f a n y u ln a r-sid e d fra ct u re . C. Art h ro sco p ic vie w o f a n a rt h ro sco p ica lly a ssist e d re p a ir a n d re a t t a ch m e n t o f a n
a vu lse d u ln o ra d ia l lig a m e n t . Th e lu n o t riq u e t ra l in t e rva l is se e n o n t o p , t h e ra d iu s jo in t su rfa ce is se e n in t h e lo w e r
le ft co rn e r, a n d t h e b lu e su t u re s a re b rin g in g d o w n t h e lig a m e n t t o w a rd t h e fo ve a o f t h e u ln a r h e a d , w h ich is n o t
se e n a rt h ro sco p ica lly.

A B C

D E F
FIG 6 • A. Th e u ln o ra d ia l lig a m e n t h a s su p e rficia l a n d d e e p e r co m p o n e n t s, w h ich in se rt a t t h e fo ve a o f
t h e u ln a r h e a d a n d p a rt ly a t t a ch t o t h e b a se o f t h e u ln a r st ylo id . Co n se q u e n t ly, a fra ct u re a t t h e b a se o f
t h e u ln a r st ylo id m a y o r m a y n o t d e t a ch t h e m a in d ist a l ra d io u ln a r jo in t -st a b ilizin g lig a m e n t . B,C. Uln a r
st ylo id fra ct u re s a t t h e b a se m a y d e t a ch t h e u ln o ra d ia l lig a m e n t a n d sh o u ld b e o p e ra t e d o n if t h e y a re
d isp la ce d m o re t h a n 2 m m .11 D. Ra d ia l d isp la ce m e n t (d e t a ch in g t h e u ln o ra d ia l lig a m e n t ) in cre a se s t h e
in d ica t io n fo r su rg ica l t re a t m e n t . E,F. Uln a r st ylo id t ip fra ct u re s re p re se n t a vu lsio n fra ct u re s fro m t h e
u ln o t riq u e t ra l co lla t e ra l lig a m e n t . Th e y d e m a n d n o fu rt h e r t re a t m e n t .
96 Se c t i o n I HAND, WRIST AND FOREARM

A B C D

FIG 7 • A,B. Ab u t m e n t o f t h e u ln a r st ylo id in t o t h e t riq u e t ru m o n t h e u ln a r sid e o f t h e ca rp u s. C,D. An u ln a r st ylo id n o n u n io n

ca u sin g p ro b le m s a s a lo o se b o d y.

Ulnar Styloid Nonunion Ulnar Head Fractures

■ The main physical findings of ulnar styloid nonunion are ■ Ulnar head fractures are most often associated with distal
ulnar-sided wrist pain worse with loading in rotation and radius fractures, and the pattern of the distal radius fracture
tenderness over the ulnar styloid. 5 Symptoms from an ulnar will have a strong influence on the overall functional outcome.
styloid nonunion are related to the following: ■ Ulnar head fractures are seen either alone or with involve-

■ DRUJ instability from a malfunctioning ulnoradial liga- ment of extra-articular portions of the distal ulna, proximally
ment (peripheral TFCC detachment)5 (Fig 5B) toward the diaphysis or distally including the styloid (Fig 3A,B).
■ Impingement of the overlying extensor carpi ulnaris

(ECU) tendon Distal Ulnar Neck and Shaft Fractures

■ Abutment on the carpus5 (FIG 7 A,B) ■ A distal ulnar neck or distal shaft fracture is a fracture that oc-
■ Soft tissue irritation from the loose body (FIG 7 C,D) curs within 4 cm of the distal dome of the ulnar head (FIG 8A–D).

A B C D

FIG 8 • A,B. Th is u ln a r sh a ft fra ct u re is b y d e fin it io n w it h in 4 cm o f t h e d ist a l d o m e o f t h e u ln a r h e a d .

C,D. Th is u ln a r sh a ft fra ct u re is m o re p ro xim a l a n d sh o u ld b e co n sid e re d a n iso la t e d u ln a r fra ct u re .
Ho w e ve r, t h e re m a y st ill b e in vo lve m e n t in t h e d ist a l ra d io u ln a r jo in t (DRUJ), w h ich n e e d s t o b e t a ke n in t o
a cco u n t . Th e DRUJ sh o u ld b e e xa m in e d fo r st a b ilit y a ft e r o p e n re d u ct io n a n d in t e rn a l fixa t io n . (co n t in u e d )
 Ch a p t e r 1 0 ORIF OF ULNAR STYLOID, HEAD, AND M ETADIAPHYSEAL FRACTURES
E F
■ Some distal ulnar fractures in association with distal radius
fractures realign after manipulation and are considered to be
stable once the radius is reduced. 10
■ It is difficult to immobilize unstable fractures with a cast
alone. Three-point fixation, even in an above-elbow cast, is
not effective (FIG 8 E,F).
Comminuted Intra-Articular Distal Ulnar Fractures
■ Comminuted distal ulnar fractures that are irreducible and
cannot be reconstructed have been mentioned in the literature
in only one case report.2
INCISION AND EXPOSURE
■ Ap p ro a ch t h e d ist a l u ln a t h ro u g h a d o rsa l zig za g in cisio n
ce n t e re d o ve r t h e DRUJ (TECH FIG 1 AB).
■ Th is a p p ro a ch a llo w s re a t t a ch m e n t o f a ll cru cia l st a b i-
lizin g st ru ct u re s a t t h e t im e o f w o u n d clo su re .
■ Ca re fu lly p ro t e ct t h e d o rsa l se n so ry b ra n ch e s o f t h e
u ln a r n e rve (TECH FIG 1 C).
■ In cise t h e re t in a cu lu m o ve rlyin g t h e fift h e xt e n so r co m -
p a rt m e n t (TECH FIG 1 D).
A B
97
FIG 8 • (co n t in u e d ) E,F. Un st a b le d ist a l ra d iu s a n d u ln a r
fra ct u re s a re d ifficu lt t o im m o b ilize w it h ca st s a lo n e . AP
a n d la t e ra l vie w s sh o w co m m in u t io n a n d d o rsa l d isp la ce -
m e n t in b o t h fra ct u re s. Th is fra ct u re ca n n o t b e t re a t e d
co n se rva t ive ly.
■ It is generally recommended that the initial approach be
geared toward restoring the anatomy and maintaining the
overall alignment of the ulna and DRUJ.
Approach
■ The described approach is used for all distal ulnar fractures,
including the ones extending into the neck of the ulna and into
the distal shaft.
■ This approach can, for instance, access an ulnar styloid frac-
ture or nonunion and at the same time visualize, assess, and
allow treatment of any associated TFCC pathology.
TECHNIQUES
■ Ele va t e t h e u ln a r re t in a cu la r fla p in t h e in t e rva l b e t w e e n
t h e e xt e n so r re t in a cu lu m a n d t h e se p a ra t e d o rsa l sh e e t
fo r t h e ECU t e n d o n .
■ Pre se rve t h e in t e g rit y o f t h e se p a ra t e ECU co m p a rt -
m e n t (TECH FIG 1 E).
■ Op e n t h e d o rsa l ca p su le o f t h e DRUJ u sin g a n u ln a rly
b a se d fla p ra ise d fro m t h e 4–5 se p t u m (TECH FIG 1 F).
■ Id e n t ify t h e 4–5 in t e rco m p a rt m e n t a l a rt e ry.
TECH FIG 1 • Su rg ica l a p p ro a ch t o a ll d ist a l u ln a r
fra ct u re s. A,B. A d o rsa l zig za g in cisio n is m a d e w it h
t h e ce n t e r d ire ct e d t o w a rd t h e d ist a l ra d io u ln a r
jo in t . (co n t in u e d )
 98 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES

C D F

Radius
Ulna

Retinacular
flap

Compartment VI

Compartment V
E opened G

TECH FIG 1 • (co n t in u e d ) C. Su b cu t a n e o u s d isse ct io n sh o u ld b e p e rfo rm e d so t h a t t h e d o rsa l cu t a n e o u s b ra n ch fro m

t h e u ln a r n e rve is p ro t e ct e d . D. Th e re t in a cu lu m is id e n t ifie d a n d a n a p p ro a ch t h ro u g h t h e fift h e xt e n so r co m p a rt m e n t
is d o n e . E. Th e re t in a cu lu m is e le va t e d a s a n u ln a rly b a se d fla p b e t w e e n t h e t ru e re t in a cu lu m a n d t h e se p a ra t e d o rsa l
sh e e t fo r t h e e xt e n so r ca rp i u ln a ris (ECU) t e n d o n (w h ich sh o u ld b e p re se rve d ). Th e ECU is t h e re b y ke p t in it s t e n d o n
sh e a t h . F. An u ln a rly b a se d ca p su la r fla p is ra ise d fro m t h e 4–5 se p t u m t o g a in a cce ss t o t h e d ist a l u ln a . G. As sh o w n
in t h is d isse ct e d sp e cim e n , t h e u ln o ca rp a l jo in t is o ft e n h id d e n b e h in d t h e syn o viu m o ve r t h e m e n iscu s h o m o lo g .
(C,D: Co u rt e sy o f M. Ga rcia -Elia s, Sp a in .)

■ Be g in t h e ca p su la r in cisio n a t t h e n e ck o f t h e u ln a a n d ■ Th e DRUJ a n d t h e sp a n n in g TFCC a re t h e n re a d ily visu a l-

e xt e n d it t o t h e 4–5 in t e rco m p a rt m e n t a l a rt e ry, w h ich is
d ia t h e rm ie d .
■ Th e in cisio n co n t in u e s a lo n g t h is lin e t o t h e le ve l o f t h e
ra d io ca rp a l jo in t , w h e re it t h e n e xt e n d s d ist a lly a n d
u ln a rly a lo n g t h e d o rsa l ra d io t riq u e t ra l lig a m e n t t o t h e
t riq u e t ru m .
■ By st a yin g in a fla t la ye r a lo n g t h e d o rsa l co rt e x o f t h e
ra d iu s, t h e d o rsa l u ln o ra d ia l lig a m e n t a t t a ch m e n t is
n o t vio la t e d .
ize d . Th e u ln o ca rp a l jo in t is o ft e n h id d e n b e h in d t h e syn -
o viu m o ve r t h e m e n iscu s h o m o lo g (TECH FIG 1 G).
■ If re q u ire d , re m o ve t h e syn o viu m d o rsa l t o t h e u ln o -
ra d ia l lig a m e n t t o g a in a cce ss t o t h e u ln a r st ylo id a n d
t h e u ln o ca rp a l jo in t .
■ In ca se s o f a d ist a l n e ck fra ct u re w it h o u t a n y in t ra -
a rt icu la r in vo lve m e n t o r so ft t issu e co m p o n e n t s, t h e
a p p ro a ch st a ys p ro xim a l t o t h e ca p su la r fla p . Ho w e ve r,
t h e re t in a cu la r fla p n e e d s t o b e ra ise d t o a d d re ss t h e
d ist a l m e t a p h yse a l fra ct u re s.

ULNAR STYLOID FRACTURES

■ Op t io n s fo r fixa t io n o f u ln a r st ylo id b a se fra ct u re s in - ■ Te n sio n b a n d w irin g (TECH FIG 2 C)
clu d e t h e fo llo w in g : ■ Wire lo o p o r su t u re
■ Sin g le o r d o u b le Kirsch n e r w ire s (TECH FIG 2 A,B) ■ Scre w fixa t io n (TECH FIG 2 D)
 Ch a p t e r 1 0 ORIF OF ULNAR STYLOID, HEAD, AND M ETADIAPHYSEAL FRACTURES 99

TECHNIQUES
A B C D

TECH FIG 2 • Th e u ln a r st ylo id ca n b e fixe d in va rio u s w a ys t o se cu re re a t t a ch m e n t o f t h e u ln o ra d ia l lig a m e n t a n d t h e re b y

st a b ilize t h e d ist a l ra d io u ln a r jo in t . A,B. Sin g le (n o t ro t a t io n a lly st a b le ) o r d o u b le Kirsch n e r w ire s. C. Te n sio n b a n d w irin g .
D. Scre w fixa t io n (n o t ro t a t io n a lly st a b le ).

ULNAR STYLOID NONUNIONS

■ Re a t t a ch m e n t o f t h e n o n u n it e d fra g m e n t t o t h e u ln a r
h e a d is in d ica t e d if t h e fra g m e n t is la rg e .5
■ If t h e fra g m e n t is sm a ll, it sh o u ld b e e xcise d a n d t h e u l-
n o ra d ia l lig a m e n t re a t t a ch e d d ire ct ly t o t h e fo ve a o f t h e
u ln a r h e a d .5
■ If t h e fra g m e n t is sm a ll a n d lo ca t e d d ist a lly a n d t h e re is
n o DRUJ in st a b ilit y, t h e u ln a r st ylo id ca n b e e xcise d w it h -
o u t a n y a sso cia t e d lig a m e n t p ro ce d u re .5

ULNAR HEAD FRACTURES

■ Uln a r h e a d fra ct u re s w it h o u t a p ro xim a l e xt ra -a rt icu la r
co m p o n e n t
■ Fract u res th at are d isp laced (w it h a n in t ra -a rt icu lar
st ep off) o r un st ab le are t re at ed w ith ORIF usin g b u ried
h eadle ss co mp re ssion scre w s6 o r Kirsch n er w ire s.
■ Im m o b iliza t io n a ft e r fixa t io n d e p e n d s o n t h e st a b ilit y
o f t h e fra ct u re a n d it s fixa t io n .
■ Uln a r h e a d fra ct u re s w it h a p ro xim a l e xt ra -a rt icu la r
co m p o n e n t
■ Th e in t ra -a rt icu la r co m p o n e n t is re d u ce d a n d st a b i-
lize d .
■ If t h e e xt ra -a rt icu la r co m p o n e n t e xt e n d s p ro xim a lly
t o w a rd t h e n e ck o f t h e d ist a l u ln a a co n d yla r b la d e
p la t e is re co m m e n d e d (TECH FIG 3 ), w h e re a s t e n sio n
b a n d w irin g is re co m m e n d e d if t h e e xt ra -a rt icu la r
co m p o n e n t in vo lve s t h e u ln a r st ylo id (Te ch Fig 2C).
■ Im m o b iliza t io n a ft e r fixa t io n d e p e n d s o n t h e st a b ilit y
o f t h e fra ct u re a n d it s fixa t io n .

TECH FIG 3 • Irre d u cib le o r u n st a b le d ist a l fo re -

a rm fra ct u re s re q u ire o p e n re d u ct io n a n d in t e r-
n a l fixa t io n . 10 AP a n d la t e ra l ra d io g ra p h s sh o w
a d o rsa lly d isp la ce d d ist a l fo re a rm fra ct u re fixe d
A B w it h a b la d e p la t e .
 100 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES

DISTAL ULNAR NECK AND SHAFT FRACTURES

■ Irre d u cib le o r u n st a b le fra ct u re s re q u ire ORIF.10
■ Th is ca n b e a ch ie ve d u sin g e it h e r a co n d yla r b la d e
p la t e 10 (Te ch Fig 3) o r t e n sio n b a n d w irin g su p p le m e n t e d
b y in t ra fra g m e n t a ry scre w s (TECH FIG 4 ).

A B C

TECH FIG 4 • A,B. AP a n d la t e ra l ra d io g ra p h s sh o w a d o rsa lly d isp la ce d d ist a l fo re a rm fra ct u re . Op e n re d u ct io n

a n d in t e rn a l fixa t io n w a s p e rfo rm e d u sin g b o t h a d o rso ra d ia l a n d a d o rso u ln a r a p p ro a ch t o st a b ilize t h e fra c-
t u re s. C. Be ca u se o f t h e co m m in u t io n a ro u n d t h e u ln a r st ylo id b a se , fixa t io n w a s a ch ie ve d w it h a su t u re lo o p .

COMMINUTED INTRA-ARTICULAR DISTAL ULNAR FRACTURES

■ Th re e t re a t m e n t o p t io n s e xist fo r co m m in u t e d in t ra - ro t a t io n t h a t m a y n o t b e co rre ct e d w it h a la t e sa l-
a rt icu la r d ist a l u ln a r fra ct u re s: va g e p ro ce d u re .
■ Re st o ra t io n o f t h e a n a t o m y a n d o ve ra ll a lig n m e n t o f ■ Prim a ry d ist a l u ln a r h e a d re p la ce m e n t 2
t h e u ln a a n d DRUJ a s m e n t io n e d a b o ve ■ Th e t h e o re t ica l a d va n t a g e is re d u ce d st iffn e ss (fro m

■ Th is ca n b e a cco m p lish e d w it h m a n ip u la t io n a n d h a vin g e a rly m o ve m e n t ) a n d le ss DRUJ p a in .

a b o ve -e lb o w ca st im m o b iliza t io n a lo n e o r a lt e rn a - ■ To t a l o r p a rt ia l e xcisio n o f t h e u ln a r h e a d a s w e ll a s
t ive ly b y su rg ica l m e a n s w it h t e m p o ra ry w irin g o r e x- DRUJ a rt h ro d e sis w it h d ist a l u ln a r n e ck re se ct io n
t e rn a l fixa t io n . (Sa u ve -Ka p a n d ji p ro ce d u re )
■ Th e p o t e n t ia l p ro b le m s w it h t h is m a n a g e m e n t

t e ch n iq u e a re w rist st iffn e ss a n d re d u ce d fo re a rm

POSTOPERATIVE CARE ■The outcome can surely be improved if distal ulnar frac-
tures are treated more directly and aggressively.
■ Stable fixation of the distal ulnar complex still requires pro- ■ The outcome will also improve if the relationship between
tection postoperatively with a below-elbow splint.
■ Intermediate stable fixation requires 4 weeks of protection
the ulnar styloid and the ulnoradial ligament is fully under-
stood and addressed.
using a sugartong-type splint to allow flexion and extension of
the elbow but protect against uncontrolled pronation and
supination.
COMPLICATION S
■ Unstable fixation after internal, external, or nonoperative ■ Stiffness of the DRUJ with limited pronation and supination
treatment requires above-elbow protection in neutral forearm ro- ■ Infection
tation to limit movement for the first 6 weeks. There is otherwise ■ N onunion
a risk that rotational forces will cause a nonunion or malunion. ■ M alunion

OUTCOMES REFEREN CES

■ O utcome is influenced by the fact that most distal ulnar 1. af Ekenstam F, H agert CG. Anatomical studies on the geometry and
fractures are neglected in comparison to the more common stability of the distal radio ulnar joint. Scand J Plast Reconstr Surg
and more extensively treated distal radius fractures. 1985;19:17–25.
 Ch a p t e r 1 0 ORIF OF ULNAR STYLOID, HEAD, AND M ETADIAPHYSEAL FRACTURES
2. Grechenig W, Peicha G, Fellinger M . Primary ulnar head prosthesis
for the treatment of an irreparable ulnar head fracture dislocation.
J H and Surg Br 2001;26B:269–271.
3. H agert CG. The distal radioulnar joint in relation to the whole fore-
arm. Clin O rthop Relat Res 1992;275:56–64.
4. H agert CG. Current concepts of the functional anatomy of the distal
radioulnar joint, including the ulnocarpal junction. In: Büchler U, ed.
Wrist Instability. Berlin: M artin Dunitz, 1996:15–21.
5. H auck RM , Skahen III J, Palmer AK. Classification and treatment of
ulnar styloid nonunion. J H and Surg Am 1996;21A:418–422.
6. Jakab E, Ganos DL, Gagnon S. Isolated intra-articular fractures of
the ulnar head. J O rthop Trauma 1993;7:290–292.
7. Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of the tri-
angular fibrocartilage complex cause distal radioulnar instability
after distal radius fractures. J H and Surg Am 2000;25A:464–468.
101
8. Lindau T, Arner M , H agberg L. Intraarticular lesions in distal frac-
tures of the radius in young adults: a descriptive arthroscopic study
in 50 patients. J H and Surg Br 1997;22B:638–643.
9. Palmer AK, Werner FW. The triangular fibrocartilage complex
of the wrist: anatomy and function. J H and Surg Am 1981;6A:
153–162.
10. Ring D, M cCarty PL, Campbell D, et al. Condylar blade plate fixa-
tion of unstable fractures of the distal ulna associated with fractures
of the distal radius. J H and Surg Am 2004;29A:103–109.
11. M ay M M , Lawton JN , Blazar PE. Ulnar styloid fractures associ-
ated with distal radius fractures: incidence and implications
for distal radioulnar joint instability. J H and Surg Am 2002;
27A:965–971.
 Pe rcu t a n e o u s Fix a t io n o f
Ch a p t e r 11 Acu t e Sca p h o id Fr a ct u re s
Pe t e r J.L. Je b so n , Jan e S. Tan , an d A n d re w W o n g
DEFIN ITION
■ Located in the proximal carpal row, the scaphoid serves as
an important link between the proximal and distal carpal
rows. It is the most commonly fractured carpal bone, account-
ing for about 1 in every 100,000 emergency room visits.12
■ There are about 345,000 scaphoid fractures annually in the
United States.
■ A scaphoid fracture classically occurs in a young, active
adult due to a fall onto an outstretched hand.
■ The H erbert classification categorizes scaphoid fractures
into acute stable, acute unstable, delayed union, and estab-
lished nonunion patterns.
AN ATOMY
■ The scaphoid has a complex three-dimensional geometry
that has been described as a “ twisted peanut.” 8 Anatomically
the scaphoid is organized into proximal pole, waist, and distal
pole regions.
■ The scaphoid articulates with the radius, lunate, capitate,
trapezium, and trapezoid; thus, its surface is almost completely
covered with hyaline cartilage. This feature has several impor-
tant implications, including articular disruption during wire or
screw insertion, paucity of vascular supply, and the absence of
periosteum.
■ Lacking periosteum, the scaphoid heals almost completely
by primary bone healing, resulting in minimal callus and a
biomechanically weak early union.17
■ Blood supply comes from branches of the radial artery
that enter the scaphoid via two main routes7 :
■ A dorsal branch, which enters the scaphoid via the dor-
sal ridge, provides the primary supply and 70% to 80%
of the overall vascularity, including the entire proximal
pole (via retrograde endosteal branches).
■ A volar branch, which enters through the tubercle, sup-
plies 20% to 30% of the internal vascularity, all in the
distal pole.
■ The precarious blood supply contributes to the high inci-
dence of nonunion after a fracture at the scaphoid waist or
proximal pole. It also places the proximal pole at risk for the
development of avascular necrosis.
PATHOGEN ESIS
■ The typical mechanism of injury involves a fall onto the wrist.
Studies have demonstrated that wrist extension of more than 95
degrees combined with more than 10 degrees of radial deviation
is required for a scaphoid fracture to occur. In this position, the
scaphoid abuts the distal radius, resulting in fracture.
■ Seventy to 80% of scaphoid fractures occur at the waist re-
gion, while 10% to 20% involve the proximal pole and 5%
occur at the distal pole and tuberosity.
■ In children, the most common location for a scaphoid frac-
ture is the distal pole. 2
102
N ATURAL HISTORY
■ The true natural history of an untreated scaphoid fracture is
unknown due to limitations in the existing literature, particu-
larly with respect to study design.11 H owever, several retro-
spective studies have suggested that if a nonunion occurs, a
predictable pattern of wrist arthritis develops usually within
10 years of the injury.14,16
■ Unrecognized, untreated, or inadequately treated scaphoid
fractures have an increased likelihood of nonunion and sec-
ondary carpal instability. A fracture through the proximal pole
has the highest likelihood of nonunion, followed by a fracture
of the scaphoid waist.
■ If the scaphoid fracture is unstable, extension forces at the
proximal fragment (via the lunate and scapholunate ligament)
and flexion forces at the distal fragment result in a flexion
(“ humpback” ) deformity of the scaphoid.
■ This loss of scaphoid support results in carpal instability,
most frequently a dorsal intercalated segment instability
(DISI) pattern, which eventually leads to arthritis as previ-
ously described.
■ The overall incidence of nonunion after fracture of the
scaphoid waist region is about 5% to 10% .13
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ A patient with an acute or subacute scaphoid fracture pre-
sents with radial-sided wrist pain, swelling, and loss of mo-
tion, particularly with dorsiflexion.
■ Classic physical examination findings include:
■ Edema over the dorsoradial aspect of the wrist
■ Tenderness to palpation between the first and third dor-
sal compartments (the “ anatomic snuffbox” )
■ Tenderness with palpation volarly over the distal tubercle
■ Pain with axial compression of the wrist (scaphoid com-
pression test)
■ Acutely, swelling and ecchymoses over the volar radial
wrist
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Initial imaging studies for a suspected scaphoid fracture
should include a posteroanterior (PA) view with the wrist in
ulnar deviation, semipronated and semisupinated 45-degree
oblique views, and a lateral view.
■ The PA ulnar deviation view produces scaphoid exten-
sion, permitting visualization of the entire scaphoid.
■ The semipronated view permits visualization of the waist
and distal-third regions.
■ The semisupinated view provides visualization of the dor-
sal ridge.
■ The lateral view can demonstrate a waist fracture, fracture
displacement and angulation, and overall carpal alignment.
 Ch a p t e r 1 1 PERCUTANEOUS FIXATION OF ACUTE SCAPHOID FRACTURES
■ Displaced and unstable fractures are defined by the follow-
ing criteria:
■ At least 1 mm of displacement
■ M ore than 10 degrees of angular displacement
■ Fracture comminution
■ Radiolunate angle of more than 15 degrees
■ Scapholunate angle of more than 60 degrees
■ Intrascaphoid angle of more than 35 degrees
■ CT scan is helpful in identifying and characterizing an acute
fracture and evaluating for a nonunion. Thin 1-mm cuts are
obtained in the sagittal and coronal planes.
■ M RI is useful for diagnosing an occult fracture and, when
combined with gadolinium administration, can be used to as-
sess the vascularity of the proximal pole and the presence of
avascular necrosis.
■ Technetium bone scan has been shown to be up to 100%
sensitive in identifying occult fractures but lacks specificity. It
is optimally used 48 hours after injury.
DIFFEREN TIAL DIAGN OSIS
■ Scapholunate injury
■ Wrist sprain
■ Wrist contusion
■ Fracture of other carpal bones
■ Distal radius fracture
N ON OPERATIVE MAN AGEMEN T
■ N onoperative management, specifically cast immobi-
lization, is indicated for a nondisplaced, acute (less than
4 weeks from injury) fracture of the distal pole. For a nondis-
placed, acute waist fracture, there is debate regarding the
preferred treatment approach—cast immobilization or surgi-
cal stabilization.
■ With cast immobilization, there is no consensus regarding the
preferred position of the wrist, the need to immobilize other
joints besides the wrist, and the duration of immobilization.4
■ Clinical studies have demonstrated no benefit with thumb
immobilization, nor any influence of wrist position on the
rate of union.
■ Studies have also demonstrated no difference in union
rates with use of a long-arm versus short-arm cast; however,
a small randomized prospective study by Gellman et al9
demonstrated a shorter time to union and fewer nonunions
and delayed unions with the initial use of a long-arm cast.
DORSAL ARTHROSCOPY-ASSISTED REDUCTION AND FIXATION
No n d isp la ce d Fra ct u re o f t h e
Sca p h o id Wa ist o r Pro xim a l Po le
■ Po sit io n t h e w rist t o o b t a in a PA vie w o f t h e w rist .
■ Un d e r flu o ro sco p ic g u id a n ce , g e n t ly p ro n a t e t h e
w rist u n t il t h e sca p h o id a p p e a rs a s a n o b lo n g cylin d e r,
in d ica t in g t h a t t h e p ro xim a l a n d d ist a l p o le s a re
a lig n e d .
■ Fle x t h e w rist a b o u t 45 d e g re e s u n t il t h e cylin d e r ro t a t e s
in t o t h e p la n e o f im a g in g , fo rm in g a “ rin g ” sig n . Th e
ce n t e r o f t h e rin g in d ica t e s t h e ce n t ra l a xis o f t h e
sca p h o id (TECH FIG 1 ).
103
■ In general, cast immobilization is required for 6 weeks after
a distal pole fracture and 10 to 12 weeks following a nondis-
placed waist fracture.
■ Confirmation of fracture union requires serial plain radi-
ographs demonstrating progressive obliteration of the frac-
ture line and clear trabeculation across the fracture site.6
■ If there is any question regarding fracture union, a CT scan
should be obtained.
SURGICAL MAN AGEMEN T
■ O perative treatment is advocated for fractures that are un-
stable or displaced (see above criteria) and following a signifi-
cant treatment delay.
■ Percutaneous fixation is indicated for:
■ N ondisplaced fractures of the scaphoid waist
■ Displaced fractures of the scaphoid waist
■ Proximal pole fractures
■ Percutaneous stabilization of scaphoid fractures may be
performed using either the dorsal arthroscopically assisted
reduction and fixation (AARF) approach 17–19 or the volar
approach.3,10
■ Regardless of the technique used, the screw must be in-
serted in the middle third or central axis of the scaphoid, as
this provides the greatest stability and stiffness, improves
fracture alignment, and decreases time to union.1,20,21
Preoperative Planning
■ All imaging studies should be reviewed to identify the loca-
tion of the fracture and the size of the scaphoid, both of which
influence implant selection.
■ Plain radiographs should be templated to determine the
approximate screw length.
■ Required equipment:
■ Portable mini-fluoroscopy unit
■ Kirschner wires
■ Cannulated headless compression screw system
■ Wrist arthroscopy equipment for AARF
Positioning
■ The patient is positioned supine on the operating table, with
the shoulder abducted 90 degrees and the arm on a radiolucent
hand table.
■ A pneumatic tourniquet is applied to the upper arm.
■ The portable fluoroscopy unit is positioned at the end of the
hand table.
TECHNIQUES
■ Usin g a 14-g a u g e a n g io ca t h e t e r a s a g u id e fo r w ire in se r-
t io n , p la ce t h e t ip o f a 0.045-in ch g u id e w ire t h ro u g h t h e
ca t h e t e r a n d o n t o t h e p ro xim a l p o le o f t h e sca p h o id , a t
t h e ce n t e r o f t h e sca p h o id rin g . Co n firm co rre ct p o sit io n -
in g w it h flu o ro sco p y.
■ In se rt t h e g u id e w ire d o w n t h e ce n t ra l a xis o f t h e
sca p h o id u sin g a w ire -d rive r. Ke e p t h e w rist fle xe d t o
a vo id b e n d in g t h e w ire .
■ In se rt t h e g u id e w ire t h ro u g h t h e t ra p e ziu m a n d a d va n ce
it u n t il t h e p ro xim a l t ip o f t h e g u id e w ire cle a rs t h e ra d io -
ca rp a l jo in t su ch t h a t t h e w rist ca n b e e xt e n d e d fo r
a rt h ro sco p ic e xa m in a t io n .
 104 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES
A B
■ Co n firm co rre ct w ire p o sit io n w it h flu o ro sco p y.
■ Th e ra d ia l m id ca rp a l p o rt a l is u se d t o e va lu a t e t h e a ccu -
ra cy o f fra ct u re re d u ct io n .
■ Th e 3-4 a n d 4-5 p o rt a ls a re u se d t o a sse ss t h e in t e g rit y o f
t h e ra d io ca rp a l a n d in t e rca rp a l lig a m e n t s.
■ Su sp e n d t h e h a n d ve rt ica lly in fin g e r t ra p s a n d a p p ly 10
lb o f t ra ct io n t o t h e u p p e r a rm t o d ist ra ct t h e ra d io ca rp a l
a n d m id ca rp a l a rt icu la t io n s.
■ Cre a t e a sm a ll lo n g it u d in a l in cisio n o ve r e a ch p o rt a l sit e ,
a n d b lu n t ly d isse ct d o w n t o t h e ca p su le w it h a h e m o st a t .
En t e r t h e ca p su le w it h a b lu n t t ro ca r.
■ Pe rfo rm a d ia g n o st ic a rt h ro sco p y t o a sse ss fo r a n y a sso ci-
a t e d in ju rie s a n d t o e va lu a t e t h e fra ct u re re d u ct io n .
■ Re m o ve t h e h a n d fro m t ra ct io n fo r scre w in se rt io n .
■ Po sit io n t h e w rist a g a in t o o b t a in t h e “ rin g ” sig n , a n d
m a in t a in t h e w rist in fle xio n .
■ Drive t h e g u id e w ire fro m d o rsa l t o vo la r, p e rp e n d icu la r
t o t h e fra ct u re lin e , u n t il t h e d ist a l t ip lie s ju st w it h in t h e
d ist a l p o le o f t h e sca p h o id (TECH FIG 2 A–C).
■ Pla ce a se co n d g u id e w ire o f e q u a l le n g t h a g a in st t h e t ip
o f t h e p ro xim a l p o le , p a ra lle l a n d n e xt t o t h e first
g u id e w ire . Th e d iffe re n ce b e t w e e n le n g t h s o f t h e p ro -
t ru d in g w ire s re p re se n t s t h e le n g t h o f t h e sca p h o id .
A B
TECH FIG 2 • A–C. Be fo re scre w in se rt io n , t h e p o sit io n o f t h e Kirsch n e r w ire m u st b e ch a n g e d fro m it s p o sit io n u se d
fo r a rt h ro sco p y. Th e Kirsch n e r w ire sh o u ld b e d rive n fro m vo la r t o d o rsa l u n t il t h e d ist a l e n d lie s ju st b e n e a t h t h e a rt ic-
u la r su rfa ce o f t h e sca p h o id . (co n t in u e d )
TECH FIG 1 • The scaphoid ring sign indi-
cates th e cen t ral axis o f th e scap h o id , wh ich
is crit ical for accurate insertion of t he can-
n u la t e d co m p re ssio n scre w . Th e w rist is
p o sit io n ed in fle xio n a n d pron a t io n until t h e
scap h o id ap pe ars as a “rin g ” (arro w ) on fluo-
ro sco p ic im a g in g . A 0.045-in ch g u id e w ire is
inserted t hrough the cent er of the ring.
■ Su b t ra ct a t le a st 4 m m fro m t h e le n g t h o f t h e sca p h o id
t o o b t a in t h e d e sire d scre w le n g t h .
■ Ma ke a sm a ll lo n g it u d in a l in cisio n a ro u n d t h e g u id e w ire ,
a n d b lu n t ly d isse ct d o w n t o t h e jo in t ca p su le . Ca re fu lly
re t ra ct t h e e xt e n so r p o llicis lo n g u s a n d e xt e n so r d ig it o -
ru m co m m u n is t e n d o n s a w a y fro m t h e su rg ica l sit e .
■ Use t h e ca n n u la t e d re a m e r t o re a m t o 2 m m sh o rt o f
t h e d ist a l a rt icu la r. It is crit ica l n o t t o re a m clo se r t h a n
2 m m , a s t h is m a y ca u se lo ss o f fra ct u re co m p re ssio n
d u rin g scre w in se rt io n .
■ In se rt a n Acu t ra k o r m in i-Acu t ra k scre w (Acu m e d ,
Be a ve rt o n , OR) o f a p p ro p ria t e le n g t h (a t le a st 4 m m
sh o rt e r t h a n t h e m e a su re d sca p h o id le n g t h ) t o w it h in 1
t o 2 m m o f t h e d ist a l su rfa ce .
■ Th e t ip o f t h e scre w sh o u ld n o t p e n e t ra t e t h e d ist a l
su rfa ce , a n d t h e p ro xim a l e n d o f t h e scre w sh o u ld re st
2 m m d e e p t o t h e p ro xim a l a rt icu la r ca rt ila g e (TECH
FIG 2 D,E).
■ Co n firm sa t isfa ct o ry scre w p o sit io n a n d fra ct u re re d u c-
t io n w it h flu o ro sco p y. Th e scre w sh o u ld b e in se rt e d
d o w n t h e ce n t ra l a xis o f t h e sca p h o id . If a n y d o u b t e xist s,
u se t h e a rt h ro sco p ic p o rt a ls t o co n firm t h a t t h e scre w is
b u rie d in t h e sca p h o id .
C
 Ch a p t e r 1 1 PERCUTANEOUS FIXATION OF ACUTE SCAPHOID FRACTURES 105

TECHNIQUES
TECH FIG 2 • (co n t in u e d ) D,E. Scre w fixa -
t io n o f m in im a lly d isp la ce d sca p h o id fra c-
t u re via t h e d o rsa l p e rcu t a n e o u s t e ch n iq u e .
Th e scre w t ip sh o u ld re st w it h in 1 t o 2 m m
o f t h e d ist a l co rt e x. Exce lle n t co m p re ssio n
D E sh o u ld b e o b t a in e d w it h t h is t e ch n iq u e .

■ Th e 3-4 p o rt a l a n d t h e ra d ia l m id ca rp a l p o rt a ls p ro - ■ Th e g u id e w ire fro m t h e Acu t ra k syst e m is in se rt e d fro m

vid e t h e b e st vie w t o e n su re t h a t t h e fra ct u re is a d e -
q u a t e ly re d u ce d a n d t h a t t h e re is n o vio la t io n o f t h e
m id ca rp a l jo in t .
Disp la ce d Sca p h o id Wa ist Fra ct u re
■ In se rt t w o p e rcu t a n e o u s 0.062-in ch sm o o t h Kirsch n e r
w ire s d o rsa lly in t o e a ch fra g m e n t p e rp e n d icu la r t o t h e
lo n g a xis o f t h e sca p h o id t o b e u se d a s jo yst icks t o re d u ce
t h e fra ct u re (TECH FIG 3 A,B).
■ Po sit io n t h e w rist a s p re vio u sly d e scrib e d .
p ro xim a l t o d ist a l, st a rt in g d o rsa lly a n d a im in g fo r t h e
ce n t ra l a xis o f t h e d ist a l fra g m e n t .
■ Th e g u id e w ire is d rive n t h ro u g h t h e d ist a l fra g m e n t
a n d o u t t h ro u g h t h e vo la r skin o f t h e h a n d . Th e p ro -
t ru d in g t ip is t h e n p u lle d vo la rly u n t il t h e w ire is o n ly
in t h e d ist a l fra g m e n t (TECH FIG 3 C).
■ Th e p ro xim a l fra g m e n t , w h ich is n o w fre e ly m o b ile , is re -
d u ce d m a n u a lly u sin g t h e Kirsch n e r w ire jo yst icks.
■ On ce t h e fra ct u re is re d u ce d , t h e ce n t ra l g u id e w ire is
d rive n fro m vo la r t o d o rsa l in t o t h e p ro xim a l fra g -
m e n t , se cu rin g it in p la ce (TECH FIG 3 D).

TECH FIG 3 • A. Re d u ct io n o f a d isp la ce d sca p h o id w a ist fra ct u re u sin g

Kirsch n e r w ire jo yst icks. B. Th e Kirsch n e r w ire jo yst ick t e ch n iq u e fo r fra c-
t u re re d u ct io n . C. Th e g u id e w ire is p u lle d vo la rly u n t il it re m a in s o n ly in t h e
d ist a l fra g m e n t . (co n t in u e d )

A
Volar exit
of guidewire

K-wire joystick K-wire joystick

Scaphoid fracture

Dorsal entry
of guidewire

B C
 106 Se c t i o n I HAND, WRIST AND FOREARM

■ Th e g u id e w ire is fu rt h e r a d va n ce d fro m vo la r t o d o rsa l

TECHNIQUES

u n t il it s d ist a l t ip is ju st w it h in t h e su b ch o n d ra l b o n e o f
t h e d ist a l a rt icu la r su rfa ce . Th is a llo w s fo r m e a su re m e n t
o f t h e scre w le n g t h a s p re vio u sly d e scrib e d .
■ An a d d it io n a l 0.045-in ch Kirsch n e r w ire is in se rt e d p a ra l-
le l t o t h e g u id e w ire t o p re ve n t ro t a t io n o f t h e sca p h o id
fra g m e n t s d u rin g re a m in g a n d scre w im p la n t a t io n .
■ Ma in t e n a n ce o f re d u ct io n d u rin g a n d a ft e r scre w in -
se rt io n is co n firm e d w it h flu o ro sco p y, a n d a ll w ire s
a re su b se q u e n t ly re m o ve d .

TECH FIG 3 • (co n t in u e d ) D. Th e g u id e w ire is d rive n fro m vo la r t o d o rsa l,

D t ra n sfixin g t h e p ro xim a l fra g m e n t .

VOLAR PERCUTANEOUS APPROACH

■ Po sit io n t h e p a t ie n t in a su p in e p o sit io n w it h t h e sh o u l-
d e r a b d u ct e d a n d t h e fo re a rm in su p in a t io n . Th e w rist is
p la ce d in t o a n e xt e n d e d a n d u ln a rly d e via t e d p o sit io n
o ve r a ro lle d t o w e l t o g a in a cce ss t o t h e d ist a l p o le o f t h e
sca p h o id .
■ Po sit io n t h e p o rt a b le flu o ro sco p y u n it su ch t h a t PA a n d
la t e ra l vie w s o f t h e w rist ca n b e o b t a in e d . Im a g e in t e n si-
fica t io n is u se d t o lo ca t e t h e d ist a l sca p h o id t u b e ro sit y.
■ A sm a ll lo n g it u d in a l st a b in cisio n is m a d e a t t h is p o in t ,
a n d t h e so ft t issu e s a re b lu n t ly d isse ct e d d o w n t o t h e
sca p h o t ra p e zia l a rt icu la t io n .
■ In t ro d u ce t h e g u id e w ire o n t h e d ist a l sca p h o id t u b e ro s-
it y. Un d e r im a g e g u id a n ce , t h e w ire is a d va n ce d t o w a rd
t h e ce n t e r o f t h e p ro xim a l p o le , a im in g fo r t h e t u b e rcle
o f List e r (TECH FIG 4 ).
■ Th e vo la r p ro m in e n ce o f t h e t ra p e ziu m m a y b e p a r-
t ia lly e xcise d t o fa cilit a t e t h e co rre ct st a rt in g p o in t
a n d t ra je ct o ry fo r t h e g u id e w ire .
■ Alt e rn a t ive ly, t h e g u id e w ire m a y b e p la ce d d ire ct ly
t h ro u g h t h e t ra p e ziu m in t o t h e sca p h o id d ist a l p o le .
We d o n o t p re fe r t h is a p p ro a ch d u e t o co n ce rn s
a b o u t t h e d e ve lo p m e n t o f sca p h o t ra p e zia l a rt h rit is.
■ Ad va n ce t h e g u id e w ire t o t h e su b ch o n d ra l b o n e o f t h e
p ro xim a l p o le .
■ Pla ce a se co n d g u id e w ire o f e q u a l le n g t h a g a in st t h e su r-
fa ce o f t h e d ist a l sca p h o id , a d ja ce n t a n d p a ra lle l t o t h e
first g u id e w ire . Th e d iffe re n ce b e t w e e n t h e le n g t h s o f
t h e w ire s re p re se n t s t h e le n g t h o f t h e sca p h o id .
■ Su b t ra ct 4 m m fro m t h e le n g t h o f t h e sca p h o id t o o b t a in
t h e d e sire d scre w le n g t h .
■ Use t h e ca n n u la t e d re a m e r t o re a m t o w it h in 2 m m o f
t h e p ro xim a l co rt e x. It is crit ica l n o t t o re a m clo se r t h a n
2 m m fro m t h e p ro xim a l co rt e x, a s t h is m a y re su lt in a
la ck o f co m p re ssio n d u rin g scre w in se rt io n .
■ In se rt a n Acu t ra k o r m in i-Acu t ra k scre w o f a p p ro p ria t e
le n g t h , re m o ve t h e g u id e w ire , a n d co n firm sa t isfa ct o ry
scre w p o sit io n a n d fra ct u re re d u ct io n w it h flu o ro sco p y.

A B C

TECH FIG 4 • In t h e p e rcu t a n e o u s vo la r a p p ro a ch , t h e g u id e w ire is in se rt e d in t o t h e sca p h o id a t t h e sca p h o t ra p e zia l jo in t ,

a n d in t o t h e ce n t e r o f t h e p ro xim a l p o le . Th e w ire sh o u ld b e in se rt e d a im in g fo r t h e t u b e rcle o f List e r.
 Ch a p t e r 1 1 PERCUTANEOUS FIXATION OF ACUTE SCAPHOID FRACTURES 107

PEARLS AND PITFALLS

Do r s a l t e ch n iq u e
In ju ry t o d o rsa l st ru ct u re s
Ma lp o sit io n in g o f g u id e w ire
Scre w p e n e t ra t io n
Re d u ct io n o f u n st a b le fra ct u re
Ext re m e ly sm a ll p ro xim a l p o le
fra ct u re s
Vo la r t e ch n iq u e
In ju ry t o vo la r st ru ct u re s
Ma lp o sit io n in g o f g u id e w ire
Scre w p e n e t ra t io n
■ Blu n t d isse ct io n t h ro u g h t h e ca p su le m in im ize s t h e risk o f in ju ry.
■ Pro n a t e a n d fle x t h e w rist u n t il t h e “ rin g ” sig n is n o t e d ; t h e ce n t e r o f t h e rin g is t h e in se rt io n
p o in t fo r t h e g u id e w ire .
■ Se le ct a scre w t h a t is a t le a st 4 m m sh o rt e r t h a n t h e m e a su re d le n g t h o f t h e sca p h o id .
■ A co m m o n m ist a ke is t o p la ce a scre w t h a t e n d s u p t o o lo n g o n ce t h e scre w co m p re sse s t h e
fra g m e n t s.
■ Re a m t o 2 m m sh o rt o f t h e d ist a l co rt e x.
■ Co n firm ce n t ra l p o sit io n o f g u id e w ire via flu o ro sco p y.
■ Kirsch n e r w ire s m a y b e u se d a s jo yst icks fo r re d u ct io n .
■ A d e ro t a t io n a l Kirsch n e r w ire sh o u ld b e p la ce d b e fo re re a m in g a n d scre w in se rt io n if t h e
fra g m e n t s a re u n st a b le .
■ Use a m in i-Acu t ra k scre w t o p re ve n t co m m in u t io n o f t h e p ro xim a l fra ct u re fra g m e n t .
■ Blu n t d isse ct io n t o t h e sca p h o id m in im ize s t h e risk o f in ju ry.
■ A ce n t ra l st a rt in g p o in t o n t h e d ist a l sca p h o id t u b e ro sit y ca n b e h in d e re d b y t h e t ra p e ziu m .
■ Pa rt o f t h e vo la r t ra p e ziu m ca n b e re se ct e d t o a ch ie ve a co rre ct st a rt in g p o in t fo r t ra je ct o ry o f
t h e g u id e w ire , o r t h e w ire m a y b e in se rt e d t h ro u g h t h e t ra p e ziu m .
■ Se le ct a scre w t h a t is a t le a st 4 m m sh o rt e r t h a n t h e m e a su re d le n g t h o f t h e sca p h o id .
■ Re a m t o 2 m m sh o rt o f t h e p ro xim a l a rt icu la r su rfa ce .
■ Co n firm ce n t ra l p o sit io n o f g u id e w ire via flu o ro sco p y.

POSTOPERATIVE CARE COMPLICATION S

■ Dressings are applied and the limb is immobilized in a
forearm-based splint, immobilizing only the wrist. The thumb
and fingers remain free for range-of-motion exercises.
■ The patient is instructed in the importance of limb elevation
and finger range-of-motion exercises.
■ At 2 weeks postoperatively, the sutures are removed, a re-
■ Complications are rare with percutaneous fixation tech-
niques. The risks associated with open reduction and internal
fixation, such as damage to the ligamentous support of the
carpus and disruption of the dorsal blood supply, are
minimized.
■ Possible complications include15,19 :

movable wrist splint is applied, and a wrist range-of-motion ■ N onunion

exercise program is initiated. ■ M alunion

■ If the patient is noncompliant, the fracture is deemed ■ Injury to the dorsal sensory branch of the radial nerve

unstable, or the fixation is less than ideal, then a short-arm ■ Extensor tendon injury

cast is applied for at least 6 weeks. ■ Infection

■ Plain radiographs are obtained at 2, 6, 12, and 24 weeks ■ Technical problems: screw protrusion, screw malposition,

postoperatively. bending or breakage of guidewire

■ The splint (or cast) is discontinued when union is confirmed ■ Erosion of the trapezium and discomfort from the head of

on serial plain radiographs. If there is any question regarding the screw has been reported with the use of a percutaneous
fracture union, a CT scan is obtained. cannulated screw inserted via the volar approach.22
■ Unprotected strenuous activity or contact sports are not per-

mitted until 3 months postoperatively. REFEREN CES

OUTCOMES
■ Results of contemporary techniques of percutaneous fixation
are excellent; it has been shown to allow for earlier mobiliza-
tion and return to activity and high satisfaction rates compared
to nonoperative measures.5,17,22
■ Earlier mobilization avoids complications such as muscle at-
rophy and joint stiffness.
■ Percutaneous techniques result in decreased soft tissue dam-
age compared to conventional open techniques.22
■ In a recent series of 27 consecutive patients, the union rate
(confirmed by CT) was 100% . The average time to union was
12 weeks, with a prolonged time to union noted in patients
with a proximal pole fracture. 18
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17. Slade JF III, Dodds SD. M inimally invasive management of scaphoid
nonunions. Clin O rthop 2006;445:108–119.
18. Slade JF III, Gutow AP, Geissler WB. Percutaneous internal fixation
of scaphoid fractures via an arthroscopically assisted dorsal ap-
proach. J Bone Joint Surg Am 2002;84:21–36.
19. Slade JF III, Jaskwhich D. Percutaneous fixation of scaphoid frac-
tures. H and Clin 2001;17:553–574.
20. Trumble TE, Clarke T, Kreder H J. N on-union of the scaphoid: treat-
ment with cannulated screws compared with treatment with H erbert
screws. J Bone Joint Surg Am 1996;78A:1829–1837.
21. Trumble TE, Gilbert M , M urray LW, et al. Displaced scaphoid frac-
tures treated with open reduction and internal fixation with a cannu-
lated screw. J Bone Joint Surg Am 2000;82A:633–641.
22. Yip H SF, Wu WC, Chang RYP, et al. Percutaneous cannulated screw
fixation of acute scaphoid waist fracture. J H and Surg Br 2002;27B:
42–46.
 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 12 Fix a t io n o f Sca p h o id Fr a ct u re s
A sh e e sh Be d i an d Pe t e r J.L. Je b so n
DEFIN ITION
■ The scaphoid is the most commonly fractured carpal bone, ac-
counting for 1 in every 100,000 emergency department visits.12
■ Scaphoid fractures typically result from a fall on an out-
stretched hand.
■ Scaphoid nonunion or proximal pole avascular necrosis
(AVN ) after a fracture has been associated with considerable
morbidity and a predictable pattern of wrist arthritis.15,17,18
■ The complex anatomy and tenuous blood supply to the
scaphoid make operative management of these fractures tech-
nically challenging.18
■ The H erbert classification system organizes scaphoid frac-
tures into four groups: acute stable, acute unstable, delayed
union, and established nonunion.
AN ATOMY
■ The scaphoid has a complex three-dimensional geometry
that has been likened to a “ twisted peanut.” It can be divided
into three regions: proximal pole, waist, and distal pole.
■ The scaphoid functions as the primary link between the
forearm and the distal carpal row and therefore plays a criti-
cal role in maintaining normal carpal kinematics.
■ Articulating with the scaphoid fossa of the radius, the lu-
nate, capitate, trapezium, and trapezoid, more than 70% of
the scaphoid is covered with articular cartilage.
■ Gelberman and M enon 8 have described the vascular supply
of the scaphoid. The main arterial supply is from the radial
artery; it enters the scaphoid via two main branches:
■ A dorsal branch, entering through the dorsal ridge, is the
primary supply and provides 70% to 80% of the vascular-
ity, including the entire proximal pole via retrograde en-
dosteal branches.
■ A volar branch, entering through the tubercle, supplies
the remaining 20% to 30% , predominantly the distal pole
and tuberosity.
■ The proximal pole is at increased risk for avascular necrosis
(AVN ) secondary to disruption of its tenuous retrograde blood
supply after a fracture of the scaphoid waist or proximal pole.
■ Due to its tenuous vascular supply, the scaphoid heals al-
most entirely by primary bone healing, resulting in minimal
callus formation.
■ The size and shape of the scaphoid, in combination with its
precarious blood supply, demands attention to detail and
accurate implantation of fixation devices during fracture
fixation.
PATHOGEN ESIS
■ Scaphoid fractures are most commonly seen in young, active
males who fall on an outstretched upper extremity.12
■ With the wrist dorsiflexed greater than 95 degrees, in com-
bination with 10 degrees or more of radial deviation, the dis-
tal radius abuts the scaphoid and precipitates a fracture.12
■ M ost of these fractures occur at the waist region, although
10% to 20% occur in the proximal pole.
■ Proximal pole fractures are associated with an increased
risk of nonunion, delayed union, and AVN .
■ In children, scaphoid fractures are less common and are
most frequently seen in the distal pole.
N ATURAL HISTORY
■ An untreated or inadequately treated scaphoid fracture has
a higher likelihood of nonunion. The overall incidence of
nonunion is estimated at 5% to 10% , but the risk is signifi-
cantly increased with nonoperative treatment of a displaced
waist or proximal pole fracture.
■ The natural history of scaphoid nonunions is controversial,
but they are believed to result in a predictable pattern of pro-
gressive radiocarpal and midcarpal arthritis.8,9,11,14,15,17,18
■ In an established scaphoid nonunion, the distal portion of
the scaphoid may flex, producing a “ humpback” deformity of
the scaphoid. The loss of scaphoid integrity can result in carpal
instability and abnormal carpal kinematics, most frequently
manifesting as a dorsal intercalated segment instability (DISI)
pattern.
■ The pattern of carpal instability and secondary arthrosis
due to an unstable scaphoid nonunion has been termed a
SN AC wrist (scaphoid nonunion advanced collapse pattern
of wrist arthritis).11,17
■ In the SN AC wrist, there is a loss of carpal height with
proximal capitate migration, flexion and pronation of the
scaphoid, and secondary midcarpal arthritis.17
■ Factors associated with the development of a scaphoid frac-
ture nonunion include14 :
■ Delayed diagnosis or treatment
■ Inadequate immobilization
■ Proximal fracture
■ Initial and progressive fracture displacement
■ Fracture comminution
■ Presence of associated carpal injuries (ie, perilunate injury)
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Scaphoid fractures classically occur in the active, young
adult population after a fall onto an outstretched hand.
Patients present with radial-sided wrist pain.
■ Classic physical examination findings include:
■ Swelling over the dorsoradial aspect of the wrist
■ Erythema over the volar radial aspect of the wrist
■ Tenderness to palpation in the “ anatomic snuffbox”
■ Tenderness with palpation volarly over the distal tubercle
■ Pain with axial compression of the wrist (scaphoid com-
pression test)
■ Scaphoid fractures can be part of a greater arc injury.
■ The physician should examine the entire wrist carefully
for areas of tenderness and swelling.
109
110 Se c t i o n I HAND, WRIST AND FOREARM
■ Plain radiographs are scrutinized for an associated liga-
mentous injury or disruption of the midcarpal joint as seen
in the transscaphoid perilunate fracture-dislocation.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ The following plain radiographs should routinely be ordered
in the patient with a suspected scaphoid fracture: posteroante-
rior (PA), oblique, lateral, and dedicated scaphoid views.
■ The PA view allows visualization of the proximal pole of
the scaphoid.
■ The semipronated oblique view provides the best visual-
ization of the waist and distal pole regions.
■ The semisupinated oblique view provides the best visual-
ization of the dorsal ridge.
■ The lateral view permits an assessment of fracture angu-
lation, carpal alignment, and carpal instability.
■ The dedicated scaphoid view is a PA view with the wrist
in ulnar deviation. This results in scaphoid extension, allow-
ing visualization of the scaphoid in profile (FIG 1 A).
■ The following criteria define a displaced or unstable fracture
as noted on plain radiographs2,9,14 :
■ At least 1 mm of displacement
■ M ore than 10 degrees of angular displacement
■ Fracture comminution
■ Radiolunate angle of more than 15 degrees
■ Scapholunate angle of more than 60 degrees
■ Intrascaphoid angle of more than 35 degrees
■ CT with reconstruction images in multiple planes is used to
identify an acute fracture not detected on plain radiographs
(FIG 1 B,C).
■ CT is most useful in evaluating an established scaphoid
nonunion or malunion. 6
A B
D E
■ Since plain radiographs are often unreliable, CT is pre-
ferred for confirming union after a scaphoid fracture.
■ M RI may be indicated in the evaluation of a suspected
scaphoid fracture not detected on plain radiographs
(FIG 1 D,E). M RI is highly sensitive, with a specificity ap-
proaching 100% when performed within 48 hours of
injury. 13
■ M RI with gadolinium contrast is helpful in assessing the
vascularity of the proximal pole, particularly in the patient
with an established nonunion.
■ A technetium bone scan has been shown to be up to 100%
sensitive in identifying an occult fracture.20 Unfortunately, it is
also associated with a low specificity and often will not be pos-
itive immediately after the fracture.
DIFFEREN TIAL DIAGN OSIS
■ Scapholunate injury
■ Wrist sprain
■ Wrist contusion
■ Fracture of other carpal bone
■ Greater arc injury
■ Distal radius fracture
N ON OPERATIVE MAN AGEMEN T
■ N onoperative management is indicated for a nondisplaced,
stable scaphoid waist or distal pole fracture. Unstable
fractures and nondisplaced fractures of the proximal pole
are indications for internal fixation based on studies that
have demonstrated a poor outcome with nonoperative
treatment. 2,4,14
■ The appropriate type and duration of cast immobilization
remain controversial. We recommend a long-arm thumb spica
cast for the first 6 weeks, followed by a short-arm thumb spica
C
FIG 1 • A. Ra dio g ra p h
(sca p h o id vie w) of a n a cu t e ,
d isp la ce d , com min u t e d sca p ho id
w a ist fra ctu re . B,C. Axial a n d
sa g it t a l CT sca n ima g e s d e m o n -
st ra tin g a fra ct u re o f t h e p ro xi-
m al p o le o f t h e scap h o id .
D,E. T1- a n d T2-w e ig h t e d MRI
im age s dem onstrat ing a
n o n disp la ce d sca ph o id w a ist
fra ct u re . (Pro p e rt y o f Pe t e r J.L.
Je b so n , MD.)

cast until the clinical examination and radiologic studies (usu-
ally a CT scan) confirm fracture union.
■ Clinical studies have failed to demonstrate any benefit
from including the thumb or fingers in the cast.2,4
■ Similarly, wrist position has not been proven to improve
scaphoid fracture healing.
■ N umerous studies have revealed no difference in union
rates for a long-arm versus short-arm cast; however, a ran-
domized prospective study by Gellman et al10 documented a
shorter time to union and fewer nonunions and delayed
unions with initial use of a long-arm cast.
■ The morbidity of a nonoperative approach, specifically cast
immobilization, has become of increasing concern. A pro-
longed duration of immobilization is often required for waist
fractures, and this can be accompanied by muscle atrophy,
stiffness, reduced grip strength, and residual pain. In addition,
cast immobilization can cause significant inconvenience for the
patient and interference with activities of daily living. The pro-
longed duration of immobilization is of particular concern in
the young laborer, athlete, or military personnel, who typically
desire expedient functional recovery.5,16,21
■ If the clinical history and physical examination are sugges-
tive of a scaphoid fracture but initial radiographs are negative,
the wrist should be immobilized for 2 weeks. Repeat radi-
ographs are then obtained. If a fracture is present, resorption
at the fracture may be noted. If wrist pain and “ snuffbox” ten-
derness persist but radiographs are negative, a bone scan may
be obtained. A negative scan excludes the presence of a
scaphoid fracture. A positive scan may indicate an occult frac-
ture or ligamentous injury. CT or M RI is usually indicated for
further evaluation.13,20
■ Alternatively, if there is a high index of suspicion at initial
presentation and there is a need to know the status of the
scaphoid, M RI or CT of the wrist is obtained.
SURGICAL MAN AGEMEN T
■ Indications for open reduction and internal fixation (O RIF)
of scaphoid fractures include2,14 :
■ Any proximal pole fracture
■ A displaced, unstable fracture of the scaphoid waist
■ Associated carpal instability or perilunar instability
OPEN DORSAL APPROACH (AUTHORS’ PREFERRED APPROACH)
Exp o su re
■ If t h e fra g m e n t s a re d isp la ce d , re q u irin g re d u ct io n ,
p ro n a t e t h e fo re a rm a n d m a ke a lo n g it u d in a l skin in ci-
sio n , a b o u t 3 t o 4 cm lo n g , b e g in n in g a t t h e p ro xim a l a s-
p e ct o f t h e t u b e rcle o f List e r a n d e xt e n d in g d ist a lly
a lo n g t h e a xis o f t h e t h ird m e t a ca rp a l (TECH FIG 1 A).
■ If t h e fra ct u re is n o n d isp la ce d , a sm a lle r skin in cisio n
a n d ca p su lo t o m y m a y b e u se d .
■ Ra ise skin fla p s a t t h e le ve l o f t h e e xt e n so r re t in a cu lu m .
■ In cise t h e e xt e n so r re t in a cu lu m o ve rlyin g t h e t h ird co m -
p a rt m e n t im m e d ia t e ly d ist a l t o t h e t u b e rcle o f List e r a n d
ca re fu lly re le a se t h e fa scia o ve rlyin g t h e e xt e n so r p o llicis
lo n g u s (EPL) t e n d o n , p e rm it t in g g e n t le re t ra ct io n o f t h e
Ch a p t e r 1 2 ORIF OF SCAPHOID FRACTURES 111
■ Associated distal radius fracture
■ Delayed presentation (more than 3 to 4 weeks) with no
prior treatment
■ A nondisplaced, stable scaphoid waist fracture (H erbert
A2 type) in a patient who wishes to avoid the morbidity of
cast immobilization. In this clinical scenario, operative treat-
ment should occur only after an explanation of the rationale
for, and the risks and benefits of, operative treatment versus
cast immobilization.
Preoperative Planning
■ All imaging studies should be reviewed to accurately define
the fracture pattern.
■ Required equipment:
■ Portable mini-fluoroscopy unit
■ Kirschner wires
■ Cannulated headless compression screw system. We pre-
fer to use the Acutrak or mini-Acutrak screw system
(Accumed, Beaverton, O R), but any cannulated screw sys-
tem that permits screw insertion beneath the articular sur-
face may be used.
Positioning
■ General or regional anesthesia may be used.
■ The patient is positioned supine on the operating table with
a radiolucent hand table at the shoulder level.
■ The fluoroscopy unit is draped and positioned at the end of
the hand table.
■ A pneumatic tourniquet is carefully applied to the proximal
arm.
■ An intravenous antibiotic is provided before inflation of the
tourniquet as prophylaxis for infection.
■ The limb is prepared and draped, followed by exsanguina-
tion of the limb with an Esmarch bandage and tourniquet in-
flation, usually to a pressure of 250 mm H g.
Approach
■ O RIF of scaphoid fractures can be performed through either
a dorsal or volar approach.
■ The specific approaches that will be described include:
■ O pen dorsal approach 16
■ O pen volar approach
TECHNIQUES
EPL ra d ia lly. Sim ila rly in cise t h e d o rsa l h a n d fa scia
lo n g it u d in a lly.
■ Ge n t ly re t ra ct t h e e xt e n so r d ig it o ru m co m m u n is
(EDC) t e n d o n s u ln a rly w h ile re t ra ct in g t h e e xt e n so r
ca rp i ra d ia lis b re vis (ECRB) a n d lo n g u s (ECRL) t e n d o n s
ra d ia lly w it h t h e EPL, t h u s e xp o sin g t h e u n d e rlyin g
ra d io ca rp a l jo in t ca p su le (TECH FIG 1 B).
■ Ma ke a lim it e d in ve rt e d T-sh a p e d ca p su lo t o m y w it h t h e
t ra n sve rse lim b p la ce d ju st d ist a l t o t h e d o rsa l rim o f
t h e ra d iu s a n d t h e lo n g it u d in a l lim b d ire ct ly o ve r t h e
sca p h o lu n a t e a rt icu la t io n (TECH FIG 1 C).
■ Th e t u b e rcle o f List e r is h e lp fu l in lo ca t in g t h e
a rt icu la t io n .
 112 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES
A B
TECH FIG 1 • A. Skin incision used for ORIF of scaphoid fractures via the dorsal approach. B. Retracting the thumb and wrist ex-
tensor tendons radially and the finger extensor tendons ulnarly facilitates exposure of the underlying capsule. C. A limited cap-
sulotomy should be performed to expose the proximal scaphoid and scapholunate ligament. (Property of Peter J.L. Jebson, MD.)
■ Ca re fu lly e le va t e t h e ca p su la r fla p s fro m t h e d o rsa l lu -
n a t e , t h e d o rsa l co m p o n e n t o f t h e sca p h o lu n a t e lig a -
m e n t , a n d t h e p ro xim a l p o le o f t h e sca p h o id .
■ Eva cu a t e fra ct u re h e m a t o m a .
■ It is o ft e n h e lp fu l t o e xt e n d t h e lo n g it u d in a l lim b
o f t h e ca p su lo t o m y t o e xp o se t h e sca p h o ca p it a t e
a rt icu la t io n a n d t h e ra d ia l a sp e ct o f t h e m id ca rp a l
jo in t .
■ Esp e cia lly w h e n e le va t in g t h e ra d ia l fla p , t a ke ca re t o
a vo id st rip p in g t h e d o rsa l rid g e ve sse ls e n t e rin g a t
t h e sca p h o id w a ist re g io n .
Fra ct u re Re d u ct io n a n d Pro visio n a l
Fixa t io n
■ Dist ra ct t h e ca rp u s m a n u a lly via lo n g it u d in a l t ra ct io n o n
t h e in d e x a n d lo n g fin g e rs.
■ If t h e fra ct u re is d isp la ce d , in se rt 0.045-in ch Kirsch n e r
w ire jo yst icks p e rp e n d icu la rly in t o t h e p ro xim a l a n d d is-
t a l sca p h o id fra g m e n t s t o a ssist in t h e re d u ct io n (TECH
FIG 2 A).
■ Th e a ccu ra cy o f t h e re d u ct io n ca n b e d e t e rm in e d b y
a sse ssin g co n g ru e n cy o f t h e ra d io sca p h o id a n d
sca p h o ca p it a t e a rt icu la t io n s.
C h a s b e e n st a b ilize d w it h a d e ro t a -
S L
A B
C
■ Wh e n a sa t isfa ct o ry re d u ct io n h a s b e e n a ch ie ve d , o b t a in
p ro visio n a l fixa t io n w it h d e ro t a t io n a l 0.045-in ch
Kirsch n e r w ire s.
■ Th e first w ire is in se rt e d d o rsa l a n d u ln a r t o t h e ce n -
t ra l a xis o f t h e sca p h o id , in t o t h e t ra p e ziu m fo r e n -
h a n ce d st a b ilit y.
■ Th e se co n d d e ro t a t io n a l w ire m a y b e in se rt e d vo la r
a n d ra d ia l t o t h e a n t icip a t e d ce n t ra l a xis in se rt io n sit e
if m o re fixa t io n is n e e d e d .
■ Th e d e ro t a t io n a l w ire s m u st b e p la ce d su ch t h a t t h e y
w ill n o t in t e rfe re w it h ce n t ra l a xis g u id e w ire p la ce -
m e n t , re a m in g , a n d scre w in se rt io n (TECH FIG 2 B).
Gu id e w ire Pla ce m e n t
■ Th e st a rt in g p o sit io n fo r g u id e w ire is a t t h e m e m b ra -
n o u s p o rt io n o f t h e sca p h o lu n a t e lig a m e n t o rig in
(TECH FIG 3 A,B).
■ In ve ry p ro xim a l fra ct u re s, t h e st a rt in g p o in t fo r t h e
g u id e w ire is a s fa r p ro xim a lly in t h e sca p h o id a s p o s-
sib le , a t t h e m id -a sp e ct o f t h e m e m b ra n o u s p o rt io n
o f t h e sca p h o lu n a t e lig a m e n t co m p le x. Th is p o in t is
crit ica l t o a vo id p ro p a g a t io n o f t h e fra ct u re in t o t h e
p ro xim a l sca p h o id d u rin g in se rt io n o f t h e scre w .
TECH FIG 2 • A. Pe rcu t a n e o u s in -
se rt io n o f Kirsch n e r w ire s in t o t h e
p ro xim a l a n d d ist a l sca p h o id (S)
fra g m e n t s is h e lp fu l t o fa cilit a t e
m a n u a l re d u ct io n o f a d isp la ce d
fra ct u re . C, ca p it a t e ; L, lu n a t e . B. A
d isp la ce d sca p h o id w a ist fra ct u re
t io n a l Kirsch n e r w ire p la ce d d o rsa l
a n d u ln a r t o t h e g u id e w ire . Th e
d e ro t a t io n a l Kirsch n e r w ire d o e s
n o t in t e rfe re w it h in se rt io n o f
t h e scre w in t h e ce n t ra l a xis.
(Ra d io g ra p h is t h e p ro p e rt y o f
Pe t e r J.L. Je b so n , MD.)
 Ch a p t e r 1 2 ORIF OF SCAPHOID FRACTURES 113

TECHNIQUES
A B C

TECH FIG 3 • A,B. No t e t h e st a rt in g p o in t a t t h e m e m b ra n o u s p o rt io n o f t h e sca p h o lu n a t e lig a m e n t (arro w ).

C. Th e 30-d e g re e p ro n a t e d o b liq u e vie w d e m o n st ra t in g g u id e w ire p la ce m e n t d o w n t h e ce n t ra l a xis o f t h e
sca p h o id . (Pro p e rt y o f Pe t e r J.L. Je b so n , MD.)

■ Wit h t h e w rist fle xe d o ve r a b o lst e r, in se rt t h e g u id e w ire Scre w In se rt io n

d o w n t h e ce n t ra l a xis o f t h e sca p h o id in lin e w it h t h e ■ De t e rm in e scre w le n g t h b y m e a su rin g t h e g u id e w ire
t h u m b m e t a ca rp a l.
(TECH FIG 4 A).
■ Be ve ry p a t ie n t w it h t h is im p o rt a n t st e p ; p ro ce e d ■ In t h e ca se o f m in im a l fra g m e n t se p a ra t io n , su b t ra ct
w it h re a m in g a n d scre w in se rt io n o n ly a ft e r ce n t ra l
4 m m fro m t h e m e a su re d le n g t h o f t h e w ire t o a llo w
p la ce m e n t h a s b e e n co n firm e d o n t h e PA, la t e ra l, a n d
re ce ssio n o f t h e p ro xim a l scre w b e n e a t h t h e a rt icu la r
30-d e g re e p ro n a t e d la t e ra l vie w s (TECH FIG 3 C).
su rfa ce .
■ It is crit ica l t o in se rt t h e w ire in t h e o p t im a l p o sit io n ■ If fra g m e n t s a re m o re d isp la ce d , co n sid e r co m p re s-
in a ll t h re e vie w s t o a vo id vio la t in g t h e m id ca rp a l
sio n a n d ch o o se a n e ve n sh o rt e r scre w .
jo in t o r t h e vo la r su rfa ce o f t h e sca p h o id . ■ Ad va n ce t h e w ire in t o t h e t ra p e ziu m t o a vo id lo ss o f p o -
■ Ta ke ca re t o a vo id b e n d in g t h e g u id e w ire .
sit io n d u rin g d rillin g .
■ Ad va n ce t h e w ire u p t o b u t n o t in t o t h e sca p h o t ra p e zia l
jo in t .

A B

TECH FIG 4 • A. De t e rm in in g
t h e a p p ro p ria t e scre w le n g t h .
B. Re a m in g w it h t h e ca n n u -
la t e d re a m e r. C,D. In se rt io n o f
t h e scre w . (Pro p e rt y o f Pe t e r J.L.
C D Je b so n , MD.)
 114 Se c t i o n I HAND, WRIST AND FOREARM

■ Use t h e ca n n u la t e d d rill (TECH FIG 4 B), t a p t h e b o n e if p ro xim a lly su ch t h a t in se rt io n o f a n Acu t ra k scre w

TECHNIQUES

n e ce ssa ry, a n d m a n u a lly in se rt t h e scre w (TECH FIG m a y re su lt in in a d ve rt e n t p ro p a g a t io n o f t h e fra ct u re

4 C,D). t o t h e in se rt io n sit e w it h fra g m e n t a t io n o f t h e p ro xi-
■ We u se t h e la rg e r Acu t ra k scre w w h e n fe a sib le , b u t m a l sca p h o id .
t h e m in i-Acu t ra k syst e m m a y b e n e ce ssa ry in p a t ie n t s ■ Re m o ve t h e g u id e w ire a n d a sse ss scre w p o sit io n via
w it h a sm a ll sca p h o id o r if t h e fra ct u re is lo ca t e d flu o ro sco p y u sin g t h e sa m e vie w s.

OPEN VOLAR APPROACH

Exp o su re ■ Pla ce a p ro visio n a l 0.045-in ch Kirsch n e r w ire t o se cu re
t h e re d u ct io n . In se rt t h e w ire in a re t ro g ra d e m a n n e r
■ Ra d ia lly d e via t e t h e w rist a n d p a lp a t e t h e sca p h o id
fro m vo la r d ist a l t o d o rsa l p ro xim a l, g a in in g fixa t io n in
t u b e rcle .
t h e p ro xim a l p o le .
■ Ma ke a 3- t o 4-cm in cisio n ce n t e re d o ve r t h e sca p h o id t u - ■ It is crit ica l t o p la ce t h is w ire su ch t h a t it d o e s n o t in -
b e rcle , d ire ct e d d ist a lly t o w a rd t h e b a se o f t h e t h u m b
t e rfe re w it h ce n t ra l a xis scre w p la ce m e n t .
a n d p ro xim a lly o ve r t h e fle xo r ca rp i ra d ia lis (FCR) t e n d o n ■ Th e ce n t ra l a xis g u id e w ire is p la ce d , t a kin g in t o co n sid e r-
sh e a t h . If t h e su p e rficia l vo la r b ra n ch o f t h e ra d ia l a rt e ry
a t io n a ll t h e fa ct o rs d e t a ile d a b o ve .
is e n co u n t e re d , ca u t e rize it a t t h e le ve l o f t h e w rist fle x- ■ To g a in t h e n e e d e d d o rsa l st a rt in g p o sit io n in t h e d ist a l
io n cre a se .
sca p h o id p o le , d isp la ce t h e t ra p e ziu m d o rsa lly w it h a n e l-
■ Op e n t h e FCR sh e a t h a n d re t ra ct t h e t e n d o n u ln a rly.
e va t o r o r re se ct a sm a ll p o rt io n o f t h e p ro xim a l vo la r
Op e n t h e flo o r o f t h e sh e a t h d ist a lly t o e xp o se t h e u n -
t ra p e ziu m w it h a ro n g e u r (TECH FIG 5 ).
d e rlyin g vo la r w rist ca p su le . ■ Th e ca n n u la t e d co m p re ssio n scre w m a y b e in se rt e d u sin g
■ Dist a lly, d e ve lo p t h e in t e rva l b y sp lit t in g t h e o rig in o f t h e
a fre e h a n d t e ch n iq u e o r a co m m e rcia l d e vice , w h ich m a y
t h e n a r m u scle s in lin e w it h t h e ir fib e rs o ve r t h e d ist a l
fa cilit a t e sim u lt a n e o u s fra ct u re re d u ct io n a n d g u id e w ire
sca p h o id a n d t ra p e ziu m .
p o sit io n in g .
■ In cise t h e ca p su le lo n g it u d in a lly, t a kin g ca re t o a vo id ■ Flu o ro sco p y is in va lu a b le d u rin g w ire a n d scre w in se r-
d a m a g e t o t h e u n d e rlyin g a rt icu la r ca rt ila g e .
t io n a n d t o co n firm a ccu ra t e p la ce m e n t a n d fra ct u re
■ Pro xim a lly, d ivid e t h e t h icke n e d ra d io lu n a t e a n d ra -
re d u ct io n a s d e scrib e d a b o ve .
d io sca p h o ca p it a t e lig a m e n t s t o a llo w e xp o su re o f t h e ■ Precisely rep air t he vo lar wrist cap su le an d rad io lun ate an d
p ro xim a l sca p h o id p o le .
ra dio scap ho ca pita t e liga me n ts w ith p e rma n e nt suture .
■ Id e n t ify t h e sca p h o t ra p e zia l jo in t w it h a Fre e r e le va t o r
a n d b lu n t ly e xp o se it .
■ Disse ct io n o ve r t h e ra d ia l a sp e ct o f t h e sca p h o id is
lim it e d t o a vo id in ju ry t o t h e d o rsa l rid g e ve sse l.
■ De fin e a n d cle a r t h e fra ct u re sit e b y irrig a t io n , sh a rp e x-
cisio n o f p e rio st e a l fla p s, a n d cu re t t in g o f d e b ris a n d
hematoma.
■ Asse ss t h e in st a b ilit y o f t h e fra ct u re b y w rist
m a n ip u la t io n .
■ It is crit ica l t o id e n t ify a n y b o n e lo ss, a s co m p re ssio n
d u rin g scre w p la ce m e n t ca n re su lt in a n ia t ro g e n ic
m a lu n io n .

Fra ct u re Re d u ct io n a n d Fixa t io n
■ Ob t a in co rre ct fra ct u re a lig n m e n t t h ro u g h lo n g it u d in a l
t ra ct io n fo llo w e d b y w rist m a n ip u la t io n .
■ An a n a t o m ic re d u ct io n m a y a lso b e a ch ie ve d b y d ire ct TECH FIG 5 • Accu ra t e in se rt io n o f a scre w via t h e vo la r a p -
m a n ip u la t io n o f t h e fra g m e n t s w it h a d e n t a l p ick, p ro a ch u su a lly re q u ire s p a rt ia l re se ct io n o r d o rsa l d isp la ce -
p o in t e d re d u ct io n fo rce p s, o r jo yst ick Kirsch n e r w ire s. m e n t o f t h e vo la r t ra p e ziu m t o e xp o se t h e d ist a l sca p h o id .

PEARLS AND PITFALLS

In ju ry t o t h e sca p h o id b lo o d su p p ly
Ma lp o sit io n in g o f g u id e w ire
Scre w p o sit io n
■ Me t icu lo u s lim it e d d isse ct io n o f t h e ca p su le . Avo id a n y d isse ct io n o n t h e d o rsa l rid g e o f
t h e sca p h o id .
■ Pro n a t e a n d fle x w rist d u rin g t h e d o rsa l a p p ro a ch t o a llo w a p p ro p ria t e t ra je ct o ry.
Co n firm p o sit io n o n m u lt ip le vie w s t o e n su re in se rt io n in t h e ce n t ra l a xis o f t h e sca p h o id .
■ Se le ct a scre w t h a t is 4 m m sh o rt e r t h a n m e a su re d le n g t h u n le ss fra ct u re fra g m e n t s a re
se p a ra t e d ; in t h a t ca se ch o o se a sh o rt e r scre w . Drill 2 m m sh o rt o f t h e d ist a l p o le .

Re d u ct io n o f a n u n st a b le fra ct u re ■ Pe rp e n d icu la r Kirsch n e r w ire jo yst icks in se rt e d in t o t h e p ro xim a l a n d d ist a l sca p h o id fra g -
m e n t s a re u se fu l t o o b t a in a re d u ct io n .
■ Pro visio n a l d e ro t a t io n a l Kirsch n e r w ire s p la ce d b e fo re scre w in se rt io n ca n b e u se d t o st a -
b ilize fra g m e n t s d u rin g scre w in se rt io n .
■ Re co g n ize co m m in u t io n a n d b o n e lo ss t o a vo id in a d ve rt e n t sh o rt e n in g o r m a lre d u ct io n
w it h scre w co m p re ssio n .
Sm a ll p ro xim a l p o le fra ct u re ■ Use o f a sm a ll scre w (ie , m in i-Acu t ra k) m a y b e n e ce ssa ry t o p re ve n t co m m in u t io n o f t h e
p ro xim a l fra g m e n t .
■ Co n firm ce n t ra l a xis scre w p o sit io n , e sp e cia lly in t h e p ro xim a l p o le .
POSTOPERATIVE CARE
■ The patient is immobilized in a below-elbow volar thumb
spica splint and discharged to home with instructions on strict
limb elevation and frequent digital range-of-motion exercises.
■ At 2 weeks, the patient returns for suture removal. Range-
of-motion exercises are begun and a removable forearm-based
thumb spica splint is worn. The splint is discontinued at 4 to
6 weeks postoperatively.
■ If the fracture involves the proximal pole or if significant
comminution was noted at surgery and there is concern re-
garding stability of the fixation, immobilization in a short-
arm cast for 6 to 10 weeks is indicated. Typically, such frac-
tures take longer to achieve union.
■ After cast removal, a formal supervised therapy program is
initiated to achieve satisfactory range of motion, strength, and
function.
■ Fracture healing is assessed at 2, 6, and 12 weeks postoper-
atively with plain radiography. Fracture union is defined as
progressive obliteration of the fracture and clear trabeculation
across the fracture site (FIG 2 ).
■ If there is any question regarding fracture union, a CT scan
is obtained at 3 months postoperatively or before the patient
is allowed to return to unrestricted sporting activities.
OUTCOMES
■ Surgical fixation of unstable, displaced scaphoid fractures has
been increasingly advocated, given the unsatisfactory outcomes
that have been reported with nonoperative management.2,4,14
FIG 2 • A h e a le d sca p h o id w a ist fra ct u re a ft e r ORIF via t h e d o r-
sa l a p p ro a ch . Alt h o u g h t h e scre w m a y a p p e a r slig h t ly lo n g ,
b o t h t h e p ro xim a l sca p h o id a n d d ist a l sca p h o id a re co ve re d
w it h h ya lin e ca rt ila g e n o t d e t e ct e d o n d ia g n o st ic im a g in g .
(Pro p e rt y o f Pe t e r J.L. Je b so n , MD.)
Ch a p t e r 1 2 ORIF OF SCAPHOID FRACTURES 115
Rigid internal fixation allows for early physiotherapy through-
out the healing phase, a more rapid time to union, improved
range of motion, and rapid functional recovery.5,10,16,21 Several
studies have reported a high rate of union and excellent clinical
outcome with minimal morbidity using both limited open and
percutaneous techniques.1,3,5,10,19,19,21
■ Clinical and biomechanical studies have also recently docu-
mented the importance of screw position after fixation of
scaphoid fractures.7,18 Central placement of the screw is bio-
mechanically advantageous, with greater stiffness and load to
failure.7 Trumble et al18 demonstrated more rapid progression
to union with central screw position in cases of scaphoid
nonunion.
■ A volar approach has traditionally been used for screw in-
sertion. H owever, recent studies have raised potential concerns
regarding eccentric screw placement and damage to the
scaphotrapezial articulation with this approach.21
■ O ur preferred technique for fixation of a scaphoid proximal
pole or waist region fracture involves a limited dorsal ap-
proach with compression screw fixation. 16 The technique is
simple and permits visualization of a reliable starting point for
screw placement within the central axis of the scaphoid, offer-
ing a significant potential advantage over the volar approach.
We recently reported our clinical experience in a consecutive
series of nondisplaced scaphoid waist fractures.3
COMPLICATION S
■ Postoperative wound infections are rare and can be prevented
with routine preoperative antibiotic prophylaxis, thorough
wound irrigation, and appropriate soft tissue management.
■ Intraoperative technical problems
■ Inadvertent bending or breakage of the guidewire can
occur if the wrist is dorsiflexed with the wire in position or
during drilling before screw insertion.
■ Care should be taken to confirm that the screw is fully
seated beneath the articular cartilage to avoid prominence
and erosion of the distal radius articular surface. Similarly,
failure to carefully judge accurate screw length intraopera-
tively can result in prominence and erosion of the scapho-
trapezial articulation.
■ N onunion with or without AVN can occur despite compres-
sion screw fixation, particularly with a proximal pole or dis-
placed waist fracture. Stripping of the dorsal ridge vasculature
should be avoided. Supplemental cancellous bone graft from
the distal radius may be used at the time of fixation if desired.
■ O ther potential but rare complications
■ H ypertrophic scar
■ Injury to the dorsal branches of the superficial radial
nerve
■ Damage to the scaphotrapezial articulation
■ Proximal pole fragment comminution
116 Se c t i o n I HAND, WRIST AND FOREARM
REFEREN CES
1. Adams BD, Blair WF, Reagan DS, et al. Technical factors related to
H erbert screw fixation. J H and Surg Am 1988;13A:893–899.
2. Amadio PC, M oran SL. Fractures of the carpal bones. In Green D,
H otchkiss R, Pederson WC, eds. Green’s O perative H and Surgery,
5th ed. Philadelphia: Churchill Livingstone, 2005:711–740.
3. Bedi A, Jebson PJL, H ayden RJ, et al. Internal fixation of acute,
nondisplaced scaphoid waist fractures via a limited dorsal approach:
an assessment of radiographic and functional outcomes. J H and Surg
Am 2007;32A:326–333.
4. Burge P. Closed cast treatment of scaphoid fractures. H and Clin
2001;17:541–552.
5. Chen AC, Chao EK, H ung SS, et al. Percutaneous screw fixation for
unstable scaphoid fractures. J Trauma 2005;59:184–187.
6. Dias JJ, Taylor M , Thompson J, et al. Radiographic signs of union of
scaphoid fractures: an analysis of inter-observer agreement and re-
producibility. J Bone Joint Surg Br 1988;70B:299–301.
7. Dodds SD, Panjabi M M , Slade JF 3rd. Screw fixation of scaphoid
fractures: a biomechanical assessment of screw length and screw aug-
mentation. J H and Surg Am 2006;31A:405–413.
8. Gelberman RH , M enon J. The vascularity of the scaphoid bone. J
H and Surg Am 1980;5A:508–513.
9. Gelberman RH , Wolock BS, Siegel DB. Fractures and non-unions of
the carpal scaphoid. J Bone Joint Surg Am 1989;71A:1560–1565.
10. Gellman H , Caputo RJ, Carter V, et al. Comparison of short and long
thumb-spica casts for non-displaced fractures of the carpal scaphoid.
J Bone Joint Surg Am 1989;71A:354–357.
11. Kerluke L, M cCabe SJ. N onunion of the scaphoid: a critical analysis
of recent natural history studies. J H and Surg Am 1993;18A:1–3.
12. Kozin SH . Incidence, mechanism, and natural history of scaphoid
fractures. H and Clin 2001;17:515–523.
13. Kukla C, Gaebler C, Breitenseher M J, et al. O ccult fractures of the
scaphoid: the diagnostic usefulness and indirect economic repercus-
sions of radiography versus magnetic resonance scanning. J H and
Surg Br 1997;22B:810–813.
14. Leslie IJ, Dickson RA. The fractured carpal scaphoid: natural history
and factors influencing outcome. J Bone Joint Surg Br 1981;63B:
225–230.
15. M ack GR, Bosse M J, Gelberman RH , et al. The natural history of
scaphoid nonunion. J Bone Joint Surg Am 1984;66A:504–509.
16. M artus J, Bedi A, Jebson PJL. Cannulated variable pitch compression
screw fixation of scaphoid fractures using a limited dorsal approach.
Tech H and Upper Ext Surg 2005;9:202–206.
17. Ruby LK, Stinson J, Belsky M R. The natural history of scaphoid non-
union: a review of fifty-five cases. J Bone Joint Surg Am 1985;67A:
428–432.
18. Trumble TE, Clarke T, Kreder H J. N on-union of the scaphoid: treat-
ment with cannulated screws compared with treatment with H erbert
screws. J Bone Joint Surg Am 1996;78A:1829–1837.
19. Trumble TE, Gilbert M , M urray LW, et al. Displaced scaphoid frac-
tures treated with open reduction and internal fixation with a cannu-
lated screw. J Bone Joint Surg Am 2000;82A:633–641.
20. Waizenegger M , Wastie M L, Barton N J, et al. Scintigraphy in the
evaluation of the “ clinical” scaphoid fracture. J H and Surg Br 1994;
19B:750–753.
21. Yip H SF, Wu WC, Chang RYP, et al. Percutaneous cannulated screw
fixation of acute scaphoid waist fracture. J H and Surg Br 2002;27B:
42–46.

Ch a p t e r 13
DEFIN ITION
■ M alunion of the radial or ulnar shaft can lead to pain, loss
of motion, loss of strength, and instability at the level of the
wrist or elbow.
■ M alrotation, angulation
(with narrowing of the in-
terosseous space between the radius and ulna), shortening, and
loss of the radial bow have been shown in various studies to
lead to decreased functional outcomes. 4,5,9,10,12
■ Arthritis has been reported at the level of the proximal ra-
dioulnar joint (PRUJ) with longstanding malunions, although
the distal radioulnar joint (DRUJ) is most commonly affected
by forearm malunions.11
AN ATOMY
■ The forearm can be thought of as a ring, connected at the
PRUJ, the interosseous membrane, and the DRUJ (FIG 1 ).
■ Force transmission occurs through the interosseous mem-
brane from the radius distally to the ulna proximally.
■ Radius
■ The radius lies parallel to the ulna in supination. With
pronation, it rotates around the ulna while the ulna main-
tains its position throughout forearm rotation.
■ The radius shaft is triangular in cross section, with the
apex toward the attachment of the interosseous membrane.
■ It contains three surfaces: anterior, lateral, and posterior.
Supination Neutral Pronation
FIG 1 • La t e ra l p ro je ct io n o f t h e ra d iu s a n d u ln a . Re la t io n sh ip
o f t h e in t e ro sse o u s m e m b ra n e t o t h e ra d iu s a n d u ln a d u rin g
fo re a rm ro t a t io n . Th e fib e rs o f t h e in t e ro sse o u s m e m b ra n e a re
lo n g e st w it h t h e fo re a rm in n e u t ra l p o sit io n a n d sh o rt e n in
b o t h p ro n a t io n a n d su p in a t io n .
Co r re ct iv e Os t e o t o m y
f o r Ra d iu s a n d Uln a
Dia p h y s e a l M a lu n io n s
Vim ala Ram ach an d ran an d Th o m as F. Vare ck a
■The shaft possesses a gentle bow, with the volar surface
concave and the dorsal and lateral surfaces convex.1
■ Schemitsch and Richards9 devised a formula that locates
the apex and defines the magnitude of the radial bow for
each individual (FIG 2 ).
■ Ulna 1
■ The ulna is a long bone that has a triangular cross section
in the proximal two thirds and a circular cross section distally.
■ It possesses three surfaces: anterior, posterior, and medial.
■ The proximal half of the shaft is slightly concave volarly.
The distal half is relatively straight.
■ The PRUJ consists of the radial head, the radial notch, the
annular ligament, and the quadrate ligament.
■ The DRUJ consists of the sigmoid notch, the ulnar head, the
dorsal and volar radioulnar ligaments, the extensor carpi ul-
naris (ECU) subsheath, and the triangular fibrocartilage com-
plex (TFCC).
PATHOGEN ESIS
■ Both-bone forearm fractures occur through a variety of
mechanisms, including indirect trauma (such as falls on an
outstretched arm or motor vehicle accidents) and direct
trauma (such as blows to the forearm).
y
a
FIG 2 • Me a su re m e n t o f t h e lo ca t io n a n d m a g n it u d e o f t h e ra -
d ia l b o w . Th e d ist a n ce y re p re se n t s t h e le n g t h o f t h e ra d iu s a s
m e a su re d fro m t h e b icip it a l t u b e ro sit y t o t h e u ln a r a sp e ct o f
t h e ra d iu s. Lin e a, d ra w n p e rp e n d icu la r t o y fro m t h e p o in t o f
g re a t e st cu rva t u re o f t h e ra d iu s, re p re se n t s t h e m a g n it u d e o f
t h e ra d ia l b o w (e xp re sse d in m illim e t e rs). Th e d ist a n ce x re p re -
se n t s t h e le n g t h o f t h e ra d iu s fro m t h e b icip it a l t u b e ro sit y t o
t h e p o in t w h e re a in t e rse ct s y. Th e lo ca t io n o f t h e ra d ia l b o w is
ca lcu la t e d b y x/y 100. (Ad a p t e d fro m Sch e m it sch EH, Rich a rd s
RR. Th e e ffe ct o f m a lu n io n o n fu n ct io n a l o u t co m e a ft e r p la t e
fixa t io n o f fra ct u re s o f b o t h b o n e s o f t h e fo re a rm in a d u lt s. J
Bo n e Jo in t Su rg Am 1992;74A:1068–1078.)
117
118 Se c t i o n I HAND, WRIST AND FOREARM

■ Acute fractures treated closed or with intramedullary nailing
techniques are more likely to heal malunited.7,8
■ Radius malunions have a greater effect on forearm rotation
than ulna malunions. 10,12
■ A torsional deformity of greater than 30 degrees in the ra-
■ Pain with compression of the radius and ulna at the level
of the DRUJ may also be indicative of DRUJ instability or
arthritis (DRUJ compression test).
■ N eurovascular examination
■ The examiner should check for anterior interosseous nerve

dius leads to significant loss of forearm motion.4 (OK sign), posterior interosseous nerve (thumb extension),
■ Changes in the length–tension curve of the interosseous and ulnar nerve (abduction–adduction of fingers) function.
membrane may also account for loss of rotation.12 ■ Inability to perform tasks identifies nerve injury.

N ATURAL HISTORY IMAGIN G AN D OTHER DIAGN OSTIC

■ Fifty degrees of supination and 50 degrees of pronation are
needed for activities of daily living.6
■ Patients with untreated forearm malunions may experience
loss of forearm rotation, PRUJ or DRUJ instability, wrist pain,
STUDIES
■ AP and lateral radiographs of both forearms should be
obtained (FIG 3 A,B).
■ Both the bicipital tuberosity and the radial styloid should

loss of strength, and arthritis at the PRUJ.11 The severity of the be visualized for the film to be adequate.
symptoms depends on the degree of malunion and the corre- ■ The degree of angulation and comminution can be calcu-

sponding alteration in degree and location of the bow of the lated from these films.
radius. ■ Contralateral forearm films provide a comparison for the
■ M alunions of 10 degrees or less lead to less than a 20-
amount of shortening as well as for the location and angle
degree loss of forearm rotation and hence are clinically of the radial bow.9
insignificant. 7
■ Angular malalignment of more than 20 degrees in the ra-

dius or ulna results in clinically significant loss of motion.

Greater than 15 degrees of malalignment leads to inability
to perform activities of daily living.5,7,10
■ Patients with greater than 15 degrees of malalignment or

loss of the radial bow will have clinically significant loss of

motion and strength if left untreated.

PATIEN T HISTORY AN D PHYSICAL

FIN DIN GS
■ The preoperative evaluation for patients with forearm malu-
nions includes a detailed assessment of the patient’s functional
limitations as well as documentation of elbow and wrist range
of motion, the supination–pronation arc of the forearm, and
the stability of the PRUJ and DRUJ.
■ Physical examination

■ The skin is inspected for scarring or previous incision sites.

■ M uscle bulk and tone are examined.

■ The wrist, elbow, and malunion site are palpated for ten-

derness.
■ Range of motion

■ The flexion–extension arc of the elbow is measured with

the shoulder at 30 degrees of forward flexion.

■ Rotation of the forearm is ascertained with the humerus A B
stabilized against the chest wall and the elbow at 90 degrees
of flexion.
■ Wrist flexion and extension are determined with the fore-

arm in neutral rotation.

■ Joint loss of motion may indicate location of pathology.

■ A high degree of motion loss will lead to functional deficits.

■ PRUJ and DRUJ

■ Stability of the PRUJ is assessed by palpation during pas-

sive pronation and supination.
■ The DRUJ is evaluated by stressing the ulna volarly and
dorsally while stabilizing the radius.
■ Subluxation of the ulnar head or the ECU is evaluated
during passive range of motion (ECU subluxation test).
■ The piano key test can also be used to assess for an unsta-
ble DRUJ. Patients with a positive piano key sign will have
an ulnar head that shifts volarly with a minimal volarly di-
rected force and then rebounds dorsally once that force is re-
moved, much like a key in a piano.
C
FIG 3 • A,B. AP a n d la t e ra l ra d io g ra p h s d e m o n st ra t e a se g m e n -
t a l ra d iu s sh a ft fra ct u re re su lt in g in a m a lu n io n b o t h p ro xim a lly
a n d d ist a lly d e sp it e o p e n re d u ct io n a n d in t e rn a l fixa t io n . No t e
t h e lo ss o f ra d ia l b o w in b o t h d ire ct io n a n d m a g n it u d e , n a rro w -
in g o f t h e in t e ro sse o u s sp a ce b e t w e e n t h e ra d iu s a n d u ln a , d o r-
sa l p o sit io n in g o f t h e d ist a l u ln a , a n d n o n u n io n o f t h e b a sila r
u ln a r st ylo id fra ct u re . Th e p a t ie n t w a s u n a b le t o su p in a t e t o
n e u t ra l a n d d e m o n st ra t e d in st a b ilit y a t t h e d ist a l ra d io u ln a r
jo in t . C. CT sca n d e m o n st ra t e s n a rro w in g o f t h e in t e ro sse o u s
sp a ce w it h h e t e ro t o p ic b o n e fo rm a t io n .
 Ch a p t e r 1 3 CORRECTIVE OSTEOTOM Y FOR RADIUS AND ULNA DIAPHYSEAL M ALUNIONS
■ A CT (FIG 3 C) scan or M RI can also be obtained to assess
for malrotation.2
DIFFEREN TIAL DIAGN OSIS
■ DRUJ injury or instability
■ PRUJ injury or instability
■ Injury to the interosseous membrane
■ Synostosis
■ N onunion
N ON OPERATIVE MAN AGEMEN T
■ Nonoperative treatment of malunions depends on the pa-
tient’s symptoms and includes occupational therapy for strength-
ening and range of motion, removable off-the-shelf braces, non-
narcotic medications, and custom molded DRUJ orthoses.
SURGICAL MAN AGEMEN T
■ O perative intervention for forearm malunions depends on
the functional limitations of the patient, not the degree of de-
formity apparent on radiographs.
■ Indications for surgery include loss of forearm rotation that
leads to a functional deficit (rotational arc less than 100 degrees),
DRUJ instability, unacceptable cosmesis, and painful nonunion.
■ Risks to the patient include vascular injury, nerve injury or
paresthesias (specifically the superficial radial nerve), infec-
tion, nonunion, delayed union, need for iliac crest bone graft,
synostosis, loss of motion, and DRUJ instability.
■ Patients treated within 1 year of the initial injury may be
more likely to improve functionally and have a lower surgical
complication rate.11
■ M alunions of the radius and ulna are generally treated with
an open approach, corrective osteotomy of one or both bones,
compression plating, and bone grafting as necessary.
■ Generally, the more deformed bone is corrected first. If
after correction of the first bone forearm rotation is still
lacking, an osteotomy is performed on the second bone.
■ If both bones are equally deformed, the ulna is os-
teotomized and provisionally plated first to provide a work-
ing length for the radius.
■ Restoration of the radial bow in large part determines func-
tional outcome.
■ Patients whose radial bow is restored within 1.5 mm of
magnitude and located within 4.3% of the contralateral
forearm regain 80% of normal motion.
■ Eighty percent of grip strength is regained if the radial
bow is located within 5% of the contralateral side. 9
■ Anatomic realignment of the radius and ulna will not im-
prove functional deficits if a synostosis or significant scarring
and contracture involving the soft tissues has occurred.
■ O ccult injury to or contracture of the DRUJ and PRUJ
must be identified and treated at the time of surgery.
Preoperative Planning
■ Radiographs of the affected and contralateral extremity
should be reviewed.
■ A CT scan is helpful to assess for rotational deformity.
■ A corrective three-dimensional osteotomy is planned using
standard AO technique (FIG 4 ).
■ The need for corticocancellous iliac crest bone graft should
be determined by the degree of shortening.
■ The surgeon should be familiar with techniques for recon-
struction or stabilization of the DRUJ should it remain unsta-
ble after correction of the malunion.
119
Positioning
■ The patient is positioned supine on the operating table. A
radiolucent hand board is attached to the table, centered on
the patient’s axilla. The affected extremity is then extended
and can be positioned for either a volar or dorsal approach to
the radius by rotating through the shoulder.
■ The subcutaneous border of the ulna can be visualized by
flexing the arm at the elbow or by placing the arm across the
chest.
■ A nonsterile tourniquet may be used on the arm.
Approach
■ Radius shaft malunions may be approached either volarly or
dorsally.
■ The volar (H enry) approach is best suited for midshaft and
distal radius shaft malunions.
■ The proximal radius shaft can be approached volarly in
this manner; however, injury to the posterior interosseous
nerve (PIN ) can occur when dissecting the supinator muscle
off the radius.
■ The approach is extensile and can be used to expose not
only the entire length of the radius but also the wrist
joint. 3
■ The dorsal (Thompson) approach to the radius is used most
commonly for proximal malunions.
■ It provides access to the PIN , allowing the surgeon to iso-
late the nerve and retract it out of harm’s way for the re-
mainder of the procedure.
■ This approach may be of value for midshaft exposure of
the radius, especially in the case of a midshaft segmental
malunion (see Fig 3A,B).
■ The entire dorsal surface of the radius can be exposed
through this approach.3
■ The ulna is approached along its subcutaneous border.
■ The entire length of the ulna can easily be exposed
through this approach.
A B C
FIG 4 • Pre o p e ra t ive p la n n in g u sin g AO t e ch n iq u e fo r co rre c-
t io n o f t h e m a lu n io n o f t h e ca se in Fig u re 3. A. Th e m a lu n io n is
first ske t ch e d o u t fro m t h e p re o p e ra t ive ra d io g ra p h s. B. Ea ch
fra g m e n t is t h e n d ra w n o u t se p a ra t e ly. C. Th e o st e o t o m y sit e s
a re n o t e d o n b o t h t h e AP a n d la t e ra l vie w s. Th e ra d iu s is t h e n
re a lig n e d t h ro u g h t h e p la n n e d o st e o t o m y sit e s a n d b o n e g ra ft
(ye llo w ) is in se rt e d t o re st o re t h e n o rm a l m a g n it u d e a n d lo ca -
t io n o f t h e ra d ia l b o w .
 120 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES

VOLAR APPROACH TO THE RADIUS

■ La n d m a rks: b ice p s t e n d o n , b ra ch io ra d ia lis (BR), ra d ia l
st ylo id
■ Ce n t e r t h e skin in cisio n o ve r t h e m a lu n io n sit e a n d fo l-
lo w a lin e t h a t b e g in s la t e ra l t o t h e b ice p s t e n d o n , co n -
t in u e s o ve r t h e m e d ia l e d g e o f t h e BR, a n d e n d s d ist a lly
a t t h e le ve l o f t h e ra d ia l st ylo id .
■ Th e le n g t h o f t h e in cisio n d e p e n d s o n t h e a m o u n t o f
e xp o su re n e e d e d t o t a ke d o w n t h e m a lu n io n a n d
p la t e t h e o st e o t o m y.
■ To e xp o se t h e m id sh a ft , d isse ct b e t w e e n t h e BR a n d t h e
p ro n a t o r t e re s (PT) p ro xim a lly (TECH FIG 1 ).
■ Th e su p e rficia l ra d ia l n e rve lie s o n t h e u n d e rsu rfa ce
o f t h e BR a n d m u st b e p ro t e ct e d .
■ Lig a t e t h e re cu rre n t ra d ia l a rt e ry t o re t ra ct t h e BR
la t e ra lly.
■ Pro n a t e t h e fo re a rm a n d re le a se t h e PT in se rt io n .
■ Disse ct t h e PT m u scle su b p e rio st e a lly fro m a la t e ra l t o
m e d ia l d ire ct io n t o e xp o se t h e vo la r su rfa ce o f t h e ra d iu s.
■ To e xp o se t h e d ist a l ra d iu s, t h e su rg ica l in t e rva l lie s b e -
t w e e n t h e fle xo r ca rp i ra d ia lis (FCR) a n d t h e ra d ia l a rt e ry.
■ Re t ra ct t h e FCR m e d ia lly a n d t h e ra d ia l a rt e ry la t e ra lly t o
e xp o se t h e fle xo r p o llicis lo n g u s (FPL) a n d t h e p ro n a t o r
q u a d ra t u s (PQ).
■ Re t ra ct t h e FPL m e d ia lly.
■ Re le a se t h e PQ fro m it s ra d ia l in se rt io n a n d d isse ct t h e
m u scle b e lly fro m t h e vo la r d ist a l ra d iu s.

Lateral antebrachial
cutaneous n.
Radiobrachialis Supinator
Radial Superficial branch Brachioradialis
of radial nerve endon

Incision
Radial artery Flexor carpi radial
A Flexor carpi radialis B Pronator teres Radius

TECH FIG 1 • Exp o su re o f t h e ra d ia l sh a ft t h ro u g h t h e vo la r a p p ro a ch .

C Th is a p p ro a ch is b e st fo r m id sh a ft a n d d ist a l sh a ft m a lu n io n s.

DORSAL APPROACH TO THE RADIUS

■ La n d m a rks: la t e ra l e p ico n d yle , t u b e rcle o f List e r
■ Th e skin in cisio n is ce n t e re d o ve r t h e m a lu n io n a n d fo l-
lo w s a g e n t ly cu rve d lin e st a rt in g ju st a n t e rio r t o t h e la t -
e ra l e p ico n d yle a n d e n d in g ju st d ist a l a n d u ln a r t o t h e
t u b e rcle o f List e r a t t h e w rist (TECH FIG 2 A).
■ In cise t h e fa scia in lin e w it h t h e skin in cisio n .
■ Disse ct b e t w e e n t h e e xt e n so r d ig it o ru m co m m u n is (EDC)
a n d t h e e xt e n so r ca rp i ra d ia lis b re vis (ECRB) p ro xim a lly.
■ Pro n a t e t h e fo re a rm .
■ Id e n t ify t h e PIN a s it e m e rg e s fro m t h e su p in a t o r 1 cm
p ro xim a l t o t h e d ist a l e d g e o f t h e m u scle (TECH FIG 2 B).
■ Fo llo w t h e n e rve in a d ist a l t o p ro xim a l d ire ct io n
t h ro u g h t h e su p in a t o r, ca re fu lly p re se rvin g it s m o t o r
b ra n ch e s.
■ On ce t h e n e rve is fu lly m o b ilize d a n d p ro t e ct e d , su p in a t e
t h e a rm a n d re le a se t h e su p in a t o r fro m t h e a n t e rio r su r-
fa ce o f t h e ra d iu s in a m e d ia l t o la t e ra l d ire ct io n .
■ To e xp o se t h e m id sh a ft o f t h e ra d iu s d o rsa lly, t h e a b d u c-
t o r p o llicis lo n g u s (APL) a n d t h e e xt e n so r p o llicis b re vis
(EPB) m u st b e m o b ilize d a s t h e y cro ss ra d ia lly o ve r t h e
d o rsa l sh a ft o f t h e ra d iu s.
■ In cise t h e fa scia a lo n g t h e in fe rio r a n d su p e rio r b o rd e rs
o f t h e t w o m u scle s a n d lift t h e m o ff t h e ra d iu s.
■ Re t ra ct t h e m d ist a lly o r p ro xim a lly a s n e e d e d fo r e x-
p o su re o f t h e m a lu n io n .
 Ch a p t e r 1 3 CORRECTIVE OSTEOTOM Y FOR RADIUS AND ULNA DIAPHYSEAL M ALUNIONS 121

TECHNIQUES
A

TECH FIG 2 • Exp o su re o f t h e ra d iu s t h ro u g h t h e d o rsa l a p -

p ro a ch . Th is a p p ro a ch is b e st fo r p ro xim a l sh a ft m a lu n io n s.
A. Skin in cisio n o n d o rsa l su rfa ce , ru n n in g fro m t ip o f la t e ra l
e p ico n d yle t o w a rd ra d ia l st ylo id . B. Th e p o st e rio r in -
Extensor Posterior t e ro sse o u s n e rve is fo llo w e d t h ro u g h t h e su p in a t o r, w it h it s
B digitorum communis interosseous nerve b ra n ch e s p re se rve d .

APPROACH TO THE ULNA

■ La n d m a rk: su b cu t a n e o u s b o rd e r o f t h e u ln a
■ Ma ke a lo n g it u d in a l in cisio n a lo n g t h e su b cu t a n e o u s
b o rd e r o f t h e u ln a (TECH FIG 3 A).
■ In cise t h e fa scia in lin e w it h t h e skin in cisio n .
■ Disse ct b e t w e e n t h e e xt e n so r ca rp i u ln a ris (ECU) d o rsa lly
a n d t h e fle xo r ca rp i ra d ia lis (FCU) vo la rly (TECH FIG 3 B).
■ Ta ke ca re t o a vo id d isru p t in g t h e ECU su b sh e a t h d is- A
t a lly o ve r t h e u ln a h e a d .

TECH FIG 3 • Exp o su re o f t h e u ln a . A. Skin in cisio n a lo n g su b -

cu t a n e o u s b o rd e r o f u ln a . B. Disse ct io n is p e rfo rm e d b e t w e e n
t h e e xt e n so r ca rp i u ln a ris d o rsa lly a n d t h e fle xo r ca rp i ra d ia lis
vo la rly. B

REDUCTION, PLATING, AND BONE GRAFTING

■ Ba se d o n t h e p re o p e ra t ive sch e m e , p e rfo rm t h e p la n n e d
o st e o t o m y a t t h e sit e o f m a lu n io n u sin g a co m b in a t io n
o f a w a t e r-co o le d sa w a n d o st e o t o m ie s.
■ Brin g t h e ra d iu s o u t t o le n g t h a n d in se rt b o n e g ra ft a s
n e ce ssa ry (TECH FIG 4 A).
■ Ma ke a t e m p la t e fo r p la t e co n t o u rin g so a s t o m a t ch t h e
ra d ia l b o w (TECH FIG 4 B,C).
■ Pla t e t h e m a lu n io n u sin g a 3.5-m m co m p re ssio n p la t e a n d
AO co m p re ssio n p la t in g t e ch n iq u e s (TECH FIG 4 D–G).
■ Ob t a in a m in im u m o f six co rt ice s o f fixa t io n p ro xim a l
a n d d ist a l t o t h e m a lu n io n .
■ In sm a lle r p a t ie n t s, a 2.7 DC p la t e m a y b e u se d
in st e a d .

A B C

TECH FIG 4 • A. Re d u ct io n a ft e r o st e o t o m y o f t h e m id sh a ft se g m e n t a l ra d iu s m a lu n io n t h ro u g h a vo la r e xp o su re in t h e p a -
t ie n t in Fig u re s 3 a n d 4. Be ca u se o f t h e se g m e n t a l n a t u re o f t h is m a lu n io n , fixa t io n w a s a cco m p lish e d b y p la t in g b o t h
vo la rly a n d d o rsa lly. B. A m e t a l t e m p la t e is p la ce d o n t h e vo la r su rfa ce o f t h e co rre ct e d ra d iu s. C. Th e t e m p la t e is u se d t o
p re cise ly co n t o u r t h e p la t e so t h a t w h e n a p p lie d , t h e n o rm a l cu rva t u re o f t h e ra d iu s is re st o re d . (co n t in u e d )
 122 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES

Bone
graft

D E

TECH FIG 4 • (co n tin u e d ) D. Pla te fixat ion. E. Sch em at ic d e-

p ict io n o f p la te an d b o n e g raft p lacem en t . F,G. Po st o p e ra tive
ra d io g ra p h s a ft e r d u a l p la tin g o f th e se g m e n t a l ra d ia l sh a ft
m alu n io n se en in Fig u re 3. Bo n e g raft w as in se rt ed a t b o t h
t h e p ro xim al an d d ista l o st eo to m y sit es fo r re alig n m en t o f t h e
ra d ia l b o w a n d n e a r re st o ra t io n o f ra d ia l le n g th . Dist a l ra -
d io u ln ar jo in t in stab ilit y w as t reat ed b y fixa tio n o f th e u ln ar
st ylo id fra ct u re (u sin g a 0.0620-in ch K-wire ) a n d p o sto p e ra tive
im m obilizat ion in sup in ation . F G

■ Aft e r fixa t io n , t a ke t h e fo re a rm t h ro u g h a fu ll su p in a - ■ If t h e jo in t is in co n g ru e n t o r a rt h rit ic, co n sid e r u ln a

t io n –p ro n a t io n a rc.
■ Blo cks t o m o t io n re su lt fro m a n u n co rre ct e d u ln a r
m a lu n io n , DRUJ in co n g ru e n cy o r in st a b ilit y, fa ilu re t o
re st o re t h e ra d ia l b o w , syn o st o sis, a n d so ft t issu e o r
in t e ro sse o u s m e m b ra n e sca rrin g a n d co n t ra ct u re .
■ If a n u ln a o st e o t o m y is re q u ire d , t h e p la t e ca n b e p la ce d
o n t h e vo la r su rfa ce o f t h e u ln a o r o n it s su b cu t a n e o u s
b o rd e r in t h e m a n n e r d e t a ile d a b o ve .
■ If t h e DRUJ is u n st a b le , co n sid e r p a lm a r ca p su la r re e fin g ,
re co n st ru ct io n w it h t e n d o n g ra ft , fixa t io n o f a n u ln a r
st ylo id b a se n o n u n io n , o r p in n in g o f t h e jo in t in fu ll
su p in a t io n .
sh o rt e n in g , m a t ch e d re se ct io n a rt h ro p la st y, Da rra ch re -
se ct io n , o r t h e Sa u ve -Ka p a n d ji p ro ce d u re .
■ Re a p p ro xim a t e t e n d o n in se rt io n s. Fo r e xa m p le , in t h e
ca se o f a vo la r e xp o su re t o t h e d ist a l ra d iu s, re p a ir t h e
PQ t o it s ra d ia l in se rt io n u sin g a b so rb a b le su t u re .
■ Clo se t h e su b cu t a n e o u s t issu e s a n d skin .
■ To m in im ize t h e risk o f co m p a rt m e n t syn d ro m e , d o
n o t clo se t h e fa scia .
■ Ap p ly a vo la r sp lin t .
■ In p a t ie n t s w it h co n co m it a n t DRUJ in st a b ilit y, a
su g a r-t o n g sp lin t w it h t h e fo re a rm in fu ll su p in a t io n
is p la ce d .

PEARLS AND PITFALLS

In d ica t io n s ■ Asse ss DRUJ st a b ilit y.
■ De t e rm in e t h a t la ck o f m o t io n is n o t d u e t o so ft t issu e co n t ra ct u re , syn o st o sis, o r in t e ro sse o u s m e m b ra n e sca rrin g ,
fo r w h ich re a lig n m e n t o f t h e m a lu n io n w o u ld n o t im p ro ve m o t io n .
Ost e o t o m y ■ Ob t a in co n t ra la t e ra l fo re a rm film s t o d e t e rm in e lo ca t io n a n d m a g n it u d e o f ra d ia l b o w .
■ Ob t a in CT o r MRI if co n ce rn e d fo r ro t a t io n a l m a lu n io n .
■ Pe rfo rm d e t a ile d p re o p e ra t ive d ra w in g s t o d e t e rm in e t h e id e a l lo ca t io n fo r t h e o st e o t o m y, t h e d e g re e a n d d ire c-
t io n o f co rre ct io n re q u ire d , a n d t h e n e e d fo r b o n e g ra ft .
■ Ob t a in co n se n t fo r b o n e g ra ft .
Ap p ro a ch ■ If a vo la r a p p ro a ch t o t h e p ro xim a l ra d iu s is ch o se n , a vo id in ju ry t o t h e PIN b y ca re fu l su b p e rio st e a l st rip p in g o f t h e
su p in a t o r fro m t h e ra d iu s a n d g e n t le re t ra ct io n o f t h e su p in a t o r la t e ra lly t o p re ve n t a t ra ct io n n e u ra p ra xia . Avo id
p la cin g a re t ra ct o r a ro u n d ra d ia l n e ck a s t h is ca n co m p re ss t h e PIN (o r ca u se a t ra ct io n in ju ry o f t h e n e rve ). Ge n t ly
re t ra ct t h e su p e rficia l ra d ia l n e rve a n d ra d ia l a rt e ry.
■ Pro t e ct t h e PIN d u rin g d isse ct io n w h e n a p p ro a ch in g t h e p ro xim a l ra d iu s d o rsa lly. Th e n e rve lie s d ire ct ly o n b o n e
d o rsa lly, o p p o sit e o f t h e b icip it a l t u b e ro sit y in 25% o f p a t ie n t s. Avo id t ra p p in g t h e n e rve b e t w e e n t h e p la t e a n d
b o n e w h e n p la cin g a p la t e p ro xim a lly.
DRUJ ■ De t e rm in e t h e ca u se o f in st a b ilit y o f t h e DRUJ o n ce m a la lig n m e n t is re st o re d .
■ Pe rfo rm a p ro ce d u re t h a t a d d re sse s t h e p re cise ca u se o f t h e DRUJ in st a b ilit y.
 Ch a p t e r 1 3 CORRECTIVE OSTEOTOM Y FOR RADIUS AND ULNA DIAPHYSEAL M ALUNIONS
POSTOPERATIVE CARE
■ In a compliant patient with secure fixation, the splint may
be removed 5 to 7 days after surgery and range-of-motion ex-
ercises initiated.
■ A removable orthosis is worn for the next 4 to 5 weeks.
■ Strengthening exercises are begun 6 weeks after surgery.
■ Resistive strength training is delayed until radiographic
evidence of healing is present (usually 8 to 12 weeks postop-
eratively).
■ N ormal activities are resumed when a solid union is present.
■ Plates are generally not removed in adults.
■ If concomitant DRUJ instability is present:
■ A M unster cast is applied at the first postoperative visit.
The forearm is held in full supination for 6 weeks.
■ Finger range-of-motion and elbow flexion–extension ex-
ercises are begun at the first postoperative visit.
■ At 6 weeks, any pins in the DRUJ are removed, and
supination–pronation exercises are initiated.
OUTCOMES
■ Trousdale and Linscheid retrospectively reviewed 27 pa-
tients with corrective osteotomies for forearm malunions.
Indications for surgery included loss of rotation (20 patients),
unstable DRUJ (6 patients), and cosmesis (1 patient). 11
■ O f the six patients with DRUJ instability, five had stable
wrist joints at follow-up. Three patients were stabilized with
correction of the deformity alone, and three required reefing
of the palmar capsule and temporary pinning of the DRUJ
with Kirschner wires (K-wires).
■ The patient who underwent the procedure for cosmesis
lost 10 degrees of rotation but was happy with the overall
appearance and function.
■ The age of the patient at the time of injury, location of the
malunion, and involvement of one or both bones were not
associated with the final outcome.
■ Shorter time from injury to corrective surgery (less than
12 months) was associated with improved forearm rotation
and a lower complication rate.
123
COMPLICATION S
■ A 48% complication rate was noted in Trousdale and
Linscheid’s study.11
■ Infection
■ Wrist pain
■ Loss of motion
■ H eterotopic ossification
■ DRUJ instability
■ Delayed union or nonunion
■ Superficial radial nerve paresthesias
REFEREN CES
1. Botte M . Skeletal anatomy. In: Doyle J, Botte M , eds. Surgical
Anatomy of the H and and Upper Extremity. Philadelphia: Lippincott
Williams & Wilkins, 2003:3–91.
2. Dumont CE, Pfirrmann CW, Z iegler D, et al. Assessment of radial
and ulnar torsion profiles with cross-sectional magnetic resonance
imaging. J Bone Joint Surg Am 2006;88A:1582–1588.
3. The forearm. In: H oppenfeld S, DeBoer P, eds. Surgical Exposures in
O rthopaedics, 2nd ed. Philadelphia: Lippincott Williams & Wilkins,
1994:117–146.
4. Kasten P, Krefft M , H esselbach J, et al. H ow does torsional deformity
of the radial shaft influence the rotation of the forearm? A biome-
chanical study. J O rthop Trauma 2003;17:57–60.
5. M atthews LS, Kaufer H , Garver DF, et al. The effect on supination-
pronation of angular malalignment of fractures of both bones of the
forearm. J Bone Joint Surg Am 1982;64A:14–17.
6. M orrey BF, Askew LJ, An KN, et al. A biomechanical study of normal
functional elbow motion. J Bone Joint Surg Am 1981;63A:872–877.
7. Sarmiento A, Ebramzadeh E, Brys D, et al. Angular deformities and
forearm function. J O rthop Res 1992;10:121–133.
8. Schemitsch EH , Jones D, H enley M B. A comparison of malreduction
after plate and intramedullary nail fixation of forearm fractures. J
O rthop Trauma 1995;9:8–16.
9. Schemitsch EH , Richards RR. The effect of malunion on functional
outcome after plate fixation of fractures of both bones of the forearm
in adults. J Bone Joint Surg Am 1992;74A:1068–1078.
10. Tarr RR, Garfinkel AI, Sarmiento A. The effects of angular and rota-
tional deformities of both bones of the forearm. J Bone Joint Surg Am
1984;66A:65–70.
11. Trousdale RT, Linscheid RL. O perative treatment of malunited frac-
tures of the forearm. J Bone Joint Surg Am 1995;77A:894–902.
12. Tynan M C, Fornalski S, M cM ahon PJ, et al. The effects of ulnar axial
malalignment on supination and pronation. J Bone Joint Surg Am
2000;82A:1726–1731.

Ch a p t e r 14
DEFIN ITION
■ A diaphyseal forearm fracture is generally considered to be
a nonunion if healing has not taken place within 6 months.
■ N onunions are generally classified as hypertrophic or at-
rophic, an important distinction in treatment selection.
■ H ypertrophic nonunions have abundant callus and a rich
blood supply and result from inadequate stability of fracture
fixation. This type of nonunion is rare in the forearm and
constitutes less than 10% of nonunion cases. 9
■ Atrophic nonunions are characterized by poor blood sup-
ply and little or no callus formation.
■ Nonunion of the forearm diaphysis is rare because of the suc-
cess of current techniques of plate and screw fixation. N onunion
rates of only 2% in the radius and 4% in the ulna are reported.2
AN ATOMY
■ The forearm consists of the radius and ulna, joined at either
end by the proximal and distal radioulnar joints (PRUJ and
DRUJ, respectively) (FIG 1 ).
■ The ulna is straight, while the radius has both an apex ra-
dial and apex dorsal curvature.
■ It can help to think of the forearm as a joint rather than a
pair of long bones.
■ Pronation and supination are achieved by rotation of the
curved radius about the straight ulna.
Proximal radiolunar joint
Distal radiolunar
joint
FIG 1 • Th e t w o b o n e s o f t h e fo re a rm fo rm a fu n ct io n a l u n it ,
w it h t h e a xis o f ro t a t io n e xt e n d in g fro m t h e ra d io ca p it e lla r
jo in t t o t h e d ist a l ra d io u ln a r jo in t .
124
Op e r a t iv e Tre a t m e n t o f
Ra d iu s a n d Uln a Dia p h y s e a l
No n u n io n s
Re n a L. St e w art
Both the curvature of the radius and the integrity of the
■
interosseous space and interosseous membrane (IO M ) must
be maintained for the forearm “ joint” to function optimally.
■ The diaphyseal portions of the radius and ulna are sur-
rounded by complex anatomy, including neural and vascular
structures, that must be considered during any surgical ap-
proach. Both radius and ulna are covered by muscle proxi-
mally, while the ulna emerges distally to be subcutaneous.
PATHOGEN ESIS
■ N onunions of the diaphysis of the forearm are rare and re-
sult most commonly from incorrect or inadequate treatment.
■ Inadequate fixation, generally less than six cortices of
screw fixation proximal and distal to the fracture, will in-
crease the rate of nonunion.
■ Lack of attention to critical surgical principles such as cre-
ating compression across the fracture site (either with the
use of an interfragmentary screw or a compression plate)
also leads to nonunion.
■ N onoperative treatment results in markedly increased rates
of nonunion and other complications.2 With the exception of
isolated, minimally displaced ulnar shaft fractures, all adult
diaphyseal forearm fractures require operative management.
■ Comminution increases the risk of nonunion, with 12% of
comminuted, diaphyseal fractures going on to develop
nonunion after treatment with dynamic compression plates.11
■ Fracture characteristics that increase the risk of nonunion
Pronation and include extensive devascularization and periosteal stripping,
supination axis bone loss, and infection.
■ O pen, comminuted fractures with bone loss have the
highest rate of nonunion. 7
■ Patient comorbidities known to increase rates of nonunion
include diabetes mellitus, steroid use, malnutrition, and renal
dysfunction.
N ATURAL HISTORY
■ O nce a nonunion of the forearm is established, it will not go
on to heal spontaneously.
■ If significant shortening of either the radius or ulna occurs,
the intricate anatomy of the entire forearm “ joint” can be dis-
rupted. M alalignment of the DRUJ secondary to such shorten-
ing can cause pain and lead to loss of motion at the wrist.
■ Loss of motion secondary to pain, particularly pronation
and supination, can lead to shortening and fibrosis of the
IO M . This can lead to permanent loss of rotational motion in
the forearm.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■Patients with nonunion of the diaphysis of the radius or ulna
most commonly present with pain.
■ This pain frequently worsens with attempts to use the ex-
tremity for lifting or pushing, but may also occur at rest.
 Ch a p t e r 1 4 OPERATIVE TREATM ENT OF RADIUS AND ULNA DIAPHYSEAL NONUNIONS
■Resisted rotational movements are frequently painful,
such as turning a key in a lock.
■ It is important to explore whether infection could be the
cause of the nonunion. Important history includes whether or
not the original fracture was open, whether postoperative
complications or drainage developed, and whether the patient
has received antibiotics.
■ During the physical examination, the examiner should do
the following:
■ Palpate the nonunion site for pain.
■ Grasp the bone on either side of the nonunion and at-
tempt to flex and extend the nonunion to assess fracture sta-
bility and healing. Palpable motion and increased pain indi-
cate lack of union.
■ Loss of flexion–extension in the elbow may result from
pain. Loss of pronation and supination indicates deranged
forearm anatomy or pain.
■ Loss of flexion or extension at the wrist may indicate pain
or scarring of muscle and tendons or IO M around the
nonunion. Loss of radioulnar deviation may indicate DRUJ
abnormality secondary to shortening at the nonunion site.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Plain radiographs are essential for diagnosis. This should in-
clude AP and lateral views of the forearm, elbow, and wrist.
■ Comparative views of the contralateral forearm, elbow,
and wrist are also essential for preoperative planning.
■ Plain radiographs will allow the surgeon to determine if
the nonunion is hypertrophic (FIG 2 A) or atrophic (FIG 2 B).
■ CT is helpful in identifying synostosis, assessing rotational
deformity, and evaluating the size of the gap between bone
ends at the nonunion site. CT also allows assessment of the
DRUJ and PRUJ.
■ The metal suppression CT technique minimizes the bright
scatter created by retained hardware.
A B
FIG 2 • A. Ra d io g ra p h sh o w in g a n in fe ct e d , h yp e rt ro p h ic
n o n u n io n . Th e a b u n d a n t ca llu s fo rm a t io n in d ica t e s a
b io lo g ica lly a ct ive n o n u n io n . B. Ra d io g ra p h sh o w in g a n
a t ro p h ic n o n u n io n . Th e re is co m p le t e a b se n ce o f ca llu s a t t h e
fra ct u re sit e . Th e p ro b le m in a n a t ro p h ic n o n u n io n is la ck o f
b io lo g ic a ct ivit y. (Co u rt e sy o f Th o m a s R. Hu n t III, MD.)
125
■ M RI is rarely used but can allow further evaluation of
the IO M .
■ A technetium-99m bone scan followed by an indium-
111–labeled leukocyte scan may be indicated when suspicion
of an infected nonunion exists.
■ False-positive and false-negative results occur.
DIFFEREN TIAL DIAGN OSIS
■ M alunion
■ Infection
■ IO M injury
■ Painful hardware
N ON OPERATIVE MAN AGEMEN T
■ The goal of treatment is to alleviate pain and restore func-
tion to the forearm. This can rarely be accomplished without
surgical intervention.
■ In rare circumstances (if the patient is a high risk for surgery
due to comorbidities, for example), an external bone stimula-
tor can be used.
■ A minority of patients develop a stable, fibrous nonunion
that is painless and allows good function. N onoperative man-
agement can be considered in such patients.
SURGICAL MAN AGEMEN T
■ In all nonunions of the forearm, the first considerations are
the patient’s level of pain and function.
■ The surgeon should not elect to operate based on radi-
ographic findings alone.
■ All patients with nonunions should undergo a workup to
determine if the cause of the nonunion is infection, particularly
after open fractures.
■ The workup should include careful history of open frac-
ture, drainage, or postoperative complications after initial
surgery.
■ Blood should be obtained for a complete blood count,
erythrocyte sedimentation rate, and C-reactive protein.
■ N uclear medicine imaging should be performed if the
suspicion of infection is high.
Preoperative Planning
■ All imaging studies should be reviewed and pathoanatomy
recognized.
■ Plain radiographs should be reviewed for presence or ab-
sence of callus in order to categorize the nonunion as hyper-
trophic or atrophic.
■ If a nonunion of the forearm is hypertrophic (which is
rare), it may be treated by simple revision of hardware, cre-
ating compression across the fracture site with either a
compression screw or a compression plate. This is the same
technique that should be used for initial management of
radius or ulna fractures (see Chap. H A-4).
■ If any possibility of infection at the nonunion site exists,
plans must be made to search for infection when the nonunion
site is opened, and to have an alternative treatment plan if in-
fection is encountered.
■ Preoperative antibiotics may be held until cultures are
obtained from the nonunion site (ensure the tourniquet is
not inflated if antibiotics are administered later in the
case).
 126 Se c t i o n I HAND, WRIST AND FOREARM
■ Intraoperative culture swabs and tissue for aerobic, anaer-
obic, and fungal cultures should be obtained from sites
within the nonunion.
■ Patients should be made aware that if severe infection is
encountered, the planned procedure may need to be altered.
For example, if frank purulence is encountered, the
nonunion repair may be abandoned in favor of débridement
and irrigation with possible antibiotic bead placement and
even external fixation if stability is compromised.
■ Template the radiographs to ensure selection of proper plate
size and length.
■ DCP, LCDCP, and combination locking plates are all
appropriate.
■ A minimum of six cortices of screw purchase proximal
and distal to the nonunion is critical. This may require
plates longer than those available in a standard plating set.
■ In osteoporotic bone, the use of locking plates should be
considered.
■ If bone graft will be required, the type of graft should be de-
termined preoperatively. While autograft is still considered the
gold standard, a vast array of bone graft substitutes are now
available. The surgeon’s preference and familiarity with vari-
ous bone graft substitutes may guide this choice. It is impor-
tant to determine if a structural graft will be required, as this
may necessitate the use of autograft.
■ Patients should be counseled regarding the possible need for
(and risks associated with) various types of autograft, includ-
ing the possible need for a tricortical iliac crest or fibula graft
if significant bone loss is encountered.
■ A vascularized fibula graft may be used to fill large de-
fects, especially those associated with infection.1,4,6,12
■ A complete examination of range of motion of the elbow
and wrist, including pronation and supination, should be per-
formed under anesthesia.
TECHNIQUES
PLATE FIXATION FOR TREATMENT OF FOREARM NONUNIONS
Pre p a ra t io n o f t h e No n u n io n
■ De t e rm in e t h e co rre ct le n g t h o f t h e ra d iu s o r u ln a b y
m e a su rin g t h e co rre sp o n d in g co n t ra la t e ra l b o n e .
■ Exp o se t h e n o n u n io n sit e a n d se a rch fo r e vid e n ce o f
in fe ct io n . If fo u n d , se n d sp e cim e n s fo r Gra m st a in a n d
cu lt u re a n d a b o rt t h e p la n n e d p ro ce d u re . Pe rfo rm a
t w o -st a g e re co n st ru ct io n .
■ Th o ro u g h ly d é b rid e a ll n e cro t ic a n d in fe ct e d b o n e
a n d so ft t issu e . Re m o ve a ll h a rd w a re .
■ Pla ce a n t ib io t ic-lo a d e d PMMA b e a d s in t h e g a p .
■ Be g in a m u lt iw e e k co u rse o f a n t ib io t ics b e fo re p ro -
ce e d in g w it h d e fin it ive n o n u n io n re p a ir.
■ If in fe ct io n is co n sid e re d u n like ly, a ft e r re m o va l o f a ll
h a rd w a re , t h o ro u g h ly d é b rid e t h e n o n u n io n sit e o f a ll
n e cro t ic a n d in fla m m a t o ry t issu e , syn o via l m e m b ra n e s,
a n d scle ro t ic o r a va scu la r b o n e (TECH FIG 1 A).
■ To o ls su ch a s cu rve d cu re t t e s, sm a ll ro n g e u rs, a n d a
sm a ll h ig h -sp e e d b u rr (w it h co p io u s irrig a t io n t o p re -
ve n t t h e rm a l in ju ry t o t h e b o n e ) a re h e lp fu l.
■ Fla t t e n t h e b o n e e n d s t o a llo w fo r e xce lle n t fra g -
m e n t -t o -fra g m e n t co n t a ct w it h co m p re ssio n .
Positioning
■ The patient should be positioned supine with the operative
arm extended on a radiolucent arm table.
■ A nonsterile or sterile tourniquet may be applied, but full ac-
cess to the elbow is necessary.
■ Because restoration of the radial bow is a critical component
in restoring forearm motion, intraoperative radiographs show-
ing the entire radius are essential. For this reason, use of the
mini C-arm should be avoided in favor of regular fluoroscopy,
with its much larger field of view.
■ The selected site for harvest of autograft should also be pre-
pared and draped.
Approach
■ The approach to either the radius or ulna should generally
be through the original surgical incisions.
■ Approach to the radius is most commonly volar through the
standard H enry approach. Proximal nonunions of the radius
may be more easily accessed via a dorsal Thompson approach,
particularly in muscular individuals.
■ Care should be taken to identify and protect the posterior
interosseous nerve during this approach.
■ The ulna is accessed along the subcutaneous border in the
interval between the flexor carpi ulnaris and the extensor carpi
ulnaris.
■ Care should be taken to identify and protect the dorsal
cutaneous branch of the ulnar nerve distally.
■ In all cases, preservation of blood supply is key to healing of
a nonunion. Therefore, periosteal stripping should be kept to
a minimum and the use of cautery should be restricted to ves-
sel coagulation.
■ Op e n t h e scle ro t ic b o n e e n d s u sin g se q u e n t ia lly la rg e r
d ia m e t e r d rills.
■ Pa ss t h e se d rills p ro xim a lly a n d d ist a lly a s fa r a s p o ssi-
b le t o o p e n t h e m e d u lla ry ca n a ls (TECH FIG 1 B).
■ Re st rict e le va t io n o f m u scle a n d p e rio st e u m t o o n ly w h a t
is n e e d e d t o t h o ro u g h ly d é b rid e t h e n o n u n io n a n d t o
re a lig n t h e b o n e .
■ Re a lig n t h e b o n e a n d re st o re le n g t h b y m a n ip u la t in g
fra g m e n t s w it h b o n e -h o ld in g fo rce p s.
■ Use o f a sm a ll ske le t a l d ist ra ct o r, sm a ll e xt e rn a l
fixa t o r, o r la m in a sp re a d e r a id s in re st o ra t io n o f
le n g t h . 10
■ Me a su re t h e le n g t h o f t h e re sid u a l b o n e d e fe ct d ire ct ly
a n d , t a kin g in t o co n sid e ra t io n t h e p re o p e ra t ive p la n , d e -
t e rm in e t h e a p p ro p ria t e b o n e g ra ft t o u se .
Co m p re ssio n Pla t in g Wit h o u t
Bo n e Gra ft
■ In ra re ca se s w it h m in im a l o r n o b o n e lo ss a t t h e
n o n u n io n sit e , t h e b o n e m a y b e p la t e d in sit u w it h o u t
ca u sin g sh o rt e n in g . Be ca u se t h e b o n e re m a in s a t n o rm a l
 Ch a p t e r 1 4 OPERATIVE TREATM ENT OF RADIUS AND ULNA DIAPHYSEAL NONUNIONS 127

TECHNIQUES
A

TECH FIG 1 • A. Co m p le t e d é b rid e m e n t o f t h e

n o n u n io n sit e is t h e e sse n t ia l first st e p . An y fib ro u s o r
n e cro t ic m a t e ria l m u st b e re m o ve d a n d t h e b o n e e n d s
d e live re d . B. Me d u lla ry ca n a ls a re o p e n e d u sin g in -
B cre a sin g -d ia m e t e r d rill b it s t o a llo w va scu la r in g ro w t h .

le n g t h , t h e re la t io n sh ip o f t h e ra d iu s a n d u ln a a t b o t h
t h e DRUJ a n d t h e PRUJ is n o t d isru p t e d a n d ro t a t io n w ill
b e p re se rve d .
■ Th is t e ch n iq u e m a y a lso b e u se d if t h e re is n o n u n io n
o f b o t h t h e ra d iu s a n d t h e u ln a . Bo t h b o n e s m a y t h e n
b e sh o rt e n e d a sym m e t rica l d ist a n ce .
■ Aft e r b o n e p re p a ra t io n a s d e t a ile d a b o ve , a n a t o m ica lly
a lig n t h e b o n e e n d s a n d p re cise ly a p p ly a co m p re ssio n
p la t e u sin g t h e sa m e t e ch n iq u e e m p lo ye d fo r a cu t e fo re -
a rm fra ct u re s.
■ En su re t h a t co m p re ssio n o f t h e b o n e e n d s is a ch ie ve d .
■ If a sm a ll b o n e g a p e xist s a ft e r co m p re ssio n , t h e o t h e r
fo re a rm b o n e m a y t h e n b e sh o rt e n e d t o re st o re t h e
le n g t h re la t io n sh ip .
■ Be ca u se t h is a p p ro a ch in vo lve s su rg e ry o n a n o rm a l
b o n e , t h is st ra t e g y sh o u ld b e u se d w it h ca u t io n .
■ Th e g ra ft sh o u ld b e slig h t ly la rg e r t h a n t h a t re q u ire d
b a se d o n p re o p e ra t ive p la n n in g .
■ Pre cise ly co n t o u r t h e g ra ft t o fit sn u g ly in t o t h e d e fe ct .
Sq u a re t h e e n d s o f t h e g ra ft t o m a t ch t h e e n d s o f t h e
b o n e fra g m e n t s.5
■ Alt e rn a t ive ly, cu t b o t h t h e b o n e e n d s o f t h e ra d iu s o r
u ln a a n d o f t h e b o n e b lo ck ch a m fe re d , o r o n t h e b ia s,
t o in cre a se t h e a re a o f b o n y co n t a ct . 3 Th is a lso a llo w s
t h e g ra ft t o b e w e d g e d se cu re ly in p la ce .
■ In se rt t h e g ra ft b e fo re p la t e fixa t io n a n d fill a n y re sid u a l
g a p s w it h ca n ce llo u s b o n e a ft e r p la t e a p p lica t io n .

Ca n ce llo u s Bo n e Gra ft in g
■ Ca n ce llo u s b o n e g ra ft in g is g e n e ra lly u se d fo r sm a ll d e -
fe ct s u p t o 3 cm t h a t ca n b e e ffe ct ive ly st a b ilize d w it h a
p la t e .
■ Ga p s o f u p t o 6 cm h a ve b e e n su cce ssfu lly t re a t e d
u sin g ca n ce llo u s b o n e fo r g ra ft in g .9
■ Firm ly p a ck t h e ca n ce llo u s a u t o g ra ft in t o t h e re sid u a l
n o n u n io n d e fe ct a ft e r t h e p la t e is a p p lie d .
■ En su re t h e g ra ft d o e s n o t e sca p e fro m t h e n o n u n io n sit e
a n d co m e t o lie o n t h e IOM (TECH FIG 2 ).

St ru ct u ra l Co rt ico ca n ce llo u s
Au t o g ra ft Bo n e Gra ft in g
■ St ru ct u ra l a u t o g ra ft h a rve st e d fro m t h e a n t e rio r o r p o s-
t e rio r ilia c cre st is u se d fo r la rg e r d e fe ct s.
■ Exp o se t h e su p e rio r cre st a n d d e fin e t h e in n e r a n d o u t e r Bone graft
t a b le s.
TECH FIG 2 • Th e n o n u n io n g a p is d ist ra ct e d if n e ce ssa ry t o
■ Ut ilize a w a t e r-co o le d sa g it t a l sa w a n d o st e o t o m e s t o re cre a t e t h e n o rm a l a n a t o m ic b o n e le n g t h . A 3.5-m m p la t e
h a rve st a t rico rt ica l b lo ck o f b o n e fro m t h e ilia c cre st . w it h a m in im u m o f t h re e scre w s p ro xim a l a n d d ist a l sh o u ld b e
Ad d it io n a lly, h a rve st ca n ce llo u s b o n e t o fill d e fe ct s t h a t u se d . Ca n ce llo u s b o n e g ra ft is in se rt e d a n d p a cke d in t h e
m a y p re se n t . n o n u n io n g a p .
 128 Se c t i o n I HAND, WRIST AND FOREARM

No n va scu la rize d St ru ct u ra l Fib u la ■ Tib ia l a llo g ra ft is re co m m e n d e d d u e t o it s su it a b le

TECHNIQUES

t h ickn e ss a n d m e ch a n ica l ch a ra ct e rist ics, w h ich p ro -

Au t o g ra ft Wit h Co rt ica l Allo g ra ft
vid e e xce lle n t scre w p u rch a se . 8
Bo n e Gra ft in g ■ Pla ce t h e co rt ica l a llo g ra ft a lo n g t h e o u t e r co rt e x o f t h e
■ An a p p ro p ria t e -le n g t h se g m e n t a l g ra ft is h a rve st e d fro m b o n e , o p p o sit e t h e p la t e , sp a n n in g b e yo n d t h e le n g t h o f
t h e fib u la a n d p la ce d in t o t h e d e fe ct . t h e fib u la a llo g ra ft .
■ Th e fib u la is a p p ro a ch e d la t e ra lly, via t h e in t ra m u scu la r ■ In se rt t h e re m a in d e r o f t h e scre w s so t h a t t h e y p a ss
p la n e b e t w e e n t h e p e ro n e a l m u scle s a n d t h e so le u s. t h ro u g h t h e p la t e a n d t h e n t h e p a t ie n t ’s b o n e a n d
■ A cu ff o f m u scle 2 t o 3 m m in t h ickn e ss sh o u ld b e le ft t o fin a lly in t o t h e co rt ica l a llo g ra ft o n t h e o p p o sit e sid e
p ro t e ct t h e p e rio st e u m . (TECH FIG 3 ).
■ Th e IOM is in cise d lo n g it u d in a lly, t a kin g ca re t o a vo id
t h e p o st e rio r n e u ro va scu la r b u n d le .
■ Th e fib u la is o st e o t o m ize d p ro xim a lly a n d d ist a lly t o cre -
a t e a n a p p ro p ria t e -le n g t h g ra ft .
■ Co m p lica t io n s o f fib u la r h a rve st a re ra re b u t in clu d e
t ra n sie n t m o t o r w e a kn e ss, p e ro n e a l n e rve p a lsy, a n d
fle xo r h a llu cis lo n g u s (FHL) co n t ra ct u re .
■ A m in im u m o f 6 cm o f t h e d ist a l fib u la m u st b e
re t a in e d t o a vo id a d ve rse ly a ffe ct in g t h e d ist a l
t ib io fib u la r syn d e sm o sis a n d a n kle jo in t fu n ct io n .
■ In se rt t h e fib u la g ra ft in t o t h e d e fe ct a n d t h e n a p p ly t h e
p la t e a s d e scrib e d b e lo w , first p la cin g t h e t w o scre w s ju st
p ro xim a l a n d ju st d ist a l t o t h e n o n u n io n t o g a in in it ia l
co m p re ssio n .
■ Se le ct a co rt ica l a llo g ra ft se ve ra l ce n t im e t e rs lo n g e r t h a n
t h e d e fe ct .
Autologous
TECH FIG 3 • Co m bine d in t e rca la ry a ut o gra ft a n d a llo g raft st ru t fibular graft
t ech n iq u e d escrib ed b y Mo ro n i et al.8 Aft er d éb rid e men t o f th e
n o n u n io n sit e, an in te rcalary g ra ft o f ap p ro p riat e le n g t h is h arvest ed Allograft
fro m th e p a tie n t’s fib u la a n d p la ce d in t h e g a p . A co rt ica l a llo g ra ft is cortical strut
p la ce d o p p o site to t h e p la te , an d screw s a re p laced p assin g th o u g h
t h e p lat e, t h e p at ien t ’s ra d iu s o r u ln a, an d fin ally th e a llo g ra ft stru t . A B

COMPRESSION PLATE FIXATION

■ Se le ct a 3.5-m m (sm a ll fra g m e n t ) co m p re ssio n p la t e o f
a d e q u a t e le n g t h t o e n su re a m in im u m o f t h re e o r fo u r
scre w s (six t o e ig h t co rt ice s) o n e it h e r sid e o f t h e
n o n u n io n .
■ Alw a ys e rr o n t h e sid e o f a lo n g e r p la t e .
■ Th in n e r lo ckin g p la t e s m a y b e co n sid e re d w h e n st ru c-
t u ra l fib u la r a u t o g ra ft s a re co m b in e d w it h co rt ica l a l-
lo g ra ft st ru t s.
■ Fix t h e p la t e t o t h e b o n e in co m p re ssio n (en su rin g t h at
p ro pe r le ng t h is m a int a in e d) w it h o ne scre w p ro xim a l a nd
o n e scre w d ist a l t o t he n on un io n , t h e n u se fu ll-le n g t h flu -
o ro sco p ic vie w s or ra d iog ra ph s o f t h e fo re a rm t o e n su re
re st o ra t io n o f le n g t h , b o w , a n d jo in t a lig n m e n t .
■ Co m p a re w it h t h e co n t ra la t e ra l fo re a rm .
■ In se rt t h e re m a in in g scre w s.
■ Id e a lly, scre w s a re n o t p la ce d in t o t h e g ra ft it se lf a n d
t h e g ra ft is st a b ilize d b y t h e co m p re ssio n cre a t e d b y
t h e p la t e (TECH FIG 4 ). Tricortical graft
■ Clo se t h e w o u n d ro u t in e ly a n d a p p ly a n a b o ve -e lb o w o r
TECH FIG 4 • Mo d ifie d Nico ll t e ch n iq u e w it h t rico rt ica l ilia c cre st
su g a rt o n g sp lin t .
g ra ft . Th e g ra ft is ch a m fe re d , a llo w in g t h e g ra ft t o b e
co m p re sse d a s t h e p la t e is a p p lie d .
 Ch a p t e r 1 4 OPERATIVE TREATM ENT OF RADIUS AND ULNA DIAPHYSEAL NONUNIONS 129

PEARLS AND PITFALLS

In d ica t io n s ■ Ca re fu l e va lu a t io n o f t h e p a t ie n t ’s p a in a n d fu n ct io n a l lim it a t io n s m u st b e d o n e b e fo re su rg ica l
m a n a g e m e n t is p la n n e d .
Ra d io g ra p h s ■ Diffe re n t ia t io n sh o u ld b e m a d e b e t w e e n h yp e rt ro p h ic a n d a t ro p h ic n o n u n io n s, a s t re a t m e n t d iffe rs.
■ Co n t ra la t e ra l ra d io g ra p h s m u st b e u se d t o d e t e rm in e t h e a p p ro p ria t e le n g t h o f t h e fo re a rm b o n e s
a n d d e g re e o f ra d ia l b o w .
■ An a t o m ic re st o ra t io n o f le n g t h a n d b o w is n e ce ssa ry t o a llo w fu ll ro t a t io n a l m o t io n o f t h e fo re a rm .
Dia g n o sis o f in fe ct io n ■ A co m p le t e p re o p e ra t ive in fe ct io n w o rku p sh o u ld b e d o n e fo r a ll p a t ie n t s w it h a n o n u n io n .
■ A n e g a t ive p re o p e ra t ive w o rku p d o e s n o t ru le o u t in fe ct io n .
■ An in t ra o p e ra t ive in fe ct io n w o rku p , in clu d in g Gra m st a in a n d cu lt u re , sh o u ld b e p e rfo rm e d a n d a n
a lt e rn a t ive p la n sh o u ld b e a va ila b le if in fe ct io n is e n co u n t e re d .
No n u n io n sit e p re p a ra t io n ■ Dé b rid e m e n t o f a ll n e cro t ic, scle ro t ic, a n d a va scu la r t issu e fro m t h e n o n u n io n sit e is e sse n t ia l.
■ Op e n in g t h e scle ro t ic b o n e e n d s a n d g e n t le re a m in g o f t h e m e d u lla ry ca n a ls p ro m o t e s in g ro w t h o f
m e d u lla ry b lo o d ve sse ls.
■ Pe rio st e a l st rip p in g a n d ca u t e ry m u st b e m in im ize d t o p re se rve p e rio st e a l b lo o d su p p ly.
Gra ft se le ct io n ■ De fe ct s u p t o 3 cm a re su cce ssfu lly m a n a g e d w it h ca n ce llo u s a u t o g ra ft a n d a p p ro p ria t e fixa t io n .
■ Bo ne gra ft su bstit ut e s m a y o ffer a ltern a tive s to a u t og ra ft, b u t n o co m p arat ive st u dies e xist a t this t ime .
Co m p re ssio n o f st ru ct u ra l ■ Co m p re ssio n m u st b e cre a t e d a cro ss a ll st ru ct u ra l g ra ft s.
g ra ft s

POSTOPERATIVE CARE ■ Recurrent nonunion and hardware failure

■ The longer motion is delayed after surgery, the greater the
chance the patient will develop stiffness. Therefore, early active
range of motion (RO M ) should be initiated at the first postop-
erative visit, except in cases with more tenuous fixation.
■ Use of the arm for activities of daily living is encouraged.
■ If the patient has difficulty in achieving satisfactory RO M
with active, active-assisted, and gentle passive RO M , static
progressive splints may be used.
■ H aving the patient sleep in a static extension splint may
significantly improve elbow extension.
■ H eavy lifting, pushing, and weight bearing are delayed
until radiographic evidence of healing is present, often 3 to
6 months after the index procedure.
OUTCOMES
■ When precise surgical techniques are used, such as creating
stable compression across structural grafts, high rates of union
are expected.
■ Rates of healing from 95% to 100% are reported for all
of the methods described in this chapter. 3,8,9
■ Failure of union is related to recurrence of previous infec-
tion in nearly all cases. The prognosis for infected nonunions
should be guarded.
■ Patient satisfaction does not correlate directly with bony
healing. In multiple studies only two thirds of patients
achieved good or excellent results.3,5,8,9
■ Unsatisfactory results are associated with poor postopera-
tive motion in the majority of cases.
■ O ther injuries to the upper extremity (common in high-
energy trauma associated with nonunions) contributed to
unsatisfactory overall function in a minority of patients.9,10
■ Because nonunion of the forearm diaphysis is a rare condi-
tion, no comparative studies of treatment methods exist, in-
cluding the use of bone graft substitutes.
COMPLICATION S
■ Infection
■ Graft displacement
■ Loss of motion
■ Synostosis
■ Pain or other complications at the autograft harvest site
REFEREN CES
1. Adani R, Delcroix L, Innocenti M , et al. Reconstruction of large post-
traumatic skeletal defects of the forearm by vascularized free fibular
graft. M icrosurgery 2004;24:423–429.
2. Chapman M W, Gordon JE, Z issimos AG. Compression-plate fixa-
tion of acute fractures of the diaphyses of the radius and ulna. J Bone
Joint Surg Am 1989;71A:159–169.
3. Davey PA, Simonis RB. M odification of the N icoll bone-grafting
technique for nonunion of the radius and/or ulna. J Bone Joint Surg
Br 2002;84B:30–33.
4. Dell PC, Sheppard JE. Vascularized bone grafts in the treatment of in-
fected forearm nonunion. J H and Surg Am 1984;9A:653–658.
5. Grace TG, Eversman WW. The management of segmental bone loss
associated with forearm fractures. J Bone Joint Surg Am 1980;62A:
1150–1155.
6. Jupiter JB, Gerhard H J, Guerrero J, et al. Treatment of segmental
defects of the radius with use of the vascularized osteoseptocuta-
neous fibular autogenous graft. J Bone Joint Surg Am 1997;79A:
542–550.
7. M oed BR, Kellam JF, Foster JR, et al. Immediate internal fixation of
open fractures of the diaphysis of the forearm. J Bone Joint Surg Am
1986;68A:1008–1017.
8. M oroni AG, Rollo G, Guzzardella M , et al. Surgical treatment of iso-
lated forearm non-union with segmental bone loss. Injury 1997;28:
497–504.
9. Ring D, Allende C, Jafarnia K, et al. Ununited diaphyseal forearm
fractures with segmental defects: plate fixation and autogenous
cancellous bone-grafting. J Bone Joint Surg Am 2004;86A:
2440–2445.
10. Ring D, Jupiter JB, Gulotta L. Atrophic nonunions of the proximal
ulna. Clin O rthop Relat Res 2003;409:268–274.
11. Ring D, Rhim R, Carpenter C, et al. Comminuted diaphyseal frac-
tures of the radius and ulna: does bone grafting affect nonunion rate?
J Trauma 2005;59:436–440.
12. Safoury Y. Free vascularized fibula for the treatment of traumatic
bone defects and nonunions of the forearm bones. J H and Surg Br
2005;30B:67–72.
 Co r re ct iv e Os t e o t o m y f o r
Ch a p t e r 15 Dis t a l Ra d iu s M a lu n io n
David Rin g , Die g o Fe rn an d e z , an d Je sse B. Ju p it e r

DEFIN ITION ■ Risk factors for fracture instability include age, metaphyseal
comminution, dorsal tilt, ulnar variance, and lack of func-
■ Distal radius malunion is best defined as malalignment asso-
tional independence.
ciated with dysfunction. ■ M anipulation of previously reduced fractures that redisplace
■ M alalignment does not always result in dysfunction. In
in a cast or splint signifies instability and is not worthwhile.
particular, the vast majority of older, low-demand patients ■ Limitations of various treatment techniques may contribute
function very well with deformity.
■ Dysfunction can include loss of motion, loss of strength, or
to creation of a malunion.
■ Percutaneous pins alone may not be sufficient to maintain
pain.1,2,5
■ Pain can be the most difficult to associate with deformity.
alignment when there is substantial metaphyseal comminution.
■ External fixation alone without ancillary percutaneous
O steotomy for pain—as with any surgery for pain—is rela-
pin fixation of the fracture
tively unpredictable and should be undertaken with caution. ■ Early removal of pins or an external fixator. Settling of
Carpal malalignment, ulnocarpal impaction, and distal ra-
the fracture can also be observed after implant removal
dioulnar joint malalignment are all potentially painful and can
more than 6 weeks after injury, particularly when there is
be variably addressed.
■ The relationship between distal radius malunion and carpal
substantial metaphyseal comminution.
■ N onlocked plates may loosen in the osteopenic metaphy-
tunnel syndrome is disputed. Some surgeons claim a direct
seal bone.
causal relationship as well as the ability to improve carpal tun- ■ Complacence must be avoided. M any older patients desire
nel syndrome with osteotomy alone.
optimal wrist alignment and function, and treatment decisions
AN ATOMY should not be made on chronological age alone.
■ Loss of alignment can be measured on radiographs.
■ Angulation of the articular surface on the lateral view is
N ATURAL HISTORY
measured as the angle between a line connecting the dorsal
■ Ulnar-sided wrist pain can improve for a year or more after
and palmar lips of the distal radius articular surface on the lat- fracture of the distal radius, so patience is warranted.
■ Lack of forearm rotation may be related to capsular con-
eral view and a line perpendicular to the radius shaft.
■ Ulnarward inclination (often called radial inclination, a mis- tracture or bony malalignment. For slight malunions, patience
nomer since the articular surface tilts toward the ulna) is mea- with exercises and rehabilitation is advisable.
sured as the angle between a line connecting the ulnar limit and
the radial limit of the distal radius articular surface on the pos-
teroanterior (PA) view and a line perpendicular to the radial shaft.
■ Ulnar variance is a better measure of shortening of the ra-

dius than radial length. It is measured as the distance between Line 1

two lines drawn perpendicular to the radial shaft on the PA
view, one at the level of the most ulnar corner of the lunate
facet and the other at the distal limit of the ulnar head.
■ Positive ulnar variance means that the ulna is longer than
A
D C
the radius. N egative means the ulna is shorter. B
■ Loss of articular surface alignment can be measured on ra-

diographs as gap, step, or subluxation.

■ This is most accurately measured using CT images (FIG 1 ).

■ Sources of variability in radiographic measurements include

variation in the radiographs, imprecision in the measurement tech-

niques, and imprecision in the selection of the points of reference.

PATHOGEN ESIS Gap = AC

■ Fractures of the distal radius heal rapidly. A malaligned
healing fracture can be considered a malunion within 4 to
6 weeks of injury.
■ Risk factors for fracture instability, loss of reduction, and
malunion include age over 60 years, more than 20 degrees of
dorsal angulation, dorsal metaphyseal comminution, com-
minution extending to the volar metaphyseal cortex, associ-
ated fracture of the ulna, and displaced articular fracture.
Step = BD
FIG 1 • Th e a rc m e t ho d fo r m e a su rin g a rt icu la r m a la lig n me nt o f
th e d ista l ra d iu s. The d ista n ce b et w een B and D is th e a rt icula r
st e p , a nd the d ista nce be t w e en A and C is th e m axim um a rt icular
g a p. (Afte r Cat ala no LW III, Cole RJ, Ge lb e rma n RH, e t a l.
Disp laced in tra-articu lar fra ct u re s o f th e d ist al asp ect o f t h e ra-
d iu s: lo n g-te rm resu lts in yo u ng a d ult s a ft e r o p e n re du ction a nd
inte rna l fixat ion. J Bone Joint Surg Am 1997;79A:1290–1302.)

130
 Ch a p t e r 1 5 CORRECTIVE OSTEOTOM Y FOR DISTAL RADIUS M ALUNION 131

■ While it is often stated that an extra-articular distal radius dissociative rather than the typical nondissociative carpal
malunion leads to future arthrosis, there are no data to sup- malalignment usually associated with distal radius malunion.
port this contention. ■ Grip strength is one measure of wrist dysfunction, but it is

■ After a recovery period of 1 to 2 years from fracture, the largely determined by pain and effort—both strongly influ-
functional deficits seem fairly stable. enced by psychosocial factors.
■ Articular incongruity or subluxation in relatively nonarticular

areas can be reasonably well tolerated, but in most cases intra-
articular incongruity will lead to arthrosis, pain, and dysfunc-
tion. There is no clear time frame for these changes—indeed,
symptoms do not correlate well with radiographic anatomy and
the predictors of arthrosis are not well established.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Pain should be very discrete and specific. It is important that
there be a direct correlation of the pain with a clear operative
target. Vague, diffuse, or disproportionate pain should not be
treated with osteotomy. Pain alone is not a good indication for
osteotomy, so the interview should elicit specific aspects of the
pain for which there is a good operative target and the risks of
surgery are justified.
■ Lack of motion should be clearly due to malalignment and
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Posteroanterior and lateral radiographs of the wrist (FIG
2 A–D) can be supplemented by specific radiographs for eval-
uation of the joint surface, particularly for potential articular
malunions.
■ Comparison with the opposite, uninjured wrist is useful
and serves as a template for surgical correction.
■ CT, particularly three-dimensional CT, is useful to precisely
evaluate the joint surfaces (FIG 2 E).
■ N europhysiologic tests (nerve conduction velocity and elec-
tromyography) are ordered to evaluate any symptoms or signs
of carpal tunnel syndrome that may need to be addressed.
DIFFEREN TIAL DIAGN OSIS

not due to pain or squeamishness—likewise for instability of

the distal radioulnar joint (DRUJ).
■ Range of motion: A goniometer is used to measure wrist
flexion, extension, radial and ulnar deviation, supination, and
pronation.
■ Ulnocarpal compression: The carpus is forcefully ulnarly
deviated toward the ulna.
■ Consistent reproduction of usual pain with ulnar devia-
tion tasks is consistent with ulnocarpal impaction.
■ The examiner can test for DRUJ instability by stabilizing the
radius and trying to subluxate the distal ulna dorsal and volar
from the sigmoid notch of the radius.
■ Substantially less stability than the opposite side may cor-
■ Stiffness: capsular stiffness and tendon adhesions
■ N umbness: idiopathic carpal tunnel syndrome
■ Pain: another discrete source of pain or even idiopathic pain
N ON OPERATIVE MAN AGEMEN T
■ N onoperative management is appropriate for low-demand
and infirm individuals. Splints are weaned after 6 weeks of
cast immobilization. Patients who struggle to regain motion
may benefit from working with an occupational therapist or a
certified hand therapist. N ormal activities are resumed in 3 or
4 months. The patient may return every 2 or 4 months or so
until satisfied with the result.
■ Patience is warranted in many situations, particularly for

relate with symptomatic DRUJ instability, but this is a very patients with ulnar-sided wrist pain thought due to an extra-
difficult and subjective test. articular malunion.
■ Scaphoid shift test: Instability would indicate a possible ■ This discomfort is the last pain to go away after a distal

scapholunate interosseous ligament tear, indicating a potential radius fracture and routinely lasts up to a year.

A B C D

FIG 2 • A,B. AP a n d la t e ra l ra d io g ra p h s o f e xt ra -a rt icu la r d o rsa lly

a n g u la t e d m a lu n io n . C,D. PA a n d la t e ra l ra d io g ra p h s o f a n e xt ra -
a rt icu la r d o rsa lly d isp la ce d m a lu n io n . E. CT sh o w s ro t a t io n a l d e fo r-
m it y a sso cia t e d w it h a vo la rly d isp la ce d e xt ra -a rt icu la r fra ct u re .
E (Co p yrig h t Die g o Fe rn a n d e z, MD, Ph D.)
132 Se c t i o n I HAND, WRIST AND FOREARM
SURGICAL MAN AGEMEN T
■ Surgery is appropriate when a radiographic deformity corre-
lates with a specific anatomically correctable problem and the
deformity is associated with a substantial risk of dysfunction
and arthrosis.
■ The patient must understand the risks and benefits of in-
tervening.
■ The surgeon should be wary of pain as the primary com-
plaint, because pain is strongly influenced by psychosocial
factors, and pain relief is an achievable goal only when con-
sistent with an objective, correctable anatomic deformity
such as discomfort clearly associated with a substantial ul-
nocarpal impingement.
■ When the issue is restriction of motion and there is less
than 20 degrees of dorsal tilt or less than 5 mm of ulnar pos-
itive variance, a nonoperative approach may be warranted.
■ There are no fixed rules or thresholds for acceptable align-
ment. The correlation with symptoms and dysfunction is more
important.
■ Intra-articular osteotomies should be considered only when
the malalignment is simple and the planned correction is
straightforward.
■ For instance, malalignment of volar shearing fracture
would be considered when the fragment is large, there is
little or no articular comminution or impaction, and the
dorsal fragments are not healed in a malaligned position.
B p a tie n t in Techn iq u e s Fig ure s 4 a n d 5. (co nt in u e d )
■ Distal radius osteotomy need not be performed urgently.
The patient should have demonstrated excellent exercise skills
and full finger motion, and there should be no significant
nerve or tendon dysfunction or edema.
■ In the case of an intra-articular malunion, intervening
early (optimally within 6 months, definitely within 1 year of
the fracture) when the fracture is not completely healed may
take precedence over these concerns.
Preoperative Planning
■ The desired angular, rotational, and length corrections are
planned based on preoperative radiologic studies, including a
radiograph of the opposite wrist if uninjured (FIG 3 A,B).
■ It can be useful to draw and write out a reconstruction plan,
particularly for complex malunions (FIG 3 C–E). In that way
every contingency is anticipated and the surgery is likely to go
more smoothly.
Positioning
■ The patient is positioned supine with the arm supported on
a hand table.
■ A nonsterile pneumatic tourniquet is used and inflated after
exsanguination and before the skin incision.
Approach
■ The operative approach is either dorsal or volar, depending
on the deformity and the chosen surgical technique.
FIG 3 • A,B. Preope ra tive pla ns for d orsal o st eot om y in
t h e p at ien t in Tech n iq u es Fig u re s 1 t o 3: p reo ste o t o my
p la n (A) and p ost oste oto my and cort icocance llous bone
g raft ing plan (B). C. Preop era tive p la n for an ext ra-
art icular ost eot om y t hrough a volar approa ch in th e
 Ch a p t e r 1 5 CORRECTIVE OSTEOTOM Y FOR DISTAL RADIUS M ALUNION
D E
DORSAL EXTRA-ARTICULAR DISTAL RADIUS OSTEOTOMY:
CORTICOCANCELLOUS GRAFT
Exp o su re
■ Ma ke a lo n g it u d in a l in cisio n ce n t e re d o ve r t h e t u b e r-
cle o f List e r, in lin e w it h t h e t h ird m e t a ca rp a l (TECH
FIG 1 A).
■ Ele va t e skin fla p s, t a kin g ca re t o p ro t e ct t h e b ra n ch e s o f
t h e su p e rficia l ra d ia l n e rve in t h e ra d ia l skin fla p .
■ In cise t h e re t in a cu lu m o ve r t h e t h ird e xt e n so r co m -
p a rt m e n t . Re m o ve t h e t e n d o n o f t h e e xt e n so r
p o llicis lo n g u s (EPL) a n d t ra n sp o se it ra d ia lw a rd
(TECH FIG 1 B).
■ Th e EPL t e n d o n w ill b e le ft in t h e su b cu t a n e o u s t is-
su e s a t t h e co m p le t io n o f t h e p ro ce d u re .
A st o re t h e a p p ro p ria t e u ln a rw a rd in clin a t io n o f t h e
B ■
TECH FIG 1 • Co rre ct io n o f e xt ra -a rt icu la r d o rsa lly a n g u la t e d
m a lu n io n in t h e p a t ie n t in Fig u re 2A,B. A. St ra ig h t lo n g it u d i-
n a l skin in cisio n . B. Th e e xt e n so r p o llicis lo n g u s is m o b ilize d
a n d t ra n sp o se d d o rso ra d ia lly in t o t h e su b cu t a n e o u s t issu e s.
(Co p yrig h t Dieg o Fern and ez, MD, Ph D.)
133
FIG 3 • (con t in u ed ) D,E. Pre o p erat ive p lans for an intra-art ic-
u la r d o rsa lly an g u lat ed m alu n io n in t h e p at ien t in
Tech niqu e s Fig u re 6. (Co p yrig ht Die go Fe rn a n d e z, MD, Ph D.)
TECHNIQUES
■ Ele va t e t h e fo u rt h d o rsa l co m p a rt m e n t a n d it s t e n d o n s
su b p e rio st e a lly.
■ Pre se rve t h e in t e g rit y o f t h is co m p a rt m e n t .
■ It is u su a lly n o t p o ssib le t o e le va t e t h e se co n d d o rsa l
co m p a rt m e n t su b p e rio st e a lly, so sim p ly re t ra ct t h e e x-
t e n so r ca rp i ra d ia lis b re vis a n d lo n g u s t e n d o n s ra d ia l-
w a rd a ft e r o p e n in g t h e co m p a rt m e n t .
Ost e o t o m y a n d Re a lig n m e n t
■ Kirsch n e r w ire s d rille d p a ra lle l t o t h e a rt icu la r
su rfa ce ca n fa cilit a t e m o n it o rin g o f re a lig n m e n t
(TECH FIG 2 A).
■ A d ist ra ct o r o r sm a ll e xt e rn a l fixa t o r m a y fa cilit a t e re -
a lig n m e n t a n d p ro visio n a lly st a b ilize t h e fra ct u re .
■ Th e p ro xim a l t h re a d e d p in is d rille d in t o t h e ra d ia l
d ia p h ysis p e rp e n d icu la rly in a p o sit io n t h a t w ill n o t
in t e rfe re w it h im p la n t a p p lica t io n .
■ Th e d ist a l t h re a d e d p in is d rille d a t a n a n g le e q u a l t o
t h e d e sire d co rre ct io n o f t h e la t e ra l t ilt o f t h e d ist a l
ra d iu s a rt icu la r su rfa ce so t h a t d ist ra ct io n o f t h e t w o
p in s w ill b rin g t h is p in p a ra lle l t o t h e p ro xim a l p in
(p e rp e n d icu la r t o t h e ra d iu s), t h e re b y re st o rin g
a lig n m e n t .
■ Th e p in s sh o u ld b e d rille d so t h a t t h e y a lso h e lp re -
d ist a l ra d iu s a rt icu la r su rfa ce w h e n d ist ra ct e d .
■ Pla n n e d a n g u la r co rre ct io n s ca n b e m o n it o re d w it h
st e rile g e o m e t ric t e m p la t e s.
■ Th e o st e o t o m y is m a d e p a ra lle l w it h t h e d ist a l Kirsch n e r
w ire a n d a s clo se t o t h e o rig in a l fra ct u re sit e a s p o ssib le
u sin g a n o scilla t in g sa w (TECH FIG 2 B).
■ If t h e fra ct u re is n o t ye t co m p le t e ly h e a le d (n a sce n t
m a lu n io n —u su a lly w it h in 4 m o n t h s o f in ju ry), re cre a t e
t h e o rig in a l fra ct u re lin e b y ca re fu lly re m o vin g fra ct u re
ca llu s a t t h e fra ct u re sit e .
■ Th is ca llu s ca n b e sa ve d a n d u se d a s b o n e g ra ft .
If t h e fra ct u re is so lid ly h e a le d , a t t e m p t t o id e n t ify t h e
p rio r fra ct u re sit e . If t h is is u n ce rt a in , ch o o se a sit e t h a t
cre a t e s a d ist a l fra g m e n t la rg e e n o u g h t o fa cilit a t e m a -
n ip u la t io n a n d in t e rn a l fixa t io n w h ile t ryin g t o st a y d is-
t a l e n o u g h t o t a ke a d va n t a g e o f t h e h e a lin g ca p a cit y o f
m e t a p h yse a l b o n e .
 134 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES

A C

B D

TECH FIG 2 • A. Kirsch n e r w ire s a re p la ce d p a ra lle l t o t h e a rt icu la r su rfa ce . Flu o ro sco p ic im a g e

sh o w in g p in p la ce m e n t . B. Th e o st e o t o m y is m a d e w it h a sa w a s clo se a s p o ssib le t o t h e o rig in a l
fra ct u re sit e . C. La t e ra l flu o ro sco p ic im a g e sh o w in g u se o f a la m in a sp re a d e r t o re a lig n t h e d ist a l
fra g m e n t . D. Th e o st e o t o m y h a s b e e n o p e n e d a n d is re a d y fo r g ra ft p la ce m e n t . (Co p yrig h t Diego
Fe rna nde z, MD, Ph D.)

■ A la m in a sp re a d e r ca n b e u se d t o h e lp re a lig n t h e d ist a l m o rb id it y a sso cia t e d w it h h a rve st o f a st a n d a rd ilia c

fra g m e n t a s w e ll (TECH FIG 2 C,D).
■ Ca re m u st b e t a ke n w h e n o p e ra t in g o n o st e o p o ro t ic
bone.
■ Ad d it io n a l p ro visio n a l st a b ilit y ca n b e p ro vid e d b y p la c-
in g 1.6-m m sm o o t h Kirsch n e r w ire s.
■ If t h e u ln a r va ria n ce ca n b e re st o re d w it h a n g u la r re -
a lig n m e n t a lo n e , t h e vo la r co rt e x ca n b e cra cke d a n d
h in g e d o p e n in a n a t t e m p t t o m a in t a in so m e st a b ilit y o f
t h e o st e o t o m y. If le n g t h e n in g o f t h e vo la r co rt e x is re -
q u ire d t o re st o re u ln a r va ria n ce , a se co n d d ist ra ct o r in
a n o t h e r p la n e (e g , d ire ct ra d ia l) m a y p ro ve u se fu l fo r o b -
t a in in g a n d m a in t a in in g a lig n m e n t .
Gra ft In se rt io n a n d Fixa t io n
■ On ce t h e o st e o t o m y is cre a t e d a n d t h e ra d iu s re a lig n e d ,
b o n e g ra ft is in se rt e d .
■ Ha rve st b o n e g ra ft (TECH FIG 3 A). Eit h e r a co rt ico ca n ce l-
lo u s (st ru ct u ra l) b o n e g ra ft o r ca n ce llo u s b o n e g ra ft ca n
b e u se d .
■ Po t e n t ia l a d va n t a g e s o f a st ru ct u ra l g ra ft in clu d e im -
m e d ia t e st ru ct u ra l su p p o rt (TECH FIG 3 B) a n d t h e
p o ssib ilit y o f u sin g a sm a lle r im p la n t a n d t h e re b y
a vo id in g t e n d o n irrit a t io n .
■ A ca n ce llo u s (n o n st ru ct u ra l) b o n e g ra ft ca n b e h a r-
ve st e d u sin g t re p h in e s (TECH FIG 3 C). Th is a vo id s t e -
d io u s, d ifficu lt , a n d u n p re d ict a b le h a rve st a n d co n -
t o u rin g o f co rt ico ca n ce llo u s g ra ft s, a s w e ll a s t h e
cre st b o n e g ra ft .
■ Ap p ly a sin g le T- o r Pi-sh a p e d p la t e o r t w o 2.0- o r 2.4-m m
p la t e s (o n e a p p lie d d o rsa lly, u ln a r t o t h e t u b e rcle o f
List e r, a n d t h e o t h e r a p p lie d ra d ia lly b e t w e e n t h e first
a n d se co n d d o rsa l co m p a rt m e n t s).
■ Wh e n a st ru ct u ra l, co rt ico ca n ce llo u s b o n e g ra ft is
u se d , a sin g le p la t e o r a p la t e a n d se p a ra t e scre w m a y
b e a d e q u a t e (TECH FIG 3 D–H).
■ Pla t e s w it h a n g u la r st a b le scre w s o r b la d e s in t h e d is-
t a l fra g m e n t m a y b e m o re re lia b le t h a n st a n d a rd
scre w s, p a rt icu la rly if t h e b o n e is o f p o o r q u a lit y a n d
if n o n st ru ct u ra l g ra ft is ch o se n .
■ On ce im p la n t s a re p la ce d a n d st a b ilit y is e n su re d , re -
m o ve a ll p ro visio n a l fixa t io n d e vice s.
■ Th is e n t ire p ro ce ss is m o n it o re d u sin g im a g e in t e n sifica -
t io n t o co n firm a p p ro p ria t e o st e o t o m y sit e , co rre ct io n o f
a lig n m e n t , a n d im p la n t p la ce m e n t .
■ Re p a ir t h e e xt e n so r re t in a cu lu m w it h a b so rb a b le su t u re .
■ In so m e ca se s, a fla p o f re t in a cu lu m is b ro u g h t d e e p
t o t h e t e n d o n s t o a d d a la ye r o f p ro t e ct io n b e t w e e n
t h e im p la n t s a n d e xt e n so r t e n d o n s.
■ We u su a lly d o n o t clo se t h e re t in a cu lu m , a n d w e n o
lo n g e r m a ke re t in a cu la r fla p s.
■ Th e t o u rn iq u e t is d e fla t e d a n d h e m o st a sis e n su re d .
■ Th e skin is clo se d .
■ A b u lky d re ssin g in co rp o ra t in g a vo la r p la st e r w rist sp lin t
is a p p lie d .
 Ch a p t e r 1 5 CORRECTIVE OSTEOTOM Y FOR DISTAL RADIUS M ALUNION 135

TECHNIQUES
A B

C D

E F

G H

TECH FIG 3 • A. Cortico can cellou s bo n e g raft is h arvest ed from th e iliac crest. B. After fin al scu lptin g it is app lied
to the oste otomy site. C. Aut og en o us cancello u s b o ne g raft is h arvested fro m the iliac crest u sin g a trep h in e. D. A
2.0-mm con d ylar blade p late can p ro vide fixed -an gle in tern al fixatio n. E,F. Int raoperat ive photographs of the fix-
at io n . G,H. Fin al AP an d lat eral rad io g rap h s. (Co p yrig h t Dieg o Fern an dez, MD, Ph D.)

VOLAR EXTRA-ARTICULAR DISTAL RADIUS OSTEOTOMY

Exp o su re
■ Use a vo la r-ra d ia l He n ry (fle xo r ca rp i ra d ia lis [FCR]) a p -
p ro a ch fo r b o t h d o rsa lly a n d vo la rly a n g u la t e d m a lu -
n io n s (se e Fig 2C,D).
■ Ma ke a 5- t o 7-cm lo n g it u d in a l in cisio n o ve r t h e FCR t e n -
d o n e n d in g a t t h e w rist fle xio n cre a se .
■ If m o re e xp o su re is re q u ire d , t h e in cisio n is a n g le d o r
zig za g g e d a t le a st 45 d e g re e s t o w a rd t h e sca p h o id
d ist a l p o le .
■ In cise t h e FCR sh e a t h , re t ra ct t h e t e n d o n u ln a rly, a n d in -
cise t h e flo o r.
■ Le a ve t h e ra d ia l a rt e ry u n d isse ct e d a n d p ro t e ct e d in
t h e ra d ia l so ft t issu e s.
 136 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES
A B
TECH FIG 4 • Re a lig n m e n t a n d p ro visio n a l fixa t io n o f a n e xt ra -a rt icu la r d o rsa lly d isp la ce d
D m a lu n io n in t h e p a t ie n t in Fig u re 2C,D.
■ Sw e e p t h e fa t o ve rlyin g t h e p ro n a t o r q u a d ra t u s t o -
g e t h e r w it h t h e d ig it a l fle xo rs a n d m e d ia n n e rve u ln a r-
w a rd w it h a sp o n g e o r b lu n t e le va t o r.
■ Pro xim a lly in t h e in cisio n , e le va t e t h e m o st d ist a l a sp e ct
o f t h e o rig in o f t h e fle xo r p o llicis lo n g u s fro m t h e vo la r
d ist a l ra d iu s (t a kin g ca re t o ca u t e rize a co n sist e n t a rt e ry
in t h is re g io n ) a n d re t ra ct it u ln a rly w it h a sm a ll
Ho h m a n n re t ra ct o r p la ce d a ro u n d t h e u ln a r b o rd e r o f
t h e ra d iu s.
■ Exp o se t h e ra d ia l b o rd e r o f t h e ra d iu s u sin g a b lu n t e le -
va t o r a n d Ho h m a n n re t ra ct o rs.
■ In cise t h e p ro n a t o r q u a d ra t u s o ve r it s m o st ra d ia l a n d
d ist a l lim it s (L-sh a p e d in cisio n ) a n d e le va t e it su b p e -
rio st e a lly.
■ Le a vin g t h e p e rio st e u m w it h t h e m u scle ca n fa cilit a t e
la t e r re p a ir.
■ Fo r d o rsa lly a n g u la t e d m a lu n io n s, re le a se o f t h e ra d ia l
a n d d o rsa l so ft t issu e s fa cilit a t e s re a lig n m e n t .
■ Th e b ra ch io ra d ia lis is Z-le n g t h e n e d a n d t h e p e rio s-
t e u m is e le va t e d fro m t h e ra d iu s sh a ft p ro xim a lly.
■ Aft e r o st e o t o m y in t h e m a n n e r d e t a ile d a b o ve (fo r t h e
d o rsa l a p p ro a ch t o m a lu n io n s), p ro n a t e t h e p ro xim a l ra -
d iu s sh a ft o u t o f t h e w o u n d , p ro vid in g a cce ss t o t h e d o r-
sa l p e rio st e u m , w h ich ca n b e iso la t e d a n d d ivid e d .
■ Wit h t h e re le a se o f t h e b ra ch io ra d ia lis a n d t h e d o rsa l
p e rio st e u m , re a lig n m e n t o f t h e ra d iu s is u su a lly co m -
p a ra b le t o a n a cu t e fra ct u re .
■ Vo la rly a n g u la t e d m a lu n io n s d o n o t n e e d a n e xt e n sive
so ft t issu e re le a se in m o st ca se s. Th e p la t e ca n fa cilit a t e
C
re a lig n m e n t b y p u sh in g t h e d ist a l fra g m e n t s in t o p o si-
t io n a s t h e p ro xim a l scre w s a re t ig h t e n e d .
Re a lig n m e n t a n d Pr o v is io n a l
Fix a t io n
■ Th e fra g m e n t s a re re a lig n e d u sin g t h e t e ch n iq u e s
d e scrib e d a b o ve (TECH FIG 4 ).
■ Th e t e ch n iq u e s a re sim ila r t o t h o se fo r a cu t e fra ct u re s
o n ce a n a d e q u a t e so ft t issu e re le a se h a s b e e n
p e rfo rm e d .
■ Ap p ly a fixe d -a n g le vo la r im p la n t .
■ In se rt p ro visio n a l Kirsch n e r w ire s e it h e r t h ro u g h o r a d ja -
ce n t t o t h e p la t e (se e Te ch Fig 4).
Pla t e Fixa t io n
■ Pla ce m e n t o f t h e p la t e w ill fre q u e n t ly h e lp re d u ce t h e
p ro xim a l a n d d ist a l fra g m e n t s (TECH FIG 5 A,B).
■ Aft e r fin a l p la t e fixa t io n a n d re m o va l o f p ro visio n a l
fixa t io n , a p p ly ca n ce llo u s g ra ft t o t h e o st e o t o m y sit e
(TECH FIG 5 C–F).
■ Exce lle n t a cce ss is a va ila b le ra d ia lly fo r p la ce m e n t o f
t h e b o n e g ra ft .
■ Th e t o u rn iq u e t is d e fla t e d a n d h e m o st a sis e n su re d .
■ Re p a ir t h e p ro n a t o r q u a d ra t u s if p o ssib le .
■ It ca n b e su t u re d t o t h e b ra ch io ra d ia lis t e n d o n .
■ Th e skin is clo se d .
■ A b u lky d re ssin g in co rp o ra t in g a vo la r p la st e r w rist sp lin t
is a p p lie d .
 Ch a p t e r 1 5 CORRECTIVE OSTEOTOM Y FOR DISTAL RADIUS M ALUNION 137

TECHNIQUES
A B C

D E F

TECH FIG 5 • A. Flu oroscopic ima ge of p la te fixa tion a nd re alignm ent . B. De fect a ft er co rre ct io n . Au to g en o u s
ca n ce llo u s g ra ft. (C) a n d g ra ft p la ce m e n t (D), sh o w in g fin a l clin ica l a p p e a ra n ce . E,F. Fin a l PA a n d la t e ra l ra d i-
o g ra p h s. (Co p yrig h t Dieg o Fern an d ez, MD, Ph D.)

INTRA-ARTICULAR DISTAL RADIUS OSTEOTOMY

■ In t ra -a rt icu la r o st e o t o m y sh o u ld b e a t t e m p t e d o n ly
w h e n t h e re is a sim p le fra ct u re lin e t h a t ca n b e cle a rly
id e n t ifie d b y d ire ct visu a liza t io n a s w e ll a s u n d e r im a g e
in t e n sifica t io n (TECH FIG 6 A–C).
■ In co m p le t e ly h e a le d fra ct u re s (fe w e r t h a n 3 t o 4
m o n t h s sin ce in ju ry) a re id e a l.
■ De p e n d in g o n t h e lo ca t io n s o f t h e m a lu n it e d a rt icu la r
fra g m e n t s, p e rfo rm e it h e r a d o rsa l o r a vo la r e xp o su re in
t h e m a n n e r d e t a ile d a b o ve .
■ Wh e n a d o rsa l e xp o su re is u se d , a t ra n sve rse ca p su lo -
t o m y a llo w s a cce ss t o t h e jo in t a n d m o n it o rin g o f t h e
a rt icu la r o st e o t o m y a n d re a lig n m e n t .
■ In t h e ca se o f a vo la r e xp o su re , t h e ca p su le is n o t in -
cise d , b u t a rt icu la r e xp o su re m a y b e p o ssib le t h ro u g h
t h e o st e o t o m y sit e .
■ Th e o st e o t o m y sh o u ld re cre a t e t h e o rig in a l fra ct u re
lin e . Th is is m o n it o re d d ire ct ly a n d u n d e r im a g e in t e n -
sifica t io n .
■ Re d u ct io n is a cco m p lish e d b y so ft t issu e re le a se a n d d i-
re ct fra g m e n t m a n ip u la t io n . Fo r m a n y m a lu n io n s it is
n e ce ssa ry t o re m o ve b o n e o r ca llu s fro m t h e fra ct u re sit e
t o re a lig n t h e fra ct u re fra g m e n t . Ca llu s o r b o n e is re -
m o ve d u n t il t h e fra ct u re fra g m e n t fit s p ro p e rly (TECH
FIG 6 D).
■ Pro visio n a l Kirsch n e r w ire s a re u se d t o h o ld t h e re d u c-
t io n (TECH FIG 6 E,F).
■ Th e im p la n t s a re t h e n a p p lie d .
■ Do rsa lly a sin g le T- o r Pi-sh a p e d p la te o r tw o 2.0- o r
2.4-mm pla te s (on e a pplied d orsally, ulnar t o t he tu-
b e rcle o f List e r, a n d t h e o t h e r a p p lie d ra d ia lly b e t we e n
th e first a n d secon d do rsal co mpa rt m en t s) can b e u sed
(TECH FIG 6 G,H).
■ Vo la rly, a T-sh a p e d p la t e is u su a lly u se d .
■ Aft e r fin a l p la t e fixa t io n , p ro visio n a l fixa t io n is re -
m o ve d .
■ Th is e n t ire p ro ce ss is m o n it o re d u sin g im a g e in t e n sifica -
t io n t o co n firm a p p ro p ria t e o st e o t o m y sit e , co rre ct io n o f
a lig n m e n t , a n d im p la n t p la ce m e n t .
■ De fla t e t h e t o u rn iq u e t , clo se t h e w o u n d , a n d a p p ly t h e
sp lin t in t h e m a n n e r d e t a ile d a b o ve .
 138 Se c t i o n I HAND, WRIST AND FOREARM
TECHNIQUES

A B C D

E F G H

TECH FIG 6 • A–C. PA a n d la t e ra l ra d io g ra p h s a n d CT o f a n in t ra -a rt icu la r d o rsa lly a n g u la t e d m a lu n io n . D. A Fre e r e le va t o r is

u se d u n d e r flu o ro sco p y t o re p o sit io n t h e a rt icu la r fra g m e n t . E,F. In t ra o p e ra t ive flu o ro sco p ic vie w s sh o w in g p ro visio n a l co rre c-
t io n a n d fixa t io n . G,H. Fin al p la t e a n d scre w fixa t io n . (Co p yrig h t Dieg o Fe rn an d ez, MD, Ph D.)

PEARLS AND PITFALLS

Pre o p e ra t ive p la n
Ext ra -a rt icu la r m a lu n io n s
■ A p o o r o r in co m p le t e p re o p e ra t ive p la n w ill in cre a se t h e a m o u n t o f u n ce rt a in t y a n d h e sit a t io n
d u rin g su rg e ry. Th is w ill in cre a se t h e o p e ra t ive t im e a n d t h e fru st ra t io n le ve l a n d w ill d e cre a se
t h e sa t isfa ct io n w it h t h e su rg e ry.
■ Ma kin g a d e t a ile d p re o p e ra t ive p la n w ill im p ro ve t h e e fficie n cy a n d e ffica cy o f t h e p ro ce d u re .
■ Ma n ip u la t in g t h e d ist a l fra g m e n t ca n b e m u ch m o re d ifficu lt w it h p o o r-q u a lit y b o n e .
■ Th e u se o f a d ist ra ct o r o r sm a ll e xt e rn a l fixa t o r g re a t ly fa cilit a t e s re a lig n m e n t a n d p ro visio n a l
st a b iliza t io n o f t h e fra g m e n t s.
■ Co n sid e r u sin g t w o d ist ra ct o rs in p e rp e n d icu la r p la n e s (e g , o n e d o rsa l a n d o n e d ire ct ra d ia l) t o

In t ra -a rt icu la r m a lu n io n s
h e lp o b t a in a n d m a in t a in a lig n m e n t .
■ Re st o ra t io n o f le n g t h in a d d it io n t o t h a t g a in e d w it h a n g u la r re a lig n m e n t (ie , le n g t h e n in g o f
b o t h t h e d o rsa l a n d vo la r co rt ice s) is m u ch m o re d ifficu lt .
■ Th e m o st d ifficu lt p a rt o f p e rfo rm in g a n o st e o t o m y fo r a d o rsa l a n g u la t e d m a lu n io n fro m a vo la r
a p p ro a ch is re a lig n m e n t o f t h e b o n e .
■ An e xt e n d e d FCR e xp o su re a llo w s re le a se o f t h e d o rsa l p e rio st e u m a n d Z-le n g t h e n in g o f t h e
b ra ch io ra d ia lis, b o t h o f w h ich fa cilit a t e re a lig n m e n t o f t h e ra d iu s.
■ Ha n d lin g sm a ll a rt icu la r fra ct u re fra g m e n t s ca n b e d ifficu lt .
■ Ea ch fra g m e n t ca n b e re a lig n e d u sin g a Kirsch n e r w ire a s a jo yst ick.

■ Th e a rt icu la r o st e o t o m y is e a sie st w h e n t h e o rig in a l fra ct u re lin e s ca n b e id e n t ifie d .

■ Try t o in t e rve n e w it h in 3 m o n t h s o f in ju ry w h e n a rt icu la r m a lu n io n is id e n t ifie d .
 Ch a p t e r 1 5 CORRECTIVE OSTEOTOM Y FOR DISTAL RADIUS M ALUNION
POSTOPERATIVE CARE
■ Active and active-assisted exercise of the fingers and forearm,
finger exercises to reduce swelling, and active functional use of
the limb for light tasks are encouraged immediately.
■ The initial plaster splint is exchanged for a custom
O rthoplast removable splint 2 weeks after the surgery.
■ The patient gradually weans out of the splint between 4 and
6 weeks after surgery and initiates active and active-assisted
wrist exercises.
■ Strengthening and forceful use of the arm are restricted until
early radiographic union is apparent.
■ Unrestricted use of the limb is allowed when solid union is
present clinically and radiographically.
OUTCOMES
■ Fernandez’ articles describing dorsal osteotomy with cortico-
cancellous bone graft with 1 and without 2 Bower arthroplasty of
the DRUJ established the value of the technique for improving
function in patients with symptomatic distal radius malunions.
■ H e documented good or excellent results in 75% and
80% of patients respectively, noting that satisfactory results
depend upon the absence of degenerative changes in the ra-
diocarpal and intercarpal joints, and the presence of ade-
quate preoperative range of motion of the wrist.
■ Corrective osteotomy with carefully preoperatively
planned structural corticocancellous bone graft does not re-
liably achieve the planned correction.12
■ N onunions, loss of alignment, and major complications
were not reported in these series.
■ Jupiter and Ring5 demonstrated that early correction of dis-
tal radius deformity shortened the period of disability without
increasing complications, and that the combination of cancel-
lous autograft and locking plates was as reliable as corticocan-
cellous bone grafting.9
■ N onunions, loss of alignment, and major complications
were not reported in these series.
■ Several small articles have established the safety and efficacy
of volar osteotomy for a dorsally displaced fracture.4,6
■ Shea et al10 established the safety and efficacy of osteotomy
for volar extra-articular malunions in a case series.
■ Fernandez et al3 established the safety and efficacy of os-
teotomy for a radially deviated extra-articular malunion in a
case series.
139
■ Several case series have documented the safety and efficacy
of intra-articular osteotomy.7,8,11
COMPLICATION S
■ N onunion
■ Loss of alignment
■ Loss of fixation
■ Infection
■ Wound problems
■ N erve injury
REFEREN CES
1. Fernandez DL. Correction of posttraumatic wrist deformity in adults
by osteotomy, bone grafting and internal fixation. J Bone Joint Surg
Am 1982;64A:1164–1178.
2. Fernandez DL. Radial osteotomy and Bowers arthroplasty for malu-
nited fractures of the distal end of the radius. J Bone Joint Surg
1988;70A:1538–1551.
3. Fernandez DL, Capo JT, Gonzalez E. Corrective osteotomy for symp-
tomatic increased ulnar tilt of the distal end of the radius. J H and
Surg Am 2001;26A:722–732.
4. H enry M . Immediate mobilisation following corrective osteotomy of
distal radius malunions with cancellous graft and volar fixed angle
plates. J H and Surg Eur Vol 2007;32:88–92.
5. Jupiter JB, Ring D. A comparison of early and late reconstruction of
the distal end of the radius. J Bone Joint Surg 1996;78A:739–748.
6. M alone KJ, M agnell TD, Freeman DC, et al. Surgical correction of
dorsally angulated distal radius malunions with fixed angle volar
plating: a case series. J H and Surg Am 2006;31A:366–372.
7. M arx RG, Axelrod TS. Intraarticular osteotomy of distal radial malu-
nions. Clin O rthop Relat Res 1996;327:152–157.
8. Ring D, Prommersberger KJ, Gonzalez del Pino J, et al. Corrective os-
teotomy for intra-articular malunion of the distal part of the radius.
J Bone Joint Surg Am 2005;87A:1503–1509.
9. Ring D, Roberge C, M organ T, et al. Comparison of structural and
non-structural bone graft for corrective osteotomy of distal radius
malunion. J H and Surg Am 2002;27A:216–222.
10. Shea K, Fernandez DL, Jupiter JB, et al. Corrective osteotomy for
malunited, volarly displaced fractures of the distal end of the radius.
J Bone Joint Surg Am 1997;79A:1816–1826.
11. Thivaios GC, M cKee M D. Sliding osteotomy for deformity correc-
tion following malunion of volarly displaced distal radial fractures.
J O rthop Trauma 2003;17:326–333.
12. von Campe A, N agy L, Arbab D, et al. Corrective osteotomies in
malunions of the distal radius: do we get what we planned? Clin
O rthop Relat Res 2006;450:179–185.
 Pla t e Fix a t io n o f
Ch a p t e r 16 Cla v icle Fr a ct u re s
David Rin g an d Je sse B. Ju p it e r
DEFIN ITION
■ Displaced, comminuted fractures of the clavicle are at risk
for nonunion and malunion 3–5,7–9 and can be considered for
open reduction and internal fixation with a plate and screws.
AN ATOMY
■ The clavicle and scapula are tightly linked through the
strong coracoclavicular and acromioclavicular ligaments and
link the axial skeleton to the upper extremity.
■ Clavicles are present only in brachiating animals and appar-
ently serve to help hold the upper limb away from the trunk to
enhance more global positioning and use of the limb.
■ The clavicle is named for its S-shaped curvature, with an
apex anteromedially and an apex posterolaterally, similar to the
musical symbol clavicula. The larger medial curvature widens
the space for passage of neurovascular structures from the neck
into the upper extremity through the costoclavicular interval.
■ The clavicle is made up of very dense trabecular bone lacking
a well-defined medullary canal. In cross section, the clavicle
changes gradually between a flat lateral aspect, a tubular mid-
portion, and an expanded prismatic medial end.
■ The clavicle is subcutaneous throughout its length and
makes a prominent aesthetic contribution to the contour of the
neck and upper part of the chest.
■ The supraclavicular nerves run obliquely across the clavicle
just superior to the platysma muscle and should be identified
and protected during operative exposure to offset the develop-
ment of hyperesthesia or dysesthesia over the chest wall.
PATHOGEN ESIS
■ Clavicle fractures usually result from a direct blow to the
point of the shoulder.
■ This is usually a moderate- to high-energy injury in younger
adults but can result from a low-energy fall from a standing
height in an older individual.
N ATURAL HISTORY
■ The overall nonunion rate for diaphyseal clavicle fractures is
4.5% .7
■ The risk of nonunion increases with age, female gender, dis-
placement, and comminution. 7
■ The risk of nonunion for completely displaced (no apposition)
and comminuted fractures is between 10% and 20% (FIG 1 ).9
■ M alunion of the clavicle can result in shoulder girdle defor-
mity and weakness.3–5,9
■ M alunion and nonunion of the clavicle can result in brachial
plexus compression.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ The mechanism and date of injury should be elicited.
■ A careful neurologic examination should be performed.
140
■In contrast to late dysfunction of the brachial plexus after
clavicular fracture, a situation in which medial cord struc-
tures are typically involved, acute injury to the brachial
plexus at the time of clavicular fracture usually takes the
form of a traction injury to the upper cervical roots. Such
root traction injuries generally occur in the setting of high-
energy trauma and have a relatively poor prognosis.
■ “ Tenting” of the skin by a fracture fragment is dangerous
only in patients who cannot protect their skin (eg, patients
who are comatose).
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ An anteroposterior (AP) radiograph can be supplemented by
a 20- to 60-degree cephalad-tilted view.
■ The so-called apical oblique view (tilted 45 degrees anterior
and 20 degrees cephalad) may facilitate the diagnosis of
minimally displaced fractures (eg, birth fractures, fractures in
children).
■ The abduction lordotic view taken with the shoulder ab-
ducted above 135 degrees and the central ray angled 25 degrees
cephalad is useful in evaluating the clavicle after internal fixa-
tion. Abduction of the shoulder results in rotation of the clav-
icle on its longitudinal axis, which causes the plate to rotate
superiorly and thereby expose the shaft of the clavicle and the
fracture site under the plate.
■ Computed tomography with 3D reconstructions can help
understand 3D deformity.
DIFFEREN TIAL DIAGN OSIS
■ Lateral or medial clavicle fracture
■ Acromioclavicular or sternoclavicular dislocation
N ON OPERATIVE MAN AGEMEN T
■ Closed reduction of clavicular fractures is rarely attempted
because the reduction is usually unstable and no reliable
means of providing external support is available.
■ A simple sling provides comfort and limits activity during
healing. A figure 8 bandage leaves the arm free, but it cannot
improve alignment.
FIG 1 • An AP ra d io g ra p h sh o w s g re a t e r t h a n 100% d isp la ce -
m e n t a n d co m m in u t io n w it h a ve rt ica l fra ct u re fra g m e n t . Th e
cla vicle is sh o rt e n e d . (Co p yrig h t Da vid Rin g , MD.)

■ There is no need to be concerned about shoulder stiffness,
and patients should be encouraged keep the arm at the side
and limit activity for the first 4 to 6 weeks.
SURGICAL MAN AGEMEN T
■ Intramedullary fixation is an option when comminution is
limited, but otherwise plate-and-screw fixation is preferred.
■ The plate can be placed on either the superior or the ante-
rior 1,2 aspect of the clavicle.
Preoperative Planning
■ Planning of the surgery using tracings of radiographs helps
limit intraoperative decision making and helps the surgeon
anticipate problems and contingencies.
Positioning
■ The patient is supine with a variable amount of flexion of
the trunk according to surgeon preference (FIG 2 ).
Approach
■ A longitudinal incision is made in line with the clavicle.
SUPERIOR PLATE-AND-SCREW FIXATION
■ An in cisio n is m a d e p a ra lle l a n d ju st in fe rio r t o t h e lo n g
a xis o f t h e cla vicle (TECH FIG 1 A). In filt ra t io n w it h d ilu t e
e p in e p h rin e ca n h e lp lim it b le e d in g .
■ Th e cro ssin g su p ra cla vicu la r n e rve s a re id e n t ifie d u n d e r
lo u p e m a g n ifica t io n a n d p re se rve d (TECH FIG 1 B).
■ Mu scle a t t a ch m e n t s a n d p e rio st e u m a re p re se rve d a s
m u ch a s p o ssib le .
■ Re a lig n m e n t a n d p ro visio n a l fixa t io n m a y b e fa cilit a t e d
b y t h e u se o f a sm a ll d ist ra ct o r o r t e m p o ra ry e xt e rn a l
fixa t o r (TECH FIG 1 C).
A B
D E
Ch a p t e r 1 6 PLATE FIXATION OF CLAVICLE FRACTURES 141
FIG 2 • Th e p a t ie n t is p o sit io n e d su p in e w it h t h e h e a d a n d
t ru n k e le va t e d slig h t ly. (Co p yrig h t Da vid Rin g , MD.)
TECHNIQUES
■ A 3.5-m m lim it e d -co n t a ct d yn a m ic co m p re ssio n p la t e
(LCDC p la t e , Syn t h e s) o r a p re co n t o u re d p la t e is a p p lie d
t o t h e su p e rio r a sp e ct o f t h e cla vicle (TECH FIG 1 D). A
m in im u m o f t h re e scre w s sh o u ld b e p la ce d in e a ch m a jo r
fra g m e n t . If t h e fra ct u re p a t t e rn is a m e n a b le , p la ce m e n t
o f a n in t e rfra g m e n t a ry scre w g re a t ly e n h a n ce s t h e st a -
b ilit y o f t h e co n st ru ct .
■ Wh e n t h e va scu la rit y o f t h e fra g m e n t s h a s b e e n p re -
se rve d , n o b o n e g ra ft is n e e d e d (TECH FIG 1 E). Wh e n
e xt e n sive st rip p in g o r g a p s h a ve o ccu rre d in t h e co rt e x
C
TECH FIG 1 • A. A st ra ig h t in cisio n in lin e
w it h t h e cla vicle a n d ju st in fe rio r t o it is in fil-
t ra t e d w it h d ilu t e e p in e p h rin e . B. Th e su p ra -
cla vicu la r n e rve s cro ss t h e cla vicle a t t h e le ve l
o f t h e p la t ysm a , a n d a n e ffo rt sh o u ld b e
m a d e t o p ro t e ct t h e m . C. A sm a ll d ist ra ct o r o r
t e m p o ra ry e xt e rn a l fixa t o r ca n b e u se d t o fa -
cilit a t e re a lig n m e n t a n d p ro vid e p ro visio n a l
fixa t io n . D. In t h is p a t ie n t , a su p e rio r 3.5-m m
LC-DCP is a p p lie d . An o scilla t in g d rill is u se d
t o lim it t h e risk t o n e rve s. E. Fin a l p la t e p la ce -
m e n t . (co n t in u e d )
 142 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

F G

TECH FIG 1 • (co n t in u e d ) F. Th e p la t ysm a is

su t u re d clo se d . G. A su b cu t icu la r skin clo su re is
u se d . H. Fin a l AP ra d io g ra p h d e m o n st ra t e s su -
p e rio r p la t e p la ce m e n t w it h la g scre w fixa t io n
o f a n o b liq u e fra ct u re lin e . (Co p yrig h t Da vid
H Rin g , MD.)

o p p o sit e t h e p la t e , o n e m ig h t co n sid e r a d d in g a sm a ll ■ If t h e skin co n d it io n is su it a b le , w o u n d clo su re is a cco m -

a m o u n t o f a u t o g e n o u s ilia c cre st ca n ce llo u s b o n e g ra ft . p lish e d in a t ra u m a t ic fa sh io n w it h a su b cu t icu la r su t u re
■ Clo se t h e p la t ysm a (TECH FIG 1 F). (TECH FIG 1 G,H).

ANTERIOR PLATE-AND-SCREW FIXATION

■ Th e t e ch n iq u e is id e n t ica l fo r a n a n t e rio r p la t e p la ce -
m e n t w it h t h e e xce p t io n t h a t t h e o rig in s o f t h e p e c-
t o ra lis m a jo r a n d d e lt o id a re p a rt ia lly e xt ra p e rio st e a lly
e le va t e d o ff t h e a n t e rio r cla vicle (TECH FIG 2 ).
■ Th e a n t e rio r p la t e p la ce m e n t m a y h e lp t o d e cre a se h a rd -
w a re p ro m in e n ce , a n d t h e d rill a n d scre w s a re d ire ct e d
p o st e rio r ra t h e r t h a n d ire ct ly in fe rio r t o t h e cla vicle ,
w h ich m a y in cre a se t h e m a rg in o f sa fe t y.

TECH FIG 2 • An a lt e rn a t ive is t o p la ce t h e p la t e o n

t h e a n t e rio r su rfa ce o f t h e cla vicle . Th is lim it s p la t e
p ro m in e n ce b u t re q u ire s g re a t e r st rip p in g a n d
m u scle e le va t io n . (Co p yrig h t Da vid Rin g , MD.)

PEARLS AND PITFALLS

Su p ra cla vicu la r n e rve n e u ro m a
Bra ch ia l p le xu s st re t ch in ju ry
Lo o se n in g o f fixa t io n
Axia l p u ll-o u t o f lo cke d scre w s
Pla t e p ro m in e n ce
■ At t e m p t s t o id e n t ify a n d p ro t e ct t h e se n e rve s a re w o rt h w h ile .
■ Re a lig n m e n t sh o u ld b e d o n e g ra d u a lly a n d ca n b e fa cilit a t e d b y t e m p o ra ry e xt e rn a l fixa t io n .
Pu llin g fra g m e n t s o u t o f t h e w o u n d sh o u ld b e lim it e d .
■ At le a st t h re e g o o d b ico rt ica l scre w s sh o u ld b e p la ce d o n e a ch sid e o f t h e fra ct u re .
■ Lo ckin g scre w s m a y b e t ro u b le so m e w h e n u se d o n t h e la t e ra l fra g m e n t w it h t h e p la t e in a
su p e rio r p o sit io n .
■ An t e rio r p la t e p la ce m e n t m a y d im in ish p la t e p ro m in e n ce .

POSTOPERATIVE CARE OUTCOMES

■ Confident use of the hand at the side is encouraged imme- ■ Plate loosening and nonunion occur in 3% to 5% of cases.6
diately. ■ H ealing leads to good function.
■ Shoulder abduction and handling of more than 15 pounds is

delayed until early healing is established. COMPLICATION S

■ Shoulder stiffness is unusual and usually responds quickly to ■ Infection and wound complications occur but are uncommon.
exercises. Shoulder exercises can therefore be delayed until ■ N eurovascular injury is very uncommon and pneumothorax

healing is established. has not been described.

 Ch a p t e r 1 6 PLATE FIXATION OF CLAVICLE FRACTURES
REFEREN CES
1. Collinge C, Devinney S, H erscovici D, et al. Anterior-inferior plate
fixation of middle-third fractures and nonunions of the clavicle. J
O rthop Trauma 2006;20:680–686.
2. Kloen P, Sorkin AT, Rubel IF, et al. Anteroinferior plating of
midshaft clavicular nonunions. J O rthop Trauma 2002;16:425–430.
3. M cKee M D, Pedersen EM , Jones C, et al. Deficits following nonop-
erative treatment of displaced midshaft clavicular fractures. J Bone
Joint Surg Am 2006;88A:35–40.
4. M cKee M D, Wild LM , Schemitsch EH . M idshaft malunions of the
clavicle. J Bone Joint Surg Am 2003;85A:790–797.
5. N owak J, H olgersson M , Larsson S. Can we predict long-term se-
quelae after fractures of the clavicle based on initial findings? A
143
prospective study with nine to ten years of follow-up. J Shoulder
Elbow Surg 2004;13:479–486.
6. Poigenfurst J, Rappold G, Fischer W. Plating of fresh clavicular
fractures: results of 122 operations. Injury 1992;23:237–241.
7. Robinson CM , Court-Brown CM , M cQ ueen M M , et al. Estimating
the risk of nonunion following nonoperative treatment of a clavicular
fracture. J Bone Joint Surg Am 2004;86A:1359–1365.
8. Robinson CM . Fractures of the clavicle in the adult: epidemiology
and classification. J Bone Joint Surg Br 1998;80B:476–484.
9. Z lowodzki M , Z elle BA, Cole PA, et al. Treatment of acute midshaft
clavicle fractures: systematic review of 2144 fractures: on behalf of
the Evidence-Based O rthopaedic Trauma Working Group. J O rthop
Trauma 2005;19:504–507.
 In t r a m e d u lla r y Fix a t io n o f
Ch a p t e r 17 Cla v icle Fr a ct u re s
Brad f o rd S. Tu ck e r, Carl Basam an ia, an d M at t h e w D. Pe p e

DEFIN ITION
■ The clavicle is one of the most commonly fractured bones.
■ The site on the clavicle most often fractured is the middle
third. 9
■ The midclavicular region is the thinnest and narrowest
portion of the bone.
■ It is the only area not supported by ligament or muscle
attachments.
■ It represents a transitional region of both cross-sectional
anatomy and curvature.
■ It is the transition point between the lateral part, with
a flatter cross section, and the more tubular medial.
■ Because of the clavicle’s S shape, an axial load creates a very
high tensile force along the anterior midcortex. (Axial load
makes a virtual right angle at midclavicle.)
AN ATOMY
■ The clavicle is the only long bone to ossify by a combination
of intramembranous and endochondral ossification.6
■ Its configuration is S-shaped, a double curve; the medial
curve is apex anterior and the lateral curve is apex posterior
(FIG 1 A).
■ The larger medial curvature widens the space for the neu-
rovascular structures, providing bony protection.
■ The cross-sectional anatomy gradually changes from flat lat-
erally, to tubular in the midportion, to expanded prismatic
medially.
■ The clavicle is subcutaneous throughout, covered by the thin
platysma muscle.
■ The supraclavicular nerves that provide sensation to the over-
lying skin of the clavicle are found deep to the platysma muscle.
■ Very strong capsular and extracapsular ligaments attach the
medial end to the sternum and first rib and the lateral end to
the acromion and coracoid.
■ Proximal muscle attachments include the sternocleidomas-
toid, pectoralis major, and subclavius. Distal muscle attach-
ments include the deltoid and trapezius (FIG 1 B).
■ The clavicle functions by providing a fixed-length strut
through which the muscles attached to the shoulder girdle can
generate and transmit large forces to the upper extremity.
PATHOGEN ESIS
■ The mechanism of clavicle fractures in the vast majority is a
direct injury to the shoulder.10 Stanley and associates studied
106 injured patients; 87% had fallen onto the shoulder, 7%
were injured by a direct blow on the point of the shoulder, and
only 6% reported falling onto an outstretched hand.
■ Stanley suggests that in the patients who described hitting the

■ The clavicle is made up of very dense trabecular bone, lack- ground with an outstretched hand, the shoulder became the
ing a well-defined medullary canal. next contact point with the ground, causing the fracture. Stanley

Trapezius
Sternocleidomastoid

Trapezius Clavicle
Sternocleidomastoid
Pectoralis
Deltoid major
Articular Spine of
Articular
cartilage scapula
cartilage
(AC joint)
A (SC joint)
Pectoralis major
Posterior
deltoid Anterior
deltoid
Lateral
deltoid

Infraspinatus

Teres minor

Teres major
FIG 1 • A. Th e cla vicle is S-sh a p e d a n d h a s a d o u b le
cu rve . Th e m e d ia l cu rve is a p e x a n t e rio r a n d t h e la t e ra l Latissimus
cu rve is a p e x p o st e rio r. B. Pro xim a l m u scle a t t a ch m e n t s dorsi
t o t h e cla vicle in clu d e t h e st e rn o cle id o m a st o id , p e ct o ra lis Biceps
m a jo r, a n d su b cla viu s. Dist a l m u scle a t t a ch m e n t s t o t h e Lateral head
of triceps
cla vicle in clu d e t h e d e lt o id a n d t ra p e ziu s. B

144
 Ch a p t e r 1 7 INTRAM EDULLARY FIXATION OF CLAVICLE FRACTURES
stated that a compressive force equivalent to body weight would
exceed the critical buckling load to cause the clavicle fracture.
N ATURAL HISTORY
■ In the 1960s, both N eer 7 and Rowe9 published large series of
midclavicle fractures, showing very low nonunion rate (0.1%
and 0.8% ) with closed treatment and a higher nonunion rate
(4.6% and 3.7% ) with operative treatment.
■ M ore recent studies have shown that nonunion is more
common then previously recognized and that a significant per-
centage of patients with nonunion are symptomatic.
■ M alunion with shortening greater than 15 to 20 mm has
also been shown to be associated with significant shoulder
dysfunction.
■ M cKee and colleagues5 identified 15 patients with mal-
union of the midclavicle after closed treatment. All patients
had shortening of more than 15 mm, all were symptomatic
and unsatisfied, and all underwent corrective osteotomy.
Postoperatively all 15 patients improved in terms of function
and satisfaction.
■ H ill and associates4 reviewed 52 completely displaced mid-
shaft clavicle fractures and found that shortening of more than
20 mm had a significant association with nonunion and unsat-
isfactory results.
■ Eskola and coworkers3 reported on 89 malunions of the
midclavicle, showing that shortening of more than 15 mm was
associated with shoulder discomfort and dysfunction.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ The diagnosis is usually straightforward and is based on ob-
taining the mechanism of injury from a good history.
■ O n visual inspection the examiner will frequently see no-
table swelling or ecchymosis at the fracture site and possibly
deformity of the clavicle, with drooping of the shoulder
downward and forward if the fracture is significantly dis-
placed. The skin is inspected for tenting at the fracture site
and characteristic bruising and abrasions that might suggest
a direct blow or seatbelt shoulder strap injury (FIG 2 A,B).
■ Palpation over the fracture site will reveal tenderness, and
gentle manipulation of the upper extremity or clavicle itself
may reveal crepitus and motion at the fracture site.
■ The amount of shortening is identified by clinically measur-
ing the distance of a straight line (in centimeters) from both
acromioclavicular joints to the sternal notch and noting the
difference (FIG 2 C).
■ It is important to perform a complete musculoskeletal and
neurovascular examination of the upper extremity and auscul-
A B
FIG 2 • A,B. An t e rio r a n d p o st e rio r p h o t o g ra p h s o f a d isp la ce d rig h t cla vicle fra ct u re sh o w in g d e fo rm it y o f t h e cla vicle
a n d d ro o p in g o f t h e sh o u ld e r g ird le d o w n w a rd a n d fo rw a rd . C. Clin ica l p ict u re o f a d isp la ce d rig h t cla vicle fra ct u re ,
sh o w in g 3.5 cm o f sh o rt e n in g , m e a su re d fro m t h e st e rn a l n o t ch t o t h e a cro m io cla vicu la r jo in t .
145
A
B
FIG 3 • Ra d io g ra p h s o f t h e sa m e d isp la ce d le ft cla vicle fra ct u re
vie w e d fro m a st a n d a rd AP p ro je ct io n (A) a n d a 45-d e g re e
ce p h a lic t ilt p ro je ct io n (B).
tation of the chest to identify the rare associated injuries; these
are more closely related to high-energy injuries.
■ Rib and scapula fracture
■ Brachial plexus injury (usually traction to upper cervical
root)
■ Vascular injury (subclavian artery or vein injury associ-
ated with scapulothoracic dissociation)
■ Pneumothorax and hemothorax
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Two orthogonal radiographic projections are necessary to
determine the fracture pattern and displacement, ideally 45-
degree cephalic tilt and 45-degree caudad tilt views.
■ Usually a standard anteroposterior (AP) view and a 45-
degree cephalic tilt (FIG 3 ) view are adequate.
■ In practice, a 20- to 60-degree cephalic tilt view will min-
imize interference of thoracic structures.
■ The film should be large enough to include the acromioclav-
icular and sternoclavicular joints, the scapula, and the upper
lung fields to evaluate for associated injuries.
■ An AP view of bilateral clavicles on a wide cassette to in-
clude the acromioclavicular joints and sternum is fairly helpful
in determining the amount of shortening; however, this is a
multiplanar deformity and a CT scan would have greater ac-
curacy, although it is rarely required.
C
146 Se c t i o n II SHOULDER AND ELBOW

DIFFEREN TIAL DIAGN OSIS ■ In a multicenter, randomized, prospective clinical trial of

displaced midshaft clavicle fractures, Altamimi and M cKee1
■ Sprain of acromioclavicular joint
■ Sprain of sternoclavicular joint
showed that operative fixation compared to nonoperative
■ Rib fracture
treatment improved functional outcome and had a lower rate
■ M uscle injury
of both malunion and nonunion.
■ Potential advantages of intramedullary fixation of the clavi-
■ Contusion

■ H ematoma
cle are as follows:
■ Less soft tissue stripping and therefore potentially better
■ Kehr sign: referred pain to the left shoulder from irritation
healing
of the diaphragm, signaled by the phrenic nerve. Irritation may ■ Smaller incision
be caused by diaphragmatic or peridiaphragmatic lesions, ■ Better cosmesis
renal calculi, splenic injury, or ectopic pregnancy. ■ Easier hardware removal

■ Less weakness of bone after hardware removal

N ON OPERATIVE MAN AGEMEN T ■ Potential disadvantages of intramedullary fixation of the
■ If the clavicle fracture alignment is acceptable, generally a
clavicle are as follows:
simple configuration with less than 15 mm of shortening, then ■ Less ability to resist torsional forces
any of a number of methods of supporting the upper extrem- ■ Skin breakdown from prominence distally
ity are adequate, including a figure 8 bandage, sling, sling and ■ Pin breakage
swathe, Sayre bandage, Velpeau dressing, and benign neglect, ■ Pin migration
just to name a few. ■ N ewer designs and techniques prevent pin migration by
■ N ordqvist and colleagues8 reported on 35 clavicle fracture
placing a locking nut on the lateral end and technically avoid-
malunions with shortening of less than 15 mm. They were
ing penetration of the medial fragment cortex.
all treated nonoperatively in a sling. All 35 had normal
mobility, strength, and function compared to the normal Preoperative Planning
shoulder. ■ After the decision has been made to fix a clavicle fracture,
■ A prospective, randomized study2 comparing sling versus
one must evaluate whether the fracture pattern is amenable to
figure 8 bandage showed that a greater percentage of patients intramedullary pin fixation.
were dissatisfied with the figure 8 bandage, and there was ■ A simple fracture pattern in the middle third of the bone is

no difference in overall healing and alignment. The study ideal.

concluded that the figure 8 bandage does little to obtain ■ The fracture should not extend past the middle third of the

reduction. bone.
■ Comminution and butterfly fragments (usually anterior) are
SURGICAL MAN AGEMEN T common and do not preclude intramedullary fixation as long
■ Indications for operative treatment of acute midshaft clavi- as the medial and distal main fragments have cortical contact.
cle fractures are as follows:
■ O pen fractures Positioning
■ Fractures with neurovascular injury ■ There are two good options for patient positioning that fa-
■ Fractures with severe associated chest injury or multiple cilitate use of an image intensifier or C-arm device, which will
trauma: patients who require their upper extremity for aid you during pin placement.
transfer and ambulation ■ The patient can be placed supine on a Jackson radiolucent

■ “ Floating shoulder” surgical table so the C-arm can be brought in perpendicular

■ Impending skin necrosis from the opposite side of the table, which is out of the way of
■ Severe displacement: possibly 15 to 20 mm of shortening the surgeon (FIG 4 A,B).

C D
A B

FIG 4 • A,B. Th e p a t ie n t is p la ce d su p in e o n a Ja ckso n ra d io lu ce n t su rg ica l t a b le . A 1-L b a g is p la ce d u n d e r t h e a ffe ct e d sh o u l-

d e r, m e d ia l t o t h e sca p u la , a n d t h e a rm is p re p a re d fre e a n d p la ce d in a n a rm h o ld e r t o a id in fra ct u re re d u ct io n . Th e C-a rm
ca n b e b ro u g h t in p e rp e n d icu la r fro m t h e o p p o sit e sid e o f t h e t a b le , w h ich is o u t o f t h e w a y o f t h e su rg e o n a n d fa cilit a t e s
g e t t in g o rt h o g o n a l ra d io g ra p h ic vie w s o f t h e fra ct u re : 45-d e g re e ca u d a d t ilt vie w (A) a n d 45-d e g re e ce p h a lic t ilt vie w
(B). C,D. Alt e rn a t ive ly, t h e p a t ie n t is p la ce d in t h e b e a ch ch a ir p o sit io n o n t h e OR t a b le , u sin g a ra d io lu ce n t sh o u ld e r-p o sit io n -
in g d e vice . C. Th e a rm is p re p a re d fre e a n d p la ce d in a n a rm h o ld e r t o fa cilit a t e fra ct u re re d u ct io n . Th e C-a rm is b ro u g h t in
fro m t h e h e a d o f t h e b e d w it h t h e g a n t ry ro t a t e d u p sid e d o w n a n d slig h t ly a w a y fro m t h e o p e ra t ive sh o u ld e r a n d o rie n t e d
w it h a ce p h a lic t ilt . D. Th e sa m e b e a ch ch a ir p o sit io n in g sh o w n st e rile ly d ra p e d .
 Ch a p t e r 1 7 INTRAM EDULLARY FIXATION OF CLAVICLE FRACTURES 147

■ A 1-L bag is placed under the affected shoulder, medial to ■ The other option is placing the patient in the beach chair po-
the scapula, to aid in fracture reduction. sition on the O R table, using a radiolucent shoulder-
■ The arm is also prepared free and placed in an arm holder positioning device (FIG 4 C,D).
to facilitate fracture reduction. ■ The C-arm is brought in from the head of the bed with the

■ This is our preferred method due to the ease and speed of gantry rotated upside down and slightly away from the
the set-up and the ease of getting orthogonal radiographic operative shoulder and oriented with a cephalic tilt.
views of the fracture (45-degree cephalic and caudad tilt ■ The arm is also prepared free and placed in an arm holder

views). to facilitate fracture reduction.

TECHNIQUES
INCISION AND DISSECTION
■ Ma rk o u t t h e cla vicle , fra ct u re sit e , a n d su rro u n d in g u la r n e rve s; it s m id d le b ra n ch e s a re fre q u e n t ly fo u n d
a n a t o m y (TECH FIG 1 A). n e a r t h e m id cla vicle (TECH FIG 1 D,E).
■ Use t h e C-a rm t o id e n t ify t h e a p p ro p ria t e p o sit io n fo r ■ Th e fra ct u re sit e is t h e n u su a lly e a sily id e n t ifia b le in
t h e in cisio n , w h ich sh o u ld b e o ve r t h e d ist a l e n d o f t h e a cu t e in ju rie s b e ca u se t h e p e rio st e u m is d isru p t e d a n d
m e d ia l fra g m e n t , in t h e La n g e r lin e s o f t h e n o rm a l skin u su a lly re q u ire s n o fu rt h e r d ivisio n .
cre a se a ro u n d t h e n e ck (TECH FIG 1 B). ■ Re m o ve a n y d e b ris, h e m a t o m a , o r in t e rp o se d m u scle
■ Ma ke a n in cisio n o f a b o u t 2 t o 3 cm o ve r th e fra ct u re site . fro m t h e fra ct u re sit e .
■ Divid e t h e su b cu t a n e o u s fa t d o w n t o t h e p la t ysm a m u s- ■ If t h e re a re b u t t e rfly fra g m e n t s, b e ca re fu l t o ke e p a n y
cle u sin g e le ct ro ca u t e ry (TECH FIG 1 C). so ft t issu e a t t a ch m e n t s.
■ Alt h o u g h t h e re is u su a lly ve ry lit t le su b cu t a n e o u s fa t ,
g e n t ly m a ke fu ll-t h ickn e ss fla p s t o in clu d e skin a n d su b -
cu t a n e o u s t issu e a ro u n d t h e e n t ire in cisio n t o fa cilit a t e
e xp o su re .
■ Blu n t ly sp lit t h e p la t ysm a m u scle in lin e o f it s fib e rs t o
id e n t ify, p ro t e ct , a n d re t ra ct t h e u n d e rlyin g su p ra cla vic-

A B C

Platysma

Middle supra-
D clavicular nerves E

TECH FIG 1 • A. Disp lace d rig h t clavicle fract u re , sh o w in g t h e cla vicle a n d fra ct u re sit e m a rke d o u t . B. A skin in cisio n o f a b o u t
2 t o 3 cm is m a de o ver t h e dist al en d o f t h e m e d ia l cla vicular fra g m en t , in t h e La n ge r line s of n o rm al skin cre a ses a ro un d t h e
ne ck. C. In cisio n o ve r a cla vicle fra ct u re sit e , sho w in g fu ll-t h ickne ss fla ps t o in clud e skin a n d sub cut a n eo us t issu e a ro un d t he en -
t ire in cisio n . Th is exp o se s t h e fa scia t h at co ve rs t h e p la t ysm a m u scle . D. Skin in cisio n o ver a d isp la ce d clavicle fra ct ure , w it h u n-
de rlyin g plat ysm a m u scle a n d t he m id d le su pra cla vicular n e rve s. E. In t ra op erat ive ph ot o sh ow ing t h e p la t ysm a m uscle blu nt ly
sp lit in t h e lin e o f it s fib e rs t o id e n t ify a n u n d e rlyin g su p ra cla vicu la r n e rve , w h ich is u n d e r t h e cla m p . Th e fra ct u re sit e is u su a lly
ea sily ide nt ifia ble in acu t e injurie s b eca use t h e p eriost e u m is disrup t ed a nd u su ally req uires n o fu rt he r d ivisio n; a s sh ow n he re ,
t h e m ed ia l cla vicu la r fra g m e n t is e a sily se en . (B,D: Co u rt e sy of St eve n B. Lip p it t , MD.)
 148 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

CLAVICLE PREPARATION
■ Th e fo llo w in g t e ch n iq u e u se s a m o d ifie d Ha g ie p in
ca lle d t h e Ro ckw o o d Cla vicle Pin (De Pu y Ort h o p a e d ics,
Wa rsa w , IN) (TECH FIG 2 A).
■ Use a b o n e -re d u cin g cla m p o r t o w e l clip t o g ra b a n d e l-
e va t e t h e m e d ia l cla vicu la r fra g m e n t t h ro u g h t h e in ci-
sio n (TECH FIG 2 B).
■ Size t h e d ia m e t e r o f t h e ca n a l w it h t h e a p p ro p ria t e -size
d rill b it ; t h e C-a rm ca n b e u se fu l t o ju d g e ca n a l fill a n d
o rie n t a t io n o f t h e d rill.
■ Th e fit sh o u ld b e sn u g t o m a xim ize fixa t io n , b u t n o t
t o o t ig h t , t o p re ve n t sp lit t in g t h e b o n e .
■ At t a ch t h e ch o se n d rill t o t h e T-h a n d le a n d re a m o u t t h e
in t ra m e d u lla ry ca n a l w it h o u t p e n e t ra t in g t h e a n t e rio r
co rt e x (TECH FIG 2 C–E).
■ Ne xt , a t t a ch t h e a p p ro p ria t e -size d t a p (t h a t co rre -
sp o n d s t o t h e d rill size ) t o t h e T-h a n d le a n d t a p t h e
in t ra m e d u lla ry ca n a l t o t h e a n t e rio r co rt e x (TECH
FIG 2 F,G).
■ Eleva te the lat era l clavicular frag me nt t hrough t he inci-
sion ; this ca n b e fa cilita te d b y e xt ern ally ro ta tin g t h e arm.
■ Use t h e sa m e d rill b it a t t a ch e d t o t h e T-h a n d le t o re a m
o u t t h e la t e ra l fra g m e n t , b u t t h is t im e , u n d e r C-a rm
g u id a n ce , p e n e t ra t e t h e p o st e ro la t e ra l co rt e x o f t h e
cla vicle (TECH FIG 2 H,I).
■ Th e d rill sh o u ld e xit p o st e rio r a n d m e d ia l t o t h e
a cro m io cla vicu la r jo in t ca p su le (TECH FIG 2 J).
■ To p re ve n t t h e p in n u t s fro m b e in g t o o p ro m in e n t ,
m a ke su re t h e d rill d o e s n o t e xit in t h e u p p e r h a lf o f
t h e p o st e ro la t e ra l cla vicle .
■ At t a ch t h e a p p ro p ria t e -size d t a p t o t h e T-h a n d le a n d t a p
t h e in t ra m e d u lla ry ca n a l o f t h e la t e ra l fra g m e n t (TECH
FIG 2 K).

A B C

D E F

G H I

TECH FIG 2 • A. Th e Ro ckw o o d Cla vicle Pin in st ru m e n t se t b y De Pu y Ort h o p a e d ics, Wa rsa w , IN, w h ich is a m o d ifie d Ha g ie
p in . B. A b o n e -re d u cin g cla m p is u se d t o e le va t e t h e m e d ia l cla vicu la r fra g m e n t t h ro u g h t h e in cisio n . C–E. Th e ch o se n d rill
is a t t a ch e d t o a T-h a n d le a n d t h e in t ra m e d u lla ry ca n a l o f t h e m e d ia l cla vicu la r fra g m e n t is re a m e d w it h o u t p e n e t ra t in g
t h e a n t e rio r co rt e x. F,G. An a p p ro p ria t e -size d t a p is a t t a ch e d t o a T-h a n d le a n d t h e in t ra m e d u lla ry ca n a l o f t h e m e d ia l
cla vicu la r fra g m e n t is t a p p e d t o t h e a n t e rio r co rt e x. H,I. Th e ch o se n d rill is a t t a ch e d t o a T-h a n d le a n d t h e in t ra m e d u lla ry
ca n a l o f t h e la t e ra l cla vicu la r fra g m e n t is re a m e d o u t , p e n e t ra t in g t h e p o st e ro la t e ra l co rt e x u n d e r d ire ct C-a rm g u id a n ce .
(co n t in u e d )
 Ch a p t e r 1 7 INTRAM EDULLARY FIXATION OF CLAVICLE FRACTURES 149

TECHNIQUES
J K

TECH FIG 2 • (co n t in u e d ) J. Wh e n d rillin g o u t t h e p o st e ro la t e ra l co rt e x o f t h e la t e ra l cla vicu la r fra g m e n t , t h e

d rill sh o u ld e xit p o st e rio r a n d m e d ia l t o t h e a cro m io cla vicu la r jo in t ca p su le . To p re ve n t t h e p in n u t s fro m b e in g
t o o p ro m in e n t , t h e d rill sh o u ld n o t e xit in t h e u p p e r h a lf o f t h e p o st e ro la t e ra l cla vicle . K. Th e a p p ro p ria t e -
size d t a p is a t t a ch e d t o t h e T-h a n d le a n d t h e in t ra m e d u lla ry ca n a l o f t h e la t e ra l fra g m e n t is t a p p e d . (C,H,J,K:
Co u rt e sy o f St e ve n B. Lip p it t , MD.)

PIN INSERTION AND FRACTURE REDUCTION

■ Re m o ve t h e n u t s fro m t h e p in a sse m b ly a n d a t t a ch t h e
T-h a n d le u sin g a Ja co b s ch u ck t o t h e m e d ia l e n d o f t h e
cla vicle p in .
■ Th is is t h e e n d w it h t h e la rg e t h re a d s.
■ Ne ve r t ig h t e n t h e ch u ck o ve r t h e m a ch in e d t h re a d s a t
e it h e r e n d .
■ Co n t in u e firm ly h o ld in g t h e la t e ra l fra g m e n t w h ile p a ss-
in g t h e t ro ca r e n d (la t e ra l e n d ) o f t h e cla vicle p in in t o
t h e in t ra m e d u lla ry ca n a l, o u t t h e p re vio u sly d rille d h o le
in t h e p o st e ro la t e ra l co rt e x (TECH FIG 3 A).
■ On ce yo u a re ju st t h ro u g h t h e co rt e x, m a ke a sm a ll in ci-
sio n o ve r t h e p a lp a b le t ip .
■ Blu n t ly d isse ct t h e su b cu t a n e o u s t issu e w it h a h e m o st a t
u n t il t h e t ip o f t h e p in ca n b e fe lt , a n d t h e n p la ce t h e
h e m o st a t o r a sm a ll e le va t o r u n d e r t h e t ip o f t h e p in
t o fa cilit a t e t h e p in ’s p a ssa g e t h ro u g h t h e in cisio n
(TECH FIG 3 B).
■ Drill t h e p in o u t la t e ra lly u n t il t h e la rg e m e d ia l
t h re a d s e n g a g e t h e la t e ra l fra g m e n t .
■ No w sw it ch t h e T-h a n d le t o t h e la t e ra l e n d o f t h e p in
a n d re t ra ct t h e p in in t o t h e la t e ra l fra g m e n t (TECH
FIG 3 C,D).
■ Re d u ce t h e fra ct u re b y lift in g t h e a rm , a n d p a ss t h e p in
in t o t h e m e d ia l fra g m e n t .
■ Use t h e C-a rm t o e n su re t h a t t h e p in a d va n ce s
co rre ct ly d o w n t h e lin e o f t h e m e d ia l fra g m e n t
a n d t h a t a ll t h e m e d ia l t h re a d s cro ss t h e fra ct u re
sit e .

TECH FIG 3 • A. Th e su rg e o n co n t in u e s
firm ly h o ld in g t h e la t e ra l fra g m e n t w h ile
p a ssin g t h e t ro ca r e n d (la t e ra l e n d ) o f t h e
cla vicle p in in t o t h e in t ra m e d u lla ry ca n a l,
o u t t h e p re vio u sly d rille d h o le in t h e p o s-
t e ro la t e ra l co rt e x. On ce ju st t h ro u g h t h e
co rt e x, t h e su rg e o n m a ke s a sm a ll in cisio n
A o ve r t h e p a lp a b le t ip . (co n t in u e d )
 150 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

D C

TECH FIG 3 • (co n t in u e d ) B. Th e su b cu t a n e o u s t issu e is blu n t ly d isse ct e d w it h a h e m o st a t u n t il t h e t ip

o f t h e p in ca n b e fe lt , a n d t h e n t h e h e m o st a t o r a sm a ll e le va t o r is p la ce d u n d e r t h e t ip o f t h e p in t o
fa cilit a t e t h e p in ’s p a ssa g e t h ro u g h t h e in cisio n . C,D. Th e T-h a n d le is sw it ch e d t o t h e la t e ra l e n d o f
t h e p in a n d t h e p in is re t ra ct e d in t o t h e la t e ra l fra g m e n t . (A,C: Co u rt e sy o f St e ve n B. Lip p it t , MD.)

FINAL POSITIONING OF PIN AND FRACTURE COMPRESSION

■ Co ld -w e ld t h e t w o n u t s o n t o t h e la t e ra l e n d o f t h e p in .
■ First p la ce t h e m e d ia l n u t o n t o t h e p in , fo llo w e d b y
t h e sm a lle r la t e ra l n u t .
■ Gra sp t h e m e d ia l n u t w it h a n e e d le -n o se p lie rs a n d
t h e n t ig h t e n t h e la t e ra l n u t a g a in st t h e m e d ia l n u t
u sin g t h e la t e ra l n u t w re n ch (TECH FIG 4 A,B).
■ Usin g t h e la t e ra l n u t w re n ch a n d C-a rm g u id a n ce , n o w
a d va n ce t h e p in a sse m b ly in t o t h e m e d ia l fra g m e n t u n t il
it co n t a ct s t h e a n t e rio r co rt e x (TECH FIG 4 C).
■ Bre a k t h e co ld w e ld b y g ra sp in g t h e m e d ia l n u t w it h
n e e d le -n o se p lie rs a n d t h e n lo o se n t h e la t e ra l n u t b y
t u rn in g it co u n t e rclo ckw ise u sin g t h e la t e ra l n u t w re n ch .
■ Ad va n ce t h e m e d ia l n u t a g a in st t h e p o st e ro la t e ra l co r-
t e x o f t h e cla vicle t o g e t d e sire d co m p re ssio n a cro ss t h e
fra ct u re sit e .
■ Co ld -w e ld t h e la t e ra l n u t b a ck o n t o t h e m e d ia l n u t
a g a in .
■ Use t h e m e d ia l n u t w re n ch t o b a ck t h e p in a sse m b ly o u t
o f t h e so ft t issu e s fa r e n o u g h t o e xp o se t h e n u t s, u su a lly
a b o u t 1 cm . Th is w ill e n a b le t h e p in t o b e cu t flu sh t o t h e
la t e ra l n u t (TECH FIG 4 D,E).
■ Fin a lly, u se t h e la t e ra l n u t w re n ch t o a d va n ce t h e p in
a sse m b ly b a ck in t o t h e m e d ia l fra g m e n t w it h t h e sa m e
d e sire d fra ct u re sit e co m p re ssio n (TECH FIG 4 F,G).

A B

TECH FIG 4 • A. Th e la t e ra l e n d
o f t h e p in w it h t h e la rg e r m e d ia l
n u t is p la ce d first , clo se st t o t h e
skin , fo llo w e d b y t h e sm a lle r la t -
e ra l n u t , in p re p a ra t io n fo r co ld
w e ld in g . B. To co ld w e ld t h e
jo in t , t h e m e d ia l n u t is g ra sp e d
w it h a n e e d le -n o se p lie rs, a n d
t h e n t h e la t e ra l n u t is t ig h t e n e d
a g a in st t h e m e d ia l n u t u sin g t h e
la t e ra l n u t w re n ch . C. Usin g t h e
la t e ra l n u t w re n ch a n d C-a rm
g u id a n ce , t h e su rg e o n a d va n ce s
t h e p in a sse m b ly in t o t h e m e d ia l
fra g m e n t u n t il it co n t a ct s t h e a n -
C t e rio r co rt e x. (co n t in u e d )
 Ch a p t e r 1 7 INTRAM EDULLARY FIXATION OF CLAVICLE FRACTURES 151

TECHNIQUES
D F

TECH FIG 4 • (co n t in u e d ) D,E. Th e m e d ia l n u t

w re n ch is u se d t o b a ck t h e p in a sse m b ly o u t
o f t h e so ft t issu e s fa r e n o u g h t o e xp o se t h e
n u t s, u su a lly a b o u t 1 cm , t o e n a b le t h e p in t o
b e cu t flu sh t o t h e la t e ra l n u t . F. Th e la t e ra l
n u t w re n ch is u se d t o a d va n ce t h e p in a sse m -
b ly b a ck in t o t h e m e d ia l fra g m e n t w it h
t h e sa m e d e sire d fra ct u re sit e co m p re ssio n . G.
Ra d io g ra p h sh o w in g fin a l p o sit io n in g o f t h e
p in a sse m b ly w it h fra ct u re sit e co m p re ssio n .
E G (B–D,F: Co u rt e sy o f St e ve n B. Lip p it t , MD.)

BUTTERFLY FRAGMENT MANAGEMENT AND WOUND CLOSURE

■ If a n a n t e rio r b u t t e rfly fra g m e n t e xist s, ce rcla g e is d o n e
u sin g n o . 0 o r n o . 1 a b so rb a b le su t u re .
■ Pa ss a n e le va t o r u n d e r t h e cla vicle t o d e fle ct t h e su -
t u re s (TECH FIG 5 A).
■ Th e n p a ss t h e su t u re in a fig u re 8 m a n n e r t h ro u g h
t h e p e rio st e u m o f t h e b u t t e rfly fra g m e n t a n d a ro u n d
t h e fra g m e n t a n d t h e cla vicle (TECH FIG 5 B).
■ Close t h e p erio st eum o verlyin g t h e fractu re sit e w ith no . 0
absorbable su ture in an inte rrupt ed figu re 8 m an ner.
■ Re a p p ro xim a t e t h e fa scia o f t h e p la t ysm a m u scle u sin g
2-0 a b so rb a b le su t u re in a n in t e rru p t e d fig u re 8 m a n n e r.
■ Clo se t h e su b cu t a n e o u s t issu e a n d skin o f b o t h in cisio n s.

A B

TECH FIG 5 • A. Ce rcla g e o f a n a n t e rio r b u t t e rfly fra g m e n t is a cco m p lish e d b y first p a ssin g
a n e le va t o r u n d e r t h e cla vicle t o d e fle ct t h e su t u re s a n d t h e n p a ssin g t h e su t u re , in a fig -
u re 8 m a n n e r, t h ro u g h t h e p e rio st e u m o f t h e b u t t e rfly fra g m e n t a n d a ro u n d t h e fra g m e n t
a n d t h e cla vicle . B. Ra d io g ra p h sh o w in g a n a d e q u a t e re d u ct io n o f a b u t t e rfly fra g m e n t .
(A: Co u rt e sy o f St e ve n B. Lip p it t , MD.)
 152 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

PIN REMOVAL
■ Th e p in is re m o ve d a t 10 t o 12 w e e ks if t h e fra ct u re h a s
h e a le d .
■ Th e p a t ie n t is p o sit io n e d o n h is o r h e r sid e a n d a lo ca l
a n e st h e t ic is d e live re d (TECH FIG 6 A).
■ An in cisio n is m a d e o ve r t h e sa m e p re vio u s la t e ra l in ci-
sio n a n d t h e su b cu t a n e o u s t issu e is d isse ct e d u sin g t h e
h e m o st a t u n t il t h e m e d ia l n u t is id e n t ifie d .
■ Th e m e d ia l n u t w re n ch is u se d t o e xt ra ct t h e p in a sse m -
b ly (TECH FIG 6 B,C).
■ If t h e n u t is st rip p e d , t h e T-h a n d le a n d ch u ck ca n b e u se d
t o e xt ra ct t h e p in a sse m b ly.

C B

TECH FIG 6 • A. Th e p a t ie n t is p o sit io n e d o n h is o r h e r sid e a n d t h e la t e ra l in cisio n is in filt ra t e d

w it h lo ca l a n e st h e sia . B,C. Th e su rg e o n m a ke s a n in cisio n o ve r t h e sa m e p re vio u s la t e ra l in ci-
sio n , d isse ct in g t h ro u g h t h e su b cu t a n e o u s t issu e u sin g t h e h e m o st a t u n t il t h e m e d ia l n u t is id e n -
t ifie d a n d fre e d u p . Th e m e d ia l n u t w re n ch is t h e n u se d t o e xt ra ct t h e p in a sse m b ly. (B: Co u rt e sy
o f St e ve n B. Lip p it t , MD.)

PEARLS AND PITFALLS

Avo id sp lit t in g t h e cla vicu la r fra g m e n t s
a n d a id in p in in se rt io n
Ach ie ve a m o re a n a t o m ic fra ct u re re d u ct io n
■ If t a p p in g t h e m e d ia l o r la t e ra l cla vicu la r fra g m e n t s is t o o t ig h t , t h e su rg e o n
sh o u ld re d rill w it h t h e n e xt la rg e r d rill size .
■ Wh e n a d va n cin g t h e p in in t o t h e m e d ia l cla vicu la r fra g m e n t , t h e su rg e o n
sh o u ld a vo id st a rt in g t o o su p e rio r a n d a n t e rio r, w h ich ca n le a d t o m a lre d u c-
t io n . In st e a d , t h e p in sh o u ld b e in se rt e d m o re in fe rio r a n d p o st e rio r t o
a ch ie ve a m o re a n a t o m ic re d u ct io n .

POSTOPERATIVE CARE
■ A sling is worn for 4 weeks. During this time the sling is
removed at least five times a day for active range of motion of
the elbow and active assisted range of motion of the shoulder
to 90 degrees of forward flexion.
■ The sling is discontinued and full active range of motion of

the shoulder is started at 4 weeks.

■ Progressive resistance exercises are started at 6 weeks if the

patient achieved full range of motion and there is clinical and

radiographic evidence of healing.
■ O nce the clavicle fracture has healed, the pin is removed at 10
FIG 5 • Ra d io g ra p h sh o w in g a h e a le d cla vicle fra ct u re a ft e r p in
to 12 weeks, as described in the Techniques section (FIG 5 ). a sse m b ly re m o va l.
 Ch a p t e r 1 7 INTRAM EDULLARY FIXATION OF CLAVICLE FRACTURES
OUTCOMES
■ O ne of the authors (C.B.) has performed intramedullary fixa-
tion of some 300 acute fractures; there have been 60 malunions
and 30 nonunions of the clavicle, with a nonunion rate of 1.2% .
■ M ost of the nonunions occurred in older, sick patients with
polytrauma.
COMPLICATION S
■ Pin migration is rare with this technique because of the
locking nut on the lateral end of the pin, the blunt tip on the
medial end of the pin, and technically avoiding penetration of
the medial fragment cortex.
■ The risk of skin breakdown from pin prominence laterally
can be minimized by making sure the drill exits the posterolat-
eral clavicle in the lower half.
■ N eurovascular complications are rare.
■ There is no drilling toward the neurovascular structures
with this technique.
■ When exposing the fracture site, the surgeon should stay
on bone at all times.
■ N onunion rates are low as long as general fracture princi-
ples are maintained, soft tissue stripping of the fracture site is
minimized, the technique is followed to get adequate fracture
site compression and alignment, and the patient is compliant
with the postoperative protocol.
■ M alunion can rarely occur, especially in fractures with large
butterfly fragments. Good imaging with the C-arm allows the
surgeon to start inserting the pin more inferior and posterior
153
down the line of the medial clavicular fragment to achieve a
more anatomic reduction.
■ Infection is rare, especially with this technique, which has a
relatively short surgical time and small exposure. Preoperative
antibiotics, meticulous handling of the soft tissues, and ade-
quate irrigation should be part of any surgical technique.
REFEREN CES
1. Altamimi S, M cKee M . N onoperative treatment compared with plate
fixation of displaced midshaft clavicle fractures. J Bone Joint Surg Am
2008;90A:1–8.
2. Andersen K, Jensen PO , Lauritzen J. Treatment of clavicular frac-
tures: figure-of-eight versus a simple sling. Acta O rthop Scand 1987;
58:71–74.
3. Eskola A, Vainionpaa S, Myllynen P, et al. Outcome of clavicular frac-
tures in 89 patients. Arch Orthop Trauma Surg 1986;105:337–338.
4. H ill J, M cGuire M , Crosby L. Closed treatment of displaced middle-
third fractures of the clavicle gives poor results. J Bone Joint Surg Br
1997;79B:537–539.
5. M cKee M , Wild L, Schemitsch E. M idshaft malunions of the clavicle.
J Bone Joint Surg Am 2003;85A:790–797.
6. M oseley H F. The clavicle: its anatomy and function. Clin O rthop
Relat Res 1968;58:17–27.
7. N eer C. N onunion of the clavicle. JAM A 1960;172:96–101.
8. N ordqvist A, Redlund-Johnell I, Von Scheele A, et al. Shortening of
clavicle after fracture, incidence and clinical significance, a 5-year
follow-up of 85 patients. Acta O rthop Scand 1997;68:349–351.
9. Rowe C. An atlas of anatomy and treatment of midclavicular frac-
tures. Clin O rthop Relat Res 1968;58:29–42.
10. Stanley D, Trowbridge EA, N orris SH . The mechanism of clavicle
fracture: a clinical and biomechanical analysis. J Bone Joint Surg Br
1988;70B:461–464.
 Pe rcu t a n e o u s Pin n in g f o r
Ch a p t e r 18 Pro x im a l Hu m e r u s Fr a ct u re s
Le e sa M . Galat z

DEFIN ITION ■ The lesser tuberosity is the insertion site for the subscapu-
laris muscle.
■ Prox im al hum erus fractures are defined as those of the ■ The rotator interval lies between the upper subscapularis
proximal portion of the humerus involving the shoulder joint.
■ Fracture lines divide the proximal humerus into parts de-
and the anterior border of the supraspinatus.
■ The long head of the biceps tendon lies in a shallow
fined by anatomic structures that arise from early centers of
groove on the anterior proximal humerus and enters the
ossification.
■ These “ parts” first were described by Codman, and led to
glenohumeral joint at the rotator interval.
■ The proximal 3 cm of the long head of the biceps tendon
development of the N eer classification,6 which is commonly
lies deep to the interval tissue intra-articularly.
used today. ■ The anterior humeral circumflex artery (FIG 2 ) courses lat-
■ The parts refer to the head of the humerus, the greater
erally along the inferior subscapularis.
tuberosity, the lesser tuberosity, and the shaft (FIG 1 ). ■ The anterolateral branch of the anterior humeral circum-
■ Proximal humerus fractures are classified as two-, three-,
flex artery travels superiorly along the lateral aspect of the
or four-part fractures according to the N eer classfication.6
■ Displacement of a “ part” is classically defined as 1 cm of
biceps groove and enters the humeral head at the proximal-
most aspect of the groove, providing about 85% of the
displacement or 45 degrees of angulation. Importantly, dis-
blood supply to the humeral head.1
placement is not necessarily an indication for surgery, but only ■ The posterior humeral circumflex artery gives off several
a criterion for classification.
■ The type of fracture and degree of displacement, as well
small branches that run adjacent to the inferior capsule of the
shoulder, providing most of the remaining blood supply.
as patient considerations, all factor into surgical decision- ■ The pectoralis major muscle inserts on the proximal shaft of
making.
the humerus lateral to the long head of the biceps tendon. The
AN ATOMY latissimus dorsi muscle inserts onto the proximal shaft medial
to the biceps groove.
■ The proximal humerus arises from four distinct centers of
ossification: the humeral head, the greater tuberosity, the
lesser tuberosity, and the shaft.
■ The greater tuberosity has three distinct facets for the in-

sertion of the supraspinatus, the infraspinatus, and the teres

minor muscles of the rotator cuff.
Anterior circumflex
humeral artery

Humeral
head

Lesser
tubercle Axillary
artery
Greater
tubercle

Posterior circumflex
humeral artery

Humeral
shaft
FIG 1 • Fra ct u re s o f t h e p ro xim a l h u m e ru s a re cla ssifie d a s t w o -,
t h re e -, o r fo u r-p a rt fra ct u re s b a se d o n fra ct u re a n d d e g re e o f
d isp la ce m e n t o f t h e g re a t e r t u b e ro sit y, t h e le sse r t u b e ro sit y,
t h e h u m e ra l h e a d , a n d t h e h u m e ra l sh a ft .
FIG 2 • Th e ro t a t o r in t e rva l lie s b e t w e e n t h e u p p e r b o rd e r o f
t h e su b sca p u la ris a n d t h e a n t e rio r b o rd e r o f t h e su p ra sp in a t u s.
Th e b ice p s t e n d o n ru n s d e e p t o t h e ro t a t o r in t e rva l t issu e .
Im p o rt a n t ly, t h e fra ct u re lin e b e t w e e n t h e g re a t e r a n d le sse r
t u b e ro sit ie s lie s ju st p o st e rio r t o t h e b ice p s g ro o ve . Th e a sce n d -
in g b ra n ch o f t h e a n t e rio r h u m e ra l circu m fle x a rt e ry p ro vid e s
85% o f t h e b lo o d su p p ly t o t h e h u m e ra l h e a d .

154
 Ch a p t e r 1 8 PERCUTANEOUS PINNING FOR PROXIM AL HUM ERUS FRACTURES
PATHOGEN ESIS
■ Proximal humerus fractures occur in a bimodal distribution.
■ M ost proximal humerus fractures are “ fractures of
senescence” in older individuals with age-related osteopenia.
They commonly result from low-energy injures such as trip-
ping and falling.
■ They also occur in younger individuals as the result of high-
energy injuries such as motorcycle or automobile accidents.
■ Associated nerve injuries can occur and usually resolve spon-
taneously. Axillary nerve neurapraxia is the most common.
N ATURAL HISTORY
■ Eighty-five percent of proximal humerus fractures can be
treated nonoperatively.6
■ Displacement at the surgical neck is better tolerated than
displacement at the greater tuberosity.
■ Because of the vast range of motion (RO M ) of the shoul-
der in multiple planes, the arm can compensate for transla-
tional displacement or angulation at the surgical neck.
■ Displacement of the tuberosities, however, affects the me-
chanics of the rotator cuff and is very poorly tolerated.
■ Four-part fractures have an extremely high incidence of
avascular necrosis—45% in N eer’s classic series—with the
exception of valgus impacted four-part fractures, in which the
incidence is only 11% .7
■ In most four-part fractures, the blood supply from the an-
terior humeral circumflex artery is disrupted, contributing
to the high incidence of avascular necrosis.
■ The blood supply is maintained in most valgus impacted
fractures by the branches from the posterior humeral circum-
flex artery along the intact medial periosteal hinge (FIG 3 ),
making this particular fracture configuration very amenable
to fixation.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ A complete history of injury is important to determine the
mechanism of injury. It is helpful to differentiate low-energy
from high-energy injuries.
■ Elderly individuals often sustain proximal humerus frac-
tures as the result of low-energy injuries such as slipping
and falling. These injuries often are very amenable to mini-
mally invasive fixation techniques, because the displacement
is manageable and the periosteal sleeve between fracture
fragments often is intact. The rotator cuff often is intact as
155
a sleeve. All these qualities facilitate minimally invasive re-
duction and fixation techniques.
■ In younger individuals, proximal humerus fractures often
result from higher-energy injuries. These fractures com-
monly have greater fracture fragment displacement, rotator
cuff tears between the tuberosities, and disruption of the
periosteal sleeve. These factors do not necessarily preclude
percutaneous pinning, but make it more challenging and
should be considered in preoperative planning.
■ O ther important aspects of the history include:
■ Previous history of injury to the affected shoulder
■ Previous shoulder function
■ H istory of numbness or tingling in the affected extremity
■ Rule out elbow and wrist fractures, especially in osteo-
porotic patients with injuries resulting from a fall on an out-
stretched arm.
■ Patients often hold the shoulder inferior on the affected side.
■ Examination should include skin integrity, presence of ecchy-
mosis, downward carriage of shoulder girdle, and deformity
consistent with shoulder dislocation or acromioclavicular joint
separation.
■ Examine for possible associated nerve injury (usually neu-
rapraxia) by testing sensation to light touch in individual nerve
distribution, two-point discrimination, and muscle strength
(testing is limited to isometric at shoulder because of limited
RO M and pain).
■ Possible associated vascular injury can be determined by
testing radial pulse and capillary refill.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ A trauma series of radiographs of the shoulder should be
obtained (FIG 4 ).
■ The series includes an AP view of the shoulder, a scapular
AP view, a scapular Y view, and an axillary view.
■ A complete series with these views allows the fracture
configuration to be determined in sufficient detail.
■ A CT scan is helpful in many cases and should be obtained
if there is any question regarding the extent of fracture in-
volvement or the level of displacement of the fragments. It also
is helpful if there is any question of joint dislocation or glenoid
fracture.
■ Radiographs are used to determine whether the fracture is a
two-, three-, or four-part fracture and to assess the degree of
displacement.
FIG 3 • Va lg u s imp a ct e d fra ctu re s m a in t a in b lo o d
su p p ly t o t he articu lar su rface via a scend ing
b ra nch es off the p o st e rio r h u me ra l circum fle x a rt e ry
along the int act m ed ia l perioste al hinge .
 156 Se c t i o n II SHOULDER AND ELBOW
A B
FIG 4 • A n o rm a l t ra u m a se rie s in clu d e s a sca p u la r AP ra d io g ra p h , a n AP ra d io g ra p h o f
t h e sh o u ld e r, a n a xilla ry vie w , a n d a Y la t e ra l vie w . A. Th e sca p u la r AP vie w is t a ke n , b y
co n ve n t io n , w it h t h e a rm in n e u t ra l ro t a t io n . B. Th e AP vie w o f t h e sh o u ld e r is t a ke n w it h
t h e a rm in in t e rn a l ro t a t io n . C. Th e a xilla ry la t e ra l vie w is t a ke n w it h t h e a rm a b d u ct e d a n d
in n e u t ra l ro t a t io n . D. Th e Y la t e ra l vie w o ft e n a llo w s t h e e xa m in e r t o d e t e ct a n y p o st e rio r
d isp la ce m e n t o f su b t le g re a t e r t u b e ro sit y fra ct u re s.
D
■ Three-dimensional reconstructions of the CT scan can be
helpful in fracture evaluation, but are not routinely required.
DIFFEREN TIAL DIAGN OSIS
■ Acromioclavicular joint separation
■ Glenohumeral joint dislocation
■ H umeral shaft fracture
■ Scapulothoracic dissociation
■ Elbow and wrist fractures (may coexist)
N ON OPERATIVE MAN AGEMEN T
■ M inimally displaced fractures can be treated nonoperatively.
■ Displacement at the surgical neck is well tolerated.
■ An AP view of the shoulder can be misleading in the case
of a surgical neck fracture.
■ The pectoralis major muscle exerts an anterior force on
the shaft, resulting in anterior displacement of the shaft
relative to the humeral head.
■ A scapular Y or axillary view can exhibit this angular
deformity.
■ Displacement of the greater tuberosity is less well tolerated.
■ H istorically, 1 cm of displacement has been used as the
criterion for clinically significant tuberosity displacement.
■ Recently, however, even 5 mm of displacement has been
considered an operative indication.
■ Patients wear a sling for 2 to 3 weeks or until the proximal
humerus feels stable with gentle internal or external rotation
of the arm.
■ Patients should be instructed to remove the sling for
elbow and hand RO M to avoid stiffness of these joints.
■ Early signs of healing (eg, callus formation) also are help-
ful indicators of when it is safe to commence RO M exercises.
■ In borderline instances, it is better to err toward a longer
period of immobilization to ensure healing, because shoulder
stiffness is easier to address than a nonunion.
■ Therapy begins with passive stretching until 6 weeks when
active RO M and strengthening can be started, progressing as
tolerated.
C
SURGICAL MAN AGEMEN T
Preoperative Planning
■ All imaging studies should be reviewed carefully to deter-
mine the type of fracture, the degree of displacement, fracture
configuration, and bone quality.
■ Certain radiographic findings that can suggest that mini-
mally invasive fracture fixation is not appropriate for a given
fracture are as follows:
■ Poor bone quality. The bone may not hold the pins and
screws well and may be better treated with a more stable
construct.
■ Com m inution of the greater tuberosity. A comminuted
bone fragment is not amenable to fixation with screws.
Fractures with a comminuted greater tuberosity require su-
ture fixation through the tendon–bone junction (required
open approach).
■ Com m inution of the m edial calcar region leads to unsta-
ble reduction of the head onto the shaft.
■ Fractures amenable to minimally invasive fixation are two-
part, three-part, and valgus impacted four-part fractures with:
■ Good bone quality
■ Substantial fracture fragments with minimal comminu-
tion of the tuberosities
■ M inimal or no comminution at the medial calcar region
■ M inimally invasive fixation is not appropriate for noncom-
pliant or unreliable patients. This procedure should be per-
formed only in patients committed to consistent follow-up in
the postoperative period.
■ The pins require close surveillance in the early postopera-
tive period.
■ Pin migration is possible and must be caught early in
order to avoid potential injury to thoracic structures.
Positioning
■ Percutaneous pinning is performed with the patient in the
straight supine or 10- to 15-degree beach chair position (FIG 5 ).
■ This allows easy intraoperative evaluation with C-arm
fluoroscopy.
 Ch a p t e r 1 8 PERCUTANEOUS PINNING FOR PROXIM AL HUM ERUS FRACTURES 157

shoulder can be imaged in the anteroposterior plane without

the table obstructing the view.
■ This image should be checked before prepping and drap-

ing to confirm adequate visualization.

■ The entire upper extremity is draped free.

Approach
■ Closed fracture reductions are performed with the aid of a
“ reduction portal” (FIG 6 ).2
■ The reduction portal is a portal (analogous to that of an

arthroscopic portal) or small incision used to access the frac-

ture fragments.
■ Instruments can be introduced through this portal to lever

fracture fragments or pull fragments into reduced position.

■ The surgeon also can insert a finger through this portal to

palpate fragments.
■ M edially, the biceps tendon can be palpated.
FIG 5 • Th e p a t ie n t is p la ce d in t h e su p in e o r g e n t ly u p rig h t ■ The surgical neck fracture is located just deep to the
p o sit io n . Th e C-a rm is b ro u g h t in p a ra lle l t o t h e p a t ie n t , le a vin g
portal.
t h e la t e ra l a sp e ct o f t h e a rm fre e fo r in st ru m e n t a t io n . Th e
■ By sweeping posterior and superior, the greater tuberos-
p a t ie n t sh o u ld b e p o sit io n e d la t e ra lly o n t h e t a b le su ch t h a t a n
a d e q u a t e flu o ro sco p ic vie w ca n b e o b t a in e d . ity and its extent of displacement can be palpated.
■ The location of the reduction portal is critical (FIG 6 B).

■ The C-arm fluoroscope is placed parallel to the patient, ex- ■ In three- and four-part fractures, the fracture line of the

tending over the shoulder from the cephalad direction. greater tuberosity is reliably 0.5 to 1 cm posterior and lat-
■ This position leaves the lateral shoulder completely acces- eral to the biceps groove.
sible for instrumentation and pin fixation. ■ Therefore, the reduction portal is located at the level

■ The patient must be positioned far lateral on the table or on of the surgical neck and 1 cm posterior to the biceps
a specialized shoulder surgery positioning device such that the groove.

Skin incision
reduction port

A B

C D E

FIG 6 • A. The re d u ct io n p o rt a l is est a blish e d o ff t h e a n t ero la t eral corn e r o f th e a cromio n . In st ru me n ts ca n b e in t ro-

duced thro ug h t h is p o rt al to h elp re d uce th e fra ct u re . B. The re duct ion port al is locat ed at th e level o f t he surgical ne ck
fra ct u re a p p ro xim a te ly 0.5 t o 1 cm p o st e rio r to t h e b ice p s g ro o ve . Th e re d u ct io n p o rt a l is d e fin it ive ly lo ca lize d u sin g C-
a rm im ag e ry. A he m o sta t is a pplie d to the skin (C) an d th e n im ag ed (D) t o confirm t hat t his porta l w ill be d irectly at
t h e le vel o f th e su rg ical n eck fra ct u re . E. A sm a ll in cisio n is ma d e in th e skin , a n d t h e d e lt o id is sp re a d b lu n tly to a vo id
injury t o t he unde rlyin g axilla ry nerve .
 158 Se c t i o n II SHOULDER AND ELBOW

■ The arm is held in neutral rotation. ■ A 2-cm incision is made in the skin (FIG 6 E).
■ The level of the surgical neck is located using fluoroscopic ■ Subcutaneous tissues and the deltoid muscle are spread

imagery (FIG 6 C,D). bluntly using a straight hemostat to avoid injury to the
■ The location of the biceps tendon is estimated based on axillary nerve on the deep surface of the deltoid. Subdeltoid
surface anatomic landmarks. adhesions are gently released by sweeping finger if necessary.
TECHNIQUES

SURGICAL NECK FRACTURE

Re d u ct io n ■ Th e p in s m u st a n g le st e e p ly t o e n t e r t h e h e a d fra g -
m e n t a n d n o t cu t o u t p o st e rio rly (TECH FIG 2 B,C).
■ Th e p e ct o ra lis m a jo r m u scle p ro vid e s t h e m a jo r d e fo rm - ■ Pins sho uld be sm o ot h t o avo id in ju ry t o soft t issu e
in g fo rce re su lt in g in d isp la ce m e n t o f su rg ica l n e ck
u p o n inse rt io n , a nd t e rm in a lly t h re a d e d t o a vo id ba ck-
fra ct u re s. Th e sh a ft u su a lly is d isp la ce d a n t e rio rly a n d
ing ou t .
m e d ia lly w it h re sp e ct t o t h e h e a d . ■ 2.5- o r 2.7-m m sm o o t h , t e rm in a lly t h re a d e d p in s co m -
■ An a xilla ry o r sca p u la r Y ra d io g ra p h is n e ce ssa ry t o
m o n ly a re fo u n d in e xt e rn a l fixa t io n o r 7.3-m m ca n -
e va lu a t e t h e e xt e n t o f t h is d isp la ce m e n t .
n u la t e d scre w se t s o f in st ru m e n t s.
■ Th e re d u ct io n m a n e u ve r in vo lve s fle xio n , a d d u ct io n , a n d ■ Th e p in s sh o u ld e n t e r a t d iffe re n t d ire ct io n s t o e n h a n ce
p o ssib ly so m e slig h t in t e rn a l ro t a t io n t o re la x t h e p u ll o f
st a b ilit y o f fixa t io n co n st ru ct .
t h e p e ct o ra lis m a jo r m u scle 3 (TECH FIG 1 ). ■ On e p in sh o u ld e n t e r la t e ra l t o t h e b ice p s in a p rim a r-
■ Lo n g it u d in a l t ra ct io n is a p p lie d t o t h e a rm , a n d a p o s-
ily a n t e rio r-t o -p o st e rio r d ire ct io n .
t e rio rly d ire ct e d fo rce is a p p lie d t o t h e p ro xim a l sh a ft ■ An o t h e r p in sh o u ld e n t e r fu rt h e r la t e ra lly in a p rim a r-
o f t h e h u m e ru s.
ily la t e ra l-t o -m e d ia l d ire ct io n .
■ A b lu n t in st ru m e n t ca n b e in se rt e d in t o t h e fra ct u re a t ■ St a b ilit y sh o u ld b e ch e cke d u n d e r flu o ro sco p ic im a g in g
t h e su rg ica l n e ck t o le ve r t h e h e a d b a ck o n t o t h e sh a ft .
w it h live , g e n t le in t e rn a l a n d e xt e rn a l ro t a t io n .
Th is m a n e u ve r ca n b e a p o w e rfu l re d u ct io n t o o l, b u t
ca re sh o u ld b e u se d t o a vo id fu rt h e r d a m a g e o r fra ct u re
t o t h e h u m e ra l h e a d d u rin g t h is m a n e u ve r, e sp e cia lly o n
o st e o p e n ic p a t ie n t s.
■ Th e lo n g h e a d o f t h e b ice p s t e n d o n ca n b e co m e in -
t e rp o se d b e t w e e n t h e fra ct u re fra g m e n t s, p re clu d in g
re d u ct io n . Th e re fo re , if re d u ct io n is n o t a ch ie ve d ,
ch e ck t h e b ice p s t e n d o n t h ro u g h t h e re d u ct io n p o rt a l
(o r co n sid e r o p e n re d u ct io n ).

Fixa t io n
■ Tw o o r t h re e re t ro g ra d e p in s a re p la ce d fro m t h e sh a ft
in t o t h e h u m e ra l h e a d (TECH FIG 2 ).
■ Th e st a rt in g p o in t fo r t h e p in s is a p p ro xim a t e ly 5 t o
6 cm d ist a l t o t h e su rg ica l n e ck fra ct u re lin e .

TECH FIG 1 • Th e re d u ct io n m a n e uve r fo r su rgica l n eck frac-
tu res in volves fle xio n a n d int e rn a l ro ta tio n o f t he a rm t o
n egat e the effect o f t he pe ct o ralis ma jo r fra g m e nt o n th e pro x-
im al asp ect o f th e sh aft . Ofte n a p o ste rio r vecto r m u st b e ap -
p lie d t o the sh a ft o r a n inst ru m e n t ca n b e int rod u ce d t h ro ug h
th e red uction p o rta l to le ve r th e he a d b a ck o nt o t h e sh aft.
B
TECH FIG 2 • A. Re t ro g ra d e p in s a re in t ro d u ce d se ve ra l ce n -
t im e t e rs b e lo w t h e le ve l o f t h e su rg ica l n e ck fra ct u re in t o
t h e h e a d . Th e p in s sh o u ld b e p la ce d in d iffe re n t d ire ct io n s
t o p ro vid e st a b ilit y t o t h e co n st ru ct . B. Pla ce m e n t o f t w o
p in s. (co n t in u e d )
 Ch a p t e r 1 8 PERCUTANEOUS PINNING FOR PROXIM AL HUM ERUS FRACTURES 159

TECHNIQUES
TECH FIG 2 • (co n t in u e d ) C. Flu o ro sco p ic
vie w o f t w o re t ro g ra d e p in s in p la ce .
D. Th e p in s sh o u ld b e cu t b e lo w t h e skin
a ft e r in se rt io n t o p re ve n t p in sit e in fe c-
t io n . Th e y a re e a sily re m o ve d a co u p le o f
w e e ks la t e r w it h a sm a ll p ro ce d u re in
C D t h e o ffice o r o p e ra t in g ro o m .

■ An y su g g e st io n o f in st a b ilit y o r m o t io n a t t h e fra c- ■ Th e re d u ct io n p o rt a l is clo se d w it h in t e rru p t e d n ylo n

t u re is a n in d ica t io n fo r o p e n re d u ct io n a n d p la t e fix- su t u re s.
a t io n a t t h a t p o in t . ■ A so ft d re ssin g a n d slin g a re a p p lie d .
■ Pin s a re cu t b e lo w t h e skin t o p re ve n t p in sit e in fe ct io n
(TECH FIG 2 D).

THREE-PART GREATER TUBEROSITY FRACTURES

Re d u ct io n
■ De fo rm in g fo rce s in flu e n cin g d isp la ce m e n t o f t h re e -
p a rt fra ct u re s in clu d e t h e p e ct o ra lis m a jo r, a s d e scrib e d
e a rlie r, a n d t h e ro t a t o r cu ff m u scle s. Th e ro t a t o r
cu ff p u lls t h e t u b e ro sit y m e d ia lly (t o a ce rt a in e xt e n t )
a n d p o st e rio rly. Po st e rio r d isp la ce m e n t a n d ro t a t io n
o ft e n a re u n d e ra p p re cia t e d a n d m u st b e co n sid e re d .
■ Th e su rg ica l n e ck co m p o n e n t is a d d re sse d first .
(Se e Su rg ica l Ne ck Fra ct u re s e a rlie r in t h is se ct io n ).
■ Th e g re a t e r t u b e ro sit y fra ct u re is re d u ce d u sin g t h e
“ re d u ct io n p o rt a l.” A d e n t a l p ick o r sm a ll h o o ke d in -
st ru m e n t is in se rt e d t h ro u g h t h e p o rt a l t o e n g a g e t h e
t u b e ro sit y a n d p u ll it in fe rio r a n d a n t e rio r in t o a re d u ce d
p o sit io n .
Fixa t io n
■ 4.5-m m ca n n u la t e d scre w s a re u se d t o fix t h e t u b e ro sit y
fra g m e n t .
■ Th e scre w is p la ce d t h ro u g h t h e t u b e ro sit y fra g m e n t
d ist a l t o t h e cu ff in se rt io n t h ro u g h b o n e o n t h e la t -
e ra l co rt e x (TECH FIG 3 A).
■ Th e p ro p e r lo ca t io n is co n firm e d w it h flu o ro sco p ic
im a g in g .
■ Th e g u id e w ire is first p a sse d t h ro u g h a sm a ll in cisio n in
t h e skin ju st la rg e e n o u g h t o p a ss t h e d rill g u id e a n d
scre w t h ro u g h t h e d e lt o id (TECH FIG 3 B,C).
■ Th e g u id e w ire is p a sse d t h ro u g h t h e t u b e ro sit y,
a cro ss t h e su rg ica l n e ck fra ct u re , a n d e n g a g e s t h e
m e d ia l co rt e x o f t h e p ro xim a l h u m e ra l sh a ft .

A B

TECH FIG 3 • A. Th e g re a t e r t u b e ro sit y is lo ca lize d u n d e r flu o ro sco p y u sin g a h e m o st a t .

B. A sm a ll in cisio n is m a d e o ve r t h e g re a t e r t u b e ro sit y, a n d a ca n n u la t e d scre w is u se d fo r
fixa t io n . Th is p h o t o g ra p h d e m o n st ra t e s t h e d rill g u id e u se d fo r so ft t issu e p ro t e ct io n .
(co n t in u e d )
 160 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

C D E

TECH FIG 3 • (co n t in u e d ) C. Th e g u id e w ire is a im e d t o

e n g a g e t h e g re a t e r t u b e ro sit y fra g m e n t a s w e ll a s t h e
m e d ia l co rt e x t o p ro vid e co m p re ssio n . D. Th is flu o ro -
sco p ic vie w d e m o n st ra t e s t h e scre w b e in g in se rt e d
o ve r t h e g u id e w ire . E. A w a sh e r is u se d t o p ro vid e
so m e co m p re ssio n . Ove r-t ig h t e n in g sh o u ld b e a vo id e d
t o p re ve n t fra ct u re o f t h e g re a t e r t u b e ro sit y fra g m e n t .
F F. Scre w a n d w a sh e r in se rt io n .

■ Aft e r t h e g u id e w ire is o ve rd rille d , t h e scre w is p a sse d t u b e ro sit y fra g m e n t , e n g a g in g ca n ce llo u s b o n e o f

o ve r t h e g u id e w ire . We u se a p a rt ia lly t h re a d e d scre w t h e h u m e ra l h e a d .
w it h a w a sh e r (TECH FIG 3 D–F). ■ Pin s a re cu t b e n e a t h t h e skin .
■ If t h e g re a t e r t u b e ro sit y fra g m e n t is la rg e e n o u g h , a ■ In cisio n s a re clo se d w it h n ylo n in t e rru p t e d su t u re s.
se co n d ca n ce llo u s scre w is d ire ct e d t h ro u g h t h e ■ A d re ssin g a n d slin g a re a p p lie d .

VALGUS IMPACTED FOUR-PART PROXIMAL HUMERUS FRACTURES

■ Va lg u s im p a ct e d fra ct u re s a re re co g n ize d b y t h e 90- ■ Th e in st ru m e n t is t a p p e d w it h a m a lle t in a d ist a l-t o -
d e g re e a n g le b e t w e e n t h e lo n g a xis o f t h e h u m e ra l sh a ft p ro xim a l d ire ct io n , lift in g t h e h e a d fra g m e n t in t o
a n d t h e a rt icu la r su rfa ce o f t h e h u m e ra l h e a d w it h lo ss a n a t o m ic p o sit io n (TECH FIG 4 C).
o f t h e n o rm a l n e ck sh a ft a n g le .4 Th e t u b e ro sit ie s a re d is- ■ Th e su rg ica l n e ck fra ct u re s a n d t u b e ro sit y fra ct u re s a re
p la ce d la t e ra lly fro m t h e h e a d o f t h e h u m e ru s a n d t h e n fixe d u sin g t h e t e ch n iq u e s d e scrib e d e a rlie r.
slig h t ly p ro xim a lly.
■ Th is fra ct u re co n fig u ra t io n re su lt s in a lo w in cid e n ce
o f a va scu la r n e cro sis co m p a re d t o t h a t o f o t h e r fo u r-
p a rt fra ct u re s, b e ca u se t h e m e d ia l p e rio st e a l h in g e o f
so ft t issu e s is in t a ct a lo n g t h e m e d ia l a n d p o st e rio r
a n a t o m ic n e ck, p re se rvin g t h e b lo o d su p p ly p ro vid e d
b y t h e p o st e rio r h u m e ra l circu m fle x a rt e ry a n d it s a s-
ce n d in g ve sse ls.
■ Th e re d u ct io n m a n e u ve r fo r t h is fra ct u re re q u ire s
ra isin g t h e h u m e ra l h e a d b a ck in t o it s a n a t o m ic
p o sit io n .
■ Th e re d u ct io n p o rt a l d e scrib e d p re vio u sly is cre a t e d ,
a n d a n in st ru m e n t su ch a s a b lu n t e le va t o r o r sm a ll
b o n e t a m p is in se rt e d b e n e a t h t h e h u m e ra l h e a d
(TECH FIG 4 A,B).
A
■ Th e in st ru m e n t p a sse s t h ro u g h t h e su rg ica l n e ck fra c-
t u re a n d t h ro u g h t h e fra ct u re lin e b e t w e e n t h e TECH FIG 4 • A. Va lg u s im p a ct e d p ro xim a l h u m e ru s fra ct u re s
t u b e ro sit ie s, w h ich re lia b ly e xist s 0.5 t o 1 cm p o st e rio r a re re d u ce d u sin g a sm a ll b o n e t a m p o r o t h e r b lu n t -t ip p e d in -
a n d la t e ra l t o t h e b ice p s g ro o ve . st ru m e n t . (co n t in u e d )
 Ch a p t e r 1 8 PERCUTANEOUS PINNING FOR PROXIM AL HUM ERUS FRACTURES 161

B C
TECHNIQUES
TECH FIG 4 • (co n t in u e d ) B. Th e in st ru m e n t is in se rt e d
t h ro u g h t h e fra ct u re lin e b e t w e e n t h e g re a t e r t u b e ro sit y
a n d t h e le sse r t u b e ro sit y, w h ich lie s p o st e rio r t o t h e b ice p s
g ro o ve . Po sit io n is co n firm e d w it h flu o ro sco p ic im a g in g .
C. Th e b o n e t a m p is im p a ct e d in a su p e rio r d ire ct io n , b rin g -
in g t h e h u m e ra l h e a d in t o a re d u ce d p o sit io n . Th e g re a t e r
a n d le sse r t u b e ro sit ie s fa ll n a t u ra lly in t o a re d u ce d p o sit io n
a ft e r t h is re d u ct io n m a n e u ve r.

■ In so m e ca se s, t h e re m a y b e sig n ifica n t m e d ia l d isp la ce - ■ In m o st ca se s, m in im a l m e d ia l d isp la ce m e n t o f t h e

m e n t o f t h e le sse r t u b e ro sit y. In t h e se ca se s, t h e le sse r
t u b e ro sit y is re d u ce d u sin g t h e h o o k t h ro u g h t h e re d u c-
t io n p o rt a l a n d fixe d w it h a scre w p la ce d in t h e a n t e -
rio r-t o -p o st e rio r d ire ct io n t h ro u g h t h e t u b e ro sit y in t o
the head.
le sse r t u b e ro sit y is w e ll t o le ra t e d a n d n o fixa t io n is
re q u ire d .
■ Pin s a re cu t b e n e a t h t h e skin .
■ In cisio n s a re clo se d w it h n ylo n su t u re s.
■ A d re ssin g a n d slin g a re a p p lie d .

PEARLS AND PITFALLS

In d ica t io n s ■ Su cce ssfu l p e rcu t a n e o u s p in n in g d e p e n d s o n a p p ro p ria t e p a t ie n t se le ct io n . Crit e ria in clu d e g o o d
b o n e st o ck, m in im a l t o n o co m m in u t io n a t t h e g re a t e r t u b e ro sit y fra g m e n t , m in im a l t o n o co m -
m in u t io n a t t h e m e d ia l ca lca r a n d p ro xim a l sh a ft , a n d p a t ie n t co m p lia n ce .
■ Co n t ra in d ica t io n s in clu d e p o o r b o n e st o ck t h a t w ill n o t h o ld p in s, co m m in u t io n o f g re a t e r t u b e ro s-
it y o r p ro xim a l sh a ft fra g m e n t s, a n d a n o n co m p lia n t p a t ie n t w it h p o o r fo llo w -u p p o t e n t ia l.
Po sit io n in g ■ Th e p a t ie n t m u st b e la t e ra l e n o u g h o n t h e t a b le t o o b t a in u n e n cu m b e re d a cce ss t o t h e sh o u ld e r
a n d cle a r flu o ro sco p ic im a g e s.
Re d u ct io n t e ch n iq u e ■ Th e lo ca t io n o f t h e re d u ct io n p o rt a l is crit ica l fo r m a xim izin g it s u se fu ln e ss d u rin g t h e p ro ce d u re .
■ Th e su rg e o n m u st h a ve a t h o ro u g h u n d e rst a n d in g o f t h re e -d im e n sio n a l a n a t o m y, a s w e ll a s in t e r-
p re t a t io n a n d a p p lica t io n o f t w o -d im e n sio n a l flu o ro sco p ic im a g e s.
Pin p la ce m e n t ■ Pin s sh o u ld e n g a g e t h e h u m e ru s d ist a l t o t h e a xilla ry n e rve , b u t p ro xim a l t o t h e d e lt o id in se rt io n
t o a vo id n e rve in ju ry.
■ Th e a n g le o f in se rt io n is st e e p t o e n t e r t h e h u m e ra l h e a d a n d a vo id cu t t in g o u t p o st e rio rly.
■ At le a st t w o flu o ro sco p ic ima g e s in d iffe re n t p la n e s a re n e ce ssa ry t o co n firm su cce ssfu l p in p la ce m e n t .
■ A d rill g u id e ca n b e u se d t o p ro t e ct t h e so ft t issu e s d u rin g p in in se rt io n .
Scre w p la ce m e n t ■ Th e d e lt o id sh o u ld b e sp re a d b lu n t ly a n d a d rill g u id e u se d t o p re ve n t in ju ry t o t h e a xilla ry n e rve in
t h is lo ca t io n . In m o st ca se s, in se rt io n w ill b e p ro xim a l t o t h e n e rve , b u t p re ca u t io n a ry m e a su re s
sh o u ld b e t a ke n .
■ Ove rt ig h t e n in g t h e scre w w it h a w a sh e r m a y re su lt in fra ct u re o f t h e g re a t e r t u b e ro sit y.
■ En g a g in g m e d ia l co rt e x o f t h e p ro xim a l sh a ft g ive s st a b ilit y t o t h e scre w co n st ru ct .
In t ra o p e ra t ive a sse ssm e n t ■ Th e a rm sh o u ld b e in t e rn a lly a n d e xt e rn a lly ro t a t e d g e n t ly u n d e r co n t in u o u s flu o ro sco p ic im a g e ry
o f st a b ilit y a ft e r co m p le t io n o f h a rd w a re p la ce m e n t . An y m o t io n o r su g g e st io n o f in st a b ilit y is a n in d ica t io n
fo r o p e n re d u ct io n a n d fixa t io n .

POSTOPERATIVE CARE plane), external rotation, and internal rotation (all in supine
position) is initiated when pins are removed.
■ The operative arm is immobilized in a sling. ■ Ideally, pins should be out and motion started no later
■ The patient is instructed to begin active elbow, wrist, and
than 4 weeks postoperatively.
hand RO M exercises. ■ Active RO M progressing as tolerated to resistance exercises
■ Radiographs are checked weekly to monitor for pin migra-
commences at 6 weeks postoperatively.
tion or loss of fixation.
■ Pins are removed as a short procedure in the office or op-

erating room about 3 to 4 weeks postoperatively or when OUTCOMES

early signs of healing are evident radiographically. ■ Jaberg et al3 reported good to excellent results in 38 of
■ Pendulum exercises are initiated 2 to 3 weeks postopera- 48 fractures. There were 29 surgical neck, 3 anatomic neck,
tively, and passive stretching (forward elevation in scapular 8 three-part, and 5 four-part fractures.
162 Se c t i o n II SHOULDER AND ELBOW
■ Resch et al8 reported results of 9 three-part fractures and
18 four-part fractures. In the four-part fractures, the incidence
of avascular necrosis was 11% . Good results correlated with
anatomic reconstruction.
■ Keener et al5 reported a multicenter study of 35 patients—
7 two-part, 8 three-part, and 12 valgus impacted fractures.
Average duration of follow-up was 35 months. All fractures
healed. American Shoulder and Elbow Surgeons and Constant
scores were 83.4 and 73.9, respectively. Four patients had
some residual malunion, and four developed posttraumatic
arthritis. N either of these affected outcome at this early
follow-up period, however.
■ M ost studies report very satisfactory results with this proce-
dure. Patient selection is critical. In published studies, patients
are not randomized to percutaneous pinning, but, rather, care-
ful patient selection is left to the treating surgeon. Therefore,
it can be concluded that this is an appropriate technique in cer-
tain patients who meet the outlined criteria.
COMPLICATION S
■ N erve injury9
■ Pin migration
■ Loss of fixation
■ M alunion
■ N onunion
■ Infection
■ Glenohumeral joint stiffness
REFEREN CES
1. Gerber C, Schneeberger AG, Vinh TS. The arterial vascularization of
the humeral head. An anatomical study. J Bone Joint Surg Am 1990;
72A:1486–1494.
2. H su J, Galatz LM . M ini-incision fixation of proximal humeral four-
part fractures. In Scuderi GR, Tria A, Berger RA, eds. M IS
Techniques in O rthopedics. N ew York: Springer, 2006:32–44.
3. Jaberg H , Warner JJ, Jakob RP. Percutaneous stabilization of unsta-
ble fractures of the humerus. J Bone Joint Surg Am 1992;74A:
508–515.
4. Jakob RP, M iniaci A, Anson PS, et al. Four-part valgus impacted
fractures of the proximal humerus. J Bone Joint Surg Br 1991;73B:
295–298.
5. Keener J, Parsons BO , Flatow EL, et al. O utcomes after percutaneous
reduction and fixation of proximal humeral fractures. J Shoulder
Elbow Surg 2007;16:330–338. Epub 2007 Feb 22.
6. N eer CS II. Displaced proximal humerus fractures. I. Classification
and evaluation. J Bone Joint Surg Am 1970;52A:1077–1089.
7. Resch H , Beck A, Bayley I. Reconstruction of the valgus impacted
humeral head fracture. J Shoulder Elbow Surg 1995;4:73–80.
8. Resch H , Povacz P, Frohlich R, et al. Percutaneous fixation of three-
and four-part fractures of the proximal humerus. J Bone Joint Surg Br
1997;79B:295–300.
9. Rowles DJ, M cGrory JE. Percutaneous pinning of the proximal
humerus: An anatomic study. J Bone Joint Surg Am 2001;83A:
1695–1699.
 Op e n Re d u ct io n a n d
Ch a p t e r 19 In t e r n a l Fix a t io n o f Pro x im a l
Hu m e r u s Fr a ct u re s
M ark T. Dillo n an d David L. Glase r

DEFIN ITION ■ Although not included in N eer’s original classification, val-

■ Proximal humerus fractures may involve the surgical neck,
the greater tuberosity, or the lesser tuberosity.
■ The N eer classification, which is most commonly used,
categorizes fractures based on the number of displaced parts
(FIG 1 ). This classification system involves four segments:
the articular surface, the greater tuberosity, the lesser
tuberosity, and the humeral shaft. Fracture fragments dis-
placed 1 cm or angulated 45 degrees are considered dis-
placed. 17,18
■ The AO /ASIF (Arbeitsgemeinschaft fuer O steosynthese-
fragen–Association for the Study of Internal Fixation)
broadly classifies fractures into three types: type 1, unifocal
extra-articular; type 2, bifocal extra-articular, and type 3,
intra-articular.
■ Each type is then further divided into groups and sub-
gus impacted fractures are a unique entity that is important to
recognize:
■ Four-part fractures in which the humeral articular surface
is impacted upon the shaft segment
■ O ften minimally displaced owing to an intact rotator cuff5
■ H ave a lower incidence of avascular necrosis, because the
blood supply to the head is less likely to be disrupted
AN ATOMY
■ The osseous anatomy of the proximal humerus consists of the
greater tuberosity, the lesser tuberosity, and the articular surface.
■ The subscapularis inserts onto the lesser tuberosity,
whereas the supraspinatus, infraspinatus, and teres minor
insert onto the greater tuberosity.
■ Knowledge of deforming forces associated with humerus

groups.16 fracture allows the surgeon to better treat proximal humerus

■ This system places more emphasis on the vascular supply
to the humerus, with intra-articular fracture patterns having
the highest risk of avascular necrosis.26
■ Studies have demonstrated that interobserver reliability for
fractures by both operative and nonoperative means.
■ In a two-part surgical neck fracture, the pectoralis major
pulls the humeral shaft anteromedial.
■ In a two-part greater tuberosity fracture, the pull of the

both classification systems is not high.1,23,24 supraspinatus, infraspinatus, and teres minor tendons dis-
places the greater tuberosity superiorly and/or posteriorly.

1-part 2-part 3-part 4-part

Greater tuberosity Greater tuberosity Classic

and
surgical neck

Surgical Lesser tuberosity Valgus impacted Lesser tuberosity

neck and (rare)
surgical neck
(rare)

FIG 1 • Sim p lifie d Ne e r cla ssifica t io n fo r fra ct u re s o f t h e p ro xim a l h u m e ru s.

163
164 Se c t i o n II SHOULDER AND ELBOW
■ With a three-part fracture involving the lesser tuberosity,
the attachment site of these tendons into the greater tuberos-
ity is intact, and the articular surface of the humeral head
rotates externally to face anteriorly.
■ Three-part fractures involving the greater tuberosity re-
sult in unopposed subscapularis function, and the humeral
articular surface rotates posteriorly.
■ Four-part fractures result in displacement of the shaft and
both tuberosities, leaving a free head fragment with little
soft tissue attachment.
■ An understanding of the vascular anatomy is crucial to treat
fractures of the proximal humerus effectively.
■ The main blood supply to the humeral head is the antero-
lateral ascending branch of the anterior circumflex artery.
■ This branch of the axillary artery runs just lateral to the
bicipital groove, entering the humeral head at the proximal
portion of the transition from bicipital groove to greater
tuberosity.9
■ The intraosseous portion of this vessel, known as the
arcuate artery, has been shown to supply the entire epiphyseal
portion of the proximal humerus except for a small portion of
the greater tuberosity and the posteroinferior humeral head,
which is supplied by the posterior humeral circumflex artery.9
PATHOGEN ESIS
■ In older patients, proximal humerus fractures usually result
from a ground-level fall. Younger patients may sustain such an
injury from a higher-energy mechanism such as an automobile
collision or from sports.
■ The presence of an associated glenohumeral dislocation also
must be determined.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ O n presentation, patients with proximal humerus fractures
complain of pain in the shoulder that is made worse with at-
tempted movement. Palpation of the proximal humerus results
in diffuse pain.
■ Visual inspection reveals ecchymosis and swelling of the arm.
■ It is necessary to determine the stability of the fracture. If the
shaft and the proximal portion move as a unit when taken
through internal and external rotation, the fracture usually is
stable. Unstable fractures will not move as a unit, and crepitus
often is appreciated.
■ If there is an associated dislocation, it may be possible to
palpate the humeral head as an anterior fullness.
■ It is crucial to perform a thorough neurovascular examina-
tion to determine the presence of associated injuries.
■ Patients over 50 years of age are more prone to nerve in-
juries. One study demonstrated nerve injury, usually of the ax-
illary nerve, in nearly 40% of patients in this age group who
sustained shoulder dislocations or surgical neck fractures.2
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Initial imaging studies consist of anteroposterior, scapular Y,
and axillary views.
■ Additional views also may include internal and external ro-
tation views if the fracture pattern is stable. Internal rotation
views help to visualize the lesser tuberosity, whereas external
rotation shows the greater tuberosity.
■ Traction views also may prove helpful if tolerated by the
patient.
■ A CT scan may be helpful if radiographs do not demon-
strate the fracture pattern adequately.
■ Studies have shown that the addition of a CT scan improves
intraobserver reproducibility only minimally and does not
affect interobserver reliability.1
■ H owever, CT scanning may prove valuable in deter-
mining the method of fixation as well as identifying asso-
ciated injuries such as H ill-Sachs fractures and bony Bankart
lesions.
■ Indications for M RI are limited, although it may prove use-
ful if there is any concern regarding soft tissue injuries, includ-
ing the glenoid labrum and rotator cuff.
DIFFEREN TIAL DIAGN OSIS
■ Glenohumeral dislocation
■ Scapula fracture
■ H ead-splitting fracture
■ Clavicle fracture
■ H umeral shaft fracture
■ N eurovascular injury
■ N europathic arthropathy
N ON OPERATIVE MAN AGEMEN T
■ H istorically, conservative treatment usually is recommended
for fractures with less than 1 cm of displacement and 45 degrees
of angulation.17 About 85% of proximal humerus fractures
can be treated nonoperatively.15 With newer fixation devices,
however, indications for surgical management have been ex-
panded. Whether a more aggressive approach leads to improved
outcomes remains to be seen.
■ There is less tolerance for displacement in isolated greater
tuberosity fractures. It has been suggested that more than 5 mm
of displacement leads to poor functional results.14
■ For proximal humerus fractures not involving the humeral
shaft, patients initially are immobilized in a simple sling.
■ When pain improves and the fracture moves as a unit,
passive range of motion (RO M ) is started. Patients begin
with pendulum exercises, usually 2 to 3 weeks after injury,
then progress to RO M in all planes.
■ Between 6 and 10 weeks, the fracture usually has healed
enough that strengthening exercises may be started.13
■ Physical therapy is very important when treating proximal
humerus fractures conservatively. Koval et al11 showed signifi-
cant improvement with one-part fractures when physical ther-
apy was initiated before 2 weeks.
■ Several studies have shown that nonoperative manage-
ment can lead to acceptable results with proximal humerus
fractures. 22,25,28
■ Studies comparing patients treated surgically and nonsurgi-
cally have shown no difference in outcome with two-part surgi-
cal neck fractures4 and displaced three- and four-part fractures,27
although these studies were done before the advent of anatomic
proximal humeral plating.
SURGICAL MAN AGEMEN T
■ It is imperative that patients have reasonable expectations of
their outcome following surgery. Patients also must be aware
of the importance of physical therapy postoperatively.
 Ch a p t e r 1 9 OPEN REDUCTION AND INTERNAL FIXATION OF PROXIM AL HUM ERUS FRACTURES
Preoperative Planning
■ Acceptable imaging studies, either plain radiographs or a
CT scan, are necessary before proceeding to surgery.
■ Each proximal humerus fracture is unique, and in most
cases a planned method of fixation is chosen before entering
the operating room. H owever, the definitive choice of fixa-
tion is not made until the fracture is visualized at surgery.
Consequently, the surgeon should be prepared with an arsenal
of different fixation techniques.
■ If the fracture is not deemed suitable for internal fixation
intraoperatively, the surgeon must be prepared to perform a
hemiarthoplasty.
■ M ultiple techniques can be employed for surgical fixation of
the proximal humerus. In this chapter, we describe several cur-
rent techniques. The final choice of appropriate manner of fix-
ation should be based on the individual patient, the fracture
pattern, and the surgeon’s own comfort level.
Positioning
■ The techniques discussed in this section are easiest to per-
form with the patient in the beach chair position. With the pa-
tient nearly seated, the hips and knees are flexed. The patient
is moved as far laterally as possible on the table to allow full
RO M of the shoulder. A lateral buttress is used to help keep
the patient in position on the table.
■ C-arm fluoroscopy is helpful in determining the quality
of reduction. The C-arm is best positioned with the intensifier
posterior to the shoulder and the arm over the patient (FIG 2 ).
FIXATION OF ISOLATED TUBEROSITY FRACTURES
■ Th e p a t ie n t is p la ce d in t h e b e a ch ch a ir p o sit io n .
■ An in cisio n is m a d e fro m t h e t ip o f t h e a cro m io n e xt e n d -
in g la t e ra lly d o w n t h e a rm .
■ Alt e rn a t ive ly, a n in cisio n ca n b e m a d e p a ra lle l t o t h e
la t e ra l b o rd e r o f t h e a cro m io n , a s u se d in o p e n ro t a -
t o r cu ff re p a ir.
■ Skin fla p s a re t h e n ra ise d .
■ Th e d e lt o id is sp lit in lin e w it h it s fib e rs, a n d t h e a n t e rio r
p o rt io n o f t h e d e lt o id m a y b e d e t a ch e d fro m t h e
a cro m io n .
■ A d e lt o p e ct o ra l a p p ro a ch a lso co u ld b e u se d .
■ The de ltoid fibers sh o u ld n o t b e sp lit fu rthe r t h a n 5 cm
b elow t h e a cro mio n , t o p reve n t da ma ge t o t h e a xillary
n erve. A sut ure at t h e d ist al asp ect o f t h e sp lit ca n h elp
p re vent ina d ve rt e n t e xt e nsio n.10
■ As w it h a ll o p e n p ro ce d u re s d e scrib e d in t h is ch a p t e r,
t h e fra ct u re sh o u ld b e cle a n e d o f h e m a t o m a t o fa cilit a t e
re d u ct io n .
■ Th e g re a t e r t u b e ro sit y u su a lly is d isp la ce d p o st e rio rly o r
su p e rio rly. Ab d u ct in g a n d e xt e rn a lly ro t a t in g t h e sh o u l-
d e r w ill t a ke t e n sio n o ff t h e p o st e ro su p e rio r ro t a t o r cu ff,
a llo w in g t h e g re a t e r t u b e ro sit y fra g m e n t t o b e m o re
e a sily re d u ce d .
■ Tra ct io n su t u re s in t h e ro t a t o r cu ff m a y p ro ve va lu -
a b le in o b t a in in g re d u ct io n .
165
FIG 2 • Po sit io n in g o f t h e p a t ie n t in t h e b e a ch ch a ir p o sit io n
w it h flu o ro sco p ic im a g in g . Th e C-a rm in t e n sifie r sh o u ld b e p o s-
t e rio r t o a llo w fo r id e a l visu a liza t io n .
Approach
■ The approach depends on the surgical technique to be used
and is discussed further in the Techniques section.
■ The deltopectoral approach is most commonly employed.
TECHNIQUES
■ Pro vision al fixat io n can t hen b e obt ained w it h a K-wire
(TECH FIG 1 A,B).
■ Ca n n u la t e d scre w s p la ce d o ve r t h e w ire m a y t h e n b e
u se d fo r d e fin it ive fixa t io n if p la ce d in a n a cce p t a b le
lo ca t io n .
■ Scre w s sh o u ld b e o f t h e a p p ro p ria t e le n g t h t o g a in
a d e q u a t e p u rch a se (TECH FIG 1 C,D) b u t n o t so lo n g
t h a t t h e y a re sym p t o m a t ic.
■ Th e u se o f w a sh e rs m a y p ro ve b e n e ficia l.
■ Alt e rn a t ive ly, su t u re fixa t io n o f t h e g re a t e r t u b e ro sit y
b a ck t o t h e h u m e ru s m a y p ro vid e b e t t e r fixa t io n t h a n
ca n n u la t e d scre w s in t h o se p a t ie n t s w it h p o o r b o n e
q u a lit y.
■ Th is ca n b e a cco m p lish e d b y p la cin g t w o su t u re a n -
ch o rs in t o t h e fra ct u re b e d (TECH FIG 1 E).
■ Bo t h lim b s o f e a ch a n ch o r ca n t h e n b e b ro u g h t
t h ro u g h d rill h o le s in t h e fra g m e n t a n d t ie d o ve r t h e
t o p (TECH FIG 1 F).
■ Su t u re a lso ca n b e p la ce d a t t h e b o n e –t e n d o n in t e r-
fa ce o f t h e t u b e ro sit y fra g m e n t a n d t h e n t h ro u g h
b o n e t u n n e ls in t h e sh a ft , a s d iscu sse d la t e r in t h is
se ct io n .
■ If t h e a n t e rio r d e lt o id w a s d e t a ch e d d u rin g t h e a p -
p ro a ch , it m u st b e re p a ire d b a ck t o t h e a cro m io n u sin g
n o n a b so rb a b le su t u re s.
 166 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

C F

TECH FIG 1 • A. Traction sutures are placed through the rotator cuff tendon to aid in reduction of the displaced greater
tuberosity. B. Wires may be used to maintain reduction of the tuberosity. C. Screw fixation with 4.5-mm cannulated screws.
D. Final fixation. Scre ws should obtain purchase in the far cortex, but they must not be long enough to damage the a xillary
nerve. E. Placement of suture anchors into the fracture bed. F. Reduced fracture with sutures tied over the greater tuberosity.
 Ch a p t e r 1 9 OPEN REDUCTION AND INTERNAL FIXATION OF PROXIM AL HUM ERUS FRACTURES 167

OPEN REDUCTION AND SUTURE FIXATION
■ Th e p a t ie n t is p la ce d in t h e b e a ch ch a ir p o sit io n .
De p e n d in g o n t h e p a t t e rn , t h e fra ct u re m a y b e a p -
p ro a ch e d via t h e d e lt o p e ct o ra l in t e rva l o r a d e lt o id -
sp lit t in g a p p ro a ch .
■ Th e ro t a t o r in t e rva l t issu e m a y b e in cise d . Th is “ in t e rva l
sp lit ” a llo w s visu a liza t io n o f t h e h u m e ra l h e a d a rt icu la r
su rfa ce , if n e e d e d , in t h e se t t in g o f in t a ct t u b e ro sit ie s
a n d ro t a t o r cu ff, a s w it h h e a d sp lit p a t t e rn s.
■ Mu lt ip le su t u re s a re p la ce d t h ro u g h t h e t e n d o n s o f t h e
ro t a t o r cu ff, p re fe ra b ly n o . 5 n o n a b so rb a b le su t u re s o r
1-m m t a p e s.
■ Bot h t he su b sca pu la ris t e nd on a n d th e po st e ro sup e rio r
cu ff te n d o n s sh o u ld b e in co rp o ra t e d 20 (TECH FIG 2A).
TECHNIQUES
■ Drill h o le s sh o u ld b e p la ce d d ist a l t o t h e fra ct u re sit e .
Th e b o n e o n e it h e r sid e o f t h e b icip it a l g ro o ve is o f
e xce lle n t q u a lit y a n d sh o u ld h o ld su t u re s w e ll (TECH
FIG 2 B,C).
■ In m o st ca se s, a n a t o m ic re d u ct io n is d e sire d .
■ Wit h t h ree-p art fra ct u re s in volvin g t h e g re at er t u b erosit y,
th e h e a d fra g m en t sh o u ld first b e secure d t o t h e shaft ,
fo llo w e d b y re d u ct io n o f the g re a te r t u be ro sit y.20
■ Fo r h ig h su rg ica l n e ck fra ct u re s, su t u re s sh o u ld b e p la ce d
in t o a n y re m a in in g t u b e ro sit y o n t h e h e a d fra g m e n t t o
h e lp m a in t a in fixa t io n .

TECH FIG 2 • A. Su t u re s a re p la ce d t h ro u g h t h e su b sca p u la ris

a s w e ll a s t h e p o st e ro su p e rio r ro t a t o r cu ff t e n d o n s a t t h e
m u scle t e n d o n ju n ct io n . B. Su t u re is p la ce d t h ro u g h d rill
h o le s in t h e p ro xim a l sh a ft fra g m e n t . C. Pro xim a l fra g m e n t
B fixe d t o t h e sh a ft w it h 1 m m t a p e t h ro u g h t h e d rill h o le s.

OPEN REDUCTION AND INTERNAL FIXATION USING ANATOMIC PLATING

Exp o su re
■ An a t o m ic p la t in g o f t h e p ro xim a l h u m e ru s co m m o n ly is
p e rfo rm e d t h ro u g h t h e d e lt o p e ct o ra l in t e rva l.
■ Wit h t h e p a t ie n t in t h e b e a ch ch a ir p o sit io n , a n in cisio n
is m a d e st a rt in g fro m a b o ve t h e co ra co id p ro ce ss a n d
e xt e n d in g d ist a lly a s n e e d e d a lo n g t h e d e lt o p e ct o ra l
g ro o ve (TECH FIG 3 A).
■ Th e p la n e b e t w e e n t h e d e lt o id a n d p e ct o ra lis m a jo r is
d e ve lo p e d , m o b ilizin g t h e ce p h a lic ve in .
■ Co b b e le va t o rs ca n b e u se d t o d e ve lo p t h is
p la n e , m a kin g it e a sie r fo r t h e su rg e o n t o id e n t ify
 168 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

A B C

TECH FIG 3 • A. The incision is m ade ext en ding from t he coracoid process d ist ally a long t he delt opectoral gro ove.
B. Ident ifying t he int erval bet w een t he delt oid a nd p ect oralis m ajor. C. Usin g t wo Co b b e le va to rs t o d eve lo p t h e in t erval,
bring in g t he ce ph a lic ve in la te ra lly.

a n d lig a t e b ra n ch e s o f t h e ce p h a lic ve in (TECH FIG ■ A Co b b e le va t o r p la ce d in t h e fra ct u re sit e w ill a id in re -

3 B,C).
■ Th e u n d e rlyin g cla vip e ct o ra l fa scia is id e n t ifie d a n d in -
cise d la t e ra lly t o t h e co n jo in e d t e n d o n .10
■ Th e co n jo in e d t e n d o n is ca re fu lly re t ra ct e d m e d ia lly
w it h t h e p e ct o ra lis m a jo r a n d t h e d e lt o id re t ra ct e d
la t e ra lly.
Re d u ct io n
■ Th e fra ct u re a n d ro t a t o r cu ff a re n o w visib le . Wit h fra c-
t u re s in vo lvin g d isp la ce d t u b e ro sit ie s, w e re co m m e n d
o b t a in in g co n t ro l o f t h e t u b e ro sit ie s w it h su t u re s p la ce d
a t t h e b o n e –t e n d o n in t e rfa ce (TECH FIG 4 A).
■ He a vy su t u re s m a y b e p la ce d t h ro u g h t h e in se rt io n s
o f t h e cu ff t e n d o n s a n d la t e r u se d a s su p p le m e n t a l
fixa t io n if n e ce ssa ry.
■ Fo r fra ct u re s w it h m in im a lly d isp la ce d t u b e ro sit ie s,
su t u re s m a y n o t b e n e e d e d b e fo re a re d u ct io n
m a n e u ve r.
d u cin g t h e fra ct u re (TECH FIG 4 B).
■ The pect oralis ma jor insert ion is elevat ed in a subpe-
rioste al fash io n if n e ce ssa ry. The p la te sh o uld be
p la ce d la te ra l t o th e b ice p s te nd o n so a s n o t t o disru pt
th e b lo od sup p ly t o t h e h u m eral he ad (TECH FIG 4C).
■ Oft en , it m ay b e n e cessary t o re le ase a sm all p ortion of
th e a n t erio r d elt oid in sertion b e fore p la cin g t h e p lat e.
Pla t e Fixa t io n
■ Flu o ro sco p y sh o u ld b e u se d t o co n firm t h e re d u ct io n b e -
fo re p la ce m e n t o f t h e p la t e , e sp e cia lly in re g a rd t o t h e
su p e rio r a sp e ct o f t h e p la t e .
■ A p la t e p o sit io n e d t o o h ig h o r a fra ct u re fixe d in
va ru s m a y re su lt in t h e p la t e im p in g in g o n t h e u n d e r-
su rfa ce o f t h e a cro m io n . K-w ire s m a y b e u se d t o t e m -
p o ra rily m a in t a in fixa t io n p ro xim a lly a n d d ist a lly.
■ Alt e rn a t ive ly, m u lt ip le g u id e w ire s m a y b e p la ce d in t o
d rill sle e ve s (TECH FIG 5 A). Co n firm p la t e lo ca t io n

A B C

TECH FIG 4 • A. Tract ion sutures through t he t endinous att achments of the rotator cuff may be helpful in correcting
varu s d efo rmity. B. Re d ucin g th e fract ure by elevating th e pro xima l frag me nt . C. Correct p lacem ent of th e p late is lateral
to the bice ps t en do n (not se e n he re ). Su ture fixation h as b e en u sed to help ma in tain fixatio n an d su p plement the plat e.
 Ch a p t e r 1 9 OPEN REDUCTION AND INTERNAL FIXATION OF PROXIM AL HUM ERUS FRACTURES 169

TECHNIQUES
A B C

TECH FIG 5 • A. K-w ire s t h ro u g h d rill sle e ve s a re u se d t o m a in -

t a in p la t e fixa t io n . No t e t h e p o sit io n o f t h e su p e rio r a sp e ct o f
t h e p la t e in re la t io n t o t h e t o p o f t h e t u b e ro sit y. B. On ce t h e
h e a d is se cu re d t o t h e p la t e , d ist a l scre w s m a y b e p la ce d . C. Fin a l
D p la t e fixa t io n . D. Flu o ro sco p ic im a g e sh o w in g scre w pla ce m e n t .

a g a in , b o t h p ro xim a lly a n d d ist a lly, b e fo re p la cin g ■ In o st e o p o ro t ic b o n e , t h e t u b e ro sit ie s ca n first b e a t -

scre w s.
■ Lo ckin g screw s u su ally are p laced p ro xima lly in t o th e h e ad
first , an d m ultip le co nfigu ra t ion s of scre w s a re p o ssib le.
■ On ce t h e h e a d is se cu re d t o t h e sh a ft , d ist a l scre w s
ca n b e p la ce d (TECH FIG 5 B).
■ Fin a l p la t e p la ce m e n t sh o u ld b e co n firm e d flu o ro -
sco p ica lly (TECH FIG 5 C,D).
■ Su t u re s p la ce d t h ro u g h t h e cu ff t e n d o n s a lso m a y b e se -
cu re d t o t h e p la t e , sh a ft , o r o t h e r t u b e ro sit y.
■ At t h e co m p le t io n o f t h e p ro ce d u re , t h e p e ct o ra lis
m a jo r m a y b e se cu re d w it h su t u re s t h ro u g h h o le s in
t h e p la t e .
t a ch e d t o t h e sh a ft w it h su t u re s, fo llo w in g w h ich a lo ck-
in g p la t e m a y b e p la ce d a lo n g t h e la t e ra l a sp e ct o f t h e
p ro xim a l h u m e ru s.
■ Fixa t io n o f d isp la ce d t w o -p a rt p ro xim a l h u m e ru s fra c-
t u re s a lso ca n b e p e rfo rm e d u sin g a lo ckin g p la t e in a
p e rcu t a n e o u s fa sh io n . Wit h t h is t e ch n iq u e , g re a t ca re
m u st b e t a ke n t o p re ve n t in ju ry t o t h e a xilla ry n e rve .
■ A re ce n t ca da ve ric stu d y8 d e mo n stra te d th a t the a xil-
lary nerve was an average of 3 m m from th e seco n d
mo st p roxima l diaphyseal screw ho le, an d an average
of 7 mm from the third most proximal screw hole. All
ot her screw holes were more than 1 cm from the nerve.

PEARLS AND PITFALLS

In d ica t io n s
Exp o su re
Ma in t a in in g fixa t io n
Po o r b o n e q u a lit y
Su p e rio r im p in g e m e n t
■ An u n d e rst a n d in g o f t h e n e u ro va scu la r a n a t o m y a s w e ll a s t h e d e fo rm in g fo rce s p re se n t in p ro xim a l
h u m e ru s fra ct u re s is vit a l t o t re a t in g t h e se in ju rie s e ffe ct ive ly.
■ Avo id d e va scu la rizin g fra ct u re fra g m e n t s b y st rip p in g p ie ce s m in im a lly.
■ De ve lo p m e n t o f t h e “ in t e rva l sp lit ” a id s in fra ct u re visu a liza t io n a n d re d u ct io n a n d d o e s n o t
re q u ire d e t a ch m e n t o f t h e ro t a t o r cu ff t e n d o n s. Th is is e sp e cia lly h e lp fu l w h e n t ryin g t o fix a h e a d -
sp lit t in g fra ct u re in a yo u n g p a t ie n t .
■ K-w ire s a re u se fu l fo r m a in t a in in g in it ia l fixa t io n .
■ Wit h su t u re fixa t io n , t h e st ro n g b o n e a lo n g t h e b icip it a l g ro o ve o f t h e d ist a l fra g m e n t w ill h o ld
su t u re s t h e b e st .
■ Wit h o st e o p o ro t ic t h re e -p a rt fra ct u re s, co n sid e r su t u re fixa t io n first , fo llo w e d b y a p ro xim a l
h u m e ra l lo ckin g p la t e .
■ An a t o m ic p la t in g is ve ry h e lp fu l w h e n m e d ia l co m m in u t io n is p re se n t .
■ Avo id p la cin g t h e lo ckin g p la t e t o o h ig h o n g re a t e r t u b e ro sit y.
170 Se c t i o n II SHOULDER AND ELBOW
POSTOPERATIVE CARE
■ Stable fixation must be obtained to allow for immediate
RO M .
■ A physical therapy regimen should be established based
on the stability of fixation, the fracture pattern, the quality
of the bone, and individual patient factors.
■ Ideally, the fixation should allow pendulum exercises on
the first postoperative day and 130 degrees of passive for-
ward flexion and 30 degrees of passive external rotation.
■ Between 4 and 6 weeks after surgery, an overhead pulley
can be added, with stretching and active motion added at 6
to 8 weeks.
■ Formal strengthening with elastic bands is not started
until 10 to 12 weeks after surgery.3
■ As with nonoperative treatment, participation in physical
therapy is key to a successful outcome.
■ In a recent study looking at fixation of two- and three-
part fractures, the only patients with unsatisfactory out-
comes were those who were noncompliant with physical
therapy.20
OUTCOMES
■ N eer’s original description called for fixation of greater
tuberosity fractures when there was more than 1 cm of dis-
placement.17
■ O ne recent study had excellent or good results in 12 of 16
patients with fixation of greater tuberosity fractures dis-
placed more than 1 cm.7 Forward elevation averaged 170 de-
grees, and external rotation averaged 63 degrees.
■ Some authors believe that greater tuberosity displacement of
greater than 5 mm may lead to poor outcomes.
■ M cLauglin 14 first suggested that patients in whom a
greater tuberosity healed with residual displacement of
more than 5 mm had longstanding pain with poor function.
Displacement of less than 5 mm does not appear to warrant
surgery.
■ Platzer et al21 looked at minimally displaced fractures of
the greater tuberosity and found no statistical significance
with varying degrees of displacement less than 5 mm.
■ O pen reduction with suture or wire fixation can achieve ac-
ceptable fixation, especially in older patients with osteoporotic
bone. The technique can be used reliably in two- and three-
part fractures.
■ O ne study showed nearly 80% excellent results with av-
erage motion of 155 degrees of average forward flexion,
46 degrees average external rotation, and internal rotation
to T11. Furthermore, there were no reported cases of os-
teonecrosis of the humeral head. 20
■ Early open reduction and internal fixation with a laterally
placed T-plate failed to yield consistently good results, espe-
cially for four-part fractures.12,19 O ther early osteosynthesis
techniques include the cloverleaf and the blade–plate, but the
current trend is toward anatomic plating technology.
■ Recent studies show promise with the use of such
locking plates, although this technique is not without
complications. 6
COMPLICATION S
■ Infection
■ N onunion
■ M alunion
■ Avascular necrosis
■ N erve injury
■ Impingement secondary to fixation or residual tuberosity
displacement
■ Failure of fixation, including varus malposition and plate
fracture with proximal humeral anatomic plating6
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3. Cameron BD, Williams GR. O perative fixation of three-part proxi-
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fractures: Results of conservative treatment. Injury 1992;23:41–43.
 Ch a p t e r 1 9 OPEN REDUCTION AND INTERNAL FIXATION OF PROXIM AL HUM ERUS FRACTURES
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 In t r a m e d u lla r y Fix a t io n o f
Ch a p t e r 20 Pro x im a l Hu m e r u s Fr a ct u re s
J. De an Co le

DEFIN ITION
■ From 50% to 80% of proximal humerus fractures are
nondisplaced or minimally displaced and stable.12 Early range
of motion after a short period of immobilization usually is
sufficient to treat these fractures and has been shown to result
in satisfactory outcomes.1 The remaining 20% to 50% of
patients with proximal humerus fractures may benefit from
operative management.
■ N umerous techniques of internal fixation for proximal
humerus fractures have been described and reported, including
cloverleaf and blade plating,1 Rush pinning,15,19 spiral pin-
ning,18 Kirschner wire and tension band fixation,3 suture and
external fixation,7 and intramedullary nail fixation.8
■ Extensive dissection and inadequate biomechanical fixation
in the context of the severe soft tissue injury and devascular-
ization associated with these complex fracture types are the
commonly cited reasons for failure of internal fixation
devices.2
■ Prosthetic arthroplasty traditionally has been the recom-
mended treatment for three-part fractures with osteoporosis,
four-part fractures, head-splitting fractures, and articular com-
pression fractures that involve more than 40% of the articular
surface.1,2,11
■ Recently, several authors have reported satisfactory results
with various types of osteosynthesis for four-part fractures,
leading them to recommend an attempt at internal fixation in
younger patients.3,4,7,16 The basis of this recommendation is
that subsequent published series have been unable to repro-
duce N eer’s results with early hemiarthroplasty for four-part
fractures.
■ Various reports have been made on the use of in-
■ M inor losses in the humeral length between the head and
the deltoid insertion can alter the deltoid length–tension ratio.
■ Avulsion of the greater tuberosity indicates injury to the
rotator cuff.
Vascular Supply of the Proximal Humerus
■ The anterior and posterior humeral circumflex arteries are
branches of the axillary artery.
■ The arcuate artery, the terminal vessel of the ascending
branch of the anterior humeral circumflex artery, supplies
most of the humeral head.
■ Avascularity of the humeral head can occur if this ves-
sel is disrupted during a fracture of the anatomic neck.
■ The posterior circumflex artery becomes important in
patients with proximal humerus fractures.
■ It may be the primary source of blood supply to the
fractured head, so care should be taken to prevent addi-
tional devascularization.
■ Traumatic and iatrogenic vascular insult may lead to devas-
cularization of the fracture fragments, resulting in delayed
union, nonunion, and avascular necrosis. Traumatic injury
cannot be predicted; well-planned minimally invasive proce-
dures should reduce the risk of further damage, however.
Innervation
■ The brachial plexus is at risk in patients with upper extrem-
ity injury, and thorough neurologic evaluation is mandatory.

tramedullary nails in the proximal humerus. We prefer to use

an intramedullary nail that permits stable fixation of the head
to the shaft of the humerus using a minimally invasive rotator
cuff–splitting approach (DePuy Inc., Warsaw, IN ).
■ The method for treatment of proximal humeral fractures

described in this chapter involves a minimally invasive ante-

rior acromial surgical approach, an indirect method of re-
duction, and a unique intramedullary rod designed to permit
a variety of proximal interlocking configurations.

AN ATOMY
Osteology
■ The proximal humerus includes the humeral head, the lesser
tuberosity, the greater tuberosity, and the proximal humeral
metaphysis.
■ The position of the head is higher than the tuberosities, and

changes in this relationship will cause impingement. The

humeral head is slightly medial (3 mm) and posterior (7 mm)
in relation to the humeral shaft (FIG 1 ).
■ The humeral head is retroverted approximately 30 degrees
(range 20 to 60 degrees).
FIG 1 • Normal sho ulde r a na to my. Th e he ad is slig htly hig he r
than the tuberosities, slightly medial and posterior to the humeral
shaft, retroverted 30 degrees. (Copyright J. Dean Cole, MD.)

172
 Ch a p t e r 2 0 INTRAM EDULLARY FIXATION OF PROXIM AL HUM ERUS FRACTURES 173

■ The axillary nerve courses through the quadrilateral space, ■ Rotator cuff tears
where it is at risk during fracture dislocation. ■ N eurovascular injury: axillary nerve, brachial plexus

■ The lateral entry site for locking screw fixation (4–5 cm dis- ■ Avascular necrosis of the humeral head often results from

tal to the tip of the acromion) places the axillary nerve at risk. disruption of the arcuate artery. The axillary artery also may
be damaged, but less commonly, in fracture-dislocations.
PATHOGEN ESIS ■ M alunion: loss of humeral length may cause deltoid

■ A blow to the anterior, lateral, or posterolateral aspect of weakness

■ Posttraumatic arthrosis
the humerus typically is the cause.
■ Axial load transmitted to the humerus may cause impacted ■ Adhesive capsulitis

■ Chronic pain
fracture in osteoporotic bone.
■ Violent muscle contractures, as in grand mal seizures and

electric shock, are associated with posterior dislocation due to PATIEN T HISTORY AN D PHYSICAL
overpowering internal rotators and adductors. FIN DIN GS
■ Pathologic causes include tumor, multiple myeloma, and ■ Associated injuries:
metastatic or metabolic disorders. ■ Rotator cuff tears

■ O steoporosis is associated with fractures of the proximal ■ Dislocation

humerus (more than any other fracture). ■ Forearm fractures

■ In a three-part fracture with intact greater tuberosity, the ■ Brachial plexus, axillary, radial and ulnar nerve injuries

humeral head is pulled by the supraspinatus and infraspinatus (5% –30% of complex proximal humerus fractures)
tendons; if the tendons are intact, the humeral head is exter-
nally rotated. The inverse is seen when the greater tuberosity IMAGIN G AN D OTHER DIAGN OSTIC
is avulsed: the intact subscapularis internally rotates the STUDIES
humeral head (FIG 2 ). ■ Trauma series
■ Scapular anteroposterior (glenoid view)

N ATURAL HISTORY ■ Trans-scapular

Epidemiology ■ Axillary

■ 4% to 5% of all fractures
■ Rotational views
■ Increased incidence in osteoporosis, older middle-aged and
■ CT scan
elderly persons (third most common fracture in elderly)
■ In persons older than 50 years of age, the female:male ratio
SURGICAL MAN AGEMEN T
is 4:1 (osteoporosis). M inor falls and trauma may cause com- ■ Indications
■ Two-part proximal humerus fracture
minuted fracture.
■ In patients younger than 50 years of age, violent trauma, con- ■ Three-part proximal humerus fracture

■ Certain four-part proximal humerus fractures

tact sports, and falls from heights are responsible for fractures.
■ Surgical neck fracture is common. ■ Prerequisites
■ Shoulder table, image intensification, and experienced ra-

Consequences of Injury diology technician

■ N ondisplaced fractures may heal without major ■ Be aware of the learning curve (do not attempt nailing of

consequences. a four-part fracture before acquiring adequate experience

■ Acute, recurrent, or chronic dislocation with two- and three-part fractures).

A B C

FIG 2 • A. Fra ct u re p a t t e rn a n d d e fo rm in g fo rce s. Th e m u scu la r a t t a ch m e n t s o f t h e g re a t e r a n d le sse r t u b e ro sit ie s w ill ca u se a b d u c-

t io n , e xt e rn a l ro t a t io n , a n d in t e rn a l ro t a t io n , re sp e ct ive ly. Th e h e a d w ill fo llo w w h ich e ve r t u b e ro sit y is in t a ct . B,C. In fo u r-p a rt fra c-
t u re s, t h e h e a d o ft e n is in a n e u t ra lly ro t a t e d p o sit io n . (Co p yrig h t J. De a n Co le , MD.)
174 Se c t i o n II SHOULDER AND ELBOW
A B
FIG 3 • Pa t ie n t p o sit io n in g sh o u ld a llo w a cce ss o f t h e C-a rm t o
o b t a in o rt h o g o n a l ra d io g ra p h s, w h ich a re crit ica l in fra ct u re re -
d u ct io n a n d fixa t io n . A. La t e ra l vie w . B. Axia l vie w . (Co p yrig h t
J. De a n Co le , MD.)
When treating patients with complex fractures, obtain the
■ of head, shaft, and tuberosity fixation. In the technique we de-
patient’s consent for a hemiarthroplasty if that is determined
to be the best treatment, and have the implant available in
case it is found to be necessary.
■ Contraindication: head-splitting, comminuted displaced
humeral head fragment devoid of soft tissue attachment
Preoperative Planning
■ Successful intramedullary nailing of the proximal humerus
fracture depends on consistent integration between image in-
tensification and the surgical steps.
■ Patient positioning on a radiolucent table will allow the sur-
geon to use a minimally invasive approach.
■ Any error on the entry site will cause inevitable problems
with the rest of the procedure.
■ It is crucial that the surgeon follow the surgical technique
precisely.
Positioning
■ Positioning on the table must allow orthogonal and over-
head axillary views.
A B
FIG 4 • Skin in cisio n s. A. De lt o id -sp lit t in g in cisio n sp e cifica lly fo r g re a t e r t u b e ro sit y
fixa t io n . B. De lt o p e ct o ra l in cisio n sp e cifica lly fo r le sse r t u b e ro sit y fixa t io n . (Co p yrig h t
J. De a n Co le , MD.)
■ The patient is placed supine in the beach chair position on a
radiolucent table tilted at 60 to 70 degrees. The C-arm should
be positioned on the opposite side of the table to allow the sur-
geon easy access to the proximal humerus (FIG 3 ).
■ A bolster is used to elevate the shoulder from the table and
to allow shoulder extension. Extension of the shoulder is nec-
essary to expose the entry site in the humeral head. Flexion of
the shoulder will result in the acromion overlying the center of
the humeral head in the sagittal plane, obscuring the entry site
or errantly directing an entry angle. Anterior cutout of the nail
in the head fragment can easily occur in an osteoporotic
humeral head with an associated greater tuberosity fracture.
Approach
■ Intramedullary nailing for isolated surgical neck fractures
may be performed completely percutaneously using most of
the techniques described in the following paragraphs.
H owever, when tuberosity reduction and fixation are re-
quired, a wider approach often is necessary.
■ The timing of the open approach depends on the sequencing
scribe in this chapter, head–shaft fixation is accomplished per-
cutaneously using nailing and interlocking screws before
tuberosity fixation. Alternatively, an open approach with
tuberosity reduction and fixation can be performed before nail
insertion.
■ The surgical approach for viewing tuberosity fractures that
require fixation is a lateral deltoid-splitting approach made
just below the acromion, approximately 4 cm long, that does
not extend distally, to avoid injury to the axillary nerve
(FIG 4 A).
■ For a lesser tuberosity approach, a separate, small deltopec-
toral incision is centered just over the lesser tuberosity, and the
lesser tuberosity fixation or fixation to the subscapularis ten-
don is performed in that plane (FIG 4 B).
■ The rotator cuff is incised longitudinally away from the lat-
eral watershed area of the rotator cuff and away from
Sharpey’s fibers and the connection of the tendon to the bone.
■ Significant rotator cuff defect is not created with this ap-
proach, as confirmed in cadaver dissection. The longitudinal
incision on the rotator cuff does not weaken the cuff.
 Ch a p t e r 2 0 INTRAM EDULLARY FIXATION OF PROXIM AL HUM ERUS FRACTURES 175

K-WIRE PLACEMENT
■ Pla ce m e n t o f K-w ire s a llo w s fra g m e n t re d u ct io n a n d
h e lp s d ict a t e p la ce m e n t o f t h e skin in cisio n a n d su rg ica l
a p p ro a ch . He n ce , t h e first st e p in vo lve s p la ce m e n t o f a
K-w ire in t h e su b a cro m ia l sp a ce ; it is in se rt e d t h ro u g h
t h e a n t e ro la t e ra l a sp e ct o f t h e sh o u ld e r u sin g t h e im a g e
in t e n sifie r (C-a rm ) a n d d ire ct e d p o st e ro m e d ia l t o w a rd
t h e g le n o id (TECH FIG 1 A,B).
■ Th is in it ia l p in w ill se rve a s a g u id e fo r t h e re t ro ve r-
sio n o f t h e h u m e ra l h e a d .
■ Ne xt , t w o K-w ire s a re p la ce d in t h e h u m e ra l h e a d , d i-
re ct e d la t e ra l t o m e d ia l, o n e a n t e rio r a n d o n e p o st e rio r
t o t h e ce n t ra l a sp e ct o f t h e h e a d (TECH FIG 1 C,D). Th e
w ire s sh o u ld b e se p a ra t e d b y e n o u g h d ist a n ce t o a llo w
in se rt io n o f t h e n a il b e t w e e n t h e m (1.5 cm ).
TECHNIQUES
■ Th e K-w ire s sh o u ld b e d ire ct e d in t h e lo n g e st a xis o f
t h e h u m e ra l h e a d in t h e a xia l p la n e . Allo w in g fo r
re t ro ve rsio n is im p o rt a n t .
■ Co n firm a t io n o f t h e co rre ct p la ce m e n t in t h e a xia l p la n e
is d o n e b y t h e o ve rh e a d a xilla ry vie w . Th e n t h e C-a rm is
p o sit io n e d t o vie w t h e a d va n ce m e n t o f t h e p in s in t h e
co ro n a l p la n e p ro je ct io n .
■ Wit h lo n g e r K-w ire s, t h e su rg e o n ’s h a n d ca n b e ke p t
o u t o f ra d io g ra p h s. Un fo rt u n a t e ly, w it h in t e rn a l
ro t a t io n , e xt e n sio n a lso o ccu rs in t h e h u m e ru s a n d
t h e h u m e ra l h e a d , d e p e n d in g o n t h e so ft t issu e
a t t a ch m e n t s.

A B

C D

TECH FIG 1 • A,B. AP a n d a xia l vie w s o f in it ia l K-w ire in se rt io n :. Th is in it ia l p in w ill se rve t o o rie n t t h e h u m e ra l h e a d ,
sp e cifica lly t h e d e sire d d e g re e o f re t ro ve rsio n . C,D. AP a n d a xia l vie w s o f p in s t o co n t ro l h e a d fra g m e n t . Th e se p in s a re
in se rt e d t o co n t ro l t h e h e a d fra g m e n t in a jo yst ick fa sh io n . (Co p yrig h t J. De a n Co le , MD.)
 176 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

FRAGMENT REDUCTION
■ Th e K-w ire s ca n t h e n b e u se d in a jo yst ick fa sh io n t o
a d d u ct a n d e xt e n d t h e h e a d , e xp o sin g t h e su p ra sp in a t u s
t e n d o n a n d o p t im a l e n t ry sit e in t h e h e a d fro m b e n e a t h
t h e a n t e rio r e d g e o f t h e a cro m io n (TECH FIG 2 A,B).
■ Im a g e in t e n sifica t io n ca n b e u se d t o p la ce a K-w ire
t h ro u g h t h e h e a d in lin e w it h in t ra m e d u lla ry a xis o f t h e
h u m e ru s. Th is m a n e u ve r in clu d e s t w o im p o rt a n t a sp e ct s:
■ Th e first is t o u se t h e jo yst icks t o e xt e n d a n d a d d u ct
t h e p ro xim a l h u m e ra l h e a d , e xp o sin g t h e a n t e ro la t -
e ra l p o rt io n o f t h e h e a d fro m u n d e r t h e a cro m io n
w h ile sim u lt a n e o u sly d ist ra ct in g t h e d ist a l sh a ft ,
t h e re b y a lig n in g t h e lo n g it u d in a l in t ra m e d u lla ry a xis
o f t h e p ro xim a l a n d d ist a l fra g m e n t s (TECH FIG 2 C,D).
■ Th e se co n d is t o d rive t h e K-w ire in t o t h e h e a d in a
ce n t ra l p o sit io n w it h re fe re n ce t o t h e m e d u lla ry ca n a l
in t h e sa g it t a l p la n e a n d la t e ra l t o ce n t ra l in re fe r-
e n ce t o t h e ca n a l in t h e fro n t a l o r co ro n a l p la n e
(TECH FIG 2 E).
■ To achieve fract ure re duction, t he joysticks in t he proxim al
fra g m en t m u st b e use d t o ro t a t e t h e h e a d w h ile simu lt a -
n e ou sly ro t at in g t h e d ist a l sh a ft ma n u a lly to o bt ain t rue
o rt h o g o n a l vie ws o f t h e he a d in re fe re n ce to th e sha ft.

A B C

D E

TECH FIG 2 • Fra g m e n t re d u ct io n m a n e u ve r. A,B. Co m b in in g ro t a t io n o f t h e h e a d fra g m e n t (K-w ire s) w it h t h e sh a ft (a rm ) is

u se d t o a ssist in fra ct u re re d u ct io n . C,D. AP a n d a xia l vie w s o f h u m e ra l h e a d re d u ct io n m a n e u ve r. Ma n ip u la t io n o f t h e fra c-
t u re fra g m e n t s w it h t h e K-w ire s a llo w s d isim p a ct io n o f t h e fra ct u re , im p ro vin g t h e va ru s o r va lg u s a lig n m e n t . E. Pin e n t ry sit e
in h um e ra l h e a d . (Co p yrig h t J. De a n Co le , MD.)

GUIDEWIRE PLACEMENT
■ Th e n a il ca n b e p la ce d p e rcu t a n e o u s ju st a n t e rio r t o t h e
a n t e rio r e d g e o f t h e a cro m io n .
■ Th e a n t e rio r e d g e m a y b e d ifficu lt t o p a lp a t e a n d t o d if-
fe re n t ia t e fro m t h e h u m e ra l h e a d b e ca u se o f e d e m a a n d
h e m a t o m a fro m t h e fra ct u re . Th e re fo re , it is h e lp fu l t o
lo ca t e t h e a n t e rio r e d g e o f t h e a n g le o f t h e a cro m io n
u n d e r im a g e in t e n sifica t io n w it h a K-w ire w h e re it in t e r-
se ct s t h e lo n g it u d in a l a xis o f t h e h u m e ru s.
 Ch a p t e r 2 0 INTRAM EDULLARY FIXATION OF PROXIM AL HUM ERUS FRACTURES
■ Co rre ct p la ce m e n t o f t h e g u id e w ire is cru cia l; it sh o u ld
b e ce n t e re d in b o t h fro n t a l a n d sa g it t a l p la n e s.
■ Ma n ip u la t io n o f t h e p ro xim a l fra g m e n t h a s b e e n t h e
o n ly re lia b le w a y t o id e n t ify co rre ct p la ce m e n t .
ENTRY SITE REAMING
■ Re a m in g o f t h e e n t ry sit e sh o u ld b e p e rfo rm e d ca re fu lly,
a s t h e p e rcu t a n e o u s in cisio n is sm a ll.
■ Th e re a m e r is in se rt e d o ve r t h e g u id e w ire , a n d t h e so ft
t issu e s a re re t ra ct e d a n d p ro t e ct e d . Th e re a m e r is a d -
va n ce d t h ro u g h t h e ro t a t o r cu ff in “ re ve rse ” u n t il b o n e
co n t a ct , t h e n o n “ fo rw a rd ” t h ro u g h t h e h u m e ra l h e a d .
Th e re a m e r is le ft in p la ce .
■ Th e g u id e w ire t h a t w a s u se d t o in it ia t e t h e e n t ry sit e is
re m o ve d , a n d a lo n g e r g u id e w ire is p a sse d t o t h e sh a ft
NAIL INSERTION
■ On ce t h e n a il is in se rt e d , co n firm t h e ro t a t io n o f t h e
h u m e ru s in t h e a xia l p la n e ; it is n e ce ssa ry t o e n su re
p ro p e r a lig n m e n t b e fo re im p a ct io n (TECH FIG 3 ).
■ Usu a lly, im p a ct io n o f t h e d ist a l fra g m e n t b y b lo w s
a g a in st t h e o le cra n o n , w h ile su p p o rt in g t h e p ro xim a l
TECH FIG 3 • Na il in se rt io n . (Co p yrig h t J. De a n Co le , MD.)
INTERLOCKING SCREW FIXATION
■ We re co m m e n d t h a t t h e o b liq u e d ist a l scre w b e t h e in i-
t ia l lo ckin g scre w (TECH FIG 4 ). Th e g o a l o f t h is scre w is
t o a t t a ch t h e h e a d t o t h e sh a ft b e fo re fixa t io n o f t h e
t u b e ro sit ie s.
■ Scre w p la ce m e n t p u t s t h e a xilla ry n e rve a t risk. Ca re fu l
b lu n t d isse ct io n t o b o n e , d rillin g w it h in t h e sh e a t h , a n d
p la cin g t h e scre w w it h in t h e co n fin e s o f t h e sh e a t h a re
n e ce ssa ry. Drillin g sh o u ld b e d o n e ve ry ca re fu lly, a l-
t h o u g h it ce rt a in ly d o e s n o t co m p le t e ly n e g a t e t h e risk
o f d rillin g t h ro u g h t h e h u m e ra l h e a d . Ca re fu l o b se rva -
t io n is im p o rt a n t .
177
■ Th is is e a sily a cco m p lish e d in t h e co ro n a l p la n e , b u t it
TECHNIQUES
is m o re d ifficu lt in t h e sa g it t a l p la n e . At t e n t io n
sh o u ld b e d ire ct e d a t t h e ro t a t io n a l a lig n m e n t .
fra g m e n t . Ma n ip u la t io n o f t h e sh a ft fra g m e n t so m e -
t im e s is n e ce ssa ry. Th e re a m e r’s so u n d m u st b e u se d t o
g a u g e t h e ca n a l d ia m e t e r. It is n e ce ssa ry t o re a m 1 m m
g re a t e r t h a n t h e a n t icip a t e d n a il size .
■ On so m e o cca sio n s, e ve n e xt e rn a l fixa t o r p la ce m e n t fro m
t h e sca p u la r sp in e t o t h e d ist a l h u m e ru s is n e ce ssa ry. Th e
e xt e rn a l fixa t o r is a p p lie d a n d d ist ra ct io n a cco m p lish e d
w it h m a n ip u la t io n o f t h e p ro xim a l a sp e ct o f t h e sh a ft ;
g u id e w ire p a ssa g e u su a lly is sim p le .
h u m e ra l h e a d in d ire ct ly t h ro u g h t h e so ft t issu e s, is
adequate.
■ La rg e g a p s a re n o t a cce p t a b le , a n d it m a y b e n e ce ssa ry
t o u se fille r su b st a n ce .
■ It is o cca sio n a lly h e lp fu l t o re m o ve t h e d rill a n d t h e n u se
a b lu n t g u id e w ire a n d a ssu re g o o d h u m e ra l h e a d su b -
ch o n d ra l b o n e co n t a ct b e fo re fu rt h e r d rillin g o r scre w
p la ce m e n t .
■ Ce n t ra l p la ce m e n t o f t h e d ist a l o b liq u e scre w in t h e
h u m e ra l h e a d is im p o rt a n t . Th is st e p sh o u ld flo w ve ry
sm o o t h ly if t h e in it ia l K-w ire s h a ve b e e n p la ce d in t h e
co rre ct a xia l p la n e a lig n m e n t .
■ Erra n t p la ce m e n t o r a cce p t a n ce o f p o o rly p o sit io n e d
K-w ire s w ill re su lt o n ly in fu rt h e r d e via t io n . If t h e
d ist a l o b liq u e scre w is n o t p la ce d a t t h e a p p ro p ria t e
 178 Se c t i o n II SHOULDER AND ELBOW

a n g le , t h e ra d io g ra p h s m a y b e d e ce p t ive a n d m a y re - ■ A a n d B scre w s a re p la ce d d e p e n d in g o n g o a ls o f
TECHNIQUES

su lt in scre w p e n e t ra t io n . fixa t io n .
■ Scre w p la ce m e n t o n t h e su b ch o n d ra l b o n e is im p o r- ■ Ove rd rillin g t o co u n t e rsin k t h e m o re p ro xim a l scre w
t a n t fo r fixa t io n . Ho w e ve r, p a t ie n t s w it h o st e o p o ro sis u su a lly is n e ce ssa ry t o a vo id im p in g e m e n t .
d o h a ve a risk o f t h e fra ct u re fra g m e n t se t t lin g . ■ Th e se scre w s ra re ly a re h e lp fu l in t u b e ro sit y fixa t io n .

TECH FIG 4 • AP a n d a xia l vie w s o f in -

t ra m e d u lla ry n a il a n d p ro xim a l lo ckin g
A B scre w . (Co p yrig h t J. De a n Co le , MD.)

TUBEROSITY FIXATION
■ Th e t u b e ro sit y fixa t io n se q u e n ce is so m e w h a t va ria b le .
■ Wit h ve ry d isp la ce d t u b e ro sit y fra ct u re s, if sh a ft -t o -h e a d
fixa t io n is p e rfo rm e d in it ia lly w it h t h e t u b e ro sit ie s d is-
p la ce d , t h e g u id e w ill p e rfo ra t e t h e cu ff a n d p in t h e cu ff
in a n o n a n a t o m ic p o sit io n , re su lt in g in in a b ilit y t o p e r-
fo rm re d u ct io n o f t h e t u b e ro sit ie s. Th e re fo re , if t u b e ro s-
it y fixa t io n is g o in g t o b e a id e d w it h t h e n a il, t h e
t u b e ro sit y a lig n m e n t m u st b e p e rfo rm e d b e fo re n a ilin g .
■ An o t h e r se q u e n ce in vo lve s fixa t io n o f t h e h e a d a n d
sh a ft fo llo w e d b y la t e r fixa t io n o f t h e t u b e ro sit y.
An ch o rs ca n b e p a sse d t h ro u g h t h e n a il w it h su t u re s
u se d la t e r t o fix t h e t u b e ro sit ie s.
■ Th e se q u e n ce o f fixa t io n sh o u ld in vo lve p a ssin g su t u re s
t h ro u g h t h e m u scu lo t e n d in o u s ju n ct io n o f t h e su b sca p u -
la ris, in fra sp in a t u s, a n d su p ra sp in a t u s. Su t u re s p a sse d
o ve r t h e su p e rio r a sp e ct o f t h e h e a d fro m t h e in fra sp in a -
t u s a n d su b sca p u la ris a n d su t u re s p a sse d la t e ra lly a ro u n d
t h e h e a d p ro vid e h e lp fu l, re lia b le fixa t io n p o in t s. Wit h
p ra ct ice , t h e se m a n e u ve rs ca n b e p e rfo rm e d in a m in i-
m a lly in va sive m a n n e r.
■ Co m m in u t e d t u b e ro sit y fixa t io n is ch a lle n g in g . It is d iffi-
cu lt t o a ch ie ve co n sist e n t fixa t io n w it h scre w s. A h e a d -
le ss scre w h a s b e e n u se d w it h so m e su cce ss in lim it e d
ca se s.

PEARLS AND PITFALLS

In d ica t io n s ■ Tw o -p a rt p ro xim a l h u m e ru s fra ct u re
■ Th re e -p a rt p ro xim a l h u m e ru s fra ct u re
■ Se le ct fo u r-p a rt p ro xim a l h u m e ru s fra ct u re
Pre re q u isit e s ■ Sh o u ld e r t a b le , im a g e in t e n sifica t io n , a n d e xp e rie n ce d ra d io lo g y t e ch n icia n
■ Be a w a re o f t h e le a rn in g cu rve .
■ Pla n B: fo r co m p le x fra ct u re s, o b t a in co n se n t fo r a h e m ia rt h ro p la st y a n d h a ve a n im p la n t a va ila b le .
Co n t ra in d ica t io n ■ He a d -sp lit t in g , co m m in u t e d d isp la ce d h u m e ra l h e a d fra g m e n t d e vo id o f so ft t issu e a t t a ch m e n t
Po sit io n in g ■ Be a ch ch a ir p o sit io n t o a llo w cle a r flu o ro sco p ic im a g e s. Ch a ir w it h m e t a l e xt e n sio n s p o sit io n e d t o
a llo w o ve rh e a d a xilla ry C-a rm vie w s.
 Ch a p t e r 2 0 INTRAM EDULLARY FIXATION OF PROXIM AL HUM ERUS FRACTURES 179

Re d u ct io n t e ch n iq u e
Na il e n t ry sit e
Scre w p la ce m e n t
■ Hu m e ra l h e a d is a d d u ct e d ; u se K-w ire a s g u id e .
■ Pe rcu t a n e o u sly d rill K-w ire s in t h e h e a d fra g m e n t a n d u se t h e m a s a “ jo yst ick” t o ro t a t e t h e h e a d
fra g m e n t .
■ Ort h o g o n a l vie w s o f t h e sh o u ld e r
■ Errin g a t t h e e n t ry sit e in e vit a b ly w ill ca u se p ro b le m s w it h t h e re st o f t h e p ro ce d u re .
■ A d rill g u id e is u se d t o p re ve n t in ju ry t o t h e a xilla ry n e rve .

POSTOPERATIVE CARE 5. Goldman RT, Koval KJ, Cuomo F, et al. Functional outcome after
humeral head replacement for acute three- and four-part proximal
■ The postoperative regimen depends on the stability of the humeral fractures. J Shoulder Elbow Surg 1995;4:81–86.
fixation and the soft tissues. 6. H awkins RJ, Switlyk P. Acute prosthetic replacement for severe frac-
■ Sling with abduction pillow that allows the proximal tures of the proximal humerus. Clin O rthop Relat Res 1993;
humerus to rest in neutral rotation and slight abduction 289:156–160.
7. Ko J, Yamamoto R. Surgical treatment of complex fracture of the
(relax the rotator cuff and decrease tension on the greater
proximal humerus. Clin O rthop Relat Res 1996;327:225–237.
tuberosity) 8. M ouradian WI. Displaced proximal humeral fractures: seven years’
■ Gentle passive, pendulum, and active-assisted exercises of
experience with a modified Z ickel supracondylar device. Clin O rthop
the shoulder Relat Res 1986;212:209–218.
■ Active elbow and wrist exercises 9. N ayak N K, Schickendantz M S, Regan WD, et al. O perative treat-
■ O nce fracture healing is detected on radiographic imag- ment of nonunion of surgical neck fractures of the humerus. Clin
O rthop Relat Res 1995;313:200–205.
ing, range of motion can be increased; weight lifting restric-
10. N eer CS. Displaced proximal humeral fractures. Part I. Classification
tions must be maintained until healing is complete. and evaluation. J Bone Joint Surg Am 1970;52A:1077–1089.
11. N eer CS. Displaced proximal humeral fractures. Part II. Treatment of
COMPLICATION S three and four part displacement. J Bone Joint Surg Am 1970;
■ Early 52A:1090–1103.
■ Injury to axillary nerve 12. N orris TR. Fractures of the proximal humerus and dislocations of the
■ Joint penetration shoulder. In: Browner BD, Jupiter JB, Levine AM , et al, eds. Skeletal
■ Loss of reduction
Trauma: Fractures–Dislocations–Ligamentous Injuries. Philadelphia:
WB Saunders, 1992:120–129.
■ Infection
13. Riemer BL, D’Ambrosia RD, Kellam JF, et al. The anterior acromial
■ Late approach for antegrade intramedullary nailing of the humeral diaph-
■ N onunion ysis. O rthopaedics 1993;16:1219–1223.
■ Posttraumatic arthrosis 14. Robinson CM , Christie J. The two-part proximal humeral fracture: a
■ Avascular necrosis of humeral head review of operative treatment using two techniques. Injury 1993;
■ Prominent hardware 24:123–125.
15. Rush LV. Atlas of Rush Pin Technique: A System of Fracture
Treatment. M eridian, M I: Bervion, 1955:166–167.
REFEREN CES 16. Szyszkowitz R, Seggl W, Schleifer P, et al. Proximal humeral frac-
1. Bigliani LU, Flatow EL, Pollock RG. Fractures of the proximal tures: management techniques and expected results. Clin O rthop
humerus: In: Rockwood CA, Green DP, Bucholz RW, et al, eds. Relat Res 1993;292:13–25.
Fractures in Adults. Philadelphia: Lippincott-Raven, 1996:1055–1107. 17. Wheeler DL, Colville M R. Biomechanical comparison of in-
2. Connor PM , Flatow EL. Complications of internal fixation of proxi- tramedullary and percutaneous pin fixation for proximal humeral
mal humeral fractures. Instr Course Lect 1997;46:25–37. fracture fixation. J O rthop Trauma 1997;11:363–367.
3. Darder A, Darder A Jr, Sanchis V, et al. Four-part displaced proximal 18. Yano S, Takamura S, Kobayashi I, et al. Use of the spiral pin for frac-
humerus fractures: O perative treatment using Kirchner wires and a ture of the humeral neck. J O rthop Science 1981;55:1607–1619.
tension band. J O rthop Trauma 1993;7:497–505. 19. Weseley, M S, Barenfeld PA, Eisenstein AL. Rush pin intramedullary
4. Esser RD. Open reduction and fixation of three- and four part fractures fixation for fractures of the proximal humerus. J Trauma 1977;
of the proximal humerus. Clin Orthop Relat Res 1994;299:244–251. 17:29–37.

Ch a p t e r 21
DEFIN ITION
■ Proximal humerus fractures involve isolated or combined
injuries to the greater tuberosity, lesser tuberosity, articular
segment, and proximal humeral shaft.
■ O verall, proximal humerus fractures account for 4% to
5% of all fractures. 8,13
AN ATOMY
■ The proximal humerus consists of four segments: the greater
tuberosity, lesser tuberosity, articular segment, and humeral
shaft (FIG 1 ).
■ The most cephalad surface of the articular segment is, on av-
erage, 8 mm above the greater tuberosity.16 H umeral version
averages 29.8 degrees (range 10 to 55 degrees).23
■ The intertubercular groove lies between the tuberosities and
forms the passageway for the long head of the biceps as it tra-
verses from the intra-articular origin into the distal arm.
■ The tuberosities attach to the articular segment at the
anatomic neck. The greater tuberosity has three facets for the
corresponding insertions of the supraspinatus, infraspinatus,
and teres minor tendons; the lesser tuberosity has a single facet
for the subscapularis.
■ The deltoid, pectoralis major, and latissimus dorsi all insert
on the humerus distal to the surgical neck. These soft tissue at-
tachments contribute to the deforming forces sustained with
proximal humerus fractures.
3 motion, and activities of daily living.
1 2
4 nance, history of malignancy, and ability to participate in a
Anatomic
neck
FIG 1 • Ne e r cla ssifica t io n o f p ro xim a l h u m e ru s fra ct u re s:
1, g re a t e r t u b e ro sit y; 2, le sse r t u b e ro sit y; 3, a rt icu la r su rfa ce ;
4, sh a ft .
180
He m ia r t h ro p la s t y f o r Pro x im a l
Hu m e r u s Fr a ct u re s
Kam al I. Bo h sali, M ich ae l A . W irt h , an d St e ve n B. Lip p it t
■ The anterolateral branch of the anterior humeral circumflex
artery (the arcuate artery of Laing) is the major blood supply
to the humeral head. This vessel courses parallel to the lateral
aspect of the long head of the biceps and enters the humeral
head at the interface between the intertubercular groove and
the greater tuberosity. Injury to the arcuate artery can result in
osteonecrosis of the articular segment.10,18
PATHOGEN ESIS
■ The incidence of proximal humerus fractures is increasing
with an aging population and associated osteoporosis.
■ The mechanism of injury may be indirect or direct and sec-
ondary to high-energy collisions in younger patients (eg, motor
vehicle accidents, athletic injuries) or falls from standing
height in elderly patients.
■ Pathologic fractures from primary or metastatic disease
should be included in the differential diagnosis.
■ Risk factors for the development of proximal humerus
fractures in the elderly patient population include low bone
density, lack of hormone replacement therapy, previous frac-
ture history, three or more chronic illnesses, and smoking. 15
N ATURAL HISTORY
■ N eer’s classic study in 1970 compared the results of nonop-
erative treatment with hemiarthroplasty for three- and four-part
displaced proximal humerus fractures. No satisfactory results
were found in the nonoperative group owing to inadequate re-
duction, nonunion, malunion, and humeral head osteonecrosis
with collapse.20
■ Stableforth 24 reaffirmed this in a study in which patients
were randomized to nonoperative management or prosthetic
replacement. The patients with displaced fractures treated
nonoperatively had worse overall results for pain, range of
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ A thorough history and complete physical examination
should be performed. H istory should include mechanism of in-
jury, pre-morbid level of function, occupation, hand domi-
structured rehabilitation program.14
■ A review of systems should involve queries regarding loss
of consciousness, paresthesias, and ipsilateral elbow or
wrist pain.
■ O n physical examination, the orthopaedic surgeon should
look for swelling, soft tissue injuries, ecchymosis, and defor-
mity. Posterior fracture-dislocations will demonstrate flatten-
ing of the anterior aspect of the shoulder with an associated
posterior prominence. Anterior fracture-dislocations present
with opposite findings.14
 Ch a p t e r 2 1 HEM IARTHROPLASTY FOR PROXIM AL HUM ERUS FRACTURES
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Appropriate radiographs include anteroposterior and axil-
lary views of the shoulder 14 (FIG 2 ). If the axillary view can-
not be obtained because of patient discomfort, alternate
views such as the Velpeau trauma axillary view can be used
to evaluate and classify the glenohumeral articulation. 2
■ The N eer classification is based on the four anatomic
segments of the proximal humerus: the humeral head, the
greater and lesser tuberosities, and the humeral shaft
(see Fig 1). 11 N umber of parts is based on 45 degrees
of angulation or 1 cm of displacement from neighboring
segments.
■ The AO /ASIF/O TA Comprehensive Long Bone Clas-
sification system distinguishes the valgus impacted four-
part proximal humerus fracture from other four-part
fractures with partial preservation of the vascular inflow
to the articular segment through an intact medial cap-
sule. 17,22
■ The current fracture classification systems have fair in-
terobserver reliability, even with the addition of CT scans.
Despite the limitations of these systems, they remain clini-
cally useful when deciding on nonoperative versus opera-
tive treatment. 2,11
■ CT scans may be helpful in evaluating tuberosity displace-
ment and articular surface involvement.14
DIFFEREN TIAL DIAGN OSIS
■ Acute hemorrhagic bursitis
■ Traumatic rotator cuff tear
■ Simple dislocation
■ Acromioclavicular separation
■ Calcific tendinitis 2
N ON OPERATIVE MAN AGEMEN T
■ N onoperative treatment usually is reserved for minimally
displaced fractures of the proximal humerus, which account
for nearly 80% of these injuries.
■ The characteristics of the fracture (ie, bone quality, fracture
orientation, concurrent soft tissue injuries), the personality of
the patient (eg, compliant, realistic expectations, mental sta-
tus), and surgeon experience all affect the decision to proceed
with operative intervention.
181
FIG 2 • AP a n d a xilla ry vie w s o f a d isp la ce d t h re e -p a rt
p ro xim a l h u m e ru s fra ct u re w it h o u t e vid e n ce o f co n co m i-
t a n t d islo ca t io n .
■M oribund individuals and patients unable to cooperate
with a postoperative rehabilitation program (eg, closed
head injury) are not appropriate candidates for operative
intervention.
■ In general, nonoperative management of complex, displaced
proximal humerus fractures has not proven as successful.
■ Initial immobilization with a sling and axillary pad may be
helpful. Gentle range-of-motion exercises may be started by 7
to 10 days after the fracture when pain has decreased and the
patient is less apprehensive.2
■ Intermittent biplanar radiographs are essential to determine
additional displacement and the interval stage of healing.2
■ Active and active assisted range-of-motion exercises are ini-
tiated with evidence of radiographic union. Inform the patient
that he or she may never attain symmetric range of motion or
strength when comparing the affected versus the uninjured side.
SURGICAL MAN AGEMEN T
■ The goal of surgery is to anatomically reconstruct the gleno-
humeral joint with restoration of humeral length, placement
of appropriate prosthetic retroversion, and establishment of
secure tuberosity fixation.
■ Prosthetic replacement is the preferred treatment of most
four-part fractures, three-part fractures and dislocations in el-
derly patients with osteoporotic bone, head-splitting articular
segment fractures, and chronic anterior or posterior humeral
head dislocations with more than 40% of the articular surface
involved.25
■ Several studies have indicated that the outcome of primary
hemiarthroplasty for acute proximal humerus fractures is su-
perior to that from late reconstruction. 6,21
Preoperative Planning
■ Although some studies have suggested urgent intervention
(ie, within less than 48 hours), most authors recommend pre-
operative planning with a careful neurovascular assessment of
the injured shoulder, medical optimization of the patient, and
preoperative templating with standard radiographs of the con-
tralateral uninjured shoulder.12
■ An interscalene block (regional anesthesia) may be used to
supplement general anesthesia.
■ Endotracheal intubation is recommended to allow for intra-
operative muscle relaxation, but laryngeal mask intubation
may be used.12,14
 182 Se c t i o n II SHOULDER AND ELBOW
Positioning
■ The patient is placed on an operating table in the beach
chair position with the arm positioned in a sterile articulating
arm holder or draped free if an appropriate number of assis-
tants are available (FIG 3 ).
Approach
■ The surgical prep site should include the entire upper ex-
tremity and shoulder region, including the scapular and pec-
toral regions.
■ Appropriate prophylactic intravenous antibiotics are given
to the patient before skin incision.
■ A standard deltopectoral incision is used. Care is taken to
minimize injury (eg, surgical detachment, contusion secondary
to retractors) to the deltoid muscle. The musculocutaneous
and axillary nerves are identified and protected during the
procedure.
TECHNIQUES
DELTOPECTORAL APPROACH
■ Th e in cisio n b e g in s su p e rio r a n d m e d ia l t o t h e co ra co id
p ro ce ss a n d e xt e n d s t o w a rd t h e a n t e rio r a sp e ct o f t h e
d e lt o id in se rt io n (TECH FIG 1 A).
■ Th e ce p h a lic ve in is id e n t ifie d , p re se rve d , a n d re t ra ct e d
la t e ra lly w it h t h e d e lt o id m u scle . Th e p e ct o ra lis m a jo r is
m o b ilize d m e d ia lly. If a d d it io n a l e xp o su re is n e ce ssa ry,
t h e p ro xim a l 1 cm o f t h e p e ct o ra lis m a jo r in se rt io n is re -
le a se d (TECH FIG 1 B).
A B
TUBEROSITY MOBILIZATION
■ Th e t e n d o n o f t h e lo n g h e a d o f t h e b ice p s is id e n t ifie d
a s it co u rse s in t h e b icip it a l g ro o ve t o w a rd t h e ro t a t o r
in t e rva l. Th e t e n d o n se rve s a s a ke y la n d m a rk w h e n
re -e st a b lish in g t h e a n a t o m ic re la t io n sh ip b e t w e e n t h e
g re a t e r a n d le sse r t u b e ro sit ie s.
■ Th e ro t a t o r in t e rva l a n d co ra co h u m e ra l lig a m e n t a re
b o t h re le a se d t o a llo w fo r m o b iliza t io n o f t h e
t u b e ro sit ie s (TECH FIG 2 A,B).
■ If t h e fra ct u re d o e s n o t in vo lve t h e b icip it a l g ro o ve , a n
o st e o t o m e o r sa w m a y b e u se d t o cre a t e a cle a va g e
FIG 3 • Be a ch ch a ir p o sit io n . Th e p a t ie n t is p la ce d w it h t h e
t h o ra x a t t h e e n d o f t h e t a b le . A kid n e y p o st a n d McCo n n e ll
h e a d h o ld e r a re u se d t o a llo w fre e a n d u n e n cu m b e re d a cce ss
t o t h e m e d u lla ry ca n a l o f t h e h u m e ru s.
■ Fra ct u re h e m a t o m a u su a lly is e n co u n t e re d o n ce t h e
cla vip e ct o ra l fa scia is in cise d . At t h is t im e , fra ct u re fra g -
m e n t s a n d t h e ro t a t o r cu ff m u scu la t u re b e co m e e vid e n t .
■ The axilla ry and muscu lo cut ane ous nerves can be ident i-
fie d t h ro u g h d ig it a l p a lp a t io n o f t h e a n t e ro in fe rio r a sp e ct
o f t h e su b sca pu la ris mu scle a n d th e p o st e rio r a sp e ct o f t he
co ra co id mu scle s re sp e ctive ly. Ext e rn a l ro ta tio n o f t h e
h u m e rus resu lts in red u ce d t e n sion o n th e a xilla ry ne rve .
TECH FIG 1 • Skin in cisio n an d d el-
to p ectoral ap p ro ach . A. The skin in-
cisio n is ce n te re d o ve r th e a n te rio r
d e lt o id. The de lto p e ct ora l inte rval
is d eve loped w it h lat eral ret ra ct ion
o f t h e ce ph a lic ve in . B. Fo r m o re
e xp o su re , t h e su p e rio r 1 cm o f
th e p ecto ra lis ma jo r t en d o n ma y
b e in cise d . (^ , p e cto ra lis m a jor; #,
d e lt o id; *, ce p h a lic ve in.)
p la n e fo r t u b e ro sit y m o b iliza t io n . Pre se rva t io n o f t h e
co ra co a cro m ia l lig a m e n t is a d visa b le t o m a in t a in t h e
co ra co a cro m ia l a rch .
■ He a vy, n o n a b so rb a b le t ra ct io n su t u re s (e g , 1-m m co t t o n y
Da cro n ) a re p la ce d t h ro u g h t h e ro t a t o r cu ff in se rt io n s o n
t h e t u b e ro sit ie s. Tw o o r t h re e su t u re s sh o u ld b e p la ce d
t h ro u g h t h e su b sca p u la ris t e n d o n , a n d t h re e o r fo u r su -
t u re s t h ro u g h t h e su p ra sp in a t u s.
■ Tu b e ro sit y fra g m e n t s va ry in size a n d m a y re q u ire t rim -
m in g fo r re d u ct io n a n d re p a ir (TECH FIG 2 C,D).
 Ch a p t e r 2 1 HEM IARTHROPLASTY FOR PROXIM AL HUM ERUS FRACTURES 183

TECHNIQUES
Open rotator Palpate
interval axillary nerve

Biceps tendon

A B

Greater
tuberosity

Lesser
C tuberosity

1
18 5 15 8
21 1 1
2

48 mm
52 mm
44 mm

ADVANTAGE HEADS

E D

TECH FIG 2 • A. Th e lo n g h e a d o f t h e b ice p s is id e n t ifie d a n d t ra ce d su p e rio rly t o t h e ro t a t o r in t e rva l. Th e t e n d o n se rve s a s a

ke y la n d m a rk w h e n re -e st a b lish in g t h e a n a t o m ic re la t io n b e t w e e n t h e g re a t e r a n d le sse r t u b e ro sit ie s. B. Th e a xilla ry n e rve is
id e n t ifie d a t t h e a n t e ro in fe rio r b o rd e r o f t h e su b sca p u la ris. C. No n a b so rb a b le su t u re s a re p la ce d a t t h e ju n ct io n o f t h e t e n -
d o n –t u b e ro sit y in t e rfa ce a n d n o t t h ro u g h t h e t u b e ro sit ie s. D. On ce t h e n a t ive h u m e ra l h e a d is re m o ve d , t h e t u b e ro sit ie s w it h
t h e ir re sp e ct ive ro t a t o r cu ff a t t a ch m e n t s a re m o b ilize d fo r h u m e ra l ca n a l p re p a ra t io n a n d la t e r re p a ir. E. Hu m e ra l h e a d siz-
in g . Th e e xt ra ct e d n a t ive h u m e ra l h e a d is size d w it h t h e u se o f a co m m e rcia lly a va ila b le t e m p la t e g u id e . (Co p yrig h t St e ve n B.
Lip p it t , MD.)

■ Wit h t h e t u b e ro sit ie s re t ra ct e d o n t h e ir m u scu la r in se r- ■ Th e g le n o id m u st b e e xa m in e d fo r co n co m it a n t p a t h o l-

t io n s, t h e h u m e ra l h e a d a n d sh a ft fra g m e n t s a re
re m o ve d .
■ Th e n a t ive a rt icu la r su rfa ce is re m o ve d a n d size d w it h
a t e m p la t e fo r t ria l h u m e ra l h e a d re p la ce m e n t (TECH
FIG 2 E).
o g y. He m a t o m a a n d ca rt ila g in o u s o r b o n y fra g m e n t s a re
re m o ve d w it h st e rile sa lin e irrig a t io n .
■ Gle n o id fra ct u re s sh o u ld b e st a b ilize d w it h in t e rn a l
fixa t io n . If t h e g le n o id e xh ib it s sig n ifica n t d e g e n e ra t ive
w e a r o r irre p a ra b le d a m a g e , a g le n o id co m p o n e n t m u st
b e u se d .
 184 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES
HUMERAL SHAFT PREPARATION
■ Th e p ro xim a l e n d o f t h e h u m e ra l sh a ft is d e live re d in t o
t h e in cisio n a l w o u n d . Lo o se e n d o st e a l b o n e fra g m e n t s
a n d h e m a t o m a a re re m o ve d fro m t h e ca n a l o f t h e
h u m e ra l sh a ft .
■ Axia l re a m e rs, p re fe ra b ly w it h o u t p o w e r, a re u se d t o
p re p a re t h e h u m e ra l sh a ft fo r t ria l im p la n t a t io n .
■ Th e t ria l h u m e ra l im p la n t is p la ce d w it h t h e la t e ra l fin
slig h t ly p o st e rio r t o t h e b icip it a l g ro o ve , a n d w it h t h e
DETERMINATION OF HUMERAL RETROVERSION
■ Co rre ct h u m e ra l re t ro ve rsio n is crit ica l w h e n re cre a t in g
t h e g le n o h u m e ra l a rt icu la t io n . Mo st t e ch n iq u e s
su g g e st 30 d e g re e s a s a g u id e d u rin g re co n st ru ct io n ,
a lt h o u g h n a t ive re t ro ve rsio n m a y va ry fro m 10 t o
50 d e g re e s.
■ Se ve ra l m e t h o d s a re e m p lo ye d t o g a u g e t h is a n g le :
■ Ext e rn a l ro t a t io n o f t h e h u m e ru s t o 30 d e g re e s fro m
t h e sa g it t a l p la n e o f t h e b o d y w it h t h e h u m e ra l h e a d
co m p o n e n t fa cin g st ra ig h t m e d ia lly
■ An im a g in a ry lin e fro m t h e d ist a l h u m e ra l e p ico n d y-
la r a xis t h a t b ise ct s t h e a xis o f t h e p ro st h e sis
■ Po sit io n in g o f t h e la t e ra l fin o f t h e p ro st h e sis
a b o u t 8 m m p o st e rio r t o t h e b ice p s g ro o ve (TECH
FIG 4 ).
DETERMINATION OF PROSTHETIC HEIGHT
■ Th e p ro st h e t ic h e ig h t a lso is crit ica l in re -e st a b lish in g a p -
p ro p ria t e m u scle t e n sio n a n d sh o u ld e r m e ch a n ics.
■ Pre o p e ra t ive t e m p la t in g m a y b e h e lp fu l.
■ In t ra o p e ra t ive e xa m in a t io n o f so ft t issu e t e n sio n , in clu d -
in g t h e d e lt o id , ro t a t o r cu ff, a n d t h e lo n g h e a d o f t h e b i-
m e d ia l a sp e ct o f t h e t ria l h e a d a t le a st a t t h e h e ig h t o f
t h e m e d ia l ca lca r.
■ Fo rm e rly, w e u se d a sp o n g e t o a n ch o r t h e t ria l st e m
w it h in t h e in t ra m e d u lla ry ca n a l o f t h e h u m e ru s. We
cu rre n t ly u se a co m m e rcia lly a va ila b le fra ct u re jig
t h a t ca n m a in t a in t h e h e ig h t a n d re t ro ve rsio n o f t h e
t ria l co m p o n e n t t h ro u g h a fu n ct io n a l ra n g e o f m o -
t io n (TECH FIG 3 ). 12,14
TECH FIG 3 • A co m m e rcia lly a va ila b le
fra ct u re jig st a b ly sit u a t e s t h e im p la n t
a t a p p ro p ria t e h e ig h t a n d re t ro ve r-
sio n . (Co u rt e sy o f De Pu y Ort h o p a e d ics,
Wa rsa w , IN.)
TECH FIG 4 • Re t ro ve rsio n a sse ss-
m e n t . Th e a n t e rio r fin o f t h e
p ro st h e sis is a lig n e d w it h t h e
fo re a rm in n e u t ra l ro t a t io n , a n d
t h e la t e ra l fin is p o sit io n e d a b o u t
Neutral 8 m m p o st e rio r t o t h e b ice p s
rotation g ro o ve , e st a b lish in g a re t ro ve r-
sio n a n g le o f a b o u t 30 d e g re e s.
(Co p yrig h t St e ve n B. Lip p it t , MD.)
ce p s, co m b in e d w it h flu o ro sco p ic im a g in g a id s in p ro s-
t h e t ic h e ig h t p la ce m e n t .
■ Co m m o n e rro rs in vo lve p la cin g t h e p ro st h e sis t o o lo w ,
re su lt in g in p o o r d e lt o id m u scle t e n sio n a n d n o ro o m fo r
t h e t u b e ro sit ie s (TECH FIG 5 ).
 Ch a p t e r 2 1 HEM IARTHROPLASTY FOR PROXIM AL HUM ERUS FRACTURES 185

TECHNIQUES
22
Align to notch 18
14
at anterior fin 10
6
2

1-2 cm

TECH FIG 5 • He ig h t a d ju st m e n t . A co m m e rcia lly

a va ila b le fra ct u re jig p e rm it s in t ra o p e ra t ive
h e ig h t a d ju st m e n t . Sim ila rly, a sp o n g e m a y b e
p la ce d h o ld in g t h e t ria l st e m a t a d e t e rm in e d
le ve l, a llo w in g fo r in t ra o p e ra t ive a sse ssm e n t .
(Co p yrig h t St e ve n B. Lip p it t , MD.)

TRIAL REDUCTION
■ Drill h o le s a re p la ce d in t h e p ro xim a l h u m e ru s m e d ia l
a n d la t e ra l t o t h e b icip it a l g ro o ve , w it h 1-m m co t t o n y
Da cro n su t u re s su b se q u e n t ly p a sse d fo r fixa t io n o f t h e
t u b e ro sit y t o t h e sh a ft (TECH FIG 6 A).
■ A t ria l re d u ct io n is t h e n p e rfo rm e d w it h t h e m o b ilize d
t u b e ro sit ie s fit t e d b e lo w t h e h e a d o f t h e m o d u la r p ro s-
t h e sis.
■ A t o w e l clip ca n b e u se d t o h o ld t h e t u b e ro sit ie s fo r flu -
o ro sco p ic e xa m in a t io n a n d a sse ssm e n t o f g le n o h u m e ra l
st a b ilit y.
■ In t ra o p e ra t ive flu o ro sco p y is h e lp fu l in co n firm in g
a p p ro p ria t e im p la n t h e ig h t a n d g le n o h u m e ra l st a b ilit y
(TECH FIG 6 B).
■ Th e h u m e ra l h e a d sh o u ld n o t su b lu xa t e m o re t h a n 25%
t o 30% o f t h e g le n o id h e ig h t in fe rio rly.

22
18
14
10
6
2
R

A B

TECH FIG 6 • A. Hu m e ra l sh a ft p re p a ra t io n . Drill h o le s a re p la ce d in t h e p ro xim a l h u m e ru s m e d ia l a n d la t e ra l t o t h e

b icip it a l g ro o ve w it h 1-m m co t t o n y Da cro n su t u re s. B. Tria l re d u ct io n . A t ria l re d u ct io n m a y b e p e rfo rm e d w it h t h e fra c-
t u re jig in p la ce , a llo w in g a sse ssm e n t o f t h e fu n ct io n a l ra n g e o f m o t io n . (Co p yrig h t St e ve n B. Lip p it t , MD.)

FINAL IMPLANT PLACEMENT

■ Th e fin a l h u m e ra l co m p o n e n t sh o u ld b e ce m e n t e d in a ll ■ Pu lsa t ile la va g e a n d re t ro g ra d e in je ct io n o f ce m e n t
fra ct u re p a t ie n t s. w it h su ct io n p re ssu riza t io n a lso is u se d (TECH
■ A ce m e n t re st rict o r is p la ce d t o p re ve n t ce m e n t e x- FIG 7 A). Exce ss ce m e n t is re m o ve d d u rin g t h e cu rin g
t ra va sa t io n d ist a lly. p h a se .
 186 Se c t i o n II SHOULDER AND ELBOW
■ Sp a ce s b e t w e e n t h e t u b e ro sit ie s, p ro st h e sis, a n d sh a ft
TECHNIQUES
a re p a cke d w it h a u t o g e n o u s ca n ce llo u s b o n e g ra ft fro m
t h e re se ct e d h u m e ra l h e a d (TECH FIG 7 B).
■ A se co n d t ria l re d u ct io n m a y b e p e rfo rm e d w it h a t ria l
h e a d a ft e r ce m e n t fixa t io n o f t h e h u m e ra l st e m .
■ Th e fin a l h e a d m a y b e im p a ct e d b e fo re st e m im p la n t a -
t io n o r a ft e r t h e re p e a t t ria l re d u ct io n .
■ A ce rcla g e su t u re is p la ce d circu m fe re n t ia lly a ro u n d t h e
g re a t e r t u b e ro sit y a n d t h ro u g h t h e su p ra sp in a t u s in se r-
t io n , a n d t h e n m e d ia l t o t h e p ro st h e sis a n d t h ro u g h t h e
su b sca p u la ris in se rt io n (le sse r t u b e ro sit y). Se ve ra l a u -
t h o rs h a ve in d ica t e d su p e rio r fixa t io n w it h t h e ce rcla g e
Lateral sutures to
Bone cement greater tuberosity
Vent
tube
Anterior sutures to
both tuberosities
Cancellous
bone plug
A C
B MD. B: Co u rt e sy o f De Pu y Ort h o p a e d ics.)
SURGICAL WOUND CLOSURE
■ Th e d e lt o p e ct o ra l in t e rva l u su a lly is n o t clo se d . Dra in
su ct io n is re co m m e n d e d in b o t h a cu t e a n d ch ro n ic in -
ju rie s t o p re ve n t h e m a t o m a fo rm a t io n .
■ A co m m e rcia lly a va ila b le p a in p u m p m a y b e u se d t o a u g -
m e n t p o st o p e ra t ive a n a lg e sia a n d t o re d u ce n a rco t ic
m e d ica t io n u se .
su t u re w h e n co m p a re d t o t u b e ro sit y-t o -t u b e ro sit y a n d
t u b e ro sit y-t o -fin fixa t io n a lo n e . 23
■ Ove rre d u ct io n o f t h e t u b e ro sit ie s sh o u ld b e a vo id e d t o
p re ve n t lim it a t io n s in e xt e rn a l (le sse r t u b e ro sit y) a n d in -
t e rn a l (g re a t e r t u b e ro sit y) ro t a t io n .
■ Su t u re s a re t h e n t ie d , b e g in n in g w it h t u b e ro sit y-t o -sh a ft
re a p p ro xim a t io n , fo llo w e d b y t u b e ro sit y-t o -t u b e ro sit y
clo su re u sin g t h e p re vio u sly p la ce d su t u re lim b s (TECH
FIG 7 C).
■ Th e la t e ra l p o rt io n o f t h e ro t a t o r in t e rva l is clo se d w it h
t h e a rm in a p p ro xim a t e ly 30 d e g re e s o f e xt e rn a l ro t a -
t io n w it h n o . 2 n o n a b so rb a b le su t u re (TECH FIG 7 D).
Medial sutures to
lesser tuberosity
D
TECH FIG 7 • A. A ce m e n t re st rict o r is p la ce d t o p re ve n t
ce m e n t e xt ra va sa t io n d ist a lly. Pu lsa t ile la va g e a n d re t ro -
g ra d e in je ct io n o f ce m e n t w it h su ct io n p re ssu riza t io n is
a lso u se d . B. Mo rse lize d ca n ce llo u s b o n e g ra ft is p la ce d
b e t w e e n t h e t u b e ro sit ie s a n d sh a ft . C. Tu b e ro sit y fixa -
t io n . Pre vio u sly p la ce d su t u re lim b s t h ro u g h t h e
t u b e ro sit ie s a n d sh a ft a re re a p p ro xim a t e d . No t sh o w n : a
m e d ia l ce rcla g e su t u re is p la ce d circu m fe re n t ia lly a ro u n d
t h e g re a t e r t u b e ro sit y a n d t h ro u g h t h e su p ra sp in a t u s in -
se rt io n , a n d t h e n m e d ia l t o t h e p ro st h e sis a n d t h ro u g h
t h e su b sca p u la ris in se rt io n (le sse r t u b e ro sit y) a n d t ie d .
D. Th e ro t a t o r in t e rva l is clo se d w it h n o . 2 n o n a b -
so rb a b le su t u re w it h t h e a rm in a b o u t 30 d e g re e s o f
e xt e rn a l ro t a t io n . (A,C,D: Co p yrig h t St e ve n B. Lip p it t ,
■ Th e su b cu t a n e o u s t issu e s a re re a p p ro xim a t e d w it h 2-0
a b so rb a b le su t u re . Su b cu t icu la r clo su re is p e rfo rm e d
w it h 2-0 m o n o fila m e n t su t u re .
■ Th e p a t ie n t is t h e n p la ce d in a slin g o r sh o u ld e r im m o b i-
lize r w it h 45 d e g re e s o f a b d u ct io n fo r co m fo rt .
 Ch a p t e r 2 1 HEM IARTHROPLASTY FOR PROXIM AL HUM ERUS FRACTURES 187

PEARLS AND PITFALLS

In d ica t io n s
Im a g in g st u d ie s
Tu b e ro sit y id e n t ifica t io n
Im p la n t p la ce m e n t
Tu b e ro sit y fixa t io n
Po st o p e ra t ive re h a b ilit a t io n
■ A co m p le t e h ist o ry a n d p h ysica l e xa m in a t io n sh o u ld b e p e rfo rm e d , w it h p a rt icu la r a t t e n t io n
p a id t o t h e n e u ro va scu la r st a t u s.
■ Ap p ro p ria t e p la in ra d io g ra p h s w it h p o ssib le CT sca n su p p le m e n t a t io n a id in t he su rg ica l
d e cisio n -m a kin g .
■ Use t h e lo n g h e a d o f t h e b ice p s t o d e fin e t h e t u b e ro sit ie s fo r m o b iliza t io n .
■ Ta g t h is fo r la t e r t e n o d e sis b e fo re w o u n d clo su re .
■ Kn o w t h e sp e cifics o f t h e im p la n t syst e m , in clu d in g it s lim it a t io n s.
■ Pla ce t h e im p la n t in a p p ro p ria t e re t ro ve rsio n (a p p ro xim a t e ly 20 t o 30 d e g re e s).
■ Ch e ck t h e h e ig h t o f t h e t ria l st e m b e fo re p e rfo rm in g ce m e n t fixa t io n , u sin g a fra ct u re jig o r
sp o n g e fo r p ro visio n a l fixa t io n .
■ In t ra o p e ra t ive flu o ro sco p y ca n b e u se d t o a sse ss a p p ro p ria t e im p la n t h e ig h t .
■ Avo id lo ss o f e xt e rn a l ro t a t io n o r in t e rn a l ro t a t io n w it h o ve rre d u ct io n o f t h e le sse r a n d
g re a t e r t u b e ro sit ie s, re sp e ct ive ly.
■ On p o st o p e ra t ive d a y 1, in it ia t e g e n t le p e n d u lu m e xe rcise s, w it h p a ssive fo rw a rd fle xio n a n d
e xt e rn a l ro t a t io n (a t 0 d e g re e s o f a b d u ct io n ). Alw a ys m o d ify re h a b ilit a t io n p ro t o co l b a se d
o n in t ra o p e ra t ive a sse ssm e n t o f so ft t issu e co m p ro m ise a n d p a t ie n t n e u ro lo g ic st a t u s.

POSTOPERATIVE CARE ■ In patients with chronic fractures treated with hemiarthro-

■ Physician-directed therapy is initiated on postoperative day
1 with gentle, gravity-assisted pendulum exercises, as well as
passive pulley-and-stick exercises to maintain forward flexion
and external rotation (motion limits placed by surgeon based
upon intraoperative stability).
■ After discharge, the patient’s wound is re-examined and
sutures removed at 10 to 14 days. Gentle range-of-motion
exercises are continued.
■ At 6 weeks, repeat radiographs are obtained to evaluate
tuberosity healing. When tuberosity healing is evident, phase
2 exercises are initiated with isometric rotator cuff exercises
and active assisted elevation with the pulley.
■ At 3 months, strength training with graduated rubber bands
(phase 3) is implemented. M aximal motion and function are
obtained at about 12 months from date of surgery.
OUTCOMES
■ About 90% of patients treated with hemiarthroplasty
demonstrate minimal pain, despite a wide range of function,
motion, and strength.
■ Factors that portend a poor outcome after hemiarthro-
plasty for fractures include tuberosity malposition, superior
migration of the humeral prosthesis, stiffness, persistent pain,
poor initial positioning of the implant (excessive retroversion,
decreased height), and age over 75 years in women. 4
■ When comparing acute intervention versus late reconstruc-
tion, most authors report poorer outcomes with delayed sur-
gical intervention (more than 2 weeks), particularly with
functional results. 20,25,26
COMPLICATION S
■ Complications include delays in wound healing, infection,
nerve injury, humeral fracture, component malposition, insta-
bility, nonunion of the tuberosities, rotator cuff tearing, re-
gional pain syndrome, periarticular fibrosis, heterotopic bone
formation, component loosening, and glenoid arthritis.3,7,19
■ The most common problems in acute fracture treatment in-
volve stiffness, nonunion, malunion or resorption of the
tuberosities.7,19
plasty, the most common problems encountered were instability,
heterotopic ossification, tuberosity malunion or nonunion, and
rotator cuff tears.19
REFEREN CES
1. Beredjiklian PK, Iannotti JP, N orris TR, et al. O perative treatment of
malunion of a fracture of the proximal aspect of the humerus. J Bone
Joint Surg Am 1998;80:1484–1497.
2. Blaine TA, Bigliani LU, Levine WN . Fractures of the proximal
humerus. In: Rockwood CA Jr, M asten FA III, Wirth M A, et al, eds.
The Shoulder, ed 3. Philadelphia: Elsevier, 2004:355–412.
3. Bohsali KI, Wirth M A, Rockwood CA Jr. Current concepts review:
complications of total shoulder arthroplasty. J Bone Joint Surg Am
2006;88A:2279–2292.
4. Boileau P, Krishnan SG, Tinsi L, et al. Tuberosity malposition and
migration: reason for poor outcomes after hemiarthroplasty for dis-
placed fractures of the proximal humerus. J Shoulder Elbow Surg
2002;11:401–412.
5. Boileau P, Walch G, Trojani C, et al. Surgical classification and lim-
its of shoulder arthroplasty. In Walch G, Boileau P, eds. Shoulder
Arthroplasty. Berlin: Springer-Verlag, 1999:349–358.
6. Bosch U, Skutek M , Fremery RW, et al. O utcome after primary and
secondary hemiarthroplasty in elderly patients with fractures of the
proximal humerus. J Shoulder Elbow Surg 1998;7:479–484.
7. Compito CA, Self EB, Bigliani LU. Arthroplasty and acute shoulder
trauma. Clin. O rthop Relat Res 1994;307:27–36.
8. DeFranco M J, Brems JJ, Williams GR Jr, et al. Evaluation and man-
agement of valgus impacted four-part proximal humerus fractures.
Clin O rthop Relat Res 2006;442:109–114.
9. Frankle M A, O ndrovic LE, M arkee BA, et al. Stability of tuberosity
attachment in proximal humeral arthroplasty. J Shoulder Elbow Surg
2002;11:413–420.
10. Gerber C, Schneeberger A, Vinh T. The arterial vascularization of the
humeral head: An anatomical study. J Bone Joint Surg Am 1990;
72:1486–1494.
11. Green A. Proximal humerus fractures. In: N orris T, ed. O rthopaedic
Knowledge Update: Shoulder and Elbow 2. Rosemont, IL: AAO S;
2002:209–217.
12. Green A, Lippitt SB, Wirth M A. H umeral head replacement arthro-
plasty. In: Wirth M A, ed. Proximal H umerus Fractures. Rosemont,
IL: AAO S, 2005:39–48.
13. Green A, N orris T. Proximal humerus fractures and fracture-
dislocations. In: Jupiter J, ed. Skeletal Trauma, ed 3. Philadelphia:
WB Saunders; 2003:1532–1624.
188 Se c t i o n II SHOULDER AND ELBOW
14. H artsock LA, Estes WJ, M urray CA, et al. Shoulder hemiarthro-
plasty for proximal humeral fractures. O rthop Clin N orth Am 1998;
467–475.
15. H uopio J, Kroger H , H onkanen R, et al. Risk factors for peri-
menopausal fractures: A prospective study. O steoporos Int 2000;
11:219–227.
16. Iannotti JP, Gabriel JP, Schneck SL, et al. The normal glenohumeral
relationships: An anatomical study of one hundred and forty shoul-
ders. J Bone Joint Surg Am 1992;74A:491–500.
17. Jakob R, M iniaci A, Anson P, et al. Four-part valgus impacted frac-
tures of the proximal humerus. J Bone Joint Surg Br 1991;73B:
295–298.
18. Laing P. The arterial supply of the adult humerus. J Bone Joint Surg
Am 1956;38A:1105–1116.
19. M uldoon M P, Cofield RH . Complications of humeral head replace-
ment for proximal humerus fractures. Instr Course Lect 1997:
46:15–24.
20. N eer CS. Displaced proximal humeral fractures. Part II: Treatment of
3-part and 4-part displacment. J Bone Joint Surg Am 1970;52A:
1090–1103.
21. N orris TR, Green A, M cGuigan FX. Late prosthetic shoulder arthro-
plasty for displaced proximal humerus fractures. J Shoulder Elbow
Surg 1995;4:271–280.
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Classification: Fracture and Dislocation Compendium. J O rthop
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23. Pearl M L, Volk AG. Retroversion of the proximal humerus in rela-
tionship to the prosthetic replacement arthroplasty. J Shoulder Elbow
Surg 1995;4:286–289.
24. Stablebforth PG. Four part fractures of the neck of the humerus.
J Bone Joint Surg Br 1984;66B:104–108.
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 Pla t e Fix a t io n o f Hu m e r a l
Ch a p t e r 22 Sh a f t Fr a ct u re s
M at t h e w J. Garb e rin a an d Ch arle s L. Ge t z
DEFIN ITION
■ H umeral shaft fractures, which account for about 3% of
adult fractures, usually result from a direct blow or indirect
twisting injury to the brachium.
■ These injuries are most commonly treated nonoperatively
with a prefabricated fracture brace. The humerus is the most
freely movable long bone, and anatomic reduction is not
required.
■ Patients often can tolerate up to 20 degrees of anterior an-
gulation, 30 degrees of varus angulation, and 3 cm of shorten-
ing without significant functional loss.
■ There are, however, several indications for surgical treat-
ment of humeral shaft fractures:
■ O pen fracture
■ Bilateral humeral shaft fractures or polytrauma; floating
elbow
■ Segmental fracture
■ Inability to maintain acceptable alignment with closed
treatment (ie, angulation greater than 15 degrees)—seen
more commonly with transverse fractures
■ H umeral shaft nonunion
■ Pathologic fractures
■ Arterial or brachial plexus injury
■ O pen reduction with internal plate fixation requires exten-
sive dissection and operative skill. H owever, it offers advan-
tages over intramedullary fixation because the rotator cuff is
not violated, which leads to improved postoperative shoulder
function.3
AN ATOMY
■ The humeral shaft is defined using Key’s landmarks: the
area between the upper margin of the pectoralis major tendon
and the supracondylar ridge.7
■ The blood supply of the humeral shaft comes from the pos-
terior humeral circumflex vessels and branches of the brachial
and profunda brachial arteries.
■ The radial nerve and profunda brachial artery pass through
the triangular interval (bordered superiorly by the teres major,
medially by the medial head of the triceps, and laterally by the
humeral shaft). The nerve then transverses from medial to lat-
eral behind the humeral shaft and travels distally to a location
between the brachialis and brachioradialis muscles.
■ The musculocutaneous nerve lies on the undersurface of
the biceps muscle and terminates distally as the lateral ante-
brachial cutaneous nerve.
■ The humeral shaft has anteromedial, anterolateral, and pos-
terior surfaces. Proximal and midshaft fractures are more
amenable to plating on the anterolateral surface, whereas dis-
tal fractures often require posterior plate fixation.
PATHOGEN ESIS
■ H umeral shaft fractures occur after both direct and indirect
injuries. Direct blows to the brachium can fracture the
humeral shaft in a transverse pattern, often with a butterfly
fragment. Injuries with high degrees of energy often result in a
greater degree of fracture comminution.
■ Indirect injuries, such as those that can occur with activities
such as arm wrestling, often involve a twisting mechanism and
result in a spiral fracture pattern. H igher-energy injuries may
result in muscle interposition between the fracture fragments,
which can inhibit reduction and healing.
■ A study of 240 humeral shaft fractures revealed radial nerve
palsies in 42 patients, for an overall rate of 18% (17% in
closed injuries). Fractures in the midshaft were more likely to
have concomitant radial nerve palsy. Twenty-five of these pa-
tients had complete recovery in a range of 1 day to 10 months.
Ten patients did not have radial nerve recovery. M edian and
ulnar nerve palsies were seen very rarely in patients with open
fractures.7
■ Concomitant vascular injuries are present in about 3% of
patients with humeral shaft fractures.
N ATURAL HISTORY
■ Almost all humeral shaft fractures heal with nonoperative
management. The most common treatment method is initial
splinting from shoulder to wrist, followed by application of a
prefabricated fracture brace when the patient is comfortable,
usually within 2 weeks of the injury.
■ Studies by Sarmiento and coauthors10,11 have shown the ef-
fectiveness of functional bracing in the treatment of humeral
shaft fractures. N onunion rates with this method of treatment
are in the 4% range, lower than seen when treating with exter-
nal fixators, plates, or intramedullary nails.
■ Closed fractures with initial radial nerve palsy can be
observed, with expected recovery over a period of 3 to
6 months. Late-developing radial nerve palsies require surgi-
cal exploration.
■ Angulation of the humeral shaft after fracture healing is ex-
pected and is well tolerated when it is less than 20 degrees.
Varus deformity is most common.10
■ Adjacent joint stiffness of the shoulder and elbow also is
common. If the situation dictates treatment, physical therapy
reliably restores joint motion in these patients.
■ Relative contraindications to closed treatment include bilat-
eral humeral shaft fractures or patients with polytrauma who
require an intact brachium to ambulate. Transverse fractures
and those with significant muscle imposition also are more
amenable to operative fixation.11
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ The examining physician must perform a complete ex-
amination of the affected limb to rule out concomitant in-
juries.
■ The skin should be thoroughly evaluated for evidence of an
open fracture. This includes examination of the axilla. Entry
189
190 Se c t i o n II SHOULDER AND ELBOW
and exit wounds are sought in gunshot victims. Swelling is
common, and the patient may have an obvious deformity.
■ The patient often braces the affected limb to his or her side,
making evaluation of shoulder and elbow range of motion dif-
ficult. Bony prominences should be gently palpated to evaluate
for other injuries, such as an olecranon fracture.
■ Evaluate the appearance and skeletal stability of the forearm
to rule out the presence of a co-existing both-bone forearm
fracture (“ floating elbow” ). This finding necessitates operative
fixation of humeral, radial, and ulnar fractures.
■ Determine the vascular status of the upper extremity by pal-
pating the radial and ulnar pulses at the wrist. Compare these
findings with the unaffected limb. Selected cases may require
Doppler arterial examination.2
■ A complete neurologic assessment is necessary, with partic-
ular attention focused on the status of the radial nerve. This
structure is at risk proximally as it passes posterior to the
humeral shaft after emerging from the triangular interval, as
well as distally, as it lies adjacent to the supracondylar ridge
(near the location of the H olstein-Lewis distal one-third spiral
humeral shaft fracture).
■ Examine sensory function in the first dorsal web space,
wrist extension, and thumb interphalangeal joint extension to
determine the functional status of the radial nerve.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ At least two plain radiographs at 90-degree angles to each
other are necessary to evaluate the displacement, shortening,
and comminution of the humeral shaft fracture.
■ Radiographic views of the shoulder and elbow are necessary
to rule out proximal extension of the shaft fracture or con-
comitant elbow injury (ie, olecranon fracture). This is espe-
cially important in high-energy injuries
■ If swelling or evidence of skeletal instability about the fore-
arm is present, dedicated forearm radiographs can determine
the presence of a floating elbow (ie, ipsilateral humeral shaft
fracture plus both-bone forearm fractures).
DIFFEREN TIAL DIAGN OSIS
■ Distal humerus fracture
■ Proximal humerus fracture
■ Elbow dislocation
■ Shoulder dislocation
N ON OPERATIVE MAN AGEMEN T
■ M ost isolated humeral shaft fractures can be treated nonop-
eratively. Initial treatment can vary with fracture location and
involves splinting in either a posterior elbow or coaptation
splint. The elbow is positioned in 90 degrees of flexion. An iso-
lated humeral shaft fracture rarely necessitates an overnight
hospital stay.
■ In the past, definitive nonoperative treatment involved coap-
tation splinting or the use of hanging arm casts. Currently,
functional fracture bracing provides adequate bony alignment,
while local muscle compression and fracture motion promote
osteogenesis. These braces provide soft tissue compression and
allow functional use of the extremity.11
■ Timing of brace application depends on the degree of
swelling and patient discomfort. O n average, the brace is ap-
plied about 2 weeks after the injury. A collar and cuff help
with initial patient comfort and should be worn during recum-
bency until the fracture heals.
■ The brace often requires frequent retightening over the first
2 weeks as swelling subsides. Elbow and wrist range-of-mo-
tion exercises out of the sling are encouraged.
■ Functional bracing requires that the patient be able to sit
erect, and weight bearing on the humerus is not allowed. The
level of humeral shaft fracture does not preclude the use of
functional bracing, even if the fracture line extends above or
below the brace.
■ Anatomic alignment of the humerus rarely is achieved, with
varus deformity most common. H owever, patients often are
able to tolerate the bony angulation and still perform activities
of daily living after injury. A cosmetic deformity rarely exists.
■ Pendulum exercises are encouraged as soon as possible
post-injury. Active elevation and abduction are avoided until
bony healing has occurred, to prevent fracture angulation.
The surgeon obtains radiographs after brace application and
again 1 week later. If alignment is acceptable, repeat radi-
ographs are obtained at 3- to 4- week intervals until fracture
healing occurs. 10,11
SURGICAL MAN AGEMEN T
■ Certain humeral shaft fractures are not amenable to conser-
vative treatment. O pen fractures or high-energy injuries with
significant axial distraction are treated with open reduction
and internal fixation. Patients with polytrauma, bilateral
humeral shaft fractures, vascular injury, or an inability to sit
erect are best treated with operative fixation. Unacceptable
fracture alignment requires abandonment of nonoperative
treatment. Finally, humeral shaft nonunion is a clear indication
for open reduction and internal fixation with bone grafting.4,9
Preoperative Planning
■ The surgeon must review all radiographic images and must
rule out ipsilateral elbow or shoulder injury.
■ Preoperative radiographs help the surgeon estimate the re-
quired plate length. H igher-energy injuries with comminution
may benefit from plating and supplemental bone grafting. The
surgeon must plan for various scenarios based on these stud-
ies: moderate comminution or bone loss can be addressed with
cancellous allograft or autograft bone, whereas more extensive
bone defects may require strut grafting.
■ Proximal and middle-third humeral shaft fractures are ad-
dressed using an anterolateral approach. Distal-third humeral
shaft fractures often are treated via a posterior approach, be-
cause the distal humeral shaft is flat posteriorly, making it an
ideal location for plate placement.
■ Fracture patterns with extension into the proximal humerus
can be exposed with a deltopectoral extension to the antero-
lateral humeral dissection.
■ The surgeon notes any pre-existing scars that may affect
the desired surgical approach, and neurovascular status
is documented, with particular attention to radial nerve
function.
Positioning
■ Positioning depends on the intended surgical approach. For
an anterolateral or medial approach, the patient is brought to
the edge of the bed in the supine position. A hand table is at-
tached to the bed and the patient’s injured arm is placed on the
hand table in slight abduction (FIG 1 A).
 Ch a p t e r 2 2 PLATE FIXATION OF HUM ERAL SHAFT FRACTURES 191

FIG 1 • A. Po sit io n in g fo r t h e a n t e ro la t e ra l
a p p ro a ch t o t h e h u m e ra l sh a ft w it h t h e
sh o u ld e r a b d u ct e d a n d t h e a rm o n a h a n d
t a b le . B. Po sit io n in g fo r t h e p o st e rio r a p -
p ro a ch t o t h e h u m e ra l sh a ft w it h t h e p a t ie n t
A B in t h e la t e ra l d e cu b it u s p o sit io n .

■ For a posterior approach, the patient can be placed prone or
in the lateral decubitus position. A stack of pillows can sup-
port the brachium during the procedure (FIG 1 B).
Approach
■ The approach depends on fracture location and the pres-
ence of any previous surgical incisions. The anterolateral
and posterior approaches to the humerus are used most com-
monly, for proximal two-third and distal third fractures,
respectively.
■ In patients who have already undergone multiple proce-
dures to the affected extremity, Jupiter 6 recommends consid-
eration of a medial approach to take advantage of virgin
tissue planes.

ANTEROLATERAL APPROACH TO THE HUMERUS
■ Th e in cisio n co u rse s o ve r t h e la t e ra l a sp e ct o f t h e b i-
ce p s, b e g in n in g p ro xim a lly a t t h e d e lt o id t u b e rcle a n d
t e rm in a t in g ju st p ro xim a l t o t h e a n t e cu b it a l cre a se
(TECH FIG 1 ).
■ A t o u rn iq u e t ra re ly is u se d , b e ca u se it o ft e n lim it s p ro xi-
m a l e xp o su re .
TECHNIQUES
■ Th e la t e ra l a n t e b ra ch ia l cu t a n e o u s n e rve lie s in t h e d is-
t a l a sp e ct o f t h e in cisio n a n d m u st b e p ro t e ct e d d u rin g
e xp o su re .
■ Blu n t ly e n t e r t h e in t e rva l b e t w e e n t h e b ice p s a n d
b ra ch ia lis b y sw e e p in g a fin g e r fro m p ro xim a l t o d ist a l.

A B

C D E

TECH FIG 1 • A. An t e ro la t e ra l in cisio n . B. Skin a n d su b cu t a n e o u s t issu e in cise d . C. Re t ra ct o r o n b ra ch ia lis m u scle , fo rce p s

o n b ra ch io ra d ia lis. D. Mu scu lo cu t a n e o u s n e rve o n u n d e rsu rfa ce o f b ice p s m u scle . E. Ra d ia l n e rve in in t e rva l b e t w e e n
b ra ch ia lis a n d b ra ch io ra d ia lis. (co n t in u e d )
 192 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

F G

TECH FIG 1 • (co n t in u e d ) F. Bice p s lift e d t o re ve a l b ra ch ia lis m u scle . G. Bra ch ia lis m u scle sp lit in it s
la t e ra l t h ird .

■ At t h e level o f t h e m id h u m eru s, id en t ify th e mu scu lo cu t a- ■ Th e b ra ch ia lis is sp lit in lin e w it h it s fib e rs b e t w e e n t h e

ne o us n erve on t he un de rsu rfa ce o f th e b ice p s mu scle .
Trace th is n e rve o u t d ist a lly to p rot e ct it s t ermin a l b ran ch,
w hich fo rm s the la t e ra l a nt e b ra ch ia l cu ta n e o us n e rve .
■ Dist a lly, t h e in t e rva l b e t w e e n t h e b ra ch ia lis a n d b ra ch io -
ra d ia lis is d isse ct e d t o e xp o se t h e ra d ia l n e rve . Pro t e ct
t h e ra d ia l n e rve w it h a ve sse l lo o p so t h a t it ca n b e id e n -
t ifie d a t a ll t im e s.
m e d ia l t w o t h ird s a n d la t e ra l o n e t h ird . Th is is a n in t e r-
n e rvo u s p la n e b e t w e e n t h e ra d ia l n e rve m e d ia lly a n d t h e
m u scu lo cu t a n e o u s n e rve la t e ra lly.
■ Id e n t ify t h e fra ct u re sit e a n d p ro ce e d w it h re d u ct io n a n d
fixa t io n .

POSTERIOR APPROACH TO THE HUMERUS

■ Ma ke a g e n e ro u s in cisio n o ve r t h e m id lin e o f t h e
p o st e rio r a rm e xt e n d in g t o t h e o le cra n o n fo ssa (TECH
FIG 2 ).
■ Id e n t ify t h e in t e rva l b e t w e e n t h e lo n g a n d la t e ra l
h e a d s o f t h e t rice p s p ro xim a lly. Blu n t ly d isse ct t h is in -
t e rva l, t a kin g t h e lo n g h e a d m e d ia lly a n d t h e la t e ra l
h e a d la t e ra lly.
■ Dist a lly, se ve ra l b lo o d ve sse ls cro ss t h is p la n e ; t h e y re -
q u ire co a g u la t io n b e fo re t ra n se ct io n .
■ Id e n t ify t h e ra d ia l n e rve p ro xim a l t o t h e m e d ia l h e a d o f
t h e t rice p s in t h e sp ira l g ro o ve . Pro t e ct t h e ra d ia l n e rve
t h ro u g h o u t t h e ca se .
■ Sp lit t h e m e d ia l h e a d o f t h e t rice p s in it s m id lin e fro m
p ro xim a l t o d ist a l t o e xp o se t h e fra ct u re sit e .

A B C D

TECH FIG 2 • A. In cisio n fo r p o st e rio r a p p ro a ch . B. Su p e rficia l t rice p s sp lit . C. De e p t rice p s sp lit . D. Th e p ro b e p o in t s

t o t h e ra d ia l n e rve a s it e xit s t h e sp ira l g ro o ve fro m m e d ia l t o la t e ra l; t h e fra ct u re sit e is se e n d ist a lly.
 Ch a p t e r 2 2 PLATE FIXATION OF HUM ERAL SHAFT FRACTURES 193

FRACTURE REDUCTION
■ Sh a rp p e rio st e a l d isse ct io n e xp o se s t h e fra ct u re sit e .
Eva lu a t e t h e d e g re e , if a n y, o f co m m in u t io n .
■ Lim it p e rio st e a l st rip p in g t o a d e q u a t e ly e xp o se t h e fra c-
t u re . Ma ke e ve ry a t t e m p t t o le a ve so m e so ft t issu e a t -
t a ch e d t o e a ch fra g m e n t so a s n o t t o d e va scu la rize t h e
fra g m e n t s.
■ Ge n t le t ra ct io n a n d ro t a t io n o ft e n ca n b rin g t h e fra ct u re
fra g m e n t s in t o b e t t e r a lig n m e n t .
■ An at o m ically red u ce th e fra ct u re wit h o n e o r m o re red u c-
t io n cla m p s. It is a d visa b le t o re d u ce t h e fra ct u re
TECHNIQUES
co m p le t e ly b e fo re d e fin it ive fixa t io n , a n d t h is o ft e n re -
qu ire s t h e use o f m u lt iple re du ct io n cla m p s (TECH FIG 3 ).
■ Aft e r t h e fra ct u re is re d u ce d , t h e fra g m e n t s ca n b e p ro -
visio n a lly fixe d w it h Kirsch n e r w ire s. Pla ce t h e w ire s so a s
n o t t o in t e rfe re w it h p la t e fixa t io n .
■ Alte rn a tively, 3.5- o r 4.5-m m in t erfra g me n ta ry screw s can
be u se d t o h o ld t h e fract u re a lig n e d u n t il pla t e fixa t io n.
■ Tra n sve rse fra ct u re s w it h m in im a l co m m in u t io n o ft e n
ca n b e d ire ct ly re d u ce d w it h t h e p la t e a n d Fa b e rg e
cla m p s.

Plate
Plate

Plate holding
wire
Plate holding
wire Butterfly
fragments

Fracture Comminuted
fracture

A B

TECH FIG 3 • A. Fra ct u re re d u ct io n m a in t a in e d t e m p o ra rily. B. Ho ld t h e p la t e o ve r t h e re d u ce d fra ct u re w it h a p la t e -

h o ld in g cla m p .

EXPOSURE OF FRACTURE NONUNION

■ Exp o su re o f t h e ra d ia l n e rve is m o re ch a lle n g in g , b u t it is
ve ry im p o rt a n t in t h is sit u a t io n . In m a n y ca se s it is b e st t o
d isse ct o u t t h e n e rve d ist a lly in t h e in t e rva l b e t w e e n t h e
b ra ch ia lis a n d b ra ch io ra d ia lis a n d p ro xim a lly m e d ia l t o
t h e sp ira l g ro o ve . Th e n e rve is t h e n ca re fu lly d isse ct e d
fre e fro m t h e n o n u n io n sit e .
■ Pin p o in t t h e e xa ct lo ca t io n o f t h e n o n u n io n w it h a n o .
15 sca lp e l.
■ Th e e n d s o f t h e n o n u n io n ca n b e b ro u g h t o u t t h ro u g h
t h e w o u n d , a n d a ll fib ro u s m a t e ria l is e xt ra ct e d .
■ Aft e r t h o ro u g h fra ct u re d é b rid e m e n t , t h e a m o u n t o f
b o n e lo ss b e co m e s cle a r. Th e su rg e o n ca n n o w d e t e r-
m in e w h e t h e r st a n d a rd ca n ce llo u s b o n e g ra ft in g o r st ru t
g ra ft in g is n e ce ssa ry.
 194 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

PLATE APPLICATION
■ Aft e r fra ct u re re d u ct io n , t h e p la t e le n g t h is d e t e rm in e d .
■ Hu m e ra l sh a ft fra ct u re s re q u ire a t le a st six co rt ice s o f fix-
a t io n a b o ve a n d b e lo w t h e fra ct u re sit e .
■ In la rg e r b o n e s, a b ro a d 4.5-m m d yn a m ic co m p re ssio n
p la t e ca n p ro vid e o p t im a l fixa t io n . In sm a lle r b o n e s, a
4.5-m m lim it e d co n t o u r d yn a m ic co m p re ssio n p la t e
o ft e n p ro vid e s a b e t t e r fit .
■ Pro visio n a lly p la ce t h e p la t e o n a fla t su rfa ce o f t h e
h u m e ru s a n d h o ld it in p la ce w it h a p la t e -h o ld in g cla m p .
■ 4.5-m m co rt ica l scre w s a re p la ce d t h ro u g h t h e p la t e
h o le s p ro xim a l a n d d ist a l t o t h e fra ct u re . Co m p re ssio n
t e ch n iq u e s ca n b e u se d , w h e re a p p ro p ria t e .
■ En su re t h a t n o so ft t issu e , e sp e cia lly n e rve , is t ra p p e d b e -
t w e e n t h e p la t e a n d t h e b o n e .
■ Ma ke su re t o o b t a in scre w p u rch a se in a t le a st six co rt ice s
a b o ve a n d b e lo w t h e fra ct u re (TECH FIG 4 ).
■ Ce rcla g e w irin g o ve r t h e p la t e ca n a d d su p p le m e n t a l fix-
a t io n , e sp e cia lly in w e a k b o n e .
■ Ro t a t e t h e a rm a n d fle x a n d e xt e n d t h e e lb o w t o e va lu -
a t e fra ct u re st a b ilit y.
■ Ap p ly ca n ce llo u s b o n e g ra ft in t o d e fe ct s a s n e e d e d .

A B

TECH FIG 4 • A. Pla t e sp a n n in g t h e fra ct u re sit e w it h a t

le a st six co rt ice s o f fixa t io n p ro xim a lly a n d d ist a lly.
B. An t e rio r p la t e w it h a p ro b e p o in t in g t o t h e ra d ia l
n e rve a s it e xit s t h e sp ira l g ro o ve p o st e rio rly (p ro xim a l is
t o t h e rig h t , d ist a l t o t h e le ft ). C. Su p p le m e n t a l ce rcla g e
C w ire fixa t io n ca n a u g m e n t st a b ilit y in w e a k b o n e .

MEDIAL APPROACH
■ Po sit io n in g is sim ila r t o t h e a n t e ro la t e ra l a p p ro a ch .
■ Ma ke a n in cisio n o ve r t h e m e d ia l in t e rm u scu la r se p t u m
fro m t h e a xilla t o 5 cm p ro xim a l t o t h e m e d ia l e p ico n d yle
(TECH FIG 5 ).
■ Mo b ilize t h e u ln a r n e rve .
■ Re se ct t h e m e d ia l in t e rm u scu la r se p t u m ; id e n t ify a n d co -
a g u la t e t h e a d ja ce n t ve n o u s p le xu s w it h b ip o la r e le ct ro -
ca u t e ry.
■ Mo b ilize t h e t rice p s p o st e rio rly a n d t h e b ice p s/b ra ch ia lis
a n t e rio rly.
■ Exp o se t h e fra ct u re sit e .
■ Th e a xilla ry in cisio n ra ise s co n ce rn fo r in fe ct io n ; t h e re is
a lso co n ce rn t h a t t h e u ln a r n e rve ca n sca r t o t h e p la t e .
Incision
TECH FIG 5 • A. In cisio n fo r t h e m e d ia l
a p p ro a ch . (co n t in u e d ) A
 Ch a p t e r 2 2 PLATE FIXATION OF HUM ERAL SHAFT FRACTURES 195

TECHNIQUES
Median
nerve
Brachial
artery
Biceps Brachialis

Fractured
humerus

Ulnar
nerve

Triceps
Triceps
Intermuscular Ulnar
B septum C nerve

TECH FIG 5 • (co n t in u e d ) B,C. Th e b ra ch ia lis a n d b ice p s a re ra ise d a n t e rio rly, a n d t h e t rice p s is ra ise d p o st e rio rly fo r
fra ct u re e xp o su re .

PEARLS AND PITFALLS

In d ica t io n s
Pre o p e ra t ive p la n n in g
Su rg ica l e xp o su re
Pla t e fixa t io n
Ra d ia l n e rve fu n ct io n
■ Op e ra t ive t re a t m e n t is re se rve d fo r o p e n fra ct u re s, p a t ie n t s w it h m u lt ip le fra ct u re s, a n d fra ct u re s w it h
in a d e q u a t e re d u ct io n .
■ Re vie w a ll ra d io g ra p h s a n d d e t e rm in e t h e b e st su rg ica l a p p ro a ch .
■ Est im a t e p o t e n t ia l p la t e le n g t h a n d p re p a re fo r p o ssib le b o n e g ra ft in g .
■ Lo ca t e a n d p ro t e ct t h e ra d ia l n e rve .
■ Exp o se a n d re d u ce fra ct u re fra g m e n t s a n d t e m p o ra rily h o ld t h e m in p la ce w it h p in s o r cla m p s.
■ Alt e rn a t ive ly, fix la rg e r fra g m e n t s w it h in t e rfra g m e n t a ry scre w s.
■ En su re t h a t p la t e le n g t h a llo w s six co rt ice s o f fixa t io n p ro xim a l a n d d ist a l t o t h e fra ct u re .
■ Use 4.5-m m d yn a m ic co m p re ssio n p la t e s o r lim it e d co n t a ct d yn a m ic co m p re ssio n p la t e s.
■ Use co m p re ssive t e ch n iq u e s w h e n in d ica t e d .
■ Pre o p e ra t ive ly, d o cu m e n t a d e t a ile d n e u ro va scu la r e xa m in a t io n .
■ En su re t h a t t h e ra d ia l n e rve is n o t t ra p p e d w it h in t h e p la t e b e fo re clo su re .

POSTOPERATIVE CARE
■ Postoperative radiographs ensure proper fracture alignment
and plate placement (FIG 2 ).
■ Initially, the patient can be placed in a sling or posterior

elbow splint. This is removed and range-of-motion exercises

are started when patient comfort allows (usually 1 to 2 days
postoperative).
■ Weight bearing on the affected upper extremity is allowed

based on patient comfort.12

■ Initial therapy consists of elbow range-of-motion and shoul-

der pendulum and passive self-assist exercises.

■ The patient can come out of the sling after 2 weeks and start

waist-level activities with the operative arm.

■ At 6 weeks, elbow motion should be near normal range,

and shoulder strengthening is added to the patient’s physical

therapy.
■ At 3 months, radiographs should reveal some callus for-

mation. If no callus is evident, radiographs are repeated

every 6 weeks until evidence of healing appears. FIG 2 • Po st o p e ra t ive ra d io g ra p h .
196 Se c t i o n II SHOULDER AND ELBOW

OUTCOMES 2. Gregory PR. Fractures of the shaft of the humerus. In Bucholz RW,
H eckman JD, eds. Rockwood and Green’s Fractures in Adults, ed 5,
■ Plate fixation leads to union in 90% to 98% of cases. vol 1. Philadelphia: Lippincott Williams & Wilkins, 2001:973–996.
■ Plating offers decreased complication rates compared 3. Gregory PR, Sanders RW. Compression plating versus in-
to intramedullary nailing, especially in terms of shoulder tramedullary fixation of humeral shaft fractures. J Am Acad O rthop
dysfunction. 8 Surg 1997;5:215–223.
■ Iatrogenic radial nerve palsy occurs in about 2% to 5% of 4. H ealy WL, White GM , M ick CA, et al. N onunion of the humeral
shaft. Clin O rthop Relat Res 1987;219:206–213.
cases and usually resolves in 3 to 6 months. Electromyography 5. H oppenfeld S, deBoer P. Surgical Exposures in O rthopaedics: The
helps monitor return of nerve function in patients with pro- Anatomic Approach. Philadelphia: Lippincott Williams & Wilkins,
longed palsy. Radial nerve exploration is indicated when no 1994:51–82.
nerve function returns by 6 months. 6. Jupiter JB. Complex non-union of the humeral diaphysis: Treatment
■ Elbow and shoulder range of motion usually return to nor- with a medial approach, an anterior plate, and a vascularized fibular
graft. J Bone Joint Surg Am 1990;72A:701–707.
mal postoperatively.
7. M ast JW, Spiegel PG, H arvey JP Jr, et al. Fractures of the humeral
shaft: A retrospective study of 240 adult fractures. Clin O rthop Relat
COMPLICATION S Res 1975;112:254–262.
■ Infection 8. M cCormack RG, Brien D, Buckley RE, et al. Fixation of fractures of
■ N onunion the shaft of the humerus by dynamic compression plate or in-
tramedullary nail: a prospective randomized trial. J Bone Joint Surg
■ M alunion
Br 2000;82B:336–339.
■ H ardware failure 9. Ring D, Perey BH , Jupiter JB. The functional outcome of operative
■ Radial nerve palsy treatment of ununited fractures of the humeral diaphysis in older pa-
■ Shoulder impingement tients. J Bone Joint Surg Am 1999;81A:177–190.
■ Elbow stiffness 10. Sarmiento A, Latta LL. Functional fracture bracing. J Am Acad
O rthop Surg 1999;7:66–75.
11. Sarmiento A, Waddell JP, Latta LL. Diaphyseal humeral fractures:
REFEREN CES Treatment options. J Bone Joint Surg Am 2001;83A:1566–1579.
1. Garberina M J, Getz CL, Beredjiklian P, et al. O pen reduction and in- 12. Tingstad EM , Wolinsky PR, Shyr Y, et al. Effect of immediate
ternal fixation of humeral shaft nonunions. Tech Shoulder Elbow weightbearing on plated fractures of the humeral shaft. J Trauma
Surg 2006;7:131–138. 2000;49:278–280.
 In t r a m e d u lla r y Fix a t io n o f
Ch a p t e r 23 Hu m e r a l Sh a f t Fr a ct u re s
Ph illip Lan g e r an d Ch rist o p h e r T. Bo rn
DEFIN ITION
■ Incidence: 3% to 5% of all fractures12
■ The AO /ASIF classification of humeral shaft fractures is
based on increasing fracture comminution and is divided into
three types according to the contact between the two main
fragments:
■ Type A: simple (contact 90% )
■ Type B: wedge/butterfly fragment (some contact)
■ Type C: complex/comminuted (no contact)
■ Intramedullary nailing (IM N ) can be used to stabilize frac-
tures 2 cm distal to the surgical neck to 3 cm proximal to the
olecranon fossa.12
■ The precise role of IMN is not defined. Proponents offer the
following benefits over formal open reduction with internal fix-
ation (O RIF): it is minimally invasive, causing limited soft tissue
damage and no periosteal stripping (preservation of vascular in-
nervation); it is biomechanically superior; it is cosmetically ad-
vantageous (smaller incision); it is capable of indirect diaphyseal
fracture reduction and metaphyseal fracture approximation.
■ Complications such as shoulder pain, delayed union or
nonunion, fracture about the implant, iatrogenic fracture
comminution, and difficulty in the reconstruction of failures,
raise questions regarding the usefulness of intramedullary
nailing over O RIF.
■ Biomechanically, intramedullary nails are closer to the nor-
mal mechanical axis; consequently they act as a load-sharing
device if there is cortical contact.
■ Unlike plate-and-screw fixation, a load-bearing construct,
intramedullary nails are subjected to lower bending forces,
making fatigue failure and cortical osteopenia secondary to
stress shielding less likely.
AN ATOMY
■ Comparatively, there are several anatomic differences be-
tween the long bones of the upper extremity versus the long
bones of the lower extremity (femur, tibia):
■ The medullary canal terminates at the metaphysis (versus
diaphysis).
■ Isthmus: junction is at the middle–distal third (versus
proximal–middle third).
■ Trumpet shape: the proximal two thirds of the humeral
canal is cylindrical; distally. the medullary canal rapidly ta-
pers to a prismatic end at the diaphysis (hard cortical bone)
versus the wide flare of the metaphysis (soft cancellous bone).
■ Because of the funnel shape of the humeral shaft, a true in-
terference fit is difficult to obtain; therefore, proximal and
distal static locking has become the standard of care for IM N
of humeral fractures.
■ N eurovascular considerations include average distances of
key structures from notable bony landmarks:
■ Axillary nerve to proximal humerus, 6.1
0.7 cm (range
4.5 to 6.9 cm)
■ Axillary nerve to surgical neck, 1.7 0.8 cm (range 0.7
to 4.0 cm)
■ Axillary nerve to greater tuberosity, 45.6 mm
■ Axillary nerve to distal edge acromion, 5 to 6 cm
■ Crossing of radial nerve at lateral intermuscular septum
to proximal humerus, 17.0 2.3 cm (range 13 to 22 cm)
■ Crossing of radial nerve at lateral intermuscular septum
to olecranon fossa, 12.0 2.3 cm (range 7.4 to 16.6 cm)
■ Crossing of radial nerve at lateral intermuscular septum
to distal humerus, 16.0 0.4 cm (range 9.0 to 20.5 cm)1,5,9
PATHOGEN ESIS
■ Biomodal distribution 17
■ Young, male 21 to 30 years old: high-energy trauma
■ O lder, female 60 to 80 years old: simple fall/rotational
injury
■ 5% open 17
■ 63% AO /ASIF type A fracture patterns17
■ Various loading modes and the characteristic fracture pat-
terns they create
■ Tension: transverse
■ Compression: oblique
■ Torsion: spiral
■ Bending: butterfly
■ H igh-energy: comminuted
■ Red flags:
■ M inimal trauma indicates a pathologic process
■ Disconnect between history and fracture type suggests
domestic abuse.
N ATURAL HISTORY
■ The humerus is well enveloped in muscle and soft tissue,
hence its good prognosis for healing in most uncomplicated
fractures.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Patients with humeral shaft fractures present with arm pain,
deformity, and swelling.
■ Demographics, medical history, and information regarding
the circumstance and mechanism of injury should be obtained.
■ Particularly significant in upper extremity trauma: hand
dominance, occupation, age, and pertinent comorbidities must
be solicited from the patient. All of these factors play a major
role in determining whether to pursue surgical versus nonsur-
gical treatment.
■ O n physical examination, the arm is typically shortened,
angulated, or grossly deformed, with motion and crepitus on
manipulation.
■ Document the status of the skin (open versus closed fracture)
and perform a careful neurovascular evaluation of the limb.
197
198 Se c t i o n II SHOULDER AND ELBOW
FIG 1 • AP a n d la t e ra l ra d io g ra p h s o f a d isp la ce d h u m e ra l sh a ft
fra ct u re , sh o rt e n e d a n d in va ru s a n g u la t io n .
■ If indicated, Doppler pulse and compartment pressures
should be checked.
■ Always examine the shoulder and elbow joint for possible
associated musculoskeletal pathology.
■ Examine the radial nerve for evidence of injury by testing
resistance.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Initial studies must always include orthogonal views (an-
teroposterior [AP] and lateral radiographs) of the fracture site,
shoulder, and elbow (FIG 1 ). To obtain these radiographs,
move the patient rather than rotating the injured limb through
the fracture site.
■ Traction radiographs may be helpful with comminuted or
severely displaced fractures, and comparison radiographs of
the contralateral side may be helpful for determining preop-
erative length.
■ CT scans rarely are indicated. Rare situations in which they
should be obtained include significant rotational abnormality,
precluding accurate orthogonal radiographs, and suspicion of
possible intra-articular extension or an additional fracture or
fractures at a different level.
■ Doppler pulse and compartment pressures should be checked
if indicated following a thorough physical examination.
■ Suspicion of vascular injuries warrants an angiogram.
DIFFEREN TIAL DIAGN OSIS
■ O steoporosis
■ Pathologic fractures
■ H igh- or low-energy trauma
■ O pen or closed fractures
■ Domestic abuse
N ON OPERATIVE MAN AGEMEN T
■ M ost non- or minimally displaced humeral shaft fractures
can be successfully treated nonoperatively, with union rates of
more than 90% often reported.12
■ Common closed techniques include hanging arm cast; coap-
tation splint; Velpeau dressing; abduction humeral/shoulder
spica cast; functional brace; and traction.
■ Each of these modalities has been successfully employed,
but most commonly either a hanging arm cast or coaptation
splint is used for 1 to 2 weeks, followed by a functional
brace, tightened as the swelling decreases.
■ H anging arm casts are a very good option for displaced,
midshaft humeral fractures with shortening, especially
oblique or spiral fracture patterns, if the cast is able to ex-
tend 2 cm or more proximal to the fracture site.
■ For nonoperative treatment to be effective, the patient
should remain upright, either standing or sitting, and avoid
leaning on the elbow for support. This allows for gravitational
force to assist in fracture reduction.
■ As soon as possible, the patient should begin range-of-
motion exercises of the fingers, wrist, elbow, and shoulder
to minimize dependent swelling and joint stiffness.
■ Acceptable alignment of humeral shaft fractures is consid-
ered to be 3 cm of shortening, 30 degrees of varus/valgus an-
gulation, and 20 degrees of anterior/posterior angulation.10
■ Varus/valgus angulation is tolerated better proximally,
and more angulation may be tolerated better in patients
with obesity.
■ Patients with large pendulous breasts are at increased risk
for varus angulation if treated nonsurgically.
■ N o set values for acceptable malrotation exist, but com-
pensatory shoulder motion allows for considerable toler-
ance of rotational deformity.10
■ Low-velocity gunshot wounds act as closed injuries after ini-
tial treatment. Following irrigation and débridement of skin at
entry and exit sites, tetanus status confirmation, and prophy-
lactic antibiotic initiation, nonoperative treatment modalities
are commonly employed.10
SURGICAL MAN AGEMEN T
■ Successful nonoperative management may be impossible for
various reasons:
■ Fracture pattern (eg, displaced, comminuted, segmental
[segmental fractures are at risk of nonunion of one or both
fracture sites])
■ Prolonged recumbency
■ M orbid obesity
■ Large, pendulous breasts (in women)
■ Patient’s inability to maintain a semisitting or reclined
position owing to polytraumatic injuries or patient non-
compliance
■ O perative indications include:
■ Proximal humeral fractures with diaphyseal extension
■ M assive bone loss
■ Displaced transverse diaphyseal fractures
■ Segmental fractures
■ Floating elbow
■ Pathologic or impending pathologic fractures
■ O pen fractures
■ Associated vascular injury
■ Intra-articular extension
 Ch a p t e r 2 3 INTRAM EDULLARY FIXATION OF HUM ERAL SHAFT FRACTURES
■Polytrauma
■ Spinal cord or brachial plexus injuries
■ Poor soft tissue over the fracture site(s), such as thermal
burns
■ The most commonly cited overall best indication for IM N
from this extensive list is a pathologic or impending pathologic
fracture.
■ The need for operative intervention secondary to radial
nerve dysfunction after closed manipulation is controversial.
■ There are advocates for both early nerve exploration and
observation.
■ This condition was once thought to be an automatic indi-
cation for surgery; however, this assumption has since been
called into question.12
■ Isolated comminution is not an indication for operative
treatment.12 H owever, if surgical fixation is chosen over non-
operative management, antegrade IM N currently is favored
over plate fixation for comminuted fractures.2
■ Relative contraindications include:
■ O pen epiphyses
■ N arrow intramedullary canal (ie, 9 mm)
■ Prefracture deformity of the humeral shaft
■ O pen fractures with obvious radial nerve palsy and neu-
rologic loss after penetrating stab injuries
■ The last two conditions require nerve exploration with
subsequent plate-and-screw fixation.
■ Chronically displaced fractures should be treated with O RIF
rather than IM N to prevent traction-induced brachial plexus
palsy and radial nerve injury.
Preoperative Planning
■ When selecting implant size, consider canal diameter, frac-
ture pattern, patient anatomy, and postoperative protocol.
■ N ail length and diameter should take into account the dis-
tal narrowing of the humerus.
■ Estimations of the nail diameter, length, and necessity of
reaming can be made using preoperative roentgenograms of
the uninjured humerus.
■ Alternatively, the length and diameter of the medullary
canal can be ascertained intraoperatively using a radiopaque
gauge and C-arm imaging of the intact humerus. Use of a
radiolucent table top will substantially improve the quality
of the image as well as the ability to obtain accurate C-arm
images.
■ Position the gauge anterior to the unaffected humerus
with its distal end 2.5 cm or more proximal to the superior
edge of the olecranon fossa and 1 cm distal to the superior
edge of the articular surface.
■ M ove the C-arm to the proximal end of the humerus and
read the correct length directly from the stamped measure-
ments on the nail length gauge. The IM N should end ap-
proximately 1 to 2 cm proximal to the olecranon fossa.
■ M easure the length of the IM N to allow the proximal end
to be buried. This will reduce the incidence of subacromial im-
pingement if an antegrade technique is used, or encroachment
on the olecranon fossa and blocked elbow extension if a retro-
grade approach is chosen.
■ In comminuted fractures, carefully chose the length to
avoid distracting the humerus, which predisposes the patient
to delayed union or nonunion.
■ M easure the diameter of the medullary canal at the narrow-
est part that will contain the nail.
199
■ In retrograde nailing, it is important to determine the rela-
tion between alignment of the humeral canal and the entry
point of the nail by measuring the anterior deviation/distal
humeral offset of the distal canal on the preoperative lateral
radiograph.
■ Based on these calculations, if the deviation is small, make
a distal, long entry portal that includes the superior border
of the olecranon fossa.
■ If the anterior deviation is large, however, make the entry
portal more proximal and shorter in length.
Positioning
■The patient’s position for surgery is determined based on the
method chosen for fixation.
Antegrade Intramedullary Nailing
■ Place the patient in either a beach chair or supine position
on a radiolucent table with the head of the bed elevated 30 to
40 degrees (FIG 2 ).
■ Put a small roll between the medial borders of the scapula
and rotate the head to the contralateral side to increase expo-
sure of the shoulder.
■ Certain fracture patterns may call for skeletal traction.
■ If it is used, place an olecranon pin and apply intermittent
traction to avoid brachial plexus palsy.
■ Clinically assess the rotational alignment by placing
the shoulder in an anatomic position and rotating the
distal fragment of the fracture humerus so that the arm and
hand point toward the ceiling and the elbow is flexed
90 degrees.
■ Prepare the affected extremity and drape the arm free in the
typical manner. The operative area should encompass the
shoulder proximal to the nipple line, the midline of the chest
to the nape of the neck, and the entire affected extremity to the
fingertips.
■ Bring the patient to the edge of the radiolucent table to im-
prove the ability to obtain orthogonal C-arm images of the af-
fected extremity.
■ It may be necessary to have the patient lying partially off
the table on a radiolucent support.
■ Cover the C-arm imager with a sterile isolation drape. M ost
commonly, the C-arm is brought in directly lateral on the in-
jured side, although some surgeons favor coming in from the
contralateral side.
■ Regardless of which direction the C-arm is brought into
the field, it is imperative to obtain orthogonal views of the
entire humerus before the first incision is made.
Retrograde Intramedullary Nailing
■ Put the patient in the lateral decubitus or prone position
with dorsum placed near the edge of the operating table.
■ If the patient is in the prone position, the affected arm
may be supported on a radiolucent arm board, or placed
over a bolster or paint roller upper extremity support. The
latter two options facilitate access to the olecranon fossa
and prevent a traction injury to the brachial plexus. The arm
should be positioned in 80 degrees of abduction with the
elbow flexed at least 90 degrees.
■ If the lateral decubitus position is used, suspend the frac-
tured extremity, taking care not to distract the fracture site
or cause neurovascular compromise. Suspension can be
aided by an olecranon pin.
 200 Se c t i o n II SHOULDER AND ELBOW

A B

FIG 2 • A. Be a ch ch a ir p o sit io n fo r a n t e g ra d e
in t ra m e d u lla ry n a ilin g . B. Be a ch ch a ir p o sit io n
fo r a n t e g ra d e in t ra m e d u lla ry n a ilin g u sin g a
McCo n n e ll p o sit io n e r (McCo n n e ll Ort h o p e d ic
Mfg . Co , Gre e n ville , TX). C. Su p in e p o sit io n .
No t e t h e b u m p u n d e r t h e sca p u la a n d t h e
C-a rm im a g e in t e n sifie r re a d y t o co m e in fro m
t h e co n t ra la t e ra l sid e . D. C-a rm im a g in g fro m
t h e co n t ra la t e ra l sid e . Th e p a t ie n t is in t h e
C D su p in e p o sit io n .

■ Prepare the affected extremity and drape the arm free in the adequate orthogonal C-arm images are possible before mak-
typical manner. Include the distal clavicle, the acromion, the ing the surgical approach.
medial scapula, and the entire arm and hand in the operative
field. Approach
■ Cover the C-arm imager with a sterile isolation drape. ■ Standard locked intramedullary humeral nails can be in-
Bring the C-arm from the ipsilateral side and make sure that serted either antegrade or retrograde.
TECHNIQUES

ANTEGRADE INTRAMEDULLARY NAILING

Ap p ro a ch
■ Th e an teg rade app ro ach , wh ich h as been th e trad itio nal
me thod of IMN, typica lly involves a sta rting p oint at th e
proximal humerus—either t hrough the rotator cuff, where
the tissue is le ss va scula r, or just la tera l to th e articu lar
surface , w here the blood supp ly is hig he r (TECH FIG 1 ).
■ Pa lp a t e a n d o u t lin e t h e su rfa ce a n a t o m y o f t h e
a cro m io n , cla vicle , a n d h u m e ra l h e a d .
■ Fe e l t h e a n t e rio r a n d p o st e rio r b o rd e rs o f t h e
h u m e ra l h e a d t o lo ca t e a n d m a rk t h e m id lin e .
■ Ma ke a sm a ll lo n g it u d in a l in cisio n a t t h e a n t e ro la t -
e ra l co rn e r o f t h e a cro m io n ce n t e re d o ve r t h e t o p o f
t h e g re a t e r t u b e ro sit y. Ext e n d it d ist a lly 3 cm .
■ Th e C-a rm ca n b e u se d t o lo ca t e t h e e xa ct e n t ry p o in t
b e fo re p e rfo rm in g t h e a n t e rio r a cro m ia l a p p ro a ch .
■ Pla ce a K-w ire in t o t h e id e a l e n t ry p o in t u n d e r C-a rm
im a g in g g u id a n ce . Co n firm t h e lo ca t io n o n o rt h o g o -
n a l im a g e s.
■ Le a ve t h e K-w ire in t a ct w h ile m a kin g a n a n t e rio r
a cro m ia l a p p ro a ch .
■ Sp lit t h e d e lt o id fib e rs in lin e w it h t h e lo n g it u d in a l cu t a -
n e o u s in cisio n .
■ Do n o t e xt e n d t h e in cisio n d ist a lly m o re t h a n 4 o r 5 cm TECH FIG 1 • Po st o p e ra t ive AP a n d la t e ra l ra d io g ra p h s o f
in t h e d e lt o id m u scle , t o a vo id da m a g e t o t he a xilla ry a n t e g ra d e in t ra m e d u lla ry n a ilin g fo r a m id sh a ft h u m e ru s
n e rve . fra ct u re .
 Ch a p t e r 2 3 INTRAM EDULLARY FIXATION OF HUM ERAL SHAFT FRACTURES
■ Excise a n y visib le su b d e lt o id b u rsa e t o im p ro ve yo u r
visu a liza t io n o f t h e ro t a t o r cu ff.
■ Lo n g it u d in a lly in cise t h e su p ra sp in a t u s in lin e w it h t h e
d e lt o id /cu t a n e o u s in cisio n fo r 1 t o 2 cm , ju st p o st e rio r t o
t h e b icip it a l t u b e ro sit y.
■ Pla cin g su t u re t a g s a t t h e m a rg in s o f t h e su p ra sp in a -
t u s w ill h e lp re t ra ct it s e d g e s d u rin g t h e re m a in d e r o f
t h e p ro ce d u re a n d a ssist in a ch ie vin g a n o p t im a l ro t a -
t o r cu ff re p a ir d u rin g w o u n d clo su re .
■ Th e re is in su fficie n t e vid e n ce t o in d ica t e t h a t a la rg e r in -
cisio n , in ca se s in w h ich t h e ro t a t o r cu ff is id e n t ifie d a n d
p u rp o se ly in cise d , is su p e rio r t o a sm a lle r in cisio n m a d e
w it h t h e a id o f C-a rm im a g in g . 13
En t ry Ho le
■ Ma ke t h e e n t ry h o le m e d ia l t o t h e t ip o f t h e g re a t e r
t u b e ro sit y, ju st la t e ra l t o t h e a rt icu la r m a rg in a n d a p -
p ro xim a t e ly 0.5 cm p o st e rio r t o t h e b icip it a l g ro o ve t o
m in im ize d a m a g e t o t h e su p ra sp in a t u s.
■ Lin e a r a cce ss t o t h e hu m e ra l m e d u lla ry ca n a l is p o ssi-
b le o n ly t h o u g h a n e n t ry p o rt a l m a d e in t h is su lcu s b e -
t w e e n t h e g re a t e r t u b e ro sit y a n d t h e a rt icu la r su rfa ce .
■ Ma ke su re t h e e n t ry p o rt a l is ce n t e re d o n AP a n d la t -
e ra l C-a rm im a g e s t o e n su re t h e n a il w ill b e in t h e
m id p la n e o f t h e h u m e ru s.
■ If t h e e n t ry h o le is t o o m e d ia l, it w ill vio la t e t h e
su p ra sp in a t u s; if t h e e n t ry p o rt a l is t o o la t e ra l, it w ill
ca u se so m e d e g re e o f va ru s a n g u la t io n (in p ro xim a l
fra ct u re s) o r su b st a n t ia lly in cre a se t h e risk o f a n ia t ro -
g e n ic fra ct u re d u rin g n a il in se rt io n .
■ Pro xim a l t h ird fra ct u re s m a y re q u ire a m o re m e d ia lly
lo ca t e d e n t ry h o le t o a vo id va ru s a n g u la t io n a t t h e
fra ct u re sit e .
En t ra n ce in t o Me d u lla ry Ca n a l
■ Aft e r e st a b lish in g t h e e n t ry h o le , in se rt a K-w ire t h ro u g h
t h e p o rt a l in t o t h e m e d u lla ry ca n a l t o t h e le ve l o f t h e
le sse r t u b e ro sit y.
■ Ne xt , t o o p e n t h e m e d u lla ry ca n a l, e it h e r u se a ca n n u -
la t e d a w l o r p a ss a ca n n u la t e d d rill b it o ve r t h e K-w ire ,
t h ro u g h a p ro t e ct io n sle e ve , a n d d rill t o t h e d e p t h o f t h e
le sse r t u b e ro sit y.
■ Ad d u ct t h e p ro xim a l co m p o n e n t o f t h e fra ct u re d
h u m e ru s a n d e xt e n d t h e sh o u ld e r t o im p ro ve cle a r-
a n ce o f t h e a cro m io n a n d fa cilit a t e a w l o r st a rt e r
re a m e r a cce ss t o t h e co rre ct p o rt a l lo ca t io n .
■ On ce t h e m e d u lla ry ca n a l h a s b e e n o p e n e d , re m o ve t h e
g u id e w ire a n d in se rt a lo n g , b a ll-t ip p e d g u id e w ire .
Be n d in g t h e t ip o f t h e g u id e w ire m a y a id in it s p a ssa g e
a cro ss t h e fra ct u re sit e .
Pro visio n a l Re d u ct io n /
Gu id e w ire Pa ssa g e
■ Ma n ip u la t e t h e e xt re m it y t o re d u ce t h e fra ct u re . In m a n y
ca se s, re d u ct io n is o b t a in e d t h ro u g h a co m b in a t io n o f
a d d u ct io n , n e u t ra l fo re a rm ro t a t io n , a n d lo n g it u d in a l
t ra ct io n .
■ Wh ile a d va n cin g t h e g u id e w ire d o w n t h e ca n a l, ro t a t e
t h e a rm a b o u t it s lo n g it u d in a l a xis a n d t a ke se ve ra l C-a rm
im a g e s t o co n firm t h a t t h e g u id e w ire re m a in s co n t a in e d
in t h e ca n a l.
201
■ Th is is e sp e cia lly im p o rt a n t if t h e h u m e ru s is su b st a n -
TECHNIQUES
t ia lly co m m in u t e d .
■ Slo w ly a n d d e lib e ra t e ly p a ss t h e g u id e w ire a cro ss t h e
fra ct u re sit e .
■ Difficu lt p a ssa g e m a y b e a t ip -o ff t h a t so ft t issu e m a y
b e in t e rp o se d (p o ssib ly t h e ra d ia l n e rve ).
■ An o p e n fra ct u re is a d va n t a g e o u s in t h is sit u a t io n
b e ca u se it p ro vid e s t h e o p p o rt u n it y t o d ire ct ly visu -
a lize a n d cle a r t h e fra ct u re sit e o f a n y p ro b le m a t ic
so ft t issu e .
■ Aft e r cro ssin g t h e fra ct u re sit e , a d va n ce t h e b a ll-t ip p e d
g u id e w ire in t o t h e ce n t e r o f t h e d ist a l fra g m e n t u n t il t h e
t ip is 1 t o 2 cm p ro xim a l t o t h e o le cra n o n fo ssa .
■ Avo id sh o rt e n in g o r d ist ra ct in g t h e fra ct u re sit e w h ile
firm ly se cu rin g t h e g u id e w ire in t o t h e d ist a l fra g m e n t .
De t e rm in in g Na il Le n g t h
■ De t e rm in e t h e co rre ct n a il le n g t h b y o n e o f t w o m e t h o d s:
■ Gu id e ro d m e t h o d : w it h t h e d ist a l e n d o f t h e ro d 1
t o 2 cm p ro xim a l t o t h e o le cra n o n fo ssa , o ve rla p a
se co n d g u id e ro d e xt e n d in g p ro xim a lly fro m t h e
h u m e ra l e n t ry p o rt a l. Su b t ra ct t h e le n g t h in m m o f
t h e o ve rla p p e d g u id e ro d fro m t h e t o t a l le n g t h o f
a n id e n t ica l g u id e w ire t o d e t e rm in e t h e co rre ct n a il
le n g t h .
■ Na il le n g t h g a u g e : p o sit io n t h e ra d io p a q u e g a u g e a n -
t e rio r t o t h e fra ct u re d h u m e ru s. Mo ve t h e C-a rm t o
t h e p ro xim a l e n d o f t h e h u m e ru s a n d re a d t h e le n g t h
fro m t h e st a m p e d m e a su re m e n t s o n t h e g a u g e .
■ Th e id e a l le n g t h o f a n IMN sh o u ld b e m e a su re d 1 cm d is-
t a l t o t h e a rt icu la r su rfa ce o f t h e h u m e ra l h e a d t o a p o in t
1 t o 2 cm p ro xim a l t o t h e o le cra n o n fo ssa .
■ If t h e ca lcu la t e d le n g t h fa lls b e t w e e n t w o st a n d a rd -
ize d n a il le n g t h s o f t h e ch o se n im p la n t , a lw a ys ch o o se
t h e sm a lle r size .
■ Lo n g n a ils a re a risk fa ct o r fo r su b a cro m ia l im p in g e -
m e n t a n d fra ct u re sit e d ist ra ct io n .
■ Bu ryin g a lo n g n a il p ro xim a lly b e lo w t h e su b ch o n -
d ra l su rfa ce h a s t h e p o t e n t ia l t o ia t ro g e n ica lly
sp lit t h e d ist a l h u m e ru s o r cre a t e a su p ra co n d yla r
fra ct u re w h e n t h e t ip o f t h e n a il is w e d g e d t o o
clo se t o t h e o le cra n o n fo ssa .
Re a m in g t h e Hu m e ra l Sh a ft
■ Re a m in g t h e h u m e ra l sh a ft u su a lly is a vo id e d , e sp e cia lly
in co m m in u t e d fra ct u re s, t o a vo id re a m in g in ju ry t o t h e
ra d ia l n e rve o r t h e ro t a t o r cu ff.
■ If it is w a rra n t e d , slo w ly re a m t h e e n t ire h u m e ru s o ve r
t h e b a ll-t ip p e d re a m e r g u id e w ire in 0.5-m m in cre m e n t s.
■ Exe rcise g re a t e r ca u t io n w h e n re a m in g t h e h u m e ru s
t h a n w h e n re a m in g t h e lo n g b o n e s o f t h e lo w e r e x-
t re m it y, b e ca u se t h e co rt ica l t h ickn e ss o f t h e h u m e ru s
is su b st a n t ia lly le ss t h a n t h a t o f t h e t ib ia o r fe m u r.
■ Re a m 0.5 m m t o 1 m m la rg e r t h a n t h e se le ct e d n a il
d ia m e t e r. Re a m m in im a lly u n t il t h e so u n d o f co rt ica l
ch a t t e r b e co m e s a u d ib le .
■ Ch o o se a n a il 1 m m sm a lle r in d ia m e t e r t h a n t h e la st
re a m e r u se d .
■ So m e im p la n t syst e m s re q u ire t h a t t h e b a ll-t ip p e d
g u id e w ire b e re p lace d w it h a ro d t h a t d o e s n o t h a ve a t ip.
■ Use t h e m e d u lla ry e xch a n g e t u b e w h e n re p la cin g t h e
g u id e w ire t o m a in t a in fra ct u re re d u ct io n .
 202 Se c t i o n II SHOULDER AND ELBOW

In se rt in g t h e Na il
TECHNIQUES

■ On ce t h e co rre ct n a il le n g t h a n d t h e d ia m e t e r o f t h e se -
le ct e d im p la n t h a ve b e e n ve rifie d , a t t a ch t h e n a il
a d a p t e r, p la ce t h e n a il-h o ld in g scre w t h ro u g h t h e n a il
a d a p t e r, a n d t h e n a t t a ch t h e ra d io lu ce n t t a rg e t in g d e -
vice o n t o t h e n a il a d a p t e r.
■ Ve rify t h a t t h is a sse m b ly is lo cke d in t h e a p p ro p ria t e
p o sit io n a n d t h a t it s a lig n m e n t is co rre ct b y in se rt in g a
d rill b it t h ro u g h t h e a sse m b le d t issu e p ro t e ct io n /d rill
sle e ve p la ce d in t h e re q u ire d h o le s o f t h e t a rg e t in g
d e vice .
■ In se rt t h e n a il w it h su st a in e d m a n u a l p re ssu re .
■ Ag g re ssive p la ce m e n t ca n re su lt in ia t ro g e n ic fra c-
t u re s o r d isp la ce m e n t o f t h e fra ct u re fra g m e n t s.
■ Use t h e C-a rm im a g e in t e n sifie r t o id e n t ify t h e so u rce
o f t h e p ro b le m if t h e IMN d o e s n o t e a sily a d va n ce .
■ In se rt t h e n a il a t le a st t o t h e first circu m fe re n t ia l g ro o ve
o n t h e n a il a d a p t e r b u t n o d e e p e r t h a n t h e se co n d
g ro o ve .
■ Id e a lly, t h e IMN sh o u ld b e co u n t e rsu n k a b o u t 5 m m
b e lo w t h e a rt icu la r su rfa ce t o a vo id su b a cro m ia l
im p in g e m e n t .
■ Sin kin g t h e n a il m o re t h a n 1 cm b e lo w t h e a rt icu la r TECH FIG 2 • Po st o p e ra t ive AP a n d la t e ra l ra d io g ra p h s o f
su rfa ce m a y p la ce t h e p ro xim a l in t e rlo ckin g scre w s a t a n t e g ra d e in t ra m e d u lla ry n a ilin g fo r a m id sh a ft h u m e ru s
t h e le ve l o f t h e a xilla ry n e rve . fra ct u re . A sp ira l b la d e h a s b e e n u se d fo r p ro xim a l in t e rlo ck
■ If t h e p ro xim a l e n d o f t h e n a il is p ro p e rly co u n t e r- fixa t io n .
su n k, t h e in cid e n ce o f sh o u ld e r p a in is re p o rt e d ly le ss
t h a n 2% .4
■ At t a ch a st rike p la t e t o t h e t a rg e t in g d e vice a n d u se a
m a lle t t o im p a ct t h e p ro xim a l jig a sse m b ly t o e lim in a t e ■ La t e ra l scre w s p la ce d t o o p ro xim a l ca n p ro d u ce su b -
a n y fra ct u re g a p o r a d va n ce t h e IMN. a cro m ia l im p in g e m e n t w it h t e rm in a l a rm e le va t io n .
■ Do n o t h it t h e t a rg e t in g d e vice o r t h e n a il-h o ld in g ■ So m e im p la n t syst e m s m a y o ffe r a sp ira l b la d e fixa -
scre w d ire ct ly. t io n a s a n o p t io n fo r p ro xim a l in t e rlo ckin g . In t h e o ry,
■ Th e d ist a l e n d o f t h e IMN sh o u ld co m e t o lie a b o u t 2 cm it cre a t e s a fixe d a n g le co n st ru ct a n d h a s a h ig h e r re -
p ro xim a l t o t h e o le cra n o n fo ssa . sist a n ce (ve rsu s scre w s) a g a in st lo o se n in g (ie , “ w in d -
■ Re m o ve t h e g u id e w ire . sh ie ld w ip e r” e ffe ct ; TECH FIG 2 ).

Co m p re ssio n
■ Be fo re p ro xim a l in t e rlo ck in se rt io n , m a ke su re t h a t o p t i-
m a l fra ct u re sit e co m p re ssio n is p re se n t .
■ Pro xim a l co m p re ssio n lo ckin g ca n b e u se d fo r t ra n sve rse
o r sh o rt o b liq u e fra ct u re p a t t e rn s. Se ve re o st e o p e n ia is a
co n t ra in d ica t io n t o it s u se .
■ Exp lo re t h e ra d ia l n e rve b e fo re co m p re ssio n lo ckin g if
a n y p o ssib ilit y o f ra d ia l n e rve e n t ra p m e n t e xist s.
■ Th e n a il m u st b e o ve rin se rt e d b y t h e sa m e d ist a n ce o f
a n t icip a t e d in t e rfra g m e n t a ry t ra ve l b e ca u se o t h e r-
w ise , d u rin g co m p re ssio n , t h e n a il w ill b a ck o u t a n d
ca u se su b a cro m ia l im p in g e m e n t .
■ Ad ditio na lly, if the fra ct ure is su it ab le fo r com p re ssio n ,
th e cho se n im p la n t sh ou ld b e 6 to 10 mm sho rt e r th an
th e calculat e d m e a sure m e n t t o avo id pro xim al mig ra -
tion of th e n a il b eyo nd t he in se rt io n site .
■ Pro xim a l lo ckin g scre w p la ce m e n t
■ Obliqu e pro xim a l lo cking scre w s a re pre fe rre d b e ca u se
t h e ir in sert io n p o in t is ce p h a la d t o a xilla ry n e rve .
■ On ly la t e ra l-t o -m e d ia l p la ce m e n t is re co m m e n d e d fo r
p ro xim a l in t e rlo ckin g scre w s.
■ It is im p o rt a n t t o m a ke su re t h a t t h e se scre w s a re in -
se rt e d a b o ve t h e le ve l o f t h e h u m e ra l n e ck t o a vo id
a xilla ry n e rve in ju ry.
De t e rm in in g Ro t a t io n
■ Co n firm ro t a t io n a l a lig n m e n t b e fo re p la cin g d ist a l in t e r-
lo ck scre w s. Ro t a t io n a l a lig n m e n t ca n b e a sce rt a in e d
clin ica lly a n d ra d io g ra p h ica lly.
■ Ma g n ifie d C-a rm AP im a g e s o f t h e fra ct u re sit e ca n
b e u se d t o ju d g e t h e m e d ia l a n d la t e ra l co rt ica l w id t h
o f t h e m o st p ro xim a l a n d m o st d ist a l a sp e ct s o f t h e
fra ct u re sit e .
■ Pro p e r ro t a t io n is a ch ie ve d w h e n t h e se w id t h s a re
id e n t ica l.
Dist a l Lo ckin g Scre w s
■ Pla ce a n t e rio r, t h e n p o st e rio r a n d /o r la t e ra l, t h e n m e d ia l
d ire ct e d d ist a l in t e rlo ckin g scre w s.
■ In se rt d ist a l in t e rlo ckin g scre w s u sin g a fre e h a n d
t e ch n iq u e .
■ To p la ce AP-d ire ct e d scre w s, a d va n ce t h e C-a rm o ve r
t h e d ist a l h u m e ru s u n t il t h e o va l slo t is se e n t o b e in
m a xim a l re lie f—t h a t is, “ p e rfe ct circle .”
■ Un d e r C-a rm im a g in g , p la ce a sca lp e l o ve r t h e skin t o
p re cise ly d e t e rm in e t h e lo ca t io n o f t h e in cisio n . Ma ke
e ve ry a t t e m p t t o ke e p t h is in cisio n ju st la t e ra l t o t h e
b ice p s t e n d o n . Th is w ill d e cre a se t h e risk t o b ra ch ia l
a rt e ry, m e d ia n n e rve , a n d m u scu lo cu t a n e o u s n e rve .
 Ch a p t e r 2 3 INTRAM EDULLARY FIXATION OF HUM ERAL SHAFT FRACTURES
■ Ca re fu lly m a ke t h e in cisio n t h o u g h t h e skin a n d u se a
b lu n t h e m o st a t t o sp re a d u n d e r t h e b ra ch ia lis m u scle
down to the bone.
■ In se rt a sh o rt d rill b it t h ro u g h a so ft t issu e p ro t e ct o r.
■ Ce n t e r t h e d rill b it in t h e lo ckin g h o le a n d t h e n p o si-
t io n it p e rp e n d icu la r t o t h e n a il.
■ Id e a lly, p la ce t h e d rill b it d ist a lly in t h e o va l h o le t o
a llo w a xia l co m p re ssio n t o o ccu r p o st o p e ra t ive ly.
■ At t a ch t h e d rill a n d p e n e t ra t e t h e n e a r co rt e x. Th e n d e -
t a ch t h e d rill b it fro m t h e d rill a n d u se a m a lle t t o g e n t ly
a d va n ce t h e d rill b it t h ro u g h t h e n a il u p t o t h e fa r co rt e x.
■ An o rt h o g o n a l C-a rm im a g e m a y b e u se d t o ve rify
t h a t t h e p o sit io n o f t h e d rill b it is sa t isfa ct o ry.
■ Re a t t a ch t h e d rill a n d p e n e t ra t e t h e fa r co rt e x.
■ A d e p t h g a u g e ca n n o w b e in se rt e d t o a sce rt a in t h e
le n g t h o f t h e in t e rlo ck scre w .
■ Th e d ist a l scre w s u su a lly a re 24 m m in le n g t h .
■ Use C-a rm im a g e in t e n sifica t io n t o co n firm scre w p o si-
t io n t h ro u g h t h e n a il a s w e ll a s scre w le n g t h .
■ Avo id a rt icu la r p e n e t ra t io n in t o t h e g le n o h u m e ra l
jo in t .
■ La t e ra l-t o -m e d ia l d ire ct e d d ist a l lo ckin g scre w s
■ Eit her in com binat ion w it h or as an alterna tive to ante-
rior-t o-post erio r screws, insert lat eral-t o-medial screw s.
RETROGRADE INTRAMEDULLARY NAILING
Ap p ro a ch
■ Ma ke a lim it e d p o st e rio r a p p ro a ch ce n t e re d o ve r t h e d is-
t a l h u m e ru s, st a rt in g a t t h e o le cra n o n t ip t o a p o in t 6 cm
p ro xim a l.
■ Lo n g it u d in a lly sp lit t h e t rice p s in lin e w it h it s fib e rs t o
t h e co rt ica l su rfa ce o f t h e h u m e ru s a n d id e n t ify t h e
o le cra n o n fo ssa .
■ Ma ke e ve ry a t t e m p t t o a vo id e n t e rin g t h e e lb o w jo in t ,
t o d e cre a se t h e p o ssib ilit y o f p e ria rt icu la r sca rrin g .
St a rt in g o r En t ry Po rt a ls
■ As p re vio u sly d iscu sse d in t h e Ap p ro a ch se ct io n , t h e
co ro n a l d e via t io n o f t h e d ist a l h u m e ru s is va ria b le , a n d ,
t h e re fo re , t w o p o t e n t ia l st a rt in g p o rt a ls e xist :
■ Tra d it io n a l m e t a p h yse a l e n t ry p o rt a l: cre a t e d b y
re a m in g in t h e m id lin e o f t h e d ist a l m e t a p h yse a l t ri-
a n g le 2.5 cm p ro xim a l t o t h e o le cra n o n fo ssa .
■ Ole cra n o n fo ssa e n t ry p o rt a l: e st a b lish e d b y re a m in g
t h e p ro xim a l slo p e o f t h e o le cra n o n a t t h e su p e rio r
b o rd e r o f t h e o le cra n o n fo ssa .
■ Th e m o re d ist a l lo ca t io n o f t h e n o n t ra d it io n a l o le cra n o n
fo ssa e n t ry p o rt a l in cre a se s t h e e ffe ct ive w o rkin g le n g t h
o f t h e d ist a l se g m e n t a n d p ro vid e s a st ra ig h t e r a lig n -
m e n t w it h t h e m e d u lla ry ca n a l.
■ Ho w e ve r, b io m e ch a n ica l in ve st ig a t io n h a s fo u n d t h a t
t h e o le cra n o n fo ssa e n t ry p o rt a l p ro vid e s g re a t e r
re d u ct io n in t o rq u e re sist a n ce a n d lo a d t o fa ilu re ,
w h ich m a y in cre a se t h e p ro b a b ilit y o f a n ia t ro g e n ic
o r p o st o p e ra t ive fra ct u re .16
■ Wh e n m a kin g e it h e r e n t ry p o rt a l, p a y ca re fu l a t t e n t io n
t o t h e re la t io n b e t w e e n t h e o le cra n o n fo ssa a n d t h e
203
■ Ma ke a g e n e ro u s 5 cm in cisio n t o d e cre a se t h e risk t o
TECHNIQUES
t h e ra d ia l n e rve .
■ Use t h e sa m e t e ch n iq u e e m p lo ye d w h e n p la cin g
AP-d ire ct e d scre w s: b lu n t d isse ct io n , a p ro t e ct in g
d rill/scre w in se rt io n sle e ve , a n d p e rfe ct circle fre e -
h a n d t e ch n iq u e .
■ Fin a lly, co n firm t h e IMN p o sit io n , fra ct u re re d u ct io n ,
a n d in t e rlo ckin g scre w (s) p la ce m e n t w it h m u lt ip le o r-
t h o g o n a l C-a rm im a g e s.
■ Aft e r o rt h o g o n a l C-a rm im a g e s d e m o n st ra t e sa t is-
fa ct o ry re d u ct io n a n d h a rd w a re im p la n t a t io n , re -
m o ve t h e p ro xim a l t a rg e t in g d e vice a n d p la ce a n e n d
ca p (t h is la st st e p is o p t io n a l, d e p e n d in g o n su rg e o n
p re fe re n ce ).
■ Ca re fu lly se le ct t h e le n g t h o f t h e e n d ca p t o a vo id
im p in g e m e n t .
Wo u n d Clo su re
■ Co p io u sly irrig a t e a ll w o u n d s b e fo re t h e y a re clo se d .
■ Du rin g clo su re o f t h e p ro xim a l in se rt io n sit e , fo rm a lly
re p a ir t h e su rg ica lly in cise d ro t a t o r cu ff a n d d e lt o id
ra p h e ; sid e -t o -sid e n o n a b so ra b le su t u re s co m m o n ly a re
re co m m e n d e d .
lo n g it u d in a l a xis o f t h e h u m e ru s in o rd e r t o p la ce t h e
e n t ry p o rt a l in lin e w it h t h e h u m e ra l sh a ft . Th e a xis o f
t h e h u m e ru s u su a lly is co lin e a r w it h t h e la t e ra l a sp e ct o f
t h e o le cra n o n fo ssa .
■ Ma ke t h e in it ia l e n t ry p o rt a l in o n e o f t w o w a ys:
■ Op e n t h e n e a r co rt e x w it h a 4.5-m m d rill b it . Co n t in u e
d rillin g w h ile p ro g re ssive ly lo w e rin g t h e d rill t o w a rd
t h e a rm u n t il t h e d rill b it is in lin e w it h t h e m e d u lla ry
ca n a l o n t h e la t e ra l C-a rm im a g e s.
■ Drill t h re e sm a ll p ilo t h o le s in a t ria n g u la r co n fig u ra -
t io n p e rp e n d icu la r t o t h e co rt ica l su rfa ce . Co n n e ct
t h e se h o le s w it h a la rg e d rill b it a n d sm a ll ro n g e u r o r
e n la rg e t h e t ria n g u la r sit e w it h a sm a ll cu rve d a w l t o
cre a t e a lo n g , o va l h o le 1 cm w id e 2 cm lo n g t h a t
le a d s d ire ct ly in t o t h e m e d u lla ry ca n a l.
■ Un d e rcu t t h e in t e rn a l a sp e ct o f t h e p o st e rio r co rt e x in
a d d it io n t o t h e m e d ia l a n d la t e ra l w a lls o f t h e e n t ry
p o rt a l t o cre a t e a d ist a l b e ve l a lo n g t h e p a t h o f n a il
in se rt io n .
■ Th is w ill fa cilit a t e e a sy p a ssa g e o f t h e g u id e w ire ,
o p t io n a l re a m e r, a n d fin a l im p la n t .
Pro visio n a l Re d u ct io n a n d
Gu id e w ire Pa ssa g e
■ No w fo llo w t h e sa m e st e p s o u t lin e d in t h e a n t e g ra d e
IMN t e ch n iq u e se ct io n t o p a ss t h e g u id e w ire , re d u ce t h e
fra ct u re , re a m (o p t io n a l), m e a su re t h e d e sire d n a il le n g t h
a n d d ia m e t e r, a n d in se rt t h e ch o se n im p la n t .
■ Re d u ct io n o f t h e fra ct u re u su a lly in vo lve s g e n t le lo n -
g it u d in a l t ra ct io n o n t h e d ist a l h u m e ru s a n d co rre c-
t io n o f t h e va ru s–va lg u s d isp la ce m e n t .
 204 Se c t i o n II SHOULDER AND ELBOW

Re a m in g (Op t io n a l) ■ Aft e r d ist a l in t e rlo ckin g , g e n t ly t a p t h e in se rt io n b o lt

TECHNIQUES

w it h a m a lle t t o co m p re ss t h e fra ct u re sit e . Asse ss t h e re -

■ If it is ne cessary to re am , care fu lly se lect th e re am er size t o
d u ct io n w it h C-a rm im a g e s.
avoid d am a ge t o t he po ste rior co rt e x. In a ddit io n, slo w ly
ad va nce t he re am e r un de r C-a rm im ag e gu idan ce to a void
excessive re am ing o f t he a nt erio r hu me ral co rte x.
Pro xim a l Lo ckin g Scre w s
■ Bo t h o f t h e se st e p s d e cre a se t h e risk o f p o ssib le ia t ro -
■ Ne xt , p la ce a p ro xim a l in t e rlo ckin g scre w , e it h e r a n -
g e n ica lly in d u ce d fra ct u re s. t e rio r t o p o st e rio r, p o st e rio r t o a n t e rio r, o r la t e ra l t o
m e d ia l.
Dist a l Lo ckin g Scre w s ■ In cise t h e skin a n d u se a b lu n t h e m o st a t t o sp re a d
d o w n t o b o n e t o p ro t e ct t h e b ice p s t e n d o n (a n t e rio r-t o -
■ Ne xt , d ist a lly lo ck t h e n a il t o p re ve n t b a ckin g o u t , t h a t is,
p o st e rio r d ire ct e d scre w s) o r a xilla ry n e rve (p o st e rio r-t o -
b lo cke d e lb o w e xt e n sio n .
a n t e rio r a n d la t e ra l-t o -m e d ia l d ire ct e d scre w s).
■ Pla ce t h e d ist a l lo ckin g scre w s fro m p o st e rio r t o a n t e -
■ Use C-a rm im a g e in t e n sifica t io n t o co n firm scre w p o si-
rio r u sin g a g u id e .
t io n t h ro u g h t h e n a il a s w e ll a s scre w le n g t h .
■ Ma ke a n in d e n t a t io n w it h t h e g u id e , in cise t h e cu t a -
n e o u s la ye r, a n d t h e n u se a b lu n t h e m o st a t t o sp re a d
down to the bone. Wo u n d Clo su re
■ Fo llo w t h e re m a in in g st e p s u n iq u e t o t h e ch o se n im - ■ Co p io u sly irrig a t e e a ch w o u n d b e fo re clo sin g it . Clo se
p la n t . t rice p s sp lit w it h in t e rru p t e d n o n a b so ra b le su t u re s.

PEARLS AND PITFALLS

IMN co n t ra in d ica t io n s ■ Pre -e xist in g sh o u ld e r p a t h o lo g y (e g , im p in g e m e n t , ro t a t o r cu ff)
■ Pe rm a n e n t u p p e r e xt re m it y w e ig h t b e a re rs (e g , p a ra - o r t e t ra p le g ics)
■ Na rro w -d ia m e t e r ( 9 m m ) ca n a ls: e xce ssive re a m in g is n o t d e sira b le in t h e h u m e ru s b e ca u se
o f t h e risk o f t h e rm a l n e cro sis o r ra d ia l n e rve in ju ry.
An t e g ra d e IMN e n t ry sit e ■ If t h e e n t ry p o rt a l is t o o fa r la t e ra l, t h e la t e ra l w a ll o f t h e p ro xim a l h u m e ru s ca n b e re a m e d
o u t o r fra ct u re d d u rin g n a il in se rt io n .
■ Pu sh in g t h e re a m e r sh a ft m e d ia lly m a y p re ve n t t h is co m p lica t io n .
Na il in se rt io n ■ If a n y re sist a n ce is m e t w h ile a t t e m p t in g t o p a ss t h e n a il, e it h e r a n t e g ra d e o r re t ro g ra d e , m a ke
a sm a ll in cisio n t o e n su re t h a t t h e ra d ia l n e rve is n o t e n t ra p p e d in t h e fra ct u re sit e .
In t e rlo ck scre w s ■ In m o st ca se s, so ft t issu e s sh o u ld b e b lu n t ly sp re a d d o w n t o t h e b o n e w it h a h e m o st a t b e fo re
h o le s a re d rille d fo r a n y in t e rlo ckin g scre w , t o m in im ize n e u ro va scu la r in ju ry.
■ An t eg rad e IMN d ist al in te rlo ck screw s: An alt ern at e an d p o ssib ly sa fe r me th o d in vo lves p lacin g t h e
scre w p o st e ro a n t e rio rly t o a vo id n e u ro va scu la r risk wh e n AP (mu scu lo cu t a n e o u s n e rve , b ra ch ia l
a rt e ry) or LM (ra dial n erve) d ire ctio n is u se d . Whe n p la cin g in te rlo ck scre w s usin g t h e fre e h an d
t ech n iq u e , tie an ab so rb ab le su t u re t o th e screw so t h at if t h e screw b e co m es d islo d g e d fro m t h e
scre w d rive r, it w ill n o t b e d isp la ce d in t h e so ft tissu e s.
■ An t e g ra d e IMN: ro t a t e t h e C-a rm 180 d e g re e s, so t h e t o p ca n b e u se d a s a t a b le t o su p p o rt t h e
a rm fo r p la cin g t h e d ist a l lo ckin g scre w s.
Na il le n g t h ■ Alw a ys e rr o n t h e sid e o f a sh o rt e r n a il: d o n o t d ist ra ct t h e fra ct u re sit e o r ca u se ia t ro g e n ic
fra ct u re s b y t ryin g t o im p a ct a n a il t h a t is e xce ssive ly lo n g .
■ Th e re t ro g ra d e IMN m u st b e lo n g e n o u g h t o e n g a g e t h e ca n ce llo u s p a rt o f t h e h u m e ra l h e a d ;
t h e w id e m e d u lla ry fla re o f t h e p ro xim a l o n e t h ird o f t h e sh a ft d o e s n o t p ro vid e su fficie n t
st a b ilit y t o t h e in se rt e d n a il.
Op e n fra ct u re s: re a m in g ■ Aft e r a t h o ro u g h irrig a t io n a n d d é b rid e m e n t is p e rfo rm e d a n d t h e g u id e w ire is su cce ssfu lly
p a sse d a cro ss t h e fra ct u re sit e , clo se t h e d e e p m u scle la ye r a ro u n d t h e fra ct u re sit e t o ke e p
t h e o st e o g e n ic re a m in g d e b ris fro m w a sh in g a w a y.

POSTOPERATIVE CARE ■ Postoperative day 2: remove the dressing and begin gentle
shoulder pendulum and elbow RO M exercises.
■ Tailor the postoperative rehabilitation regimen to the ■ Postoperative days 10 to 14: remove the sutures. Institute

method of nailing (antegrade versus retrograde), stability of a structured, supervised physical therapy program. Close
the fracture, overall patient health, and preinjury level of ac- patient monitoring and formal therapy are key components
tivity/workplace demands. to achieving maximum postoperative function.
■ Antegrade IM N ■ Subsequently, schedule follow-up visits at 4- to 6-week in-

■ Place the affected arm in a sling or shoulder immobilizer tervals, depending on the patient’s clinical and radiographic
at the end of surgery. progression. H ealing often takes 12 weeks or longer.
 Ch a p t e r 2 3 INTRAM EDULLARY FIXATION OF HUM ERAL SHAFT FRACTURES
■ As union progresses, the therapist may begin supervised
exercises to recover upper extremity strength. Caution the
therapist against instituting programs or exercises that cre-
ate large rotational stresses to the arm until radiographic
healing becomes evident.
■ Retrograde IM N
■ Initial postoperative management is identical to treatment
following antegrade nailing, unless weight bearing is neces-
sary for wheelchair transfers, walkers, or crutch ambulation.
Use a posterior splint and platform attachment if crutches
are necessary.
■ It is important to institute early elbow active RO M or gen-
tle passive RO M by the patient to prevent elbow stiffness.
■ Avoid
■ Aggressive PRO M or stretching to decrease the risk of
myositis ossificans formation
■ Resisted elbow extension for the first 6 weeks after
surgery to protect the repair of the triceps split.
OUTCOMES
■ Randomized clinical trials comparing IM N to compression
plating show a higher reoperation rate and greater shoulder
morbidity with the use of nails.11
■ Locked antegrade IM N has resulted in loss of shoulder
motion in 6% to 37% of cases.13
■ Recent antegrade nails designed to eliminate insertion site
shoulder morbidity though an extra-articular start point have
been introduced, and prospective randomized trials are pending.
■ Retrograde IM N union rates range from 91% to 98% , and
the mean healing time is 13.7 weeks.15
■ Retrospective reviews of retrograde IM N have found
shoulder function to be excellent in 92.3% of patients and
elbow function excellent in 87.2% of patients after fracture
consolidation. 15
■ Functional end results were excellent in 84.6% of patients,
moderate in 10.3% of patients, and bad in 5.1% of patients.
■ Biomechanical studies have shown that, for midshaft frac-
tures, both antegrade and retrograde nailing showed similar
initial stability and bending and torsional stiffness—20% to
30% of normal humeral shafts. 8
■ In proximal fractures (ie, 10 cm distal to the greater
tuberosity tip), antegrade nails demonstrated significantly
more initial stability and higher bending and torsional
stiffness, as was true for distal fractures with retrograde
nailing.
COMPLICATION S
■ N onunion 3
■ Antegrade IM N : 11.6%
■ Retrograde IM N : 4.5%
■ Infection: 1% to 2%
■ Insertion site morbidity
■ Antegrade IM N : shoulder pain, impingement, stiffness,
and weakness
■ Retrograde IM N : elbow pain, stiffness, and triceps
weakness
■ Iatrogenic fractures3
205
■ Antegrade IM N : 5.1%
■ Retrograde IM N : 7.1%
■ Iatrogenic comminution and distraction at the fracture site
■ N eurovascular risk
■ Risk to the radial nerve in the spiral groove from canal
preparation and nail insertion
■ Risk to the axillary nerve from proximal interlocking
■ Risk to the radial, musculocutaneous, and median nerves
or brachial artery from distal interlocking
■ H eat-induced segmental avascularity after reaming
REFEREN CES
1. Bono CM , Grossman M G, H ochwald N , et al. Radial and axillary
nerves. Anatomic considerations for humeral fixation. Clin O rthop
Relat Res 2000;373:259–264.
2. Chen AL, Joseph TN , Wolinsky PR, et al. Fixation stability of com-
minuted humeral shaft fractures: locked intramedullary nailing versus
plate fixation. J Trauma 2002;53:733–737.
3. Court-Brown C. Paper presented at the O rthopaedic Trauma
Association Specialty Day M eeting; February 26, 2005;
Washington, DC.
4. Crates J, Whittle AP. Antegrade interlocking nailing of acute humeral
shaft fractures. Clin O rthop Relat Res 1998;350:40–50.
5. Farragos AF, Schemitsch EH , M cKee M D. Complications of in-
tramedullary nailing for fractures of the humeral shaft: a review. J
O rthop Trauma 1999;13:258–267.
6. Foster RJ, Swiontowski M F, Back AW, et al. Radial nerve palsy
caused by open humeral shaft fractures. J H and Surg Am 1993;18:
121–124.
7. Green AG, Reid JS, Carlson DA. Fractures of the humerus. In:
Baumgaertner M R, Tornetta P, eds. O rthopaedic Knowledge
Update: Trauma. Rosemont, IL: American Academy of O rthopaedic
Surgeons, 2005:163–180.
8. Lin J, Inoue N , Valdevit A, et al. Biomechanical comparison of ante-
grade and retrograde nailing of humeral shaft fracture. Clin O rthop
Relat Res 1998;351:203–213.
9. Lin J, H ou SM , Inoue N , et al. Anatomic considerations of locked
humeral nailing. Clin O rthop Relat Res 1999;368:247–254.
10. Lyons RP, Lazarus M D. Shoulder and arm trauma: bone. In:
O rthopaedic Knowledge Update 8. Rosemont, IL: American
Academy of O rthopaedic Surgeons, 2005:275–277.
11. M cCormack RG, Brien D, Buckley RE, et al. Fixation of fractures of
the shaft of the humerus by dynamic compression plate or in-
tramedullary nail: A prospective randomized trial. J Bone Joint Surg
Br 2000;82B:336–339.
12. M cKee M D. Fractures of the shaft of the humerus. In: Bucholz RW,
H eckman JD, Court-Brown C, eds. Rockwood and Green’s Fractures
in Adults, ed 6. Philadelphia: Lippincott Williams & Wilkins, 2006:
1117–1157.
13. Riemer BL, Foglesong M E, Burke CJ. Complications of Seidel in-
tramedullary nailing of narrow diameter humeral diaphyseal frac-
tures. O rthopedics 1994;17:19–29.
14. Roberts CS, Walz BM , Yerasimides JG. H umeral shaft fractures:
Intramedullary nailing. In: Wiss D, ed. M aster Techniques in
O rthopaedic Surgery: Fractures, ed 2. Philadelphia: Lippincott
Williams & Wilkins, 2006:81–95.
15. Rommens PM , Verbruggen J, Broos PL. Retrograde locked nailing of
humeral shaft fractures. A review of 39 patients. J Bone Joint Surg Br
1995;77B: 84–89.
16. Strothman D, Templeman DC, Varecka T, et al. Retrograde nailing
of humeral shaft fractures: a biomechanical study of its effects on
strength of the distal humerus. J O rthop Trauma 2000;14:101.
17. Tytherleigh-Strong G, Walls N , M cQ ueen M M . The epidemiology of
humeral shaft fractures. J Bone Joint Surg Br 1998;80B:249–253.

Ch a p t e r 24
DEFIN ITION
■ N onarticular scapular fractures include fractures of the gle-
noid neck, scapular spine and body, acromial process, and cora-
coid process. They account for 90% of scapular fractures.6
■ M ost nonarticular scapular fractures can be treated nonop-
eratively, including all isloated scapular body–spine fractures.
■ Significant displacement at one or more of these sites, alone
or in conjunction with ligamentous disruptions of the superior
shoulder suspensory complex, require evaluation for surgical
intervention.1,10
AN ATOMY
■ The scapula is a flat triangular bone with three processes lat-
erally: the glenoid process, the acromial process, and the cora-
coid process.
■ The glenoid proocess consists of the glenoid fossa, the gle-
noid rim, and the glenoid neck.
■ The superior shoulder suspensory complex is a bone and
soft tissue ring at the end of a superior and an inferior bony
strut (FIG 1 ). This ring is composed of the glenoid process,
the coracoid process, the coracoclavicular ligament, the distal
clavicle, the acromioclavicular joint, and the acromial
process. The superior strut is the middle third of the clavicle,
whereas the inferior strut is the junction of the most lateral
portion of the scapular body and the most medial portion of
the glenoid neck. 1
Acromioclavicular
ligament
Coracoclavicular
ligament
Clavicle
FIG 1 • Su p e rio r sh o u ld e r su sp e n so ry co m p le x.
206
Op e n Re d u ct io n a n d In t e r n a l
Fix a t io n o f No n a r t icu la r
Sca p u la r Fr a ct u re s
Bre t t D. Ow e n s an d Th o m as P. Go ss
PATHOGEN ESIS
■ Scapular fractures usually are the result of high-energy
trauma and have a high rate of associated musculoskeletal and
underlying thoracic injuries.3
■ Fractures of the acromion process may be the result of
direct trauma due to its subdermal location, whereas cora-
coid process fractures may be due to a sudden muscular
contraction. 4
N ATURAL HISTORY
■ The results of nonoperative treatment of nonarticular scapu-
lar fractures generally are good. N onunion is rare because the
area has a rich blood supply. Angular deformities often are
well compensated for by the wide range of motion of the
glenohumeral joint and scapulothoracic articulation.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ In addition to the specifics of the injury, it is helpful to
obtain an understanding of the functional demands on the
extremity. H and dominance, occupation, and sports partici-
pation are all relevant.
■ A thorough neurovascular examination must be performed
and deficits evaluated with angiography and electromyogra-
phy, as necessary.
■ A thorough soft tissue examination also is warranted, as
wounds may represent an open fracture and warrant explo-
ration. Blisters or swelling may delay surgery.
IMAGIN G AN D OTHER DIAGN OSTIC
Coracoacromial STUDIES
ligament ■ N onarticular scapular fractures usually are identified on
routine shoulder trauma series radiographs: a true anteropos-
terior (AP) view of the shoulder with the arm in neutral rota-
tion, a true axillary view of the glenohumeral joint, and a
true lateral scapular view. An AP weight-bearing view may
be indicated.
Acromial ■ CT scans and three-dimensional reconstructions can be
process helpful for identification and classification of fractures owing
to the complex bony anatomy in this region. In addition, the
Coracoid bony relationships should be evaluated for evidence of any lig-
process amentous disruption.
Glenoid DIFFEREN TIAL DIAGN OSIS
process ■ N onarticular scapular fractures
■ Intra-articular scapular fractures
■ Double disruptions of the superior shoulder suspensory
complex including a floating shoulder (ie, glenoid neck frac-
ture with ipsilateral middle third clavicle fracture)
■ Scapulothoracic dissociation
 Ch a p t e r 2 4 OPEN REDUCTION AND INTERNAL FIXATION OF NONARTICULAR SCAPULAR FRACTURES
N ON OPERATIVE MAN AGEMEN T
■ M ost (over 90% ) scapular fractures can be treated nonoper-
atively.
■ Glenoid fossa and rim fractures may require operative man-
agement and are discussed in Chapter SE-23.
■ Glenoid neck fractures with more than 40 degrees of angu-
lation in the coronal or sagittal plane or translational dis-
placement of 1 cm or more require surgical management.
Anatomic neck fractures (lateral to the coracoid process) are
inherently unstable and should also be considered for opera-
tive intervention. 2
■ Isolated acromial and coracoid process fractures usually are
minimally displaced and can be managed nonoperatively.
Significant displacement or fractures in conjunction with other
bony and soft tissue injuries to the shoulder girdle may require
surgical stabilization.4
SURGICAL MAN AGEMEN T
Preoperative Planning
■ Imaging studies should be reviewed and available for ref-
erence in the operating room. A draped fluoroscopy unit
A B
FIG 2 • A. Th e la t e ra l d e cu b it u s p o sit io n is u se d fo r p o st e rio r a n d p o st e ro su p e rio r a p p ro a ch e s t o t h e g le n o id p ro ce ss. B. Th e b e a ch
ch a ir p o sit io n .
POSTERIOR APPROACH TO GLENOID NECK
■ Bo n y la n d m a rks a re o u t lin e d w it h m a rkin g p e n (TECH
FIG 1 A).
■ An in cisio n is m a d e a lo n g t h e sca p u la r sp in e a n d
a cro m io n a n d d o w n t h e la t e ra l a sp e ct o f t h e sh o u ld e r,
as needed.
■ Th e o rig in s o f t h e p o st e rio r a n d m id d le h e a d s o f t h e
d e lt o id m u scle a re sh a rp ly d e t a ch e d fro m t h e sca p u la r
sp in e –a cro m ia l p ro ce ss a n d re t ra ct e d d ist a lly (TECH
FIG 1 B).
207
and competent technician should be available during the
surgery.
Positioning
■ O pen reduction with internal fixation (O RIF) of scapular
fractures requires wide access to the entire shoulder girdle. The
patient may be placed in either the lateral decubitus position
(FIG 2 A) or in the beach chair position (FIG 2 B), but care
must be taken to allow adequate exposure of the entire scapula
and clavicle.
■ The shoulder girdle is prepped and draped widely, and the
entire upper extremity is prepped and draped “ free.”
■ Alternatively, a staged procedure can be performed using sep-
arate positions, sterile preparations, and separate exposures.9
Approach
■ Glenoid neck fractures are approached posteriorly.
■ A superior approach can added for control and positioning
of a difficult-to-control glenoid fragment.
■ An anterior approach is used for coracoid process fractures.
■ A superior approach is used for access to acromial process
fractures.
TECHNIQUES
■ Th e in t e rva l b e t w e e n in fra sp in a t u s a n d t e re s m in o r is
d e ve lo p e d .
■ If a cce ss t o t h e g le n o id fo ssa is n e ce ssa ry, t h e in fra -
sp in a t u s t e n d o n a n d u n d e rlyin g p o st e rio r g le n o -
h u m e ra l jo in t ca p su le a re in cise d 2 cm la t e ra l t o t h e ir
in se rt io n o n t h e g re a t e r t u b e ro sit y a n d re fle ct e d la t -
e ra lly (TECH FIG 1 C,D).
■ Mo b iliza t io n o f t h e t e re s m in o r m u scle a llo w s a cce ss t o
t h e la t e ra l sca p u la r b o rd e r.
 208 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES
A C
B D
■ Re d u ct io n o f t h e fra ct u re is p e rfo rm e d w it h la t e ra l t ra c-
t io n o n t h e d ra p e d a rm a n d m a n ip u la t io n o f t h e fra ct u re
sit e .
■ Te m p o ra ry fixa t io n m a y b e o b t a in e d w it h K-w ire s.
■ Rig id fixat ion m a y b e ob ta in ed wit h a co n to u re d re co n -
st ru ct io n plat e an d 3.5-m m cortica l scre ws (TECH FIG 1 D).
SUPERIOR APPROACH TO GLENOID NECK
■ Th e su p e rio r a p p ro a ch t o t h e g le n o id n e ck is m a d e in a n
e xt e n sile fa sh io n b y e xt e n d in g t h e p o st e rio r in cisio n su -
p e rio rly.
■ Th e t ra p e ziu s a n d u n d e rlyin g su p ra sp in a t u s m u scle s a re
sp lit in t h e lin e o f t h e ir fib e rs (TECH FIG 2 ).
TECH FIG 2 • In t h e in t e rva l b e t w e e n t h e cla vicle a n d t h e
sca p u la r sp in e –a cro m ia l p ro ce ss, t h e t ra p e ziu s a n d su p ra sp in a -
t u s t e n d o n h a ve b e e n sp lit in lin e o f t h e ir fib e rs fo r e xp o su re .
(Fro m Go ss TP. Gle n o id fra ct u re s: Op e n re d u ct io n a n d in t e rn a l
fixa t io n . In Wiss DA, e d . Ma st e r Te ch n iq u e s in Ort h o p a e d ic
Su rg e ry: Fra ct u re s. Ph ila d e lp h ia : Lip p in co t t –Ra ve n , 1998.)
ORIF OF ACROMIAL PROCESS FRACTURE
■ In cisio n d ire ct ly o ve r t h e a cro m ia l p ro ce ss
■ Su b p e rio st e a l d isse ct io n t o e xp o se t h e su p e rio r su rfa ce
o f t h e a cro m io n
■ An a t o m ic fra ct u re re d u ct io n u n d e r d ire ct visu a liza t io n
TECH FIG 1 • A. Th e st an da rd p o st erior in cisio n ex-
te n d s alo n g t h e in fe rior ma rg in o f th e scapu la r
spine a nd t he a cro mio n . At t h e lat eral t ip o f t h e
acrom ion, th e incision co ntinu es in the midlat eral
lin e for 2.5 cm. B. The p ost erior a nd midd le head s
of t h e d elto id mu scle h ave bee n d et ach ed fro m t he
sca pu la r sp in e –p o st erio r acro mial p ro ce ss a nd re -
tracte d d ist a lly t o exp o se th e in frasp in at u s muscu -
lote ndinous unit . C. Th e in fra spin a t u s–t e re s mino r
inte rval h as b ee n d eve lo ped , wit h t h e in fra sp ina tu s
re tracte d su p erio rly a n d t h e t e re s min o r re t ra ct e d
infe riorly to expose t he poste rior g le nohum eral
joint ca psule (t he inferior port ion of t he infra spina -
tus in sert io n h a s b ee n relea se d). D. Th e in fra sp ina -
tus t en d on a n d un d erlyin g p o st erio r g le n oh um eral
jo in t ca p su le are in cised 2 cm fro m in se rt io n o n t h e
gre at e r tu b ero sit y t o a llo w a cce ss to th e g le no-
hu me ra l joint . (From Go ss TP. Gle n o id fra ctu re s:
Op en red u ct io n a n d in t ern al fixat io n . In Wiss DA,
ed. Maste r Techniques in Ort hopae dic Surgery:
Fract u res. Ph ilad elp h ia: Lip p in co tt –Ra ven , 1998.)
■ Ca re m u st b e t a ke n t o a vo id vio la t in g t h e g le n o id fo ssa
w it h t h e scre w s in t h e g le n o id fra g m e n t .
■ Me t icu lo u s re p a ir o f t h e d e lt o id o rig in t o t h e sca p u la r
sp in e –a cro m io n sh o u ld b e p e rfo rm e d w it h p e rm a n e n t
su t u re s t h ro u g h d rill h o le s.
■ Pro xim a l fra ct u re s: fixa t io n w it h a co n t o u re d 3.5-m m re -
co n st ru ct io n p la t e (TECH FIG 3 A)
■ Dist a l fra ct u re s: fixa t io n w it h a t e n sio n b a n d co n st ru ct
(TECH FIG 3 B)
 Ch a p t e r 2 4 OPEN REDUCTION AND INTERNAL FIXATION OF NONARTICULAR SCAPULAR FRACTURES 209

TECHNIQUES
A B

TECH FIG 3 • Fixa t io n t e ch n iq u e s fo r a cro m io n p ro ce ss fra ct u re s. A. Pla t e -a n d -scre w co n st ru ct fo r a fra ct u re o f t h e b a se

o f t h e a cro m io n . B. Te n sio n b a n d w ire co n st ru ct .

ORIF OF CORACOID PROCESS FRACTURE

■ Ve rt ica l in cisio n 1 cm la t e ra l t o co ra co id p ro ce ss (TECH
FIG 4 A)
■ De ve lo p m e n t o f d e lt o p e ct o ra l in t e rva l o r sp lit o f t h e d e l-
t o id m u scle in lin e w it h it s fib e rs d ire ct ly o ve r t h e co ra -
co id p ro ce ss
■ Exp o su re o f t h e fra ct u re sit e (m a y n e e d t o o p e n t h e ro -
t a t o r in t e rva l)
■ If co ra co id t ip h a s su fficie n t st o ck, ca n n u la t e d scre w fix-
a t io n ca n b e p e rfo rm e d (TECH FIG 4 B).
■ If n o t , fra g m e n t e xcisio n a n d su t u re fixa t io n o f co n jo in t
t e n d o n t o re m a in in g co ra co id is p e rfo rm e d (TECH
FIG 4 C).
■ Co ra co id b a se fra ct u re s a re fixe d w it h a sin g le ca n n u -
la t e d co rt ica l scre w (TECH FIG 4 D).

TECH FIG 4 • A. St a n d a rd a n t e rio r in cisio n e x-

t e n d s fro m t h e su p e rio r t o in fe rio r m a rg in o f
t h e h u m e ra l h e a d , ce n t e re d o ve r t h e g le n o -
h u m e ra l jo in t . B–D. Th re e re p a ir t e ch n iq u e s fo r
co ra co id fra ct u re s. B. Ca n n u la t e d scre w fixa t io n
o f t ip a vu lsio n w it h su fficie n t b o n e t o re p a ir.
(co n t in u e d ) B
 210 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

C D

TECH FIG 4 • (co n t in u e d ) C. Su t u re fixa t io n o f co n jo in t t e n d o n w h e n in su fficie n t b o n e is a va ila b le t o re p a ir.

D. Ca n n u la t e d scre w fixa t io n fo r p ro xim a l fra ct u re . (A: Fro m Go ss TP. Op e n re d u ct io n a n d in t e rn a l fixa t io n o f g le -
n o id fra ct u re s. In : Cra ig EV, e d . Ma st e r Te ch n iq u e s in Ort h o p a e d ic Su rg e ry: Th e Sh o u ld e r, 2n d e d . Ph ila d e lp h ia :
Lip p in co t t Willia m s & Wilkin s, 2004.)

PEARLS AND PITFALLS

In d ica t io n s ■ CT ca n h e lp d e fin e t h e fra ct u re , a sse ss p o ssib le in t ra -a rt icu la r in vo lve m e n t , a n d id e n t ify co n co m it a n t
in ju rie s.
■ Mo st n o n a rt icu la r in ju rie s a n d a ll sca p u la r b o d y–sp in e fra ct u re s a re t re a t e d n o n o p e ra t ive ly.
Ap p ro a ch ■ De lt o id d e t a ch m e n t a n d re fle ct io n p ro vid e s m a xim a l visu a liza t io n a n d is re co m m e n d e d fo r su rg e o n s
u n fa m ilia r w it h t h e p o st e rio r a p p ro a ch .
■ Du rin g t h e p o st e rio r a p p ro a ch , t h e in t e rn e rvo u s p la n e is b e t w e e n t h e in fra sp in a t u s (a b ip e n n a t e
m u scle ) su p e rio rly a n d t h e t e re s m in o r in fe rio rly.
Re d u ct io n ■ K-w ire s ca n b e p la ce d t o se rve a s “ jo yst icks” t o a ssist w it h fra ct u re re d u ct io n .
Fixa t io n ■ K-w ire s sh o u ld b e a vo id e d fo r p e rm a n e n t fixa t io n . Ho w e ve r, t h e y ca n b e p la ce d p e rcu t a n e o u sly a n d
u se d fo r t e m p o ra ry o r su p p le m e n t a l fixa t io n , b e in g re m o ve d a t 4 t o 6 w e e ks.
■ Re co n st ru ct io n p la t e s m a y b e p re -co n t o u re d u sin g a sca p u la m o d e l.
Clo su re ■ Me t icu lo u s re p a ir o f t h e d e lt o id t o t h e sca p u la r sp in e –a cro m ia l p ro ce ss is n e ce ssa ry, u sin g n o n a b -
so rb a b le su t u re s p la ce d t h ro u g h d rill h o le s.

POSTOPERATIVE CARE OUTCOMES

■ H ow aggressive the rehabilitation program following O RIF ■ Relatively few outcome studies detailing the results of
of nonarticular scapular fractures must be is determined by the scapular fractures treated operatively are available.
rigidity of the fixation construct and the adequacy of the soft ■ While most nonarticular scapular fractures are treated non-

tissue repair.5 operatively, those that warrant surgical intervention appear to

■ Patients are immobilized in a sling and swathe binder benefit from this treatment. 7,8
and started on gentle pendulum exercises during the first
2 weeks. COMPLICATION S
■ Progressive passive and active-assisted range of motion exer- ■ When neurologic complications occur, they most commonly
cises are emphasized during weeks 2 through 6 postoperatively. are caused by overly aggressive retraction or misdirected dis-
■ All protection is discontinued by 6 weeks postoperatively.
section.
■ Strengthening is begun after 6 weeks postoperatively and ■ The musculocutaneous and axillary nerves are vulnerable

after range of motion is satisfactory. in the anterior approach, the suprascapular nerve in the su-
■ Return to sports or labor is restricted until 4 to 6 months
perior approach, and the axillary and suprascapular nerves
postoperatively. in the posterior approach.9
 Ch a p t e r 2 4 OPEN REDUCTION AND INTERNAL FIXATION OF NONARTICULAR SCAPULAR FRACTURES
REFEREN CES
1. Goss TP. Double disruptions of the superior shoulder complex. J
O rthop Trauma 1993;7:99.
2. Goss TP. Fractures of the glenoid neck. J Shoulder Elbow Surg
1994;3:42–61.
3. Goss TP. Scapular fractures and dislocation: diagnosis and treatment.
J Am Acad O rthop Surg 1995;3:22.
4. Goss TP. The scapula: Coracoid, acromial and avulsion fractures. Am
J O rthop 1996;25:106.
5. Goss TP. Glenoid fractures: O pen reduction and internal fixation. In:
Wiss DA, ed. M aster Techniques in O rthopaedic Surgery: Fractures,
2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006.
211
6. Goss TP, O wens BD. Fractures of the scapula: Diagnosis and treat-
ment. In: Iannotti JP, Williams GR, eds. Disorders of the Shoulder:
Diagnosis and M anagement, 2nd ed. Philadelphia: Lippincott
Williams & Wilkins, 2007.
7. H ardegger FH , Simpson LA, Weber BG. The operative treatment of
scapular fractures. J Bone Joint Surg Br 1984;66B:725.
8. Kavanagh BF, Bradway JK, Cofield RH . O pen reduction of displaced
intra-articular fractures of the glenoid fossa. J Bone Joint Surg Am
1993;75A:479.
9. O wens BD, Goss TP. Surgical approaches for glenoid fractures. Tech
Shoulder Elbow Surg 2004;5:103–115.
10. O wens BD, Goss TP. The floating shoulder. J Bone Joint Surg Br
2006;88(11):1419–1424.
 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 25 Fix a t io n o f In t r a -a r t icu la r
Sca p u la r Fr a ct u re s
Bre t t D. Ow e n s, Jo an n a G. Bran st e t t e r, an d Th o m as P. Go ss

DEFIN ITION ■ A thorough neurovascular examination must be performed.

Deficits are evaluated with angiography and electromyogra-
■ Intra-articular scapular fractures include fractures of the gle-
phy, as necessary.
noid cavity, which includes the glenoid rim and the glenoid ■ A thorough soft tissue examination also is warranted.
fossa. They account for 10% of scapular fractures.6 M ost
Wounds may represent an open fracture and warrant explo-
scapular fractures are extra-articular, and 50% involve the
ration. Blisters or swelling may delay surgery.
body and spine.
■ O ver 90% of fractures of the glenoid cavity are insignifi-
IMAGIN G AN D OTHER DIAGN OSTIC
cantly displaced and are managed nonoperatively.3 STUDIES
■ Significant displacement requires evaluation for surgical in-

tervention to achieve the best possible outcome.

AN ATOMY
■ The scapula is a flat triangular bone with three processes:
the glenoid process, the acromial process, and the coracoid
process.
■ The glenoid process consists of the glenoid cavity (the gle-
noid rim and glenoid fossa) and the glenoid neck.
■ The glenoid cavity provides a firm concave surface with
which the convex humeral head articulates. The average depth
of the articular cartilage is 5 mm.
■ Glenoid cavity fractures are classified according to whether
they involve the glenoid rim or the glenoid fossa and the direc-
tion of the fracture line (FIG 1 ).
■ Intra-articular scapular fractures initially are evaluated with
a routine scapula trauma radiographic series (a true anteropos-
terior view of the shoulder with the arm in neutral rotation, a
true axillary view of the glenohumeral joint, and a true lateral
scapular view; FIG 2 A).
■ CT scans and three-dimensional studies with reconstruc-
tions can be helpful in evaluating articular congruity and
fracture displacement (FIG 2 B–D). In addition, the bony
relationships should be evaluated for evidence of ligamentous
disruption(s) or instability.
DIFFEREN TIAL DIAGN OSIS
■ Intra-articular scapular fractures
■ N onarticular scapular fractures
■ Scapulothoracic dissociation

■ Double disruptions of the superior shoulder suspensory

PATHOGEN ESIS
complex, including a floating shoulder (a glenoid neck fracture
■ Scapular fractures usually are the result of high-energy
with an ipsilateral middle third clavicle fracture)
trauma and have a high rate (90% ) of associated bony and soft
tissue injuries, both local and distant. 5 N ON OPERATIVE MAN AGEMEN T
■ Fractures of the glenoid rim occur when the humeral head
■ M ost (over 90% ) intra-articular scapular fractures are in-
strikes the periphery of the glenoid cavity. They are true frac-
significantly displaced and are managed nonoperatively.
tures, not avulsion injuries caused by indirect forces applied to ■ Significantly displaced glenoid fossa and glenoid rim frac-
the periarticular soft tissues by the humeral head.
■ Fractures of the glenoid fossa occur when the humeral head
tures require operative management.
is driven into the center of the concavity. The fracture then SURGICAL MAN AGEMEN T
promulgates in a number of different directions, depending on
the characteristics of the humeral head force.
■ Surgical indications are as follows:
■ Rim fractures: 25% or more of the glenoid cavity anteri-

N ATURAL HISTORY
■ The results of nonoperative treatment of intra-articular
scapular fractures usually are good if the fracture displacement
is minimal and the humeral head lies concentrically within the
glenoid cavity.
■ Significant displacement can result in posttraumatic degen-
erative joint disease, glenohumeral instability, and even
nonunion.2
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ In addition to the specifics of the injury, it is helpful to
obtain an understanding of the functional demands on the
extremity. H and dominance, occupation, and sports participa-
tion are all relevant.
orly or 33% or more of the glenoid cavity posteriorly and
displacement of the fragment 10 mm or more
■ Fossa fractures: an articular step-off of 5 mm or more,
significant separation of the fracture fragments, or failure of
the humeral head to lie in the center of the glenoid cavity
Preoperative Planning
■ Imaging studies should be reviewed before the surgery and
should be available for reference in the operating room. A
draped fluoroscopy unit and a competent technician should be
available. An examination for instability can be performed
while under anesthesia.
Positioning
■ O pen reduction with internal fixation (O RIF) of intra-
articular scapular fractures requires wide access to the entire

212
 Ch a p t e r 2 5 OPEN REDUCTION AND INTERNAL FIXATION OF INTRA-ARTICULAR SCAPULAR FRACTURES 213

FIG 1 • Go ss-Id e b e rg cla ssifica t io n o f g le n o id ca vit y fra ct u re s. Ia , a n t e rio r rim ; Ib , p o st e rio r rim ;
II, in fe rio r g le n o id ; III, su p e rio r g le n o id ; IV, t ra n sve rse t h ro u g h t h e b o d y; V; co m b in a t io n II-IV;
VI, co m m in u t e d .

FIG 2 • A. The AP radiogra ph shows a

typ e Vc gleno id cavity fract u re. B. Axilla ry
CT imag e sh o w s a larg e anterosup erio r
g le n o id ca vity fra g m e n t includ ing th e
A B co ra co id p ro ce ss. (cont inued)
 214 Se c t i o n II SHOULDER AND ELBOW
C D
A B
FIG 3 • Pa t ie n t p o sit io n : la t e ra l d e cu b it u s (A) a n d b e a ch ch a ir (B).
shoulder girdle. Depending on the particular fracture, the
patient is placed in either the lateral decubitus position
(FIG 3 A) or the beach chair position (FIG 3 B).
■ Care must be taken to allow adequate exposure of the entire
scapula and clavicle. The shoulder girdle is prepped and
draped widely, and the entire upper extremity is prepped and
draped “ free.”
■ In some cases, a staged procedure may be necessary using
separate positions, sterile preparations, and exposures.10
TECHNIQUES
POSTERIOR APPROACH TO THE GLENOID CAVITY
■ Bo n y la n d m a rks a re o u t lin e d w it h a m a rkin g p e n .
■ An in cisio n is m a d e a lo n g t h e sca p u la r sp in e a n d
a cro m io n a n d d o w n t h e m id la t e ra l a sp e ct o f t h e sh o u l-
d e r, a s n e e d e d (TECH FIG 1 A).
■ Orig in s o f t h e p o ste rio r an d mid d le h e ad s o f t h e d e lt o id
mu scle a re sh a rp ly de t a che d fro m t h e sca p u la r sp in e –
acrom ial process, and t he delt oid m uscle is split in t he line
o f it s fibers for 2.5 cm in t h e m id la t era l lin e. It is th e n
re t ra ct e d dista lly (TECH FIG 1B).
FIG 2 • (co n t in u e d ) C. Axilla ry CT im a g e sh o w s
t h e la t e ra l a sp e ct o f t h e sca p u la r b o d y lyin g
b e t w e e n t h e t w o g le n o id ca vit y fra g m e n t s a n d
a b u t t in g t h e h u m e ra l h e a d . D. Axilla ry CT
im a g e sh o w s a la rg e p o st e ro in fe rio r ca vit y
fra g m e n t . (Fro m Go ss TP, Ow e n s BD. Fra ct u re s
o f t h e sca p u la : Dia g n o sis a n d t re a t m e n t . In :
Ia n n o t t i JP, Willia m s GR, e d s. Diso rd e rs o f t h e
Sh o u ld e r: Dia g n o sis a n d Ma n a g e m e n t , 2n d e d .
Ph ila d e lp h ia : Lip p in co t t Willia m s & Wilkin s,
2007:793–840.)
Approach
■ The posterior approach is used for fractures of the posterior
glenoid rim and most fractures of the glenoid fossa.
■ The superior approach is used, in conjunction with a poste-
rior approach, for fractures of the glenoid fossa with a difficult-
to-control superior fragment.
■ The anterior approach is used for fractures of the anterior
glenoid rim and some fractures involving the superior aspect
of the glenoid fossa.
■ Th e in t e rva l b e t w e e n in fra sp in a t u s a n d t e re s m in o r is
d e ve lo p e d (TECH FIG 1 C). To g a in a cce ss t o t h e g le n o id
fo ssa , t h e in fra sp in a t u s t e n d o n a n d u n d e rlyin g p o st e rio r
g le n o h u m e ra l jo in t ca p su le a re in cise d 2 cm la t e ra l t o
t h e ir in se rt io n o n t h e g re a t e r t u b e ro sit y a n d re fle ct e d
p o st e rio rly (TECH FIG 1 D).
■ Su b p e rio st e a l m o b iliza t io n o f t h e t e re s m in o r m u scle
a llo w s a cce ss t o t h e la t e ra l sca p u la r b o rd e r.
 Ch a p t e r 2 5 OPEN REDUCTION AND INTERNAL FIXATION OF INTRA-ARTICULAR SCAPULAR FRACTURES 215

TECHNIQUES
A B C

TECH FIG 1 • A. Po st e rio r a p p ro a ch u sin g a skin in cisio n a lo n g t h e sca p u la r

sp in e a n d a cro m io n . B. Th e p o st e rio r a n d p o st e ro m e d ia l h e a d s o f t h e d e lt o id
a re d e t a ch e d fro m t h e sca p u la r sp in e a n d a cro m ia l p ro ce ss. C. In t e rva l d e ve l-
o p e d b e t w e e n t h e in fra sp in a t u s a n d t e re s m in o r. D. Th e in fra sp in a t u s t e n d o n
a n d u n d e rlyin g p o st e rio r g le n o h u m e ra l ca p su le a re in cise d 2 cm fro m in se rt io n
o n t h e g re a t e r t u b e ro sit y t o a llo w a cce ss t o t h e g le n o h u m e ra l jo in t . (Fro m
Go ss TP. Gle n o id fra ct u re s: o p e n re d u ct io n a n d in t e rn a l fixa t io n . In Wiss
DA, e d . Ma st e r Te ch n iq u e s in Ort h o p a e d ic Su rg e ry: Fra ct u re s. Ph ila d e lp h ia :
D Lip p in co t t –Ra ve n , 1998.)

SUPERIOR APPROACH TO THE GLENOID CAVITY

■ Th e su p e rio r a p p ro a ch t o t h e g le n o id ca vit y is m a d e b y
e xt e n d in g t h e p o st e rio r in cisio n su p e rio rly.
■ Th e t ra p e ziu s a n d u n d e rlyin g su p ra sp in a t u s m u scle s a re
sp lit in t h e lin e o f t h e ir fib e rs (TECH FIG 2 ).

TECH FIG 2 • Su p e rio r a p p ro a ch . Th e t ra p e ziu s a n d u n d e rly-

in g su p ra sp in a t u s m u scle s a re sp lit in lin e w it h t h e ir fib e rs.
(Fro m Go ss TP. Gle n o id fra ct u re s: o p e n re d u ct io n a n d in t e rn a l
fixa t io n . In Wiss DA, e d . Ma st e r Te ch n iq u e s in Ort h o p a e d ic
Su rg e ry: Fra ct u re s. Ph ila d e lp h ia : Lip p in co t t –Ra ve n , 1998.)

ANTERIOR APPROACH TO THE GLENOID CAVITY

■ Th e in cisio n is m a d e in La n g e r’s lin e s a n d ce n t e re d o ve r
t h e g le n o h u m e ra l jo in t fro m t h e su p e rio r t o in fe rio r
le ve l o f t h e h u m e ra l h e a d (TECH FIG 3 A).
■ Th e d e lt o id m u scle is sp lit in t h e lin e o f it s fib e rs o ve r t h e
p a lp a b le co ra co id p ro ce ss a n d re t ra ct e d m e d ia lly a n d
la t e ra lly.
■ Th e co n jo in e d t e n d o n is re t ra ct e d m e d ia lly a ft e r d ivi-
sio n o f t h e o ve rlyin g fa scia a lo n g it s m e d ia l b o rd e r
(TECH FIG 3 B).
■ Ca re m u st b e t a ke n t o p ro t e ct a ll n e uro va scu la r st ru ct u re s
fro m in ju ry.
■ In cise t h e su b sca p u la ris t e n d o n ve rt ica lly 2.5 cm m e d ia l
t o it s in se rt io n o n t h e le sse r t u b e ro sit y a n d a lo n g it s
su p e rio r a n d in fe rio r b o rd e rs.
■ Disse ct it o ff t h e u n d e rlyin g a n t e rio r g le n o h u m e ra l
ca p su le .
■ Ta g t h e co rn e rs o f t h e su b sca p u la ris u n it a n d t u rn it b a ck
m e d ia lly (TECH FIG 3 C).
■ In cise t h e a n t e rio r g le n o h u m e ra l ca p su le in t h e sa m e
fa sh io n , t a g it s co rn e rs, a n d t u rn it b a ck m e d ia lly t o g a in
a cce ss t o t h e g le n o h u m e ra l jo in t .
 216 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

A B C

TECH FIG 3 • A. An t e rio r a p p ro a ch u sin g a skin in cisio n m a d e in La n g e r’s lin e s a n d ce n t e re d o ve r t h e g le n o h u m e ra l

jo in t . B. Th e co n jo in e d t e n d o n is re t ra ct e d m e d ia lly. C. In cise t h e su b sca p u la ris t e n d o n 2 cm fro m it s in se rt io n o n t h e
le sse r t u b e ro sit y, d isse ct it o ff t h e g le n o h u m e ra l ca p su le , in cise t h e ca p su le sim ila rly, a n d t u rn b o t h o f t h e m b a ck
m e d ia lly t o g a in a cce ss t o t h e g le n o h u m e ra l jo in t . (Fro m Go ss TP. Op e n re d u ct io n a n d in t e rn a l fixa t io n o f g le n o id
fra ct u re s. In : Cra ig EV, e d . Ma st e r Te ch n iq u e s in Ort h o p a e d ic Su rg e ry: Th e Sh o u ld e r, 2n d e d . Ph ila d e lp h ia : Lip p in co t t
Willia m s & Wilkin s, 2004.)

FIXATION TECHNIQUES
■ Th e fra ct u re is re d u ce d a s a n a t o m ica lly a s p o ssib le .
■ Te m p o ra ry fixa t io n m a y b e o b t a in e d w it h K-w ire s.
■ Rig id fixa t io n m a y b e o b t a in e d w it h a co n t o u re d re co n -
st ru ct io n p la t e a n d 3.5-m m co rt ica l scre w s o r w it h ca n n u -
la t e d in t e rfra g m e n t a ry co m p re ssio n scre w s, d e p e n d in g
o n t h e ch a ra ct e rist ics o f t h e fra ct u re .
■ Ca re m u st b e t a ke n t o a vo id vio la t in g t h e g le n o id fo ssa
w it h a n y scre w s p la ce d in t h e g le n o id fra g m e n t (TECH
FIG 4 A,B).
■ If se ve re co m m in u t io n is p re se n t , a n ilia c cre st t rico rt ica l
b o n e g ra ft is a n o p t io n (TECH FIG 4 C).
■ All so ft t issu es d ivid ed to g a in access t o th e fra ctu re sit e
m u st b e met icu lo u sly rep aire d . With p o sterio r ap p ro ach es,
t h e d elto id mu st b e secu rely re att ach ed t o t h e acro mio n
a n d sca pula r sp in e w it h p e rm a n e n t sut ure s th ro ug h d rill
h oles.

A B

TECH FIG 4 • A. Po st o p e ra t ive AP im a g e o f t h e p a t ie n t sh o w n in Te ch Fig 1. B. Axilla ry ra d io g ra p h

sh o w in g t h e g le n o id ca vit y fra g m e n t s se cu re d t o g e t h e r w it h ca n n u la t e d scre w s a n d t h e g le n o id u n it
se cu re d t o t h e sca p u la r b o d y w it h a m a lle a b le re co n st ru ct io n p la t e (t h e a cro m ia l fra ct u re w a s re d u ce d
a n d st a b ilize d w it h a t e n sio n b a n d co n st ru ct ). (co n t in u e d )
 Ch a p t e r 2 5 OPEN REDUCTION AND INTERNAL FIXATION OF INTRA-ARTICULAR SCAPULAR FRACTURES 217

TECHNIQUES
TECH FIG 4 • (co n t in u e d ) C. If se ve re
co m m in u t io n is p re se n t , a n ilia c cre st
t rico rt ica l b o n e g ra ft is a n o p t io n .
(A,B: Fro m Go ss TP, Ow e n s BD. Fra c-
t u re s o f t h e sca p u la : d ia g n o sis a n d
t re a t m e n t . In : Ia n n o t t i JP, Willia m s
GR, e d s. Diso rd e rs o f t h e Sh o u ld e r:
Dia g n o sis a n d Ma n a g e m e n t , 2n d e d .
Ph ila d e lp h ia : Lip p in co t t Willia m s &
C Wilkin s, 2007:793–840.)

PEARLS AND PITFALLS

In d ica t io n s ■ Rim fra ct u re s: 25% o r m o re o f t h e g le n o id ca vit y a n t e rio rly o r 33% o r m o re o f t h e g le n o id ca vit y p o st e rio rly
a n d d isp la ce m e n t o f t h e fra g m e n t 10 m m o r m o re
■ Fo ssa fra ct u re s: a n a rt icu la r st e p -o ff o f 5 m m o r m o re , sig n ifica n t se p a ra t io n o f t h e fra ct u re fra g m e n t s, o r
fa ilu re o f t h e h u m e ra l h e a d t o lie in t h e ce n t e r o f t h e g le n o id ca vit y
Ap p ro a ch ■ In cisin g t h e ro t a t o r in t e rva l a n d le a vin g t h e su b sca p u la ris u n it in t a ct m a y a llo w a d e q u a t e e xp o su re fo r in ju rie s
in vo lvin g a d isp la ce d su p e rio r g le n o id fra g m e n t .
■ So m e in ju rie s re q u ire co m b in e d a n t e ro p o st e rio r o r p o st e ro su p e rio r a p p ro a ch e s.
■ De lt o id d e t a ch m e n t a n d re t ra ct io n p ro vid e m a xim a l p o st e rio r e xp o su re a n d a cce ss.
■ Du rin g t h e p o st e rio r a p p ro a ch , d e ve lo p t h e in t e rn e rvo u s p la n e in b e t w e e n t h e in fra sp in a t u s (a b ip e n n a t e
m u scle ) su p e rio rly a n d t h e t e re s m in o r in fe rio rly.
Re d u ct io n ■ K-w ire s ca n b e p la ce d t o se rve a s “ jo yst icks” t o a ssist w it h fra ct u re re d u ct io n . Th e y a lso ca n b e d rive n a cro ss
t h e fra ct u re sit e t o p ro vid e t e m p o ra ry o r p e rm a n e n t fixa t io n .
Fixa t io n ■ Bo n e st o ck ca p a b le o f a llo w in g in t e rn a l fixa t io n is a t a p re m iu m in t h e sca p u la . Th e fo u r sa t isfa ct o ry a re a s
in clu d e t h e g le n o id n e ck, t h e a cro m io n –sca p u la r sp in e , t h e la t e ra l sca p u la r b o rd e r, a n d t h e co ra co id p ro ce ss.
Re co n st ru ct io n p la t e s m a y b e p re -co n t o u re d u sin g a sca p u la m o d e l a n d fla sh -st e rilize d . If se ve re co m m in u t io n
is p re se n t , a n ilia c cre st t rico rt ica l b o n e g ra ft is a n o p t io n . Ca n n u la t e d in t e rfra g m e n t a ry scre w s ca n b e in se rt e d
u sin g p re vio u sly p la ce d K-w ire s a s g u id e w ire s.
Clo su re ■ If t h e d e lt o id m u scle is d e t a ch e d , m e t icu lo u s re p a ir t o t h e sca p u la r sp in e –a cro m ia l p ro ce ss is n e ce ssa ry u sin g
n o n a b so rb a b le su t u re s p la ce d t h ro u g h d rill h o le s.

POSTOPERATIVE CARE
■ The aggressiveness of the rehabilitation program following
O RIF of intra-articular scapular fractures is determined by the
rigidity of the fixation construct and the adequacy of the soft
tissue repair.4
■ Patients are immobilized in a sling and swathe binder and
started on gentle pendulum exercises during the first 2 weeks.
■ Progressive passive and active-assisted range-of-motion exer-
cises emphasizing forward flexion and internal–external rotation
are prescribed during weeks 2 through 6 postoperatively.
218 Se c t i o n II SHOULDER AND ELBOW
■ All protection is discontinued at 6 weeks postoperatively.
■ Strengthening is begun after 6 weeks postoperatively and
when range of motion is satisfactory.
■ Return to sports or physical labor is restricted until 3 to
6 months postoperatively.
■ Close outpatient follow-up with radiographs, especially early
in recovery, and a well-defined, closely monitored physical
therapy program are extremely important.
OUTCOMES
■ Good results have been reported for the operative manage-
ment of glenoid rim fractures.9,12
■ Bauer et al1 reviewed six patients treated surgically for gle-
noid cavity fractures. Four patients with an anatomic reduction
had good results; two patients with nonanatomic reductions
developed arthritic changes.
■ Kavanaugh and colleagues7 presented their experience at the
M ayo Clinic in which 10 displaced intra-articular fractures of
the glenoid cavity were treated with O RIF. They found O RIF
to be “ a useful and safe technique” that “ can restore excellent
function of the shoulder.” In their series, the major articular
fragments were displaced 4 to 8 mm.
■ Schandelmaier and coauthors11 reported a series of 22 frac-
tures of the glenoid fossa treated with O RIF with good results.
■ Leung and colleagues8 reviewed 14 displaced intra-articular
fractures of the glenoid treated with O RIF (30.5-year average
follow-up) and reported 9 excellent and 5 good results.
■ O n the basis of these reports, it seems reasonable to conclude
that there is a definite role for surgical management in the treat-
ment of glenoid cavity fractures.
COMPLICATION S
■ N eurologic complications most commonly are caused by
overly aggressive retraction or misdirected dissection.
■ The musculocutaneous and axillary nerves are vulnerable
in the anterior approach.
■ The suprascapular nerve is at risk in the superior approach,
and the axillary and suprascapular nerves are vulnerable in
the posterior approach.10
■ A variety of other complications can occur as a result of
poor surgical technique, inadequately directed or managed
rehabilitation, and poor patient compliance.
REFEREN CES
1. Bauer G, Fleischmann W, DuBler E. Displaced scapular fractures:
Indication and long term results of open reduction and internal fixa-
tion. Arch O rthop Trauma Surg 1995;14:215.
2. DePalma AF. Surgery of the Shoulder, 3rd ed. Philadelphia: JB
Lippincott, 1983.
3. Goss TP. Fractures of the glenoid cavity. J Bone Joint Surg Am 1992;
74:299–305.
4. Goss TP. Glenoid fractures—open reduction and internal fixation. In
Wiss DA, ed: M aster Techniques in O rthopaedic Surgery: Fractures.
Philadelphia: Lippincott-Raven, 1998.
5. Goss TP. Scapular fractures and dislocation: diagnosis and treatment.
J Am Acad O rthop Surg 1995;25:106.
6. Goss TP, Owens BD. Fractures of the scapula: Diagnosis and treat-
ment. In: Iannotti JP, Williams GR, eds. Disorders of the Shoulder:
Diagnosis and M anagement, 2nd ed. Philadelphia: Lippincott Williams
& Wilkins, 2007:793–840.
7. Kavanagh BF, Bradway JK, Cofield RH . O pen reduction of displaced
intra-articular fractures of the glenoid fossa. J Bone Joint Surg Am
1993;75A:479.
8. Leung KS, Lam TB, Poon KM . O perative treatment of displaced
intra-articular glenoid fractures. Injury 1993;24:324.
9. N iggebrugge AH P, van H eusden H A, Bode PJ, van Vugt AB.
Dislocated intra-articular fracture of the anterior rim of glenoid
treated by open reduction and internal fixation. Injury 1993;24:130.
10. O wens BD, Goss TP. Surgical approaches for glenoid fractures. Tech
Shoulder Elbow Surg 2004;5:103–115.
11. Schandelmaier P, Blauth M , Schneider C, Krethek C. Fractures of the
glenoid treated by operation. A 5- to 23-year follow-up of 22 cases.
J Bone Joint Surg Br 2002;84B:173–177.
12. Sinha J, M iller AJ. Fixation of fractures of the glenoid rim. Injury
1992;23:418.

Ch a p t e r 26
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Distal humerus fractures occur in two age groups:
■ Younger patients who sustain high-energy trauma
■ O lder patients with underlying osteopenia
■ Comminution is the dominant feature of supracondylar and
intercondylar fractures and complicates internal fixation.
■ The goals of the initial evaluation are to:
■ Understand the fracture pattern.
■ Determine the existence of previous symptomatic elbow
pathology.
■ Determine the extent of associated soft tissue (open
fractures).
■ Identify associated musculoskeletal or neurovascular
injuries.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Elbow radiographs in the anteroposterior and lateral planes
are the first imaging studies obtained and should be carefully
scrutinized to identify the fracture lines and fragments as well
as the extent of comminution.
■ A complete understanding of the fracture pattern is diffi-
cult to obtain based only on simple radiographs because of
the complex geometry of the distal humerus and fragment
overlapping (FIG 1 A,B).
■ CT with three-dimensional reconstruction is extremely help-
ful, especially in the more complex cases. It allows the surgeon
to look for specific fractured fragments at the time of fixation,
facilitating accurate fracture reduction (FIG 1 C,D).
A B
FIG 1 • A,B. AP a n d la t e ra l ra d io g ra p h s sh o w in g a co m m in u t e d in t ra -a rt icu la r su p ra in t e rco n d yla r fra ct u re o f t h e d ist a l h u m e ru s. Th e
co m p le xit y o f t h e fra ct u re is d ifficu lt t o a p p re cia t e fu lly b e ca u se o f t h e g e o m e t ry o f t h e d ist a l h u m e ru s, fra ct u re co m m in u t io n , a n d
fra g m e n t o ve rla p p in g . C,D. Th e u se o f CT w it h t h re e -d im e n sio n a l re co n st ru ct io n a n d su rfa ce re n d e rin g h e lp s u n d e rst a n d t h e fra ct u re
co n fig u ra t io n a n d a n t icip a t e t h e su rg ica l fin d in g s.
Op e n Re d u ct io n a n d In t e r n a l
Fix a t io n o f Su p r a co n d y la r
a n d In t e rco n d y la r Dis t a l
Hu m e r u s Fr a ct u re s
Jo aq u in San ch e z -So t e lo
■ Traction radiographs obtained in the operating room with
the patient under anesthesia just before surgery also can be
helpful, especially if a CT scan is not available.
SURGICAL MAN AGEMEN T
■ Internal fixation is the treatment of choice for most frac-
tures of the distal humerus.
■ M odern fixation techniques seem to benefit from:
■ Fixation strategies designed to improve the mechanical
stability of the construct
■ Use of precontoured periarticular plates
■ Use of screws locked to the plates
■ Elbow arthroplasty should be considered in elderly patients
with previous elbow pathology or in very low, comminuted
fractures in patients with osteopenia.
■ The goal of the internal fixation technique is to achieve
a construct stable enough to allow immediate unprotected
motion without fear of redisplacement. 12 This can be attained
in most distal humerus fractures—even the most complex—
provided the following principles are adhered to (FIG 2 ):
■ Plates used for internal fixation are applied so that
fixation in the distal fragments is maximized.
■ Distal screw fixation contributes to stability at the
supracondylar level, where true interfragmentary compres-
sion is achieved.
Approaches
■ Adequate exposure is necessary to achieve satisfactory re-
duction and fixation.
■ Subcutaneous transposition of the ulnar nerve is associated
with a decreased incidence of postoperative ulnar neuropathy.
C D
219
 220 Se c t i o n II SHOULDER AND ELBOW
■ Triceps reflection and triceps split 8 allow preservation of the
intact ulna.
A B
FIG 2 • A. In t e rn a l fixa t io n u sin g t w o p a ra lle l m e d ia l a n d la t e ra l
p la t e s a llo w s m a xim a l fixa t io n o f t h e p la t e s in t h e d ist a l fra g -
m e n t s a n d in cre a se d st a b ilit y a t t h e su p ra co n d yla r le ve l. B. Th is
■ Bilaterotricipital approach 1
p o st o p e ra t ive AP ra d io g ra p h sh o w s a n a t o m ic re d u ct io n o f a
co m p le x d ist a l h u m e ru s fra ct u re a n d st a b le fixa t io n u sin g t h e
p rincip le s a n d t e ch niq u e d e scrib e d in t h is ch a p t e r. Th e o le cra -
n o n o st e o t o m y w a s fixe d w it h a p la t e . (A: Co p yrig h t Ma yo .)
■ M ost fractures require mobilization of the extensor mecha-
nism of the elbow through an olecranon osteotomy, triceps re-
flection, or triceps split.
■ Simple fractures occasionally may be addressed working on
both sides of the triceps without mobilization of the extensor
mechanism.
■ O lecranon osteotomy is the preferred surgical approach for
internal fixation for most distal humerus fractures.11
■ Advantages
■ Provides excellent exposure
TECHNIQUES
SURGICAL APPROACH
Ole cra n o n Ost e o t o m y
■ Ch e vro n o st e o t o m y p ro vid e s in cre a se d st a b ilit y (TECH
FIG 1 A).
■ Th e d ist a l a p e x o f t h e ch e vro n o st e o t o m y is ce n t e re d
w it h t h e b a re a re a o f t h e o le cra n o n a rt icu la r su rfa ce .
■ Th e a n co n e u s is d ivid e d w it h e le ct ro ca u t e ry in lin e w it h
t h e la t e ra l lim b o f t h e o st e o t o m y.
■ Alt e rn a t ive ly, t h e a n co n e u s m a y b e p re se rve d b y d is-
se ct in g it fre e o n it s d ist a l a sp e ct a n d re fle ct in g it
p ro xim a lly a t t a ch e d t o t h e p ro xim a l u ln a r fra g m e n t . 2
■ St a rt t h e o st e o t o m y w it h a t h in o scilla t in g sa w .
■ Co m p le t e t h e o st e o t o m y w it h a n o st e o t o m e .
■ De cre a se s risk o f d a m a g e t o t h e a rt icu la r ca rt ila g e o n
u ln a a n d h u m e ru s
■ Cre a t e s irre g u la rit ie s a t t h e o p p o sin g cu t su rfa ce s,
w h ich m a y in cre a se in t e rd ig it a t io n
■ Mo b ilize t h e fra g m e n t t o fa cilit a t e e xp o su re (TECH
FIG 1 B).
■ Fixa t io n (TECH FIG 1 C)
■O ffers the potential of bone-to-bone healing, thereby
limiting the risk of triceps dysfunction
■ Disadvantages
■ Complications: nonunion, intra-articular adhesions
■ H ardware removal may be needed.
■ Limits the ability for intraoperative conversion to
elbow arthroplasty
■ M ay devitalize the anconeus muscle
■ The proximal ulna cannot be used as a template to
judge reduction and motion.
■ Avoids complications related to olecranon osteotomy
■ Facilitates intraoperative conversion to total elbow
arthroplasty
■ Allows use of the proximal ulna as a template for reduc-
tion of the distal humerus articular surface
■ Allows assessment of extension deficit after fracture fixa-
tion, which is especially useful in fractures requiring meta-
physeal shortening
■ Goals and indications
■ The goal is to provide adequate exposure for fracture
fixation without violating the extensor mechanism.
■ This approach is used only for the more simple fracture
patterns (eg, extra-articular or simple intra-articular distal
humerus fractures [AO /O TA A, C1, C2]) or when elbow
arthroplasty is being considered.
■ Advantages
■ This approach avoids complications related to the ex-
tensor mechanism.
■ N o postoperative protection is needed.
■ Surgical time is decreased.
■ Disadvantage
■ The procedure provides limited exposure of the articu-
lar surface.
■ So m e b io m e ch a n ica l st u d ie s su p p o rt t h e co m b in a t io n
o f a 7.3-m m ca n ce llo u s scre w a n d t e n sio n b a n d o ve r
e it h e r a scre w a lo n e o r K-w ire s p lu s t e n sio n b a n d ;
o t h e rs h a ve fo u n d n o d iffe re n ce s.
■ Th e a u t h o r’s p re fe rre d m e t h o d u se s K-w ire s p lu s a
t e n sio n b a n d .
■ If scre w fixa t io n is p la n n e d , d rill a n d t a p t h e u ln a
b e fo re p e rfo rm in g t h e o st e o t o m y.
■ Pla t e fixa t io n is p re fe rre d b y so m e .
■ It p ro vid e s im p ro ve d fixa t io n , b u t t h e risk o f
w o u n d co m p lica t io n s is in cre a se d .
Trice p s Re fle ct io n a n d Trice p s Sp lit
■ Brya n -Mo rre y t rice p s-sp a rin g a p p ro a ch (TECH FIG 2 )
■ Th e t rice p s is e le va t e d fro m t h e m e d ia l in t e rm u scu la r
se p t u m .
■ Th e fo re a rm fa scia a n d p e rio st e u m a re in cise d ju st
la t e ra l t o t h e fle xo r ca rp i u ln a ris.
■ Th e t rice p s, fo re a rm fa scia , a n d a n co n e u s a re e le -
va t e d in co n t in u it y fro m m e d ia l t o la t e ra l.
 Ch a p t e r 2 6 ORIF OF SUPRACONDYLAR AND INTERCONDYLAR DISTAL HUM ERUS FRACTURES 221

TECHNIQUES
A B C

TECH FIG 1 • Olecranon oste ot omy p rovides a n excellent exp osure for dist al h ume rus fractu re fixa tion.
A. A ch e vro n o ste o t o my is in it iat ed w ith a m icro sa g itt al saw an d co m p let ed w it h an o st eo t o m e. Drillin g
a nd ta pp in g b e fo re p e rforming t he o st eo t o m y fa cilita te s fixat io n of t h e o ste oto my if scre w fixa t io n is
se le ct e d . B. Proxim al mobiliza tion of th e ost eot om ized fragm ent a nd t riceps allow s am ple e xposure o f
t h e art icu lar su rfa ce an d co lu m n s. C. Fixa tio n ma y b e p e rfo rme d w ith a can cello u s screw a n d t en sio n
band , wire s a nd a te n sio n b a nd , or a p la te .

■ Th e a n t e rio r b u n d le o f t h e m e d ia l co lla t e ra l lig a m e n t ■ As n o t e d e a rlie r, t h e a n t e rio r b u n d le o f t h e m e d ia l

a n d t h e la t e ra l u ln a r co lla t e ra l lig a m e n t m u st b e p re - co lla t e ra l lig a m e n t a n d t h e la t e ra l u ln a r co lla t e ra l
se rve d t o a vo id p o st o p e ra t ive in st a b ilit y. lig a m e n t m u st b e p re se rve d t o a vo id p o st o p e ra t ive
■ Ma yo -m o d ifie d e xt e n sile Kö ch e r a p p ro a ch in st a b ilit y.
■ Th e t rice p s is e le va t e d fro m t h e la t e ra l in t e rm u scu la r
se p t u m . Bila t e ro t ricip it a l Ap p ro a ch
■ Th e t rice p s a n d a n co n e u s a re e le va t e d in co n t in u it y ■ Th e t rice p s is e le va t e d fro m t h e m e d ia l a n d la t e ra l in t e r-
fro m la t e ra l t o m e d ia l.
m u scu la r se p t a e .
■ La t e ra l d isse ct io n ca n b e e xt e n d e d a n t e rio r t o t h e a n -
co n e u s m u scle (TECH FIG 3 ).
■ Art h ro t o m y is p e rfo rm e d p o st e rio r t o t h e m e d ia l co lla t -
Flexor carpi e ra l lig a m e n t a n d la t e ra l co lla t e ra l lig a m e n t co m p le x.
Extensor carpi
ulnaris
ulnaris

Anconeus

Olecranon

Modified
Köcher Bryan-Morrey

Triceps

Lateral Medial

TECH FIG 2 • Th e e xt e n so r m e ch a n ism (ie , t rice p s, a n co n e u s,

a n d fo re a rm fa scia ) m a y b e e le va t e d o ff t h e u ln a su b p e - TECH FIG 3 • Fra ct u re s w it h n o o r lim it e d a rt icu la r in vo lve -
rio st e a lly in co n t in u it y fro m m e d ia l t o la t e ra l (Brya n -Mo rre y m e n t m a y b e fixe d w o rkin g o n b o t h sid e s o f t h e t rice p s. As
a p p ro a ch ) o r fro m la t e ra l t o m e d ia l (Ma yo -m o d ifie d e xt e n sile sh o w n in t h is im a g e , t h e e xt e n so r m e ch a n ism is le ft m o st ly
Kö ch e r a p p ro a ch ). u n d ist u rb e d .
 222 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

INTERNAL FIXATION
Te ch n ica l Ob je ct ive s
■ Scre w s in t h e d ist a l fra g m e n t s (a rt icu la r se g m e n t ) sh o u ld
b e p la ce d a cco rd in g t o t h e fo llo w in g p rin cip le s:
■ Eve ry scre w sh o u ld p a ss t h ro u g h a p la t e .
■ Ea ch scre w sh o u ld e n g a g e a fra g m e n t o n t h e o p p o -
sit e sid e t h a t a lso is fixe d t o a p la t e .
■ As m a n y scre w s a s p o ssib le sh o u ld b e p la ce d in t h e
d ist a l fra g m e n t s.
■ Ea ch scre w sh o u ld b e a s lo n g a s p o ssib le .
■ Ea ch scre w sh o u ld e n g a g e a s m a n y a rt icu la r fra g -
m e n t s a s p o ssib le .
■ The screw s should lock tog et her b y inte rdig it at ion
wit hin t he dist al se gme nt , th ereby rigid ly linking t he
me d ia l a n d la t e ra l column s t og e the r, cre a t in g a n arch i-
te ct ura l st ru ct u re simila r t o t h a t o f an a rch o r d o me .
■ Pla t e s a re u se d fo r fixa t io n .
■ Pla t e s sh o u ld b e a p p lie d su ch t h a t co m p re ssio n is
a ch ie ve d a t t h e su p ra co n d yla r le ve l fo r b o t h co lu m n s.
■ Pla t e s m u st b e st ro n g e n o u g h a n d st iff e n o u g h t o re -
sist b re a kin g o r b e n d in g b e fo re u n io n o ccu rs a t t h e
su p ra co n d yla r le ve l.
Pro visio n a l Asse m b ly o f t h e Art icu la r
Su rfa ce a n d Pla t e Pla ce m e n t
■ Re d u ce t h e a rt icu la r su rfa ce fra g m e n t s a n a t o m ica lly.
■ Th e p ro xim a l u ln a a n d ra d ia l h e a d m a y b e u se d a s
t e m p la t e s.
■ Ro t a t io n a l a lig n m e n t sh o u ld b e ca re fu lly a sse sse d .
■ Use sm o o t h K-w ire s t o m a in t a in t h e re d u ct io n p ro visio n -
a lly (TECH FIG 4 A).
■ Tw o 2.0-m m sm oot h w ire s in troduced a t the m edial
and lat eral ep icondyle s facilit at e provisiona l pla ce-
men t o f th e plat es a n d ca n be re p laced b y screw s la te r.
■ Fin e -t h re a d e d w ire s o r a b so rb a b le p in s m a y b e u se d fo r
d e fin it ive fixa t io n o f sm a ll fra ct u re fra g m e n t s.
■ Me d ia l a n d la t e ra l p la t e s a re p la ce d so t h a t o n e o f t h e
d ist a l h o le s o f e a ch p la t e slid e s o ve r t h e m e d ia l a n d la t -
e ra l 2.0-m m sm o o t h w ire s in t ro d u ce d a t t h e m e d ia l a n d
la t e ra l e p ico n d yle s (TECH FIG 4 B).
■ On e co rt ica l scre w is lo o se ly in t ro d u ce d in t o a slo t t e d
h o le o f e a ch p la t e t o h o ld t h e p la t e s in p la ce ; u se o f slo t -
t e d h o le s fo r t h e se scre w s fa cilit a t e s la t e r a d ju st m e n t s in
p la t e p o sit io n in g .
Art icu la r a n d Dist a l Fixa t io n
■ Tw o o r m o re d ist a l scre w s a re in se rt e d t h ro u g h t h e
p la t e s m e d ia lly a n d la t e ra lly. As n o t e d , t h e scre w s sh o u ld
b e a s lo n g a s p o ssib le a n d e n g a g e t h e o p p o sit e co lu m n .
■ Be fo re scre w a p p lica t io n , a la rg e b o n e cla m p is u se d
t o co m p re ss t h e a rt icu la r fra ct u re lin e s, u n le ss t h e re is
co m m in u t io n o f t h e a rt icu la r su rfa ce .
■ Th e t w o 2.0-m m sm o o t h p in s m a y b e re p la ce d w it h d is-
t a l scre w s w it h o u t p re vio u s d rillin g , t o a vo id a ccid e n t a l
b re a ka g e o f t h e d rill w h e n co n t a ct in g t h e o t h e r scre w s.
Usu a lly, t h e se la st scre w s w ill in t e rd ig it a t e w it h t h e p re -
vio u sly a p p lie d d ist a l scre w s, t h e re b y in cre a sin g t h e st a -
b ilit y o f t h e co n st ru ct (TECH FIG 5 ).
Su p ra co n d yla r Co m p re ssio n a n d
Pro xim a l Pla t e Fixa t io n
■ Th e p ro xim a l scre w o n o n e sid e is b a cke d o u t , a n d a
la rg e b o n e cla m p is a p p lie d d ist a lly o n t h a t sid e a n d
p ro xim a lly o n t h e o p p o sit e sid e t o a p p ly m a xim u m co m -
p re ssio n a t t h e su p ra co n d yla r le ve l. Co m p re ssio n is
m a in t a in e d b y a p p lica t io n o f o n e p ro xim a l scre w in t h e
co m p re ssio n m o d e (TECH FIG 6 A,B).
■ Th e sa m e st e p s a re fo llo w e d o n t h e o p p o sit e sid e .

A B

TECH FIG 4 • A. An a t o m ic re d u ct io n o f t h e a rt icu la r su rfa ce is m a in t a in e d p ro visio n a lly w it h fin e w ire s p la ce d so t h a t t h e y w ill

n o t in t e rfe re w it h p la t e a n d scre w a p p lica t io n . B. Th e m e d ia l a n d la t e ra l p la t e s a re h e ld in p la ce p ro visio n a lly w it h t w o d ist a l
2.0-m m p in s (w h ich la t e r w ill b e re p la ce d b y scre w s) a n d t w o p ro xim a l scre w s t h ro u g h a n o va l h o le t o a llo w sm a ll a d ju st m e n t s
in p la t e p o sit io n in g . (Co p yrig h t Ma yo .)
 Ch a p t e r 2 6 ORIF OF SUPRACONDYLAR AND INTERCONDYLAR DISTAL HUM ERUS FRACTURES 223

■ Th e re m a in in g d ia p h yse a l scre w s a re t h e n in t ro d u ce d ,

TECHNIQUES
p ro vid in g a d d it io n a l co m p re ssio n a s t h e y p u sh t h e u n -
d e rco n t o u re d p la t e s t o g a in in t im a t e co n t a ct w it h t h e
u n d e rlyin g b o n e (TECH FIG 6 C,D).
■ Sm a ll p o st e rio r fra g m e n t s ca n b e fixe d w it h t h re a d e d
w ire s o r a b so rb a b le p in s.
■ Pro visio n a l w ire s a re re m o ve d .
■ Th e e lb o w is p u t t h ro u g h ra n g e o f m o t io n . Mo t io n
sh o u ld b e sm o o t h . If e xt e n sio n is lim it e d , t h e t ip o f t h e
o le cra n o n m a y b e re m o ve d .

TECH FIG 5 • Ma xim a l d ist a l p la t e a n ch o ra g e is t h e n

a ch ie ve d b y in se rt io n o f m u lt ip le lo n g scre w s t h ro u g h t h e
p la t e s a n d in t o t h e d ist a l fra g m e n t s. Usu a lly t h e scre w s fro m
t h e m e d ia l a n d la t e ra l d ire ct io n s w ill e n g a g e , cre a t in g a n in -
t e rlo cke d st ru ct u re t h a t in cre a se s fra ct u re st a b ilit y.
(Co p yrig h t Ma yo .)

TECH FIG 6 • A,B. Su p ra co n d yla r

co m p re ssio n is a ch ie ve d w it h t h e u se
o f a la rg e cla m p , in se rt io n o f scre w s
in t h e co m p re ssio n m o d e , a n d slig h t
u n d e rco n t o u rin g o f t h e p la t e s. Th e
sa m e t e ch n iq u e is a p p lie d la t e ra lly
a n d m e d ia lly. C. In t e rn a l fixa t io n o f
a co m p le x d ist a l h u m e ru s fra ct u re .
(A,B: Co p yrig h t Ma yo .) B C

SUPRACONDYLAR SHORTENING
■ In ca se s w it h su p ra co n d yla r co m m in u t io n (ie , b o n e lo ss),
co m p re ssio n a t t h e su p ra co n d yla r le ve l ca n n o t b e
a ch ie ve d u n le ss t h e h u m e ru s is sh o rt e n e d in t o a n o n -
a n a t o m ic re d u ct io n t h a t w ill p ro vid e a d e q u a t e b o n e
co n t a ct (TECH FIG 7 A,B).
■ Th e h u m e ru s m a y b e sh o rt e n e d b e t w e e n a fe w m il-
lim e t e rs a n d 2 cm w it h o n ly m in o r lo sse s in e xt e n sio n
st re n g t h .9
■ Bo n e is t rim m e d fro m t h e d ia p h ysis t o e n su re a d e q u a t e
b o n e co n t a ct w it h t h e d ist a l fra g m e n t s.
■ Th e d ist a l fra g m e n t s a re t ra n sla t e d p ro xim a lly a n d a n t e -
rio rly. An t e rio r t ra n sla t io n is n e ce ssa ry t o cre a t e ro o m
fo r t h e ra d ia l h e a d a n d t h e co ro n o id in fle xio n .
■ Th e fra ct u re is fixe d in t h e d e sire d p o sit io n u sin g t h e
t e ch n iq u e d e scrib e d p re vio u sly.
■ A n e w d e e p a n d w id e o le cra n o n fo ssa is cre a t e d b y re -
m o vin g b o n e fro m t h e d ist a l a n d p o st e rio r a sp e ct o f t h e
d ia p h ysis (TECH FIG 7 C). Ot h e rw ise , e xt e n sio n w ill b e
re st rict e d .
 224 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

A B C

TECH FIG 7 • In cases of severe supracondylar comminut ion, adequate interfragmentary cont act and com-
pression takes priority over anatomic reduction. The hum erus may be shortened anywhere from a few
millime te rs to 2 cm by trim min g th e bo ny spikes o f the dia p hysis (A), advancing t he distal segment prox-
imally an d ant erio rly, an d fixing it in a n on an ato mic fash io n (B). C. The olecranon fossa is recreated in this
ca se b y re mo vin g b o n e fro m th e po st e rio r a sp e ct o f th e d ia p hysis w ith a bu rr. (A,B: Cop yrig ht Mayo .)

PEARLS AND PITFALLS

Ole cra n o n o st e o t o m y
Trice p s re fle ct io n a n d
t rice p s sp lit
Bila t e ro t ricip it a l a p p ro a ch
■ Po sit io n t h e a p e x o f t h e o st e o t o m y d ist a lly.
■ Use a t h in o scilla t in g sa w t o m in im ize b o n e lo ss.
■ If p la t e fixa t io n is p re fe rre d , co n sid e r d rillin g t h e h o le s fo r t h e p la t e b e fo re b e g in n in g t h e
o st e o t o m y. Th is fa cilit a t e s p la t e fixa t io n o f t h e o st e o t o m y a t t h e co n clu sio n o f t h e su rg e ry.
■ Similarly, if t en sio n b an d fixa tio n w it h a n in t ram ed u llary scre w is p referred , p red rill t h e scre w h o le.
■ Su b p e rio st e a l d e t a ch m e n t o f t h e e xt e n so r m e ch a n ism is crit ica l t o p re se rve it s t h ickn e ss a n d
fa cilit a t e a st ro n g re a t t a ch m e n t .
■ Re p ro d u ce a n a t o m ic re a t t a ch m e n t o f t h e e xt e n so r m e ch a n ism .
■ Use h e a vy n o n a b so rb a b le su t u re (n o . 5 Et h ib o n d [Et h ico n , In c., So m e rville , NJ] o r n o . Fib e rWire
[Art h re x, In c., Na p le s, FL]) t h ro u g h b o n e .
■ Pro t e ct e xt e n sio n a g a in st re sist a n ce fo r 6 w e e ks.
■ Se p a ra t e t h e t rice p s fro m t h e u n d e rlyin g m e d ia l a n d la t e ra l jo in t ca p su le s.
■ Re se ct t h e p o st e rio r ca p su le a n d fa t p a d t o im p ro ve visu a liza t io n .

POSTOPERATIVE MAN AGEMEN T OUTCOMES

■ After closure, the elbow is placed in a bulky noncompressive ■ The results of internal fixation for fractures of the distal
dressing with an anterior plaster splint to maintain the elbow humerus using modern techniques are summarized in Table 1.
in extension, and the upper extremity is kept elevated. ■ The results of the different studies are difficult to inter-

■ M otion is initiated according to the extent of soft tissue pret, because the severity of the injuries included cannot be
damage. M otion usually can be initiated on the first or second compared, and there may be variations in the accuracy of
postoperative day, but it may be necessary to wait for several range-of-motion measurements.
days in the case of open fractures or severe soft tissue damage. ■ Improvements in fixation techniques have resulted in a de-

■ M ost patients benefit from a program of continuous passive creased rate of hardware failure and nonunion, but range of
motion for the first week or two after fixation; some may ben- motion is not reliably restored in every patient.
efit from a longer period of passive motion.
■ When postoperative motion fails to progress as expected, a COMPLICATION S
program of patient-adjusted static flexion and extension ■ Infection
splints is implemented. ■ N onunion

■ Treatment with indomethacin or single-dose radiation to the ■ Stiffness, with or without heterotopic ossification

soft tissues shielding the fracture site may be considered for ■ N eed for removal of the hardware used for fixation of the

patients with high risk of heterotopic ossification, such as olecranon osteotomy

those with associated head or spinal trauma as well as those ■ Posttraumatic osteoarthritis or avascular necrosis requiring

who require several surgeries in a short period of time. interposition arthroplasty or elbow replacement
 Ta b le 1 Re s u lt s o f In t e r n a l Fix a t io n f o r Dis t a l Hu m e r u s Fr a ct u r e s Af f e ct in g t h e Hu m e r a l Co lu m n s

M e a n Ag e Fr a ct u r e Ty p e Me a n
(Ra n g e ) Fo llo w - (n o .) (AO De g r e e s Ov e r a ll
St u d y No . (y ) u p (m o ) Cla s s if ica t io n ) Op e n ROM (r a n g e ) r e s u lt s Co m p lica t io n s (n o .) Re o p e r a t io n s (n o .)
Jupiter et al5 34 57 (17–79) 70 (25–139) C1 (13) 14 (41%) 76% achieved at 79% satisfactory* Nonunion (2) Hardware removal (24)
C2 (2) least 30–120 Refracture (1) Capsulectomy (3)
C3 (19) Olecranon osteotomy nonunion (2) HO removal (1)
Class II HO (1) Nerve decompression (4)
Ulnar neuropathy (4)
Median neuropathy (1)
Henley et al4 33 32 (15–61) 18.3 C1 (23) 14 (42%) Mean extension, 19; 92% satisfactory* Hardware failure (5) Repeat ORIF (2)
C2 (8) mean flexion 126 (only 25 patients Infection (2) TBW removal (6)
C3 (2) evaluated) Olecranon osteotomy nonunion (2) Olecranon osteotomy repeat
Class II HO (2) ORIF (2)
Sanders et al14 17 51 (12–85) 24 C1 (4) 7 (41%) 108 (55–140) 76% satisfactory* Delayed union (2) Hardware removal (3)
C2 (3) Infection (2) Ulnar nerve decompression (1)
C3 (10) Pulmonary embolism (1)
Ulnar neuropathy (1)
McKee et al 25 47 (19–85) 37 (18–75) C (25) None 108 (55–140) Mean DASH: 20 Ulnar neuritis (3) TBW removal (3)
(closed (0–55) Transient radial nerve palsy (1) Repeat ORIF (1)
fractures)7 Nonunion (1) Elbow release (2)
Malunion (1)
McKee et al 26 44 (17–78) 51 (10–141) C1 (5) 100% 97 (55–140) Mean DASH 23.7 Septic nonunion (1) Repeat ORIF (3)
(open fractures)6 C2 (13) (0–57.5) Delayed union (4)
C3 (8) 60% satisfactory Transient radial nerve palsy (1)
MEPS
Pajarinen et al10 21 44 (16–81) 24 (10–41) C1 (6) 5 (24%) 107 (98–116) 56% satisfactory Deep infection (1) Repeat ORIF (2)
C2 (12) OTA Nonunion (2)
C3 (3) Traumatic nerve injuries (3)
Olecranon osteotomy nonunion (1)
Gofton et al3 23 53 (16–80) 45 (14–89) C1 (3) 7 (30%) 122 (extension loss Mean DASH: 12 Deep infection (1) Olecranon osteotomy repeat
C2 (11) 19 12, flexion (0–38) Olecranon osteotomy nonunion (2) ORIF (2)
C3 (9) 142 6) Subjective Class II HO (3) Elbow release (3)
satisfaction: 93% Avascular necrosis (1) Capitellar ORIF (1)
87% satisfactory Reflex sympathetic dystrophy (1)
MEPS Capitellar nonunion (1)
Soon et al15 15 43 (21–80) 12 (2–27) B (3) None 109 (45–145) 86% satisfactory Transient ulnar neuritis (2) Total elbow arthroplasty (1)
C1 (4) MEPS Hardware failure (3) Repeat ORIF (3)
C2 (4) Nonunion (1) Elbow manipulation or release (4)
C3 (4)
Sanchez-Sotelo 32 58 (16–99) 24 (12–60) A3 (3) 13 (44%) Mean extension: 83% satisfactory Delayed union (1) Wound débridement or coverage (4)
et al13 C2 (4) 26 (0–55) MEPS Ulnar neuropathy (6) Bone grafting (1)
C3 (25) Mean flexion: Class II HO (5) HO removal (4)
124 (80–150) Infection (1) HO removal and distraction
Ch a p t e r 2 6 ORIF OF SUPRACONDYLAR AND INTERCONDYLAR DISTAL HUM ERUS FRACTURES

arthroplasty (1)
Triceps reconstruction (1)

Class II HO, heterotopic ossification restricting motion; DASH, Disabilities of the Arm, Shoulder and Hand questionnaire; MEPS, Mayo Elbow Performance Score; ORIF, open reduction and internal fixation; OTA, Orthopedic Trauma Association rating;
225

ROM, range of motion; TBW, tension band wiring.

* According to the Jupiter rating system.
226 Se c t i o n II SHOULDER AND ELBOW
REFEREN CES
1. Alonso-Llames M . Bilaterotricipital approach to the elbow. Its appli-
cation in the osteosynthesis of supracondylar fractures of the
humerus in children. Acta O rthop Scand 1972;43:479–490.
2. Athwal GS, Rispoli DM , Steinmann SP. The anconeus flap transole-
cranon approach to the distal humerus. J O rthop Trauma 2006;20:
282–285.
3. Gofton WT, M acdermid JC, Patterson SD, et al. Functional outcome
of AO type C distal humeral fractures. J H and Surg Am 2003;28:
294–308.
4. H enley M B, Bone LB, Parker B. O perative management of intra-
articular fractures of the distal humerus. J O rthop Trauma 1987;
1:24–35.
5. Jupiter JB, N eff U, H olzach P, et al. Intercondylar fractures of the
humerus. An operative approach. J Bone Joint Surg Am 1985;67:
226–239.
6. M cKee M D, Kim J, Kebaish K, et al. Functional outcome after open
supracondylar fractures of the humerus. The effect of the surgical ap-
proach. J Bone Joint Surg Br 2000;82B:646–651.
7. McKee MD, Wilson TL, Winston L, et al. Functional outcome follow-
ing surgical treatment of intra-articular distal humeral fractures through
a posterior approach. J Bone Joint Surg Am 2000;82A:1701–1707.
8. M orrey BF. Anatomy and surgical approaches. In: M orrey BF, ed.
Joint Replacement Arthroplasty. Philadelphia: Churchill-Livingstone,
2003:269–285.
9. O ’Driscoll SW, Sanchez-Sotelo J, Torchia M E. M anagement of the
smashed distal humerus. O rthop Clin N orth Am 2002;33:19–33.
10. Pajarinen J, Bjorkenheim JM . O perative treatment of type C inter-
condylar fractures of the distal humerus: Results after a mean follow-
up of 2 years in a series of 18 patients. J Shoulder Elbow Surg
2002;11:48–52.
11. Ring D, Gulotta L, Chin K, et al. O lecranon osteotomy for exposure
of fractures and nonunions of the distal humerus. J O rthop Trauma
2004;18:446–449.
12. Sanchez-Sotelo J, Torchia M E, O ’Driscoll SW. Principle-based inter-
nal fixation of distal humerus fractures. Tech H and Upper Extremity
Surg 2001;5:179–187.
13. Sanchez-Sotelo J, Torchia M E, O ’Driscoll SW. Complex distal
humeral fractures: internal fixation with a principle-based parallel-
plate technique. J Bone Joint Surg Am 2007;89A:961–969.
14. Sanders RA, Raney EM , Pipkin S. O perative treatment of bicondylar
intraarticular fractures of the distal humerus. O rthopedics 1992;15:
159–163.
15. Soon JL, Chan BK, Low CO . Surgical fixation of intra-articular frac-
tures of the distal humerus in adults. Injury 2004;35:44–54.

Ch a p t e r 27
DEFIN ITION
■ Capitellar fractures are uncommon, accounting for less
than 1% of all elbow fractures and 6% of all distal humerus
fractures. 3
■ They often are associated with radial head fractures and
posterior elbow dislocations.
■ A classification system for capitellar fractures has been pro-
posed by Bryan and M orrey3 and modified by M cKee:
■ Type 1: complete fractures of the capitellum 11
■ Type 2: superficial subchondral fractures of the capitellar
articular surface22
■ Type 3: comminuted fractures2
■ Type 4: coronal shear fractures that include a portion of
the trochlea as well as the capitellum as one piece17 (FIG 1 )
■ Ring and Jupiter 21 have proposed a new classification, ex-
panding on the growing understanding that isolated capitellum
fractures are rare and often are involved as part of articular
shear fractures of the distal humerus. The classification in-
cludes five anatomic components:
■ The capitellum and lateral aspect of the trochlea
■ The lateral epicondyle
■ The posterior aspect of the lateral column
■ The posterior aspect of the trochlea
■ The medial epicondyle
FIG 1 • Typ e 4 co ro n a l sh e a r fra ct u re s o f t h e d ist a l h u m e ru s.
(Ad a p t e d fro m McKe e MD, Ju p it e r JB, Bo sse G, e t a l. Co ro n a l
sh e a r fra ct u re s o f t h e d ist a l e n d o f t h e h u m e ru s. J Bo n e Jo in t
Su rg Am 1996;78A:49–54.)
Op e n Re d u ct io n a n d In t e r n a l
Fix a t io n o f Ca p it e llu m a n d
Ca p it e lla r –Tro ch le a r Sh e a r
Fr a ct u re s
A sif M . Ilyas an d Je sse B. Ju p it e r
AN ATOMY
■ The two condyles of the distal humerus diverge from the
humeral shaft to form the lateral and medial columns, which
support the trochlea between them. The anterior aspect of the
lateral column is covered with articular cartilage, forming the
capitellum. Distally, these two condyles can be visualized as
forming a triangle at the end of the humerus.
■ The capitellum is the first epiphyseal center of the elbow to
ossify.
■ It is covered by articular surface anteriorly but devoid of it
posteriorly.
■ The capitellum is directed distally and anteriorly at an angle
of 30 degrees to the long axis of the humerus.
■ The radial head rotates on the anterior surface of the
capitellum in elbow flexion and articulates with its inferior
surface in elbow extension.
■ The lateral collateral ligament inserts next to the lateral
margin of the capitellum.
■ The blood supply of the capitellum is derived posteriorly. It
arises from the lateral arcade, which is the anastomosis of the
radial collateral arteries of the profunda brachii and the radial
recurrent artery.23
PATHOGEN ESIS
■ Capitellar fractures usually result from a fall on an out-
stretched hand or forearm as the radial head impacts the
capitellum on impact.
■ Capitellar–trochlear shear fractures involve impaction of the
radial head against the lateral column of the distal humerus in
a semi-extended position, resulting in a shearing mechanism of
the distal humerus.
■ Fracture fragments vary in size and displace superiorly and
anteriorly into the radial fossa, resulting in impingement with
elbow flexion.
N ATURAL HISTORY
■ Capitellar fractures occur almost exclusively in adults.
These fractures do not occur in children, because in that age
group the capitellum is largely cartilaginous, and a similar
mechanism of injury would instead cause a supracondylar or
lateral condyle fracture.
■ Capitellar fractures are more common in females, a finding
that has been attributed to the higher carrying angle of the
elbow.
■ Elderly patients of both genders are more susceptible to
capitellum and complex capitellar–trochlear shear fractures
because of the metabolic susceptibilities of osteoporosis.
■ Displaced fractures that go untreated can have a poor out-
come owing to progressive loss of motion and posttraumatic
arthrosis.
227
228 Se c t i o n II SHOULDER AND ELBOW
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Symptoms of capitellar fractures are similar to those of ra-
dial head fractures, including pain and swelling along the lat-
eral elbow and pain with elbow motion.
■ Although there may be variable loss of forearm rotation,
loss of flexion and extension is common, often accompanied
by crepitus and pain.
■ The association of concomitant radial head fractures and
ligamentous injuries with capitellar fractures is high.18
■ The shoulder and wrist should be examined for concomitant
injury.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Standard radiography is inadequate for accurate assessment
of capitellar fractures.
■ Lateral radiographs are best for obtaining an initial evalua-
tion of capitellar fractures.
■ Anteroposterior views do not reliably show the fracture,
because the outline of the distal humerus is not consistently
affected.
■ The radial head–capitellum view can help identify fractures of
the capitellum. This view is a lateral oblique projection taken
with the x-ray beam pointing 45 degrees dorsoventrally, thereby
eliminating the ulno- and radiohumeral articulation shadows.10
■ A type 1 fracture appears as a semilunar fragment sitting
superiorly with its articular surface pointing up and away
from the radial head in most cases.
■ Type 2 fractures are more difficult to diagnose, depending
on the amount of subchondral bone accompanying the ar-
ticular fragment. They may appear as a loose body lying in
the superior part of the joint.
■ Type 3 fractures display variable amounts of comminution.
■ Coronal shear fractures show a characteristic “ double
arc” sign on lateral radiographic views (FIG 2 A).
■ CT scans are necessary for delineating the fracture pattern
and should be performed in all cases.
■ CT scanning of the elbow should be done at 1- to 2-mm
intervals using axial or transverse cuts.
■ Three-dimensional (3D) CT reconstructions provide the best
detail and ability to appreciate the anatomic orientation of the
fracture patterns and should be ordered if 3D imaging is avail-
able (FIG 2 B,C).
A B
FIG 2 • A. Ch a ra ct e rist ic “ d o u b le a rc” sig n o n la t e ra l ra d io g ra p h s o f co ro n a l sh e a r fra ct u re s. B,C. 3D CT re co n -
st ru ct io n s o f a co ro n a l sh e a r fra ct u re o f t h e d ist a l h u m e ru s.
DIFFEREN TIAL DIAGN OSIS
■ Radial head fracture
■ Distal humeral lateral condyle fracture
■ Elbow dislocation
N ON OPERATIVE MAN AGEMEN T
■ Truly nondisplaced and isolated capitellum fractures can be
splinted for 3 weeks, followed by protected motion. We do not
advocate nonoperative management for any other type of
capitellum fracture.
■ Closed reduction techniques, which have been described in
the literature, should be performed with caution, and only
complete anatomic reduction should be accepted.4,19
■ Capitellar–trochlear shear fractures should not be treated
nonoperatively because of their inherent instability and articu-
lar incongruity.
SURGICAL MAN AGEMEN T
■ The goal of surgery is anatomic reduction and fixation of
the fracture to allow for early motion without mechanical
block.
■ Long-term goals are pain-free and maximal motion with
minimal stiffness.
■ Capitellar fractures are uncommon, and the wide array of
treatment options presented in the literature is based on rela-
tively small series.
■ Treatment options include closed reduction, 4,19 open ex-
cision,1,8,16 open reduction and internal fixation (O RIF),
and arthroplasty.5,9
■ With the improvement in techniques for fixation of small
fragments and management of articular surfaces, O RIF has be-
come the mainstay of treatment.
■ Advantages of O RIF include restoration of anatomy and
stability.
■ Disadvantages include stiffness and failed fixation.
■ In elderly patients, we do consider total elbow arthroplasty
for complex intra-articular distal humerus fractures.
■ Advantages include early return to function and motion.
■ Disadvantages include functional limitations.
Preoperative Planning
■ Before proceeding with surgery, a thorough understanding
of the fracture and its orientation should be obtained with the
help of a CT scan, and, if possible, 3D reconstructions.
C
 Ch a p t e r 2 7 ORIF OF CAPITELLUM AND CAPITELLAR–TROCHLEAR SHEAR FRACTURES
■ The timing of surgery is important. Fractures preferably
should be approached within 2 weeks, before osseous healing
sets in, but after swelling has gone down.
■ Ensure that the necessary implants and hardware are
available.
■ Reduction and fixation of the fracture will require K-wires,
articular or headless screws, and small-fragment AO screws.
■ An image intensifier should be used during surgery to con-
firm reduction of the fracture and proper positioning of im-
planted hardware.
Positioning
■ General anesthesia is recommended.
■ The patient usually is positioned supine on the operating
table, with a radiolucent hand table.
■ Alternatively, a lateral or prone position can be considered,
with the anterior surface of the elbow supported by a padded
bolster to use the universal posterior approach.
CAPITELLAR FRACTURES
Exp o su re
■ Th e in cision sh ou ld beg in 2 cm pro ximal to th e lateral ep i-
cond yle and exte nd 3 to 4 cm dista l to wa rd the rad ial n eck.
■ If n o la rg e so ft t issu e o r ca p su la r d e fe ct is p re se n t , a d i-
re ct la t e ra l Kö ch e r a p p ro a ch b e t w e e n t h e a n co n e u s a n d
ECU in t e rva l is re co m m e n d e d .
■ Th e co m m o n e xt e n so r o rig in is sh a rp ly ra ise d o ff t h e la t -
e ra l e p ico n d yle a n d re fle ct e d a n t e rio rly t o e xp o se t h e
la t e ra l e lb o w jo in t .
■ Ca re m u st b e t a ke n t o a vo id d a m a g e t o t h e ra d ia l
n e rve t ra ve lin g b e t w e e n t h e b ra ch ia lis a n d b ra ch io ra -
d ia lis.
■ Oft e n t h e la t e ra l lig a m e n t o u s co m p le x w ill b e a vu lse d
fro m t h e d ist a l a sp e ct o f t h e h u m e ru s, w it h o r w it h o u t
so m e a sp e ct o f t h e la t e ra l e p ico n d yle .
■ Th is lig a m e n t o u s vio la t io n ca n b e e xp lo it e d t o im -
p ro ve e xp o su re b y h in g in g o p e n t h e jo in t o n t h e m e -
d ia l co lla t e ra l lig a m e n t w it h a va ru s st re ss.
A B
229
Approach
■ Either a lateral or posterior midline incision should be used,
depending on the nature of the fracture, followed by a lateral
approach into the elbow joint.
■ M ultiple intervals that can be exploited in the lateral ap-
proach to the elbow.
■ We advocate the Köcher approach, which uses the inter-
val between the extensor carpi ulnaris and the anconeus
and affords greater protection of the posterior interosseous
nerve.
■ To increase exposure, the origin of the extensor carpi ul-
naris (ECU), extensor digitorum communis, and extensor
carpi radialis longus can be raised off of the lateral epi-
condyle anterior to its interval with the triceps.
■ In many cases, a capsular violation has occurred. This can
be exploited and used as the interval to expose the fracture,
thereby avoiding the need to cause an additional soft tissue
defect.
TECHNIQUES
■ Th e ca p it e lla r fra ct u re u su a lly is d isp la ce d p ro xim a lly a n d
ro t a t e d a n d h a s n o so ft t issu e a t t a ch m e n t s.
Re d u ct io n a n d Fixa t io n
■ Th e fra g m e n t is re d u ce d u n d e r d ire ct visu a liza t io n , h e ld
w it h re d u ct io n t e n a cu lu m s, a n d p ro visio n a lly fixe d w it h
0.045-in ch K-w ire s fro m a n a n t e rio r-t o -p o st e rio r
d ire ct io n .
■ In t e rn a l fixa t io n o p t io n s in clu d e fixa t io n fro m p o st e rio r
t o a n t e rio r w it h AO ca n ce llo u s scre w s o r fro m e it h e r d i-
re ct io n w it h h e a d le ss co m p re ssio n scre w s.
■ Ca n ce llo u s scre w s a re b e st fo r fra ct u re fra g m e n t s w it h a
la rg e su b ch o n d ra l co m p o n e n t , a s in t yp e 1 fra ct u re fra g -
m e n t s. Ho w e ve r, e xt e n d in g t h e d isse ct io n p o st e rio rly
a ro u n d t h e la t e ra l co lu m n t h e o re t ica lly in cre a se s t h e risk
o f o st e o n e cro sis (TECH FIG 1 ).
■ He a d le ss co m p re ssio n scre w s, su ch a s t h e He rb e rt
scre w , a re b e st fo r fra g m e n t s w it h le ss su b ch o n d ra l
TECH FIG 1 • Fixat io n o f a typ e 1 ca p ite llum
fractu re wit h a he a d le ss scre w a n te riorly
and AO screw s from poste rior t o a nte rior.
 230 Se c t i o n II SHOULDER AND ELBOW
b o n e , su ch a s t yp e 2 a n d sm a ll t yp e 1 fra ct u re fra g -
TECHNIQUES
m e n t s. Th e h e a d o f t h e scre w m u st b e b u rie d b e lo w t h e
a rt icu la r su rfa ce .
■ Excisio n o f fra ct u re fra g m e n t s is re co m m e n d e d in t yp e 2
fra ct u re s w it h sm a ll, t h in a rt icu la r p ie ce s a n d t yp e 3 co m -
m in u t e d fra ct u re s w h e re t h e fra g m e n t s a re n o t
a m e n a b le t o in t e rn a l fixa t io n .
■ Fra g m e n t re d u ct io n a n d h a rd w a re p o sit io n sh o u ld b e
co n firm e d b y im a g e in t e n sifie r.
CAPITELLAR–TROCHLEAR SHEAR FRACTURES
Exp o su re
■ A p o st e rio r m id lin e in cisio n sh o u ld b e m a d e , a n d fu ll-
t h ickn e ss fla p s sh o u ld b e ra ise d m e d ia lly a n d la t e ra lly o ff
o f t h e e xt e n so r m e ch a n ism .
■ Th is in cisio n p ro vid e s e xt e n sile e xp o su re , a cce ss t o
b o t h sid e s, a n d e a se o f o st e o t o m y if n e ce ssa ry
(TECH FIG 2 A).
■ Be g in n in g m e d ia lly, t h e u ln a r n e rve sh o u ld b e d e co m -
p re sse d in sit u b e h in d t h e m e d ia l e p ico n d yle (TECH
FIG 2 B).
■ Re t u rn in g la t e ra lly, t h e in t e rva l b e t w e e n t h e a n co n e u s
a n d t h e ECU sh o u ld b e d e ve lo p e d . In m a n y ca se s, a ca p -
su la r vio la t io n ca n b e e xp lo it e d (TECH FIG 2 C).
■ Th e co m m o n e xt e n so r o rig in , in clu d in g t h e ECU, e xt e n -
so r d ig it o ru m co m m u n is, a n d e xt e n so r ca rp i ra d ia lis
lo n g u s, is t h e n sh a rp ly ra ise d o ff t h e la t e ra l e p ico n d yle
a n d re fle ct e d a n t e rio rly t o e xp o se t h e la t e ra l e lb o w jo in t
a n d im p ro ve visu a liza t io n m e d ia lly.
A B
C D
■ Un re st rict e d fo re a rm ro t a t io n a n d e lb o w fle xio n –
e xt e n sio n w it h o u t m e ch a n ica l b lo ck o r ca t ch in g sh o u ld
b e co n firm e d in t ra o p e ra t ive ly.
■ If the lateral collateral ligament is fou nd to be avulsed , it
sh ould be repaired b ack to the lateral epicondyle with drill
holes and nonabsorbable no. 2 suture or suture anchors.
■ Th e ca p su le sh o u ld b e clo se d .
■ Th e re t ra ct e d e xt e n so r o rig in sh o u ld b e re la xe d a n d
clo se d t o t h e su rro u n d in g so ft t issu e .
■ Ca re m u st b e t a ke n t o a vo id in ju ry t o t h e ra d ia l n e rve
p ro xim a lly a s it t ra ve ls b e t w e e n t h e b ra ch ia lis a n d b ra -
ch io ra d ia lis, a n d t o t h e p o st e rio r in t e ro sse o u s n e rve d is-
t a lly w h e n ra isin g t h e ECU a n t e rio rly. Th is m a y b e d o n e
b y ke e p in g t h e fo re a rm p ro n a t e d .
■ In m a n y ca se s, t h e la t e ra l e p ico n d yle w ill h a ve a vu lse d
o ff o f t h e d ist a l h u m e ru s, a n d t h is t ra u m a t ic o st e o t o m y
ca n b e e xp lo it e d .
■ Ot h e rw ise , a fo rm a l la t e ra l e p ico n d yle o st e o t o m y
ca n b e p e rfo rm e d t o e n h a n ce visu a liza t io n w h ile
m a in t a in in g t h e in t e g rit y o f t h e la t e ra l lig a m e n t o u s
co m p le x.
■ Ad d it io n a lly, a n o le cra n o n o st e o t o m y m a y b e p e rfo rm e d
t o im p ro ve visu a liza t io n a n d fixa t io n o f fra ct u re s e xt e n d -
in g m e d ia lly a n d p o st e rio rly.
■ Th e fra ct u re fra g m e n t s sh o u ld n o w b e visu a lize d a n d a c-
co u n t e d fo r. Th e y a re m o st co m m o n ly d isp la ce d p ro xi-
m a lly a n d in t e rn a lly ro t a t e d (TECH FIG 2 D).
TECH FIG 2 • A. Po st e rio r m id lin e in ci-
sio n u se d t o fo r ca p it e lla r–t ro ch le a r
sh e a r fra ct u re s. B. Uln a r n e rve co m p re s-
sio n m e d ia lly. C. La t e ra l a p p ro a ch t o
e lb o w t a kin g a d va n t a g e o f vio la t io n o f
t h e ca p su le a n d e xt e n so r m u scle s a t t h e
le ve l o f t h e e xt e n so r ca rp i u ln a ris (ECU)
a n d a n co n e u s. D. Th e fra ct u re fra g -
m e n t s t e n d t o d isp la ce p ro xim a lly a n d
b e co m e in t e rn a lly ro t a t e d .
 Ch a p t e r 2 7 ORIF OF CAPITELLUM AND CAPITELLAR–TROCHLEAR SHEAR FRACTURES 231

Re d u ct io n a n d Fixa t io n ■ He a d le ss co m p re ssio n scre ws, su ch a s t h e He rb e rt scre w,

■ Th e fra g m e n t is re d u ce d u n d e r d ire ct visu a liza t io n , h e ld
w it h re d u ct io n t e n a cu lu m s, a n d p ro visio n a lly fixe d
w it h 0.045-in ch K-w ire s fro m a n t e rio r t o p o st e rio r
(TECH FIG 3 A).
■ In a b ilit y t o re d u ce t h e fra ct u re a n a t o m ica lly m a y re p re -
se n t fra ct u re im p a ct io n , re q u irin g e it h e r d isim p a ct io n o r
b o n e g ra ft in g , o r b o t h .
■ Op t io n s fo r in t e rn a l fixa t io n in clu d e fixa t io n fro m p o st e -
rio r-t o -a n t e rio r w it h AO scre w s o r fro m e it h e r d ire ct io n
w it h h e a d le ss co m p re ssio n scre w s.
■ Cancellous scre w s a re be st w h e n t h e fra ct ure frag m en t
h as a la rg e sub ch on d ral co m po n e n t , b ut th ey m ake it n ec-
essary t o e xt end th e d issection poste riorly around th e la t-
e ra l co lu m n , t h e o re t ica lly in cre a sin g t h e risk o f o s-
te o ne crosis.
TECHNIQUES
are best fo r fragm ent s wit h less sub chond ral b one a nd
p ro vid e the a d d ed b e ne fit t h a t th e y ca n b e u se d in e it he r
d ire ct io n , an t eriorly o r p o st e rio rly. Dilig e n ce mu st be
ma in t ain e d t o co nfirm th a t t h e h ead o f th e scre w is
b u rie d b e lo w t h e a rticu la r su rfa ce w h e n p la ce d a n te riorly.
■ Fra g m e n t re d u ct io n a n d h a rd w a re p o sit io n sh o u ld b e
co n firm e d b y im a g e in t e n sifie r.
■ Un re st rict e d fo re a rm ro t a t io n a n d e lb o w fle xio n –e xt e n -
sio n w it h o u t m e ch a n ica l b lo ck o r ca t ch in g sh o u ld b e co n -
firm e d in t ra o p e ra t ive ly.
■ Th e la t e ra l e p ico n d yle , if a vu lse d o r o st e o t o m ize d ,
sh o u ld b e re p a ire d w it h a t e n sio n b a n d t e ch n iq u e o r
p la t e a n d scre w s (TECH FIG 3 A,B).
■ Th e ca p su le sh o u ld b e clo se d .
■ Th e in t e rva l a n d re le a se d e xt e n so r o rig in sh o u ld b e re -
la xe d a n d clo se d t o t h e su rro u n d in g so ft t issu e .

A B

TECH FIG 3 • A. Th e fra ct u re is re d u ce d an d p in n e d w it h 0.045-in ch K-w ire s.

B. Po st o p e ra t ive ra d io g ra p h s illu st ra t e re p a ir o f t h e la t e ra l e p ico n d yle a n d fra ct u re
fixa t io n .

PEARLS AND PITFALLS

Dia g n o sis
Im a g in g
No n o p e ra t ive m a n a g e m e n t
Su rg ica l m a n a g e m e n t
Po st o p e ra t ive m a n a g e m e n t
■ Dilig e n ce sh o u ld b e p a id t o id e n t ifyin g co n co m it a n t in ju rie s su ch a s d islo ca t io n s, ra d ia l h e a d
fra ct u re s, a n d lig a m e n t o u s in st a b ilit y.
■ Pla in ra d io g ra p h s a re in su fficie n t , a n d a CT sca n sh o u ld b e p e rfo rm e d ro u t in e ly.
■ Ord e r 3D re co n st ru ct io n s if p o ssib le .
■ No n o p e ra t ive m a n a g e m e n t sh o u ld b e ch o se n ca u t io u sly. An a t o m ic a n d st a b le re d u ct io n o f t h e
fra ct u re is n e ce ssa ry. Ot h e rw ise , a p a in fu l e lb o w w it h re st rict e d m o t io n m a y re su lt .
■ We d o n o t re co m m e n d n o n o p e ra t ive m a n a g e m e n t o f a n y ca p it e lla r–t ro ch le a r sh e a r fra ct u re s.
■ A st ra ig h t p o st e rio r skin in cisio n w ill a llo w u ln a r n e rve d e co m p re ssio n a n d fra ct u re fixa t io n .
■ La t e ra l e p ico n d yle o st e o t o m y ca n e n h a n ce e xp o su re .
■ In a b ilit y t o re d u ce t h e fra ct u re a n a t o m ica lly m a y re p re se n t im p a ct io n o f t h e la t e ra l co lu m n
a n d re q u ire d isim p a ct io n o r b o n e g ra ft in g .
■ Excisio n o f co m m in u t e d fra g m e n t s t h a t ca n n o t b e fixe d in t e rn a lly is p re fe rre d o ve r
n o n a n a t o m ic re d u ct io n a n d m a lu n io n .
■ Co n co m it a n t fra ct u re s a n d lig a m e n t o u s in ju rie s sh o u ld b e t re a t e d sim u lt a n e o u sly t o o p t im ize
o u t co m e s.
■ St a b le fixa t io n sh o u ld b e so u g h t t o a llo w fo r e a rly m o t io n .
■ He t e ro t o p ic o ssifica t io n is co m m o n a ft e r e lb o w fra ct u re s, a n d p ro p h yla xis w it h n o n st e ro id a l
a n t i-in fla m m a t o ry d ru g s sh o u ld b e co n sid e re d .
232 Se c t i o n II SHOULDER AND ELBOW
POSTOPERATIVE CARE
■ If secure fixation has been obtained, immediate mobilization
can be initiated postoperatively.
■ If fixation is tenuous, splint or cast the elbow for 3 to 4 weeks,
followed by active and assisted range-of-motion exercises.
OUTCOMES
■ Focusing initially on outcomes after O RIF of types 1 and 2
capitellar fractures, multiple small series have shown good re-
sults using H erbert screws in an anterior to posterior direc-
tion. 6,13,14,20
■ M ore recently, M ahirogullari et al15 reported on 11 cases of
type 1 capitellum fractures treated with H erbert screws, which
yielded 8 excellent and 3 good results. They recommended fix-
ation in a posterior-to-anterior direction with at least two
H erbert screws.
■ Reported outcomes on type 4 capitellar–trochlear shear
fractures are limited. M cKee et al17 originally described this
pattern and reported on 6 cases.
■ Each case involved an extended lateral Köcher approach
and fixation with H erbert screws from an anterior to poste-
rior direction. Good or excellent results were achieved in all
cases, with average elbow motion of 15 to 141 degrees, and
forearm rotation of 83 degrees pronation and 84 degrees
supination.
■ Ring and Jupiter examined 21 cases of articular fractures of
the distal humerus treated with H erbert screw fixation and
found 4 excellent results, 12 good results, and 5 fair results.
■ All of the fractures healed and had an average range of
motion of 96 degrees. N o ulnohumeral instability, arthrosis,
or osteonecrosis was reported.
■ The authors stressed the importance of proper evaluation
of these fractures and awareness that apparent capitellum
fractures often are complex articular fractures of the distal
humerus.21
■ Dubberley et al7 further subclassified type 4 fractures in
their series of 28 cases. They achieved an average range of mo-
tion of flexion–extension of 25 degrees less than the contralat-
eral elbow and 4 degrees of supination–pronation less than the
contralateral elbow.
■ Two comminuted cases required conversion to a total
elbow arthroplasty.
■ Varied fixation methods were used, including H erbert
screws, cancellous screws, absorbable pins, and supplemen-
tation with K-wires.
COMPLICATION S
■ The most common complication of capitellar fractures is loss
of elbow motion and residual pain. The compromised motion
most commonly is manifested in loss of flexion and extension.
■ Ulnar neuropathy has been noted after O RIF, and some rec-
ommend routine ulnar nerve decompression.21
■ O steonecrosis may occur from the initial fracture displace-
ment or surgical exposure. Blood is supplied to the capitellum
from a posterior to anterior direction and may be compro-
mised by surgical dissection.
■ In symptomatic cases in which revascularization after fix-
ation has not occurred, delayed excision is indicated.
■ Malunions may occur when the patient has delayed seeking
treatment, when inadequate reduction or loss of closed reduction
occurs, or after ORIF. Malunions result in loss of motion and
may require excision of the fragment and soft tissue releases.
■ N onunions may occur, although this is uncommon. They
most likely result secondary to inadequate reduction or lack of
revascularization of the fragment.
REFEREN CES
1. Alvarez E, Patel M , N imberg P, et al. Fractures of the capitellum
humeri. J Bone Joint Surg Am 1975;57A:1093–1096.
2. Broberg M A, M orrey BF. Results of delayed excision of the radial
head after fracture. J Bone Joint Surg Am 1986;68A:669–674.
3. Bryan RS, M orrey BF. Fractures of the distal humerus. In: M orrey
BF, ed. The Elbow and Its Disorders. Philadelphia: WB Saunders,
1985:302–399.
4. Christopher F, Bushnell L. Conservative treatment of fractures of the
capitellum. J Bone Joint Surg 1935;17:489–492.
5. Cobb TK, M orrey BF. Total elbow arthroplasty as primary treatment
for distal humerus fractures in elderly patients. J Bone Joint Surg Am
1997;79A:826–832.
6. Collert S. Surgical management of fracture of the capitulum humeri.
Acta O rthop Scand 1977;48:603–606.
7. Dubberley JH , Faber KJ, M acdermid JC, et al. O utcome after open
reduction and internal fixation of capitellar and trochlear fractures.
J Bone Joint Surg Am 2006;88A:46–54.
8. Fowles JV, Kassab M T. Fracture of the capitulum humeri: treatment
by excision. J Bone Joint Surg Am 1975;56A:794–798.
9. Garcia JA, M yulka R, Stanley D. Complex fractures of the distal
humerus in the elderly: the role of total elbow replacement as primary
treatment. J Bone Joint Surg Br 2002;84B:812–816.
10. Greenspan A, N orman A. The radial head, capitellum view: useful
technique in elbow trauma. AJR Am J Roentgenol 1982;138:
1186–1188.
11. H ahn N F. Fall von einer besonderes Varietat der Frakturen des
Ellenbogens. Z Wund Geburt 1853;6:185.
12. Jupiter JB, N eff U, Ragazzoni P, et al. Unicondylar fractures of the
distal humerus: an operative approach. J O rthop Trauma 1988;2:
102–109.
13. Lansinger O , M are K. Fracture of the capitulum humeri. Acta O rthop
Scand 1981;52:39–44.
14. Liberman N , Katz T, H oward CV, et al. Fixation of capitellar frac-
tures with H erbert screws. Arch O rthop Trauma Surg 1991;110:
155–157.
15. M ahirogullari M , Kiral A, Solakoglu C, et al. Treatment of fractures
of the humeral capitellum using H erbert screws. J H and Surg Eur Vol
2006;31:320–325.
16. M azel M S. Fracture of the capitellum. J Bone Joint Surg 1935;
17:483–488.
17. M cKee M D, Jupiter JB, Bosse G, et al. Coronal shear fractures of the
distal end of the humerus. J Bone Joint Surg Am 1996;78A:49–54.
18. M ilch H . Fractures and fracture-dislocations of the humeral condyles.
J Trauma 1964;13:882–886.
19. O chner RS, Bloom H , Palumbo RC, et al. Closed reduction of coro-
nal fractures of the capitellum. J Trauma 1996;40:199–203.
20. Richards RR, Khoury GW, Burke FD, et al. Internal fixation of
capitellar fractures using H erbert screw: a report of four cases. Can
J Surg 1987;30:188–191.
21. Ring D, Jupiter JB, Gulotta L. Articular fractures of the distal part of
the humerus. J Bone Joint Surg Am 2003;85A:232–238.
22. Steinthal D. Die isolirte Fraktur der eminentia Capetala in
Ellengogelenk. Z entralk Chir 1898;15:17.
23. Yamaguchi K, Sweet FA, Bindra R, et al. The extraosseous and in-
traosseous arterial anatomy of the adult elbow. J Bone Joint Surg Am
1997;79A:1653–1662.

Ch a p t e r 28
DEFIN ITION
■ The radial head is distinctive in anatomy and function with
unique considerations regarding the diagnostic and treatment
options available to the surgeon.
■ Radial head and neck fractures are the most common elbow
fractures in adults, representing 33% of elbow fractures.
■ The original M ason classification was modified by Johnson,
then M orrey. H otchkiss proposed that the classification
system be used to provide guidance for treatment. It has poor
intraobserver and interobserver reliability (FIG 1 ).9
■ Type I fractures are nondisplaced and offer no block to
pronation and supination on examination.
■ Type II fractures have displaced marginal segments that
block normal forearm rotation. We only include fractures
with three or fewer articular fragments, which meet criteria
for fractures that can be operatively reduced and fixed with
reproducibly good results.
■ Type III fractures are comminuted or impacted articular
fractures that are optimally managed with prosthetic
replacement.
■ Type IV fractures are associated with elbow instability
and should never be resected in the acute setting.
AN ATOMY
■ The radial head is entirely intra-articular. It has two articu-
lations, one with the humerus, via the radiocapitellar joint,
and another with the ulna, via the proximal radioulnar joint
(PRUJ).
■ The radiocapitellar joint has a saddle-shaped articulation
allowing both flexion and extension as well as rotation.
■ The PRUJ, constrained by the annular ligament, allows
rotation of the radial head in the lesser sigmoid notch of the
proximal ulna.
■ To avoid creating a mechanical block to pronation and
supination, implants must be limited to a 90-degree arc
(the “ safe zone” ) outside the PRUJ (FIG 2 ).4
Type I Type II
FIG 1 • Th e m o d ifie d Ma so n cla ssifica t io n fo r ra d ia l h e a d fra ct u re s.
Op e n Re d u ct io n a n d In t e r n a l
Fix a t io n o f Ra d ia l He a d a n d
Ne ck Fr a ct u re s
A n sh u Sin g h , Ge o rg e Fre d e rick Hat ch III,
an d Jo h n M . It am u ra
■ Blood supply to the radial head is tenuous, with a major
contribution from a single branch of the radial recurrent artery
in the safe zone and minor contributions from both the radial
and interosseous recurrent arteries, which penetrate the cap-
sule at its insertion into the neck (FIG 3 ).13
■ There is considerable variability in the shape of the radial
head, from nearly round to elliptical, as well as variability in
the offset of the head from the neck.
■ The anterior band of the medial collateral ligament (M CL)
is the primary stabilizer to valgus stress. The radial head, a
secondary stabilizer, maintains up to 30% of valgus resistance
in the native elbow. Therefore, in cases where the M CL is
ruptured:
■ A radial head that is not reparable should be replaced
with a prosthesis and not excised given its biomechanical
importance.
■ It may be prudent to protect a repaired radial head from
high valgus stress during early range of motion by placing a
hinged external fixator.
■ The radial head also functions in the transmission of axial
load, transmitting 60% of the load from the wrist to the
elbow. 10 This is a crucial consideration when the interosseous
membrane is disrupted in the Essex-Lopresti lesion.5 Resection
of the radial head in this setting results in devastating longitu-
dinal radioulnar instability, proximal migration of the radius,
and possible ulnar-carpal impingement.
PATHOGEN ESIS
■ Radial head fractures result from trauma. A fall on an out-
stretched hand with the elbow in extension and the forearm in
pronation produces an axial or valgus load (or both) driving
the radial head into the capitellum, fracturing the relatively os-
teopenic radial head.
■ Loading at 0 to 35 degrees of extension causes coronoid
fractures.
■ Loading at 0 to 80 degrees of extension produces radial
head fractures.
Type III Type IV
233
234 Se c t i o n II SHOULDER AND ELBOW

FIG 2 • Th e “ sa fe zo n e ” is a ro u g h ly 90-
d e g re e a rc o f t h e ra d ia l h e a d t h a t d o e s n o t
a rt icu la t e w it h t h e u ln a in t h e p ro xim a l
ra d io u ln a r jo in t w it h fu ll su p in a t io n a n d
p ro n a t io n . Wit h t h e w rist in n e u t ra l
Pronation Neutral Supination ro t a t io n , t h e sa fe zo n e is a n t e ro la t e ra l.

■ Associated soft tissue injuries can lead to considerable com- ■ The axial loading may also rupture the interosseous mem-
plications, including pain, arthrosis, stiffness, and disability: brane, causing longitudinal radioulnar instability with disloca-
■ M CL injury in 50% tion of the distal radioulnar joint (DRUJ) (FIG 4 ).
■ Lateral ligament disruption in about 80% ■ The “ terrible triad” injury results from valgus loading of the

■ Capitellar bone bruises in 90% 8 elbow, disrupting the M CL or lateral ulnar collateral ligament
■ Capitellar cartilage defects in about 50% and fracturing the radial head and coronoid process.

N ATURAL HISTORY
■ Results are mixed regarding the efficacy of radial head exci-
sion for treatment of radial head fracture. Good or fair results
may be possible, with a few caveats:

FIG 3 • A. Th e ra d ia l re cu rre n t a rt e ry, a b ra n ch o f t h e ra d ia l

a rt e ry, p ro vide s t h e m a in b lo o d su p p ly t o t h e ra d ia l h e a d . B. In
m o st ca d a ve ric sp e cim e n s, a b ra n ch o f t h e ra d ia l re cu rre n t p e n -
e t ra t e s t h e ra d ia l h e a d in t h e sa fe zo n e . (Fro m Ya m a g u ch i K,
Sw e e t FA, Bin d ra R, e t a l. Th e e xt ra o sse o u s a n d in t ra o sse o u s a r-
t e ria l a n a t o m y o f t h e a d u lt e lb o w . J Bo n e Jo in t Su rg Am
1997;79A:1653–1662.)
B
FIG 4 • A. AP ra d io g ra p h o f t h e w rist in ca se s o f lo n g it u d in a l
ra d io u ln a r in st a b ilit y (t h e Esse x-Lo p re st i le sio n ). Su b t le sh o rt e n -
in g o f t h e ra d iu s is d e m o n st ra t e d . B. La t e ra l ra d io g ra p h o f t h e
w rist m a y sh o w d o rsa l su b lu xa t io n o f t h e d ist a l u ln a .
 Ch a p t e r 2 8 ORIF OF RADIAL HEAD AND NECK FRACTURES
■ There is a demonstrable increase in ulnar variance at the
wrist and increased carrying angle.
■ 10% to 20% loss of strength is expected.
■ It is contraindicated in the face of associated soft tissue
injuries.
■ Radiographic, but usually clinically silent, degenerative
changes such as cysts, sclerosis, and osteophytes occur radi-
ographically in about 75% of elbows after radial head excision
(FIG 5 ).
■ Results of excision are poor in patients with concomitant
M CL, coronoid, or interosseous membrane injury.
■ Radial head resection should be reserved for patients with
low functional demands or limited life expectancy, and
when the surgeon has excluded elbow instability with a flu-
oroscopic examination.
■ Delayed excision of the radial head after failed nonoperative
management may be considered with modest increase in func-
tion; it has shown 23% fair or poor results at 15 years of
follow-up. 3 O ther studies suggest that there is no difference
between delayed and primary excision.6
■ Although open reduction and fixation of a comminuted
fracture can be attempted, a large series by experienced elbow
surgeons found that fixation of a radial head with more than
three articular fragments is fraught with poor results.11
■ N onanatomic reduction of the shaft or joint may result in
limited range of motion due to a cam effect in the PRUJ, but
no literature or prospective studies indicate what parameters
are “ acceptable.”
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ The history typically involves a fall on an outstretched hand
followed by pain and edema over the lateral elbow, accompa-
nied by limited range of motion.
■ The examiner should note the patient’s activity level and
profession.
■ Physical examination should include neurovascular status
and examination of the skin to look for medial ecchymosis,
which may suggest injury to the M CL.
■ A detailed examination of the elbow must include bony
palpation of the medial and lateral epicondyles, olecranon
process, DRUJ, and radial head, as well as the squeeze test
FIG 5 • A CT sca n d e m o n st ra t in g sym p t o m a t ic p o st t ra u m a t ic
a rt h ro sis w it h cyst fo rm a t io n in t h e u ln o h u m e ra l a rt icu la t io n
a ft e r ra d ia l h e a d re se ct io n .
235
Extensor carpi
ulnaris muscle
Posterior
approach
Anconeus
muscle Posterolateral
approach
FIG 6 • Th e e lb o w jo in t ca n b e a sp ira t e d a n d in je ct e d t h ro u g h
t h e p o st e rio r a n d p o st e ro la t e ra l a p p ro a ch e s. Th e y a re e q u a lly
e ffe ct ive a n d sh o u ld b e u se d b a se d o n so ft t issu e in ju ry.
of the interosseous membrane and DRUJ to screen for po-
tential longitudinal instability.
■ Varus and valgus stress testing, with or without fluo-
roscopy, can indicate injury to the anterior band of the
M CL or to the lateral ulnar collateral ligament, respectively.
■ Range-of-motion and stress examinations are vital to proper
decision making and may obviate the need for advanced imag-
ing if performed correctly with adequate anesthesia. If omit-
ted, this will lead to undiagnosed associated injuries and may
result in flawed decision making.
■ In the emergency department or office, adequate anesthe-
sia may be obtained by aspirating hematoma, then injecting
the elbow joint with 5 mL of local anesthetic and examining
the elbow under fluoroscopy. This may be performed by the
traditional lateral injection in the “ soft spot” or posteriorly
into the olecranon fossa (FIG 6 ).12
■ If operative intervention is clearly indicated, this examina-
tion can be performed under a general anesthetic, provided
the surgeon and patient are prepared for a change in opera-
tive plan as dictated by the examination.
■ N ormal values are 0 to 145 degrees of flexion–extension,
85 degrees of supination, and 80 degrees of pronation. The
examiner should check for a bony block to motion.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
Radiography
■ Anteroposterior (AP), lateral, and oblique views are the
standard of care, but they underestimate or overestimate joint
impaction and degree of comminution (FIG 7 A,B).
■ A radiocapitellar view with forearm in neutral and at 45
degrees cephalad gives an improved view of the articular
surfaces.
236 Se c t i o n II SHOULDER AND ELBOW

A B

FIG 7 • A,B. AP a n d la t e ra l ra d io g ra p h s
re ve a l a t yp e 2 d isp la ce d ra d ia l h e a d fra ct u re .
Wit h st a n d a rd ra d io g ra p h y it is d ifficu lt t o
ju d g e co m m in u t io n a n d a sso cia t e d in ju rie s.
C. A T2-w e ig h t e d MR im a g e d e m o n st ra t in g
a b o n y m e d ia l co lla t e ra l lig a m e n t a vu lsio n
w it h su rro u n d in g e d e m a a sso cia t e d w it h a
ra d ia l h e a d fra ct u re . Th e lig a m e n t ca n b e
C se e n in se rt in g d ist a lly t o t h e su b lim e t u b e rcle .

■ If the examination reveals wrist or forearm tenderness, DIFFEREN TIAL DIAGN OSIS
the examiner should have a low threshold for obtaining ■ Simple elbow dislocation
bilateral wrist posteroanterior (PA) views to rule out an ■ Distal humerus fracture
Essex-Lopresti lesion. ■ O lecranon fracture
Magnetic Resonance Imaging ■ Septic elbow
■ M agnetic resonance imaging (M RI) is a useful adjunct to
physical examination for evaluating associated injuries such as N ON OPERATIVE MAN AGEMEN T
collateral ligament tears, chondral defects, and loose bodies,8 ■ The standard protocol for treating radial head fractures is
but it is not routinely indicated (FIG 7 C). shown in FIGURE 8.

Displacement ≥ 2 mm?

No Yes

Early motion Fragment size ≥ 33%?

No Yes

Block to rotation? Three or fewer fragments

No Yes No Yes

Early motion Three or fewer fragments MCL/LCL/IOM injury or ORIF

associated dislocation?
Yes No
Yes No

ORIF Low demand

Radial head arthroplasty High Low demand
soft tissue reconstruction demand
Fragment excision
Radial head excision

FIG 8 • Tre a t m e n t a lg o rit h m fo r ra d ia l h e a d fra ct u re s.

 Ch a p t e r 2 8 ORIF OF RADIAL HEAD AND NECK FRACTURES
FIG 9 • In t ra o p e ra t ive p h o t o g ra p h d e m o n st ra t in g t h e flu o ro -
sco p ic e xa m in a t io n . Th is is cru cia l t o p ro p e r d e cisio n m a kin g
a n d m a y b e p e rfo rm e d ju st b e fo re o p e ra t ive m a n a g e m e n t .
■ Conservative management, with a week of sling immobiliza-
tion followed by range of motion once the acute pain resolves,
it is the treatment of choice in nondisplaced radial head frac-
tures, where universally good and excellent results have been
reported.
■ N onoperative management is also the treatment of choice
in fractures with less than 2 mm of displacement, with minor
head involvement, and without bony blockage to range of
motion.
■ A 7-day period of cast or splint immobilization is fol-
lowed by aggressive motion after the inflammatory phase.
■ O ur current practice for fractures that are more than 2 mm
displaced is to determine whether there is a blockage of motion
on fluoroscopic examination.
■ If there is maintenance of at least 50 degrees of both prona-
tion and supination, we recommend conservative treatment.
■ If there is a blockage or instability, excision, fixation, or
arthroplasty is recommended based on patient factors and
instability.
■ A recent report regarding the long-term results of nonoper-
ative management (similar to that described) of 49 patients
with radial head fractures encompassing over 30% of the
joint surface and displaced 2 to 5 mm revealed that 81% of
patients had no subjective complaints and minimal loss of
motion versus the uninjured extremity. O nly one patient had
daily pain. 1
BOYD APPROACH
■ An 8-cm st ra ig h t lo n g it u d in a l in cisio n is m a d e ju st la t e ra l
t o t h e o le cra n o n (TECH FIG 1 A).
■ Fu ll-t h ickn e ss skin fla p s a re d e ve lo p e d b lu n t ly o ve r t h e
fa scia .
■ Th e fa scia is lo n g it u d in a lly in cise d in t h e in t e rva l b e -
t w e e n t h e a n co n e u s a n d u ln a (TECH FIG 1 B).
■ Th e a n co n e u s is d isse ct e d o ff t h e u ln a , e le va t in g p ro xi-
m a l t o d ist a l t o p re se rve t h e d ist a l va scu la r p e d icle .
Gre a t ca re is t a ke n n o t t o vio la t e t h e jo in t ca p su le o r
237
SURGICAL MAN AGEMEN T
Preoperative Planning
■ It is essential to review all radiographs and, most impor-
tantly, perform thorough history, physical, and fluoroscopic
examinations before making an incision.
■ The presence of instability or associated fractures war-
rants a more extensile approach (FIG 9 ).
Positioning
■ Positioning depends on the planned approach and the sur-
geon’s preference.
■ We prefer the patient supine with the affected extremity
brought across the chest over a bump to allow access to the
posterolateral elbow.
■ A tourniquet is placed high on the arm.
Approach
■ Two approaches, the extensile posterior (Boyd) and postero-
lateral (Köcher), will be presented (FIG 1 0 ).
■ The extensile posterior (Boyd) approach 2 with an interval be-
tween the ulna and anconeus allows for excellent visualization
compared to traditional approaches. This versatile approach
facilitates O RIF or arthroplasty of the radial head if the frac-
ture proves to be more comminuted than preoperative imaging
would predict. It can be easily accessed through a universal
extensile incision that allows the surgeon to address ligamen-
tous injuries in addition to the radial head fracture.
Extensor carpi
ulnaris muscle
Köcher
interval
Ulna
Anconeus
Boyd muscle
interval
FIG 1 0 • Su rg ica l in t e rva ls fo r t h e Bo yd a p p ro a ch a n d t h e
Kö ch e r a p p ro a ch .
TECHNIQUES
la t e ra l u ln a r co lla t e ra l lig a m e n t b y u sin g b lu n t fa sh io n
(TECH FIG 1 C).
■ Th e la t e ra l u ln a r co lla t e ra l lig a m e n t a n d a n n u la r lig a -
m e n t co m p le x a re sh a rp ly d ivid e d a n d t a g g e d fro m t h e ir
in se rt io n o n t h e crist a su p in a t o ru s o f t h e u ln a . Th e ra d ia l
h e a d a n d it s a rt icu la t io n w it h t h e ca p it e llu m a re n o w
e vid e n t (TECH FIG 1 D).
■ Aft e r re p a ir o r re p la ce m e n t , t h e lig a m e n t s a re re p a ire d
t o t h e ir in se rt io n w it h su t u re a n ch o rs.
 238 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

A B C

TECH FIG 1 • Bo yd a p p ro a ch . A. Ma ke a n 8-cm lo n g it u d in a l

in cisio n a t t h e ju n ct io n o f t h e u ln a a n d a n co n e u s st a rt in g a b o u t
fo u r fin g e rb re a d t h s d ist a l t o t h e o le cra n o n a n d e xt e n d in g 2 cm
p ro xim a l t o t h e o le cra n o n . B. Th e in t e rva l b e t w e e n t h e u ln a
a n d a n co n e u s is in cise d sh a rp ly, w it h ca re t a ke n n o t t o vio la t e
t h e p e rio st e u m o r m u scle t o m in im ize t h e risk o f p ro xim a l
ra d io u ln a r syn o st o sis. C. Blu n t e le va t io n o f t h e a n co n e u s is cru -
cia l t o a vo id d a m a g in g t h e ca p su le o r la t e ra l lig a m e n t co m p le x.
D. Th e ca p su le a n d la t e ra l lig a m e n t co m p le x a re t a g g e d d u rin g
D t h e a p p ro a ch t o fa cilit a t e fin a l re p a ir w it h su t u re a n ch o rs.

KÖCHER APPROACH
■ Th e t ra d it io n a l p o st e ro la t e ra l (Kö ch e r) a p p ro a ch b e -
t w e e n t h e a n co n e u s a n d e xt e n so r ca rp i u ln a ris is co sm e t ic
a n d sp a re s t h e la t e ra l u ln a r co lla t e ra l lig a m e n t .
■ We re co m m e n d n o t u sin g a n Esm a rch t o u rn iq u e t t o
a llo w visu a liza t io n o f p e n e t ra t in g ve in s t h a t h e lp
id e n t ify t h e in t e rva l.
■ A 5-cm o b liq u e in cisio n is m a d e fro m t h e p o st e ro la t e ra l
a sp e ct o f t h e la t e ra l e p ico n d yle o b liq u e ly t o a p o in t
t h re e fin g e rb re a d t h s b e lo w t h e t ip o f t h e o le cra n o n in
lin e w it h t h e ra d ia l n e ck (TECH FIG 2 A).
■ Th e ra d ia l h e a d a n d e p ico n d yle a re p a lp a t e d a n d t h e
fa scia is d ivid e d in lin e w it h t h e skin in cisio n .
■ Th e Kö ch e r in t e rva l is id e n t ifie d d ist a lly b y sm a ll
p e n e t ra t in g ve in s a n d b lu n t ly d e ve lo p e d , re ve a lin g
t h e la t e ra l lig a m e n t co m p le x a n d jo in t ca p su le (TECH
FIG 2 B).
■ Th e a n co n e u s is re fle ct e d p o st e rio rly a n d t h e e xt e n so r
ca rp i u ln a ris o rig in a n t e rio rly. Th e ca p su le is in cise d
o b liq u e ly a n t e rio r t o t h e la t e ra l u ln a r co lla t e ra l lig a m e n t
(TECH FIG 2 C,D).
■ Th e p ro xim a l e d g e o f t h e a n n u la r lig a m e n t m a y a lso
b e d ivid e d a n d t a g g e d , w it h ca re t a ke n n o t t o p ro -
ce e d d ist a lly a n d d a m a g e t h e p o st e rio r in t e ro sse o u s
n e rve .

TECH FIG 2 • Kö ch e r a p p ro a ch .
A. Th e skin in cision p roce ed s dis-
t a lly fro m t h e p o st e ro la t e ra l
a sp e ct of t h e la t e ra l e p icon dyle
t o t h e p o ste rio r asp ect o f th e
p ro xima l rad iu s. B. Fu ll-th ickn e ss
fla p s a re m a d e a n d th e fa scia l
in t e rva l b e t w e e n t h e e xt e n so r
carp i u ln aris an d a n co n eu s m u s-
A B cles is id en t ifie d . (co n t in u e d)
 Ch a p t e r 2 8 ORIF OF RADIAL HEAD AND NECK FRACTURES 239

TECHNIQUES
TECH FIG 2 • (cont inued) C. Wit h
longit udinal in cision of t he fa scia
and blunt divisio n of th e muscle s,
th e jo in t cap su le is e vid en t . D.
The cap sule is longit udinally in-
cise d a n d t h e fa scia is t a g g e d
w it h fig u re 8 st itch e s fo r la t er
C D ana tom ic re pair.

FRACTURE INSPECTION AND PREPARATION

■ Th e fra ct u re is n o w visib le (TECH FIG 3 ).
■ Th e w o u n d is irrig a t e d a n d lo o se b o d ie s a re re m o ve d .
■ Th e fo re a rm is ro t a t e d t o o b t a in a circu m fe re n t ia l vie w
o f t h e fra ct u re a n d a p p re cia t e t h e sa fe zo n e fo r h a rd -
w a re p la ce m e n t .
■ If co m m in u t io n (m o re t h a n t h re e p ie ce s) is e vid e n t a t t h is
st e p , w e e le ct t o re p la ce t h e ra d ia l h e a d .

TECH FIG 3 • Here t h e fractu re d rad ial h ead fra g me n t h as vio late d
th e lat e ra l ca psule, ind ica t in g a h ig h-en e rgy in ju ry. Th e p roxim a l
rad iu s is n ow e xpo se d for fixa t io n or p ro sthe tic re pla ce m en t .

REDUCTION AND PROVISIONAL FIXATION

■ An y jo in t im p a ct io n is e le va t e d a n d t h e vo id file d w it h
lo ca l ca n ce llo u s g ra ft fro m t h e la t e ra l e p ico n d yle .
■ Th e fra g m e n t s a re re d u ce d p ro visio n a lly w it h a t e n a cu -
lu m a n d h e ld w it h sm a ll Kirsch n e r w ire s p la ce d o u t o f
t h e zo n e w h e re d e fin it ive fixa t io n is p la n n e d .
■ It is a cce p t a b le t o p la ce t h is t e m p o ra ry fixa t io n in t h e
sa fe zo n e (TECH FIG 4 ).

TECH FIG 4 • We p re fe r t o u se 0.062-in ch Kirsch n e r w ire s p la ce d

o u t sid e t h e zo n e o f p la n n e d d e fin it ive fixa t io n t o p ro visio n a lly
h o ld t h e re d u ct io n .
 240 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

FIXATION
■ Th e re a re m a n y o p t io n s fo r d e fin it ive fixa t io n 7 :
■ On e o r t w o co u n te rsu n k 2.0-m m o r 2.7-m m AO co rt ical
scre ws pe rp e nd icu la r to th e fra ct u re (TECH FIG 5A)
■ Min i-p la t e s (TECH FIG 5 B)
■ Sm a ll h e a d le ss scre w s
■ Po lyg lyco lid e p in s
■ Sm a ll t h re a d e d w ire s
■ We p refe r t o u se t w o sm a ll p a ralle l scre w s fo r iso la t e d
h e a d fra ct u re s. For fra ct u re s w it h n e ck e xt e n sio n , w e p re-
fe r AO 2.0-m m o r 2.7-m m m in i-p la t e s a lo n g t h e sa fe zo n e .

TECH FIG 5 • A. Tw o scre w s a re p la ce d

in t h e sa fe zo n e p e rp e n d icu la r t o t h e fra c-
t u re . B. A p la t e is p la ce d o n a ra d ia l n e ck
A B fra ct u re .

CLOSURE
■ An y re le a se s o r in ju ry t o t h e a n n u la r lig a m e n t o r la t e ra l ■ Skin clo su re is p e rfo rm e d in st a n d a rd fa sh io n w it h d ra in s
u ln a r co lla t e ra l lig a m e n t m u st b e re p a ire d a n a t o m ica lly. a t t h e su rg e o n ’s d iscre t io n . Sm a ll h e m o va c d ra in s a re
Drill h o le s w it h t ra n so sse o u s su t u re s a re a p ro ve n ro u t in e ly p u lle d o n p o st o p e ra t ive d a y 1.
m e t h o d , b u t m o st a u t h o rs n o w u se su t u re a n ch o rs w it h
re p ro d u cib le re su lt s.

PEARLS AND PITFALLS

Pro t e ct io n o f t h e p o st e rio r ■ Pro n a t io n o f t h e fo re a rm m o ve s t h e p o st e rio r in t e ro sse o u s n e rve a w a y fro m t h e o p e ra t ive fie ld
in t e ro sse o u s n e rve d u rin g p o st e rio r a p p ro a ch e s.
■ Disse ct io n sh o u ld re m a in su b p e rio st e a l.
Co m m in u t io n ■ We h a ve a lo w t h re sh o ld fo r e xcisio n o r a rt h ro p la st y in t h e se t t in g o f co m m in u t io n .
Flu o ro sco p y ■ A flu o ro sco p y u n it sh o u ld b e a va ila b le fo r e xa m in a t io n u n d e r a n e st h e sia b e fo re st e rile p re p a ra t io n .
Ha rd w a re ■ Pro st h e t ic ra d ia l h e a d re p la ce m e n t sh o u ld b e d iscu sse d w it h t h e p a t ie n t a s a n o p t io n a n d sh o u ld b e
a va ila b le in t h e ro o m sh o u ld t h e fra ct u re p ro ve t o b e co m m in u t e d .
■ A h in g e d e xt e rn a l fixa t o r sh o u ld b e a va ila b le if in st a b ilit y m a y b e a n issu e .
Exa m in a t io n ■ A t h o ro u g h flu o ro sco p ic e xa m in a t io n is t h e m o st im p o rt a n t fa ct o r in d e cid in g w h a t t re a t m e n t is a p -
p ro p ria t e . To o b t a in a t ru e la t e ra l w e re co m m e n d a b d u ct in g t h e a rm a n d e xt e rn a lly ro t a t in g t h e
sh o u ld e r w h ile p la cin g t h e e lb o w o n t h e im a g e in t e n sifie r.

POSTOPERATIVE CARE RESULTS

■ The elbow is immobilized in a splint for 7 to 10 days. ■ The results of open reduction and internal fixation depend
■ Active range of motion is allowed as soon as tolerable. both on host factors such as the type of fracture, smoking, com-
Supervised therapy may be considered if the patient is not pliance, demand, as well as surgical and rehabilitation protocols.
making adequate progress. ■ In uncomplicated fractures, over 90% satisfactory results

■ Associated injuries may call for more protected range of can be expected.
motion. ■ Complications and resultant secondary procedures will be

■ Light activities of daily living are allowed at 2 weeks, with more likely in cases with undiagnosed instability and associ-
increased weight bearing at 6 weeks. ated injury.
 Ch a p t e r 2 8 ORIF OF RADIAL HEAD AND NECK FRACTURES 241

A B C

FIG 1 1 • A. AP ra d io g ra p h d e m o n st ra t in g a scre w p e n e t ra t in g t h e p ro xim a l ra d io u ln a r jo in t . B,C. Alt h o u g h t h e se lo w -

p ro file im p la n t s w e re a p p a re n t ly w e ll p la ce d , t h is p a t ie n t w e n t o n t o d e ve lo p a va scu la r n e cro sis w it h fra g m e n t a t io n o f
t h e ra d ia l h e a d .

COMPLICATION S 3. Broberg M A, M orrey BF. Results of delayed excision of the radial

■ Stiffness is the most common complication, with loss of
terminal extension, supination, and pronation being most
evident.
■ Arthritis of the radiocapitellar joint or proximal radioulnar
joint
■ H eterotopic ossification
■ Symptomatic hardware may require secondary removal
(FIG 1 1 A).
■ Infection
■ Early and late instability from missed or failed treatment of
associated injuries
■ The rate of avascular necrosis is about 10% , significantly
higher in displaced fractures. This is expected given that the
radial recurrent artery inserts in the safe zone where hardware
is placed. This is generally clinically silent.
■ Loss of reduction
■ N onunion (FIG 1 1 B,C)
REFEREN CES
1. Akesson T, H erbertsson P, Josefsson PO , et al. Primary nonoperative
treatment of moderately displaced two-part fractures of the radial
head. J Bone Joint Surg Am 2006;88A:1909–1914.
2. Boyd H B. Surgical exposure of the ulna and proximal third of the
radius through one incision. Surg Gynecol O bstet 1940;71:86–88.
head after fracture. J Bone Joint Surg Am 1986;68A:669–674.
4. Caputo AE, M azzocca AD, Sontoro VM . The nonarticulating portion
of the radial head: Anatomic and clinical correlations for internal fix-
ation. J H and Surg Am 1998;23A:1082–1090.
5. Essex-Lopresti P. Fractures of the radial head with distal radioulnar
dislocation. J Bone Joint Surg Br 1951;33B:244–250.
6. H erbertsson P, Josefsson PO , H asserius R, et al. Fractures of the
radial head and neck treated with radial head excision. J Bone Joint
Surg Am 2004;86A:1925–1930.
7. Ikeda M , Sugiyama K, Kang C, et al. Comminuted fractures of the
radial head: comparison of resection and internal fixation. J Bone
Joint Surg Am 2006;88A:11–23.
8. Itamura J, Roidis N , Vaishnav S, et al. M RI evaluation of commin-
uted radial head fractures. J Shoulder Elbow Surg 2005;
14:421–424.
9. M organ SJ, Groshen SL, Itamura JM , et al. Reliability evaluation of
classifying radial head fractures by the system of M ason. Bull H osp
Jt Dis 1997;56:95–98.
10. M orrey BF, An KN , Stormont TJ. Force transmission through the ra-
dial head. J Bone Joint Surg Am 1988;70A:250–256.
11. Ring D, Q uintero J, Jupiter JB. O pen reduction and internal fixation
of fractures of the radial head. J Bone Joint Surg Am 2002;84A:
1811–1815.
12. Tang CW, Skaggs DL, Kay RM . Elbow aspiration and arthrogram:
an alternative method. Am J O rthop 2001;30:256.
13. Yamaguchi K, Sweet FA, Bindra R, et al. The extraosseous and in-
traosseous arterial anatomy of the adult elbow. J Bone Joint Surg Am
1997;79A:1653–1662.
 Ch a p t e r 29 Ra d ia l He a d Re p la ce m e n t
Y ish ai Ro se n b lat t an d Grah am J. W . Kin g
DEFIN ITION
■ Radial head fractures are the most common fracture of the
elbow and usually can be managed either nonoperatively or
with open reduction and internal fixation.
■ Radial head arthroplasty is indicated for unreconstructable
displaced radial head fractures with an associated elbow dislo-
cation or a known or possible disruption of the medial collat-
eral, lateral collateral, or interosseous ligaments.16
■ M ost comminuted radial head fractures have an associated
ligament injury, so radial head excision without replacement is
uncommonly indicated in the setting of an acute radial head
fracture.
■ Biomechanical studies have shown that the kinematics and
stability of the elbow are altered by radial head excision, even
in the setting of intact collateral ligaments,15 and are improved
with a metallic radial head arthroplasty.19,23
■ Radial head replacement is also indicated to treat posttrau-
matic conditions such as radial head nonunion and malunion
and to manage elbow or forearm instability after radial head
excision.
AN ATOMY
■ The radial head has a circular concave dish that articulates
with the spherical capitellum and an articular margin that ar-
ticulates with the lesser sigmoid notch of the ulna.
■ The articular dish has an elliptical shape that varies consid-
erably in size and shape and is variably offset from the axis of
the radial neck.
■ There is a poor correlation between the size of the radial
head and the medullary canal of the radial neck, making a
modular implant desirable for an optimal fit. 18
■ Elbow stability is maintained by joint congruity, capsu-
loligamentous integrity, and an intact balanced musculature.
■ The radial head is an important valgus stabilizer of the elbow,
particularly in the setting of an incompetent medial collateral
ligament, which is the primary stabilizer against valgus force.
■ The radial head is also important as an axial stabilizer of the
forearm and resists varus and posterolateral rotatory instabil-
ity by tensioning the lateral collateral ligament.
■ The radial head accounts for up to 60% of the load transfer
across the elbow.11
■ The lateral ulnar collateral ligament is an important stabi-
lizer against varus and posterolateral rotational instability of
the elbow and should be preserved or repaired after radial
head arthroplasty (FIG 1 ).
PATHOGEN ESIS
■ Displaced radial head fractures typically result from a fall
on the outstretched arm.
■ Axial, valgus, and posterolateral rotational patterns of
loading are all thought to be potentially responsible for these
fractures.
242
■ Injuries of the medial collateral or lateral collateral ligament
or the interosseous ligament are typically associated with com-
minuted displaced unreconstructable radial head fractures. 6
■ In more severe injuries, dislocations of the elbow and fore-
arm and fractures of the coronoid, olecranon, and capitellum
can occur and further impair stability.
N ATURAL HISTORY
■ Long-term follow-up studies suggest a high incidence of
radiographic arthritis with radial head excision, although the
incidence of symptomatic arthritis varies widely between se-
ries.4,13,14
■ Biomechanical data have demonstrated an alteration in the
kinematics, load transfer, and stability of the elbow after ra-
dial head excision 3,15 that may lead to premature cartilage
wear of the ulnohumeral joint and secondary pain due to
arthritis.
■ M etallic radial head replacement in elbows with intact liga-
ments restores the kinematics and stability similar to that of a
native radial head and has been shown to provide good clinical
and radiographic outcome in most patients at medium-term
follow-up; however, long-term outcome studies are lacking.3
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ The mechanism of injury is typically a fall on the out-
stretched hand.
■ The patient will complain of pain and limitation of elbow or
forearm motion.
Humerus
Annular ligament
Biceps tendon
Radial
Radius collateral
ligament
Capsule
Triceps
tendon
Ulna Lateral ulnar
collateral ligament
FIG 1 • Th e lig a m e n t s o n t h e la t e ra l a sp e ct o f t h e e lb o w in -
clu d e t h e la t e ra l u ln a r co lla t e ra l lig a m e n t , t h e ra d ia l co lla t e ra l
lig a m e n t , a n d t h e a n n u la r lig a m e n t . Th e la t e ra l u ln a r co lla t e ra l
lig a m e n t is a n im p o rt a n t st a b ilize r a g a in st va ru s a n d p o st e ro la t -
e ra l ro t a t io n a l in st a b ilit y o f t h e e lb o w a n d sh o u ld b e p re se rve d
o r re p a ire d a ft e r ra d ia l h e a d a rt h ro p la st y.

■ A history of forearm or wrist pain should be sought.
■ Inspection may reveal ecchymosis along the forearm or me-
dial aspect of the elbow. Deformity may be evident if there is
an associated dislocation.
■ Careful palpation of the radial head, the medial and lateral
collateral ligaments of the elbow, the interosseous ligament of
the forearm, and the distal radioulnar joint should be per-
formed. Local tenderness over one or all of these structures im-
plies a possible derangement of the relevant structure.
■ Since associated injuries of the shoulder, forearm, wrist, and
hand are common, these areas should be carefully examined.
■ Range of motion, including forearm rotation and elbow
flexion–extension, should be evaluated. The presence of palpa-
ble and auditory crepitus should be noted.
■ Loss of terminal elbow flexion and extension is expected
as a consequence of a hemarthrosis in acute fractures, while
loss of forearm rotation typically is caused by a mechanical
impingement.
■ A careful neurovascular assessment of all three major nerves
that cross the elbow should be performed.
■ The examiner should observe for localized or diffuse
swelling in the elbow. Effusion represents hemarthrosis due to
intra-articular fracture.
■ The examiner should compare active and passive range of
motion to the uninjured side. Reduced range of motion may be
a result of hemarthrosis or mechanical block from a broken
fragment. Intra-articular injection of a local anesthetic helps
differentiate between reduced range of motion due to a me-
chanical block versus pain inhibition.
■ The examiner should look for varus–valgus instability. Any
gapping on the medial or lateral side beneath the examiner’s
hand is noted. Positive findings suggest mediolateral collateral
ligament insufficiency. Typically, this test is positive only when
performed under a general anesthetic.
■ The lateral pivot shift test is performed. Positive apprehen-
sion or a clunk that is seen or felt when the ulna and radius re-
duce on the humerus suggests posterolateral rotatory instability.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Anteroposterior (AP), lateral, and oblique elbow radi-
ographs, with the x-ray beam centered on the radiocapitellar
joint, usually provide sufficient information for the diagnosis
and treatment of radial head fractures.
■ Bilateral posteroanterior radiographs of both wrists in neu-
tral rotation should be performed to evaluate ulnar variance in
patients with wrist discomfort or a comminuted radial head
fracture, since there is a higher incidence of an associated in-
terosseous ligament injury in these patients.6
■ Computed tomography with sagittal, coronal, and 3D re-
constructions may assist with preoperative planning and can
help the surgeon predict whether a displaced radial head frac-
ture can be repaired with open reduction and internal fixation
or if an arthroplasty will likely be needed.
DIFFEREN TIAL DIAGN OSIS
■ Acute radial head fractures
■ O ther fractures or dislocations about the elbow (eg, supra-
condylar, capitellar, coronoid, osteochondral fractures)
■ Radial head nonunion or malunion, posttraumatic arthritis
■ Congenital dislocation of the radial head
■ Forearm or elbow instability
Ch a p t e r 2 9 RADIAL HEAD REPLACEM ENT 243
■ Lateral epicondylitis
■ Rheumatoid arthritis or osteoarthritis
■ Synovitis, inflammatory or infectious
■ Tumors
N ON OPERATIVE MAN AGEMEN T
■ The indications for surgical management of radial head
fractures are not well defined in the literature. Fragment size,
number of fracture fragments, degree of displacement, and
bone quality influence decision making regarding the optimal
management.
■ N ondisplaced fractures or small (less than 33% of radial
head) minimally displaced fractures (less than 2 mm) can be
treated with early motion with an excellent outcome in the
majority of patients.
■ Associated injuries and a block to motion are also important
factors to consider when deciding between nonoperative and
surgical management.
SURGICAL MAN AGEMEN T
■ Small displaced fractures that cause painful crepitus or lim-
ited motion are managed with fragment excision if they are
too small (typically less than 25% of the diameter of the radial
head) or osteopenic to be internally fixated.
■ Larger displaced fractures are typically managed with O RIF
with good outcomes in most patients.
■ Radial head fractures that are displaced but too commin-
uted to be anatomically reduced and stably fixed and that are
too large to consider fragment excision (involve more than a
quarter to a third of the radial head) should be managed by ra-
dial head excision with or without arthroplasty.
■ Patients who are known to have, or are likely to have, an as-
sociated ligamentous injury of the elbow or forearm should
have a radial head arthroplasty because radial head excision is
contraindicated (FIG 2 ).
■ The decision as to what fracture is reconstructable depends
on surgeon factors (eg, experience), patient factors (eg, osteo-
porosis), and fracture factors (eg, fragment number and size,
comminution, associated soft tissue injuries). The final deci-
sion is often made only at the time of surgery.
■ O ther indications for radial head arthroplasty include radial
head nonunion or malunion, primary or secondary manage-
ment of forearm or elbow instability (eg, Essex-Lopresti in-
jury), rheumatoid arthritis or osteoarthritis, and tumors.
Preoperative Planning
■ Currently available devices include spacer implants, press-fit
and ingrowth stems, and bipolar and ceramic articulations.
■ Silicone radial head implants offer little in the way of axial or
valgus stability to the elbow and have been complicated by a
high incidence of implant wear, fragmentation, and silicone syn-
ovitis leading to generalized joint damage. As a result, they have
fallen out of favor and have been replaced by metallic implants.
■ M ost metallic radial head implants that have been devel-
oped and used to date employ a monoblock design, making
size matching suboptimal and implant insertion often difficult
because of the need to subluxate the elbow to allow for inser-
tion of these devices.10
■ Recently, modular metallic radial head prostheses have be-
come available with separate heads and stems, allowing im-
proved size matching of the native radial head and neck 18 and
easier placement in the setting of competent lateral ligaments.17
 244 Se ct io n II SHOULDER AND ELBOW

A C E

B D F

FIG 2 • A,B. AP a n d la t e ra l ra d io g ra p h s o f a 54-ye a r-o ld w o m a n w h o su st a in e d a p o st e ro la t e ra l

e lb o w d islo ca t io n a sso cia t e d w it h a co m m in u t e d fra ct u re o f t h e ra d ia l h e a d a n d co ro n o id —t h e “ t e r-
rib le t ria d .” C,D. Pre o p e ra t ive 3D re co n st ru ct io n im a g e s d e m o n st ra t in g a co m m in u t e d ra d ia l h e a d
fra ct u re w it h a sm a ll u n d isp la ce d co ro n o id fra ct u re . E,F. Po st o p e ra t ive ra d io g ra p h s a ft e r m o d u la r ra -
d ia l h e a d a rt h ro p la st y (Evo lve , Wrig h t Me d ica l Te ch n o lo g y, Arlin g t o n , TN) a n d re p a ir o f t h e la t e ra l
co lla t e ra l lig a m e n t . Me d ia l co lla t e ra l lig a m e n t a n d co ro n o id re p a irs w e re n o t re q u ire d sin ce t h e
e lb o w w a s su fficie n t ly st a b le a t t h e e n d o f t h e p ro ce d u re . A g o o d fu n ct io n a l o u t co m e w a s a ch ie ve d
a t t h e fin a l fo llo w -u p .

■ Precise implant sizing and placement are critical with these Positioning
devices to ensure correct capitellar tracking and to avoid a cam ■ The patient is placed supine on the operating table and a
effect with forearm rotation, which may cause premature
sandbag is placed beneath the ipsilateral scapula to assist in
capitellar wear due to shearing of the cartilage and stem loos-
positioning the arm across the chest.
ening due to increased loading of the stem–bone interface. ■ Alternatively, the patient can be positioned in a lateral posi-
■ Preoperative radiographic templating of the contralateral
tion with the affected arm held over a bolster.2
normal radial head should be employed in the setting of a sec- ■ Prophylactic intravenous antibiotics are administered.
ondary radial head replacement but is not needed for acute ■ General or regional anesthesia is employed.
fractures because the excised radial head is available for accu- ■ A sterile tourniquet is applied.
rate implant sizing.
TECHNIQUES

SURGICAL APPROACH
■ A m id lin e p o st e rio r e lb o w in cisio n is m a d e ju st la t e ra l t o
t h e t ip o f t h e o le cra n o n (TECH FIG 1 A).
■ A fu ll-t h ickn e ss la t e ra l fa scio cu t a n e o u s fla p is e le va t e d
o n t h e d e e p fa scia . Th is e xt e n sile in cisio n d e cre a se s t h e
risk o f cu t a n e o u s n e rve in ju ry a n d p ro vid e s a cce ss t o t h e
ra d ia l h e a d , co ro n o id , a n d m e d ia l a n d la t e ra l co lla t e ra l
lig a m e n t s fo r t h e m a n a g e m e n t o f m o re co m p le x in ju rie s
(TECH FIG 1 B). 8,22
■ Alt e rn a t ive ly, a la t e ra l skin in cisio n ce n t e re d o ve r t h e la t -
e ra l e p ico n d yle a n d p a ssin g o b liq u e ly o ve r t h e ra d ia l
h e a d ca n b e u se d (se e Te ch Fig 1A).
 Ch a p t e r 2 9 RADIAL HEAD REPLACEM ENT 245

TECHNIQUES
Extensor carpi
radialis longus

Extensor digitorum
communis

Triceps

Anconeus
Extensor carpi
A B ulnaris

TECH FIG 1 • A. Th e p a t ie n t is p la ce d su p in e o n t h e o p e ra t in g t a b le a n d a sa n d b a g is p la ce d b e n e a t h t h e ip sila t e ra l sca p u la

t o a ssist in p o sit io n in g t h e a rm a cro ss t h e ch e st . Th e p o st e rio r in cisio n is in d ica t e d in re d . Alt e rn a t ive ly, a la t e ra l skin in ci-
sio n ce n t e re d o ve r t h e la t e ra l e p ico n d yle a n d p a ssin g o b liq u e ly o ve r t h e ra d ia l h e a d ca n b e u se d (b lu e ). B. A m id lin e p o s-
t e rio r e lb o w in cisio n m a d e ju st la t e ra l t o t h e t ip o f t h e o le cra n o n . A fu ll-t h ickn e ss la t e ra l fa scio cu t a n e o u s fla p is e le va t e d
o n t h e d e e p fa scia . Th is e xt e n sile in cisio n a llo w s a cce ss t o b o t h t h e la t e ra l a n d m e d ia l a sp e ct s o f t h e e lb o w , in ca se o f m o re
co m p le x in ju rie s, a n d re d u ce s t h e in cid e n ce o f cu t a n e o u s n e rve in ju ry.

COMMON EXTENSOR SPLIT

■ Th e e xt e n so r d ig it o ru m co m m u n is t e n d o n is id e n t ifie d . Radial collateral
■ Th e la n d m a rks fo r t h is p la n e a re a lin e jo in in g t h e la t - ligament Extensor carpi
radialis longus
e ra l e p ico n d yle a n d t h e t u b e rcle o f List e r.
■ Th e e xt e n so r d ig it o ru m co m m u n is t e n d o n is sp lit lo n g i- Extensor digitorum
t u d in a lly a t t h e m id d le a sp e ct o f t h e ra d ia l h e a d , a n d t h e communis
u n d e rlyin g ra d ia l co lla t e ra l a n d a n n u la r lig a m e n t s a re in -
cise d (TECH FIG 2 A).
■ Disse ct io n sh o u ld st a y a n t e rio r t o t h e la t e ra l u ln a r
co lla t e ra l lig a m e n t t o p re ve n t t h e d e ve lo p m e n t o f
p o st e ro la t e ra l ro t a t o ry in st a b ilit y (se e Fig 1).
Triceps
■ Th e fo re a rm is m a in t a in e d in p ro n a t io n t o m o ve t h e
p o st e rio r in t e ro sse o u s n e rve m o re d ist a l a n d m e d ia l
d u rin g t h e su rg ica l a p p ro a ch .7
■ If fu rt h e r e xp o su re is re q u ire d :
■ Th e h u m e ra l o rig in o f t h e ra d ia l co lla t e ra l lig a m e n t
a n d t h e o ve rlyin g e xt e n so r m u scle s a re e le va t e d a n t e -
rio rly o ff t h e la t e ra l e p ico n d yle t o im p ro ve t h e e xp o -
su re if n e e d e d (TECH FIG 2 B). Anconeus
Extensor carpi
■ Re le a se o f t h e p o st e rio r co m p o n e n t o f t h e la t e ra l co l-
A ulnaris
la t e ra l lig a m e n t ca n b e co n sid e re d , b u t ca re fu l lig a -
m e n t re p a ir is re q u ire d a t t h e e n d o f t h e p ro ce d u re in TECH FIG 2 • A. Th e e xt e n so r d ig it o ru m co m m u n is t e n d o n
o rd e r t o re st o re t h e va ru s a n d p o st e ro la t e ra l ro t a t o ry is sp lit lo n g it u d in a lly a t t h e m id d le a sp e ct o f t h e ra d ia l h e a d
st a b ilit y o f t h e e lb o w .9 a n d t h e u n d e rlyin g ra d ia l co lla t e ra l a n d a n n u la r lig a m e n t s
a re in cise d . Th e fo re a rm is p ro n a t e d t o p ro t e ct t h e p o st e rio r
in t e ro sse o u s n e rve . (co n t in u e d )
 246 Se ct io n II SHOULDER AND ELBOW

Radial collateral
TECHNIQUES

Extensor carpi
ligament
radialis longus
Extensor digitorum
communis

TECH FIG 2 • (co n t in u e d ) B. Th e h u m e ra l o rig in o f t h e ra -

d ia l co lla t e ra l lig a m e n t a n d t h e o ve rlyin g e xt e n so r m u scle s
Extensor carpi a re e le va t e d a n t e rio rly o ff t h e la t e ra l e p ico n d yle t o im -
B ulnaris p ro ve t h e e xp o su re if n e e d e d .

PREPARATION OF THE RADIAL HEAD AND NECK

■ All fra g m e n t s o f t h e ra d ia l h e a d a re re m o ve d , a s w e ll a s
a m in im a l a m o u n t o f ra d ia l n e ck a t a rig h t a n g le t o t h e
m e d u lla ry ca n a l, t o m a ke a sm o o t h su rfa ce fo r se a t in g o f
t h e p ro st h e t ic ra d ia l h e a d .
■ Co m p le t e fra g m e n t e xcisio n ca n b e co n firm e d w it h
t h e u se o f a n im a g e in t e n sifie r.
■ Th e ca p it e llu m is e va lu a t e d fo r ch o n d ra l in ju rie s o r o s-
t e o ch o n d ra l fra ct u re s.
■ Th e ra d ia l h e a d p ro st h e sis is size d in o n e o f se ve ra l w a ys:
■ Th e re se ct e d ra d ia l h e a d is re a sse m b le d in t h e p ro -
vid e d sizin g t e m p la t e t o a ssist in t h e a ccu ra t e sizin g
o f t h e p ro st h e sis (TECH FIG 3 A–C).
■ Th e d ia m e t e r o f ra d ia l h e a d p ro st h e sis sh o u ld b e
b a se d o n t h e size o f t h e a rt icu la r d ish . Th is is t yp ica lly
2 m m sm a lle r t h a n t h e o u t e r d ia m e t e r o f t h e e xcise d
ra d ia l h e a d .
■ Alternatively, if th e radial head has been previou sly ex-
cised, radiograph ic templating of the contralateral nor-
mal radial he ad may be u sed to determine the appro-
p riate diameter and he igh t of th e radial he ad implant.
■ If t h e n a t ive ra d ia l h e a d is in b e t w e e n a va ila b le im -
p la n t size s, t h e im p la n t d ia m e t e r o r t h ickn e ss sh o u ld
b e d o w n size d .
■ Th e ra d ia l n e ck is d e live re d la t e ra lly u sin g a Ho h m a n n re -
t ra ct o r ca re fu lly p la ce d a ro u n d t h e p o st e rio r a sp e ct o f
t h e p ro xim a l ra d ia l n e ck (TECH FIG 3 D).
■ An a n t e rio rly b a se d re t ra ct o r sh o u ld b e a vo id e d b e -
ca u se o f t h e risk o f in ju ry fro m p re ssu re o n t h e p o st e -
rio r in t e ro sse o u s n e rve .
■ Th e m e d u lla ry ca n a l o f t h e ra d ia l n e ck is re a m e d u sin g
h a n d re a m e rs u n t il co rt ica l co n t a ct is e n co u n t e re d .
■ A t ria l st e m o n e size sm a lle r t h a n t h e ra sp is in se rt e d
t o a ch ie ve a n o n t ig h t p re ss-fit .

A B

TECH FIG 3 • Th e re se ct e d ra d ia l h e a d is re a sse m b le d in t h e p ro vid e d sizin g t e m p la t e (A) t o a ssist in

t h e a ccu ra t e sizin g o f t h e p ro st h e sis in t e rm s o f d ia m e t e r (B) (co n t in u e d )
 Ch a p t e r 2 9 RADIAL HEAD REPLACEM ENT 247

Capitellum

TECHNIQUES
Fractured
radial head

Anconeus

Hohmann Lateral ulnar

C D retractor collateral ligament

TECH FIG 3 • (co n t in u e d ) a n d h e ig h t (C), a n d t o e n su re t h a t a ll t h e fra g m e n t s h a ve b e e n re m o ve d fro m t h e

e lb o w . D. Th e ra d ia l n e ck is d e live re d la t e ra lly u sin g a Ho h m a n n re t ra ct o r ca re fu lly p la ce d a ro u n d t h e p o st e rio r
a sp e ct o f t h e p ro xim a l ra d ia l n e ck. An a n t e rio rly b a se d re t ra ct o r sh o u ld b e a vo id e d b e ca u se o f t h e risk o f in ju ry
t o t h e p o st e rio r in t e ro sse o u s n e rve .

RADIAL HEAD REPLACEMENT

■ A t ria l h e a d is in se rt e d o n t o t h e st e m , a n d t h e d ia m e t e r,
h e ig h t , t ra ckin g , a n d co n g ru e n cy o f t h e p ro st h e sis a re
e va lu a t e d b o t h visu a lly a n d w it h t h e a id o f a n im a g e in -
t e n sifie r.
■ Th e rad ial h ead pro sth esis sho uld articu late at th e same
height as the radial notch of the ulna and about 1 mm
distal to the tip of the coronoid (TECH FIG 4 A).
■ Th e a lig n m e n t o f t h e d ist a l ra d io u ln a r jo in t , u ln a r
va ria n ce , a s w e ll a s t h e w id t h o f t h e la t e ra l a n d m e -
d ia l p o rt io n s o f t h e u ln o h u m e ra l jo in t , a re ch e cke d
a n d co m p a re d t o t h e co n t ra la t e ra l w rist a n d e lb o w ,
re sp e ct ive ly, u n d e r flu o ro sco p y.
■ Ove rle n g t h e n in g t h e ra d io ca p it e lla r jo in t w it h a ra -
d ia l h e a d im p la n t t h a t is t o o t h ick sh o u ld b e a vo id e d
t o re d u ce t h e risk o f ca rt ila g e w e a r o n t h e ca p it e llu m
fro m e xce ssive p re ssu re ; a n o n p a ra lle l m e d ia l u ln o -
h u m e ra l jo in t sp a ce t h a t is w id e r la t e ra lly is su g g e s-
t ive o f o ve rst u ffin g .
■ So m e m o d u la r a n d b ip o la r im p la n t s a llo w in se rt io n o f
t h e st e m first , t h e n p la ce m e n t o f t h e h e a d o n t o t h e
st e m w it h co u p lin g in sit u , w h ich sig n ifica n t ly re d u ce s
t h e su rg ica l e xp o su re n e e d e d (TECH FIG 4 B).
■ If t h e p ro st h e sis is m a lt ra ckin g o n t h e ca p it e llu m w it h
fo re a rm ro t a t io n , a sm a lle r st e m size sh o u ld b e t ria le d t o
e n su re t h a t t h e a rt icu la t io n o f t h e ra d ia l h e a d w it h t h e
ca p it e llu m is co n t ro lle d b y t h e a n n u la r lig a m e n t a n d a r-
t icu la r co n g ru e n cy a n d n o t d ict a t e d b y t h e p ro xim a l ra -
d ia l sh a ft .

A B

TECH FIG 4 • A. A t ria l st e m is in se rt e d . A t ria l h e a d is in se rt e d o n t o t h e st e m a n d t h e d ia m e t e r, h e ig h t , t ra ckin g , a n d co n -

g ru e n cy o f t h e p ro st h e sis a re e va lu a t e d b o t h visu a lly a n d w it h t h e a id o f a n im a g e in t e n sifie r. B. So m e m o d u la r a n d b ip o -
la r im p la n t s a llo w in se rt io n o f t h e st e m first , t h e n p la ce m e n t o f t h e h e a d o n t o t h e st e m w it h co u p lin g in sit u , w h ich sig -
n ifica n t ly re d u ce s t h e su rg ica l e xp o su re n e e d e d .
 248 Se ct io n II SHOULDER AND ELBOW
TECHNIQUES

LATERAL SOFT TISSUE CLOSURE

■ Aft e r ra d ia l h e a d re p la ce m e n t , t h e la t e ra l co lla t e ra l lig a -
m e n t a n d e xt e n so r m u scle o rig in s a re re p a ire d b a ck t o
t h e la t e ra l co n d yle .
■ If t h e p o st e rio r h a lf o f t h e la t e ra l co lla t e ra l lig a m e n t is
st ill a t t a ch e d t o t h e la t e ra l e p ico n d yle , t h e n t h e a n t e rio r
h a lf o f t h e la t e ra l co lla t e ra l lig a m e n t (t h e a n n u la r lig a -
m e n t a n d ra d ia l co lla t e ra l lig a m e n t ) a n d e xt e n so r m u s-
cle s a re re p a ire d t o t h e p o st e rio r h a lf u sin g in t e rru p t e d
a b so rb a b le su t u re s (TECH FIG 5 A).
■ If t h e la t e ra l co lla t e ra l lig a m e n t a n d e xt e n so r o rig in h a ve
b e e n co m p le t e ly d e t a ch e d e it h e r b y t h e in ju ry o r su rg ica l
e xp o su re , t h e y sh o u ld b e se cu re ly re p a ire d le ss e q u a lize
t o t h e la t e ra l e p ico n d yle u sin g d rill h o le s t h ro u g h b o n e
a n d n o n a b so rb a b le su t u re s o r su t u re a n ch o rs.
■ A sin g le d rill h o le is p la ce d a t t h e a xis o f m o t io n (t h e
ce n t e r o f t h e a rc o f cu rva t u re o f t h e ca p it e llu m ) a n d
co n n e ct e d t o t w o d rill h o le s p la ce d a n t e rio r a n d p o s-
t e rio r t o t h e la t e ra l su p ra co n d yla r rid g e .
■ A lo ckin g (Kra cko w ) su t u re t e ch n iq u e is e m p lo ye d t o
g a in a se cu re h o ld o f t h e la t e ra l co lla t e ra l lig a m e n t
a n d co m m o n e xt e n so r m u scle fa scia (TECH FIG
5 B–D).
■ The ligament sutures are pulled into t he holes drilled in
t he d istal h u meru s u sing su tu re ret rievers an d th e fore-
arm is pronat ed, and varus forces are avoided, while
t ensio n in g t he su tu res befo re tyin g (TECH FIG 5E).
■ Th e kn o t s sh o u ld b e le ft a n t e rio r o r p o st e rio r t o t h e
la t e ra l su p ra co n d yla r rid g e t o a vo id p ro m in e n ce .

Radial collateral
ligament

Extensor digitorum
communis

Extensor carpi
A ulnaris B

C D

TECH FIG 5 • A. If t h e p o st e rio r h a lf o f t h e la t e ra l co lla t e ra l lig a m e n t is st ill a t t a ch e d t o t h e la t e ra l e p ico n d yle ,

t h e n t h e a n t e rio r h a lf o f it (t h e a n n u la r lig a m e n t a n d ra d ia l co lla t e ra l lig a m e n t ) a n d e xt e n so r m u scle s a re re -
p a ire d t o t h e p o st e rio r h a lf u sin g in t e rru p t e d a b so rb a b le su t u re s. ECU, e xt e n so r ca rp i u ln a ris; EDC, e xt e n so r d ig -
it o ru m co m m u n is. B–D. If t h e la t e ra l co lla t e ra l lig a m e n t a n d e xt e n so r o rig in h a ve b e e n co m p le t e ly d isru p t e d b y
t h e in ju ry o r d e t a ch e d b y t h e su rg ica l e xp o su re , t h e y sh o u ld b e se cu re ly re p a ire d t o t h e la t e ra l e p ico n d yle . A sin -
g le d rill h o le is p la ce d a t t h e ce n t e r o f t h e a rc o f cu rva t u re o f t h e ca p it e llu m a n d co n n e ct e d t o t w o d rill h o le s
p la ce d a n t e rio r a n d p o st e rio r t o t h e la t e ra l su p ra co n d yla r rid g e . A lo ckin g (Kra cko w ) su t u re t e ch n iq u e is e m -
p lo ye d t o g a in a se cu re h o ld o f t h e la t e ra l co lla t e ra l lig a m e n t (B) a s w e ll a s o f t h e a n n u la r lig a m e n t (C). D. A se c-
o n d st it ch is u se d in a sim ila r m a n n e r t o re p a ir t h e co m m o n e xt e n so r m u scle fa scia . (co n t in u e d )
 Ch a p t e r 2 9 RADIAL HEAD REPLACEM ENT 249

TECHNIQUES
TECH FIG 5 • (co n t in u e d ) E. Th e su t u re s a re p u lle d in t o t h e
h o le s d rille d in t h e d ist a l h u m e ru s u sin g su t u re re t rie ve rs,
t e n sio n e d w h ile ke e p in g t h e fo re a rm p ro n a t e d a n d w h ile
a vo id in g va ru s fo rce s, a n d e ve n t u a lly t ie d o ve r t h e la t e ra l
E su p ra co n d yla r rid g e .

COMPLETION
■ Aft e r re p la ce m e n t a rt h ro p la st y a n d la t e ra l so ft t issu e clo -
su re , t h e e lb o w sh o u ld b e p la ce d t h ro u g h a n a rc o f fle x-
io n –e xt e n sio n w h ile ca re fu lly e va lu a t in g fo r e lb o w st a -
b ilit y in p ro n a t io n , n e u t ra l, a n d su p in a t io n .2
■ Pronation is g enerally b eneficial if the lateral ligaments are
deficient,9 supination if the medial ligaments are defi-
cient,1 and neutral position if both sides have been injured.
■ In p a t ie n t s w h o h a ve a n a sso cia t e d e lb o w d islo ca t io n ,
a d d it io n a l re p a ir o f t h e m e d ia l co lla t e ra l lig a m e n t a n d
fle xo r p ro n a t o r o rig in sh o u ld b e p e rfo rm e d if t h e e lb o w
su b lu xa t e s a t 40 d e g re e s o r m o re o f fle xio n .
■ To u rn iq u e t d e fla t io n a n d h e m o st a sis sh o u ld b e se cu re d
b e fo re w o u n d clo su re .

KÖCHER APPROACH
■ Alt e rn a t ive ly, t h e ra d ia l h e a d m a y b e a p p ro a ch e d b y
u sin g t h e Kö ch e r in t e rva l20 b e t w e e n t h e e xt e n so r ca rp i Radial collateral
u ln a ris a n d a n co n e u s. ligament
■ Th e fa scia l in t e rva l b e t w e e n t h e se m u scle s is id e n t ifie d
b y n o t in g t h e d ive rg in g d ire ct io n o f t h e m u scle g ro u p s
a n d sm a ll va scu la r p e rfo ra t o rs t h a t e xit a t t h is in t e rva l Annular ligament
(TECH FIG 6 ).
■ Ca re sh o u ld b e t a ke n t o p re se rve t h e la t e ra l u ln a r co lla t -
e ra l lig a m e n t , w h ich is vu ln e ra b le a s t h e d isse ct io n is ca r-
rie d d e e p e r t h ro u g h t h e ca p su le .

Triceps

TECH FIG 6 • Th e e xt e n so r ca rp i u ln a ris is e le va t e d a n t e rio rly

a n d a n a rt h ro t o m y is p e rfo rm e d a t t h e m id p o rt io n o f t h e ra - Anconeus
d ia l h e a d . Ca re sh o u ld b e t a ke n t o p re se rve t h e la t e ra l u ln a r Extensor carpi
co lla t e ra l lig a m e n t , w h ich is vu ln e ra b le a s t h e d isse ct io n is ulnaris Lateral ulnar
ca rrie d d e e p e r t h ro u g h t h e ca p su le . collateral ligament
250 Se ct io n II SHOULDER AND ELBOW

PEARLS AND PITFALLS

In d ica t io n s ■ Disp la ce d u n re co n st ru ct a b le fra ct u re o f t h e ra d ia l h e a d w it h kn o w n o r p ro b a b le a sso cia t e d m e d ia l o r la t e ra l
co lla t e ra l o r in t e ro sse o u s lig a m e n t in ju ry
Pe a rls ■ A p re o p e ra t ive ra d io g ra p h ic t e m p la t e o f t h e co n t ra la t e ra l n a t ive ra d ia l h e a d sh o u ld b e u se d in t h e se t t in g o f a
se co n d a ry ra d ia l h e a d re p la ce m e n t .
■ Disse ct io n sh o u ld st a y a n t e rio r t o t h e la t e ra l u ln a r co lla t e ra l lig a m e n t t o p re ve n t t h e d e ve lo p m e n t o f
p o st e ro la t e ra l ro t a t o ry in st a b ilit y.
■ Th e ra d ia l h e a d sh o u ld b e size d b a se d o n t h e d ia m e t e r o f t h e a rt icu la r d ish a n d t h ickn e ss o f t h e e xcise d ra d ia l
head.
■ Th e ra d ia l h e a d im p la n t is t yp ica lly 2 m m sm a lle r t h a n t h e o u t e r d ia m e t e r o f t h e ra d ia l h e a d .
■ Ra d ia l h e a d a rt icu la r su rfa ce h e ig h t sh o u ld b e a t t h e le ve l o f t h e p ro xim a l ra d io u ln a r jo in t .
■ If t h e ra d ia l h e a d d o e s n o t t ra ck w e ll o n t h e ca p it e llu m , t h e st e m sh o u ld b e d o w n size d .
■ If t h e n a t ive ra d ia l h e a d is in b e t w e e n im p la n t size s, t h e im p la n t sh o u ld , in g e n e ra l, b e d o w n size d .
■ In t ra o p e ra t ive flu o ro sco p y is u se d t o a sse ss t h e a lig n m e n t o f t h e ra d io ca p it e lla r a n d d ist a l ra d io u ln a r jo in t s a n d
t o a vo id o ve rle n g t h e n in g o f t h e ra d iu s.
Pit fa lls ■ Ho h m a n n re t ra ct o rs sh o u ld n o t b e u se d a ro u n d t h e a n t e rio r a sp e ct o f t h e ra d ia l n e ck a n d t h e fo re a rm sh o u ld b e
ke p t p ro n a t e d t o a vo id d a m a g e t o t h e p o st e rio r in t e ro sse o u s n e rve .
■ Th e su rg e o n sh o u ld a vo id o ve rst u ffin g t h e t h ickn e ss o r d ia m e t e r o f t h e ra d ia l h e a d b e ca u se o f t h e risk o f ca p it e l-
la r w e a r a n d p a in . Fillin g t h e g a p b e t w e e n t h e ca p it e llu m a n d ra d ia l n e ck is n o t a u se fu l la n d m a rk fo r p ro st h e sis
t h ickn e ss b e ca u se la t e ra l so ft t issu e s a re o ft e n d e ficie n t o w in g t o t h e su rg ica l e xp o su re o r in it ia l in ju ry.

POSTOPERATIVE CARE ligaments are deficient, 9 supination if the medial ligaments

■ The elbow with stable ligaments should be splinted using an-
terior plaster slabs in extension and elevated for 24 to 48 hours
to diminish swelling, decrease tension on the posterior wound,
and minimize the tendency to develop a flexion contracture.
■ In the setting of a more tenuous ligamentous repair or the
presence of some residual instability at the end of the operative
procedure, the elbow should initially be splinted in 60 to 90
degrees of flexion in the optimal position of forearm rotation
to maintain stability.
■ Perioperative antibiotics are continued for 24 hours postop-
eratively.
■ Indomethacin 25 mg three times daily for 3 weeks may be
considered in patients undergoing radial head arthroplasty to
decrease postoperative pain, reduce swelling, and potentially
lower the incidence of heterotopic ossification.
■ Indomethacin should be avoided in elderly patients and
those with a history of peptic ulcer disease, asthma, known al-
are deficient, 1 and neutral position if both sides have been
injured.
■ A resting splint with the elbow maintained at 90 degrees
and the forearm in the appropriate position of forearm ro-
tation is employed for 3 to 6 weeks.
■ Passive stretching is not permitted for 6 weeks to reduce the
incidence of heterotopic ossification.
■ Strengthening exercises are initiated once the ligament in-
juries and any associated fractures have adequately healed,
usually at 8 weeks postoperatively.
OUTCOMES
■ Silicone radial head arthroplasty, while initially successful in
many patients,5,24 has fallen out of favor because of problems
with residual instability and arthritis, implant fracture, and sil-
icone synovitis due to particulate debris.25
■ While the short- and medium-term results of metallic radial

lergy, or other contraindications to anti-inflammatory medica- head implants are encouraging, there is a paucity of literature
tions. demonstrating the long-term outcome with respect to loosen-
■ For an isolated radial head replacement treated with a lat- ing, capitellar wear, and arthritis.
eral ulnar collateral ligament-sparing approach, active range ■ M etallic radial head replacement in elbows with intact lig-

of motion should be initiated on the day after surgery.
■ A collar and cuff with the elbow maintained at 90 degrees
is employed for comfort between exercises.
■ A static progressive extension splint is fabricated for
nighttime use for patients without associated ligamentous
disruptions and is employed for a period of 12 weeks. The
splint is adjusted weekly as extension improves.
aments restores the kinematics and stability similar to that
measured with a native radial head. M oreover, when the
fractured radial head occurs in combination with ligamen-
tous and soft tissue disruption, a metallic prosthesis restores
elbow stability, with only mild residual deficits in strength
and motion.
■ M oro et al21 reported the functional outcome of 25 cases

■ In patients with associated elbow dislocations or residual
instability, extension splinting is not implemented until 6
weeks after surgery.
■ Patients with associated fractures, dislocations, or ligamen-
tous injuries should commence active flexion and extension
managed with a metallic radial head arthroplasty for unrecon-
structable fractures of the radial head at an average follow-up
of 39 months. The results were rated as 17 good or excellent,
5 fair, and 3 poor.
■ The radial head prosthesis restored elbow stability when

motion within a safe arc 1 day postoperatively.
■ Active forearm rotation is performed with the elbow in
flexion to minimize stress on the medial or lateral ligamen-
tous injuries or repairs.
■ Extension is performed with the forearm in the appro-
the fractured radial head occurred in combination with a
dislocation of the elbow, rupture of the medial collateral lig-
ament, fracture of the coronoid, or fracture of the proximal
ulna.
■ There were mild residual deficits in strength and motion,

priate rotational position—that is, pronation if the lateral and no patient required removal of the implant.

■ H arrington et al12 reported their experience with metallic
radial head arthroplasty in 20 patients at an average follow-up
of 12 years. The results were excellent or good in 16 and fair
or poor in 4.
■ Improvements in radial head arthroplasty designs, sizing,
and implantation techniques may lead to improved outcomes
for unreconstructable radial head fractures.
COMPLICATION S
■ Posterior interosseous nerve injury can occur as a conse-
quence of dissection distal to the radial tuberosity and place-
ment of anterior retractors around the distal radial neck.
■ Infection
■ Loss of motion, mainly terminal extension due to capsular
contracture, heterotopic ossification, or retained cartilaginous
or osseous fragments
■ Prosthetic loosening or polyethylene wear
■ Capitellar wear and pain due to implant overstuffing
■ Complex regional pain syndrome
■ Instability or recurrent dislocations of the elbow due to an
inadequate or failed ligament repair
■ O steoarthritis of the capitellum as a consequence of articu-
lar cartilage damage from the initial injury, from component
insertion, from persistent instability, or due to loading from a
radial head implant that is too thick.
REFEREN CES
1. Armstrong AD, Dunning CE, Faber KJ, et al. Rehabilitation of the
medial collateral ligament-deficient elbow: an in vitro biomechanical
study. J H and Surg Am 2000;25A:1051–1057.
2. Bain GI, Ashwood N , Baird R, et al. M anagement of M ason type III
radial head fractures with a titanium prosthesis, ligament repair, and
early mobilization. J Bone Joint Surg Am 2005;87A:136–147.
3. Beingessner DM , Dunning CE, Gordon KD, et al. The effect of radial
head excision and arthroplasty on elbow kinematics and stability. J
Bone Joint Surg Am 2004;86A:1730–1739.
4. Boulas H J, M orrey BF. Biomechanical evaluation of the elbow fol-
lowing radial head fracture: comparison of open reduction and inter-
nal fixation versus excision, Silastic replacement and non-operative
management. Ann Chir M ain 1998;17:314–320.
5. Carn RM , M edige J, Curtain D, et al. Silicone rubber replacement of
the severely fractured radial head. Clin O rthop Relat Res 1986;209:
259–269.
6. Davidson PA, M oseley JB Jr, Tullos H S. Radial head fracture: a po-
tentially complex injury. Clin O rthop Relat Res 1993;297:224–230.
Ch a p t e r 2 9 RADIAL HEAD REPLACEM ENT 251
7. Diliberti T, Botte M J, Abrams RA. Anatomical considerations re-
garding the posterior interosseous nerve during posterolateral ap-
proaches to the proximal part of the radius. J Bone Joint Surg Am
2000;82A:809–813.
8. Dowdy PA, Bain GI, King GJ, et al. The midline posterior elbow inci-
sion: an anatomical appraisal. J Bone Joint Surg Br 1995;77B:696–699.
9. Dunning CE, Z arzour Z D, Patterson SD, et al. M uscle forces and
pronation stabilize the lateral ligament deficient elbow. Clin O rthop
Relat Res 2001;388:118–124.
10. Gupta GG, Lucas G, H ahn DL. Biomechanical and computer analy-
sis of radial head prostheses. J Shoulder Elbow Surg 1997;6:37–48.
11. H alls AA, Travill A. Transmission of pressures across the elbow joint.
Anat Rec 1964;150:243–248.
12. H arrington IJ, Sekyi-O tu A, Barrington TW, et al. The functional
outcome with metallic radial head implants in the treatment of unsta-
ble elbow fractures: a long-term review. J Trauma 2001;50:46–52.
13. Ikeda M , O ka Y. Function after early radial head resection for frac-
ture: a retrospective evaluation of 15 patients followed for 3–18
years. Acta O rthop Scand 2000;71:191–194.
14. Janssen RP, Vetger J. Resection of the radial head after M ason type
III fracture of the elbow. J Bone Joint Surg Br 1998;80B:231–233.
15. Jensen SL, O lsen BS, Sojbjerg JO . Elbow joint kinematics after exci-
sion of the radial head. J Shoulder Elbow Surg 1999;8:238–241.
16. Johnston GW. A follow-up of one hundred cases of fracture of the
head of the radius with a review of the literature. Ulster M ed J
1962;31:51–56.
17. King GJ. M anagement of radial head fractures with implant arthro-
plasty. J Am Soc Surg H and 2004;4:11–26.
18. King GJ, Z arzour Z D, Patterson SD, et al. An anthropometric study
of the radial head: implications in the design of a prosthesis. J
Arthroplasty 2001;16:112–116.
19. King GJ, Z arzour Z D, Rath DA, et al. M etallic radial head arthro-
plasty improves valgus stability of the elbow. Clin O rthop Relat Res
1999;368:114–125.
20. Köcher T. Textbook of O perative Surgery. London: Adam and
Charles Black, 1911.
21. M oro JK, Werier J, M acDermid JC, et al. Arthroplasty with a metal
radial head for unreconstructible fractures of the radial head. J Bone
Joint Surg Am 2001;83A:1201–1211.
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Clin O rthop Relat Res 2000;370:19–33.
23. Pomianowski S, M orrey BF, N eale PG, et al. Contribution of
monoblock and bipolar radial head prostheses to valgus stability of
the elbow. J Bone Joint Surg Am 2001;83A:1829–1834.
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radial head: the role of silicone-implant replacement arthroplasty. J
Bone Joint Surg Am 1981;63A:1039–1049.
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 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 30 Fix a t io n o f Ole cr a n o n
Fr a ct u re s
David Rin g

DEFIN ITION ■ A secondary survey is performed to identify any other frac-

tures, ipsilateral arm injuries in particular.
■ Fracture of the olecranon process is common, usually dis- ■ The skin is carefully inspected for any wounds associated
placed, and nearly always treated operatively.
■ Important injury characteristics include displacement, com-
with the fracture.
■ The pulses are palpated, capillary refill inspected, and an
minution, and subluxation or dislocation of the elbow, and all
Allen test performed if necessary.
are accounted for in the M ayo classification (FIG 1 ).6 ■ Peripheral nerve function is assessed.
■ Fracture-dislocations of the olecranon can be anterior
■ Patients with high-energy injuries, particularly those with
(trans-olecranon) or posterior (the most proximal type of
ipsilateral wrist or forearm injuries, are at risk for compart-
posterior M onteggia according to Jupiter and colleagues3 ) in
ment syndrome. If the clinical examination is suggestive or un-
direction.2,3,9,10
■ O pen injuries are unusual.
reliable (owing to problems with mental status), compartment
pressure monitoring should be performed.
AN ATOMY
■ The greater sigmoid notch of the ulna is formed by the coro-
noid and olecranon processes and forms a nearly 180-degree
arc capturing the trochlea. Type I - undisplaced
■ The region between the coronoid and olecranon articular

facets is the nonarticular transverse groove of the olecranon, a

common location of fracture and a place where precise articu-
lar reduction is not critical.
■ The triceps has a broad and thick insertion from just supe-

rior to the point of the olecranon and the tip of the olecranon
process that can be used to enhance fixation of small, osteo-
porotic, or fragmented fractures and can be split longitudi-
nally, if needed, when applying a plate.

PATHOGEN ESIS Type II - displaced/stable

■ Fractures of the olecranon are most often the result of a di-

rect blow to the point of the elbow, but occasionally they re-
sult from indirect forces during a fall on the outstretched hand.

N ATURAL HISTORY
■ Stable nondisplaced or minimally displaced fractures are
uncommon.
■ The majority of olecranon fractures are displaced and bene-

fit from operative treatment.

Noncomminuted Comminuted
■ The occasional untreated displaced simple olecranon frac-
Type III - unstable
ture demonstrates a slight flexion contracture, some weakness
of extension, no arthrosis, and little if any pain.
■ In contrast, undertreated or poorly treated fracture-disloca-

tions lead to severe arthrosis with or without instability.

■ Even well-treated complex injuries are at risk for stiffness,

heterotopic ossification, arthrosis, and occasionally nonunion.

PATIEN T HISTORY AN D PHYSICAL

FIN DIN GS
■ Knowledge of the characteristics of the patient (age, gender,
medical health) and the injury (mechanism, energy) will help the
surgeon understand the injury and determine optimal treatment.
■ First the patient is assessed for life-threatening injuries
(ATLS protocol) and any medical problems that may have
contributed to the injury.
Noncomminuted Comminuted
FIG 1 • Th e Ma yo cla ssifica t io n o f o le cra n o n fra ct u re s a cco u n t s
fo r t h e fa ct o rs t h a t w ill in flu e n ce t re a t m e n t d e cisio n s: d isp la ce -
m e n t , co m m in u t io n , a n d d islo ca t io n o r su b lu xa t io n o f t h e
a rt icu la t io n s.

252
 Ch a p t e r 3 0 ORIF OF OLECRANON FRACTURES 253

IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Anteroposterior (AP) and lateral radiographs are used for
initial characterization of the injury.
■ Radiographs after reduction or splinting, or oblique views
can be useful.
■ Computed tomography (CT) is useful for characterization
of fracture-dislocations. In particular, 3D CT reconstructions
can be useful for assessment of the coronoid and radial head.
DIFFEREN TIAL DIAGN OSIS
■ Transverse, noncomminuted fractures not associated with
fracture-dislocation are treated with tension band wiring.4,8
■ Comminuted fractures and fracture-dislocations are treated
with dorsal contoured plate and screw fixation. 1–3
■ The treatment of fracture-dislocations requires attention
to the coronoid, radial head, and lateral collateral ligament.2,9–11
Preoperative Planning
■ The fracture characteristics that determine treatment are de-
fined on radiographs and CT.
■ Templating the surgery with tracings of the radiographs is a

■ Elbow dislocation useful way of running through the surgery in detail before per-
■ M onteggia and Essex-Lopresti fracture-dislocations of the forming it, familiarizing oneself with the anatomy, anticipat-
forearm ing problems, and ensuring that all of the implants and equip-
■ Distal humerus fracture ment that might be necessary are available.

N ON OPERATIVE MAN AGEMEN T Positioning

■ N onoperative management is appropriate for the rare frac-
ture of the olecranon that is less than 2 millimeters displaced
with the elbow flexed 90 degrees.
■ Four weeks of splint immobilization followed by active as-
sisted mobilization of the elbow will usually result in a healed
fracture and good elbow function.
■ In most patients a lateral decubitus position with the arm
over a bolster or support is best.
■ Some patients with fracture-dislocations that require both
medial and lateral access may be positioned supine with the
arm supported on a hand table.
■ A sterile pneumatic tourniquet is used.

SURGICAL MAN AGEMEN T Approach

■The vast majority of olecranon fractures are displaced and ■ A dorsal longitudinal skin incision is used.
merit operative treatment.

TECHNIQUES
TENSION BAND WIRING
Re d u ct io n a n d Kirsch n e r Wire ■ Tw o 1.0-m m sm o o t h Kirsch n e r w ire s a re d rille d a cro ss
t h e fra ct u re sit e (TECH FIG 1 C).
Fixa t io n ■ If t h e se a re d rille d o b liq u e ly fro m d o rsa l p ro xim a l t o
■ Blo o d clo t a n d p e rio st e u m a re cle a re d fro m t h e fra ct u re vo la r d ist a l, t h e y w ill e xit t h e a n t e rio r u ln a r co rt e x
sit e t o fa cilit a t e re d u ct io n . d ist a l t o t h e co ro n o id p ro ce ss, p ro vid in g a n a n ch o rin g
■ Lim it e d p e rio st e a l e le va t io n is p e rfo rm e d a t t h e fra ct u re p o in t o f co rt ica l b o n e t o lim it t h e p o t e n t ia l fo r p in
sit e t o m o n it o r re d u ct io n . m ig ra t io n .
■ A la rg e t e n a cu lu m cla m p is u se d t o se cu re t h e fra ct u re in ■ In a n t icip a t io n o f la t e r im p a ct io n o f t h e p ro xim a l
a re d u ce d p o sit io n (TECH FIG 1 A,B). A d rill h o le ca n b e e n d s o f t h e w ire s, t h e Kirsch n e r w ire s sh o u ld b e re -
m a d e in t h e d o rsa l co rt e x o f t h e d ist a l fra g m e n t t o fa cil- t ra ct e d 5 t o 10 m m a ft e r d rillin g t h ro u g h t h e a n t e rio r
it a t e cla m p a p p lica t io n . u ln a r co rt e x.

TECH FIG 1 • A. A lat eral rad i-

o g ra p h w it h t h e a rm in p la st e r
sh o w s a t ra n sverse , n on com m in ute d
fra ctu re o f th e o le cra no n . B. An
o p e n re d u ct io n is h e ld w it h a fra c-
A B tu re re d u ct ion force ps. (co n tin ue d )
 254 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

TECH FIG 1 • (co n t in u e d ) C. Tw o 1-m m Kirsch n e r w ire s a re

d rille d o b liq u e ly a cro ss t h e fra ct u re sit e so t h a t t h e y e xit t h e
a n t e rio r u ln a r co rt e x d ist a l t o t h e co ro n o id p ro ce ss. (A,B:
C Co p yrig h t Da vid Rin g , MD.)

Wirin g ■ Ea ch w ire is t e n sio n e d b o t h m e d ia lly a n d la t e ra lly b y

t w ist in g t h e w ire w it h a n e e d le h o ld e r (TECH FIG 2 C,D).
■ Th e a p e x o f t h e u ln a r d ia p h ysis ju st d ist a l t o t h e fla t p o r- ■ Th is sh o u ld b e d o n e t o t a ke u p sla ck o n ly. Th e se sm a ll
t io n o f t h e p ro xim a l u ln a is d rille d w it h a 2.0-m m d rill,
w ire s w ill b re a k if t h e y a re firm ly t ig h t e n e d , w h ich is
w it h o r w it h o u t p rio r su b p e rio st e a l d isse ct io n .
n o t n e ce ssa ry.
■ Wh e n t w o w ire s a re u se d , a se co n d d rill h o le is m a d e ■ Th e t ig h t e n in g sh o u ld b e d o n e in a p la ce t h a t w ill
a ce n t im e t e r m o re d ist a l.
m a ke t h e w ire kn o t s le ss p ro m in e n t .
■ If o n e w ire is u se d , it sh o u ld b e 18 g a u g e . My p re fe re n ce ■ Aft e r t ig h t e n in g t h e kn o t s a re t rim m e d a n d b e n t in t o
is t o u se t w o 22-g a u g e st a in le ss st e e l w ire s t o lim it t h e
t h e so ft t issu e s t o e it h e r sid e .
size o f t h e kn o t s, w h ich m a y d im in ish im p la n t p ro m i- ■ Th e Kirsch n e r w ire s a re t h e n b e n t 180 d e g re e s a n d
n e n ce . Th e w ire s a re p a sse d t h ro u g h t h e d rill h o le s. A
t rim m e d .
la rg e -b o re n e e d le ca n b e u se d t o fa cilit a t e p a ssa g e o f ■ Th e se b e n t e n d s a re t h e n im p a ct e d in t o t h e p ro xim a l
t h e w ire t h ro u g h t h e d rill h o le (TECH FIG 2 A).
o le cra n o n , b e n e a t h t h e t rice p s in se rt io n , u sin g a n o s-
■ Th e t w o t e n sio n w ire s a re e a ch p a sse d o ve r t h e d o rsa l
t e o t o m e (TECH FIG 2 E–H).
u ln a in a fig u re 8 fa sh io n , t h e n a ro u n d t h e Kirsch n e r
w ire s, a n d u n d e rn e a t h t h e in se rt io n o f t h e t rice p s t e n -
d o n u sin g a la rg e -b o re n e e d le (TECH FIG 2 B).

A B

C D

TECH FIG 2 • A. Tw o 22-g a u g e st a in le ss st e e l t e n sio n w ire s a re p a sse d in a fig u re 8 fa sh io n t h ro u g h d rill h o le s

in t h e u ln a r sh a ft . B. Th e y e n g a g e t h e t rice p s in se rt io n p ro xim a lly. C,D. Th e w ire s a re t e n sio n e d o n b o t h sid e s.
Th e se d o n o t n e e d t o b e t ig h t , b u t sim p ly sn u g , w it h a ll sla ck t a ke n u p . At t e m p t s t o t ig h t e n t h e se sm a lle r 22-
g a u g e w ire s w ill b re a k t h e m . (co n t in u e d )
 Ch a p t e r 3 0 ORIF OF OLECRANON FRACTURES 255

TECHNIQUES
E G

F H
TECH FIG 2 • (co n t in u e d ) E. Th e p ro xim a l e n d s o f t h e Kirsch n e r w ire s a re b e n t 180 d e g re e s a n d im p a ct e d in t o
t h e o le cra n o n p ro ce ss, b e n e a t h t h e t rice p s in se rt io n . F. Th e re su lt in g fixa t io n h a s a re la t ive ly lo w p ro file a n d
is u n like ly t o m ig ra t e . G,H. Eve n t h e se sm a ll w ire s a re st ro n g e n o u g h fo r a ct ive e xe rcise s t o re g a in e lb o w m o -
t io n . (A,B,D,F–H: Co p yrig h t Da vid Rin g , MD.)

PLATE AND SCREW FIXATION OF OLECRANON FRACTURES

■ Co n t o u r t h e p la t e t o w ra p a ro u n d t h e p ro xim a l a sp e ct o f
t h e o le cra n o n o r u se a p re co n t o u re d p la t e (TECH FIG
3 A–C).
■ A st ra ig h t p la t e w ill h a ve o n ly t w o o r t h re e scre w s in
m e t a p h yse a l b o n e p ro xim a l t o t h e fra ct u re .
■ Bending t he p la t e a rou n d th e p roxima l asp e ct o f th e o le -
cra n o n p ro vid e s a d d it io n a l scre w s in th e p ro xim a l fra g -
me n t. Th e mo st p ro xim al scre ws ca n b e ve ry lon g, cro ssing
the fracture line in t o the d ist a l fra gm e n t . In som e ca se s,
th e se screw s ca n be directe d t o e n g ag e o n e o f the cort ice s
o f th e d ista l frag me n t, such a s t h e a nt e rio r u ln a r co rte x.
■ A p la t e co n t o u re d t o w ra p a ro u n d t h e p ro xim a l u ln a ca n
b e p la ce d o n t o p o f t h e t rice p s in se rt io n . Alt e rn a t ive ly,
t h e t rice p s in se rt io n ca n b e in cise d lo n g it u d in a lly a n d
p a rt ia lly e le va t e d m e d ia lly a n d la t e ra lly su fficie n t ly t o
a llo w d ire ct p la t e co n t a ct w it h b o n e .
■ If t h e p ro xim a l (o le cra n o n ) fra g m e n t is sm a ll, fra g -
m e n t e d , o r o st e o p o ro t ic, it ca n b e u se fu l t o a d d a fig u re

A B C

TECH FIG 3 • A. A la t e ra l ra d io g ra p h illu st ra t e s a co m m in u t e d o le cra n o n fra ct u re w it h a sm a ll p ro xim a l o le cra n o n fra g m e n t .

B. An o b liq u e vie w sh o w s t h e fra g m e n t a t io n . C. A 3.5-m m lim it e d -co n t a ct d yn a m ic co m p re ssio n p la t e a n d scre w s co n t o u re d t o
w ra p a ro u n d t h e d o rsa l su rfa ce o f t h e o le cra n o n is u se d fo r fixa t io n . (co n t in u e d )
 256 Se c t i o n II SHOULDER AND ELBOW

8 t e n sio n w ire t h a t e n g a g e s t h e t rice p s in se rt io n a n d

TECHNIQUES

p a sse s o ve r t h e t o p o f t h e p la t e a n d a ro u n d o n e o f t h e
scre w s a t t h e m e t a p h yse a l le ve l.
■ Dist a lly, a d o rsa l p la t e w ill lie d ire ct ly o n t h e a p e x o f t h e
u ln a r d ia p h ysis. Th e m u scle n e e d o n ly b e sp lit su fficie n t ly
t o g a in a cce ss t o t h is a p e x—t h e re is n o n e e d t o e le va t e
t h e m u scle o r p e rio st e u m o ff e it h e r t h e m e d ia l o r la t e ra l
fla t a sp e ct o f t h e u ln a .
■ No a t t e m p t is m a d e t o p re cise ly re a lig n in t e rve n in g fra g -
m e n t a t io n —o n ce t h e re la t io n sh ip o f t h e co ro n o id a n d
o le cra n o n fa ce t s is re st o re d a n d t h e o ve ra ll a lig n m e n t is
re st o re d , t h e re m a in in g fra g m e n t s a re b rid g e d , le a vin g
t h e ir so ft t issu e a t t a ch m e n t s in t a ct .
■ Bo n e g ra ft s a re ra re ly n e ce ssa ry if t h e so ft t issu e a t -
D t a ch m e n t s a re p re se rve d .
■ If t h e o le cra n o n fra g m e n t is sm a ll, o st e o p o ro t ic, o r fra g -
TECH FIG 3 • (co n t in u e d ) D. A 22-g a u g e st a in le ss st e e l w ire
m e n t e d , a w ire e n g a g in g t h e t rice p s in se rt io n sh o u ld b e
e n g a g e s t h e t rice p s in se rt io n —t h is is u se fu l w h e n t h e o le cra -
n o n fra g m e n t is sm a ll, fra g m e n t e d , o r o st e o p e n ic. (Co p yrig h t u se d t o re in fo rce t h e fixa t io n (TECH FIG 3 D).
Da vid Rin g , MD.)
■ Th e p la t e a n d scre w s w ill se rve t o h o ld t h e co ro n o id
a n d o le cra n o n fa ce t s in p ro p e r a lig n m e n t a n d b rid g e
fra g m e n t a t io n , a n d t h e w ire w ill h e lp e n su re fixa t io n
e ve n if scre w p u rch a se is lo st .

PLATE AND SCREW FIXATION OF FRACTURE-DISLOCATIONS OF

THE OLECRANON
Exp o su re
■ In t h e se t t in g o f a fra ct u re -d islo ca t io n o f t h e o le cra n o n
(TECH FIG 4 A), fra ct u re s o f t h e ra d ia l h e a d a n d co ro n o id
p ro ce ss ca n b e e va lu a t e d a n d o ft e n d e fin it ive ly t re a t e d
t h ro u g h t h e e xp o su re p ro vid e d b y t h e fra ct u re o f t h e
o le cra n o n p ro ce ss.
■ Wit h lit t le a d d it io n a l d isse ct io n , t h e o le cra n o n fra g -
m e n t ca n b e m o b ilize d p ro xim a lly a s o n e w o u ld d o
w it h a n o le cra n o n o st e o t o m y, p ro vid in g e xp o su re o f
t h e co ro n o id t h ro u g h t h e u ln o h u m e ra l jo in t .
■ If t h e e xp o su re o f t h e ra d ia l h e a d t h ro u g h t h e p o st e rio r
in ju ry is in a d e q u a t e , a se p a ra t e m u scle in t e rva l (e g ,
Kö ch e r o r Ka p la n in t e rva ls) a cce sse d b y t h e e le va t io n o f
a b ro a d la t e ra l skin fla p ca n b e u se d .
■ If t h e e xp o su re o f t h e co ro n o id is in a d e q u a t e t h ro u g h
p o st e rio r in ju ry a n d o le cra n o n fra ct u re , a se p a ra t e m e -
d ia l o r la t e ra l e xp o su re ca n b e d e ve lo p e d .

B Visualize

TECH FIG 4 • A. A co m p le x a n t e rio r fra ct u re -d islo ca t io n

o f t h e e lb o w . A la t e ra l ra d io g ra p h sh o w s e xt e n sive co m -
m in u t io n o f t h e t ro ch le a r n o t ch o f t h e u ln a , in clu d in g
t h e co ro no id , a n d a n t e rio r displa ce m e n t o f t h e fore a rm .
B,C. Th e co ro n o id fra g m e n t s a re co n n e ct e d t o t h e d o rsa l
m e t a p h yse a l fra g m e n t s in t h is pa t ie n t , w h ich fa cilit a t e s
C re d u ct io n a n d fixa t io n . (A,C: Co p yrig h t Da vid Rin g , MD.)
 Ch a p t e r 3 0 ORIF OF OLECRANON FRACTURES 257

■ A m e d ia l e xp o su re , b e t w e e n t h e t w o h e a d s o f t h e t ro ch le a a n d a se co n d w ire in t h e d ist a l u ln a r d ia p h -

fle xo r ca rp i u ln a ris, o r b y sp lit t in g t h e fle xo r-p ro n a t o r
m a ss m o re a n t e rio rly, o r b y e le va t in g t h e e n t ire
fle xo r–p ro n a t o r m a ss fro m d o rsa l t o vo la r, m a y b e
n e e d e d t o a d d re ss a co m p le x fra ct u re o f t h e co ro -
n o id , p a rt icu la rly o n e t h a t in vo lve s t h e a n t e ro m e d ia l
fa ce t o f t h e co ro n o id p ro ce ss.
■ Wh e n t h e la t e ra l co lla t e ra l lig a m e n t is in ju re d , it is u su -
a lly a vu lse d fro m t h e la t e ra l e p ico n d yle . Th is fa cilit a t e s
re p a ir t h a t ca n b e p e rfo rm e d u sin g su t u re a n ch o rs o r su -
t u re p la ce d t h ro u g h d rill h o le s in t h e b o n e .
■ Th e fra ct u re o f t h e co ro n o id ca n o ft e n b e re d u ce d d i-
re ct ly t h ro u g h t h e e lb o w jo in t u sin g t h e lim it e d a cce ss
p ro vid e d b y t h e o le cra n o n fra ct u re (TECH FIG 4 B,C).
Fixa t io n
■ Pro visio n a l fixa t io n ca n b e o b t a in e d u sin g Kirsch n e r
w ire s t o a t t a ch t h e fra g m e n t s e it h e r t o t h e m e t a p h yse a l
o r d ia p h yse a l fra g m e n t s o f t h e u ln a , o r t o t h e t ro ch le a o f
t h e d ist a l h u m e ru s w h e n t h e re is e xt e n sive fra g m e n t a -
t io n o f t h e p ro xim a l u ln a .
■ An a lt e rn a t ive t o ke e p in m in d w h e n t h e re is e xt e n sive
fra g m e n t a t io n o f t h e p ro xim a l u ln a is t h e u se o f a
ske le t a l d ist ra ct o r (a t e m p o ra ry e xt e rn a l fixa t o r; TECH
FIG 5 A).
■ Ext e rn a l fixa t io n a p p lie d b e t w e e n a w ire d rive n
t h ro u g h t h e o le cra n o n fra g m e n t a n d u p in t o t h e
TECHNIQUES
ysis ca n o ft e n o b t a in re d u ct io n in d ire ct ly w h e n d is-
t ra ct io n is a p p lie d b e t w e e n t h e p in s.
■ De fin it ive fixa t io n ca n u su a lly b e o b t a in e d w it h
scre w s a p p lie d u n d e r im a g e in t e n sifie r g u id a n ce .
■ Th e scre w s a re p la ce d t h ro u g h t h e p la t e w h e n t h e re is
e xt e n sive fra g m e n t a t io n o f t h e p ro xim a l u ln a .
■ A se co n d , m e d ia l p la t e m a y b e u se fu l w h e n t h e co ro n o id
is fra g m e n t e d .
■ If t h e co ro n o id fra ct u re is ve ry co m m in u t e d a n d ca n n o t
b e se cu re ly re p a ire d , t h e u ln o h u m e ra l jo in t sh o u ld b e
p ro t e ct e d w it h t e m p o ra ry h in g e d o r st a t ic e xt e rn a l
fixa t io n , o r t e m p o ra ry p in fixa t io n o f t h e u ln o h u m e ra l
jo in t , d e p e n d in g o n t h e e q u ip m e n t a n d e xp e rt ise
a va ila b le .
■ A lo n g p la t e is co n t o u re d t o w ra p a ro u n d t h e p ro xim a l
o le cra n o n (TECH FIG 5 B).
■ A ve ry lo n g p la t e sh o u ld b e co n sid e re d (b e t w e e n 12
a n d 16 h o le s), p a rt icu la rly w h e n t h e re is e xt e n sive
fra g m e n t a t io n o r t h e b o n e q u a lit y is p o o r.
■ Wh e n t h e o le cra n o n is fra g m e n t e d o r o st e o p o ro t ic, a
p la t e a n d scre w s a lo n e m a y n o t p ro vid e re lia b le fixa t io n .
■ In t h is sit u a t io n , it ca n b e u se fu l t o u se a n cilla ry t e n -
sio n w ire fixa t io n t o co n t ro l t h e o le cra n o n fra g m e n t s
t h ro u g h t h e t rice p s in se rt io n (TECH FIG 5 C).

A C

TECH FIG 5 • A. Wh e n t h e re is d ia p h yse a l co m m in u t io n , a t e m p o ra ry e xt e rn a l fixa t o r m a y b e u se fu l. B. A lo n g ,

3.5-m m lim it e d -co n t a ct d yn a m ic co m p re ssio n p la t e is u se d fo r fixa t io n . A 22-g a u g e st a in le ss st e e l w ire is u se d
t o e n h a n ce fixa t io n o f t h e co m m in u t e d o le cra n o n fra g m e n t s. C. Th e co m m in u t io n e xt e n d in g in t o t h e d ia p h -
ysis h e a ls w it h t h e b rid g in g p la t e . Th e t ro ch le a r n o t ch is re st o re d w it h g o o d e lb o w fu n ct io n . (B,C: Co p yrig h t
Da vid Rin g , MD.)
258 Se c t i o n II SHOULDER AND ELBOW

PEARLS AND PITFALLS

Pro m in e n ce o f o le cra n o n
h a rd w a re
Na rro w in g o f t ro ch le a r n o t ch
Pla t e lo o se n in g
Lo ss o f fixa t io n o f t h e
p ro xim a l (o le cra n o n )
fra g m e n t
Fa ilu re t o re co g n ize a
co m p le x in ju ry
■ Th e u se o f t w o sm a ll (22-g a u g e ) w ire s ra t h e r t h a n o n e la rg e o n e w ill re su lt s in sm a lle r kn o t s.
Ca re t a ke n t o p la ce t h e Kirsch n e r w ire s b e lo w t h e t rice p s in se rt io n a n d im p a ct in g t h e m in t o
b o n e w ill lim it p ro m in e n ce a n d t h e p o t e n t ia l fo r m ig ra t io n . 5,8
■ Th e su rg e o n sh o u ld n o t u se a t e n sio n w ire a lo n e o n a co m m in u t e d fra ct u re . An in t a ct a rt icu la r
su rfa ce t o a b so rb co m p re ssive fo rce s w it h a ct ive m o t io n is m a n d a t o ry fo r t e n sio n b a n d w irin g t o
b e e ffe ct ive .
■ Th e su rg e o n sh o u ld u se a d o rsa l p la t e co n t o u re d t o w ra p a ro u n d t h e o le cra n o n , p ro vid in g a
g re a t e r n u m b e r o f scre w s a n d scre w s a t d iffe re n t , n e a rly o rt h o g o n a l a n g le s. Use o f a m e d ia l o r
la t e ra l p la t e sh o u ld b e a vo id e d .10,11
■ Scre w fixa t io n a lo n e sh o u ld n o t b e t ru st e d if t h e fra g m e n t is sm a ll,
fra g m e n t e d , o r o st e o p o ro t ic. A t e n sio n w ire e n g a g in g t h e t rice p s in se rt io n sh o u ld b e a d d e d .
■ Th e su rg e o n sh o u ld b e vig ila n t fo r su b lu xa t io n o r d islo ca t io n o f t h e e lb o w , fra ct u re o f t h e
co ro n o id o r ra d ia l h e a d , a n d in ju ry t o t h e la t e ra l co lla t e ra l lig a m e n t . Wh e n id e n t ifie d , e a ch
in ju ry is t re a t e d a cco rd in g ly. Th e o le cra n o n a n d p ro xim a l u ln a is a lw a ys se cu re d w it h a p la t e a n d
scre w s.

POSTOPERATIVE CARE ■ Dorsal plates perform better, but the elbow is often compro-
mised in the setting of such complex injuries.
■ When good fixation is obtained (which occurs in most pa-
tients), active assisted and gravity-assisted elbow and forearm COMPLICATION S
exercises can be initiated immediately after surgery. A delay of
several days for comfort is reasonable.
■ Implant loosening
■ If the lateral collateral ligament was repaired, the patient
■ Implant breakage
must be instructed not to abduct the shoulder for the first
■ N onunion
month.
■ M alunion
■ If the fixation is tenuous, it is reasonable to immobilize the
■ Instability
arm in a splint for a month or so before beginning exercises.
■ Arthrosis

OUTCOMES REFEREN CES

■ N onunion is nearly unheard of after simple olecranon
fractures, and early implant failure is usually due to non-
compliance. 6
■ The appeal of tension band wiring has been limited by
prominence of the implants; however, if the techniques de-
scribed herein are followed, few patients will request a second
surgery specifically for implant removal.8
■ M acko and Szabo pointed out that it was initial implant
prominence and not migration that led to implant-related
problems after tension band wiring of olecranon fractures.5
■ In any case, a second surgery for implant removal is not un-
reasonable, and it may not be appropriate to consider this a
complication.
■ Some surgeons have considered plate-and-screw fixation of
simple, noncomminuted olecranon fractures.1 H owever, plates
can also cause symptoms, and if only a few screws can be
placed in the olecranon fragment, particularly in the setting of
fragmentation or osteoporosis, it may be preferable to use the
soft tissue attachments to enhance fixation rather than relying
10. Ring D, Jupiter JB, Simpson N S. M onteggia fractures in adults. J
on implant–bone purchase alone.
■ M edial and lateral plates have been associated with early
11. Ring D, Tavakolian J, Kloen P, et al. Loss of alignment after surgical
failure, malunion, and nonunion in the treatment of complex
proximal ulna fractures.10,11
1. Bailey CS, M acDermid J, Patterson SD, et al. O utcome of plate fixa-
tion of olecranon fractures. J O rthop Trauma 2001;15:542–548.
2. Doornberg J, Ring D, Jupiter JB. Effective treatment of fracture-
dislocations of the olecranon requires a stable trochlear notch. Clin
O rthop Relat Res 2004;429:292–300.
3. Jupiter JB, Leibovic SJ, Ribbans W, et al. The posterior M onteggia le-
sion. J O rthop Trauma 1991;5:395–402.
4. Karlsson M , H asserius R, Besjakov J, et al. Comparison of tension-
band and figure-of-eight wiring techniques for treatment of olecranon
fractures. J Shoulder Elbow Surg 2002;11:377–382.
5. M acko D, Szabo RM . Complications of tension-band wiring of ole-
cranon fractures. J Bone Joint Surg Am 1985;67A:1396–1401.
6. M orrey BF. Current concepts in the treatment of fractures of the ra-
dial head, the olecranon, and the coronoid. J Bone Joint Surg Am
1995;77A:316–327.
7. O ’Driscoll SW, Jupiter JB, Cohen M , et al. Difficult elbow fractures:
pearls and pitfalls. AAO S Instruct Course Lect 2003;52:113–134.
8. Ring D, Gulotta L, Chin K, et al. O lecranon osteotomy for exposure
of fractures and nonunions of the distal humerus. J O rthop Trauma
2004;18:446–449.
9. Ring D, Jupiter JB, Sanders RW, et al. Trans-olecranon fracture-
dislocation of the elbow. J O rthop Trauma 1997;11:545–550.
Bone Joint Surg Am 1998;80A:1733–1744.
treatment of posterior M onteggia fractures: salvage with dorsal con-
toured plating. J H and Surg Am 2004;29A:694–702.
 Op e n Re d u ct io n a n d In t e r n a l
Fixa t io n o f Fra ct u re -Dislo ca t io n s
Ch a p t e r 31 o f t h e Elb o w Wit h Co m p le x
In s t a b ilit y
Ju b in B. Payan d e h an d M ich ae l D. M cKe e

DEFIN ITION
■ Simple dislocations of the elbow can most often be treated
successfully with closed means: reduction and short-term im-
mobilization followed by early motion.
■ Fracture-dislocations of the elbow are more troublesome in
that they often require operative intervention.
■ Fractures associated with elbow dislocations often involve
the radial head and coronoid. When both are combined with
dislocation, this is termed the “ terrible triad.”
■ The principle of treating fracture-dislocations of the elbow
is to provide sufficient stability through reconstruction of bony
Lateral view
Humerus
Articular
capsule
Annular
and ligamentous restraints such that early motion can be insti-
tuted without recurrent instability.
■ Failure to achieve this will result in either recurrent instabil-
ity or severe stiffness after prolonged immobilization.
AN ATOMY
■ Posterolateral dislocations of the elbow are associated with
disruption of the medial and lateral collateral ligaments.
■ The medial collateral ligament (M CL) is the primary stabi-
lizer to valgus stress (FIG 1 ).
■ The lateral collateral ligament (LCL) is the primary stabilizer
to posterolateral rotatory instability. Most often the disruption
is from the lateral epicondyle, leaving a characteristic bare spot.
Less commonly, the ligament may rupture mid-substance.5
Secondary restraints on the lateral side that may also be dis-
rupted are the common extensor origin and the posterolateral
capsule.
■ Radial head fractures have been classified by M ason:

ligament ■ Type I: small or marginal fracture with minimal dis-

placement
■ Type II: marginal fracture with displacement
Triceps ■ Type III: comminuted fractures of the head and neck 2
Radius
brachii ■ Coronoid fractures have been classified by Regan and
tendon
M orrey9 (FIG 2 ):
■ Type I: tip fractures (not avulsions)
Ulna
■ Type II: less than 50% of the coronoid

■ Type III: more than 50% of the coronoid

■ The insertion of the M CL is at the base of the coronoid

Lateral ulnar collateral
ligament and it may be involved in type III fractures1

Medial view

Humerus
Articular
capsule
Annular
ligament

Radius
I
II
III
Ulna Triceps
brachii
tendon
Ulnar collateral
ligament

FIG 1 • Th e m e d ia l a n d co lla t e ra l lig a m e n t co m p le xe s o f t h e

e lb o w . No t e t h e ir p o in t s o f a t t a ch m e n t o n t h e d ist a l h u m e ru s FIG 2 • La t e ra l vie w o f t h e e lb o w d e p ict in g t h e d iffe re n t t yp e s
a n d p ro xim a l u ln a . o f co ro n o id fra ct u re s.

259
260 Se ct io n II SHOULDER AND ELBOW

Valgus

Supination FIG 4 • Th re e -d im e n sio n a l CT re co n st ru ct io n o f “ t e rrib le t ria d ”

in ju ry. Th e arro w re p re se n t s t h e la rg e co ro n o id fra g m e n t a n t e -
rio r t o t h e e lb o w . (Fro m Pu g h DMW, Wild LM, Sch e m it sch EH,
e t a l. St a n d a rd su rg ica l p ro t o co l t o t re a t e lb o w d islo ca t io n s
Axial w it h ra d ia l h e a d a n d co ro n o id fra ct u re s. J Bo n e Jo in t Su rg Am
Compression 2004;86A:1122–1130.)

systemic injuries must accompany evaluation of the elbow.

The ipsilateral shoulder and wrist should be evaluated.
■ The evaluation and documentation of peripheral nerve and

vascular function in the injured extremity is critical.

IMAGIN G AN D OTHER DIAGN OSTIC

FIG 3 • Typ ica l m e ch a n ism o f e lbo w fra ct u re d islo ca t io n . No t e
t h e fo rce s a t p la y o n t h e e lb o w .
STUDIES
■ H igh-quality plain radiographs in the anteroposterior (AP)
and lateral plane should be obtained before and after closed
reduction.
■ Cast material can obscure bony detail after closed

reduction.
■ If there is any evidence of forearm or wrist pain associated

PATHOGEN ESIS with the elbow injury, these should be imaged as well.
■ Fracture-dislocations of the elbow occur during falls onto ■ Computed tomography (CT) scans with reformatted images

an outstretched hand, falls from a height, motor vehicle acci-
dents, or other high-energy trauma (FIG 3 ).
■ Typically there is a hyperextension and valgus stress applied
to the pronated arm.
N ATURAL HISTORY
■ Elbow dislocations with associated coronoid or radial head
and 3D reconstructions are helpful in understanding the con-
figuration of bony injuries and are helpful in treatment plan-
ning (FIG 4 ).
DIFFEREN TIAL DIAGN OSIS
■ Radial head or neck fractures without associated dislocation
■ Coronoid fracture associated with posteromedial instability.

fractures have a poor natural history. Redislocation or sublux-
ation is likely with closed treatment.
■ Treatment of the radial head fracture by excision alone in
the context of an elbow dislocation has a high rate of failure
due to recurrent instability.
■ Problems of recurrent instability, arthrosis, and severe stiff-
ness lead to poor functional results.10
This results from a varus force and is associated with rupture
of the LCL. The radial head is not fractured, making diagno-
sis more difficult.
N ON OPERATIVE MAN AGEMEN T
■ Initial treatment involves closed reduction and splinting
with radiographs to confirm reduction (FIG 5 ).
■ If reduction cannot be maintained because of bone or soft

PATIEN T HISTORY AN D PHYSICAL tissue injury, repeated attempts at closed reduction should not
FIN DIN GS be attempted. This is thought to contribute to the formation of
■ Fracture-dislocations of the elbow are acute and traumatic, heterotopic ossification.
so the history should be straightforward. ■ The ability of nonoperative management to meet treatment

■ It is not unusual for these injuries to occur with high-energy goals in these situations is rare and surgery is indicated in al-
trauma, so a diligent search for other musculoskeletal and most all cases.
 Ch a p t e r 3 1 ORIF OF FRACTURE-DISLOCATIONS OF THE ELBOW WITH COM PLEX INSTABILITY
FIG 5 • Ra d io g ra p h re ve a lin g n o n co n ce n t ric re d u ct io n a ft e r
clo se d re d u ct io n . Th e sm all arro w s h ig h lig h t t h e n o n co n ce n t ric
re d u ct io n o f t h e u ln o h u m e ra l jo in t . (Fro m Pu g h DMW, Wild
LM, Sch e m it sch EH, e t a l. St a n d a rd su rg ica l p ro t o co l t o t re a t
e lb o w d islo ca t io n s w it h ra d ia l h e a d a n d co ro n o id fra ct u re s. J
Bo n e Jo in t Su rg Am 2004;86A:1122–1130.)
SURGICAL MAN AGEMEN T
■ The goals of surgery are to obtain and maintain a con-
centric and stable reduction of the ulnohumeral and
radiocapitellar joint such that early motion within a flex-
ion–extension arc of 30 to 130 degrees can be initiated. Early
motion is key to avoid elbow stiffness and resultant poor
function.
■ M anagement of elbow dislocations with associated radial
head and coronoid fractures should follow an established pro-
tocol (Table 1) that has produced reliable results. 8
■ The radial head is an important secondary stabilizer of the
elbow to valgus stress and posterior instability.7
■ It is also a longitudinal stabilizer of the forearm to proxi-
mal translation.
■ If fractured in this setting, it must be fixed or replaced,
as excision leads to recurrent instability and unacceptable
results. 10
Preoperative Planning
■ Before surgery, the surgeon must ensure that the proper
equipment and implants are available.
Tr e a t m e n t Pr o t o co l f o r Elb o w
Dis lo ca t io n Wit h As s o cia t e d
Ta b le 1 Ra d ia l He a d a n d Co r o n o id
Fr a ct u r e s
St ep Act ion
1 Fix the coronoid fracture
2 Fix or replace the radial head
3 Repair the lateral collateral ligament
4 Assess elbow stability within 30 to 130 degrees of
flexion–extension with the forearm in full pronation
5 If the elbow remains unstable, consider fixing the medial
collateral ligament
6 Failing this, apply a hinged external fixator to maintain
concentric reduction and allow for early motion
261
FIG 6 • Pa t ie n t p o sit io n e d su p in e w it h h a n d t a b le .
■ Coronoid fractures are fixed with small fragment or cannu-
lated screws of appropriate size.
■ Radial head and neck fracture fixation is accomplished with
small fragment plates and screws.
■ We often use countersunk H erbert screws to fix articular
head fragments.
■ A metallic, modular radial head implant system should be
available if primary osteosynthesis cannot be achieved.
■ An image intensifier is helpful during surgery. Films con-
firming concentric reduction and the proper positioning of im-
planted hardware should always be obtained before leaving
the operating room.
■ In rare instances in which bony and ligamentous repair fails
to restore sufficient elbow stability, dynamic hinged external
fixation is used.
■ This is a highly specialized technique that may not be ap-
propriate for all surgeons.
■ In that case, static external fixation and patient referral is
an appropriate alternative.
Positioning
■ M ost commonly, the patient is positioned supine on the op-
erating table under general anesthesia.
■ The operative limb is supported on a hand table and a
tourniquet is applied to the upper arm before preparation and
draping (FIG 6 ).
■ Alternatively, the lateral decubitus position can be used with
the operative limb supported by a padded bolster. This posi-
tion is used if hinged fixation is deemed likely.
Approach
■ The lateral approach is the workhorse for treatment of these
injuries where the coronoid, radial head, and LCL can be ad-
dressed. A direct lateral incision with the patient supine and
the arm on a hand table is used.
■ Landmarks and skin incision are shown in FIGURE 7A.
■ The surgeon should use the traumatic dissection that oc-
curred at the time of injury to gain exposure of the elbow.
■ Typically the LCL has been avulsed from the lateral distal
humerus, leaving a bare spot (FIG 7 B).8
■ Some cases require a medial approach as well for either
medial ligament reconstruction or plating of a coronoid
 262 Se ct io n II SHOULDER AND ELBOW

A B

FIG 7 • A. Landm arks an d skin incision. The underlying bone s have be en represen ted and t he po sit ion
o f t he la t e ra l skin in cisio n is ma rke d w ith t h e hash e d lin e. B. Avu lsio n o f la te ra l co llat eral lig a me n t .
Th e arro w is point in g t o t he bare spot on th e dista l lat eral hu me rus w here the lat eral collat eral liga-
m en t co mp le x h as b ee n avu lse d .

fracture. This can be accomplished through a second medial ■ Alternatively, a posterior skin incision can be used with el-
incision. evation of full-thickness flaps at the fascial level to approach
■ The ulnar nerve is at risk in this approach and should be both laterally and medially.
identified and protected. The common flexor origin is split ■ The patient can be placed in the lateral decubitus po-

distal to the medial epicondyle to expose the coronoid sition or supine with the arm across the chest for this
medially. approach.
TECHNIQUES

LATERAL EXPOSURE
■ Ma ke a n in cisio n a lo n g t h e la t e ra l su p ra co n d yla r rid g e o f
t h e h u m e ru s cu rvin g a t t h e la t e ra l e p ico n d yle t o w a rd
t h e ra d ia l h e a d a n d n e ck.
■ At t h e fa scia l le ve l, e le va t e fu ll-t h ickn e ss fla p s a n d in se rt
a se lf-re t a in in g re t ra ct o r (TECH FIG 1 ).
■ Sp lit t h e co m m o n e xt e n so r o rig in in lin e w it h it s fib e rs.
■ Ma ke u se o f t h e t ra u m a t ic d isse ct io n t h a t o ccu rre d a t t h e
t im e o f in ju ry.
■ Mo st co m mo n ly, th e LCL w ill h a ve a vu lse d fro m t h e
d ist al h u me ru s, le a ving a ba re sp o t. Th e co mm o n ex-
te n sor o rigin is a vu lse d a s we ll tw o th ird s o f t h e tim e.7
■ Re co n st ru ct io n o ccu rs in a n o rd e rly fa sh io n fro m d e e p t o
su p e rficia l.
■ If t h e ra d ia l h e a d is t o b e re p la ce d , it s e xcisio n p ro vid e s
e xce lle n t e xp o su re o f t h e co ro n o id t h ro u g h t h e la t e ra l TECH FIG 1 • La t e ra l a p p ro a ch . In t h is ca se , t h e ra d ia l n e ck
a p p ro a ch . w a s fra ct u re d a n d t h e h e a d h a s b e e n re m o ve d . An e xce lle n t
■ If, o n t h e o t h e r h a n d , it is t o b e fixe d , se t fre e fra g - vie w o f t h e co ro n o id is a ch ie ve d . He re a t yp e I co ro n o id fra c-
m e n t s a sid e t o a llo w a cce ss t o t h e co ro n o id . t u re is p re se n t .

ORIF OF CORONOID FRACTURE

Typ e I Co ro n o id Fra ct u re s
■ Fo r t yp e I fra ct u re s, w e re co m m e n d fixa t io n w it h a n o n -
a b so rb a b le (n o . 2 b ra id e d ) su t u re p a sse d t h ro u g h t h e
a n t e rio r e lb o w ca p su le ju st a b o ve t h e b o n y fra g m e n t
(TECH FIG 2 ).
■ Tw o p a ra lle l d rill h o le s a re m a d e fro m t h e d o rsa l su rfa ce
o f t h e u ln a t h ro u g h a se p a ra t e sm a ll in cisio n a n d d ire ct e d
t o w a rd t h e co ro n o id t ip . Th e se a re m a d e w it h a sm a ll drill
o r Kirsch n e r w ire .
■ On ce t h e su t u re is p a sse d t h ro u g h t h e ca p su le , it s e n d s
a re b ro u g h t o u t e a ch o f t h e d rill h o le s a n d t ie d o ve r t h e
u ln a t o p lica t e t h e a n t e rio r e lb o w ca p su le .
■ Th e su t u re e n d s ca n b e re t rie ve d t h ro u g h t h e d rill h o le s
u sin g a n e ye le t e d Kirsch n e r w ire , a Ke it h n e e d le , o r a su -
t u re re t rie ve r.
 Ch a p t e r 3 1 ORIF OF FRACTURE-DISLOCATIONS OF THE ELBOW WITH COM PLEX INSTABILITY
TECH FIG 2 • Su t u re fixa t io n o f a t yp e I co ro n o id fra ct u re . Th e
su t u re is p a sse d t h ro u g h t h e a n t e rio r ca p su le a b o ve t h e co ro -
n o id . It s e n d s w ill b e p a sse d t h ro u g h t h e p ro xim a l u ln a a n d
t ie d o ve r t h e d o rsa l su rfa ce . Th is t yp e o f fixa t io n is u se d if t h e
co ro n o id fra g m e n t is t o o sm a ll t o a cce p t a scre w . (Fro m
McKe e MD, Pu g h DM, Wild LM, e t a l. St a n d a rd su rg ica l p ro t o -
co l t o t re a t e lb o w d islo ca t io n w it h ra d ia l h e a d a n d co ro n o id
fra ct u re s. J Bo n e Jo in t Su rg Am 2005;87A:22–32.)
Typ e II a n d III Co ro n o id Fra ct u re s
■ Typ e II a n d III co ro n o id fra ct u re s ca n b e fixe d w it h o n e o r
t w o ca n n u la t e d scre w s. Re g u la r, p a rt ia lly t h re a d e d , ca n -
ce llo u s scre w s ca n a lso b e u se d .
■ On ce t h e fra ct u re h a s b e e n d é b rid e d su ch t h a t it ca n b e
a n a t o m ica lly re d u ce d , p a ss a g u id e w ire fro m t h e d o rsa l
su rfa ce o f t h e p ro xim a l u ln a su ch t h a t it e xit s a t t h e fra c-
t u re sit e .
■ Ba ck t h e g u id e w ire u p u n t il it is ju st b u rie d , a n d re -
d u ce t h e fra ct u re .
■ Ho ld t h e fra g m e n t re d u ce d w it h a p o in t e d in st ru m e n t
su ch a s a d e n t a l p ick a n d a d va n ce t h e w ire a cro ss t h e
fra ct u re sit e in t o t h e fra g m e n t (TECH FIG 3 ). If t h e re is
e n o u g h sp a ce , in se rt a se co n d w ire a cro ss t h e fra ct u re .
RADIAL HEAD OR NECK FRACTURE
■ Ra d ia l h e a d fra ct u re is a d d re sse d a ft e r t re a t m e n t o f t h e
co ro n o id in ju ry b e ca u se o n ce t h e h e a d is fixe d o r re -
p la ce d , a cce ss t o t h e co ro n o id fro m t h e la t e ra l a p p ro a ch
is lim it e d .
■ Th e d e cisio n t o fix a ra d ia l h e a d is la rg e ly b a se d o n t h e
fra ct u re co n fig u ra t io n . If fra ct u re co m m in u t io n is lim it e d
su ch t h a t t h e h e a d is in t w o o r t h re e fra g m e n t s, re d u c-
t io n a n d fixa t io n is u su a lly p o ssib le .
■ Fra ct u re s t h a t a re co m m in u t e d o r w it h a rt icu la r su r-
fa ce d a m a g e re q u ire re p la ce m e n t .
■ Exp o se t h e h e a d a n d n e ck a s n e ce ssa ry fo r fra ct u re re -
d u ct io n a n d fixa t io n b y e xt e n d in g t h e Kö ch e r in t e rva l.
■ Th e p o st e rio r in t e ro sse o u s n e rve is a t risk d u rin g m o re
d ist a l ra d ia l n e ck e xp o su re s. It s d ist a n ce fro m t h e o p e ra -
t ive sit e ca n b e m a xim ize d b y ke e p in g t h e fo re a rm in fu ll
p ro n a t io n .
263
TECHNIQUES
TECH FIG 3 • Co ro n o id fra ct u re h e ld re d u ce d w it h Kirsch n e r
w ire . (Fro m McKe e MD, Pu g h DM, Wild LM, e t a l. St a n d a rd
su rg ica l p ro t o co l t o t re a t e lb o w d islo ca t io n w it h ra d ia l
h e a d a n d co ro n o id fra ct u re s. J Bo n e Jo in t Su rg Am 2005;
87A:22–32.)
■ On ce o n e o r t w o g u id e w ire s a re in p la ce , t h e y a re re -
p la ce d w it h a p p ro p ria t e -le n g t h scre w s, ca n n u la t e d o r
re g u la r. It is crit ica l t o t a p t h e fra g m e n t b e fo re scre w
p la ce m e n t t o a vo id sp lit t in g t h e fra g m e n t o n scre w
in se rt io n .
■ Co ro n o id fra ct u re s t h a t a re co m m in u t e d m a y b e d ifficu lt
t o t re a t . Typ ica lly, t h e la rg e st fra g m e n t w it h a rt icu la r
ca rt ila g e is fixe d .
■ If scre w fixa t io n is n o t p o ssib le o r a cce ss is d ifficu lt d u e
t o a n in t a ct ra d ia l h e a d , t h e co ro n o id ca n a lso b e a d -
d re sse d t h ro u g h a m e d ia l a p p ro a ch .
■ A med ial incision a long the su pracon dylar rid ge is u se d.
■ Th e u ln a r n e rve is id e n t ifie d a n d p ro t e ct e d .
■ Th e co m m o n fle xo r o rig in is sp lit t o g a in a cce ss t o t h e
co ro n o id o n t h e p ro xim a l u ln a .
■ Fro m t h e m e d ia l sid e , a b u t t re ss o r sp rin g p la t e ca n b e
u se d t o se cu re a co m m in u t e d fra ct u re .
ORIF o f Ra d ia l He a d Fra ct u re s
■ Fo r ra d ia l h e a d fra g m e n t s, re d u ce a n d h o ld t h e fra g -
m e n t t o t h e in t a ct h e a d w it h a p o in t e d re d u ct io n cla m p .
■ We se cu re t h e fra g m e n t s w it h He rb e rt scre w s. Th e fra g -
m e n t s ca n b e h e ld t e m p o ra rily w it h a 2-m m Kirsch n e r
w ire a n d t h e n re p la ce d w it h a He rb e rt scre w .
■ If t h e scre w is in se rt e d t h ro u g h a rt icu la r ca rt ila g e , it s
h e a d m u st b e co u n t e rsu n k.
■ Ra d ia l n e ck fra ct u re s, o n ce re d u ce d , ca n b e h e ld p ro vi-
sio n a lly w it h a Kirsch n e r w ire .
■ De fin it ive fixa t io n is w it h a sm a ll fra g m e n t T p la t e o ve r
t h e “ sa fe zo n e ” (TECH FIG 4 ).
■ Ca re is ta ke n to n o t in ju re t h e p o ste rio r in te ro sse o u s
n erve wh ile exp o sin g th e sh aft o r b y trap p in g it u n d er
t h e p lat e d ist ally.
■ If t he ra dial he ad cann ot be reconstructe d, it is re p la ce d .
 264 Se ct io n II SHOULDER AND ELBOW
TECHNIQUES
Neutral
“Safe zone”
Supination Pronation
“Safe zone”
“Safe zone”
TECH FIG 4 • Th e “ sa fe zo n e ” fo r p la t in g ra d ia l n e ck fra c-
t u re s. Th e 90-d e g re e a rc o u t lin e d d o e s n o t a rt icu la t e w it h t h e
p ro xim a l u ln a t h ro u g h o u t t h e fu ll ra n g e o f fo re a rm ro t a t io n .
Pla t in g a ra d ia l n e ck fra ct u re in t h is zo n e w ill n o t in t e rfe re
w it h ro t a t io n .
Ra d ia l He a d Re p la ce m e n t
■ Th e rep lacement u sed mu st b e metallic as silico ne implants
are inad equ ate bo th biomech an ically an d b io lo g ically.6
■ We u se a m o d u la r im p la n t su ch t h a t t h e st e m d ia m e -
t e r ca n b e va rie d in d e p e n d e n t o f t h e h e a d d ia m e t e r
a n d t h ickn e ss.
REPAIR OF THE LATERAL COLLATERAL LIGAMENT COMPLEX
■ Re p a ir o f t h e LCL co m p le x is crit ica l t o re -e st a b lish e lb o w
st a b ilit y (TECH FIG 6 A).
■ It is m o st o ft en avu lse d fro m th e d ista l h u m eru s. Its
anat om ic at ta chm ent point is slight ly post erior t o th e la t-
era l epicondyle at t he ce nte r of the arc of t he capit ellum .
A B
TECH FIG 5 • Ra d ia l h e a d im p la n t . An a p p ro p ria t e ly size d ra -
d ia l h e a d im p la n t h a s b e e n in se rt e d . It is h e ld re d u ce d w it h
t h e fo re a rm in fu ll p ro n a t io n . No t e t h e a n a t o m ic a lig n m e n t
w it h t h e ca p it e llu m .
■ If re q u ire d , cu t t h e p ro xim a l ra d iu s a t t h e le ve l o f t h e
n e ck w it h a m icro -sa g it t a l sa w .
■ Re a m t h e ca n a l o f t h e p ro xim a l ra d iu s t o co rt ica l b o n e
w it h se q u e n t ia lly la rg e r re a m e rs.
■ Ra d ia l h e a d size ca n b e ju d g e d b y a sse m b lin g t h e fra c-
t u re d fra g m e n t s t h a t h a ve b e e n re m o ve d . In g e n e ra l,
d o w n sizin g t h e h e a d slig h t ly is re co m m e n d e d su ch t h a t
t h e e lb o w jo in t is n o t o ve rst u ffe d .
■ A t ria l im p la n t sh o u ld b e in se rt e d t o t e st st a b ilit y a n d
m o t io n . Elb o w ra n g e o f m o t io n , b o t h fle xio n –e xt e n sio n
a n d fo re a rm ro t a t io n , sh o u ld b e ch e cke d . Vie w t h e a r-
t icu la t io n b e t w e e n t h e p ro xim a l ra d iu s a n d u ln a t o se e
if t h e d ia m e t e r o f t h e im p la n t se e m s a p p ro p ria t e .
■ On ce sa t isfie d w it h sizin g , t h e d e fin it ive im p la n t is in -
se rt e d (TECH FIG 5 ).
■ Th e LCL is a d iscre t e st ru ct u re d e e p t o t h e co m m o n e x-
t e n so r o rig in , w h ich ru n s fro m t h e la t e ra l e p ico n d yle t o
t h e su p in a t o r cre st o f t h e u ln a (TECH FIG 6 B).
■ Use a n o . 2, b ra id e d , n o n a b so rb a b le su t u re fo r t h e re p a ir.
TECH FIG 6 • A. Elb o w in st a b ilit y a sso ci-
a t e d w it h d e ficie n t la t e ra l co lla t e ra l lig a -
m e n t . Wit h o u t re p a ir o f t h e la t e ra l co lla t -
e ra l lig a m e n t , t h e ra d ia l h e a d su b lu xe s
in t o a p o st e ro la t e ra l p o sit io n w it h fo re -
a rm su p in a t io n . No t e t h a t t h e ra d ia l h e a d
a n d ca p it e llu m a re n o lo n g e r in n o rm a l
a lig n m e n t . B. Th e la t e ra l co lla t e ra l lig a -
m e n t is h e ld b y t h e fo rce p s. It is a d ist in ct
st ru ct u re e a sily id e n t ifie d in t h is a cu t e ly
in ju re d e lb o w . (co n t in u e d )
 Ch a p t e r 3 1 ORIF OF FRACTURE-DISLOCATIONS OF THE ELBOW WITH COM PLEX INSTABILITY 265

■ Th e lig a m e n t ca n b e re a t t a ch e d t o t h e d ist a l h u m e ru s

TECHNIQUES
t h ro u g h b o n e t u n n e ls o r u sin g su t u re a n ch o rs. We p re fe r
b o n y t u n n e ls.
■ Usin g a d rill, Kirsch n e r w ire , o r p o in t e d t o w e l clip , m a ke
h o le s in t h e d ist a l la t e ra l h u m e ru s a b o ve t h e e p ico n d yle .
■ Pa ss t h e su t u re t h ro u g h t h e h o le s a n d in t o t h e la t e ra l lig -
a m e n t su ch t h a t it w ill t ig h t e n o n t yin g t h e su t u re s.
■ At le a st t w o , p re fe ra b ly t h re e , su t u re s t h ro u g h b o n e
a re re q u ire d . Pa ss, cu t , a n d sn a p a ll o f t h e su t u re s (TECH
FIG 6 C).
■ En su re t h a t t h e e lb o w is n o w h e ld in 90 d e g re e s o f
fle xio n a n d fu ll fo re a rm p ro n a t io n .
■ In co rp o ra t e t h e m o re su p e rficia l co m m o n e xt e n so r
C
o rig in in t h e re p a ir.
TECH FIG 6 • (co n t in u e d ) C. Su t u re s p a sse d fo r la t e ra l co lla t -
■ Tie t h e su t u re s o n ce t h e y h a ve a ll b e e n p a sse d a n d t h e n
e ra l lig a m e n t re p a ir. clo se t h e la t e ra l w o u n d in la ye rs.

PERSISTENT INSTABILITY
■ On o cca sio n , re p a ir o f t h e co ro n o id , ra d ia l h e a d , a n d LCL
fro m t h e la t e ra l a p p ro a ch is in su fficie n t t o re st o re e lb o w
st a b ilit y su ch t h a t e a rly m o t io n m a y b e in it ia t e d .
■ In t h e se ca se s, fu rt h e r e ffo rt s m u st b e m a d e t o o b t a in
su ch st a b ilit y.
■ Re p a ir o f t h e MCL t h ro u g h a se p a ra t e m e d ia l in cisio n is
o n e o p t io n if a la t e ra l a p p ro a ch h a s b e e n u se d fo r co ro -
n o id a n d ra d ia l h e a d fra ct u re fixa t io n .
■ Alt e rn a t ive ly, a p o st e rio r skin in cisio n ca n b e u se d
w it h fu ll-t h ickn e ss fla p s cre a t e d t o a cce ss b o t h sid e s.
Po sit io n in g t h e p a t ie n t in t h e la t e ra l d e cu b it u s p o si-
t io n fa cilit a t e s t h is a p p ro a ch .
■ A d e e p a p p ro a ch t o t h e m e d ia l a sp e ct o f t h e e lb o w p u t s
t h e u ln a r n e rve a t risk, a n d it m u st b e id e n t ifie d a n d p ro -
t e ct e d d u rin g t h e p ro ce d u re .
■ Usu a lly t h e MCL is t o rn in it s m id -su b st a n ce . Su t u re re -
p a ir o f t h is is o ft e n u n sa t isfyin g . Usin g a g ra ft t o re p la ce
t h e MCL is n o t re co m m e n d e d in t h e a cu t e in ju ry se t t in g .
■ If e lb o w st a b ilit y re m a in s in su fficie n t , a p p lyin g a h in g e d
fixa t o r is t h e fin a l o p t io n .3
■ If t h e h in g e is n o t a va ila b le o r t h e su rg e o n is n o t fa -
m ilia r w it h it s u se , a st a t ic fixa t o r ca n b e a p p lie d t o
m a in t a in e lb o w re d u ct io n .
Hin g e d Ext e rn a l Fixa t io n
■ Ap p lica t io n o f t h e h in g e d fixa t o r st a rt s w it h t h e in se r-
t io n o f a g u id e p in t h ro u g h t h e ce n t e r o f e lb o w ro t a t io n .
■ In se rt t h e p in fro m m e d ia l t o la t e ra l st a rt in g a t t h e
m e d ia l e p ico n d yle t h ro u g h a sm a ll in cisio n a n d p ro -
t e ct t h e u ln a r n e rve . Th e p in sh o u ld b e d ire ct e d
t h ro u g h t h e ce n t e r o f t h e ca p it e llu m .
■ Aft e r p in in se rt io n , t h e e lb o w is h e ld re d u ce d w h ile t h e
fra m e is a sse m b le d a ro u n d it .
■ Th e h in g e slid e s o ve r t h e g u id e p in o n e it h e r sid e o f t h e
e lb o w . Th re e -q u a rt e r rin g s a re a t t a ch e d p ro xim a l a n d
d ist a l t o t h e e lb o w .
■ In se rt t w o h a lf-p in s in t h e h u m e ru s a b o ve t h e e lb o w
t h ro u g h sm a ll o p e n in cisio n s o ve r t h e p o st e rio r su rfa ce
b y b lu n t ly sp re a d in g t h e t rice p s fib e rs.
■ In se rt t w o h a lf-p in s in t h e u ln a o ve r it s su b cu t a n e o u s
b o rd e r d o rsa lly.
■ At t a ch t h e p in s t o t h e rin g s a n d t ig h t e n a ll p a rt s o f t h e
h in g e d fixa t o r.
■ Ve rify t h a t t h e e lb o w re m a in s re d u ce d in t h e fra m e
t h ro u g h 30 t o 130 d e g re e s o f m o t io n . Th e fo re a rm is
m a in t a in e d in p ro n a t io n t o p ro t e ct t h e la t e ra l lig a m e n t
re p a ir.
■ Lo ck t h e e lb o w a t 90 d e g re e s in t h e h in g e fo r t h e in it ia l
p o st o p e ra t ive co u rse .
■ Ob t a in p la in ra d io g ra p h s in t h e o p e ra t in g ro o m b e fo re
t h e co n clu sio n o f t h e p ro ce d u re .

PEARLS AND PITFALLS

In d ica t io n s
Go a ls o f t re a t m e n t
Co ro n o id fra ct u re s
Ra d ia l h e a d
■ Elb o w d islo ca t io n s w it h a sso cia t e d fra ct u re s o f t h e co ro n o id o r ra d ia l h e a d m u st b e re co g n ize d a s co m p le x
d islo ca t io n s. Th e y u su a lly re q u ire su rg ica l t re a t m e n t .
■ Th e g o a ls a re t o o b t a in a co n ce n t ric re d u ct io n w it h su fficie n t e lb o w st a b ilit y su ch t h a t e a rly ra n g e o f m o -
t io n is p o ssib le , a n d t o a vo id p e rsist e n t in st a b ilit y, e lb o w st iffn e ss, a n d a rt h rit is.
■ Re p a ir o f co ro n o id fra ct u re s is t e ch n ica lly d e m a n d in g b u t n e ce ssa ry fo r su cce ssfu l t re a t m e n t .
■ Th e su rg e o n sh o u ld b e p re p a re d t o re p la ce t h e ra d ia l h e a d if n e ce ssa ry w it h a m e t a l, m o d u la r p ro st h e sis.
■ Excisio n a lo n e is n o t a n o p t io n .
266 Se ct io n II SHOULDER AND ELBOW
La t e ra l lig a m e n t s ■ Re p a ir o f t h e la t e ra l lig a m e n t s is im p o rt a n t t o im p a rt t h e n e ce ssa ry st a b ilit y fo r e a rly m o t io n a n d t o a vo id
la t e p o st e ro la t e ra l ro t a t o ry in st a b ilit y.
Ph ysio t h e ra p y ■ It is im p o rt a n t t o e m p h a size t o t h e p a t ie n t t h e n e e d t o b e d ilig e n t w it h re h a b ilit a t io n a n d e xe rcise s, a s
t h is w ill h a ve a g re a t e ffe ct o n t h e e n d re su lt .
POSTOPERATIVE CARE
■ The injured elbow is placed in a well-padded plaster splint
at 90 degrees of flexion and full pronation. The patient is given
a sling for comfort.
■ AP and lateral radiographs are obtained in the operating
room to ensure congruent reduction and verify hardware
placement.
■ The patient typically stays in hospital one night to receive
adequate analgesia and prophylactic antibiotics.
■ We do not routinely give prophylaxis for heterotopic ossifi-
cation unless the patient has a concomitant head injury: in this
case, indomethacin 25 mg three times a day is prescribed with
a cytoprotective agent for 3 weeks.
■ The patient returns to our clinic at 7 to 10 days postopera-
tively for staple removal. The splint is typically removed at this
point.
■ Range-of-motion exercises are initiated at this time under
the supervision of a physiotherapist.
■ Active and active-assisted flexion–extension between 30 and
130 degrees and forearm rotation with the elbow at 90 degrees
of flexion is initiated.
■ A lightweight resting splint is made for the injured elbow
that is removed for hygiene and physiotherapy.
■ The patient returns at 4, 8, and 12 weeks after surgery for
clinical review with plain radiographs. Thereafter the interval
of clinic visits is widened, but we follow our patients out to 2
years.
■ At 4 weeks we allow unrestricted range of motion and at 8
weeks unrestricted strengthening.
■ Evidence of fracture union is usually present between 6 and
8 weeks.
■ Progress with range of motion can be slow and frustrating
for the patient but does not plateau until 1 year of follow-up.
OUTCOMES
■ Following the protocol outlined for fracture-dislocations of
the elbow should yield satisfactory functional results.
■ Pugh et al8 reported the results of this treatment protocol for
36 elbows at 34 months.
■ The flexion–extension arc averaged 112 degrees and rota-
tion 136 degrees.
■ Fifteen patients had excellent results, 13 good, 7 fair, and
1 poor by the M ayo Elbow Performance Score.
■ Eight patients had a complication requiring reoperation.
COMPLICATION S
■ The most likely complication after treatment is unacceptable
elbow stiffness with a resultant nonfunctional range of motion.
■ An acceptable range is 30 to 130 degrees of flexion.
■ At about 1 year after surgery, once motion has plateaued,
patients are candidates for release with hardware removal if
they are not happy with their range of motion and the
flexion–extension arc is less than 100 degrees.
■ This is done through the lateral approach with an ante-
rior and posterior capsulectomy plus manipulation under
anesthesia.
■ A radial head implant in place can be downsized to im-
prove motion, but it should not be simply removed. The lat-
eral ligament complex is preserved.
■ In our series, this was necessary in 11% of cases. 8
■ Synostosis around the elbow is another possible cause of ro-
tational forearm stiffness.
■ A resection can be planned to improve motion.
■ CT scanning preoperatively helps to define the extent of
the lesion. Resection is technically demanding.
■ Superficial and deep wound infection is possible after repair.
Immediate and aggressive treatment is recommended with an-
tibiotics initially and irrigation with débridement if rapid im-
provement is not seen.
■ Persistent instability is rare but may occur despite best ef-
forts at repair.
■ Posttraumatic arthritis may be a long-term problem.
REFEREN CES
1. Cage DJ, Abrams RA, Callahan JJ, et al. Soft tissue attachments of
the ulnar coronoid process: an anatomic study with radiographic cor-
relation. Clin O rthop Relat Res 1995;320:154–158.
2. M ason M L. Some observations on fractures of the head of the radius
with a review of one hundred cases. Br J Surg 1954;42:123–132.
3. M cKee M D, Bowden SH , King GJ, et al. M anagement of recurrent,
complex instability of the elbow with a hinged external fixator. J
Bone Joint Surg Br 1998;80B:1031–1036.
4. M cKee M D, Pugh DM , Wild LM , et al. Standard surgical protocol to
treat elbow dislocation with radial head and coronoid fractures. J
Bone Joint Surg Am 2005;87A:22–32.
5. M cKee M D, Schemitsch EH , Sala M J, et al. The pathoanatomy of lat-
eral ligamentous disruption in complex elbow instability. J Shoulder
Elbow Surg 2003;12:391–396.
6. M oro JK, Werier J, M acDermid JC, et al. Arthroplasty with a metal
radial head for unreconstructable fractures of the radial head. J Bone
Joint Surg Am 2001;83A:1201–1211.
7. M orrey BF, Tanaka S, An KN . Valgus stability of the elbow: a defin-
ition of primary and secondary constraints. Clin O rthop Relat Res
1991;265:187–195.
8. Pugh DM W, Wild LM , Schemitsch EH , et al. Standard surgical pro-
tocol to treat elbow dislocations with radial head and coronoid frac-
tures. J Bone Joint Surg Am 2004;86A:1122–1130.
9. Regan W, M orrey B. Fractures of the coronoid process of the ulna. J
Bone Joint Surg Am 1989;71:1248–1254.
10. Ring D, Jupiter JB, Z ilberfarb J. Posterior dislocation of the elbow
with fractures of the radial head and coronoid. J Bone Joint Surg Am
2002;84A:547–551.
 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 32 Fix a t io n o f M o n t e g g ia
Fr a ct u re s in Ad u lt s
M at t h e w L. Ram se y
DEFIN ITION
■ This injury was initially reported by Giovanni M onteggia in
1814 as a fracture of the ulna associated with an anterior dis-
location of the radial head.6
■ The term “ M onteggia lesions” was coined by Bado to de-
scribe any fracture of the ulna associated with a dislocation of
the radiocapitellar joint.1
■ The Bado classification of Monteggia lesions,1 with the Jupiter
subclassification of type II fractures,4 is shown in Table 1.
■ Equivalent injuries in adults
■ Variable pathology that is thought to be equivalent to in-
juries classified by the Bado system
■ Equivalent injuries do not always fall within the tradi-
tional definition of a M onteggia fracture in that they do not
always have a concomitant radiocapitellar dislocation.
Therefore, it can be argued that these injuries are not neces-
sarily equivalent to M onteggia fractures.
■ Type I and II injuries are the only ones that have equiva-
lent injury patterns.
PATHOGEN ESIS
■ The exact mechanism of injury for M onteggia fractures is
controversial.
■ Proposed mechanisms of injury for type I injuries include
the following:
■ Direct blow to the posterior aspect of the elbow
■ Fall on outstretched arm with hyperpronated hand (fore-
arm pronation levers radial head anteriorly)
■ Fall on outstretched arm
■ Violent contraction of biceps pulling radial head anteriorly
■ Proposed mechanism for type II injuries: hypothesized to
occur when a supination force tensions the ligaments that are
stronger than bone
■ Proposed mechanism for type III injuries: direct blow to the
inside of the elbow with or without rotation
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ The initial examination should systematically evaluate:
■ Skin integrity
■ N eurovascular status of the extremity
■ Bony injury
■ Ulna fracture
■ Injury pattern
■ N oncomminuted
■ Comminution
■ Associated injury to key structural elements of the ulna
(coronoid, olecranon)
■ Radial head injury
■ Isolated dislocation without fracture
■ Radial head or neck fracture
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Plain radiographs (FIG 1 ): O rthogonal radiographs of the
elbow, forearm, and wrist are required.
■ Ulna fracture is easily identified.
■ Radial head fracture or dislocation can be subtle, espe-
cially if radial head dislocation reduces.
■ Computed tomography (CT) scans can be helpful to deter-
mine the extent of the bony injury and the location of fracture
fragments. They are particularly helpful in fractures involving
the coronoid, olecranon, and radial head.
■ 3D CT reconstructions provide information on the spatial
relationship of fracture fragments in comminuted fractures.
DIFFEREN TIAL DIAGN OSIS
■ Isolated ulna fracture
■ N ightstick fracture
■ O lecranon fracture
■ Fracture-dislocation of the elbow (“ terrible triad” injury)
■ Transolecranon fracture-dislocation
N ON OPERATIVE MAN AGEMEN T
■ M onteggia fracture-dislocations in the adult population are
generally treated surgically.
■ Improved fixation methods and surgical technique have re-
markably improved the results of surgery, making it a more re-
liable treatment option.
SURGICAL MAN AGEMEN T
Preoperative Planning
■ The timing of surgery depends on the condition of the soft
tissues and the availability of necessary equipment and
personnel.
■ The surgeon should define all injuries that need to be
addressed.
■ Equipment requirements:
■ Small fragment plates and screws or anatomic plating
system
■ M inifragment system
■ Threaded Kirchner wires
■ Radial head replacement
■ Bone graft (allograft or autograft)
Patient Positioning
■ Lateral decubitus position with the arm over a padded arm
support (FIG 2 )
■ Supine positioning is an alternative approach (although it is
not preferred because of difficulty in maintaining the arm
across the chest). If this approach is used, a saline bag under
the ipsilateral shoulder will help keep the arm across the chest.
267
268 Se c t i o n II SHOULDER AND ELBOW

Ba d o Cla s s if ica t io n o f M o n t e g g ia Le s io n s , Wit h Ju p it e r Su b cla s s if ica t io n o f Ty p e

Ta b le 1 II Fr a ct u r e s

Ty p e De s cr ip t io n Illu s t r a t io n
I Anterior dislocation of the radial head with fracture of the diaphysis of the ulna
with anterior angulation of the ulna fracture (most common type of lesion)

II Posterior or posterolateral dislocation of the radial head with fracture of the ulnar
diaphysis with posterior angulation of the ulna fracture

IIA Fracture at the level of the trochlear notch (ulna fracture involves the distal part of
the olecranon and coronoid)

IIB Ulna fracture is at the metaphyseal–diaphyseal junction, distal to the coronoid

IIC Ulna fracture is diaphyseal

IID Comminuted fractures involving more than one region

 Ch a p t e r 3 2 ORIF OF M ONTEGGIA FRACTURES IN ADULTS 269

Ta b le 1 (co n t in u e d )

Ty p e De s cr ip t io n Illu s t r a t io n
III Lateral or anterolateral dislocation of the radial head with fracture of the ulnar
metaphysis

IV Anterior dislocation of the radial head with a fracture of the proximal third of the
radius and ulna at the same level

Adapted from Bado J. The Monteggia lesion. Clin Orthop Relat Res 1967;50:717; and Jupiter JB, Leibovic SJ, Ribbans W, et al. The posterior Monteggia lesion. J Orthop Trauma
1991;5:395–402.

A B

FIG 1 • Pla in AP a n d la t e ra l ra d io g ra p h s t yp ica lly d e m o n st ra t e fra ct u re

p a t t e rn .

FIG 2 • La t e ra l d e cu b it u s p o sit io n in g is
p re fe rre d .
 270 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

SURGICAL APPROACH
■ A m id lin e p o st e rio r skin in cisio n is p la ce d la t e ra l t o t h e
t ip o f t h e o le cra n o n (TECH FIG 1 A).
■ Su b cu t a n e o u s fla p s a re e le va t e d o n t h e fa scia o f t h e
fo re a rm . Th e m e d ia l a n t e b ra ch ia l cu t a n e o u s n e rve d o e s
n o t n e e d t o b e id e n t ifie d if d isse ct io n is p e rfo rm e d o n
t h e fa scia o f t h e fle xo r–p ro n a t o r m u scle s sin ce it is m o b i-
lize d w it h t h e m e d ia l skin fla p .
■ Th e in t e rva l b e t w e e n t h e fle xo r ca rp i u ln a ris (FCU) a n d
a n co n e u s is d e ve lo p e d a lo n g t h e su b cu t a n e o u s b o rd e r
o f t h e u ln a t o e xp o se t h e fra ct u re sit e . Th e a m o u n t o f
d isse ct io n re q u ire d fo r e xp o su re is d ict a t e d b y t h e fra c-
t u re p a t t e rn a n d t h e t yp e o f fixa t io n t o b e u se d (TECH
FIG 1 B).
■ If t h e ra d ia l h e a d n e e d s t o b e a d d re sse d su rg ica lly, t h e
a n co n e u s ca n b e m o b ilize d m o re e xt e n sive ly t h ro u g h a
Bo yd a p p ro a ch (TECH FIG 1 C). If t h e u ln a fra ct u re p e r-
m it s, t h e ra d ia l h e a d ca n b e fixe d t h ro u g h t h e fra ct u re
b e d o f t h e u ln a b e fo re d e fin it ive fixa t io n o f t h e u ln a .
On ce t h e u ln a is fixe d , a cce ss t o t h e ra d ia l h e a d is n o t
p o ssib le .

Triceps
muscle
Flexor carpi
ulnaris muscle

Extensor carpi
ulnaris muscle
A
Line of
Anconeus Extensor carpi
incision
muscle ulnaris muscle
Anconeus
B muscle

TECH FIG 1 • A. Po st e rio r m id lin e in cisio n p o sit io n e d ju st

o ff t h e la t e ra l a sp e ct o f t h e o le cra n o n . B. De e p su rg ica l in -
t e rva l u se s t h e in t e rn e rvo u s p la n e b e t w e e n t h e a n co n e u s
a n d fle xo r ca rp i u ln a ris. C. Exp o su re o f t h e ra d ia l h e a d ca n
Triceps Flexor digitorum b e a cco m p lish e d b y re le a sin g t h e a n co n e u s fro m t h e
tendon Flexor carpi profundus muscle h u m e ru s a n d re fle ct in g it p ro xim a lly t o exp o se t h e ra d ia l
C Olecranon ulnaris muscle head.

RADIAL HEAD MANAGEMENT

■ Ra d ia l h e a d fra ct u re s a re t yp ica lly fixe d b e fo re t h e u ln a
fra ct u re is a d d re sse d . If t h e le sse r sig m o id n o t ch o f t h e
u ln a is in vo lve d , d e t e rm in in g ra d ia l le n g t h if ra d ia l h e a d
re p la ce m e n t is re q u ire d ca n b e d ifficu lt . Th e re fo re , fra c-
t u re s a re g e n e ra lly fixe d b e fo re t h e u ln a w h ile re p la ce -
m e n t m a y n e e d t o b e p e rfo rm e d a ft e r u ln a r fixa t io n is
co m p le t e d in o rd e r t o e st a b lish a p p ro p ria t e ra d ia l h e a d
sizin g .
■ Re co n st ru ct a b le fra ct u re s o f t h e ra d ia l h e a d a re fixe d
(TECH FIG 2 A,B).
■ Un re co n st ru ct a b le fra ct u re s o f t h e ra d ia l h e a d a re re -
p la ce d (TECH FIG 2 C).

A B

TECH FIG 2 • A,B. Pre o p e ra t ive a n d p o st o p e ra t ive ra d io g ra p h s

d e m o n st ra t in g o p e n re d u ct io n a n d in t e rn a l fixa t io n o f t h e ra -
d ia l h e a d co m p o n e n t o f t h e Mo n t e g g ia fra ct u re . (co n t in u e d )
 Ch a p t e r 3 2 ORIF OF M ONTEGGIA FRACTURES IN ADULTS 271

TECHNIQUES
TECH FIG 2 • (co n t in u e d ) C. Po st o p e ra t ive ra d io g ra p h o f a Mo n t e g g ia fra ct u re in
C w h ich t h e ra d ia l h e a d fra ct u re n e e d e d t o b e re p la ce d .

ULNA FRACTURE FIXATION

No Ar t icu la r In v o lv e m e n t o f t h e ■ De fin it ive fixa t io n is p e rfo rm e d w it h a d o rsa l p la t e . Th e
t rice p s is p a rt ia lly sp lit t o a llo w t h e p ro xim a l a sp e ct o f
Uln o h u m e r a l Jo in t
t h e p la t e t o o p p o se t h e o le cra n o n (TECH FIG 3 D).
■ Uln a fra ct u re s d ist a l t o t h e co ro n o id ca n b e p la t e d la t e r-
a lly o r o n t h e su b cu t a n e o u s b o rd e r o f t h e u ln a .
■ La t e ra l p la t e p la ce m e n t is p re fe rre d b y so m e t o p re ve n t
h a rd w a re p ro m in e n ce .

Ar t icu la r In v o lv e m e n t o f t h e
Uln o h u m e r a l Jo in t
■ Fra ct u re s e xt e n d in g p ro xim a l t o t h e co ro n o id re q u ire t h e
p la t e b e p la ce d o n t h e su b cu t a n e o u s b o rd e r o f t h e u ln a
t o a cco m m o d a t e t h e co m p le x g e o m e t ry o f t h is re g io n .
■ In g e n e ra l, t h e u ln a fra ct u re is re co n st ru ct e d fro m d ist a l
t o p ro xim a l. En su re t h a t a n y a sso cia t e d in ju ry t o t h e
co ro n o id is id e n t ifie d a n d a d d re sse d . A
■ The fractu re is recon structed b y fixin g the distal frag men ts;
this may require interfragmentary fixation or subarticular
Kirchner wire s (TECH FIG 3A). As fixation progresses prox-
imally, recon struction of the coron oid and greater sig moid
notch is performed. Particular attention is directed at
anatomic recon stru ction o f the articular su rface.
■ Co ro n o id in vo lve m e n t w it h a Mo n t e g g ia fra ct u re -d islo -
ca t io n o ft e n e xt e n d s d ist a lly in t o t h e vo la r co rt e x o f t h e
u ln a , a s o p p o se d t o t h e a xia l-p la n e fra ct u re p a t t e rn s
ch a ra ct e rize d b y Re g a n a n d Mo rre y9 (TECH FIG 3 B).
■ La rg e r fra g m e n t s ca n b e d e fin it ive ly fixe d w it h a n t e -
g ra d e la g scre w s fro m t h e d o rsa l a sp e ct o f t h e u ln a r o r
ca n b e p ro visio n a lly fixe d w it h t h re a d e d w ire s a n d u lt i-
B
m a t e ly d e fin it ive ly fixe d o n ce t h e p la t e is a p p lie d t o t h e
d o rsa l a sp e ct o f t h e u ln a . TECH FIG 3 • A. Mo n t e g g ia fra ct u re s w it h a rt icu la r in vo lve -
■ Co ro n o id fra ct u re e xp o su re ca n t yp ica lly b e o b t a in e d m e n t sh o u ld b e fixe d d ist a l t o p ro xim a l. Fixa t io n m a y re q u ire
t h ro u g h t h e o le cra n o n fra ct u re . If t h is d o e s n o t p ro vid e in t ra m e d u lla ry Kirsch n e r w ire s o r in t e rfra g m e n t a ry fixa t io n .
su fficie n t e xp o su re , t h e FCU ca n b e e le va t e d fro m t h e B. Co ro n o id fra ct u re o ft e n e xt e n d s in t o t h e vo la r co rt e x o f
d o rsa l a sp e ct o f t h e u ln a . t h e u ln a r. (co n t in u e d )
■ Th e fin a l fra g m e n t t o b e fixe d is t h e o le cra n o n fra g m e n t .
Th e a t t a ch e d t rice p s w ill o b scu re fra ct u re re d u ct io n if re -
d u ce d b e fo re d ist a l re co n st ru ct io n (TECH FIG 3 C).
 272 Se c t i o n II SHOULDER AND ELBOW
TECHNIQUES

C D

TECH FIG 3 • (co n t in u e d ) C. Th e o le cra n o n fra g m e n t w it h a t t a ch e d t rice p s is re d u ce d a n d p ro visio n a lly h e ld

w it h m e d ia l a n d la t e ra l Kirsch n e r w ire s p e n d in g d e fin it ive fixa t io n . D. Fin a l fixa t io n fo r m o st Mo n t e g g ia fra c-
t u re s is w it h a rig id p la t e a p p lie d t o t h e d o rsa l co rt e x.

WOUND CLOSURE
■ Th e t o u rn iq u e t is d e fla t e d a n d h e m o st a sis is o b t a in e d .
■ Th e fa scia b e t w e e n t h e FCU a n d a n co n e u s is clo se d w it h
in t e rru p t e d a b so rb a b le 0 o r 1 su t u re .
■ Su b cu t a n e o u s t issu e s a re clo se d w it h 3-0 a b so rb a b le su -
t u re a n d skin is clo se d w it h st a p le s.
■ I p re fe r t o clo se t h e w o u n d o ve r a d ra in p la ce d in t h e
su b cu t a n e o u s t issu e s t o a vo id h e m a t o m a .
■ A w e ll-p a d d e d d re ssin g is a p p lie d a n d a n a n t e rio r sp lin t
is p la ce d w it h t h e e lb o w in fu ll e xt e n sio n .

PEARLS AND PITFALLS

In d ica t io n s ■ Mo n t e g g ia fra ct u re -d islo ca t io n s in a d u lt s re q u ire su rg ica l in t e rve n t io n .
Go a ls o f t re a t m e n t ■ Th e first g o a l is t o re st o re u ln a r le n g t h a n d lo ca t io n o f t h e ra d ia l h e a d . Wh e n t h e a rt icu la t io n is in -
vo lve d , t h e g o a l is t o o b t a in a co n ce n t ric re d u ct io n w it h su fficie n t e lb o w st a b ilit y t h a t e a rly ra n g e o f
m o t io n is p o ssib le .
■ Th e se co n d g o a l is t o a vo id co m p lica t io n s t h a t co m p ro m ise fu n ct io n .
Uln a fra ct u re s ■ Fra ct u re s d ist a l t o t h e co ro n o id n e e d o n ly t o b e fixe d su ch t h a t u ln a r le n g t h is re -e st a b lish e d .
■ Wh e n p la t in g t h e se fra ct u re s, a vo id in g m a lre d u ct io n o f t h e u ln a is crit ica l t o re d u ct io n o f t h e ra -

d ia l h e a d . Fa ilu re t o re -e st a b lish u ln a r g e o m e t ry ca n re su lt in p e rsist e n t su b lu xa t io n o r d islo ca t io n

o f t h e ra d ia l h e a d (FIG 3 ).
■ Fra ct u re s in vo lvin g t h e a rt icu la t io n re q u ire st a b le fixa t io n t o re -e st a b lish a co m p e t e n t jo in t .
Ra d ia l h e a d ■ Ra d ia l h e a d fra ct u re s a re fixe d o r re p la ce d .
Ph ysica l t h e ra p y ■ Ea rly ra n g e o f m o t io n is t h e g o a l o f t re a t m e n t b u t m a y b e d e la ye d if fixa t io n is q u e st io n a b le .

FIG 3 • Ma lu n io n o f t h e u ln a w it h re su lt in g a p e x d o rsa l a n g u la -
t io n re su lt s in d islo ca t io n o f t h e ra d ia l h e a d .
 Ch a p t e r 3 2 ORIF OF M ONTEGGIA FRACTURES IN ADULTS
POSTOPERATIVE CARE
■ The arm is splinted in full extension to take pressure off the
posterior soft tissues.
■ If a drain is used, the splint and dressing are removed when
the drain output is less than 30 mL in 8 hours. If no drain is
used, the dressing is removed on postoperative day 1.
■ Active or active-assisted flexion and gravity-assisted exten-
sion is begun once the surgical dressings are removed.
■ If fixation is tenuous because of poor-quality bone or com-
minution, mobilization is delayed.
OUTCOMES
■ H istorically, the results of operative treatment of M onteggia
fracture-dislocations have been unpredictable.3,7,8,11
■ The advent of rigid internal fixation has improved the re-
sults of operative treatment.2,4,7
■ Certain factors have been associated with a poor clinical re-
sult 5 :
■ Bado type II injury
■ Jupiter type IIa injury
■ Fracture of the radial head
■ Coronoid fracture
■ Complications requiring further surgery
COMPLICATION S
■ Complications associated with M onteggia fracture-disloca-
tions occur with frequency. A multicenter study evaluating
M onteggia fracture-dislocations in adults demonstrated com-
plications in 43% of the patients treated, with an unsatisfac-
tory outcome in 46% of the patients treated.10
■ Radial nerve palsy
■ M ost commonly posterior interosseous nerve
■ Causes of injury include:
■ Compression at the arcade of Frosche
■ Direct trauma
■ Traction with lateral displacement of the radial head
■ M ost common with type III fractures
■ Complete resolution typically occurs.
■ M alunion
■ M ost common in type II fractures with volar comminu-
tion that is not appreciated or addressed
273
■ If radial head subluxation persists, malunion must be con-
sidered.
■ N onunion
■ Causes of nonunion include:
■ Infection
■ Inadequate internal fixation
■ Compression plate fixation required, particularly if frac-
ture is comminuted
■ Semitubular and reconstruction plates are not structurally
strong enough.
■ Radioulnar synostosis
■ Seen with high-energy injuries with associated comminution
■ H igher incidence if radial head fracture associated with
ulna fracture at the same level
■ Boyd approach implicated since the radius and ulna are
exposed through the same incision
REFEREN CES
1. Bado J. The M onteggia lesion. Clin O rthop Relat Res 1967;50:71.
2. Boyd H , Boals J. The M onteggia lesion: a review of 159 cases. Clin
O rthop Relat Res 1969;66:94–100.
3. Bruce H , H arvey JJ, Wilson JJ. M onteggia fractures. J Bone Joint
Surg Am 1974;56A:1563–1576.
4. Jupiter JB, Leibovic SJ, Ribbans W, et al. The posterior M onteggia le-
sion. J O rthop Trauma 1991;5:395–402.
5. Konrad GG, Kundel K, Kreuz PC, et al. M onteggia fractures in
adults: long-term results and prognostic factors. J Bone Joint Surg Br
2007;89B:354–360.
6. M onteggia GB. Instituzioni Chirurgiche. 2nd ed. M ilan: G. M asperp,
1813–1815.
7. Reckling F. Unstable fracture-dislocations of the forearm (M onteggia
and Galeazzi lesions). J Bone Joint Surg Am 1982;64A:857–863.
8. Reckling FW, Cordell LD. Unstable fracture-dislocations of the fore-
arm: the M onteggia and Galeazzi lesions. Arch Surg 1968;96:999–
1007.
9. Regan W, M orrey B. Fractures of the coronoid process of the ulna. J
Bone Joint Surg Am 1989;71A:1348–1354.
10. Reynders P, De Groote W, Rondia J, et al. Monteggia lesions in adults:
a multicenter Bota study. Acta Orthop Belg 1996;62(Suppl 1):78–83.
11. Speed J, Boyd H. Treatment of fractures of ulna with dislocation of the
head of radius (M onteggia fracture). JAM A 1940;115:1699–1705.
 Ch a p t e r 33 Ex t e r n a l Fix a t io n o f t h e Pe lv is
St e p h e n Ko t t m e ie r, Jo h n C. P. Flo yd , an d Nich o las Divaris
DEFIN ITION
■ Pelvic instability is defined as inability of the pelvis to as-
sume physiologic loads without displacement and functional
compromise.
■ Pelvic external fixation can serve several different purposes
depending on hemodynamic and pelvic structural instability.
■ Early external fixator application during resuscitative
acute phase management can serve to control intrapelvic
hemorrhage. 8
■ External fixation of the pelvis may confer sufficient pro-
visional stability to some injury patterns to facilitate patient
mobilization. It may, however, prove inadequate in achieving
long-term goals in the absence of additional surgical stabiliz-
ing efforts.
■ With certain rotationally unstable yet vertically stable pat-
terns, external fixation of the pelvis may serve as definitive
management.
AN ATOMY
■ The pelvis provides structural continuity between the axial
skeleton and lower extremities.
■ The pelvis affords protection and passage for genitourinary,
gastrointestinal, and neurovascular structures.
■ Life-threatening massive hemorrhage, a complication of
pelvic injury, can be of arterial (branches of the iliac system),
venous plexus, or fracture surface origins.
■ Additional concerns when treating pelvic ring trauma in-
clude injury to the lumbosacral and coccygeal nerves and male
urethra.
■ The anterior portion of the pelvic ring assumes minimal
weight-bearing function and affords little pelvic ring stability.
■ The pelvic ring is made up of the sacrum and paired innom-
inate bones. Ligamentous, rather than osseous, support is the
sole source of stability to the pelvis.
■ Stability of the pelvis is particularly dependent on the ten-
sion band of the posterior weight-bearing sacroiliac complex
(comprising the anterior sacroiliac ligaments, the interosseous
ligaments, and the posterior sacroiliac ligaments) in addition
to the iliosacral ligaments within the pelvic floor (sacrospinous
and sacrotuberous). The iliolumbar ligaments confer addi-
tional stability between the axial skeleton (L5 transverse
process) and the hemipelvis (ilium).
PATHOGEN ESIS
■ Pelvic injury patterns (osseous or ligamentous) are deter-
mined by the direction, point of application, and magnitude of
applied forces.
■ Applied forces can be simplified into anteroposterior com-
pression, lateral compression, and vertical shear. Actual forces
and accordingly mechanism of injury are likely more complex.
■ Resultant instability patterns are categorized as (1) vertically
and rotationally stable, (2) rotationally unstable and vertically
stable; and (3) rotationally and vertically unstable.
274
■ Anteroposterior compression and hemipelvic rotational forces
tend to result in injury to the “ anterior ligamentous” complex
(severity order: symphysis pubis, ischiosacral ligaments, anterior
sacroiliac ligament). The integrity of the posterior tension band
is preserved and vertical stability accordingly maintained (FIG
1 A). Depending on the severity of injury to the anterior liga-
mentous complex, rotational instability may ensue.
■ Lateral compression injuries, depending on severity, may
result in internal collapse of the pelvis. Ligaments both anteri-
orly and posteriorly generally remain intact. O sseous injuries
both anteriorly and posteriorly are typically stable impaction
variants. O ccasionally internal rotatory instability is suffi-
cient to warrant surgical stabilization (external or internal
fixation).
■ Vertical instability implies disruption of the posterior ten-
sion band of the pelvic ring. This may be of osseous, ligamen-
tous, or combined origin. Division of the sacrospinous and
sacrotuberous ligaments in the presence of intact posterior
ligaments will render a pelvis rotationally unstable. Further
division of the posterior ligaments of the sacroiliac complex
will result in both rotational and vertical instability. The in-
volved hemipelvis is unstable in the axial, sagittal, and coro-
nal planes (FIG 1 B).
■ Any injury mechanism (anteroposterior compression, lateral
compression, vertical shear) may result in complete (vertical
and rotational) instability if the magnitude of force is sufficient.
N ATURAL HISTORY
■ Life-threatening hemorrhage associated with pelvic frac-
tures may be intrapelvic or extrapelvic. Identifying the source
of bleeding may be challenging.25 In the absence of extrapelvic
and intraperitoneal sources, external fixation of the pelvis may
prevent life-threatening exsanguination.
■ Early sheeting (circumferential external compression) may
offer an initial beneficial hemodynamic response. Suspected
sustained hemorrhage of indeterminate source may be in-
trapelvic arterial in origin.2 This may respond favorably to
angiographic transcatheter embolization.
■ Exploratory laparotomy, from the standpoints of role and
timing, remains controversial.
■ Imaging findings, results of diagnostic peritoneal lavage
(if indicated), and response to fluid resuscitation must be
considered before exposing the unstable trauma victim to
the potential negative effects of abdominal exploration (de-
compression of intrapelvic tamponade, among others).
■ Pelvic fractures associated with violation of the perineal,
rectal, or vaginal regions must be identified immediately, and
early measures directed toward preventing regional and sys-
temic sepsis must be implemented. Appropriate soft tissue
management requires early aggressive débridement and
restoration of pelvic stability to facilitate wound care. External
fixation is of paramount importance in many such cases, as is
diverting colostomy.

A of the abdomen, thorax, and head.
B
FIG 1 • A. An e xt e rn a l ro t a t io n in ju ry (AP co m p re ssio n ) re su lt -
in g in “ a n t e rio r lig a m e n t o u s co m p le x in ju ry.” In st a b ilit y is
ro t a t io n a l in ch a ra ct e r a n d d e m o n st ra t e d in t h e a xia l p la n e .
Th e p o st e rio r t e n sio n b a n d is in t a ct a n d ve rt ica l st a b ilit y is
p re se rve d . B. A ve rt ica l sh e a r in ju ry. In a d d it io n t o co m p ro m ise
t o t h e “ a n t e rio r lig a m e n t o u s co m p le x,” t h e in t e g rit y o f t h e
p o st e rio r t e n sio n b a n d is d isru p t e d . Th e in vo lve d h e m ip e lvis is
u n st a b le in a ll p la n e s. (Mo d ifie d fro m Bu ckle R, Bro w n e r B,
Mo ra n d i M. Em e rg e n cy re d u ct io n fo r p e lvic rin g d isru p t io n s
a n d co n t ro l o f a sso cia t e d h e m o rrh a g e u sin g t h e p e lvic st a b i-
lize r. Te ch Ort h o p 1995;9:258–266.)
■ Lumbosacral plexopathy may present in combination with
sacral spinal canal or foraminal fractures. Pelvic reduction
with restoration of stability and occasionally neurologic de-
compression may afford a more favorable prognosis if prop-
erly indicated and executed. 22
■ Insufficient restoration of pelvic stability may result in com-
plications associated with prolonged recumbency. Additional
concerns include malunion and nonunion. Lower extremity
limb-length inequality and rotational deformity may result in
functional deficits. Anterior ring injuries with significant dis-
placement (tilt fragments) can result in sexual dysfunction,
particularly in females.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ The history, in terms of the mechanism of injury, offers
insight into the energy of injury imparted. Force application
Ch a p t e r 3 3 EXTERNAL FIXATION OF THE PELVIS 275
and magnitude in turn determine pelvic injury and instability
patterns as well as the type and frequency of associated
injuries.7
■ The patient’s age may affect both physiologic reserve and
bone quality. This dictates, respectively, the hemodynamic
response and the energy of injury required to generate certain
pelvic ring injuries.
■ Preexisting medical comorbidities must be ascertained, as
they may have considerable impact on survivability and com-
plications associated with both operative and nonoperative
management of pelvic injuries.
■ Pelvic ring disruption is often accompanied by potentially
life-threatening injuries to organs, vessels, and nerves within
the pelvis, as well as other extrapelvic and closed cavity lesions
■ Adequate adherence and response to principles of resu-
scitation must be assessed and primary and secondary surveys
completed.
■ Clinical evaluation includes inspection for abrasions, contu-
sions, limb-length discrepancy, or abnormal rotation of the
lower extremities.
■ Palpation and manual testing for instability patterns may be
pursued with caution. Stability is suggested (not confirmed)
both radiographically and clinically.
■ Identification of any open fracture variants and those with
rectal or vaginal continuity is mandatory, as mortality rates in
the presence of such lesions are considerable. 5
■ Physical examination should include:
■ Pelvic inspection to identify threatened or compromised
soft tissues
■ Inspection of lower extremities for limb-length inequal-
ity, rotational deformity, associated limb fractures or dis-
locations
■ Significant asymmetry in limb length or rotation im-
plies rotational or vertical pelvic instability.
■ Further clinical examination or imaging of the limb is
warranted if asymmetry is of other than pelvic origin.
■ Assessment of pelvic instability
■ Lateral compression injury is implied by internal rota-
tion and shortening.
■ Vertical shear injury is implied by external rotation and
shortening.
■ The genitourinary area is observed for regional hemor-
rhage. If present, it implies a urethral tear in a male and a
vaginal tear in a female.
■ N eurologic assessment to identify deficits in voluntary
sphincter control or perianal sensation. Lumbosacral plex-
opathy implies pelvic instability.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Imaging studies offer a static view of the pelvis. These ac-
cordingly may imply but do not confirm stability (or instabil-
ity) of the pelvis.
■ Conventional radiography is initiated with performance of
an anteroposterior (AP) radiograph of the pelvis. In the hemo-
dynamically unstable patient, this image alone is sufficient to
allow implementation of treatment.
■ The pelvic inlet and outlet views in combination with the AP
radiograph constitute the pelvic trauma radiographic triad
(FIG 2 A). The inlet view (FIG 2 B) best depicts axial (most
 276 Se ct io n III PELVIS AND HIP

A B

FIG 2 • A. AP vie w . Th e x-ra y b e a m is d ire ct e d p e rp e n d icu la r t o

t h e m id p e lvis. Th is vie w a lo n e (p a rt icu la rly in t h e p re se n ce o f h e -
m o d yn a m ic in st a b ilit y) m a y b e u se d t o co n firm t h e p re se n ce o f
p e lvic in st a b ilit y a n d o ffe r in d ica t io n fo r p e lvic e xt e rn a l fixa t io n .
B. In le t vie w . Th e x-ra y b e a m is d ire ct e d ca u d a d a t 45 d e g re e s t o
t h e ve rt ica l a xis ce n t e re d o n t h e m id p e lvis. AP d isp la ce m e n t a n d
a xia l ro t a t io n a l d e fo rm it ie s a re d e m o n st ra t e d . C. Ou t le t vie w . Th e
x-ra y b e a m is d ire ct e d ce p h a la d a t 45 d e g re e s t o t h e ve rt ica l a xis
ce n t e re d o n t h e m id p e lvis (p e rp e n d icu la r t o t h e sa cru m ). Ve rt ica l
C a n d sa g it t a l p la n e d e fo rm it ie s a re d e m o n st ra t e d .

often posterior) and rotational displacement. In contrast, the ment is confirmed, as is integrity of the posterior tension band.
outlet view (FIG 2 C) best demonstrates vertical displacement. Sacral impaction as opposed to gap displacement may suggest
■ Posterior pelvic displacement of more than 1 cm suggests (but does not confirm) inherent stability.
posterior pelvic disruption. Symphyseal diastasis of more than ■ The role of diagnostic and therapeutic angiography remains

2.5 cm denotes disruption of the anterior ligament complex.
■ O ther radiographic clues implying vertical or rotational in-
stability include the following:
■ Sacrospinous ligament avulsions (ischial spine or sacral
border fractures)
■ Iliolumbar ligament avulsion (L5 transverse process
fracture)
■ Sacral fractures or sacroiliac joint displacement
controversial with regard to management pathways. 4,9,16
External fixation of the pelvis may effectively arrest venous
and osseous hemorrhage (the source of 90% of intrapelvic he-
morrhage). Sustained hemodynamic instability may suggest
extrapelvic or intrapelvic arterial blood loss. In such cases ex-
ploratory angiography may be considered and therapeutic
arterial angiographic embolization performed as necessary.
■ Diagnostic peritoneal tap and lavage (first described in 1965)

■ Stress radiographs (“ push–pull” studies) may offer a dy-
namic interpretation of pelvic instability (FIG 3 ). Longitudinal
load and traction are sequentially imparted to the lower ex-
tremity of the involved hemipelvis with manual stabilization of
the contralateral extremity.
has a poorly defined contemporary role.15 Procedure perfor-
mance, indications, and assay result criteria (cell count) remain
ambiguous. The presence of a pelvic fracture may contribute to
a false-positive result.
■ Current imaging technology (contrast-enhanced CT, fo-

■ This is performed with the patient anesthetized and under
AP radiographic control.
■ Such maneuvers are contraindicated in the presence of
lumbosacral plexopathy, hemodynamic instability, or ipsi-
lateral lower extremity fractures.
■ Computed tomography (CT) serves as a valuable adjunctive
study. Cross-sectional axial images characterize posterior le-
cused abdominal ultrasound) may prove a more reliable tool
to determine the likelihood of abdominal injury and the
need for laparotomy.
DIFFEREN TIAL DIAGN OSIS
■ Low-energy pelvic fractures in senescent bone
■ H igh-energy pelvic fractures in younger patients with better-

sions best. Sacral foraminal and central spinal canal involve- quality bone
 Ch a p t e r 3 3 EXTERNAL FIXATION OF THE PELVIS 277

N ON OPERATIVE MAN AGEMEN T

■ Circumferential pelvic antishock sheeting may offer comfort
and enhance ring stability.23 This noninvasive method em-
ploys readily available and inexpensive materials.
■ N onsurgical management is appropriate for lesions accu-

rately deemed stable (confirmed on follow-up both clinically

and radiographically).
■ The goals for nonsurgical and surgical management are

identical. These include avoidance or correction of deformity,

maintenance of stability, and pain-free function.

SURGICAL MAN AGEMEN T

■ The role of the external fixator must be defined before ap-
plication.20 By decreasing pelvic volume, it offers intrapelvic
tamponade. This, in addition to diminishing fracture motion,
encourages hemostasis. In this capacity it serves as acute phase
management.
■ It may offer provisional stabilization of some injury patterns

to facilitate patient mobilization. Attempts to stabilize verti-

cally unstable lesions with external fixation alone are ina-
A dequate (FIG 4 ); these injuries require staged supplemental
posterior fixation. Used for this purpose, it serves as provi-
sional stabilization.
■ Rotationally unstable yet vertically stable patterns may be

amenable to external fixation as a source of definitive stabi-

lization. Lesions with considerable symphyseal comminution
unreceptive to anterior plating may be managed to union with
external fixation, provided the posterior tension band remains
functionally intact.

Preoperative Planning
■ The surgeon must identify associated intrapelvic, vascular,
urologic, and gynecologic comorbidities.
■ The surgeon must confirm the patient’s neurologic status

and document deficits. Soft tissues are inspected thoroughly

and circumferentially.
■ The surgeon characterizes, if applicable, the presence and

type of pelvic instability, assigning the injury pattern to a clas-

sification scheme.
■ The intended purpose of external fixator must be defined

(resuscitation or provisional versus definitive stabilization).

FIG 3 • “ Pu sh –p u ll” ra d io g ra p h s (p e rfo rm e d u n d e r

co n t ro lle d circu m st a n ce s a n d in t h e a b se n ce o f h e m o d yn a m ic
in st a b ilit y) m a y a id in id e n t ifica t io n o f ve rt ica lly u n st a b le
fra ct u re va ria n t s. (Mo d ifie d fro m Ia n n a co n e WM, Bra t h w a it e
CEM. Use o f t h e e xt e rn a l fixa t io n fra m e fo r a cu t e st a b iliza t io n
o f u n st a b le p e lvic fra ct u re s. Op e r Te ch Ort h o p 1993;3:2–12.)

■ Similar fracture patterns in the two groups above suggest a

high magnitude of force in the younger population. This in
turn is more commonly associated with additional injuries of
FIG 4 • An t e rio r e xt e rn a l fixa t io n o f t h e p e lvis d o e s n o t co n fe r
concerning severity.
p o st e rio r st a b ilit y. In t h is e xa m p le le ft p o st e rio r sa cro ilia c
■ “ N on-ring” fractures: iliac crest, ischial tuberosity
d ia st a sis is u n re so lve d . In su ch ca se s a n t e rio r e xt e rn a l fixa t io n
■ Ring fractures of increasing severity and instability
m a y e ffe ct ive ly m a n a g e h e m o d yn a m ic in st a b ilit y b u t d o e s n o t
■ Rotationally and vertically stable
o ffe r st ru ct u ra l p o st e rio r st a b ilit y. (Fro m Pe t e rs P, Bu ch o lz RW.
■ Rotationally unstable and vertically stable
Th e a sse ssm e n t o f p e lvic st a b ilit y fo llo w in g p e lvic rin g d isru p -
■ Rotationally and vertically unstable t io n s. Te ch Ort h o p 1990;4:52–59.)
278 Se ct io n III PELVIS AND HIP
■ If for purposes of provisional stabilization, the surgeon
should determine the anticipated timing, sequence, and
method of subsequent definitive stabilization.
■ Frame design and pin location are selected (anterior iliac
crest, supra-acetabular, posterior C-clamp) based on the pelvic
injury pattern, the patient’s hemodynamic status, the available
imaging, and surgeon familiarity.
■ An immediate presurgical pelvic radiograph is obtained to
assess the impact of retained bowel gas or contrast on imaging
capability (if required).
Positioning
■ The patient is placed supine on a radiolucent table.
■ Adequacy of imaging and efficacy of closed reduction ma-
neuvers are confirmed.
■ Preparation is done from the umbilicus to the anterior
thighs, including both iliac crests.
■ O ne or both lower extremities are included circumferentially
as required to effect rehearsed closed reduction maneuvers.
Approach
■ Adequate fixation and accordingly proper pin placement are
the principal requirements for restoring pelvic stability when
applying an external fixator.
■ Pins for purposes of anterior pelvic external fixation may
be placed either in the anterior iliac crest or in the supra-
acetabular region (FIG 5 ).
■ Ease of insertion is an important attribute when applying a
resuscitation frame.
■ Pin placement within the iliac crest is more expeditiously
performed and lacks significant regional anatomic hazards.
■ O n occasion, this area may be compromised by soft tissue
concerns or proximity to fracture planes.
■ In such cases, pin placement within the supra-acetabular re-
gion is an option.
B a n t e rio rly a p p lie d fra m e s. A . Sch e m a t ic. B. Ca se AP ra d io g ra p h .
FIG 5 • Th e a n t e rio r h e m ip e lvis o ffe rs t w o sit e s fo r p in in se r-
t io n : t h e ilia c cre st (su p e rio rly) a n d t h e su p ra -a ce t a b u la r re g io n
(m o re in fe rio rly). A . Pro file vie w . B. Fro n t a l vie w .
■ Pins and frames in this lower position may offer improved
access to the abdomen and unlike pins placed within the iliac
crest are less irritating to anterolateral abdominal soft
tissues. 18
■ In an obese patient, these pins (supra-acetabular) may be
better tolerated and less prone to loosening and infection.
■ The dense bone of the supra-acetabular region offers stabil-
ity of fixation as good as or better than the iliac crest.
■ Some authors investigating the biomechanical performance
of these pins (supra-acetabular) demonstrated superior pur-
chase within bone and diminished displacement of posterior
portions of the pelvic ring.11
■ Because supra-acetabular pin insertion is more time-
consuming and instrumentation and fluoroscopy dependent,
its role as a resuscitative measure is limited.
■ The pelvic antishock clamp (C-clamp) is a posteriorly (or
trochanteric) applied device that may offer greater stability to
vertically unstable fractures than anteriorly applied frames
(FIG 6 ).1,10 It is designed for the emergent treatment of unsta-
ble pelvic ring injuries.
■ The device is indicated in both rotationally and vertically
unstable pelvic ring injuries.
■ It is contraindicated in lateral compression injuries
and fractures involving comminution of the iliac wing or
sacrum. If the device is used in lateral compression-type in-
juries, it may accentuate the deformity. Use of the pelvic
antishock clamp with iliac wing fractures may lead to the
pins traversing the fracture sites, subsequently causing in-
ternal injury.
FIG 6 • “ An t ish o ck” cla m p . Th is d e vice , a p p lie d p o st e rio rly, m a y
o ffe r m o re st a b ilit y t o ve rt ica lly u n st a b le in ju ry p a t t e rn s t h a n
(A: Mo d ifie d fro m Sim o n ia n PT, Ro u t t MLCJ, Ha rrin g t o n RM, e t
a l. An t e rio r ve rsu s p o st e rio r p ro visio n a l fixa t io n in t h e u n st a b le
p e lvis: a b io m e ch a n ica l co m p a riso n . Clin Ort h o p Re la t Re s
1995;310:245–251.)

CIRCUMFERENTIAL PELVIC ANTISHOCK SHEETING
■ Se ve ra l t e ch n iq u e s o f n o n in va sive e xt e rn a l p e lvic rin g
st a b iliza t io n h a ve b e e n d e scrib e d . Am o n g t h e m a re t h e
u se o f in fla t a b le a n t ish o ck t ro u se rs a n d sp ica ca st s. Th e se
d o n o t p e rm it a b d o m in a l a cce ss, t h e y re q u ire skill a n d fa -
m ilia rit y, a n d t h e y co n ce a l t h e a b d o m e n .
■ Th e sim p le a p p lica t io n o f a circu m fe re n t ia l b e d sh e e t
m a y b e co n sid e re d d u rin g t h e re su scit a t io n o f t h e h e m o -
d yn a m ica lly u n st a b le p a t ie n t . 24 Un like m e t h o d s d e -
scrib e d a b o ve , t h is t e ch n iq u e re q u ire s m a t e ria ls t h a t a re
in e xp e n sive , e a sy t o a p p ly, a n d re a d ily a va ila b le . No in ci-
sio n s t h a t m a y je o p a rd ize su b se q u e n t o p e ra t ive p ro ce -
d u re s a re re q u ire d . Th e sh e e t m a y b e p o sit io n e d t o a llo w
a sse ssm e n t o f a b d o m in a l a n d lo w er e xt re m it y re g io n s.
■ Th e p a t ie n t ’s clo t h in g sh o u ld b e re m o ve d b e fo re a p p li-
ca t io n . Th e sh e e t e n d s a re cro sse d a n d o ve rla p p e d
a n t e rio rly.
A B
TECH FIG 1 • Circu m fe re n t ia l a n t ish o ck sh e e t in g . A. Th e sh e e t is p o sit io n e d
w it h in clu sio n o f t h e t ro ch a n t e rs o f t h e h ip s. It is n e xt p u lle d t a u t (B), o ve r-
D la p p e d (C), a n d se cu re d w it h cla m p s (D).
ANTERIOR ILIAC CREST: OPEN TECHNIQUE
■ A m a n u a l t ria l re d u ct io n is re co m m e n d e d b e fo re e st a b -
lish in g a sit e fo r a skin in cisio n .
■ An 8- t o 10-cm o b liq u e w o u n d a d ja ce n t a n d p a ra lle l t o
t h e ilia c cre st a n t e rio rly is e st a b lish e d .
■ Th is in cisio n is m a d e in t h e a n t icip a t e d sit e o f t h e re -
d u ce d h e m ip e lvis t o m in im ize t e n sio n o n so ft t issu e s
(TECH FIG 2 A).
■ Disse ct io n co n t in u e s t h ro u g h skin a n d su b ja ce n t so ft t is-
su e s, a llo w in g p a lp a t io n o f t h e u n d e rlyin g ilia c cre st .
■ Su b p e rio st e a l e le va t io n o f t h e e xt e rn a l o b liq u e e xp o se s
t h e in n e r t a b le (TECH FIG 2 B,C).
■ Su b p e rio st e a l e le va t io n o f t h e h ip a b d u ct o rs e xp o se s t h e
o u t e r t a b le (TECH FIG 2 D).
■ Exp o su re o f t h e in n e r a n d o u t e r t a b le s co n t in u e s w it h in
t h e co n fin e s o f t h e su rg ica l w o u n d .
■ Th e t h ick a n t e rio r p illa r is id e n t ifie d (TECH FIG 2 E).
■ Th e su rg e o n ’s in d e x d ig it is in t ro d u ce d , co n firm in g in n e r
t a b le in clin a t io n .
Ch a p t e r 3 3 EXTERNAL FIXATION OF THE PELVIS 279
TECHNIQUES
■ Th e p o sit io n o f sh e e t a p p lica t io n is d ire ct e d m o re a t t h e
le ve l o f t h e g re a t e r t ro ch a n t e rs o f t h e h ip s t h a n m o re
p ro xim a lly a t t h e in ju re d p e lvis. Cla m p s se cu re t h e
sn u g g e d sh e e t s (TECH FIG 1 ).
■ Lo n g -t e rm p e lvic sh e e t in g is d isco u ra g e d a s so ft t issu e
co m p ro m ise is a co n ce rn . It is co n t ra in d ica t e d in t h e
p re se n ce o f u n st a b le la t e ra l co m p re ssio n in ju rie s. It s
u se in su ch sit u a t io n s m a y a g g ra va t e d e fo rm it y, re su lt -
in g in in t e rn a l visce ra l in ju ry a n d p o st e rio r n e u ro lo g ic
co m p re ssio n .
■ Pe lvic circu m fe re n t ia l co m p re ssio n d e vice s m a y o ffe r t h e
sim p licit y a n d e ffe ct ive n e ss o f sh e e t in g w it h t h e b e n e fit
o f fe e d b a ck co n t ro lle d fo rce . Th is m a y p re ve n t in a d e -
q u a t e o r e xce ssive co m p re ssio n . 3,13
C
■ Th e su rg e o n ’s t h u m b a n d in d e x fin g e rs p a lp a t e t h e o u t e r
a n d in n e r t a b le s re sp e ct ive ly t o a id in e st a b lish in g p ro p e r
p in o rie n t a t io n w it h in t h e t w o t a b le s (TECH FIG 2 F).
■ Th e first p in is p la ce d a n t e rio rly w it h in t h e a n t e rio r p il-
la r, a b o u t 1 t o 2 cm p o st e rio r t o t h e a n t e rio r su p e rio r
ilia c sp in e .
■ Th e ilia c cre st a n t e rio rly is a sym m e t ric w it h re g a rd t o
cro ss-se ct io n a l a n a t o m y.
■ Th e id e a l st a rt in g p o in t is t h u s a lo n g t h e m e d ia l t h ird o f
t h e cre st a t t h e ju n ct io n o f t h e in n e r a n d m id d le t h ird s
(“ ru le o f t h ird s” ) (TECH FIG 2 G).
■ Pins placed centrally or laterally are likely to be misdirect-
ed, exiting the desired intercortical path (TECH FIG 2H).
■ A u n ico rt ica l d rill h o le , n o m o re t h a n 1 t o 2 cm d e e p , in i-
t ia t e s a cce ss w it h in t h e cre st .
■ Pin d ire ct io n is ju d g e d b y m a n u a lly g ra sp in g t h e cre st
w it h in t h e su rg e o n ’s d ig it s a s d e scrib e d . Th is is t yp ica lly
25 t o 45 d e g re e s m e d ia lly a n d 10 t o 15 d e g re e s ca u d a d .
 280 Se ct io n III PELVIS AND HIP

■ Th e p in m a y b e in t ro d u ce d t h ro u g h t h e e st a b lish e d su r- ■ In a n e ffo rt t o re t a in in t ra p e lvic t a m p o n a d e , p in s m a y b e

TECHNIQUES

g ica l w o u n d o r a d ja ce n t (m e d ia l) p e rcu t a n e o u s o n e s in t ro d u ce d t h ro u g h a sim ila r a p p ro a ch w it h o u t e le va t io n

(TECH FIG 2 I).
■ Th e p in is a d va n ce d 5 cm (50-m m t h re a d e d 5.0-m m -
d ia m e t e r p in ), d ire ct e d w it h in t h e p illa r b e t w e e n t h e
o sse o u s t a b le s o f t h e ile u m .
■ Th e se co n d p in a n d t h e t h ird if a p p lica b le a re in se rt e d
o n e fin g e rb re a d t h p o st e rio r t o t h e p re vio u s p in .
■ Th e n a rro w a n d cu rve d p ro file o f t h e cre st d o e s n o t
a llo w p a ra lle l p in in se rt io n a n d o n o cca sio n a cco m m o -
d a t e s n o m o re t h a n t w o p in s.
■ Su b se q u e n t p in s sh o u ld a p p e a r t o co n ve rg e t o w a rd e a ch
o t h e r a n d t h e co m m o n t a rg e t o f t h e su p ra -a ce t a b u la r re -
g io n w it h in t h e a n t e rio r p illa r (TECH FIG 2 J).
o f p e rio sse o u s m u scu la r a t t a ch m e n t s.
■ Sm a ll Kirsch n e r w ire s o r sp in a l n e e d le s a re d ire ct e d
a lo n g t h e ilia c fo ssa t o o rie n t p ro p e r p in p la ce m e n t .
■ In n e r a n d o u t e r t a b le so ft t issu e a t t a ch m e n t s a re p re -
se rve d . He m a t o m a is n o t a cce sse d a n d in t ra p e lvic t a m -
p o n a d e is p re se rve d .
■ A flu o ro sco p ic o b t u ra t o r o b liq u e o u t le t vie w o f t h e
p e lvis ca n a id in id e n t ifica t io n o f m isd ire ct e d p in s e xit in g
t h e d e sire d in t e rco rt ica l p a t h (TECH FIG 2 K).

A B
Internal oblique m.

Iliac crest

Gluteus medius m.

Gluteus maximus m.

D
Iliotibial band

TECH FIG 2 • An t e rio r ilia c cre st p in in se rt io n , o p e n t e ch -

n iq u e . A. Th e skin in cisio n is m a d e a t t h e a n t icip a t e d sit e o f
t h e re d u ce d ilia c cre st . B,C. Th e in t e rn a l o b liq u e is e le va t e d
fro m t h e in n e r t a b le . D. Th e h ip a b d u ct o rs a re e le va t e d fro m
t h e o u t e r p e lvic t a b le . E. Th e t h ick o sse o u s p illa r (*) is t h e
d e sire d sit e o f p in in se rt io n . (co n t in u e d ) E
 Ch a p t e r 3 3 EXTERNAL FIXATION OF THE PELVIS 281

TECHNIQUES
F G

H I

J K

TECH FIG 2 • (co n t in u e d ) F. Pa lp a t io n o f t h e in n e r a n d o u t e r t a b le s co n firm s p ro p e r p in t ra je c-

t o ry. G. Th e “ ru le o f t h ird s” (cro ss-se ct io n a l ju n ct io n o f in n e r t h ird a n d o u t e r t w o t h ird s o f
t h e cre st ) a id s in e st a b lish in g t h e p re fe re n t ia l p in e n t ry p o in t . H. Th is fa cilit a t e s p in in se rt io n ,
p re ve n t in g m isd ire ct io n a n d p re m a t u re e xit . I. Alt e rn a t ive ly, p in s m a y b e p la ce d t h ro u g h
p e rcu t a n e o u s w o u n d s su b ja ce n t t o t h e o p e n su rg ica l in cisio n . J. Pin s sh o u ld co n ve rg e o n t h e
su p ra -a ce t a b u la r re g io n w h ile re m a in in g w it h in t h e a n t e rio r p illa r. K. Flu o ro sco p ic g u id a n ce
fa cilit a t e s p ro p e r p in p la ce m e n t w it h in t h e in n e r a n d o u t e r t a b le s. (A: Mo d ifie d fro m Ya n g AP,
Ia n n a co n e WM. Ext e rn a l fixa t io n fo r p e lvic rin g d isru p t io n s. Ort h o p Clin No rt h Am
1997;28:331–344. J: Mo d ifie d fro m Po ka A, Lib b y EP. In d ica t io n s a n d t e ch n iq u e s fo r e xt e rn a l
fixa t io n o f t h e p e lvis. Clin Ort h o p Re la t Re s 1996;329:54–59.)
 282 Se ct io n III PELVIS AND HIP
TECHNIQUES
ANTERIOR ILIAC CREST: PERCUTANEOUS TECHNIQUE
■ St a b w o u n d s 1 t o 2 cm lo n g a re d ire ct e d p e rp e n d icu la r
fro m t h e a n t e rio r ilia c cre st t o w a rd t h e u m b ilicu s (TECH
FIG 3 ).
■ Th is o rie n t a t io n d im in ish e s u n d e sira b le so ft t issu e t e n -
sio n a ro u n d t h e p in o n p e lvic re d u ct io n a n d g re a t ly e n -
a b le s p in t ra ct re le a se in t h e e ve n t o f im p e n d in g p in
t ra ct in fe ct io n .
■ Aft e r co m p le t in g t h e skin in cisio n , d isse ct io n co n t in u e s
b y sp re a d in g a su rg ica l cla m p , cle a rin g a w a y su b cu t a -
n e o u s fa t .
■ Th roug h th ese small wo und s, Kirschn er wires or sp inal n ee-
dles can be introduced along both sides of the iliac wing.
■ Th is p ro vid e s a t a rg e t in g m e t h o d t o a ccu ra t e ly p o sit io n
t h e p in s w it h in t h e t w o t a b le s o f t h e iliu m .
TECH FIG 3 • An t e rio r ilia c cre st p in in se rt io n , p e rcu t a n e o u s t e ch n iq u e .
St a b w o u n d s (1 t o 2 cm lo n g ) a re e st a b lish e d p e rp e n d icu la r t o t h e ilia c
cre st in t h e d ire ct io n o f t h e u m b ilicu s.
SUPRA-ACETABULAR TECHNIQUE
■ Th e p a t ie n t is p o sit io n e d su p in e o n a ra d io lu ce n t t a b le .
■ Sa fe in t ro d u ct io n a n d p ro p e r p o sit io n in g o f t h e p in re -
q u ire t h e a ssist a n ce o f flu o ro sco p ic g u id a n ce .
■ Th e o p e n a p p ro a ch fo r p in p la ce m e n t b e g in s w it h a
ve rt ica lly o rie n t e d 5- t o 10-cm in cisio n , d e p e n d in g o n
p a t ie n t b o d y h a b it u s a n d p re re d u ct io n p e lvic d e fo r-
m it y. A sm a lle r t ra n sve rse in cisio n h a s b e e n d e scrib e d
in a d d it io n t o e n t ire ly p e rcu t a n e o u s t e ch n iq u e s o f p in
in se rt io n .
■ Th is ve rt ica l a p p ro a ch b e g in s a lo n g t h e la t e ra l b o rd e r o f
t h e a n t e rio r su p e rio r ilia c sp in e , e xt e n d in g d ist a lly a n d
la t e ra l t o t h e a n t e rio r in fe rio r ilia c sp in e .
■ Th e in t e rva l b e t w e e n t h e sa rt o riu s a n d t e n so r fa scia la t a
is id e n t ifie d (TECH FIG 4 A).
■ Tissu e p la n e s a re d e ve lo p e d w it h b lu n t d isse ct io n a n d
t h e a n t e rio r in fe rio r sp in e is p a lp a t e d .
■ Th e la t e ra l fe m o ra l cu t a n e o u s n e rve is m o st co m m o n ly
id e n t ifie d m e d ia l t o t h e a n t e rio r ilia c sp in e .
■ An a t o m ic st u d ie s h a ve d e m o n st ra t e d t h e la t e ra l fe m o ra l
cu t a n e o u s n e rve t o h a ve a va ria b le co u rse , o ft e n w it h in
10 m m o f in se rt e d p in s. 6
■ Wit h b lu n t d isse ct io n a n d t h e u se o f p ro t e ct ive d rill
sle e ve s, t h e la t e ra l fe m o ra l cu t a n e o u s n e rve m a y b e a d -
e q u a t e ly p ro t e ct e d .
■ Su p ra -a ce t a b u la r p in s sh o u ld b e in se rt e d n o le ss t h a n
2 cm p ro xim a l t o t h e jo in t t o a vo id in t ra -a rt icu la r p e n e -
■ Gu id e d b y t h e sp in a l n e e d le s, a so ft t issu e t ro ca r a sse m -
b ly is in t ro d u ce d a n d sit u a t e d m e d ia l o f t h e m id lin e t o
a cco u n t fo r la t e ra l o ve rh a n g (“ ru le o f t h ird s” ).
■ Sa g it t a l p la n e o rie n t a t io n o f t h e p in m u st b e co n sid e re d
a s w e ll.
■ Th is re q u ire s t h a t t h e d rill b e h e ld m o re ce p h a la d (d i-
re ct e d ca u d a d ) t h a n e xp e ct e d t o a llo w p ro p e r p o sit io n
w it h in t h e d e sire d su p ra -a ce t a b u la r b o n e (su p e rio r a n d
ce p h a la d t o t h e a ce t a b u lu m ), ra t h e r t h a n t h e t h in b o n e
o f t h e iliu m . Trip le ca n n u la t e d d rill sle e ve s a re u se d t o
p ro t e ct so ft t issu e s.
■ Th e fixa t io n p in is in se rt e d , a llo w in g t h e co rt ica l w a lls o f
t h e iliu m t o e st a b lish d ire ct io n . An im a g e in t e n sifie r m a y
a id in e le ct ive n o n e m e rg e n t fixa t o r a p p lica t io n .
t ra t io n . Ca p su la r e xt e n sio n o f t h e h ip m a y b e u p t o
16 m m su p e rio rly.
■ An o b t u ra t o r o b liq u e vie w w it h slig h t ce p h a la d a n g u la -
t io n (o b t u ra t o r o u t le t vie w ) is first o b t a in e d . A m e t a llic
m a rke r is p o sit io n e d 2 cm p ro xim a l t o t h e h ip jo in t u n d e r
flu o ro sco p ic co n t ro l (TECH FIG 4 B).
■ Th e t ro ca r a sse m b ly is p o sit io n e d u n d e r flu o ro sco p ic
co n t ro l su p e rio r t o t h e h ip jo in t .
■ On ly t h e o u t e r co rt e x is d rille d . A t rip le ca n n u la t e d g u id e
fa cilit a t e s a t ra u m a t ic d rill a n d p in in se rt io n .
■ Th e d rill, fo llo w e d b y t h e p in , is d ire ct e d w it h in t h e pe lvis,
a vo id in g in t ra -a rt icu la r p e n e t ra t io n o f t h e h ip jo in t .
■ Pin a n g u la t io n is t yp ica lly 20 d e g re e s m e d ia l fro m t h e
ve rt ica l a xis a n d slig h t ly ce p h a la d .
■ Th e drill is d irected toward an d sup erio r to the sciatic
notch (30 to 45 degrees in the sagittal plane). Fluoroscopic
guidance (iliac oblique view with slight cephalad angula-
tion) en su res p roper pin trajecto ry and depth of insertion
(TECH FIG 4C,D).
■ In t e rco rt ica l p in o rie n t a t io n w it h in t h e t a b le s o f t h e
p e lvis is m o n it o re d o n a n o b t u ra t o r o b liq u e in le t vie w
(“ ro llo ve r vie w ” ) (TECH FIG 4 E,F).
■ A 5-m m -d ia m e t e r 50-m m t h re a d le n g t h p in is in se rt e d t o
t h e d e p t h o f t h e t h re a d s.
■ A se co n d p in m a y b e in se rt e d p ro xim a l t o t h e first , if
d e sire d .
 Ch a p t e r 3 3 EXTERNAL FIXATION OF THE PELVIS 283

TECHNIQUES
*

A B

C D E

TECH FIG 4 • Su p ra -a ce t a b u la r p in in se rt io n t e ch n iq u e . A. Th e in t e rva l b e -

t w e e n t h e sa rt o riu s a n d t h e t e n so r fa scia la t a is e st a b lish e d (la t e ra l fe m o ra l
cu t a n e o u s n e rve p ro t e ct e d (*). B. An o b t u ra t o r o u t le t vie w id e n t ifie s t h e
p ro p e r p in e n t ry sit e . C,D. An ilia c o b liq u e vie w w it h ce p h a la d a n g u la t io n d i-
re ct s t h e a d va n cin g p in . E,F. Th e ro llo ve r vie w (o b t u ra t o r o b liq u e in le t vie w )
F e n su re s p in p la ce m e n t w it h in t h e in n e r a n d o u t e r t a b le s o f t h e p e lvis.

FRAME APPLICATION AND REDUCTION

■ No fra me, re g ard less o f co mp le xity, resto res su fficien t
d e fin it ive fixa t io n t o ve rt ica lly u n st a b le le sio n s. 21
Acco rd in g ly, sim p le co n st ru ct s are p re fe rred to p erm it p a-
t ien t m o b iliza tio n , ab d o m in al a ccess, a n d p e rfo rma n ce o f
su b se q u e n t d ia g n o st ic a n d th e ra p e u t ic p ro ce d u re s.
■ Accu ra t e p in p la ce m e n t w it h in t h e cu rve d ilia c cre st
m a n d a t e s a n o n p a ra lle l co n ve rg in g p in p a t t e rn . Pin
cla m p s w it h a st ra ig h t co n fig u ra t io n re q u ire t h a t p in s b e
p re st re sse d t o co n fo rm a n d a cco m m o d a t e su ch cla m p s
(TECH FIG 5 A). Th o se w it h a n in d e p e n d e n t b a ll jo in t d e -
sig n o ffe r a n a t t ra ct ive a lt e rn a t ive (TECH FIG 5 B).
■ Ap p lie d p in cla m p s sh o u ld re m a in t h re e fin g e rb re a d t h s
a b o ve t h e skin su rfa ce . Th is is le ss t h re a t e n in g t o su b ja -
ce n t so ft t issu e s a n d p e rm it s a d e q u a t e p in t ra ct ca re .
■ Th e fra m e is fa b rica t e d w it h in clu sio n o f u n ive rsa l b a ll
jo in t s a n d re d u ct io n is p e rfo rm e d . Ant e ro p o st e rio r co m -
p re ssio n in ju rie s a re re d u ce d w it h m id lin e -d ire ct e d co m -
p re ssio n a n d la t e ra l co m p re ssio n in ju rie s w it h d ist ra ct io n .
Ad ju n ct ive lo w e r e xt re m it y ske le t a l t ra ct io n m a y b e co n -
sid e re d fo r ve rt ica lly d isp la ce d p a t t e rn s. Ba r-t o -b a r
co n n e ct o rs a re n e xt se cu re d a n d o p e ra t ive in cisio n s a re
clo se d a n d d re sse d .
 284 Se ct io n III PELVIS AND HIP
TECHNIQUES

A B

TECH FIG 5 • Pin cla m p s: st ra ig h t (A) a n d m u lt ip la n a r (B).

PELVIC ANTISHOCK CLAMP: C-CLAMP

■ Th e su rg e o n ca n ch o o se b e t w e e n t w o co ro n a lly o ri-
e n t e d p in p la ce m e n t p o sit io n s (a n t e rio r o r p o st e rio r)
(TECH FIG 6 A). 19 An t e rio r p in s a re p la ce d in t h e d e n se
co lu m n o f b o n e o f t h e g lu t e a l rid g e . An t e rio r p in p la ce -
m e n t w ill a llo w fo r co m p re ssio n o f t h e a n t e rio r a n d , t o
so m e d e g re e , t h e p o st e rio r p e lvic rin g . Po st e rio r p in
p la ce m e n t a llo w s fo r co m p re ssio n o f t h e p o st e rio r
p e lvic rin g .
■ La n d m a rks fo r a n t e rio r p in p la ce m e n t in clu d e t h e a n t e -
rio r su p e rio r ilia c sp in e , t h e t ip o f t h e g re a t e r t ro ch a n t e r,
a n d t h e a xis o f t h e fe m u r.
■ Th e su rg e o n sh o u ld e n su re t h a t t h e p a t ie n t ’s le g s a re
n o t e xt e rn a lly ro t a t e d , a s t h is w ill p la ce p in s t o o fa r
p o st e rio r.
■ Th e su rg e o n fin d s t h e g lu t e a l rid g e , w h ich is t h re e
fin g e rb re a d t h s p o st e rio r t o t h e a n t e rio r su p e rio r ilia c
sp in e o n t h e ilia c w in g .
■ Ne xt , t h e su rg e o n lo ca t e s t h e t ip o f t h e g re a t e r
t ro ch a n t e r a n d t h e a xis o f t h e fe m u r w it h le g s in n e u -
t ra l ro t a t io n .
■ Th e ce n t e r o f t h e lin e co n n e ct in g t h e g lu t e a l rid g e
a n d t h e g re a t e r t ro ch a n t e r co rre sp o n d s t o t h e p in

Sacroiliac
joint
Superior
Neural gluteal
foramen artery
and vein

Piriformis m.
Sciatic n.

TECH FIG 6 • Pe lvic a n t ish o ck cla m p . A. An t e rio r a n d

A p o st e rio r sit e s o f a p p lica t io n . B. Pin sit e . (co n t in u e d )

C D
TECH FIG 6 • (co n t in u e d ). C–E. Ap p lica t io n la n d m a rks a n d
a n t e rio r p in sit e la n d m a rks. (A: Mo d ifie d fro m Bu ckle R,
Bro w n e r B, Mo ra n d i M. Em e rg e n cy re d u ct io n fo r p e lvic rin g
d isru p t io n s a n d co n t ro l o f a sso cia t e d h e m o rrh a g e u sin g t h e
p e lvic st a b ilize r. Te ch Ort h o p 1995;9:258–266.) F. Pe lvic a n t i-
sh o ck cla m p a p p lica t io n la n d m a rks a n d p o st e rio r p in sit e
la n d m a rks.
sit e . Th is p o in t sh o u ld b e a b o u t 5 t o 6 cm fro m t h e
t o p o f t h e ilia c w in g (TECH FIG 6 B–E).
■ La n d m a rks fo r p o st e rio r p in p la ce m e n t in clu d e t h e a n t e -
rio r su p e rio r ilia c sp in e , p o st e rio r su p e rio r ilia c sp in e , a n d
d o rsa l a xis o f t h e fe m u r. A lin e is d ra w n b e t w e e n t h e a n -
t e rio r a n d p o st e rio r su p e rio r ilia c sp in e s. Th e in t e rse ct io n
o f t h is lin e a n d t h e d o rsa l a xis o f t h e fe m u r co rre sp o n d s
t o t h e p in sit e . Th e p in sit e sh o u ld b e a b o u t 4 t o 5 cm a n -
t e rio r t o t h e p o st e rio r ilia c sp in e (TECH FIG 6 F). Th e su r-
g e o n m u st a vo id t h e g re a t e r scia t ic n o t ch a n d t h e so ft
b o n e o f t h e ilia c fo ssa .
Ch a p t e r 3 3 EXTERNAL FIXATION OF THE PELVIS 285
TECHNIQUES
F
■ The p in sit e is infilt rate d w ith lo cal a nesthe tic and an
in cisio n is m ad e. Blu n t d isse ct io n is ca rried d o wn to b o n e.
■ Th e p in s a re a d ju st e d t o b e in a sin g le a xis. Th is o rie n t a -
t io n a llo w s ro t a t io n o f t h e C-cla m p , p e rm it t in g a b d o m i-
n a l a cce ss. Re d u ct io n o f a n y ve rt ica l d isp la ce m e n t is n o w
co m p le t e d w it h t ra ct io n .
■ Alt e rn a t ive ly, t h e C-cla m p m a y b e d ire ct ly a p p lie d t o t h e
t ro ch a n t e ric re g io n o f t h e fe m u r.1 Th e a n a t o m ic h a za rd s
o f t h e p re vio u s m e t h o d o f a p p lica t io n a re t h u s a vo id e d .
In t h is m a n n e r, it se rve s a ro le sim ila r t o circu m fe re n t ia l
sh e e t in g .
286 Se ct io n III PELVIS AND HIP

PEARLS AND PITFALLS

En h a n cin g p in fixa t io n
Avo id in g co n flict in g
su rg ica l e xp o su re s
An t e rio r ilia c cre st w o u n d
An t icip a t in g p in t ra je ct o ry
in t h e u n re d u ce d p e lvis
Avo id in g e xt ra p e lvic
m isg u id e d p in s
Ove rco m p re ssio n is p o ssib le
■ Th e p in –b o n e in t e rfa ce h a s m a xim a l st re ss co n ce n t ra t io n a n d re p re se n t s t h e w e a ke st
co m p o n e n t o f t h e e xt e rn a l fra m e a sse m b ly.
■ Bo n e q u a lit y, fra m e rig id it y, p in n u m b e r, a n d p in p la ce m e n t a n d d ia m e t e r ca n a ll a ffe ct t h e
st re n g t h o f t h e p in –b o n e in t e rfa ce .
■ Th e in se rt io n le n g t h , a lso re fe rre d t o a s t h e in t e rco rt ica l d ist a n ce , g re a t ly in flu e n ce s p u llo u t
fo rce s.
■ As a g e n e ra l ru le , p in s sh o u ld b e m a in t a in e d w it h in t h e t w o co rt ice s a s lo n g a s p o ssib le . Dist a l
co rt ica l p e n e t ra t io n is t e ch n ica lly u n d e sira b le a n d sh o u ld b e a vo id e d .
■ Pin s o f a d e q u a t e in t e rco rt ica l d ist a n ce co n sist e n t ly a p p e a r t o o u t p e rfo rm t h o se w it h
t ra n sco rt ica l p u rch a se (u n d e sire d e xt ra co rt ica l e xit ).
■ Su rg ica l w o u n d s a n d p in lo ca t io n in t h e su p ra -a ce t a b u la r re g io n a re le ss like ly t o co m p ro m ise
fu t u re a n t icip a t e d su rg ica l w o u n d s. Th is is p a rt icu la rly im p o rt a n t if a n t e rio r a cce ss t o t h e
sa cro ilia c jo in t is a n t icip a t e d a n d p u rsu e d la t e r.
■ Th e su rg ica l w o u n d a n t e rio rly sh o u ld b e p la ce d in t h e a n t icip a t e d re g io n o f t h e h e m ip e lvis
a ft e r re d u ct io n . Th is m in im ize s t e n sio n o n so ft t issu e s.
■ Pe rcu t a n e o u s w o u n d s m a y b e m a d e a d ja ce n t t o t h e o p e n e xp o su re t o a llo w p in in t ro d u ct io n .
■ Th e w o u n d is clo se d b e fo re fra m e a p p lica t io n .
■ Pin in clin a t io n in t h e u n re d u ce d p e lvis d o e s n o t re fle ct n o rm a l p a ra m e t e rs.
■ De p e n d in g o n d e fo rm it y, p in in clin a t io n m a y b e m o re ve rt ica l (la t e ra l co m p re ssio n ) o r
h o rizo n t a l (e xt e rn a lly ro t a t e d , AP co m p re ssio n ).
■ “ Pre fe re n t ia l e rro rs” d o e xist !
■ Fo r AP co m p re ssio n in ju rie s, a n in t e rn a l e xit is p re fe rre d . Fo r la t e ra l co m p re ssio n in ju rie s, a n
e xt e rn a l e xit is p re fe rre d . Th is m a in t a in s t h re e -p o in t fixa t io n in a m e ch a n ica lly a d va n t a g e o u s
m a n n e r.
■ De p e n d in g o n t h e m e t h o d o f a p p lica t io n , re d u ct io n , a n d fra ct u re p a t t e rn , co m p re ssio n w it h a n
a n t e rio rly a p p lie d fra m e m a y a cce n t u a t e p o st e rio r d isp la ce m e n t .

POSTOPERATIVE CARE
■ After satisfactory application of the frame, individual pin
sites are scrutinized and soft tissues are released to prevent
tension-induced necrosis and subsequent infection.
■ Post-application imaging confirms pelvic stability, symmetry,
and indications for additional anterior or posterior (open or per-
cutaneous) stabilization techniques.
■ Pin sites are débrided of organized blood and cleansed once
or twice daily with peroxide solution. Dressings may be ap-
plied (if inspected regularly) or the wounds may be left open.
Peripheral pin site tension should be released with sharp dis-
section under local anesthesia. Regional necrosis and subse-
quent pin tract sepsis are thereby avoided.
■ M obilization and weight bearing are dictated by the injury
pattern and designated stability classification.
■ The transient use of external fixation is efficacious if its role
and indication are clearly defined. Use for definitive treatment
is associated with a high rate of infection and aseptic pin loos-
ening. Unstable posterior lesions are inadequately managed
with external fixation alone.
COMPLICATION S
■ Sheeting: overcompression (lateral compression injuries)
■ General: pin tract sepsis, loss of pin fixation, malreduction,
loss of reduction 14
■ Anterior external pelvic fixation: inadequate or aggravated
posterior alignment
■ Supra-acetabular pin placement: lateral femoral cutaneous
nerve injury, intra-articular hip penetration, sciatic notch neu-
rovascular injury
■ C-clamp: intrapelvic pin penetration

OUTCOMES
■ Severe hemodynamic instability on arrival is a useful predic-
tor of mortality and transfusion demands. Death within the
first 24 hours is often due to acute blood loss; after this time it
is usually secondary to multisystem organ failure.
■ Reported mortality rates of open pelvic fractures range from
10% to 45% . These injuries are often associated with injuries
of prognostic significance. Life-saving strategies to address this
problem continue to evolve. The degree of pelvic instability
clearly parallels rates of morbidity and mortality.
■ Vertically unstable fractures, despite adequate contempo-
rary management, have significant neurologic and associated
injuries that remain of long-term consequence and disability.
Those with rotational instability alone have a considerably
more favorable prognosis.17,26
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13. Krieg JC, M ohr M , Ellis TJ, et al. Emergent stabilization of pelvic
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trial. J Trauma 2005;59:659–664.
14. M ason WT, Khan SN , James CL, et al. Complications of temporary
and definitive external fixation of pelvic ring injuries. Injury 2005;
36:599–604.
15. M endez C, Gubler KD, Maier RV. Diagnostic accuracy of peritoneal
lavage in patients with pelvic fractures. Arch Surg 1994;129:477–481.
16. M iller PR, M oore PS, M ansell E, et al. External fixation or arteri-
ogram in bleeding pelvic fracture: initial therapy guided by markers
of arterial hemorrhage. J Trauma 2003;54:437–443.
Ch a p t e r 3 3 EXTERNAL FIXATION OF THE PELVIS 287
17. M iranda M A, Riemer BL, Butterfield SL, et al. Pelvic ring injuries: a
long-term functional outcome study. Clin O rthop Relat Res 1996;
329:152–159.
18. N oordeen M H , Taylor BA, Briggs TW, et al. Pin placement in pelvic
external fixation. Injury 1993;24:581–584.
19. Pohlemann T, Braune C, Gansslen A, et al. Pelvic emergency clamps:
anatomic landmarks for a safe primary application. J O rthop Trauma
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20. Poka A, Libby EP. Indications and techniques for external fixation of
the pelvis. Clin O rthop Relat Res 1996;329:54–59.
21. Ponsen KJ, H oek van Dijke GA, Joosse P, et al. External fixators for
pelvic fractures: comparison of the stiffness of current systems. Acta
O rthop Scand 2003;74:165–171.
22. Reilly M C, Z inar DM , M atta JM . N eurologic injuries in pelvic ring
fractures. Clin O rthop Relat Res 1996;329:28–36.
23. Routt M L Jr, Falicov A, Woodhouse E, et al. Circumferential pelvic
antishock sheeting: a temporary resuscitation aid. J O rthop Trauma
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24. Simpson T, Krieg JC, H euer F, et al. Stabilization of pelvic ring dis-
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 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 34 Fix a t io n o f t h e Sy m p h y s is
M ich ae l S. H. Kain an d Pau l To rn e t t a III

DEFIN ITION
■ The pubic symphysis comprises a fibrocartilaginous disc
between the bodies of the two pubic bones.
■ A diastasis of the pubic symphysis indicates a disruption of
the pelvic ring and an unstable pelvis.
■ The symphysis is disrupted in anterior–posterior compres-
sion (APC) injuries as classified by Young and Burgess and oc-
casionally in lateral compression fractures.
AN ATOMY
■ The symphysis is an amphiarthrodial joint, consisting of a
fibrocartilaginous disc, and stabilized by the superior and in-
ferior arcuate ligaments (FIG 1 A).
■ The corona mortis is a vessel that represents the anasto-
■ The arcuate ligaments are the main soft tissue stabilizers of
the anterior pelvis.
■ These ligaments arc both superiorly and inferiorly and are
firmly attached to the pubic rami.
■ The sacrospinous and sacrotuberous ligaments play an im-
portant role in the stability of pelvic fractures. These ligaments
connect the sacrum to the ilium via the ischial spine and the is-
chial tuberosity. The sacrospinous ligament resists the rota-
tional forces of the hemipelvis, and the sacrotuberous ligament
prevents rotation as well as translation of the hemipelvis.13
■ If these ligaments and the pelvic floor are torn in conjunc-
tion with a pelvic fracture, symphyseal widening is more sig-
nificant (see Chap. TR-1). 4

mosis between the obturator artery and the external iliac
artery. It is located about 6 cm laterally on either side of the
symphysis (FIG 1 B). 14
■ Lateral to the symphysis on the superior rami is the pubic
tubercle, a prominence representing the attachment of the in-
guinal ligament.
PATHOGEN ESIS
■ The Young and Burgess classification describes the injury by
the type of force acting on the pelvis. Symphyseal diastasis is
most commonly seen in APC injuries or open book pelvis
injuries.
■ In APC injuries minor widening of the symphysis may not in-

■ This bony landmark must be accounted for when con- volve disruption of the pelvic floor, including the sacrospinous
touring a plate that is going to span the symphysis. ligaments.
■ Anatomic variation exists between the sexes, with females ■ In cadaver pelvi, where the symphysis and sacrospinous lig-

having a wider and more rounded pelvis, making their anterior aments were sectioned, more than 2.5 cm of symphyseal
pelvic ring more concave than males (FIG 2 ). widening was observed, thus defining a rotationally unstable
■ The pelvic arch formed by the convergence of the inferior pelvis.12
rami tends to be more rounded in females because their ■ If the pelvic floor and the sacrospinous ligaments are torn,

pubic bodies are shallower than males. the involved hemipelvis can externally rotate down and out,

External
Pubic arch iliac a.
Arcuate
ligaments Rectus
Pubic tubercle
abdominis m.
Interior
epigastric a.

Corona
mortis a.

Obturator a.

A B

FIG 1 • A. Vie w o f t h e a n t e rio r p e lvis d e m o n st ra t in g t h e fib ro ca rt ila g in o u s d isc b e t w e e n t h e p u b ic b o d ie s, t h e su p e rio r

a n d in fe rio r a rcu a t e lig a m e n t s, a n d t h e re la t io n sh ip b e t w e e n t h e sym p h ysis a n d t h e p u b ic t u b e rcle s. B. Th e co ro n a m o r-
t is is d e m o n st ra t e d o n t h e in sid e o f t h e su p e rio r p u b ic ra m i a b o u t 6 cm fro m t h e sym p h ysis. It re p re se n t s t h e a n a st o m o -
sis o f t h e o b t u ra t o r a rt e ry a n d t h e e xt e rn a l ilia c a rt e ry.

288

A B
C D
rotating on the intact posterior sacroiliac ligaments and cre-
ating an unstable pelvis (FIG 3 ).4
■ O ccasionally, lateral compression (LC) injuries involve frac-
tures of the pubic rami and a symphyseal disruption. This oc-
curs when the compressed hemipelvis causes the contralateral
rami to fracture and the contralateral symphyseal body to tilt
inferiorly. Because one side of the symphysis is off and can
FIG 3 • Th e h e m ip e lvis e xt e rn a lly ro t a t e s o u t w h e n t h e p o st e rio r
sa cro ilia c lig a m e n t s re m a in in t a ct , a s in a n a n t e rio r–p o st e rio r
co m p re ssio n t yp e II in ju ry. Th e p o st e rio r lig a m e n t s a ct a s a
h in g e , a n d w it h sa cro sp in o u s lig a m e n t s t o rn t he in vo lve d
h e m ip e lvis w ill ro t a t e d o w n a n d o u t , so t h e p u b ic b o d y o n t h e
in ju re d sid e w ill b e be lo w t h e in t a ct p u b ic b o d y.
Ch a p t e r 3 4 ORIF OF THE SYM PHYSIS 289
FIG 2 • Exa m p le s o f t h e a n a t o m ic va ria n t s b e t w e e n
g e n d e rs. Th e fe m a le p e lvis h a s a m o re co n ca ve sh a p e
t o t h e rin g a n d t h e p u b ic a rch h a s le ss o f a n a cu t e
a n g le b e ca u se o f t h e b ro a d e r p u b ic b o d y, a s d e m o n -
st ra t e d in t h e in le t (A) a n d o u t le t (B) vie w s o f a fe -
m a le p e lvis. Th e m a le p e lvic rin g is m o re o va l, w it h a
m u ch m o re a cu t e a n g le a n t e rio rly b e ca u se o f t h e
t h in n e r p u b ic b o d y, a s se e n t h e co rre sp o n d in g in le t
(C) a n d o u t le t (D) vie w s.
compress the bladder or uterus, altering the pelvic ring, it should
be reduced to the other pubic body, which remains intact.
■ These are referred to as tilt fractures, and open reduction
and internal fixation should be considered to prevent im-
pingement of the birth canal and bladder.13
■ A diastasis of the pubic symphysis can also occur in pregnancy
and during childbirth because of hormonally induced ligamen-
tous laxity. This can lead to chronic instability, and stabilization
of the symphysis has been shown to relieve painful symptoms.16
N ATURAL HISTORY
■ Persistent low back pain, anterior pain, sitting imbalance,
and an impaired, painful gait are common sequelae after pelvic
fractures.
■ Early studies looking at pelvic fractures without surgical
treatment demonstrated that almost a third of these patients
had disabling pain and impaired gait. O nly a third had no
symptoms if the posterior ring was involved.16
■ APC type I injuries are Tile type A stable pelvic injuries,
which do well with nonoperative treatment. These injuries
tend to occur in younger patients involved in motor vehicle
trauma or in elderly patients as a result of a direct injury such
as a fall.
■ APC type II and III injuries are unstable injuries. N on-
operative treatment has resulted in late pain in these injuries. In
a retrospective study by Tile, APC type II injuries treated non-
operatively had a 13% incidence of late pain, with the major-
ity of patients reporting persistent moderate pain. The patients
with APC type III injuries reported a 16% incidence of late
pain, with most pain being reported as moderate or severe.13
■ Patients with pelvic trauma tend to have other organ sys-
tems involved, and these associated injuries contribute to long-
term disability. The more severe injuries associated with pelvic
fractures are urologic and neurologic injuries.16
■ Whitbeck et al demonstrated higher morbidity and mortal-
ity rates as well as an increased incidence of arterial injuries in
APC type III injuries compared to other pelvic fractures.18
290 Se ct io n III PELVIS AND HIP
■ Disruption of the pubic symphysis is associated with uro-
logic injuries. Bladder ruptures and urethral tears occur about
15% of the time in association with pelvic trauma and can
lead to late complications such as strictures and incontinence.
These associated injuries potentially lead to a higher infection
rate when open reduction and internal fixation is performed.8
An increased incidence of incontinence has also been seen in
women with APC injuries.
■ N eurologic injuries associated with pelvic fractures occur
when there is posterior pathology and are more common with
sacral fractures and vertically unstable fracture patterns.
■ Dyspareunia and sexual dysfunction are also described as com-
plications after pelvic fractures.7 They can occur directly from the
injury or as a result of ectopic bone formation during healing.
■ Symphyseal pelvic dysfunction, a relatively common condi-
tion, presents as anterior pelvic pain secondary to the laxity in
the symphysis. This condition typically resolves spontaneously
and can take some time but needs to be differentiated from trau-
matic symphyseal diastasis as a result of childbirth. Traumatic
diastasis occurs in about 1 in 2000 births to 1 in 30,000 births,
and the diastases from pregnancy can be as great as 12 cm.3
■ M ost patients with postpartum displacement recover with
no residual pain or instability after treatment with pelvic
binders, girdles, and the recommendation to lie in the lateral
decubitus position.
■ There are a limited number of studies looking at symphyseal
disruption secondary to pregnancy. The exact incidence of per-
sistent long-term pain is unknown, but chronic pelvic instabil-
ity can occur if it is unrecognized.9
■ In the few series reporting operative treatment, the indication
was persistent pain for at least 4 to 6 months postpartum.3,9
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Pelvic injuries usually occur as a result of any high-energy
trauma, such as high-speed motor vehicle accidents, motorcy-
cle accidents, or falls from heights.
■ Patients with pelvic fractures may become hemodynamically
unstable, and close monitoring of blood pressure and fluid re-
quirements is needed.
■ Typically, if a patient requires more than 4 units of blood
to maintain hemodynamic stability, an angiogram should be
obtained to diagnose and embolize any arterial injuries.
Clotting factors and platelets should also be administered.
■ Patients may have tenderness to palpation in the area of the
symphysis. If motion of the pelvis is detected, manipulation of
the pelvis should cease, as unnecessary manipulation may dis-
turb any clot formation (see Exam Table for Pelvis and Lower
Extremity Trauma, pages 1 and 2).
■ If there is no radiographic demonstration of displacement,
the iliac wings can be compressed to test for stability of the
pelvic ring and each hemipelvis.
■ A careful examination of the skin to identify areas of ecchy-
mosis and hematoma formation, particularly in the flanks,
groin, and abdominal regions, also needs to be performed.
■ The presence of a M orel-Lavalle lesion indicates that high-
energy trauma has occurred in the pelvic region (FIG 4 ).
Recognition of this lesion is important to prevent infection.
■ A good pelvic examination and evaluation of the perineum
are essential. Swelling or open wounds in the perineal area
may indicate a high-energy mechanism of injury. O pen injuries
require emergent management.
FIG 4 • Mo re l-La va lle le sio n .
■ Evaluation of other organ systems, looking for associated
injuries, is essential.
■ In males, a high-riding prostate on the rectal examination
or blood at the meatus may indicate injury to the urethra or
bladder, and placement of a Foley catheter should be de-
layed until a retrograde urethrogram is performed, unless
the patient is in extremis.
■ Urethral injuries are less common in females because the
urethra is shorter.
■ A thorough neurologic examination of the lower extremities
also needs to be performed, as injuries to the L4 and L5 nerve
roots can occur in pelvic fractures. It is essential to test the sen-
sation and motor functions of specific roots, identifying any
neurologic injury that can differentiate between a nerve root
lesion or a more central lesion.
■ A limb-length discrepancy or a rotational deformity of the
lower extremities should prompt radiographic evaluation of
the pelvis.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Radiographic evaluation of the pelvis consists of anteropos-
terior (AP), inlet, outlet, and Judet views (FIG 5 ).
■ A retrograde urethrogram and sometimes a CT cystogram
should be performed to rule out an injury to the genitourinary
system in men. A CT cystogram is sufficient for females.
■ A CT scan of the pelvis is also indicated to help evaluate
intra-articular injuries to the sacroiliac joints and further delin-
eate the fracture pattern.
■ A CT angiogram can also be used at the time of the trauma
scan to help predict if an arterial bleed is present and requires
further treatment with angiography and embolization.10
■ Angiography may be used to treat patients who are hemody-
namically unstable and do not respond to standard resuscita-
tion, particularly if a CT angiogram indicates arterial bleeding.
■ A stress examination in the operating room can be per-
formed under fluoroscopy to assess stability if there is a ques-
tion of an unstable pelvis.
■ Single-leg stance views can also be performed if it is not
clear whether an injury is unstable. This is a good examination
for evaluating patients who may have chronic instability, such
as a female patient with ligamentous laxity secondary to preg-
nancy or unrecognized pelvic injury.9,14
DIFFEREN TIAL DIAGN OSIS
■ Rami fractures
■ Symphyseal strain
■ H ip fracture

A B
D E
■ M uscle strain or avulsion
■ Lumbar fracture
ACUTE MAN AGEMEN T
■ The patients should be hemodynamically stabilized.
■ The pelvis can be stabilized by placing ankles together with
Ace wraps. H eels and ankles should be padded to prevent skin
breakdown and ulcer formation.
■ Placing a sheet across the pelvis at the level of the greater
trochanters can be used to reduce the symphysis and tem-
porarily stabilize the pelvis. The sheet can be affixed with
towel clips to hold it with tension rather than tying a knot
across the abdomen (see Chap. TR-1).
N ON OPERATIVE MAN AGEMEN T
■ If minimal separation of the symphysis is present, the pa-
tient can be made non-weight bearing on the affected side and
can be allowed to ambulate.
■ Close radiographic monitoring should ensue, with weekly
radiographs. Single-leg stance views can be used to help iden-
tify late instability.
SURGICAL MAN AGEMEN T
■ A diastasis larger than 2.5 mm indicates a disruption of the
sacrospinous ligaments and thus an unstable pelvis. O pen fix-
ation of the symphysis stabilizes the anterior pelvis.2
■ O pen injuries can be stabilized with external fixation, using
iliac wing pins or H anover pins placed at the level of the ante-
rior inferior iliac spine. Refer to Chapter TR-1 for more details.
■ In APC type II injuries with an intact hemipelvis, no poste-
rior fixation is needed, and the symphysis is reduced and
stabilized first.
■ For type III injuries, if the innominate bone is broken, the
anterior pelvic ring is reduced and fixed after the posterior
ring is reduced and fixed. The anterior pelvic ring is reduced
Ch a p t e r 3 4 ORIF OF THE SYM PHYSIS 291
C
FIG 5 • Ap p ro p ria t e AP (A), in le t
(B), o u t le t (C), a n d Ju d e t vie w s
(D,E) o f t h e p e lvis in a p a t ie n t w it h
p e lvic t ra u m a a n d w id e p u b ic sym -
p h ysis. (Co u rt e sy o f Jo d i Sie g e l,
MD, a n d Da vid Te m p le m a n , MD.)
and fixed as a first step if the innominate bone remains
intact.
■ Indications for anterior stabilization for vertically unstable
pelvic fractures include improving anterior stability to
the pelvic ring, stabilizing a pelvic injury that is associated
with an injury requiring a laparotomy, treatment of bone pro-
truding into the perineum (ie, a tilt fracture), or in association
with an acetabular fracture requiring open reduction.13
Preoperative Planning
■ The surgeon should review appropriate radiographic studies
(AP, inlet, and outlet views and CT scan).
■ Identifying all rami fractures and the presence of any
pubic body fractures is essential, as this will help determine
how to obtain a reduction as well as dictate the type of
fixation necessary.
■ The surgeon should plan to obtain stress views in the oper-
ating room to determine the stability of the pelvis if there is
any question of stability.
■ The surgeon should rule out the presence of a bladder
rupture or urethral tear. If one is present, repair should be per-
formed at the same time as internal fixation of the symphysis
if possible to avoid a more complex late reconstruction.
■ Any history of previous abdominal surgery or the presence
of prior incisions should be identified before going to the op-
erating room.
■ The proper equipment must be available, such as C-arm, ra-
diolucent table, large bone clamps, external fixation equip-
ment, and a C-clamp.
Positioning
■ The patient is placed on a radiolucent flat-top table with
legs together to facilitate reduction of the symphysis.
■ Fluoroscopic radiographs confirming the ability to obtain a
good inlet and outlet views with the C-arm are obtained before
preparing and draping the patient.
 292 Se ct io n III PELVIS AND HIP

■ Right-handed surgeons may prefer to have the C-arm on the ■ Venodyne boots are placed on both legs if possible for deep
patient’s right side and the drill and instruments on the pa- vein thrombosis prophylaxis during the case.
tient’s left for easier access to the symphysis with the drill.
■ Placement of a Foley catheter is needed to decompress the Approach
bladder; it can also be felt intraoperatively to help identify the ■ O pen reduction of the symphysis is performed with an ante-
bladder. rior Pfannenstiel approach.
TECHNIQUES

PFANNENSTIEL APPROACH
■ Th e e n t ire lo w e r a b d o m e n is p re p a re d , in clu d in g b o t h
a n t e rio r su p e rio r ilia c sp in e s, t h e sym p h ysis, a n d t h e
u m b ilicu s.
■ Acce ss t o t h e a n t e rio r su p e rio r ilia c sp in e s is im p o r-
t a n t if a n e xt e rn a l fixa t o r is t o b e p la ce d t o a ssist in
re d u ct io n o r fo r a d d it io n a l fixa t io n .
■ A t ra n sve rse in cisio n is m a d e 2 cm a b o ve t h e sym p h ysis
(TECH FIG 1 A).
■ On ce t h ro u g h t h e skin , a la rg e ra ke is p la ce d t o h e lp cre -
a t e a p la n e a b o ve t h e re ct u s fa scia .
■ A lo n g it u d in a l in cisio n is t h e n m a d e a lo n g t h e fa scia o f
t h e lin e a a lb a . Th e re ct u s m u scle in se rt io n is n o t t a ke n
d o w n , a lt h o u g h it is co m m o n t o se e a n a vu lsio n o f o n e
o f t h e re ct u s m u scle s o ff t h e ra m i fro m t h e in it ia l in ju ry
(TECH FIG 1 B).
■ Blu n t d isse ct io n is co n t in u e d lo n g it u d in a lly t o sp re a d t h e
re ct u s m u scle a n d p ro t e ct t h e u n d e rlyin g p e rit o n e u m
a n d b la d d e r.
■ Ele ct ric ca u t e ry ca n b e u se d t o d ivid e t h e re m a in in g
fib e rs o f t h e re ct u s w h ile p ro t e ct in g t h e u n d e rlyin g
st ru ct u re s.
■ Th e b la d d e r a n d b la d d e r n e ck a re e va lu a t e d fo r t h e p re s-
e n ce o f a n y in ju ry.
■ At t h is p o in t , a b lu n t m a lle a b le re t ra ct o r ca n b e p la ce d
in t o t h e sp a ce o f Re t ziu s t o p ro t e ct t h e b la d d e r (TECH
FIG 1 C).
■ Ca re sh o u ld b e t a ke n la t e ra lly, a s t h e ve sse ls kn o w n a s
t h e co ro n a m o rt is t e n d t o b e a b o u t 6 cm la t e ra l t o t h e
sym p h ysis.
■ Th e co ro n a m o rt is is a n a n a st o m o sis o f t h e o b t u ra t o r
a n d e xt e rn a l ilia c a rt e rie s (se e Fig 1B).14
■ Ho h m a n n re t ra ct o rs a re p la ce d t h ro u g h t h e p e rio st e u m
su p e rio rly o ve r t h e su p e rio r p u b ic ra m i o n e sid e a t a t im e
t o re t ra ct t h e re ct u s m u scle la t e ra lly a n d e xp o se t h e su -
p e rio r b o d y o f t h e sym p h ysis.
■ Th e se re t ra ct o rs a re p la ce d clo se t o t h e e xt e rn a l ilia c
ve sse ls, so t h e y n e e d t o b e p la ce d w it h ca re d ire ct ly
onto bone.
■ The periosteum on th e sup erio r aspect of the rami can no w
be stripped off with an electric cautery and osteotomes.
■ So m e su rg e o n s re m o ve t h e sym p h yse a l ca rt ila g e t o p ro -
m o t e fu sio n , a n d w e a g re e w it h t h is a p p ro a ch .

A B C

TECH FIG 1 • A. Th e skin is m a rke d fo r t h e in cisio n . Th e e n t ire lo w e r a b d o m e n is p re p a re d , t o in clu d e t h e u m b ili-

cu s a n d b o t h a n t e rio r su p e rio r ilia c sp in e s a s w e ll a s t h e a n t e rio r in fe rio r ilia c sp in e s b ila t e ra lly. An in cisio n is m a rke d
a b o u t t w o fin g e rb re a d t h s su p e rio rly t o t h e p u b ic b o n e s. B. Th e lin e a a lb a is cle a rly id e n t ifie d o n ce t h e su b cu t a -
n e o u s fa t h a s b e e n d isse ct e d a w a y fro m t h e fa scia . An in cisio n a lo n g t h e lin e a a lb a , b e t w e e n t h e t w o re ct u s m u s-
cle s, is m a d e t o a llo w e xp o su re o f t h e sp a ce o f Re t ziu s. C. On ce t h e sp a ce o f Re t ziu s is e xp o se d , a d e ve r o r b lu n t re -
t ra ct o r is u se d t o re t ra ct t h e b la d d e r a n d t w o Ho h m a n n re t ra ct o rs a re p la ce d o n t h e o u t sid e o f e a ch su p e rio r ra m i
t o e xp o se t h e su p e rio r a sp e ct a n d a llo w re d u ct io n a n d p la t in g .

WEBER CLAMP REDUCTION

■ On ce t h e su p e rio r a sp e ct o f t h e sym p h yse a l b o d ie s is e x-
p o se d , t h e We b e r cla m p is p la ce d a n t e rio rly t o a vo id re -
m o vin g t h e in se rt io n o f t h e re ct u s (TECH FIG 2 A).
■ Th e g o a l in u sin g t h is t e ch n iq u e is t o h a ve t h e t ip s o f t h e
We b e r cla m p a t t h e sa m e le ve l o n e a ch sym p h yse a l b o d y.
■ If a n t e rio r d isp la ce m e n t is p re se n t o n e it h e r sid e , t h e t ip
o f t h e cla m p is p la ce d slig h t ly a n t e rio r o n t h a t sid e so a t
t h e t im e o f re d u ct io n t h e t ip s a re a t t h e sa m e le ve l.4
■ The clamp is tilted distally to engage the tines (TECH FIG 2B).
■ Th e cla m p is p la ce d a n t e rio r t o t h e re ct u s in se rt io n s.
 Ch a p t e r 3 4 ORIF OF THE SYM PHYSIS 293

TECHNIQUES
A B

TECH FIG 2 • A. We b e r cla m p o r la rg e b o n e t e n t a cu lu m is u se d t o re d u ce t h e sym p h ysis w it h t h e

t in e s a t t h e sa m e le ve l o n e a ch p u b ic b o d y a n t e rio r t o t h e re ct u s m u scle . B. Tilt in g t h e cla m p d is-
t a lly w ill h e lp e n g a g e t h e t in e s.

USE OF A C-CLAMP TO AID IN REDUCTION

■ Th e C-cla m p h a s b e e n d e scrib e d fo r u se in u n st a b le APC
p e lvic fra ct u re s in p a t ie n t s re q u irin g a n e xp lo ra t o ry la -
p a ro t o m y o r a s t e m p o ra ry p e lvic fixa t io n if t h e p a t ie n t
ca n n o t g o t o t h e o p e ra t in g ro o m . It ca n a lso b e u se d t o
a ssist in t h e o p e n re d u ct io n o f t h e sym p h ysis if co n ve n -
t io n a l cla m p s ca n n o t h o ld t h e re d u ct io n .
■ Th is is a sim ila r co n ce p t t o t h e o n e d e scrib e d b y Wrig h t
e t a l fo r a ssist in g in t h e re d u ct io n o f t h e p o st e rio r p e lvic
rin g .17
■ To a p p ly t h e C-cla m p , t h e p in s a re p la ce d t w o fin g e r-
b re a d t h s d ire ct ly p o st e rio r t o t h e a n t e rio r su p e rio r ilia c
sp in e . Th is p la ce s t h e p in s in t h e g lu t e u s p illa r, a t h ick-
e n e d p o rt io n o f t h e la t e ra l iliu m a b o ve t h e a ce t a b u lu m
(TECH FIG 3 A).
■ On ce t h e p in s a re in p la ce , t h e cla m p ca n b e fit t e d o n t o
t h e p in s. Th e cla m p is t h e n u se d t o co m p re ss t h e p e lvis
a n d re d u ce t h e ro t a t io n a lly u n st a b le h e m ip e lvis (TECH
FIG 3 B,C). On ce re d u ce d , t h e cla m p is t ig h t e n e d a n d
lo cke d d o w n . Flu o ro sco p y is u se d t o co n firm re d u ct io n o f
t h e sym p h ysis a s w e ll a s a n y p o st e rio r p a t h o lo g y. (Se e
Ch a p . TR-1 fo r fu rt h e r d e scrip t io n o f t h e C-cla m p .)
■ Ca re sh o u ld b e t a ke n n o t t o o ve rre d u ce ra m i fra ct u re s if
t h e y a re p re se n t .
■ Th e g o a l o f t h is t e ch n iq u e is t o o b t a in m o st o f t h e re d u c-
t io n a n d t h e n fin e -t u n e t h e re d u ct io n o n ce t h e sym p h -
ysis is e xp o se d in t h e u su a l m a n n e r w it h t h e We b e r
cla m p .

A B C

TECH FIG 3 • Pla ce m e n t o f p in s fo r t h e C-cla m p (A) a n d h o w it is a p p lie d t o o b t a in a re d u ct io n o f t h e sym p h ysis (B,C).

 294 Se ct io n III PELVIS AND HIP
TECHNIQUES

JUNGABLUTH CLAMP REDUCTION (TECHNIQUE OF MATTA)

■ Ju n g a b lu t h cla m p re d u ct io n is u se d w h e n t h e in n o m i-
n a t e b o n e is in t a ct a n d t h e p o st e rio r rin g is u n st a b le .
■ The inn omina te bone t en ds t o be ext erna lly rot at ed , p os-
te rio rly displa ce d , a n d su p eriorly t ra n sla te d . If th is is t h e
ca se o r ve rtica l in st a b ilit y e xist s, th e e n t ire in n o m in a t e
bon e need s t o b e m a nipu la te d t o o bta in a re du ct io n .
■ In t h e se ca se s, t h e u se o f t h e Ju n g a b lu t h cla m p m a y
b e n e ce ssa ry t o a ch ie ve re d u ct io n .
■ Drill h o le s a re m a d e in a n a n t e rio r-t o -p o st e rio r d ire ct io n
fo r t h e p la ce m e n t fo r 4.5-m m scre w s.
■ Fo r t h e scre w b e in g p la ce d o n t h e u n st a b le sid e (w it h
p o st e rio r d isp la ce m e n t ), a 4.5-m m g lid in g h o le is d rille d
a n d t h e scre w is se cu re d t o t h e b o n e t h ro u g h a sm a ll
p la t e o n t h e p o st e rio r sid e o f t h e p u b is u sin g a n u t (TECH
FIG 4 A,B).
■ Th e p la t e w ill a ct a s a w a sh e r a n d p ro vid e s a la rg e r
su rfa ce a re a o f fo rce t o b e e xe rt e d o n t h e h e m ip e lvis
so o n e d o e s n o t h a ve t o re ly o n t h e p u llo u t st re n g t h
o f a sin g le scre w .
■ Th e Ju n g a b lu t h cla m p is t h e n p la ce d a n t e rio rly a n d se -
cu re d t o t h e 4.5-m m scre w s a n d ca n t h e n b e u se d t o
a ch ie ve t h e re d u ct io n (TECH FIG 4 C,D).5

A B

C D

TECH FIG 4 • The Ju ngablut h cla mp can be used to red uce the symp hysis if th ere is posterior tran slat ion
of th e h e mip e lvis a n d in t a ct in n om in at e b o n e . A,B. On th e side of t he displa cem ent , a screw is pla ced w ith
a sma ll pla te at ta che d wit h a n ut so t he pla te act s a w asher. C,D. Th e cla mp is t hen a tt ached t o t he he ad
o f t h e scre w a n d is u se d t o p u ll t h e h e m ip e lvis fo rw a rd t o re d u ce t h e sym p h ysis. A g lid in g h o le m u st b e
u se d so t h e cla m p p u lls t h ro u g h t h e p la t e a n d d o e s n o t re ly o n t h e p u llo u t st re n g t h o f a sin g le scre w .
(Ad a p t e d fro m Ma t t a JM, To rn e t t a P. In t e rn a l fixa t io n o f p e lvic fra ct u re s. Clin Ort h o p Re la t Re s
1996;329:129–140.)
 Ch a p t e r 3 4 ORIF OF THE SYM PHYSIS 295

PLATE PLACEMENT
■ Be fo re fixa t io n p la ce m e n t , t h e re d u ct io n sh o u ld b e co n -
firm e d o n t h e AP, in le t , a n d o u t le t vie w s w it h t h e C-
a rm .
■ Wit h t h e sym p h ysis re d u ce d , a six-h o le , cu rve d 3.5 re co n -
st ru ct io n p la t e o r p re co n t o u re d p la t e is p la ce d a cro ss t h e
sym p h ysis.
■ A Kirsch n e r w ire ca n b e p la ce d in t o t h e fib ro ca rt ila g i-
n o u s d isc sp a ce t o a id in ce n t e rin g t h e p la t e .
■ Be fo re t h e p la t e is p la ce d , it is co n t o u re d t o fit t h e
cu rve o f t h e su p e rio r su rfa ce o f t h e sym p h ysis a n d
ra m i. Th e e n d s a re co n t o u re d if a six-h o le p la t e is u se d
t o a llo w fo r a n a t o m ic co n t a ct t o t h e ra m u s (TECH
FIG 5 A). Alt e rn a t ive ly, p re co n t o u re d p la t e s ca n b e
u se d .
■ In a six-h o le p la t e , t h e t w o m e d ia l scre w s o n e a ch sid e
g o in t o t h e sym p h yse a l b o d y a n d t h e m o st la t e ra l
scre w g o e s in t o t h e ra m i.
TECHNIQUES
■ Ca re fu l p la n n in g o f scre w p la ce m e n t m u st b e co n sid e re d
if t h e Ju n g a b lu t h cla m p is u se d so t h a t t h e scre w s a re
p la ce d in t o t h e p la t e w it h o u t lo o sin g t h e re d u ct io n .
■ Th e first scre w s p la ce d a re a d ja ce n t t o t h e sym p h ysis o n
e it h e r sid e (TECH FIG 5 B).
■ Th e d rill h o le sh o u ld b e p la ce d e cce n t rica lly, la t e ra lly
in t h e h o le t o g e n e ra t e co m p re ssio n . Th e d rill sh o u ld
b e o rie n t e d p a ra lle l t o t h e p o st e rio r a sp e ct o f t h e
sym p h yse a l b o d y.
■ Th e p ro p e r a n g le ca n b e d e t e rm in e d b y u sin g a fin g e r
t o fe e l t h e in n e r su rfa ce o f t h e p u b ic b o d y, u sin g it a s
a g u id e fo r t h e d rill (TECH FIG 5 C).
■ Th e se in it ia l scre w s sh o u ld b e a n g le d slig h t ly a n t e rio rly
a n d la t e ra lly in t h e p u b ic b o d y so t h a t t h e y st a y in b o n e
a n d a ch ie ve t h e b e st b it e .
■ Th e se scre w s ca n b e p la ce d t o g o d o w n t o t h e isch iu m
if n e ce ssa ry.

Anterior

2 1

Posterior
A B

C D E

TECH FIG 5 • A. Exa m p le o f h o w t h e p la t e n e e d s t o b e co n t o u re d t o a cco m -

m o d a t e t h e p u b ic t u b e rcle o n e it h e r sid e o f t h e sym p h ysis. Th e co n ca vit y o f t h e
p la t e a lso h a s t o b e co n t o u re d , a n d t h is ca n va ry b e t w e e n g e n d e rs (se e Fig 2).
B. Clin ica l p h o t o g ra p h o f p la t e a ft e r a ll scre w s a re p la ce d . Nu m b e rin g in d ica t e s
t h e o rd e r o f scre w p la ce m e n t , w it h t h e scre w s clo se st t o t h e sym p h ysis b e in g
p la ce d first . Aft e r scre w s 1 a n d 2 a re p la ce d , a n y o rd e r m a y fo llo w fo r t h e re -
m a in in g scre w s. C. Drillin g t h e p ro p e r a n g le is im p e ra t ive t o e n su re t h e scre w
w ill st a y in b o n e . To g a u g e t h e a n g le , o n e m a y p la ce a fin g e r o n t h e p o st e rio r
a sp e ct o f t h e p u b ic b o d y a n d t h e n d rill p a ra lle l t o t h a t fin g e r t o e n su re t h e d rill
is h e ld a t t h e p ro p e r a n g le . D–F. Po st o p e ra t ive AP, in le t , a n d o u t le t vie w ra d i-
F o g ra p h s o f a p re -co n t o u re d p la t e a n d a re d u ce d sym p h ysis.
 296 Se ct io n III PELVIS AND HIP

■ Th e t w o m o st m e d ia l scre w s o n e a ch sid e o f t h e sym p h - ■ Th e la t e ra l scre w s in t h e p la t e a re p la ce d la st a n d w ill b e

TECHNIQUES

ysis ca n b e p la ce d e it h e r p a ra lle l t o e a ch o t h e r o r in sh o rt e r t h a n t h e o t h e r scre w s, a s t h e y w ill b e a t t h e le ve l

a cro ssin g p a t t e rn w it h in t h e sym p h yse a l b o d y (TECH o f t h e o b t u ra t o r fo ra m e n .
FIG 5 D–F). ■ Wh e n d rillin g fo r t h e se scre w s, ca re sh o u ld b e t a ke n
a s t h e o b t u ra t o r ve sse ls a re a t risk.

DOUBLE PLATING TECHNIQUE

■ Tile d e scrib e d p la cin g a se co n d p la t e a n t e rio rly if t h e re is
n o p o st e rio r fixa t io n t o b e p la ce d in ve rt ica lly u n st a b le
p a t t e rn s (TECH FIG 6 ). 13
■ Th is t e ch n iq u e ca n a lso b e u se d if in su fficie n t p u rch a se is
a ch ie ve d w it h in it ia l p la t e p la ce m e n t .
■ In p la cin g t h e a n t e rio r p la t e , ca re m u st b e t a ke n in p la c-
in g scre w s a ro u n d t h e scre w s o f t h e o t h e r p la t e .
■ Th e sa m e se q u e n ce o f scre w p la ce m e n t sh o u ld b e fo l-
lo w e d , w it h t h e m e d ia l scre w s p la ce d first a n d su b se -
q u e n t scre w s p la ce d la t e ra lly.

TECH FIG 6 • Exa m p le o f d o u b le p la t in g d e scrib e d b y Tile .

WOUND CLOSURE
■ On ce t h e sym p h ysis is re d u ce d a n d t h e p la t e is in p la ce , a
He m o va c is p la ce d in t h e sp a ce o f Re t ziu s, b e t w e e n t h e
b la d d e r a n d t h e sym p h ysis, a n d is b ro u g h t t h ro u g h t h e
re ct u s fa scia .
■ Aft e r d ra in p la ce m e n t , t h e w o u n d is p u lse la va g e d a n d
t h e re ct u s fa scia is clo se d w it h ru n n in g h e a vy a b so rb a b le
su t u re s. Ca re sh o u ld b e t a ke n n o t t o in clu d e t o o m a n y
m u scle fib e rs t o a vo id m u scle n e cro sis.
■ In t e rru p t e d su t u re s a re u se d a t t h e d ist a l e n d t o p ro vid e
a sid e -t o -sid e clo su re o f t h e a vu lse d sid e .
■ Th e skin is t h e n clo se d w it h su b cu t a n e o u s su t u re s a n d
st a p le s.

PEARLS AND PITFALLS

Se t u p ■ It is im p o rt a n t t o m a ke su re t h a t a d e q u a t e flu o ro sco p ic AP, in le t , a n d o u t le t vie w s ca n b e
o b t a in e d in t h e o p e ra t in g ro o m b e fo re d ra p in g .
Re d u ct io n ■ Re d u ct io n is co n firm e d u n d e r d ire ct visio n a s w e ll a s o n in le t a n d o u t le t vie w s o f t h e p e lvis.
Th e C-cla m p ca n a lso b e u se d t o m a in t a in re d u ct io n b e fo re p la t in g if co n ve n t io n a l cla m p s
ca n n o t h o ld t h e re d u ct io n .
Re d u ct io n a id s ■ A se co n d cla m p o r a b a ll-sp ike ca n b e u se d t o a ssist in re d u ct io n if t h e re is d ifficu lt y o b t a in -
in g re d u ct io n o r h o ld in g t h e sym p h ysis re d u ce d . Fo r in st a n ce , in t ilt fra ct u re s a b a ll-sp ike ca n
b e u se d t o p u sh a g a in st t h e in t a ct ra m i w h ile p u llin g u p t h e p u b ic b o d y o n t h e fra ct u re d
sid e . Ag a in , t h e C-cla m p o r a n e xt e rn a l fixa t o r ca n b e p la ce d t o h e lp a p p ro xim a t e t h e p u b ic
b o d ie s t o fa cilit a t e re d u ct io n w it h a We b e r cla m p .
Ba cku p ■ If fixa t io n is t e n u o u s o r if t h e p a t ie n t b e co m e s t o o sick t o co n t in u e w it h p la t in g , a n e xt e rn a l
fixa t o r ca n a lw a ys b e a d d e d .
Scre w p la ce m e n t ■ C-a rm is u se d t o co n firm p la ce m e n t o f scre w s a n d co n firm t h a t t h e y a re n o t t o o p ro m in e n t
Po o r fixa t io n w it h o n e p la t e ■ Do u b le p la t in g ca n b e u se d t o im p ro ve fixa t io n b y cre a t in g a 90-90 co n st ru ct .
Tw o -h o le p la t e ■ A t w o -h o le p la t e sh o u ld n o t b e u se d : it a llo w s fo r ro t a t io n a l in st a b ilit y a n d h a s a h ig h fa ilu re
ra t e .

POSTOPERATIVE CARE
■ Deep vein thrombosis prophylaxis is imperative, as 35% to
60% of patients with a pelvic fracture are at risk. O f these,
proximal thrombosis can occur 2% to 10% of the time, and
they are at higher risk of developing a pulmonary embolism.6
■ With such a high risk of deep venous thrombosis, prophy-
laxis should consist of a combination of mechanical and chem-
ical means. Venodyne boots or serial compression devices are
essential.
■ Chemical modalities consist of unfractionated heparin, low-
molecular-weight heparin, vitamin K antagonists, and factor
Xa indirect inhibitors.
■ If patients have a contraindication for chemical prophylaxis
secondary to another injury such as a head bleed, an inferior
vena cava filter should be considered.
■ O ur protocol consists of serial compression devices and
subcutaneous heparin three times a day preoperatively.
Postoperatively patients are started on low-dose Coumadin.
Patients remain on Coumadin for at least 6 weeks, depending
on their mobility.
■ Early mobilization is imperative to prevent comorbid condi-
tions from arising.
■ O nce stable fixation is in place, patients should be out of
bed to a chair within 24 hours of surgery if their overall con-
dition allows.
■ The patient’s weight-bearing status is highly dependent on
the operative surgeon understanding the overall injury pattern
of the pelvis.
■ If anterior fixation is used alone, such as for an APC type
II injury, patients are made partial weight bearing for about
8 weeks on the operative side.
■ If there is more extensive injury to the posterior pelvis and
fixation is required, partial weight bearing should be contin-
ued for up to 12 weeks.
■ Patients should be followed routinely with radiographs. O n
postoperative day 1, before the patient gets upright, AP, inlet,
and outlet radiographs should be obtained to assess the reduc-
tion and more importantly to be used for comparison for
future follow-up radiographs taken at 6 and 12 weeks.
OUTCOMES
■ Stabilizing the anterior pelvis improves outcomes, and
anatomic alignment allows for ligamentous healing.
■ Kellam 1 defined an adequate reduction of anterior symphy-
seal widening as less than 2 cm and reported that when this
was obtained in rotationally unstable fractures, 100% of pa-
tients returned to normal function. Patients with posterior
pathology had poor outcomes, with only 31% reporting nor-
mal function.
■ Pohlemann et al7 reported no residual posterior displace-
ment in 95 patients with type B fractures treated with anterior
plating. This was associated with an 11% incidence of late
pain that occurred after exercise. N o patients had pelvic pain
at rest.
■ Tornetta et al15,16 also reported that APC type II injuries,
when treated with anatomic open reduction and internal fixa-
tion, have a 96% rate of good to excellent outcomes.
■ Pohlemann et al7 also demonstrated type C injuries radi-
ographically had more residual posterior displacement than
type B injuries. O nly 33% of these type C patients were pain-
free after combined anterior and posterior fixation.
Ch a p t e r 3 4 ORIF OF THE SYM PHYSIS 297
■ In general, functional outcomes correlate with the initial dis-
placement of the injury.
■ Associated injuries will also dictate outcome. Patients with
associated urologic injuries are at risk for urethral strictures,
urinary tract infections, and even late infections.
■ There is a greater than 90% chance of a good outcome in
patients with near-anatomic fixation of the symphysis in APC
type II pelvic fractures, and about 96% will be able to return
to work within a year of injury.15
COMPLICATION S
■ Proximal deep vein thrombosis occurs in 25% to 35% of
pelvic fractures, so it is imperative to provide proper prophy-
laxis both mechanically and chemically.6
■ Plates and screws can fracture or loosen secondary to fa-
tigue due to the physiologic motion that is maintained between
the two pubic bodies. This tends to occur after 8 weeks and
generally does not affect healing.
■ If it occurs earlier and a loss of reduction occurs, then re-
vision osteosynthesis should be considered.4,5,16
■ Loss of reduction can also occur with widening of the sym-
physis with and without the plate breaking. Although no data
exist, the quality of the initial reduction appears to be the best
predictor. Therefore, if a perfect reduction cannot be main-
tained, additional fixation should be added or activity modifi-
cation should be implemented postoperatively.5,15
■ In most series of pelvic fractures reporting on the use of an-
terior fixation there is a low incidence of anterior wounds
developing deep infections.
■ M ost resolve with irrigation and débridement and go on
to union.2,4,5
■ Urologic injuries occur in about 15% of pelvic fractures.
Urologic complications include late urethral strictures, incon-
tinence, and erectile dysfunction.
■ Early repair of bladder or urethral injuries at the same time
of fixation avoids more complex reconstructions, but the rate
of late urologic complications is still relatively high.8
REFEREN CES
1. Kellam JF. The role of external fixation in pelvic disruptions. Clin
O rthop Relat Res 1989;241:66–82.
2. Lange R, H ansen S. Pelvic ring disruptions with symphysis pubis di-
astasis. Clin O rthop Relat Res 1985;201:130–137.
3. Lindsey RW, Leggon RE, Wright DG, et al. Separation of the symph-
ysis pubis in association with childbearing: a case report. J Bone Joint
Surg Am 1988;70A:289–292.
4. M atta JM . Indications for anterior fixation of pelvic fractures. Clin
O rthop Relat Res 1996;329:88–96.
5. M atta JM , Tornetta P. Internal fixation of pelvic fractures. Clin
O rthop Relat Res 1996;329:129–140.
6. M ontgomery KD, Geertz WH , Potter H G, et al. Thromboembolic
complications in patients with pelvic trauma. Clin O rthop Relat Res
1996;329:68–87.
7. Pohlemann T, Bosch U, Gansslen A, et al. The H annover experience
in management of pelvic fractures. Clin O rthop Relat Res 1994;
305:69–80.
8. Routt M L, Simonian PT, Defalco AJ, et al. Internal fixation in pelvic
fractures and primary repairs of associated genitourinary disruptions:
a team approach. J Trauma 1996;40:784–790.
9. Siegel J, Tornetta P, Templeman D. Single leg stance views for the
diagnosis of pelvic instability. Presented at O rthopaedic Trama
Association annual meeting, Boston, 2007.
10. Siegel J, Tornetta P, Burke P, et al. CT angiography for pelvic trauma
predicts angiographically treatable arterial bleeding. Presented at
O rthopaedic Trauma Association annual meeting, Boston, 2007.
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11. Templeman D, Schmidt A, Sems SA. Diastasis of the symphysis pubis:
open reduction and internal fixation. In: Wiss DA, ed. M asters
Techniques in O rthopaedic Surgery: Fractures, ed 2. Philadelphia:
Lippincott Williams & Wilkins, 2006:639–649.
12. Tile M . Fracture of the Pelvis and Acetabulum. Baltimore: Williams
& Wilkins, 1984.
13. Tile M . Pelvic ring fractures: should they be fixed? J Bone Joint Surg
Br 1988;70B:1–12.
14. Tornetta P, H ochwald N , Levine R. Corona mortis: incidence and lo-
cation. Clin O rthop Relat Res 1996;329:97–101.
15. Tornetta P, Dickson K, M atta JM . O utcome of rotationally unstable
pelvic ring injuries. Clin O rthop Relat Res 1996;329:147–151.
16. Tornetta P, Templeman D. Expected outcomes after pelvic ring in-
jury. AAO S Instr Course Lect 2005;54:401–407.
17. Wright RD, Glueck DA, Selby JB, et al. Intraoperative use of the
pelvic C-clamp as an aid in reduction for posterior sacroiliac fixation.
J O rthop Trauma 2006;20:576–579.
18. Whitbeck M G Jr, Z wally H J II, Burgess AR. Innominosacral dissoci-
ation: mechanism of injury as a predictor of resuscitation require-
ments, morbidity, and mortality. J O rthop Trauma 1997;11:82–88.
 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 35 Fix a t io n o f t h e Sa cro ilia c
Jo in t a n d Sa cr u m
He n ry Clau d e Sag i

DEFIN ITION
■ Pelvic fractures are serious injuries associated with a diverse
assortment of morbidities and mortality rates ranging from
0% to 50% .
■ Fractures and dislocations of the pelvis involve, in broad
terms, injuries to the anterior and posterior structures of the
pelvic ring.
■ Injuries to the anterior pelvic ring include symphyseal dis-
ruption and pubic body or rami fractures.
■ Injuries to the posterior pelvic ring involve iliac wing
fractures, sacroiliac (SI) joint dislocations and fracture-
dislocations, and sacral fractures.
■ The implications and treatment of damage to these struc-
tures vary widely with the broad spectrum of injury patterns,
combinations of injuries, and degree of displacement.
■ This chapter will focus on treatment of displaced sacral frac-
tures and type 3 SI joint dislocations.
AN ATOMY
■ The pelvis is a ring structure composed of the two hemipelves,
■ The sacrum represents the terminal structural segment of the
spinal column that connects the pelvis and extremities to the
trunk and spine.
■ As the sacrum is essentially a spinal element, it is subject to
segmentation abnormalities and dysmorphisms.
■ M ost commonly, segmentation anomalies such as a lum-
barized S1 and a sacralized L5 will be present (FIG 2 ).
■ The only true way to be sure which defect, if any, is pres-
ent, is to count down from the first thoracic vertebrae,
which is the first vertebra to have transverse processes that
are inclined cephalad.
■ As a general rule of thumb, however, the top of the iliac
crest is usually at the same level as the L4/5 disc space. This
rule can be used to judge the presence of dysmorphism (see
Fig 2A).
■ These issues are pertinent to interpretation of the radi-
ographic landmarks required to safely place iliosacral screws
(see later).
■ Being wedge-shaped, the sacrum forms a keystone articula-
tion with the innominate bones.
■ By virtue of this shape and their orientation, the SI joints

or innominate bones, and the sacrum. Each innominate bone is
formed as the result of fusion of the three embryonic bony ele-
ments: the ilium, the pubis, and the ischium (FIG 1 A).
■ The two innominate bones are joined anteriorly at the pubic
symphysis, a symphyseal joint. Posteriorly, the two innominate
are inherently unstable and the maintenance of posterior
pelvic ring integrity is wholly dependent on the support pro-
vided by the ligamentous structures for stability (see Fig 1B
and FIG 3 ).
■ With axial loading, the natural tendency is for each hemipelvis

bones articulate with the wings, or alae, of the sacrum via the to externally rotate and translate in a cephalad and posterior di-
strong SI joints to complete the ring (FIG 1B). rection. The pelvic ligaments are structured and positioned to re-

Iliac
crest

Ilium Iliolumbar
ligament

Anterior
sacroiliac
Greater ligament
sciatic
notch Acetabulum
Ischium Pubic Sacrospinous
tubercle ligament

Obturator Pubis Sacrotuberous

foramen ligament

Ischial Symphysis
A tuberosity B pubis

FIG 1 • A. Th e t h re e e m b ryo n ic b o n e s (p u b is, isch iu m , iliu m ) fu sin g t o fo rm t h e in n o m in a t e b o n e o r h e m ip e lvis. B. Th e t w o

in n o m in a t e b o n e s a n d sa cru m fo rm in g t h e p e lvic rin g w it h su p p o rt in g lig a m e n t s.

299
300 Se c t i o n III PELVIS AND HIP

■ The symphyseal ligaments (themselves contributing no

more than 15% to pelvic ring stability), the sacrotuberous
ligaments, and the sacrospinous ligaments resist external
rotation. 13,32
■ The bladder is immediately posterior to the pubic bodies

and symphysis, separated only by a thin layer of fat and the

potential space of Retzius.
■ The intimate relationship of the L5 nerve root to the supe-

rior aspect of the sacral ala as it courses to join the lum-

bosacral plexus is a key anatomic feature that must be kept in
mind during reduction and stabilization of posterior pelvic
ring injuries (FIG 4 ).
■ The superior gluteal artery is immediately lateral to the in-

ferior aspect of the SI joint as it arises from the internal iliac

artery to exit the greater sciatic notch with the superior
gluteal nerve. The obturator nerve and artery course along
the quadrilateral plate (medial wall) of the acetabulum as
they exit the superior and lateral quadrant of the obturator
foramen (see Fig 4).
A

External
iliac a.

L5 nerve root

Superior
gluteal a.

Internal
B iliac a.

FIG 2 • A. Ou t le t ra d io g ra p h o f t h e p e lvis d e m o n st ra t in g Sacral plexus

fa ilu re o f se g m e n t a t io n o f t h e rig h t sid e , g ivin g a sa cra lize d L5.
Th e le ft sid e is n o rm a lly se g m e n t e d . Th e cre st , d e sp it e t h e Obturator a.
se g m e n t a t io n a n o m a ly, re m a in s a t t h e L4–5 d isc le ve l. B. Th re e -
d im e n sio n a l CT re co n st ru ct io n o f t h e sa m e p e lvis.

sist these deformations as static stabilizers of the pelvis. There

are no specific dynamic stabilizers of the pelvic ring.
■ The SI ligaments (anterior, posterior and intra-articular

ligaments) are the strongest ligaments in the body, with the

A
posterior SI ligaments being the most important in resisting
posterior and cephalad displacement (see Fig 3).
IV

Posterior V
L5

Intra-articular I
II
III
Anterior

FIG 4 • A. Ne u ro va scu la r st ru ct u re s a ro u n d t h e p o st e rio r p e lvic

FIG 3 • Sa cro ilia c jo in t lig a m e n t s. rin g . B. No t e in t im a t e re la t io n sh ip o f L5 n e rve ro o t t o sa cra l a la .
 Ch a p t e r 3 5 ORIF OF THE SACROILIAC JOINT AND SACRUM
PATHOGEN ESIS
■ Because the SI ligaments are the most resilient in the human
body, SI dislocations occur purely as a result of high-energy
traumatic injuries.
■ Anteroposterior compression of the pelvic ring causing
external rotation of the innominate (which may or may not
be coupled with a vertical shearing force) is the most com-
mon cause of SI joint dislocation.
■ Sacral fractures, however, can occur in three distinctly dif-
ferent situations.
■ Insufficiency fractures of the sacrum arise secondary to
failure through excessively osteoporotic or ostepenic bone.
■ Stress fractures of the sacrum result from fatigue and
cyclic failure of normal bone in high-level athletes or mili-
tary recruits.
■ Traumatic disruptions result from high-energy lateral or
anteroposterior compression or vertical shear injuries such
as (in order of decreasing frequency) motorcycle crashes,
auto–pedestrian collisions, falls from height, motor vehicle
accidents, or crush injuries.13,32
N ATURAL HISTORY
■ Pelvic fractures occur in at least 20% of blunt trauma ad-
missions, most frequently in young males.
■ They can result in small insignificant fractures of the
pubic rami with no compromise of pelvic ring stability, or
major injuries and disruptions that can be associated with
life-threatening bleeding or visceral injury.
■ The pelvic ring encloses the true pelvis (organs contained
below the pelvic brim, extraperitoneal) and the false pelvis
(organs contained above the pelvic brim, both peritoneal and
retroperitoneal).
■ The most commonly associated injuries to structures con-
tained within the true pelvis are the internal iliac arterial and
venous systems and branches, the bladder (20% ) and ure-
thra (14% ), the lumbosacral plexus, and the rectum and
vaginal vault (open pelvic fractures).
■ Injuries to structures within the false pelvis as a direct result
of the pelvic fracture are uncommon, but severe iliac wing
fractures with abdominal wall disruption can result in intesti-
nal injury and even entrapment.
■ M orbidity and mortality from pelvic fractures can be high
and are most commonly secondary to pelvic hemorrhage.
■ The mortality rate associated with pelvic fracture with an
associated bladder rupture approaches 35% in some series,
and the mortality rate of open pelvic fractures involving the
perineum used to be as high as 50% .
■ Fortunately, this has decreased to about 2% to 10% with
the liberal use of diverting colostomies and more advanced
stabilization techniques.
■ N eurologic injury to the lumbosacral plexus can lead to sig-
nificant sensorimotor dysfunction involving the extremities,
bowel, bladder, and sexual functions.
■ Because of these associated neurovascular and visceral in-
juries, pelvic fractures often result in prolonged recovery peri-
ods, significant chronic pain, permanent disability, and loss of
psychological and socioeconomic structure.5,7,9,21–29
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Any patient presenting with a history of trauma or satisfy-
ing criteria for a Trauma Alert in the emergency department
301
should be suspected of having a pelvic fracture until otherwise
ruled out by radiologic and physical examination.
■ The physical examination should follow the primary and sec-
ondary survey of the Advanced Trauma Life Support protocol.1
■ Examination of a patient suspected of having a pelvic frac-
ture should be divided into the examination of the abdomen,
pelvic ring, perineum, rectum, vagina, and lower extremities.
■ The abdominal examination should elucidate:
■ Tenderness, fullness, or rigidity
■ Abdominal wall disruptions, defects, or open wounds
■ Flank ecchymosis
■ Presence of internal degloving or a M orel-Lavalle lesion
(separation of the subcutaneous tissues from the underlying
fascia). This can be recognized by subcutaneous fluctuance
or a fluid wave and, later, extensive ecchymosis.
■ The rectal and vaginal examination should consider:
■ The position of the prostate (a high-riding prostate may
be a sign of urethral injury)
■ Palpable bony fragments perforating the rectal or vaginal
mucosa
■ Defects or tears in the wall of the rectum or vagina indi-
cating possible bony penetration
■ Rectal or vaginal bleeding indicating possible tears or
bony penetration
■ Urethral bleeding at the meatus indicating possible ure-
thral or bladder disruption
■ Scrotal or labial swelling and ecchymosis indicating pelvic
hemorrhage (FIG 5 )
■ Rectal tone, perianal sensation, voluntary sphincter con-
trol, and bulbocavernosus reflex to assess for the presence of
cauda equina syndrome or lower sacral nerve root injury
■ Examination of the pelvic ring and extremities should focus
on the following key factors:
■ Palpable internal or external rotation instability of the
pelvic ring with manually applied anteroposterior and lateral
compressive forces on the iliac wings and crests
■ Leg-length discrepancy with asymmetrical internal or ex-
ternal rotation
■ N eurologic status in patients able to comply can be assessed
as follows:
■ L1/2: iliopsoas (hip flexors) and upper anterior thigh
sensation
■ L3/4: quadriceps (knee extensors) and lower anterior
thigh and medial calf sensation
■ L5: extensor hallucis longus, digitorum longus (toe
dorsiflexion), peroneal eversion (although this can have a
FIG 5 • Scro t a l e cch ym o sis fro m in t e rn a l p e lvic h e m o rrh a g e .
302 Se c t i o n III PELVIS AND HIP
strong L4 component) and lateral calf and dorsum of foot
sensation
■ S1: gastrocsoleus complex (ankle plantarflexion) and pos-
terior calf sensation
■ S2/3: flexor hallucis and digitorum longus (toe plantar
flexion) and sole of foot sensation
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
Plain Radiographs
■ The standard anteroposterior (AP pelvis) view should be
part of the initial trauma series screening. With enough expe-
rience, many of the injuries to the posterior pelvic ring can be
diagnosed with this single projection (FIG 6 A,B).
■ A good AP radiograph should have the pubic symphysis
co-linear with the sacral spinous processes.
■ This allows side-to-side comparison of bony landmarks
to aid in diagnosis of subtle displacements of the sacrum
or SI joint.
■ The cortical density of the pelvic brim and iliopectineal
line should be traced back to its intersection with the lateral
margin of the sacral ala.
■ This intersection should be at the same level (usually
the inferior margin of the S2 foramen) bilaterally.
■ Asymmetry in the SI joint space and the appearance of the
sacral foramina should alert the surgeon to the presence of
an SI joint dislocation or sacral fracture.
■ Fractures of the L5 transverse process may be a clue to
a vertical shear injury that has avulsed the transverse
process via the iliolumbar ligament.
■ Symphyseal diastasis or displaced rami fractures should
alert the examiner to additional injuries in the posterior
ring, even though they may not be readily apparent on
first glance.
A B
D E
FIG 6 • A,B. AP p e lvis ra d io g ra p h s. Id e a l film sh o u ld h a ve sym p h ysis a lig n e d w it h sa cra l sp in o u s p ro ce sse s. C,D.
In le t p e lvic ra d io g ra p h s. No t e sa cra l p ro m o n t o ry a n d a la r re g io n s. E,F. Ou t le t p e lvic ra d io g ra p h s. No t e sa cra l
fo ra m in a a n d sa cro ilia c jo in t s. Id e a l im a g e sh o u ld h a ve t o p o f sym p h ysis–ra m i a t t h e S2–3 le ve l.
■ The inlet projection is taken with the x-ray beam directed
caudally about 45 degrees to the radiographic film.
■ A true inlet view of the pelvis, however, may require vari-
ations on this degree of angulation because of the normal
variations in sagittal plane pelvic obliquity.
■ This view simulates a direct view into the pelvis from
above along its longitudinal axis (FIG 6 C,D).
■ The inlet view is helpful in imaging:
■ External or internal rotation of the hemipelvis
■ O pening of the SI joint or an impaction fracture of the
sacrum
■ “ AP” displacement or translation of the hemipelvis
(see below)
■ The outlet projection of the pelvis is obtained by directing the
x-ray beam about 45 degrees cephalad to the radiographic film.
■ This view simulates looking at the sacrum and SI joints di-
rectly en face (FIG 6 E,F).
■ The outlet view is helpful in imaging:
■ Cephalad or “ vertical” shift of the hemipelvis
■ Sacral fractures relative to the foramina
■ Flexion–extension deformity of the hemipelvis
■ These radiographs are taken at about 45 degrees to the long
axis of the patient’s body.
■ Therefore, a given amount of translation or displace-
ment seen on the inlet or outlet view is in fact the sum of
displacement vectors in both the coronal and axial planes.
For example, “ posterior” shift seen on the inlet projection
is in fact a combination of both posterior and cephalad
translation.
■ Another important point to bear in mind is the appearance
of the sacrum on the AP projection.
■ If one sees a paradoxical inlet view of the upper sacrum
and outlet view of the distal sacrum, a lateral radiograph and
CT scan with sagittal reconstruction must be performed to
rule out an occult sacral fracture-dislocation (a U-shaped
C
F
 Ch a p t e r 3 5 ORIF OF THE SACROILIAC JOINT AND SACRUM
A
B B
C ■ If no extravasation is seen, the catheter is advanced into the
FIG 7 • A. AP ra d io g ra p h o f p a t ie n t w it h a U-sh a p e d sa cra l
fra ct u re . No t e in le t vie w o f p ro xim a l sa cru m b u t o u t le t a p p e a r-
a n ce o f ca u d a l sa cru m . Axia l (B) a n d sa g it t a l (C) CT sca n re co n -
st ru ct io n s o f t h e sa m e p a t ie n t w it h a U-sh a p e d sa cra l fra ct u re .
Th e fra ct u re a lm o st a lw a ys o ccu rs a t t h e le ve l o f t h e ve st ig ia l
d isc sp a ce a t S1–2.
sacral fracture otherwise known as spinal-pelvic dissociation;
FIG 7 ).
Computed Tomography
■ CT is imperative in any suspected pelvic ring injury.
■ As the pelvis is a ring structure, any disruption in one loca-
tion (no matter how seemingly insignificant) must (by virtue
of ring structure mechanics) be accompanied by disruption in
another location.
■ Three-millimeter axial sections (or 3 mm of vertical travel
per 360-degree rotation of the gantry in a spiral CT) are rec-
ommended to disclose the majority of significant injuries and
to allow for good-quality three-dimensional reconstructions
(FIG 8 ).
303
A
FIG 8 • A. Axia l CT sca n o f t ra n sfo ra m in a l (De n is zo n e 2) sa cra l
fra ct u re . B. Axia l CT sca n o f sa cro ilia c jo in t d islo ca t io n . No t e d i-
a st a sis o f a n t e rio r a n d p o st e rio r jo in t .
Retrograde Urethrography and Cystography
■ Retrograde urethrography and cystography are mandatory
in pelvic fractures with ring disruption to rule out urethral and
bladder injury.
■ The Foley catheter is partially inserted into the urethra, and
the balloon is inflated with 2 to 3 mL of sterile saline to oc-
clude the urethra. Ten to 15 mL of water-soluble contrast is
then injected into the urethra and the outlet view of the pelvis
is repeated.
bladder with injection of a further 300 mL of water-soluble
contrast to rule out a bladder rupture. If no contrast extrava-
sation is noted, the bladder is drained with the Foley, and any
residual dye is noted.
■ If passage of the catheter is not possible or there is a tear of
the urethra or bladder neck, suprapubic catheterization should
be performed well above the umbilicus if possible (to avoid
contamination of potential future anterior pelvic operations).
Pelvic Angiography
■ Angiography is indicated in patients with persistent hemo-
dynamic instability despite10 :
■ Adequate volume resuscitation
■ O ther sources of hemorrhage being ruled out (abdomen,
thorax, and long bone fractures)
■ Attempts to “ close” the pelvic ring (see below) have failed
to stop pelvic hemorrhage
■ M ost cases of pelvic hemorrhage (85% ) arise from venous
bleeding, which is not amenable to angiographic embolization.
■ Arterial bleeding is usually from branches of the internal
iliac system (median sacral, superior gluteal, pudendal, or
obturator arteries; FIG 9 ).
304 Se c t i o n III PELVIS AND HIP
A
B
FIG 9 • An g io g ra m s sh o w in g e xt ra va sa t io n a n d e m b o liza t io n o f
su p e rio r g lu t e a l a rt e ry. (Co u rt e sy o f Pro f. Jo h a n n e s Re u g e r.)
■ If diagnostic peritoneal lavage is being performed to rule out
abdominal hemorrhage, then it must be performed above the
umbilicus and arcuate line to avoid false-positive results from
pelvic hemorrhage.
N ON OPERATIVE MAN AGEMEN T
■ As a general rule, traumatic type 3 SI dislocations should
not be managed nonoperatively.
■ Progressive cephalad displacement of the hemipelvis will
result in pelvic malunion. Leg-length inequality, chronic me-
chanical low back and buttock pain, pelvic obliquity with
sitting imbalance, and dyspareunia are common complaints
when the hemipelvis and ischial tuberosities are positioned
medially or cephalad.
■ For patients in extremis or those with sepsis or critical med-
ical comorbidity, nonoperative therapy may be the only option.
■ In these cases, the pattern of deformity dictates the ma-
neuvers to be used to minimize the malunion.
■ Patients with any evidence of vertical instability should be
placed into balanced longitudinal skeletal traction in an at-
tempt to reduce or prevent further cephalad displacement.
■ Distal femoral traction is preferable.
■ Patients with external rotation deformity of the pelvic ring
(ie, “ open book” pelvis) should be initially treated with some
form of temporizing pelvic binder (ie, the T-PO D pelvic
binder, Bio-Cybernetics, LaVerne, CA) or an external fixa-
tion clamp.
■ This helps to reduce the external rotation deformity, sta-
bilize the pelvic hemorrhage and clot, and improve patient
comfort in the acute resuscitative period.2
■ Ideally, circumferential devices such as pelvic binders
(FIG 1 0 ) should be applied over the greater trochanters, and
frequent skin checks are mandatory to prevent full-thickness
FIG 1 0 • TPOD p e lvic b in d e r. (Co u rt e sy o f Mid Me d ,
Qu e e n sla n d , Au st ra lia .)
pressure ulceration. As such, they are rarely if ever indicated
for definitive treatment. Anterior pelvic external fixators can
be applied either in the iliac crest or the anterior inferior iliac
spine and supra-acetabular bone.
■ Anterior external fixators are good for controlling exter-
nal and internal rotation of the anterior pelvic ring. Thus,
the surgeon may elect to use them definitively if the SI joint
is disrupted only through the anterior SI ligaments (a type 2
injury with no vertical or sagittal plane instability) or with
certain lateral compression injuries where the sacral fracture
is stable by virtue of its impaction.
■ By themselves, however, anterior external fixators are
not effective in controlling the posterior pelvic ring, and if
applied incorrectly they can make some pelvic deformities
worse.16,30
■ For external fixation control of the posterior ring, external
C-clamps and pelvic clamps are used on occasion, but expertise
is required in their use to prevent serious complications from
misplacement.8,18
■ In contrast to SI joint dislocations, most traumatic sacral
fractures can be treated successfully with nonoperative care.
■ Although vertical shear sacral fractures represent the far
end of the spectrum of unstable sacral fractures needing
operative stabilization, impacted sacral fractures resulting
from lateral compression mechanisms can be relatively sta-
ble injuries (FIG 1 1 A,B).
■ If the radiographic and CT scanning evaluation reveals an
impacted sacral alar fracture without significant displacement
in other planes, a trial of nonoperative therapy is warranted.
The patient must comply with the weight-bearing restrictions
and close radiographic follow-up to prevent gradual shift that
will result in a pelvic malunion and leg-length inequality with
sitting imbalance (FIG 1 1 C).
■ O ften, the presentation of the patient in bed can help to pre-
dict success with nonoperative treatment of impacted sacral
fractures.
■ Patients able to roll in bed on their own and help with hy-
gienic care with only minimal or moderate discomfort often
have a relatively stable pelvis and will be able to mobilize
with physical therapy.
■ Some patients, however, will not be able to tolerate even
log-rolling in the bed with nursing care.
■ They may be found on examination under anesthesia to
have an unstable pelvis despite innocuous-appearing imag-
ing studies.
 Ch a p t e r 3 5 ORIF OF THE SACROILIAC JOINT AND SACRUM
A nate forms of fixation to augment the SI screw (such as
B
C ments within the sacral foramen.
FIG 1 1 • A,B. Im p a ct e d sa cra l fra ct u re fro m la t e ra l co m p re ssio n
m e ch a n ism w it h in t e rn a l ro t a t io n . C. No n o p e ra t ive t re a t m e n t
o f ve rt ica l sh e a r sa cra l fra ct u re w it h re su lt a n t m a lu n io n a n d
le g -le n g t h in e q u a lit y.
■ If a patient with an impacted sacral fracture is deemed to be
a candidate for nonoperative treatment, he or she is mobilized
with physical therapy in 3 to 5 days so long as all other injuries
permit.
■ The patient is instructed in touch-down weight bearing on
the affected extremity.
■ If the patient can successfully mobilize, then AP, inlet, and
outlet radiographs are repeated within a week to assess for
any further displacement and increasing leg-length inequality.
■ If no further displacement occurs, the patient is instructed
to continue touch-down weight bearing for another 8 to
10 weeks, with repeat radiographs every 4 weeks.
SURGICAL MAN AGEMEN T
Treatment Options
Iliosacral Screws
■ In general, all complete SI joint dislocations and unstable
displaced nonimpacted sacral fractures should be treated with
operative stabilization.
■ The choice of fixation in most instances for both SI joint
dislocations and sacral fractures will be with iliosacral
screws (SI screws).
■ Biomechanical studies have validated the strength of this
technique in comparison to more traditional anterior SI plat-
ing and transsacral bars and plates.11,26
305
■ Also, SI screws can be applied with the patient in either the
prone or supine position, and in either an open or closed per-
cutaneous fashion.
■ SI screw placement, however, does require an exacting
knowledge of the radiographic correlates of anatomic land-
marks to prevent neurologic and vascular injury.3,6,15,22,31,33
■ Transforaminal sacral fractures with comminution and ver-
tical instability treated with standard SI screw fixation alone
may be suboptimal and have a high reported failure rate.
■ In these instances, the surgeon may elect to place alter-
with transsacral screws or with some form of spinal pelvic
construct to better resist the tendency for vertical displace-
ment). 12,24,27
Spinal Pelvic Fixation
■ Also known as lum bopelvic fix ation and triangular osteosyn-
thesis, spinal pelvic fixation is done to augment an SI screw for
a very unstable posterior ring injury that has been reduced and
temporarily stabilized but remains at risk for failure of fixation
and subsequent redisplacement.
■ This usually arises in the case of extensively comminuted
transforaminal sacral fractures.
Sacral Nerve Decompression
■ Sacral nerve decompression is indicated in either of two
situations:
■ The patient has a neurologic deficit attributable to sacral
radiculopathy and preoperative imaging shows fracture frag-
■ The patient is neurologically intact, but preoperative imag-
ing studies disclose a large bone fragment within the foramen
that during reduction will further compress the nerve root
and stenose the foramen, resulting in iatrogenic nerve root
injury (FIG 1 2 ).
Zone 3 Sacral Fractures
■ Vertically oriented zone 3 sacral fractures are usually the
result of wide anteroposterior compression forces and are
associated with anterior ring disruption.
■ Generally, they can be treated with internal rotation and
anterior ring fixation alone.
■ If residual sacral gapping persists, however, an SI screw with
short threads can be placed into the contralateral S1 body to
close the residual gap.
U-Shaped Sacral Fractures
■ O therwise known as spinal-pelvic dissociation, this fracture
is essentially a sacral fracture-dislocation.
■ It tends to occur through the vestigial disc space and re-
sult in kyphosis.
FIG 1 2 • Axia l CT sca n o f a sa cra l fra ct u re sh o w in g la rg e in -
t ra fo ra m in a l b o n y fra g m e n t .
306 Se c t i o n III PELVIS AND HIP
A lows traction to be applied in some fashion.
B position, depending on the surgeon’s assessment of the abil-
FIG 1 3 • U-sh a p e d sa cra l fra ct u re s ca n b e d ifficu lt t o d e t e ct o n
st a n d a rd AP p e lvis vie w s (A) b u t a re m o re e vid e n t o n sa g it t a l
CT re co n st ru ct io n (B).
■ These fractures can be easily missed on the standard
AP pelvis view (FIG 1 3 A) and even axial CT scans, but
they are quite evident on the sagittal CT reconstruction
(FIG 1 3 B).
■ These injuries generally do not result in pelvic ring instabil-
ity, as the SI joints and distal surrounding sacrum are intact;
they are more commonly associated with spinal instability.
■ They can be associated with cauda equina syndrome and
significant spinal instability and should be treated by an expe-
rienced spinal surgeon.
■ Although some trauma surgeons have advocated bilateral SI
screw fixation alone for these injuries, they more commonly
require reduction, decompression, and some form of posterior
lumbopelvic fixation to control kyphotic deformity.
Preoperative Planning
■ Proper preparation and preoperative planning for any major
pelvic surgery are mandatory.
■ These operations can be associated with prolonged anes-
thetics, lengthy prone positioning, extensive blood loss, and
complex reduction maneuvers that can pose serious risk to
the patient with other medical or traumatic comorbidities.
■ H aving a detailed understanding of the deformity and the
reduction and fixation strategy can help to significantly
decrease operative time and blood loss.
■ All patients should have had anticoagulation started within
24 hours of admission.
■ If there are contraindications to anticoagulation, inferior
vena caval filter placement should be requested.29
■ If an open reduction is predicted to be necessary, waiting for
3 to 5 days is prudent to allow the pelvic clot to stabilize and
diminish intraoperative bleeding.
■ Patients should have at least three units of typed and
cross-matched blood on hold.
■ The surgery should be booked semielectively if possible,
with a surgical team that is familiar with complex pelvic
surgery.
Positioning
■ Patients should be positioned on a radiolucent table that al-
■ Regarding the standard O SI (O rthopaedic Systems Inc.,
Union City, CA) fracture table with the perineal post, ade-
quate caudal translation cannot be obtained as long as the per-
ineal post is in place because the ischial tuberosity and pubis
tend to abut the post, preventing further caudal translation of
the hemipelvis.
■ This problem can be overcome by stabilizing the contralat-
eral extremity in a traction boot without applying traction to
provide some vertical support for the contralateral side while
traction is applied to the affected extremity.
■ Another alternative in cases with severe vertical displace-
ment is to rigidly fix the contralateral pelvis to the O R table
with Schanz pins and an external fixator with a frame supplied
by O SI.
■ Patient positioning will be in either the prone or supine
ity to achieve reduction using closed (supine) or open (prone)
means.
■ In some cases, initial reduction of the anterior pelvic
ring will facilitate reduction of the posterior ring, allow-
ing the entire procedure to be performed in the supine
position.
■ H owever, an imperfect reduction of the anterior pelvic
ring and subsequent rigid stabilization may actually impair
reduction of the more important posterior ring. In this case,
anterior fixation would have to be removed to allow for an
exact reduction of the posterior ring.
■ For the patient positioned in the prone position (FIG 1 4 ),
the surgeon must ensure proper padding and support for the
chest to allow adequate ventilation.
FIG 1 4 • Po sit io n in g a n d se t u p o f p a t ie n t fo r p o st e rio r a p p ro a ch
a n d re d u ct io n o f sa cra l fra ct u re o r sa cro ilia c jo in t d islo ca t io n .
No t e t h e p e lvis h a n g in g fre e ly, t ra ct io n se t u p , a n d rig id st a b i-
liza t io n fra m e o n co n t ra la t e ra l st a b le h e m ip e lvis.
 Ch a p t e r 3 5 ORIF OF THE SACROILIAC JOINT AND SACRUM 307

■ It is preferable to use longitudinal chest rolls that come short
of the pelvis, allowing the lower trunk to hang freely and not
rest on the anterior superior iliac spine.
■ If the pelvis is permitted to rest on the anterior superior
iliac spine, posterior translation of the unstable hemipelvis
may result or reduction may be impaired.
■ The extremity ipsilateral to the unstable hemipelvis should be
draped free to allow longitudinal traction and internal–external
rotation.
■ It should be placed in either boot or skeletal (distal
femoral or proximal tibial) traction that allows for rotation
and abduction–adduction.
■ If there is posterior displacement of the hemipelvis, placing
the bump under the buttock will help to anteriorly translate
the pelvis when traction is applied.
■ If there is anterior translation of the hemipelvis, placing
the bump directly midline will help to lift the pelvis away
from the table and also let the affected hemipelvis hang
freely to allow posterior translation during reduction
maneuvers.
Approach
■ Approach to the SI joint can be either anterior or posterior.
■ If significant displacement exists and a difficult open reduc-

■ Extension of the hip and extremity will help to indirectly tion is predicted, the posterior approach should be chosen. 17
reduce the hemipelvis as well, since some degree of flexion ■ The anterior approach does not afford good visualization of

deformity exists in vertically displaced pelvic fractures. the entire SI joint, only the superior aspect at the top of the ala.
■ Draping of the operative field should include the entire flank ■ Also, placement of reduction clamps anteriorly across the

on the affected side. SI joint, while possible, is cumbersome and places the L5
■ The field should continue to include the buttock and nerve root at risk.28
upper thigh, with free draping of the affected extremity. ■ The anterior approach to the SI joint is advocated only in

■ The natal cleft and contralateral buttock are excluded situations in which:
from the field. ■ The soft tissues do not permit the posterior approach.

■ For the patient positioned in the supine position, a small ■ The patient will not tolerate prone positioning because of

folded sheet or pad should be placed under the sacrum or poor pulmonary status.
buttock on the affected side to lift the pelvis away from the ■ A close-to-anatomic closed reduction of the SI joint can

table. Again, the affected extremity should be placed into be obtained with traction and manipulation and only minor
traction to aid in reduction, as detailed above. adjustments need to be made.

POSTERIOR APPROACH
■ Fo r t h e p o st e rio r a p p ro a ch t o t h e SI jo in t d islo ca t io n
a n d sa cra l fra ct u re , t h e in cisio n is ve rt ica l a n d p a ra m e -
d ia n , ce n t e re d d ire ct ly o ve r t h e in vo lve d SI jo in t . Th e
in cisio n is n o t ca rrie d d ire ct ly o ve r t h e b o n y p ro m i-
n e n ce o f t h e p o st e rio r su p e rio r ilia c sp in e ; ra t h e r, it is
TECHNIQUES
p la ce d ju st m e d ia l t o t h e p o st e rio r su p e rio r ilia c sp in e
(TECH FIG 1 A).
■ Th e t issu e s t h a t b rid g e t h e SI jo in t p o st e rio rly in t h e in -
t a ct st a t e in clu d e t h e lu m b o d o rsa l fa scia , t h e t ra n sve rse
fib e rs o f t h e g lu t e u s m a xim u s (TGM), t h e p a ra sp in a l

Spinalis m.

Erector spinae m.

Multifidus m.

Posterior
superior iliac
A spine

Gluteus
maximus m.
B

TECH FIG 1 • A. Skin in cisio n fo r p o st e rio r a p p ro a ch t o sa cru m a n d

sa cro ilia c jo in t . B. Dia g ra m o f fa scia l fib e rs a n d m u scu la r la ye rs fo r
p o st e rio r a p p ro a ch t o sa cru m a n d sa cro ilia c jo in t . C. Po st e rio r e xp o -
C su re fo r sa cra l fra ct u re re d u ct io n .
 308 Se c t i o n III PELVIS AND HIP
e re ct o r sp in a e m u scle s, t h e ilio lu m b a r lig a m e n t , a n d t h e
TECHNIQUES
p o st e rio r SI lig a m e n t s (TECH FIG 1 B).
■ Wit h SI jo in t d islo ca t io n s, so m e o r a ll o f t h e se fa scia l,
m u scu la r, a n d lig a m e n t o u s la ye rs m a y b e co m p le t e ly d is-
ru p t e d , a n d n o fu rt h e r d isse ct io n is n e e d e d .
■ Oft e n , h o w e ve r, t o visu a lize t h e in fe rio r a sp e ct o f t h e
SI jo in t p o st e rio rly, t h e TGM n e e d s t o b e m o b ilize d .
Th e TGM a t t a ch m e n t t o t h e sa cra l sp in o u s p ro ce sse s
a n d t h o ra co lu m b a r fa scia is re le a se d a n d t h e TGM is
re fle ct e d la t e ra lly a n d in fe rio rly t o e xp o se t h e in fe rio r
a sp e ct o f t h e SI jo in t . To p re ve n t w o u n d co m p lica -
t io n s, t h e a t t a ch m e n t a n d o rig in o f t h e g lu t e u s m a x-
im u s m u st b e p re se rve d .
■ Occa sio n a lly so m e o f t h e lu m b o d o rsa l fa scia w ill n e e d t o
b e re le a se d fro m t h e p o st e rio r ilia c cre st .
■ Th is a llo w s d isse ct io n u p o ve r t h e su p e rio r a sp e ct o f
t h e SI jo in t a n d sa cra l a la t o p e rm it d ig it a l p a lp a t io n
t o a sse ss re d u ct io n o f t h e a n t e rio r SI jo in t .
■ On ce e xp o su re is co m p le t e , it is u su a lly n e ce ssa ry t o e va c-
u a t e a sig n ifica n t a m o u n t o f b lo o d clo t a n d h e m a t o m a
fro m t h e jo in t .
■ On o cca sio n , lo o se fra g m e n t s o f d e n u d e d a rt icu la r
ca rt ila g e w ill re q u ire re m o va l.
■ Ro u t in e re m o va l o f a rt icu la r su rfa ce s fo r a p rim a ry SI
jo in t fu sio n is n o t p e rfo rm e d , h o w e ve r, u n le ss t h e re is
sig n ifica n t ca rt ila g in o u s d e st ru ct io n t o b e g in w it h .
■ Du rin g re m o va l o f b lo o d clo t a n d d e b ris, sp e cific a t t e n -
t io n m u st b e p a id t o t h e su p e rio r g lu t e a l ve sse ls a n d t h e
in t e rn a l ilia c va scu la r syst e m .
■ Re m o va l o f clo t m a y re st a rt a rt e ria l b le e d in g t h a t w a s
in it ia lly co n t ro lle d b y t a m p o n a d e a n d sp a sm , o r d ire ct
ia t ro g e n ic in ju ry m a y o ccu r w it h d isse ct io n t h ro u g h
t h e fra ct u re h e m a t o m a a n d clo t .
■ All sa cra l fra ct u re s t h a t n e ce ssit a t e a n o p e n re d u ct io n re -
q u ire a p o st e rio r a p p ro a ch .
■ An t e rio r a p p ro a ch e s a re n o t re co m m e n d e d a s it is n o t
p o ssib le t o d isse ct o n t o t h e a n t e rio r a sp e ct o f t h e
sa cru m w it h o u t p o sin g e xce ssive risk t o t h e lu m -
b o sa cra l n e rve ro o t s a n d ilia c ve sse ls.
■ Th e p o st e rio r a p p ro a ch fo r sa cra l fra ct u re re d u ct io n
va rie s d e p e n d in g o n t h e fra ct u re lo ca t io n a n d t h e n e e d
fo r sa cra l n e rve ro o t d e co m p re ssio n .
■ In g e n e ra l, h o w e ve r, m o st sa cra l fra ct u re s a n d fo ra m in a l
d e co m p re ssio n s ca n b e p e rfo rm e d t h ro u g h t h e sa m e
A B
TECH FIG 2 • A. Web er re d u ctio n clam p p o sit io n ed t o red u ce in fe rio r a sp e ct o f sacro iliac jo in t, fro m p o ste rio r ap -
p roa ch. B,C. Ma tt a o ffse t cla m p re d u cin g su p e rio r a n d a n t e rio r a sp e ct o f sa cro ilia c. Th e cla m p is p o sit io n e d fro m o ve r
th e to p b e t w e e n ilia c crest a n d L5 tra nsve rse pro cess. (continu ed)
p a ra m e d ia n a p p ro a ch a s d e scrib e d a b o ve fo r SI jo in t d is-
lo ca t io n s. Th e o n ly a lt e ra t io n s in t e ch n iq u e w o u ld b e a s
fo llo w s:
■ Su b p e rio st e a l e le va t io n o f t h e p a ra sp in a l m u scle s
fro m t h e d o rsa l a sp e ct o f t h e sa cru m t o t h e sp in o u s
p ro ce sse s is re q u ire d t o e xp o se t h e w h o le p o st e rio r
su rfa ce o f t h e sa cru m (TECH FIG 1 C).
■ Pro xim a l e xt e n sio n in t h e in t e rm u scu la r p la n e o f t h e
p a ra sp in a l m u scle s e xp o se s t h e L4–L5 fa ce t jo in t in
t h e m a n n e r d e scrib e d b y Wilt se , if a sp in a l p e lvic co n -
st ru ct is t o b e a p p lie d .
Op e n Re d u ct io n o f t h e SI Jo in t a n d
Sa cru m via t h e Po st e rio r Ap p ro a ch
■ Re d u ct io n o f t h e d islo ca t e d SI jo in t is co m p le x a n d re -
q u ire s a g o o d kn o w le d g e o f t h e t h re e -d im e n sio n a l
a n a t o m y o f t h e sa cru m , iliu m , a n d SI jo in t .
■ Alt h o u g h so m e a n t e ro p o st e rio r t ra n sla t io n a n d la t -
e ra l–m e d ia l t ra n sla t io n m a y b e n e ce ssa ry t o re d u ce t h e SI
jo in t , lo n g it u d in a l t ra ct io n is t h e sin g le m o st im p o rt a n t
in d ire ct m a n e u ve r t o p e rfo rm .
■ Ad e q u a t e lo n g it u d in a l t ra ct io n ca n b e a sse sse d in t ra o p -
e ra t ive ly w it h d ire ct visu a liza t io n , d ig it a l p a lp a t io n , a n d
t h e im a g e in t e n sifie r.
■ Re d u ct io n o f t h e su p e rio r a sp e ct o f t h e SI jo in t ca n b e
a sse sse d w it h d ig it a l p a lp a t io n , e n su rin g t h a t t h e
su p e rio r–a n t e rio r a sp e ct o f t h e SI jo in t is flu sh .
■ Fin a l co n firm a t io n w it h in le t , o u t le t , a n d AP ra d io g ra p h s
w ill h e lp d isclo se su b t le ro t a t io n a l d e fo rm it ie s n o t a p p re -
cia t e d b y d ire ct visu a liza t io n o r p a lp a t io n .
■ On ly o n ce a d e q u a t e le n g t h h a s b e e n re st o re d ca n t h e
n e e d fo r a d d it io n a l a n t e ro p o st e rio r o r m e d ia l-t o -la t e ra l
t ra n sla t io n b e a sse sse d .
■ Fin e -t u n in g o f t h e SI jo in t re d u ct io n w ill re q u ire t h e
p la ce m e n t o f o n e o r t w o re d u ct io n cla m p s t o m e d ia lly
t ra n sla t e a n d in t e rn a lly ro t a t e t h e h e m ip e lvis. La rg e
p o in t e d re d u ct io n cla m p s (e g , We b e r cla m p o r o ffse t
Ma t t a cla m p s) a re u se d .
■ Po st e rio rly, a cla m p ca n b e p la ce d o ve r t h e sa cra l sp in o u s
p ro ce ss o r in t o t h e p o st e rio r co rt e x o f t h e sa cru m in fe ri-
o rly a n d in t o t h e co rt ica l b o n e o f t h e m e d ia l a sp e ct o f
t h e g re a t e r scia t ic n o t ch . Th is ca n h e lp clo se t h e in fe rio r
a sp e ct o f t h e SI jo in t (TECH FIG 2 A).
C
 Ch a p t e r 3 5 ORIF OF THE SACROILIAC JOINT AND SACRUM
D E
■ A se co n d cla m p ca n b e u se d su p e rio rly, w it h o n e t in e
p la ce d ca re fu lly o ve r t h e t o p o f t h e jo in t o n t o t h e sa cra l
a la a n t e rio rly a n d t h e se co n d t in e p la ce d ju st la t e ra l t o
t h e p o st e rio r su p e rio r ilia c sp in e (TECH FIG 2 B,C).
■ Alt e rn a t ive ly, t h is se co n d cla m p ca n b e p la ce d t h ro u g h
t h e g re a t e r n o t ch , w it h o n e t in e o n t h e sa cra l a la a n d
ANTERIOR APPROACH
■ Th e a n t e rio r a p p ro a ch t o t h e SI jo in t u se s t h e u p p e r lim b
o f t h e Sm it h -Pe t e rso n a p p ro a ch , t a kin g t h e e xt e rn a l
o b liq u e fib e rs o ff t h e ilia c cre st a n d e le va t in g t h e ilia cu s
m u scle su b p e rio st e a lly fro m t h e in n e r t a b le o f t h e iliu m .
■ Wh e n t h e SI jo in t is e n co u n t e re d , ca re fu l m o b iliza t io n
o f t h e t issu e o n t h e sa cra l a la u sin g a b lu n t p e rio st e a l e l-
e va t o r a n d fin g e r d isse ct io n h e lp s t o m o ve t h e L5 n e rve
ro o t m e d ia lly o u t o f h a rm ’s w a y.
A ■
B ■
TECH FIG 3 • Dia g ra m o f in cisio n (A) a n d vie w o f sa cro ilia c
jo in t fro m t h e a n t e rio r a p p ro a ch (B). No t e p o sit io n o f sh a rp
Ho h m a n n re t ra ct o r in t h e a la t o p ro t e ct t h e L5 n e rve ro o t .
309
TECHNIQUES
TECH FIG 2 • (con tin u e d ) D,E. Matt a o ffset
clam p re d u cin g a n te rio r asp ect o f sa cro ilia c.
Th e cla mp is p ositio n e d t h ro u g h t h e g re a te r
n o tch o n to t h e la t e ra l a spe ct o f the a la, la t-
e ra l to th e L5 n e rve ro o t .
t h e o t h e r o n t h e p o st e rio r co rt e x o f t h e iliu m (TECH
FIG 2 D,E).
■ While th ese clamps are be ing closed to re du ce the sup erio r
SI jo int, inte rna l rotation of the e xtremity or pu sh ing on
the anterior iliac wing with a ball-spike pusher (picador)
can help to close do wn the a nte rior a spe ct of the SI joint.
■ On ce t h is t issu e is m o b ilize d a n d t h e sa cra l a la is se e n
u n d e r d ire ct visio n , a sh a rp Ho h m a n n re t ra ct o r is d rive n
in t o t h e a la r co rt e x a n d u se d t o p ro t e ct t h e L5 n e rve ro o t ,
w h ich lie s m e d ia l (TECH FIG 3 ).
Op e n Re d u ct io n o f t h e SI Jo in t via
t h e An t e rio r Ap p ro a ch
■ On ce t h e SI jo in t a n d sa cra l a la e h a ve b e e n e xp o se d , re -
d u ct io n ca n b e ca rrie d o u t .
■ Sim ila r t o t h e p o st e rio r a p p ro a ch , lo n g it u d in a l t ra c-
t io n is a p p lie d w it h in t e rn a l ro t a t io n o f t h e e xt re m it y.
■ If t h e re is w id e d ia st a sis o f t h e SI jo in t a n d sym p h ysis, t h e
su rg e o n m a y e le ct a t t h is st a g e t o e xp o se t h e sym p h ysis
a n d t e m p o ra rily re d u ce it w it h a cla m p t o a id in in t e rn a l
ro t a t io n a n d re d u ct io n .
■ Ho w e ve r, p e rm a n e n t fixa t io n o f t h e sym p h ysis a t t h is
t im e is n o t in d ica t e d , a s it m a y im p e d e a n a t o m ic re d u c-
t io n o f t h e SI jo in t b y lim it in g m o t io n o f t h e u n st a b le
h e m ip e lvis.
■ If o p e n re d u ct io n o f t h e sym p h ysis is p e rfo rm e d , it is
h e ld t e m p o ra rily w it h a cla m p so t h a t it ca n b e
re m o ve d o r a d ju st e d if t h e SI jo in t d o e s n o t re d u ce
sa t isfa ct o rily.
Sh o u ld p e rsist e n t d ia st a sis o f t h e SI jo in t e xist d e sp it e
t h e se in d ire ct m a n e u ve rs, a Ve rb ru g g e o r Fa ra b e u f re -
d u ct io n cla m p ca n b e u se d t o co m p le t e t h e re d u ct io n .
■ A sin g le co rt ica l scre w is p la ce d o n e it h e r sid e o f t h e
SI jo in t in t o t h e iliu m a n d sa cra l a la , re sp e ct ive ly.
■ Th e h e a d s o f t h e scre w s a re le ft p ro u d o ff t h e co rt e x,
a llo w in g t h e re d u ct io n cla m p t o e n g a g e t h e scre w
h e a d s.
■ Th e cla m p s ca n b e ro t a t e d a n d t w ist e d in a n y d ire c-
t io n w h ile clo sin g t h e g a p t o a ch ie ve re d u ct io n o f t h e
jo in t (TECH FIG 4 ).
Alt e rn a t ive ly, a n o ffse t re d u ct io n cla m p o r Kin g To n g
re d u ct io n cla m p ca n b e p la ce d o n t h e a la a n d e xt e rn a l
ilia c w in g , a s in Te ch n iq u e s Fig u re 2B, b u t fro m t h e
fro n t .
 310 Se c t i o n III PELVIS AND HIP
TECHNIQUES
A B
TECH FIG 4 • Fa ra b e u f p e lvic re d u ct io n cla m p re d u cin g t h e sa cro ilia c jo in t
fro m t h e a n t e rio r a p p ro a ch u sin g t h e t w o -scre w t e ch n iq u e .
PLACEMENT OF ILIOSACRAL SCREWS
En t ry Po in t s
■ La rg e ca n n u la t e d p a rt ia lly t h re a d e d scre w s a re u se d (7.3
o r 8.0 m m ).
■ Th e e n t ry p o in t e xt e rn a lly is t yp ica lly 10 t o 20 m m a n t e -
rio r t o t h e crist a g lu t e a t w o t h ird s o f t h e w a y fro m t h e
ilia c cre st (p o st e rio r su p e rio r ilia c sp in e ) t o t h e g re a t e r
scia t ic n o t ch , o r 2 cm u p a n d 2 cm p o st e rio r t o t h e n o t ch
(TECH FIG 5 A).
■ Pe rcu t a n e o u sly, t h e e xt e rn a l la n d m a rk fo r ch o o sin g t h e
co rre ct e n t ry sit e is t h e p o in t o f in t e rse ct io n b e t w e e n a
lin e e xt e n d in g p ro xim a lly fro m t h e g re a t e r t ro ch a n t e r
a n d a h o rizo n t a l lin e e xt e n d in g la t e ra lly fro m t h e p o st e -
rio r su p e rio r ilia c sp in e (TECH FIG 5 B).
■ In p e rcu t a n e o u s p ro ce d u re s, t h e su rg e o n m u st b e
w a ry o f in ju ry t o t h e su p e rio r g lu t e a l n e u ro va scu la r
b u n d le sin ce t h e e n t ry p o in t is clo se t o t h e n e u ro va s-
cu la r b u n d le a s it e xit s t h e g re a t e r scia t ic n o t ch .4,23
A
B
TECH FIG 5 • A. En try po in t for sa croilia c screw on ou te r t able
of th e ilium. No t e p ro xim it y t o t h e su p erior g lu te a l ne u rova s-
cula r bundle. B. Su perficial la n d ma rks fo r percu t ane ou s sacro il-
iac screw placem ent .
■ “ Sa fe ” p la ce m e n t is m a xim ize d b y ca re fu l a t t e n t io n t o
ra d io g ra p h ic b o n y la n d m a rks.6,33
Sa fe Pla ce m e n t a n d Tra je ct o ry
■ Th e t h re e crit ica l p ro je ct io n s fo r p la cin g a n SI scre w a re :
■ Th e la t e ra l p ro je ct io n t o ce n t e r t h e g u id e w ire o n t h e
sa cru m a n t e rio r t o t h e ca n a l a n d t o e n su re t h a t t h e
g u id e w ire is b e lo w t h e ilia c co rt ica l d e n sit y a n d sa cra l
a la r slo p e t o p re ve n t in ju ry t o t h e L5 n e rve ro o t (TECH
FIG 6 A)
■ Th e o u t le t p ro je ct io n t o e n su re t h a t t h e g u id e w ire
p a sse s a b o ve t h e S1 sa cra l fo ra m e n (TECH FIG 6 B)
■ Th e in le t vie w t o e n su re t h a t t h e g u id e w ire is a t t h e
p ro p e r t ra je ct o ry a n d co m in g t o re st in t h e a n t e rio r
a sp e ct o f t h e sa cra l b o d y–p ro m o n t o ry fo r m a xim a l
p u rch a se (TECH FIG 6 C)
■ Th e su rg e o n sh o u ld b e a t t e n t ive t o sa cra l d ysm o rp h ism
a n d se g m e n t a t io n d e fe ct s t h a t g ive rise t o a lt e re d
a n a t o m y, su ch a s lu m b a rize d S1 o r sa cra lize d L5 ve rt e b ra l
b o d ie s.
■ The case show n in TECHNIQUES FIGURE 7A,B d emo n -
stra t e s a u n ila t e ra l sa cra lize d L5 o n th e rig h t . Th e le ft
sid e is n o rm a l. Th e ilia c cre st is in lin e w it h t h e L4–5 d isc
sp a ce .
■ Th e sa fe co rrid o r fo r t h e SI scre w is b e t w e e n t h e va lle y
o f t h e a la a n t e rio rly (L5 n e rve ro o t ), t h e sa cra l ca n a l
p o st e rio rly (ca u d a e q u in a ), a n d t h e sa cra l fo ra m e n in fe -
rio rly (S1 n e rve ro o t ).
■ In t h e n o rm a l sit u a t io n (n o se g m e n t a t io n a b n o rm a l-
it y), t h e co rrid o r is w e ll d e fin e d (TECH FIG 7 C), b u t in
t h e ca se o f a sa cra lize d L5, t h e sa fe co rrid o r is e it h e r
e xce e d in g ly n a rro w o r n o n e xist e n t (TECH FIG 7 D,E).
■ If t h is a b n o rm a lit y is n o t re co g n ize d a n d a n SI scre w is
p la ce d in t o L5 a ssu m in g it is S1, t h e L5 n e rve ro o t is
like ly t o b e in ju re d .
■ If t h e su rg e o n is u n su re , t h e la t e ra l p ro je ct io n w it h
t h e ilia c co rt ica l d e n sit ie s is ke y in d e t e rm in in g t h e
co rre ct le ve l t o p la ce t h e scre w , sin ce t h e y a re co n -
st a n t w it h t h e ir re la t io n sh ip t o S1 e ve n in se g m e n t a -
t io n a b n o rm a lit ie s (TECH FIG 7 F).
■ TECHNIQUES FIGURE 7 G sh o w s a re d u ce d SI jo in t
d islo ca t io n w it h a sa fe ly p la ce d SI scre w .
■ Fo r SI jo in t d islo ca t io n s, t h e scre w t ra je ct o ry sh o u ld b e
fro m in fe rio r t o su p e rio r o n t h e o u t le t vie w , a n d fro m
 Ch a p t e r 3 5 ORIF OF THE SACROILIAC JOINT AND SACRUM 311

TECHNIQUES
A B C

TECH FIG 6 • A. La t e ra l p ro je ct io n o f p e lvis sh o w in g t h e ilia c co rt ica l d e n sit y (ICD) o r sa cra l a la r slo p e lin e . Th e t ip
o f t h e sa cro ilia c scre w a n d g u id e w ire m u st b e b e lo w t h is lin e w h e n t h e scre w is a t t h e le ve l o f t h e fo ra m e n o n t h e
o u t le t p ro je ct io n . Ou t le t (B) a n d in le t (C) p ro je ct io n sh o w in g p a t h o f ilio sa cra l scre w fo r sa cro ilia c jo in t d islo ca t io n .

p o st e rio r t o a n t e rio r o n t h e in le t vie w (p e rp e n d icu la r t o ■ In sit u a t io n s o f co m m in u t e d t ra n sfo ra m in a l sa cra l fra c-

t h e p la n e o f t h e SI jo in t ).
■ Fo r sa cra l fra ct u re s, t h e scre w t ra je ct o ry sh o u ld b e
st ra ig h t a cro ss fro m la t e ra l t o m e d ia l o n t h e in le t vie w
(p e rp e n d icu la r t o t h e fra ct u re p la n e ).
■ Th e t ip o f t h e SI scre w sh o u ld co m e t o re st in t h e co n -
t ra la t e ra l sid e o f t h e S1 b o d y a n d p ro m o n t o ry.
■ Ca rryin g t h e scre w in t o t h e a la p ro vid e s w e a ke r p u r-
ch a se se co n d a ry t o p o o r b o n e q u a lit y a n d in cre a se d
risk t o t h e co n t ra la t e ra l L5 n e rve ro o t .
t u re s, t h e t h e o re t ica l risk o f o ve rco m p re ssio n a n d ia t ro -
g e n ic sa cra l n e rve ro o t in ju ry e xist s. To g a in st a b ilit y w it h
t h e co n st ru ct a n d a vo id a n o n u n io n , so m e co m p re ssio n is
n e ce ssa ry, h o w e ve r.
■ If t h is risk e xist s, sa cra l n e rve ro o t d e co m p re ssio n
sh o u ld b e p e rfo rm e d b e fo re p la cin g t h e SI scre w , o r
a n a lt e rn a t ive fo rm o f fixa t io n su ch a s sp in a l p e lvic
fixa t io n o r a t ra n ssa cra l scre w sh o u ld b e p la ce d .

A B C

D E F

TECH FIG 7 • Ou t le t p ro je ct io n (A) a n d t h re e -d im e n sio n a l re co n st ru ct io n

(B) sh o w in g t h e se g m e n t a t io n a n o m a ly (in t h is ca se a u n ila t e ra l sa cra lize d
L5). C. Sa fe co rrid o r fo r p la ce m e n t o f a n S1 ilio sa cra l scre w in t o t h e a la o f
S1. D,E. La ck o f sa fe co rrid o r in t o “ S1” d e m o n st ra t e d o n t h is a xia l CT o f t h e
p a t ie n t w it h t h e u n ila t e ra l sa cra lize d L5. On so m e cu t s a n d t h e la t e ra l p ro -
je ct io n t h is m a y a p p e a r a s S1 w h e n it is in fa ct L5. Th e re is n o sa fe co rrid o r
a t t h is le ve l. F. Sa fe p la ce m e n t o f a n ilio sa cra l scre w in t o S1 u n d e r t h e ilia c
co rt ica l d e n sit ie s (re d arro w ). G. AP p ro je ct io n d e m o n st ra t in g a re d u ce d
G sa cro ilia c jo in t w it h a w e ll-p la ce d sa cro ilia c scre w .
 312 Se c t i o n III PELVIS AND HIP
TECHNIQUES

SPINAL PELVIC FIXATION

■ Th ro u g h a p o st e rio r a p p ro a ch a s d e scrib e d a b o ve , t h e
L4–5 fa ce t jo in t is e xp o se d , t a kin g ca re n o t t o d isru p t t h e
ca p su le .
■ A 6.2-m m t it a n iu m Sch a n z scre w is p la ce d in t o t h e L5
p e d icle , w it h t h e e n t ry p o in t a t t h e ju n ct io n o f t h e
t ra n sve rse p ro ce ss a n d t h e la t e ra l b o rd e r o f t h e fa ce t
jo in t .
■ A se co n d Sch a n z scre w is p la ce d in t o t h e iliu m a t t h e p o s-
t e rio r su p e rio r o r in fe rio r ilia c sp in e , a n d t h e n d ire ct e d
b e t w e e n t h e in n e r a n d o u t e r t a b le s o f t h e iliu m .
■ Th e t ra je ct o ry sh o u ld b e a im in g fo r t h e ip sila t e ra l
g re a t e r t ro ch a n t e r a s a n e xt e rn a l la n d m a rk. Th e
scre w sh o u ld b e d ire ct e d t o p a ss t h ro u g h t h e re g io n
o f t h e scia t ic b u t t re ss a s se e n o n t h e ilia c o b liq u e
vie w .
■ Pla ce m e n t o u t o f t h e SI jo in t a n d w it h in t h e co n fin e s
o f t h e in n e r a n d o u t e r t a b le s ca n b e co n firm e d o n t h e
o b t u ra t o r a n d ilia c o b liq u e vie w s (TECH FIG 8 A,B).
■ Th e se t w o scre w s a re t h e n co n n e ct e d w it h fixe d -a n g le
cla m p s a n d a 5.0-m m ro d , su p p le m e n t in g t h e SI scre w t o
re sist ve rt ica l d isp la ce m e n t (TECH FIG 8 C).
■ Sa cra l fra ct u re re d u ct io n a n d fixa t io n w it h cla m p s a n d
a n SI scre w a s d e scrib e d a b o ve sh o u ld b e p e rfo rm e d b e -
fo re p la cin g a n y sp in a l p e lvic co n st ru ct .
■ Th is a vo id s rig id fixa t io n w it h re sid u a l sa cra l g a p a n d
su b se q u e n t n o n u n io n o r d e la ye d u n io n .

A B C

TECH FIG 8 • Ju d e t o b t u ra t o r (A) a n d ilia c o b liq u e (B) vie w s t o sh o w t h e p a t h o f t h e ilia c scre w fo r t ria n g u la r o st e o syn -
t h e sis. Th is p a t h is b e t w e e n t h e in n e r a n d o u t e r t a b le s (o u t lin e d w it h re d h ash m ark s) o n t h e o b t u ra t o r o b liq u e vie w a n d
ju st a b o ve t h e scia t ic b u t t re ss o n t h e ilia c o b liq u e vie w . C. AP ra d io g ra p h o f t h e p e lvis a ft e r sp in a l p e lvic fixa t io n (t ria n -
g u la r o st e o syn t h e sis).

SACRAL NERVE ROOT DECOMPRESSION

■ In m o st t ra n sfo rm in a l fra ct u re s, t h e in crim in a t in g fra g -
m e n t o f b o n e ca n b e fo u n d a n d re m o ve d b y w o rkin g d i-
re ct ly t h ro u g h t h e fra ct u re in t h e sa cru m .
■ A la m in a r sp re a d e r ca n b e p la ce d in t o t h e fra ct u re t o
sp re a d t h e re sp e ct ive p o rt io n s o f t h e fra ct u re .
■ Aft e r t h e clo t is re m o ve d , ca re fu l d isse ct io n a lo n g t h e e x-
p o se d su rfa ce o f t h e m e d ia l sa cra l fra g m e n t w ill d isclo se
so m e p o rt io n o f t h e fo ra m e n .
■ Tra cin g t h e n e rve ro o t a n t e rio rly w ill u su a lly le a d t o t h e
b o n e fra g m e n t .
■ Occa sio n a lly, a Ke rriso n a n d p it u it a ry ro n g e u r w ill b e
n e e d e d t o re m o ve so m e p o rt io n o f t h e sa cra l la m in a t o
fin d t h e n e rve ro o t , so t h e se in st ru m e n t s sh o u ld a lw a ys
b e re a d ily a va ila b le .

PEARLS AND PITFALLS

Po o r SI scre w p u rch a se
Fixa t io n o f sa cra l fra ct u re w it h re sid u a l g a p
■ Pla ce m e n t o f a se co n d SI scre w in t o S2
■ Th e su rg e o n sh o u ld e n su re a p p ro p ria t e le n g t h in t o t h e a n t e rio r a sp e ct o f t h e
sa cra l ve rt e b ra l b o d y a n d p ro m o n t o ry. Ala r p u rch a se is p o o r se co n d a ry t o lo w
b o n e d e n sit y h e re .
■ Pla ce m e n t o f a t ra n ssa cra l SI scre w in t o co n t ra la t e ra l SI jo in t
■ Pla ce m e n t o f t ra n silia c b a rs o r p la t e s
■ Cla m p s a n d SI scre w s a re u se d t o clo se t h e fra ct u re g a p u n d e r flu o ro sco p ic co n t ro l,
w it h o u t o ve rco m p re ssin g .
■ Th e sp in a l p e lvic fixa t io n co n st ru ct sh o u ld n o t b e u se d b e fo re m a n ip u la t ive re d u c-
t io n a n d SI scre w s, a s it w ill lo ck d o w n t h e fra ct u re , p re ve n t in g re d u ct io n a n d g a p
clo su re .

PEARLS AND PITFALLS
SI scre w m a lp o st io n
Po o r SI scre w p u rch a se
Sa cra l d ysm o rp h ism
Fixa t io n o f sa cra l fra ct u re w it h re sid u a l g a p
Wound dehisce nce and infe ct ion
Pa t ie n t w a ke s u p w it h n e w n e u ro lo g ic d e ficit
(ia t ro g e n ic n e rve in ju ry, m o st co m m o n ly L5)
In a b ilit y t o re d u ce t h e SI jo in t o r sa cra l
fra ct u re
POSTOPERATIVE CARE
■ Provided that all other injuries permit, the patient is mobi-
lized the first postoperative day.
■ The patient is instructed to be touch-down weight bearing
on the ipsilateral extremity for 10 to 12 weeks for SI dislo-
cations and sacral alar fractures stabilized with SI screws.
■ Patients with spinal pelvic fixation can be allowed to bear
full weight within 4 to 6 weeks.
■ All patients are given a regimen of pelvic, core trunk, hip,
and knee range-of-motion exercises.
■ Common early postoperative problems in patients with se-
vere pelvic fractures include ileus and urinary retention; these
need to be addressed early.
■ The Foley catheter is usually not removed until the patient
can mobilize well with physical therapy.
■ Diet is not advanced until flatus and normal bowel sounds
have returned.
■ Anticoagulation is administered in all patients for 6 weeks,
with low-molecular-weight heparin or Coumadin for deep
venous thrombosis and pulmonary embolism prophylaxis.
OUTCOMES
■ O utcome studies after fixation of pelvic fracture-dislocations
are difficult to interpret because of poor follow-up, hetero-
geneity of the injury pattern, associated visceral and neurologic
injury, and the lack of reliable outcome measures for pelvic
ring injuries.
■ Improved short-term patient outcomes with early stabiliza-
tion and mobilization as well as numerous reports citing
Ch a p t e r 3 5 ORIF OF THE SACROILIAC JOINT AND SACRUM 313
■ Th e su rg e o n sh o u ld a lw a ys o rd e r a p o st o p e ra t ive CT sca n .
■ If a n y sym p t o m s o r sig n s o f ra d icu lit is o r ra d icu lo p a t h y e xist , t h e n scre w re m o va l is
in dceica
■ Pla mteendt. oIff tah ese pcoa nt ie
d nSIt is a sym
scre w inp t o m S2a t ic fro m a m isp la ce d scre w , t h e n o b se rva t io n
■ This ewsua rra
rg enot endsh. Ho
o uw lde even r,suifre sym
a p ppro t opmria
s tdee vele nlogpt ha tinat olattheer da na t e ,rio
t hreanspt heect noefrve
t h erosao cra
t l
mrta eybsca
ve ra lr boor dbye acon m
d ep ro a dmh oe nret no try.t oAlat h er pscre
u rchw a, se
m aiskin p ogore m co
r se o va n dl ma ryo re
t o dloifficu
w b oltn. e d e n -
■sit
Go y ohde re
AP. p e lvic, lu m b a r, a n d ch e st ra d io g ra p h s a re o b t a in e d t o e n su re n o se g m e n -
■ Pla ce m e n t o f a t ra n ssa cra l SI scre w in t o co n t ra la t e ra l SI jo in t
t a t io n a n o m a ly e xist s.
■ ■Pla ce m e n t o f t ra n silia c b a rs o r p la t e s
Th e ilia c cre st s a re o ft e n a t t h e le ve l o f t h e L4–5 d isc sp a ce .
■■ Unmilap tsearan ld seSIgscre
Cla m e nwt as taioren udse
e fe
d ct
t os clo
a resea lso
t h ecofra
mct
muore
n . g a p u n d e r flu o ro sco p ic co n t ro l,
■w3-D
it h oreu co
t onvest rco
ru ctmiopnres ssin
a re go. ft e n h e lp fu l in d ia g n o sin g sa cra l d ysm o rp h ism a n d
a sse ssin g t h e re g io n o f t h e sa cra l a la re la t ive t o t h e first sa cra l fo ra m e n .
■ These sho uld be trea te d ea rly an d agg re ssively t o avoid de ep-seat ed pelvic absce sses
and infection s.
■ Pro lo nged dra inage (whe th er th e pa tie nt is febrile o r not, and whe the r the w hite
ce ll co u n t is e le va t e d o r n o t ) sh o u ld in d ica te a re p e a t t rip to th e o p e ra tin g ro o m fo r
o p en irrig at io n an d d é b rid e me n t, a nd d ra in a g e . In cisio n a l va cu u m-a ssist ed closu re is
h elpfu l in d e crea sin g d ra in a ge a nd wo u n d d e hisce n ce .
■ First , p re o pe ra t ive ly t h e p a t ie nt sh o u ld b e in fo rm e d o f t h e risk o f n e u ro lo g ic in ju ry
t h a t ca n o ccu r w it h re d u ct io n .
■ A CT sca n is o rd e re d t o a sse ss fo r p o ssib le ca u se s fo r n e rve ro o t in ju ry:
■ Ma lp o sit io n e d scre w : re m o ve
■ Bo n e fra g m e n t (u su a lly fro m sa cra l fra ct u re ): d e co m p re ss, u su a lly a n t e rio rly o n
t o p o f a la
■ Ho w e ve r, a p o st o p e ra t ive CT sca n w ill n o t d isclo se a n y o ffe n d in g e t io lo g y, in
w h ich ca se o b se rva t io n a n d p ra ye r is in d ica t e d .
■ First t h e su rg e o n sh o u ld e n su re t h a t a d e q u a t e lo n g it u d in a l t ra ct io n is a p p lie d , a s
t h a t is t h e ke y t o re d u ct io n .
■ A st a n d a rd fra ct u re t a b le wit h a p e rin e a l p o st sh o u ld n o t b e u se d , a s th is w ill im-
p ed e ca u da l t ran sla t io n o f t h e h em ip e lvis.
improved outcomes with anatomic reduction of the posterior
ring continued to provide the impetus to develop more rigid
and stable posterior fixation constructs.
■ Earlier outcome studies support the position that the long-
term functional results are improved if reduction with less
than 1 cm of combined displacement of the posterior ring is
obtained, especially with pure dislocations of the SI complex.
■ Fractures of the posterior ring, as opposed to pure SI dislo-
cations, tend to display superior outcomes, presumably because
bony healing can restore initial strength and stability.
■ In contrast, SI dislocations rely purely on ligamentous heal-
ing and scar formation; as a result, these patients tend to have
worse functional outcomes in the short term and long term
with pain and ambulation compared to patients with other
injury patterns.
■ More recent detailed clinical outcome studies have shown
that with current fixation techniques, many patients continue to
have poor outcomes with chronic posterior pelvic pain despite
seemingly anatomic reductions and healing, with less than 50%
returning to previous level of function and work status.
■ This disparity in results is likely related to multiple con-
founding factors, such as:
■ Poor financial and psychosocial and emotional status of
trauma patients
■ Extensive soft tissue damage and associated long bone
and extremity fractures
■ Associated neurologic, visceral, and urogenital injuries, re-
sulting in dyspareunia, sexual dysfunction, and incontinence
■ Prolonged recovery and rehabilitation time, with loss of
job, home, and family roles
314 Se c t i o n III PELVIS AND HIP
COMPLICATION S
■ Blood loss and the need for transfusion is common with any
open procedure on the posterior pelvic ring, particularly with
open reduction of the SI joint and sacral fracture, where injury
to the superior gluteal artery is always a danger.
■ Wound infection occurs surprisingly infrequently given the
medical condition of these patients, prolonged ICU and hospi-
tal admission, and associated soft tissue injury.
■ Infection and wound complications occur in about 3% of
all patients.
■ Patients with internal degloving injuries (a M orel-Lavalle le-
sion), where the skin and subcutaneous fatty layer are sheared
and separated from the underlying musculofascial layers, are
particularly prone to severe wound complications, with dehis-
cence, necrosis, and slough.
■ Patients who have been identified as having an internal
degloving lesion in the area of operative approach should
first have drainage and débridement of the lesion, and the
reduction and placement of fixation should be performed
through an alternate approach.
■ N eurologic injury from manipulation of fracture fragments
or placement of SI screws is also a possibility.
■ Careful attention to the radiologic landmarks and clear
appropriate imaging should allow the surgeon to avoid
these iatrogenic complications, although even smooth, gen-
tle reductions of widely displaced fractures and dislocations
can result in neuropraxic injury to the nerve roots and post-
operative deficits.
■ Patients need to be informed of this risk preoperatively.
■ The risk of misplaced SI screws varies widely with sur-
geon and individual experience.
■ Loss of reduction and failure of fixation can occur in very
comminuted and unstable fracture-dislocations, particularly in
patients with poor bone quality.
■ These situations should be recognized preoperatively and
intraoperatively, and the appropriate supplemental fixation
(additional SI screws or spinal pelvic fixation constructs)
should be applied.
■ N onunion of sacral fractures and SI dislocations is rare and
not reported specifically in the literature.
■ Rigidly stabilizing a sacral fracture with a residual gap
predisposes to malunion and nonunion.
■ Some patients with SI dislocations continue to have chronic
SI joint pain, requiring SI joint fusion.
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nal fixation of vertical shear fractures of the pelvis. J O rthop Res
1991;9:237–245.
31. Templeman D, Schmidt A, Freese J, et al. Proximity of iliosacral screws
to neurovascular structures after internal fixation. Clin Orthop 1996;
329:194–198.
32. Vrahas M , H earn TC, Diangelo D, et al. Ligamentous contributions
to pelvic stability. O rthopedics 1995;18:271–274.
33. Xu R, Ebraheim NA, Robke J, et al. Radiologic evaluation of iliosacral
screw placement. Spine 1996;21:582–588.
 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 36 Fix a t io n o f t h e Po s t e r io r Wa ll
o f t h e Ace t a b u lu m
Jo d i Sie g e l an d David C. Te m p le m an

DEFIN ITION AN ATOMY

■ A posterior wall fracture is one of the elementary fracture ■ The hip is a constrained ball-and-socket joint composed
types as described by Letournel.6 It is a fracture of the poste- of the femoral head as the ball and the acetabulum as the socket.
rior rim of the socket portion of the ball-and-socket joint of ■ The capsule surrounding the joint extends from the bony ac-

the hip (FIG 1 ). etabular rim to the intertrochanteric line anteriorly and to the
■ The disruption separates a segment of articular surface that femoral neck posteriorly. It is thickened in specific areas, cre-
involves varying amounts of the bony posterior wall of the ac- ating ligaments.
etabulum. It can exist as one single fragment or as several com- ■ Anteriorly, the iliofemoral Y ligament exists as two bands.

minuted pieces. The inferior capsule is supported by the pubofemoral liga-

■ The wall fracture can exist alone or as part of an associated ment and the posterior capsule is strengthened by the is-
acetabular fracture. chiofemoral ligament.
■ By definition, the posterior column, and therefore the iliois- ■ The acetabular labrum is a fibrocartilaginous structure at-

chial line, remains intact, despite varying amounts of retroac- tached to the bony rim, deepening the socket and making the
etabular surface disruption. joint more stable. It adds an additional 10% of coverage to the
femoral head.

A
B

FIG 1 • AP (A) a n d Ju d e t (B,C) ra d io g ra p h s o f a p o st e rio r w a ll

C fra ct u re . Th e p o st e rio r w a ll fra ct u re fra g m e n t is o u t lin e d .

315
316 Se c t i o n III PELVIS AND HIP
■ The acetabulum is composed of two columns, two walls,
and the roof within the pelvis. The anterior and posterior
columns form an inverted Y and are attached to the sacrum via
the sacral buttress. The articular surface of the joint sits on the
anterior and posterior walls and the roof, which is located
within the arms of the Y.
■ The anatomic roof is located between the anterior inferior
iliac spine and the ilio-ischial notch of the acetabular
margin.6
■ The weight-bearing dome, as determined by 45-degree
roof arc measurements on anteroposterior (AP) and Judet
radiographs, is the most important articular portion of
the acetabulum. This functional aspect of the acetabulum
includes the excursions of all resultant force vectors dur-
ing normal daily activities.9
■ Two additional segments should also be considered
separately.
■ The posterosuperior segment is the bridge between the
roof and the posterior wall.
■ The posteroinferior segment is the lower part of the
posterior wall and the posterior horn of the cartilage.6
■ Due to the large area of muscular attachments, the blood
supply to the acetabulum is vast.6 Small arteries start periph-
erally and flow centrally, parallel to each other.
■ The largest nutrient foramina on the internal aspect of the
ilium is reliably located 1 cm lateral to the sacroiliac joint
and 1 cm above the iliopectineal line. It is fed by a branch
of the iliolumbar artery.
■ A branch of the superior gluteal artery feeds the largest
nutrient foramina on the external surface in the center of the
iliac wing, just anterior to the anterior gluteal line.
■ The obturator artery supplies foramina in front of the sci-
atic notch just below the iliopectineal line and in the roof of
the obturator canal. The body of the pubis is also supplied
by the obturator artery. A branch of this artery, the acetab-
ular branch, feeds the cotyloid fossa via a number of small
perforators.
■ A complete vascular circle supplies multiple nutrient vessels
around the periphery of the acetabulum. The artery of the
roof of the acetabulum (from the superior gluteal artery), the
obturator artery, and the inferior gluteal artery are main
contributors.
■ The iliac crest, from the anterior inferior iliac spine poste-
riorly to the auricular articular surface of the sacroiliac
joint, is supplied by branches of the external anterior iliac
artery, branches of the fourth lumbar artery, and branches
of the iliolumbar artery.
■ The sciatic buttress receives its blood supply from multi-
ple branches of the superior gluteal artery.
PATHOGEN ESIS
■ Acetabular fractures occur when a force is transmitted from
the femur, through the femoral head, to the acetabulum. The
specific pattern of the fracture is determined by the position of
the hip at the time of injury and the magnitude of the force of
the trauma.
■ A common mechanism of injury of posterior wall fractures
and fracture-dislocations is a motor vehicle crash in which the
unrestrained patient is sitting with a flexed knee and the knee
strikes the dashboard, creating an axial load along the length
of the femur, loading the posterior aspect of the acetabulum.
FIG 2 • Axia l CT cu t sh ow in g im p a ction . Th e imp a ct e d fra g me n t
(arrow ) is rotat ed wit h the articular cartilage now facing laterally.
■ Posterior wall fractures of the acetabulum occur when the
hip is flexed to 90 degrees and is in neutral coronal and axial
plane orientation. In this position, when an axial load is ap-
plied to the femur, the posterior articular surface of the joint
is stressed. The amount of comminution, displacement, and ar-
ticular impaction will depend on the quality of the bone and
the magnitude of the force.
■ A typical posterior wall fracture is completely below the
roof of the acetabulum.
■ With less hip flexion and a force applied along the axis of
the femoral shaft, a superior posterior wall variant will re-
sult, which includes part of the adjacent roof.
■ A posterior inferior fracture includes the inferior horn of
the articular surface, the subcotyloid groove, and often the
superior ischium.
■ Extended fractures, massive posterior wall fractures, and
transitional forms are mentioned for completeness but are
outside the scope of this text.
■ A variation of a posterior wall fracture is a fracture-disloca-
tion, which involves single or multifragmented pieces of the
posterior wall separated by the dislocating femoral head. This
pattern is often associated with impaction of the articular sur-
face of either the head or the wall (FIG 2 ).
■ With a posterior wall fracture or fracture-dislocation, one
of two possibilities exists for the capsule.
■ The capsule can rupture and allow the head to dislo-
cate. In this scenario, varying sizes of wall fragments and
labral injury can exist.
■ Alternatively, the capsule can remain intact to the wall
fragment and to the femur, with all of the displacement
(or even the dislocation) occurring through the fracture
site.
■ The size of the posterior wall fragment and the integrity
of the capsule and the labrum play a role in hip stability.
Despite attempts to quantitate fragment size to define op-
erative indications,2,5,7,16 stress examination remains the
only method to predict instability.14
■ When the capsule remains intact and the head dislo-
cates, the fracture edges often fragment. This creates os-
teochondral fragments, which can lead to impaction or
incarceration of the pieces upon reduction of the femoral
head.
 Ch a p t e r 3 6 ORIF OF THE POSTERIOR WALL OF ACETABULUM
N ATURAL HISTORY
■ The goal of the treatment of acetabular fractures is to
achieve a stable, congruent hip joint with an anatomically re-
duced articular surface. Anatomic reduction and stabilization
will decrease the incidence of posttraumatic arthritis.8
■ Although fractures of the posterior wall are common, repre-
senting 24% of Letournel’s initial series, they are frequently
reported as having poor results, with 10% to 30% of patients
developing post-traumatic arthritis within 1 year.
■ N onoperative treatment is unsuccessful, and Epstein 3 has
documented that 88% of patients treated with closed reduc-
tion alone had unsatisfactory long-term results.
■ Roof arc and subchondral arc measurements do not apply
to typical posterior wall fractures; however, the size of the
posterior wall fragment may play a role.
■ M ultiple authors have attempted to define the size of the
fragment that will predict instability.
■ In cadaveric studies, fragments that include greater
than 50% of the wall were always unstable, while those
less than 20% were stable.5,16
■ A clinical study revealed that acetabuli with less than
34% of the posterior wall intact were unstable and those
with greater than 55% intact were stable.2
■ Dynamic stress examination that uses fluoroscopy to
assist with the detection of subtle subluxation can define
a stable or unstable joint without depending on fragment
size measurements.14
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Acetabular fractures are often the result of high-energy
trauma, and therefore other associated injuries must be sought.
■ H emorrhage and hemodynamic instability are rarely associ-
ated with isolated fractures of the posterior wall; however, the
superior gluteal artery and vein may be lacerated when frac-
tures extend to the greater sciatic notch.
■ Patients will frequently present with hip or groin pain and a
shortened lower extremity due to the posterior, superior dislo-
cation of the femoral head.
■ Soft tissue injuries around the pelvis are uncommon because
the mechanism of injury is indirect. N onetheless, the skin over-
lying the hip and pelvis of any pelvic or acetabular fracture
should be carefully evaluated for any subcutaneous fluctuance,
ecchymosis, or cutaneous anesthesia.
■ The M orel-Lavallée lesion, a subcutaneous degloving in-
jury, although a closed injury, is culture positive in up to
40% of cases.4 Initial débridement of these lesions as well as
a delay in internal fixation is recommended by some authors.
■ Soft tissue injuries at the knee are more common and often
missed. Ligamentous or chondral injuries are often discovered
on secondary survey, but only if they are considered and a
careful and thorough examination is performed.
■ The incidence of damage to the femoral head is unknown
as the head is not routinely dislocated during fixation of the
acetabular fracture for complete evaluation. H owever, it is
not surprising when associated femoral head fractures or
chondral lesions are noted, as the large amount of force
needed to cause the acetabular fracture is transmitted via the
femoral head.
■ Careful neurologic examination at the time of injury reveals
deficits in up to 30% of cases. The peroneal division of the sci-
317
atic nerve is the most commonly seen nerve injury, especially
when the femoral head is dislocated posteriorly.
■ O ther ipsilateral extremity injuries often discovered include
fractures of the femur, tibia, and foot.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ The diagnosis and classification of an acetabular fracture is
made from the initial trauma AP radiograph.
■ Two 45-degree oblique radiographs (Judet views) must
be obtained also to aid in classification and treatment plan-
ning.
■ Completing the five views of the pelvis series with pelvic
inlet and outlet views allows potential injuries to the pelvic
ring to be evaluated.
■ A CT scan of the pelvis will assist in defining displacement,
intra-articular fragments, marginal articular impaction, and
associated femoral head injuries.
■ The size of the posterior wall fragment can also be deter-
mined more accurately using a CT scan, which is optimally
obtained after the initial reduction.
■ The size and number of incarcerated fragments can be
more precisely determined with a CT scan. Preoperative
planning allows determination of the size and number of
free fragments that must be removed from the joint, as well
as the location of any impaction that must be elevated.
DIFFEREN TIAL DIAGN OSIS
■ Posterior hip dislocation
■ Associated acetabular fracture
■ Associated transverse and posterior wall fracture
■ Associated posterior column and posterior wall fracture
■ Associated T-shaped fracture
■ Associated both-column fracture
■ Pelvic fracture
■ Femoral head fracture
■ Proximal femur fracture
N ON OPERATIVE MAN AGEMEN T
■ N ondisplaced, stable fractures with a congruent joint can
be treated with protected, footflat weight-bearing restrictions
if no instability is evident on fluoroscopic-assisted stress
examination. 14
■ Posterior wall fractures that present dislocated should be
considered a surgical emergency.
■ A prompt closed reduction with satisfactory general anes-
thesia is recommended.
■ The surgeon should check the femoral neck before
reduction.
■ O nce reduced, the joint should be evaluated fluoro-
scopically in both the AP and obturator oblique views
for stability: the joint should be axially loaded with the
hip in flexion and in flexion plus adduction. 14 O nly if the
joint is stable (nonsubluxated) is nonoperative management
sufficient.
SURGICAL MAN AGEMEN T
■ Surgical management of acetabular fractures is technically
demanding. The goal of surgery is to obtain an anatomic re-
duction of the joint surface and to create a congruent and sta-
ble hip joint while avoiding complications.
 318 Se c t i o n III PELVIS AND HIP
■ O ther factors that play a role in surgical management
include surgeon experience and the timing of operative inter-
vention.
■ Letournel described his learning curve in 4-year intervals.
■ H e also reported reduced ability to achieve anatomic re-
duction when fractures are operated on more than 21 days
after injury.
■ Unlike most conditions in orthopedic surgery, all displaced
fractures of the acetabulum, which include marginal im-
paction, are indicated for surgery unless specific criteria for
nonoperative management are met.15 These include:
■ A congruent hip joint on AP and Judet radiographs and
on CT scan
■ An intact weight-bearing surface, as defined by roof arc
measurements and subchondral arc measurements on CT scan
■ At least 50% of the posterior wall intact on CT scan
■ A stable joint, including on a dynamic stress examination
■ Patient factors must also be considered.
■ Age, bone quality, comorbidities, preinjury functional
status, type of employment, and personal expectations all
must factor into the decision-making process.
Preoperative Planning
■ O pen reduction and internal fixation of a posterior wall
fracture is based upon evaluation of the AP pelvic and Judet
view radiographs and the CT scan.
■ The surgeon should closely evaluate the films for a trans-
verse component, which may be overlooked on initial viewing.
■ The identification of marginal impaction necessitates elevat-
ing the articular cartilage and packing behind it with some
form of bone graft or bone void filler to reconstruct the joint
surface successfully (see Fig 2).
■ Careful review of the CT scan will allow identification and
quantification of the number of intra-articular fragments that
exist to ensure that all foreign bodies are removed from the
joint upon exploration.
Positioning
■ M ost acetabular surgeons position the patient prone on a
fracture table (FIG 3 ).
■ The affected side is suspended using a distal femoral trac-
tion pin.
■ The peroneal post must be appropriately padded to pre-
vent pudendal nerve palsy.
■ The affected leg is placed in traction, with the hip in ex-
tension and the knee flexed to at least 80 degrees; the foot is
TECHNIQUES
KOCHER-LANGENBECK APPROACH
In cisio n a n d Disse ct io n
■ Th e in cisio n is b a se d o n t w o lim b s (TECH FIG 1 A).
■ On e st a rt s a t t h e p o st e rio r t ip o f t h e g re a t e r
t ro ch a n t e r a n d e xt e n d s d ist a lly a lo n g t h e p o st e rio r
a sp e ct o f t h e fe m o ra l sh a ft , d ist a l t o t h e t ro ch a n t e r
a n d t h e g lu t e a l cre a se , w h ich se rve s a s a n e xt e rn a l
la n d m a rk fo r t h e g lu t e u s m a xim u s t e n d o n .
■ Th e p ro xim a l lim b e xt e n d s a b o u t 45 d e g re e s t o w a rd
a sp o t 1 cm ce p h a la d t o t h e p o st e rio r su p e rio r ilia c
FIG 3 • Pro n e p o sit io n in g o n a fra ct u re t a b le w it h t h e a ffe ct e d
le g in d ist a l fe m o ra l ske le t a l t ra ct io n , t h e h ip e xt e n d e d , a n d t h e
kn e e fle xe d t o a t le a st 80 d e g re e s. Se q u e n t ia l co m p re ssio n d e -
vice s a re in p la ce o n b o t h lo w e r e xt re m it ie s.
well padded and secured in a fracture table boot in the rest-
ing position. Sequential compression devices are applied to
both lower extremities.
■ Traction is positioned to pull in line, neutral abduction–
adduction, neutral internal/external rotation, with the table’s
arm holding the foot free enough to allow internal and exter-
nal rotation intraoperatively.
■ The contralateral leg is in extension in a fracture table
boot with the foot well padded and in neutral position.
■ Pads are placed to support both thighs.
■ Chest pads are positioned to allow adequate room for the
abdomen and breasts, and for chest excursion.
■ Arms are abducted to 90 degrees at the shoulders and 90
degrees at the elbows.
■ O nce positioning is completed, PA and oblique views are
obtained with the C-arm before draping or preparation to en-
sure that the hip is reduced and that the necessary images can
be obtained.
■ The obturator oblique view can be obtained by rotating
the C-arm 45 degrees toward a lateral view.
■ Pushing upward on the anterior superior iliac spine can
assist with the last 15 degrees of rotation to obtain an iliac
oblique view, an image that most C-arms cannot otherwise
obtain.
Approach
■ The posterior wall of the acetabulum is accessed via the
Kocher-Langenbeck approach.
sp in e . Th e le n g t h o f t h is lim b d e p e n d s o n t h e a m o u n t
o f p o st e rio r co lu m n t h a t m u st b e a cce sse d .
■ Th e skin a n d su b cu t a n e o u s t issu e a re d ivid e d d o w n t o
t h e fa scia la t a a n d t h e g lu t e a l a p o n e u ro t ic fa scia .
■ On ce id e n t ifie d , t h e t e n so r fa scia la t a a n d ilio t ib ia l b a n d
a re sh a rp ly d ivid e d lo n g it u d in a lly in lin e w it h t h e u n d e r-
lyin g fe m o ra l sh a ft (TECH FIG 1 B).
■ To o p e n t h e p ro xim a l lim b , t h e su rg e o n sh a rp ly d i-
vid e s t h e g lu t e a l a p o n e u ro sis a n d t h e n g e n t ly sp lit s
t h e g lu t e u s m a xim u s m u scle via fin g e r d isse ct io n .
 Ch a p t e r 3 6 ORIF OF THE POSTERIOR WALL OF ACETABULUM
B C
■ Th e su rg e o n m u st w a t ch fo r cro ssin g ve sse ls a n d ca u -
t e rize t h e m b e fo re t h e y a re t o rn .
■ Th e n e rve s t h a t in n e rva t e t h e p ro xim a l t h ird o f t h e
g lu t e u s m a xim u s w ill cro ss in t h is a re a , a b o u t
h a lfw a y b e t w e e n t h e g re a t e r t ro ch a n t e r a n d t h e
p o st e rio r su p e rio r ilia c sp in e . Th e su rg e o n sh o u ld
st o p sp lit t in g a t t h e first n e rve t ru n k t o p re ve n t p o st -
o p e ra t ive p a lsy.
■ Th e Ch a rn le y re t ra ct o r is h e lp fu l fo r h o ld in g t h e fa scia
a w a y fro m t h e o p e ra t ive fie ld . Th e su rg e o n m u st t a ke
ca re n o t t o in se rt t o o d e e p ly t o p re ve n t ia t ro g e n ic in ju ry
t o t h e scia t ic n e rve .
■ Th e b u rsa o ve r t h e t ro ch a n t e r is o ft e n h e m o rrh a g ic fro m
t h e in ju ry a n d ca n b e re se ct e d a t t h is t im e if it is la rg e
a n d h in d e rin g visu a liza t io n (TECH FIG 1 C).
Pro t e ct in g t h e Scia t ic Ne rve
■ Th e scia t ic n e rve is id e n t ifie d . Th is ca n b e d ifficu lt
o w in g t o t h e co n d it io n s o f t h e t ra u m a t ize d t issu e s;
o ft e n it w ill b e e a sie st t o id e n t ify t h e n e rve in a n a re a
o f h e a lt h y t issu e , su ch a s a t t h e le ve l o f t h e q u a d ra t u s
fe m o ris.
■ If o ve ra ll visu a liza t io n is in a d e q u a t e a t t h is p o in t , t h e
g lu t e u s m a xim u s t e n d o n ca n b e d ivid e d a t it s in se rt io n
o n t h e fe m u r. A cu ff o f t issu e is le ft o n t h e fe m u r so a n
a d e q u a t e re p a ir ca n la t e r b e p e rfo rm e d .
■ Wit h t h e p o st e rio r a sp e ct o f t h e g lu t e u s m e d iu s t e n d o n
re t ra ct e d a n t e rio rly, t h e p irifo rm is t e n d o n ca n b e id e n t i-
fie d (TECH FIG 2 A).
■ It ca n b e h e lp fu l t o in t e rn a lly ro t a t e t h e le g t o p u t t h e
sh o rt e xt e rn a l ro t a t o rs a n d t h e p irifo rm is o n st re t ch
t o a ssist w it h id e n t ifica t io n .
■ In so m e ca se s t h e sh o rt e xt e rn a l ro t a t o rs h a ve b e e n
a vu lse d b y t h e d islo ca t io n .
■ It is e a sie r t o p a lp a t e t h e e d g e s o f t h e p irifo rm is t e n -
d o n w it h a fin g e r a n d t h e n p a ss a fin g e r b e h in d t h e
t e n d o n t o b e t t e r iso la t e it .
319
TECH FIG 1 • A. Ko ch e r-La n g e n b e ck in cisio n .
TECHNIQUES
B. Th e su rg e o n d ivid e s t h e fa scia a n d t h e n sp lit s
t h e g lu t e u s m a xim u s m u scle . C. Wit h t h e
Ch a rn le y re t ra ct o r in p la ce , t h e su rg e o n e xcise s
t h e b u rsa if it o b st ru ct s visu a liza t io n .
■ Th e su rg e o n co n firm s t h a t t h e co rre ct m u scle h a s
b e e n id e n t ifie d b y fo llo w in g it s p a t h b a ckw a rd a n d
t o w a rd t h e g re a t e r scia t ic n o t ch .
■ On ce iso la t e d , t h e t e n d o n is t a g g e d a n d d ivid e d a t it s
a t t a ch m e n t t o t h e fe m u r (TECH FIG 2 B). Th is t a g su -
t u re is u se d t o re t ra ct t h e m u scle p o st e rio rly (TECH
FIG 2 C).
■ Wit h t h e p irifo rm is re t ra ct e d , t h e scia t ic n e rve sh o u ld
n o w b e e a sily visib le , lyin g o ve r t h e sh o rt e xt e rn a l ro t a -
t o rs. Th e su rg e o n visu a lly e xa m in e s t h e scia t ic n e rve fo r
a n y co n t u sio n o r la ce ra t io n .
■ Ne xt , t h e su rg e o n id e n t ifie s t h e t e n d o n co m p o se d o f t h e
su p e rio r a n d in fe rio r g e m e lli a n d t h e o b t u ra t o r in t e rn u s.
■ An o t h e r t a g su t u re is p a sse d t h ro u g h t h is t e n d o n ,
a n d it is re le a se d fro m t h e fe m u r.
■ Sin ce t h e p irifo rm is lie s su p e rficia l t o t h e scia t ic n e rve ,
it w ill n o t re t ra ct o r p ro t e ct t h e n e rve .
■ In co n t ra st , t h e g e m e lli a n d t h e o b t u ra t o r in t e rn u s
ca n b e u se d t o e ffe ct ive ly p ro t e ct a n d re t ra ct t h e sci-
a t ic n e rve p o st e rio rly (TECH FIG 2 D).
■ By p u llin g u p w a rd o n t h is t a g st it ch –t e n d o n , t h e su r-
g e o n ca n p a ss a fin g e r in t o b o t h t h e g re a t e r a n d le sse r
scia t ic n o t ch e s, b e n e a t h t h e m u scle , a n d t h e re fo re t h e
n e rve , m a kin g a p a t h .
■ A scia t ic n e rve re t ra ct o r ca n t h e n b e p la ce d a lo n g t h is
p a t h , in t o e it h e r n o t ch . (Ca re sh o u ld b e e xe rcise d if a
re t ra ct o r m u st b e p la ce d in t o t h e g re a t e r scia t ic n o t ch
d u e t o t h e p re se n ce o f t h e su p e rio r g lu t e a l n e u ro va s-
cu la r b u n d le .)
■ By con t in u o u sly ch e ckin g t h at t h e e xt ern al ro t at o rs are
above the ret ract or, t he surg eon ca n ensure t ha t th e
scia tic n e rve is pro t e cted . In ad d it io n t o p ro te ct in g t he
n erve, t h is h elp s to ret ract t h e so ft t issu es an d p ro vides
excellent visua lizat io n of t he re troacet abular surfa ce .
■ Th e p o st e rio r h ip ca p su le , t h e fra ct u re lin e , a n d t h e p o s-
t e rio r w a ll fra g m e n t a re n o w w it h in t h e su rg ica l fie ld
(TECH FIG 2 E).
 320 Se c t i o n III PELVIS AND HIP
TECHNIQUES

A B

C D

TECH FIG 2 • A. By ret ract in g th e g lu t eu s m ed iu s

a n t erio rly, t h e p irifo rm is an d o b tura t or in te rn u s t e n do n s
a re re vea led . B. Pirifo rm is a nd obt ura tor int ernus t en-
d o n s are t ag g ed an d rele ased fro m th eir in se rt io n o n t h e
p ro ximal fem u r. C. Usin g th e ta g su t u res, t h e p irifo rm is
t en d o n ca n b e ret ra ct ed p o st erio rly. D. Ret ra ct in g t h e
p irifo rmis allo ws id en tificat io n o f t h e sciat ic n erve rest-
in g on t he short ext ern al ro ta tors. By using th e t ag
su t u re on th e o b tu ra t o r in t e rn u s te n d o n to re tra ct it
p o st eriorly, th e sciat ic n erve w ill b e p ro t ect ed a n d safe ly
re t ra ct ed o u t o f t h e o p e ra tive fie ld . E. Fe mo ra l h ead a n d
E p o st erior w all fra g me n ts a re visib le.

FRACTURE SITE EXPOSURE AND DÉBRIDEMENT

■ Wit h t h e re t ro a ce t a b u la r su rfa ce n o w e xp o se d , t h e fra c-
t u re sit e a n d t h e jo in t m u st b e d é b rid e d a n d p re p a re d .
■ By re m o vin g a n y re sid u a l h e m a t o m a fro m t h e fie ld ,
t h e p o st e rio r w a ll fra g m e n t a n d t h e p o st e rio r co lu m n
w ill b e co m e e a sily visib le .
■ Th e p o st e rio r co lu m n is in sp e ct e d ca re fu lly fo r a n y
n o n d isp la ce d t ra n sve rse fra ct u re lin e . It is b e t t e r t o
re co g n ize t h is e a rly t h a n t o d isp la ce it la t e r.
■ Th e su rg e o n “ b o o ks o p e n ” t h e fra ct u re sit e b y flip p in g
t h e w a ll p ie ce o u t in t o t h e w o u n d .
■ Th e p o st e rio r w a ll p ie ce w ill t yp ica lly re m a in a t t a ch e d
b y t h e ca p su le a n d so m e p e rio st e u m . Th e su rg e o n
st rip s a w a y fro m t h e w a ll a n y p e rio st e u m t h a t m a y b e
p re ve n t in g it s m o b iliza t io n , t a kin g ca re n o t t o in ju re
t h e la b ra l a t t a ch m e n t s. Th e su rg e o n m u st b e su re t o
p e e l a ll t h e p e rio st e u m o ff t h e fra ct u re e d g e s. Dire ct
visu a liza t io n o f in t e rd ig it a t io n a t t h e fra ct u re sit e is
vit a l in ju d g in g a n a t o m ic re d u ct io n , a n d t h e ra t e o f
n o n u n io n is lo w a ft e r re d u ct io n a n d fixa t io n o f a c-
e t a b u la r fra ct u re s. 8
■ It is o ft e n n e ce ssa ry t o sh a rp ly d isse ct t h e o ve rlyin g
g lu t e u s m in im u s m u scle fro m t h e p o st e rio r w a ll t o
a llo w m o b iliza t io n .
■ Th e fe m o ra l h e a d w ill b e e a sily visu a lize d o n ce t h e
w a ll is m o b ilize d a n d t h e in t e rio r o f t h e h ip jo in t is
in sp e ct e d .
■ An y d a m a g e t o t h e fe m o ra l h e a d is n o t e d .
■ In t ra -a rt icu la r fra g m e n t s ca n b e re m o ve d a n d t h e
jo in t ca n b e irrig a t e d t o re m o ve a n y o t h e r d e b ris.
■ Wit h t h e fra ct u re t a b le u se d t o p u ll t ra ct io n , t h e
jo in t ca n b e d ist ra ct e d , w h ich w ill a ssist w it h jo in t
d é b rid e m e n t . If t h e fra ct u re t a b le a llo w s su ch m o ve -
m e n t , t h e h ip ca n b e fle xe d t o a ssist w it h fra g m e n t
re m o va l.
■ Th e in t a ct se g m e n t m u st b e p re p a re d in a sim ila r
fa sh io n .
 Ch a p t e r 3 6 ORIF OF THE POSTERIOR WALL OF ACETABULUM
■ The su rge on st rips any add it iona l perioste um and soft
tissue t hat re m a in s a tt a ch ed to th e in t a ct re troa ce t ab -
u lar surface at t he fra ctu re ed ge . Aga in , t his are a will
la te r b e in sp e ct ed fo r fra ct u re lin e in te rd ig it at io n .
■ An y so ft t issu e is e le va t e d fro m t h e t o p o f t h e is-
ch iu m . Th is w ill p re p a re t h e isch iu m t o re ce ive t h e re -
co n st ru ct io n p la t e .
■ Th e so ft t issu e s su p e ro la t e ra l t o t h e a ce t a b u lu m , o n
t h e o u t e r t a b le o f t h e iliu m , m u st b e e le va t e d in
p re p a ra t io n t o re ce ive t h e p ro xim a l a sp e ct o f t h e
FRACTURE REDUCTION
Re d u ct io n o f M a r g in a l Im p a ct io n
■ Ca re fu l d isse ct io n o f t h e p o st e rio r w a ll fra g m e n t s a n d
t h e in t a ct p o rt io n o f t h e p e lvis is n e ce ssa ry fo r a n a ccu -
ra t e re d u ct io n .
■ Pre o p e ra t ive re vie w o f a ll t h e ra d io g ra p h ic im a g e s w ill
n o rm a lly id e n t ify a n y m a rg in a l im p a ct io n , w h ich m u st b e
re d u ce d .
■ Wh e n t h e fe m o ra l h e a d is sit t in g in t h e a ce t a b u lu m , t h e
a re a s o f im p a ct io n ca n b e re d u ce d t o t h e h e a d .
■ An o st e o t o m e is p la ce d d e e p t o t h e d e p re sse d su b -
ch o n d ra l b o n e . Ge n t le m a lle t in g a llo w s t h e o st e o t o m e
b e n e a t h t h e im p a ct e d b o n e . By m a n ip u la t in g t h e b o n e
a n d it s o ve rlyin g ca rt ila g e , t h e a rt icu la r su rfa ce is re -
d u ce d t o t h e fe m o ra l h e a d w it h it s in t a ct ca rt ila g e .
■ On ce re d u ce d , t h e re w ill b e a n e m p t y sp a ce d e e p t o t h e
su b ch o n d ra l b o n e w h e re t h e o st e o t o m e e n t e re d a n d
t h e o rig in a l b o n e co lla p se d . Th is a re a is p a cke d w it h a n
o st e o co n d u ct ive b o n e vo id fille r t h a t ca n p ro vid e st ru c-
t u re a n d p re ve n t re co lla p se . Op t io n s in clu d e a u t o g e -
n o u s ca n ce llo u s b o n e , a llo g ra ft ca n ce llo u s b o n e ch ip s,
a n d ca lciu m su lfa t e b o n e g ra ft su b st it u t e .
■ As in o t h e r a re a s o f t h e b o d y, o ve rre d u ct io n is b e t t e r
t h a n u n d e rre d u ct io n , a s o ft e n t h e re is se t t lin g .
■ On ce t h e fra ct u re b e d h a s b e e n m e t icu lo u sly d é b rid e d o f
fra ct u re h e m a t o m a a n d so ft t issu e , in t e rd ig it a t io n o f t h e
p o st e rio r w a ll t o t h e re m a in in g in t a ct re t ro a ce t a b u la r
su rfa ce ca n b e visu a lize d .
Re d u cin g t h e Po st e rio r Wa ll Fra g m e n t
■ Wit h t h e m a rg in a l im p a ct io n re d u ce d , a t t e n t io n is
t u rn e d t o re d u cin g t h e p o st e rio r w a ll fra g m e n t in t o it s
b e d in t h e in t a ct a ce t a b u lu m .
INTERNAL FIXATION
Pro visio n a l Fixa t io n
■ On ce t h e p o st e rio r w a ll p ie ce s a re re d u ce d , p ro visio n a l
fixa t io n t o h o ld t h e fra g m e n t in p la ce ca n m a ke t h e
o ve ra ll p ro ce d u re e a sie r.
■ Op t io n s fo r p ro visio n a l fixa t io n in clu d e e it h e r in t e r-
fra g m e n t a ry la g scre w s (2.7 o r 3.5 m m ) o r Kirsch n e r
w ire s.
■ By u sin g a b a ll sp ike p u sh e r, t h e fra ct u re fra g m e n t is st a -
b ilize d w it h in it s b e d , a n d a Kirsch n e r w ire o r a la g scre w
ca n b e p la ce d t o h o ld t h e re d u ct io n .
321
p la t e . In t h is a re a , it is o ft e n n e ce ssa ry t o e le va t e t h e
TECHNIQUES
o ve rlyin g g lu t e u s m in im u s m u scle .
■ It is safe t o p a ss an e le va to r u n d e r t h e a b d u cto r
mu scle s, sta yin g o n b o n e , do w n to wa rd t he ilia c
cre st a t t h e le ve l o f th e a n t e rio r su p e rio r ilia c sp in e .
A sp ike d Ho h m a n n re tra cto r in se rt e d in t h is p a t h
ca n a lso a ssist w ith re tra ctio n a n d visu a liza t io n .
■ Wit h t h e fra ct u re b e d , t h e jo in t , t h e w a ll fra g m e n t , a n d
t h e in t a ct se g m e n t d é b rid e d , fra ct u re re d u ct io n is t h e
n e xt st e p .
■ Th e w a ll fra g m e n t is flip p e d in t o it s b e d .
■ Usin g a b a ll sp ike p u sh e r, t h e su rg e o n g e n t ly m a -
n ip u la t e s t h e p ie ce u n t il a sm o o t h , co n ve x re t ro -
a ce t a b u la r su rfa ce w it h n o e xt e rn a l st e p -o ffs is
o b t a in e d . If t h is ca n n o t b e p ro d u ce d , t h e w a ll
p ie ce is flip p e d o u t o f it s b e d a g a in a n d t h e su rg e o n
lo o ks fo r a ca u se o f t h e m a lre d u ct io n . If t h e fra g -
m e n t d o e s n o t re d u ce p e rfe ct ly a t t h e re t ro a ce t a b u -
la r su rfa ce , it w ill n o t b e re d u ce d p e rfe ct ly a t t h e
jo in t .
■ On ce re in sp e ct io n is co m p le t e , t h e w a ll is re in t ro -
d u ce d t o it s b e d . Th e p ie ce is m a n ip u la t e d in t o p la ce .
Ge n t le p e rsu a sio n w it h a m a lle t ca n h e lp t h e fra g -
m e n t fin d it s h o m e , e sp e cia lly if m a rg in a l im p a ct io n
re d u ct io n re q u ire d g ra ft in g .
■ Pro visio n a l fixa t io n is p la ce d n e xt . Th is ca n h o ld
t h e fra g m e n t in p la ce w h ile t h e su rg e o n e va lu a t e s
t h e re d u ct io n a n d p la ce s t h e d e fin it ive in t e rn a l
fixa t io n .
■ If m u lt ip le w a ll fra g m e n t s e xist , ca re fu l p la n n in g o f t h e
o rd e r o f re d u ct io n is vit a l. Oft e n ce rt a in p ie ce s m u st b e
re d u ce d first , a s t h e co rt ica l sh e ll o f o t h e r fra g m e n t s
m a y n e e d t o re st o u t sid e o f t h e ca n ce llo u s b o n e
a t t a ch e d t o it s n e ig h b o rin g fra g m e n t . Wit h o u t a t t e n -
t io n t o t h is d e t a il, a n a n a t o m ic re d u ct io n m a y b e
im p o ssib le .
■ Pro vision ally holding a m ultifra gm ent ed post erior w all
ca n b e d ifficu lt . Mu lt ip le Kirsch n e r wire s o r sp rin g
p la te s m a y b e n e ed e d. So m e t ime s, o n ly t h e d e finitive
fixa tio n ca n b e use d .
■ We p re fe r t o u se 2.7-m m la g scre w s. Wit h t h e se
scre w s, t h e h e a d s sit flu sh w it h t h e b o n y co rt e x a n d
d o n o t in t e rfe re w it h t h e su b se q u e n t p la ce m e n t o f
t h e d e fin it ive fixa t io n .
■ An a lt e rn a t ive t o a la g scre w is t h e u se o f o n e o r m u l-
t ip le Kirsch n e r w ire s. If Kirsch n e r w ire s a re u se d , t h e
re co n st ru ct io n p la t e ca n b e p la ce d a ro u n d t h e w ire s
w it h o u t d ifficu lt y, a n d su b se q u e n t re m o va l is e a sy.
■ Occa sio n a lly, w h e n t h e p o st e rio r w a ll p ie ce is sm a ll o r
co m m in u t e d , la g scre w s a n d Kirsch n e r w ire s m a y n o t b e
 322 Se c t i o n III PELVIS AND HIP
p o ssib le . A sp rin g p la t e ca n b e u se d (sim ila r t o w h e n p re -
TECHNIQUES
ve n t in g m e d ia l w a ll “ kick-u p ” ).
■ Th e e n d h o le o f a o n e -t h ird t u b u la r p la t e is cu t
in t o a V, cre a t in g t in e s. Th e p la t e is b e n t so t h e
t in e s ca n e ffe ct a re d u ct io n . Th is p la t e ca n b e u se d
a s p ro visio n a l fixa t io n t o h o ld a sm a ll w a ll fra g -
m e n t in p la ce o r a s a sp rin g p la t e t o p re ve n t t h e
m e d ia l a sp e ct o f a la rg e w a ll fra g m e n t fro m “ kick-
in g u p .”
■ Th e t in e s a n d a p o rt io n o f t h e p la t e a re p la ce d
o ve r t h e w a ll fra g m e n t . Th e fra ct u re e d g e is
sp a n n e d w it h t h e re m a in in g p la t e . Eit h e r o f t h e re -
m a in in g h o le s o f t h e p la t e ca n b e u se d fo r scre w
p la ce m e n t , d e p e n d in g o n t h e size o f t h e w a ll b e in g
st a b ilize d .
■ Th e p la t e is p o sit io n e d so it is p o ssib le t o d rill o u t sid e
o f t h e jo in t . On ce se cu re d , t h is sp rin g p la t e w ill p re -
ve n t t h e w a ll p ie ce (if sm a ll) o r t h e m e d ia l fra ct u re
e d g e (if t h e w a ll p ie ce is la rg e ) fro m “ kickin g u p ” o r
d isp la cin g .
Re co n st ru ct io n Pla t e St a b iliza t io n
■ No w t h a t t h e w a ll p ie ce is re d u ce d , it is d e fin it ive ly st a -
b ilize d w it h a 3.5-m m p e lvic re co n st ru ct io n p la t e (TECH
FIG 3 ).
■ Mo st co m m o n ly, a slig h t ly u n d e rb e n t , co n t o u re d e ig h t -
h o le p la t e is u se d . It is fa sh io n e d t o sit a t t h e e d g e o f
t h e p o st e rio r w a ll, fro m t h e t o p o f t h e isch ia l t u b e ro s-
it y t o t h e b o n e p o st e rio r t o t h e a n t e rio r in fe rio r ilia c
sp in e .
■ By u sin g a fin g e r o r a Kirsch n e r w ire t o fe e l t h e e d g e o f
t h e w a ll a n d t h e la b ru m , t h e su rg e o n ca n e n su re t h a t
t h e re is n o p o rt io n o f t h e p la t e re st in g o n t h e la b ru m o r
in t h e jo in t . Pla ce m e n t in t h is lo ca t io n p ro vid e s t h e
g re a t e st b io m e ch a n ica l a d va n t a g e in b u t t re ssin g t h e
w a ll.
■ It is n o t u n u su a l fo r t h e re co n st ru ct io n p la t e t o sit o n t o p
o f t h e h e a d s o f t h e la g scre w s o r re st o ve r t h e t in e s o f
t h e sp rin g p la t e .
■ Wit h t h e p la t e a d e q u a t e ly co n t o u re d a n d p o sit io n e d , it
is in it ia lly fixe d t o t h e p e lvis a t t h e le ve l o f t h e isch ia l
t u b e ro sit y.
TECH FIG 3 • Th e su rg e o n re d u ce s t h e p o st e rio r w a ll p ie ce in
t h e fra ct u re b e d a n d fixe s it w it h a b u t t re ss p la t e p la ce d a lo n g
t h e e d g e o f t h e w a ll.
■ Th e su rg e o n d rills in t o scre w h o le n o . 2 fro m t h e d is-
t a l a sp e ct o f t h e p la t e , w h ich sh o u ld b e re st in g w it h in
t h e re ce ss a t t h e t o p o f t h e isch ia l t u b e ro sit y. Th e su r-
g e o n a im s d ist a lly a n d m e d ia lly, in t o t h e p ro xim a l
p o rt io n o f t h e isch iu m . Th e re w ill b e g o o d b o n e in
t h is lo ca t io n .
■ Ne xt , t h e p la t e p o sit io n is ch e cke d a g a in , a t t h e
e d g e o f t h e w a ll b u t n o t im p in g in g o n t h e la b ru m ,
a n d t h e n a b a ll sp ike p u sh e r is p la ce d in t o scre w
h o le n o . 8.
■ Sin ce t h e p la t e is u n d e rb e n t , u se o f a b a ll sp ike
p u sh e r a n d t h e first p ro xim a l scre w , p la ce d in scre w
h o le n o . 7, w ill co m p re ss t h e p la t e t o t h e p o st e rio r
w a ll, fu rt h e r e n h a n cin g re d u ct io n , fixa t io n , a n d st a -
b ilit y o f t h e p o st e rio r w a ll fra g m e n t .
■ Th e su rg e o n m u st t a ke ca re n o t t o vio la t e t h e
jo in t o r t h e fe m o ra l h e a d w h ile d rillin g . In m o st
p a t ie n t s, scre w h o le s n o . 7 a n d n o . 8 a re p ro xi-
m a l t o t h e jo in t e ve n w h e n d rillin g “ st ra ig h t ”
a cro ss.
■ Th e p la t e w ill n o w b e h o ld in g t h e re d u ct io n , so if a n y
Kirsch n e r w ire s w e re u se d t h e y ca n b e re m o ve d .
■ Th e su rg e o n sh o u ld n o t e w h e t h e r t h e m e d ia l a sp e ct
o f t h e fra ct u re fra g m e n t sp rin g s u p w it h re m o va l o f
t h e Kirsch n e r w ire . If it d o e s, fu rt h e r fixa t io n w ill b e
re q u ire d in a d d it io n t o t h e p rim a ry re co n st ru ct io n
p la t e .
■ Th is is a n e xce lle n t t im e t o o b t a in C-a rm im a g e s t o e va l-
u a t e t h e re d u ct io n a n d t o e n su re t h a t t h e scre w s h a ve
b e e n p la ce d e xt ra -a rt icu la rly.
■ On e o r t w o a d d it io n a l scre w s sh o u ld b e p la ce d in t h e
p ro xim a l e n d o f t h e p la t e , a n d a t le a st o n e m o re scre w
n e e d s t o b e in se rt e d in t o t h e d ist a l p a rt o f t h e p la t e , a t
t h e m o st d ist a l h o le .
■ Th e m o st d ist a l scre w ca n b e p la ce d in t o t h e isch iu m ,
t o w a rd t h e t u b e ro sit y, w h e re o n e sh o u ld fin d g re a t
b o n y p u rch a se .
Ch e ckin g t h e Fixa t io n
■ On ce t h e fin a l scre w s a re p la ce d , t h e su rg e o n e va lu a t e s
t h e re t ro a ce t a b u la r su rfa ce , e n su rin g t h a t t h e m e d ia l a s-
p e ct o f t h e fra ct u re p ie ce h a s n o t “ kicke d u p .”
■ If t h e m e d ia l w a ll kicks u p , it m u st b e fu rt h e r
st a b ilize d .
■ A la g scre w ca n b e u se d in t h e sa m e w a y a s p re vi-
o u sly d e scrib e d .
■ A t h re e -h o le o n e -t h ird t u b u la r p la t e sp rin g p la t e is
a n o t h e r o p t io n , a s d e scrib e d .
■ On ce t h e m e d ia l a sp e ct o f t h e w a ll is re d u ce d a n d st a -
b ilize d , t h e sm o o t h co n ve xit y o f t h e re t ro a ce t a b u la r
su rfa ce sh o u ld o n ce a g a in b e re st o re d .
■ An y t ra ct io n t h a t h a s b e e n a p p lie d t o t h e e xt re m it y is
re m o ve d .
■ Fin a l C-a rm im a g e s a re o b t a in e d t o b e su re t h a t t h e jo in t
is re d u ce d a n d co n g ru e n t a n d t h a t a ll scre w s a re o u t o f
t h e jo in t .
■ Th e p ro xim a l scre w s a re b e st se e n w it h a n o b t u ra t o r
o b liq u e vie w .
■ Th e d ist a l scre w s a re b e st co n firm e d a s e xt ra -a rt icu la r
w it h t h e ilia c o b liq u e vie w .
 Ch a p t e r 3 6 ORIF OF THE POSTERIOR WALL OF ACETABULUM 323

WOUND CLOSURE
■ Th e w o u n d is co p io u sly irrig a t e d .
■ Th e su rg e o n ch e cks t h e in t e g rit y a n d co n d it io n o f t h e sci-
a t ic n e rve o n e fin a l t im e .
■ A He m o va c d ra in is p la ce d o n t h e b o n e , a lo n g t h e p o st e -
rio r a sp e ct o f t h e p o st e rio r w a ll. A lo n g p a t h w ill h e lp
p re ve n t in a d ve rt e n t p u llo u t o f t h e d ra in a n d w ill a llo w
h e m a t o m a t o d ra in o ve r a lo n g d ist a n ce .
■ Th e first st a g e o f clo su re is t o re a t t a ch t h e p irifo rm is a n d
t h e e xt e rn a l ro t a t o rs. Th is ca n b e a cco m p lish e d in se ve ra l
d iffe re n t w a ys, in clu d in g d rill h o le s in t o t h e g re a t e r
t ro ch a n t e r o r su t u rin g t o t h e g lu t e u s m e d iu s t e n d o n .
Th e a u t h o r p re fe rs t o su t u re t o t h e t e n d o n , a sit e sh o rt e r
t h a n t h e o rig in a l in se rt io n sit e , t o d e cre a se t h e risk o f
p u llo u t o r fa ilu re o f t h e re p a ir.
TECHNIQUES
■ If t h e g lu t e u s m a xim u s t e n d o n w a s re le a se d , it is re -
p a ire d n e xt . Typ ica lly, t h e t e n d o n e d g e s a re e a sily visu a l-
ize d a n d su t u re d t o e a ch o t h e r.
■ An y in ju re d o r d e vit a lize d m u scle sh o u ld b e fu rt h e r
d é b rid e d t o d e cre a se t h e risk o f h e t e ro t o p ic o ssifica t io n .
■ Ne xt , t h e fa scia la t a is id e n t ifie d a n d clo se d w a t e rt ig h t .
■ Ro u t in e so ft t issu e clo su re is p e rfo rm e d . We p re fe r t o d e -
cre a se d e a d sp a ce , a n d t h e re fo re a re a s fo r h e m a t o m a t o
co lle ct , w it h a la ye re d clo su re , w h e n p o ssib le , b e t w e e n
t h e fa scia la t a a n d t h e skin .
■ We p re fe r t o o b t a in a n AP p e lvis ra d io g ra p h w it h t h e p a -
t ie n t su p in e o n t h e re g u la r h o sp it a l b e d t o in sp e ct t h e re -
d u ct io n , t h e fixa t io n , a n d t h e jo in t b e fo re e xt u b a t io n
(TECH FIG 4 ).

A B C

TECH FIG 4 • Po st o p e ra t ive AP (A) a n d Ju d e t (B,C) ra d io g ra p h s.

PEARLS AND PITFALLS

Ta b le a n d
p o sit io n in g
Int erna l fixat io n
Su p e rio r p o st e rio r
w a ll fra ct u re s
Imaging
Tra n sve rse fra ct u re
Me d ia l w a ll kick-u p
■ Usin g a fra ct u re t a b le , p ro n e p o sit io n in g , a n d d ist a l fe m o ra l ske le t a l t ra ct io n re d u ce s t h e risk o f in ju rin g
t h e scia t ic n e rve . Th e h ip is e xt e n d e d a n d t h e kn e e fle xe d t o a t le a st 80 d e g re e s in t h e p ro n e p o sit io n
o n t h e t a b le a t a ll t im e s, a llo w in g t h e su rg e o n t o co n ce n t ra t e o n t h e p ro ce d u re . Fre e d o m is a llo w e d in
t h e in t e rn a l–e xt e rn a l ro t a t io n p la n e d u rin g t h e p ro ce d u re t o a id in so ft t issu e id e n t ifica t io n a n d m a n ip -
u la t io n a n d t o a llo w d iffe re n t ia t io n b e t w e e n t h e fe m o ra l h e a d a n d t h e e d g e o f t h e p o st e rio r w a ll.
■ The re const ruction plat e is pla ced at t he la te ra l edg e of t he poste rior w all t o ga in m axim um but t ressing
ca p a b ilit y. A Kirsch n e r w ire is u se d t o fe e l th e e d g e o f th e w a ll a n d t h e b e g in n in g o f th e la b ru m t o cle a rly
d e fin e lo ca t io n if un a ble t o visu a lize w it h ce rt a in t y. The p la t e is u n d e rbe nt t o a ssist w ith th e re du ct io n.
■ Th e se fra ct u re s sh o u ld b e st a b ilize d w it h a su p e rio r a n t ig lid e p la t e in a d d it io n t o t h e t ra d it ion a l b u t t re ss
p la t e .
■ In traop erative C-arms o ften ro tate to on ly 30 deg rees “over th e t op .” To o b tain an adeq u ate iliac o bliq u e
imag e, the su rg eon can p ush u p o n t he ant erio r sup erio r iliac sp in e, wh ich w ill further ro tate th e p elvis
an d pro vid e a mo re familiar rad io g raph ic im ag e. Th e surg eo n mu st b e certain th at all screw s are o u t of th e
jo in t! With a co n vex joint, if th e screw is co mpletely ou t o n o ne image, it is lo cated o u tsid e of t he jo in t.
■ Th e su rg e o n m u st lo o k fo r it !
■ Oft e n t h e m e d ia l a sp e ct o f t h e p o st e rio r w a ll p ie ce w ill “ kick u p ” w h e n t h e p la t e a lo n g t h e e d g e o f t h e
w a ll is se cu re d . To p re ve n t t h is, t h e su rg e o n m u st first lo o k fo r it a n d re co g n ize it . Th e n , a t h re e -h o le
o n e -t h ird t u b u la r p la t e , w it h o n e d ist a l h o le cu t in t o a V t o a ct a s a h o o k (o r a t u b u la r 2.7 m in ifra g m e n t
p la t e ), ca n b e p la ce d a lo n g t h is m e d ia l a sp e ct o f t h e fra ct u re . On e o r t w o scre w s ca n se cu re t h is p la t e ,
w h ich w ill fu n ct io n a s a sp rin g p la t e a n d p re ve n t t h e m e d ia l w a ll fro m kickin g u p . Th is w ill h e lp re st o re
t h e sm o o t h co n ve xit y o f t h e re t ro a ce t a b u la r su rfa ce .
324 Se c t i o n III PELVIS AND HIP
POSTOPERATIVE CARE
■ A drain is maintained until drainage measures less than 30
cc in a 24-hour period.
■ Antibiotics are prophylactically used until 24 hours after
the drain is discontinued or until the wound is completely
free of any drainage.
■ O ften hip wounds will have serous drainage for several
days postoperatively. It is the author’s opinion that this sig-
nifies that the wound is not sealed and therefore the patient
should continue to receive prophylactic antibiotics.
■ Indomethacin 25 mg is given orally three times a day to pre-
vent heterotopic ossification.
■ Chemical deep venous thrombosis prophylaxis is given at
the surgeon’s discretion, plus sequential compression boots
for mechanical prophylaxis.
■ Physical therapy restrictions
■ N o active range of motion at the hip
■ Passive range of motion only; this is easily accomplished
with use of a continuous passive motion (CPM ) machine.
■ Any necessary flexion limit will be determined by intraop-
erative evaluation.
■ Footflat weight bearing for 3 months is instituted immedi-
ately and patients are allowed to get out of bed the next day,
once they understand their limitations.
■ This weight-bearing restriction (about 30 pounds) un-
loads the weight of the extremity from the hip joint.
■ By choosing footflat weight bearing and no active muscle
contraction, the joint reaction forces of the hip joint are de-
creased to attempt to further protect the internal fixation
and cartilage during the reparative and healing process.
■ At the 3-month mark, with evidence of callus on the radi-
ographs, weight bearing will be advanced to partial weight
bearing, with the patient and the physical therapist advancing
further as tolerated.
■ Strengthening and gait training will begin at this time,
with special concentration on the hip abductors.
OUTCOMES
■ The outcome of an acetabular fracture after surgical inter-
vention correlates with the quality of reduction and avoidance
of complications.
■ Although regarded as the simplest type of acetabular frac-
ture, most posterior wall fractures are either comminuted or
have marginal impaction, making anatomic reduction difficult
and clinical outcomes worse than for most more complex, as-
sociated types of acetabular fractures.1,13
■ Letournel reported only a 93.7% perfect reduction rate for
posterior wall fractures and an 82% good to excellent clinical
outcome.6
■ M atta reported 100% anatomic reduction of posterior
wall fractures in his series but only 68% good to excellent
clinical outcome. 8 Similarly, M oed et al had 97% perfect re-
ductions and 89% good to excellent clinical outcomes for
their series. 12
COMPLICATION S
■ Posttraumatic osteoarthritis was reported in 17% (97 of
569) of Letournel and Judet’s patients operated on within 3
weeks of injury with at least 1 year of follow-up.6 It occurred
in 10.2% (43 of 418) of hips after perfect reductions and in
35.7% (54 of 151) of hips after imperfect reductions. The
incidence of osteoarthritis for posterior wall fractures was
22.7% (22 of 97). It occurred in 16% (19 of 119) patients
with perfect reductions. The rate after perfect reductions is
higher compared to perfect reductions for all types of acetab-
ular fractures (16% versus 10.2% respectively).
■ M atta reported a 32% (7 of 22) clinical failure rate de-
spite perfect reduction of posterior wall fractures, which
was higher than for any other fracture pattern in his
series. 8
■ Infection after acetabular surgery is reported in about
2% to 5% of patients. 6,8,9 It can be intra-articular or extra-
articular, depending on the approach used. The presence of a
soft tissue injury, such as a M orel-Lavallée, can increase the
risk of infection. 4,6
■ H eterotopic ossification occurs after use of the extended il-
iofemoral approach, the Kocher-Langenbeck approach, or the
ilioinguinal approach when it is combined with elevation of the
external fossa. Letournel and Judet reported it in 20% (41 of
208) of operatively treated posterior wall fractures.6 They also
reported a decrease from 24.6% (123 of 499) in all cases via all
approaches before treatment to prevent formation to 10.2% (5
of 49) in patients receiving indomethacin for prophylaxis to
0% (0 of 29) in patients receiving both indomethacin and radi-
ation therapy.
■ Indomethacin is generally considered safe and effective,
although a randomized trial has questioned its utility in
prevention.10
■ The unknown long-term complications associated with
radiation therapy, however, make it generally not recom-
mended for isolated posterior wall fractures in young,
healthy patients.
■ Avascular necrosis of the femoral head must not be con-
fused with rapid mechanical wear or deterioration due to
osteochondral injury. Epstein reported a rate of 5.3% in oper-
atively treated posterior wall fractures.3 Letournel and Judet
reported a 7.5% incidence after posterior dislocation (17 of
227) and a total of 22 of 569 (3.1% ) fractures operated on
within the first 3 weeks after injury.6
■ The rate of iatrogenic nerve injury, typically the sciatic
nerve, is reported to be about 2% (range 2% to 18% ) in the
hands of experienced surgeons.6,9,11
REFEREN CES
1. Baumgaertner M . Fractures of the posterior wall of the acetabulum.
J Am Acad O rthop Surg 1999;7:54–65.
2. Calkins M , Z ych G, Latta L, et al. Computed tomography evaluation
of stability in posterior fracture dislocation of the hip. Clin O rthop
Relat Res 1988;227:152–163.
3. Epstein H . Posterior fracture-dislocations of the hip: long-term fol-
low-up. J Bone Joint Surg Am 1974;56:1103–1127.
4. H ak D, O lson S, M atta J. Diagnosis and management of closed inter-
nal degloving injuries associated with pelvic and acetabular fractures:
the M orel-Lavallee lesion. J Trauma 1997;42:1046–1051.
5. Keith J, Brashear H , Guilford W. Stability of posterior fracture-dislo-
cations of the hip: quantitative assessment using computed tomogra-
phy. J Bone Joint Surg Am 1988;70A:711–714.
6. Letournel E, Judet R. Fractures of the Acetabulum. Berlin: Springer-
Verlag, 1993.
7. Lieberman J, Altchek D, Salvati E. Recurrent dislocation of a hip with
a labral lesion: treatment with a modified Bankart-type repair. J Bone
Joint Surg Am 1993;75A:1524–1527.
8. M atta J. Fractures of the acetabulum: accuracy of reduction and clin-
ical results in patients managed operatively within three weeks after
the injury. J Bone Joint Surg Am 1996;78A:1632–1645.
 Ch a p t e r 3 6 ORIF OF THE POSTERIOR WALL OF ACETABULUM
9. M atta J, Anderson L, Epstein H , et al. Fractures of the acetabulum: a
retrospective analysis. Clin O rthop Relat Res 1986;205:230–240.
10. M atta J, Siebenrock K. Does indomethacin reduce heterotopic bone
formation after operations for acetabular fractures? J Bone Joint Surg
Br 1997;79B:959–963.
11. M iddlebrooks E, Sims S, Kellam J, et al. Incidence of sciatic nerve
injury in operatively treated acetabular fractures without soma-
tosensory evoked potential monitoring. J O rthop Trauma 1997;11:
327–329.
12. M oed B, Willson Carr S, Watson J. Results of operative treatment of
fractures of the posterior wall of the acetabulum. J Bone Joint Surg
Am 2002;84A:752–758.
325
13. Saterbak A, M arsh L, N epola J, et al. Clinical failure after posterior
wall acetabular fractures: the influence of initial fracture patterns. J
O rthop Trauma 2000;14:230–237.
14. Tornetta P. N on-operative management of acetabular fractures:
the use of dynamic stress views. J Bone Joint Surg Br
1999;81B:67–70.
15. Tornetta P. Displaced acetabular fractures: indications for operative
and nonoperative management. J Am Acad O rthop Surg 2001;9:
18–28.
16. Vailas J, H urwitz S, Wiesel S. Posterior acetabular fracture-disloca-
tions: fragment size, joint capsule, and stability. J Trauma 1989;
29(11):1494–1496.
 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 37 Fix a t io n o f Fe m o r a l He a d
Fr a ct u re s
Darin Frie ss an d Th o m as Ellis
DEFIN ITION
■ Fractures of the femoral head are rare, and occur almost ex-
clusively with associated high-energy hip dislocations, where
they may be seen in 5% to 15% of cases.
■ Associated injuries to the femur, acetabulum, or acetabular
labrum can affect treatment options.
AN ATOMY
■ The spherical femoral head is almost completely covered by
articular cartilage, which often is damaged during the hip dis-
location.
■ Blood is primarily supplied to the superior dome of the
femoral head by the medial femoral circumflex artery, which
travels around the posterior aspect of the proximal femur,
traveling deep to the quadratus femoris and penetrating the
joint capsule just inferior to the piriformis tendon (FIG 1 ).
■ Additional vascular support is supplied by the lateral
femoral circumflex artery and the foveal artery within the
ligamentum teres.
■ The anterior half of the femoral neck is devoid of vascu-
lar structures. Therefore, anterior surgical approaches to the
hip joint do not compromise the vascular supply of the
femoral head.
■ The acetabular labrum increases the coverage of the femoral
head, but may be damaged during hip dislocation.
PATHOGEN ESIS
■ Both the position of the leg at the time of impact and the
patient’s hip anatomy have been shown to play a role in the
etiology of hip fracture-dislocations.
■ Posterior dislocations, the most common type, occur when
the hip is in a flexed, adducted, and internally rotated position.
Decreased femoral anteroversion leads to reduced femoral
head coverage by the acetabulum and increases the risk of hip
dislocation.
■ The fracture is a shearing injury. Injury to the articular
cartilage of the femoral head is common with femoral head
fractures, and posterior wall fractures also can occur with this
injury.
■ Anterior dislocations are less common. They occur when
the hip is in an abducted and externally rotated position,
which results in an impaction injury to the anterolateral
femoral head (FIG 2 ).
N ATURAL HISTORY
■ In an intermediate-term follow-up study by Jacob et al,4 de-
spite open or closed treatment, only 40% of patients had sat-
isfactory results after hip dislocation at an average of 4.5 years
after injury. M ore than half of the patients had posttraumatic
arthrosis.
■ O steonecrosis of the femoral head may develop in 20% of pa-
tients with femoral head fractures despite anatomic reduction.
326
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Because of the high energy required to induce a fracture-
dislocation of the hip, all patients should undergo a thorough
trauma evaluation for associated injuries.
■ Airway, cardiovascular, head, and spine injuries should
be stabilized emergently.
■ N arcotic pain medication usually is required.
■ Careful evaluation of the affected extremity is essential.
■ The leg often appears shortened and internally rotated or
flexed and abducted after a posterior hip dislocation.
■ Suspicion for associated injuries, particularly around the
knee, should remain high; such injuries can be recognized on
physical examination.
■ Injury to the knee ligaments or extensor mechanism is
associated with traumatic hip dislocations and should be
assessed with a stability examination.
■ Because sciatic nerve injuries are common, motor and sen-
sory examination of the affected extremity is critical, with par-
ticular attention paid to strength grades (1–5) and sensation in
the peroneal and tibial nerve distribution.
IMAGIN G AN D OTHER
DIAGN OSTIC STUDIES
■ The hip fracture-dislocation is first evaluated on the trauma
anteroposterior (AP) pelvis radiograph (FIG 3 A). The goal
should be to emergently reduce the hip, and further imaging
should not delay such treatment excessively.
■ Associated injuries such as femoral neck fractures, acetabular
fractures, or pelvis fractures may require additional dedicated
hip, Judet view, or pelvic inlet and outlet radiographs.
Terminal branch
Posterior aspect
of medial
circumflex artery
of femoral neck
Trochanteric branch of
medial circumflex artery
FIG 1 • Th e b lo o d su p p ly t o t h e su p e rio r d o m e o f t h e fe m o ra l
h e a d is p rim a rily su p p lie d b y t h e m e d ia l fe m o ra l circu m fle x
a rt e ry. It t ra ve ls a ro u n d t h e p o st e rio r a sp e ct o f t h e p ro xim a l
fe m u r, t ra ve lin g d e e p t o t h e q u a d ra t u s fe m o ris a n d p e n e t ra t in g
t h e jo in t ca p su le ju st in fe rio r t o t h e p irifo rm is t e n d o n .
 Ch a p t e r 3 7 ORIF OF FEM ORAL HEAD FRACTURES 327

Pip k in Cla s s if ica t io n o f

Ta b le 1 Fe m o r a l He a d Fr a ct u r e s

Ty p e De s cr ip t io n Illu s t r a t io n
I Fracture inferior to the
femoral head fovea

II Fracture superior to the

femoral head fovea

FIG 2 • An t e ro la t e ra l fe m o ra l h e a d im p a ct io n in ju ry fo llo w in g
a n t e rio r h ip d islo ca t io n .

■ A fine-cut CT scan of the pelvis and femoral neck with coro-

nal and sagittal reconstructions will further define the anatomy
of the femoral head fracture and associated injuries (FIG 3 B,C).
■ This should be obtained after reduction of the hip. A pre-
III Femoral head fracture
reduction CT scan of the hip is not typically indicated. plus femoral neck
■ Although M RI can be used to evaluate femoral head os- fracture
teonecrosis in follow-up care, acute imaging has not been
demonstrated to be prognostic of this complication.

DIFFEREN TIAL DIAGN OSIS

■ Femoral head fractures typically are classified according to
Pipkin (Table 1).
■ An isolated posterior wall fragment may be confused with a
IV Femoral head fracture
femoral head fracture. plus acetabular
fracture
N ON OPERATIVE MAN AGEMEN T
■ Surgical management to reconstruct the articular surface
usually is indicated.
■ N onoperative management is used only in Pipkin type I

fractures with small articular fragments with an associated

concentric reduction of the hip.

N o quality clinical studies are available to define the

■

amount of displacement of the fragment that can be toler-

ated. The accepted guideline is that the fragment should be
congruent with the intact femoral head.
■ Small impaction injuries associated with anterior dislocation

B also may be treated nonoperatively in many cases.

■ Patients managed nonoperatively should remain toe-touch

weight bearing for 8 to 12 weeks. For posterior dislocations,

hip flexion beyond 70 degrees should be avoided for 6 weeks
to protect the posterior capsule. Pool therapy can be initiated
between 6 and 8 weeks.

SURGICAL MAN AGEMEN T

A C ■ Most patients with femoral head fractures require surgery to
FIG 3 • A. Pre o p e ra t ive AP ra d io g ra p h d e m o n st ra t in g fe m o ra l provide an anatomic reduction of the femoral head, remove os-
he a d fra ct u re . B,C Pre o p e ra t ive CT sca n s d e m o n st ra t in g fe m o ra l teochondral loose bodies, or obtain a concentric reduction of the
he a d fra ct u re . hip joint. Loose body removal can delay the onset of arthrosis.
 328 Se c t i o n III P E LVI S A N D H IP
■ Large, displaced fragments should be anatomically fixed.
Smaller fragments inferior to the fovea can be excised if a qual-
ity, stable reduction of the fracture fragment cannot be obtained.
■ H ip arthroplasty is another good treatment option in elderly
patients, especially with large head fragments. Femoral head
fractures in this age group tend to have a large amount of as-
sociated articular cartilage damage and impaction of the bone
at the fracture line, which compromises the patient’s outcome.
■ Although their significance is unknown, labral tears often
can be evaluated and treated surgically.
■ Algorithm for surgical management:
■ N ondisplaced fracture or small impaction injury
■ N onoperative treatment
■ Displaced fragment
■ Small: surgical excision
■ Large: surgical fixation
■ Elderly patient
■ Small fragment with evidence of associated femoral
head impaction: surgical excision
■ Large fragment or significant femoral head im-
paction: hip arthroplasty
Preoperative Planning
■ If the hip is dislocated, it should be emergently reduced
under general anesthesia with skeletal relaxation.
■ Inadequate anesthesia during this reduction can lead to fur-
ther damage to the articular surfaces of the femoral head and
acetabulum as the hip is relocated.
■ If the hip is reduced, the patient should be placed in 30
pounds of longitudinal skeletal traction until formal open re-
duction and internal fixation of the femoral head occurs.
Traction will unload the femoral head and prevent ongoing
third-body wear within the hip joint.
■ Repeat radiographs and a post-reduction CT scan should
be obtained to evaluate the hip joint.
■ It is reasonable at this point to delay definitive surgery
until the appropriate surgeon, anesthesiologist, and equip-
ment are available.
■ If the hip is irreducible, or there is an associated femoral
neck fracture, emergent open reduction and internal fixation
are required.
Positioning
■ For an anterior Smith-Peterson approach, the patient is po-
sitioned supine on a radiolucent table with a hip bump and the
affected leg draped free.
TECHNIQUES
SMITH-PETERSON ANTERIOR APPROACH
In cis io n a n d Dis s e ct io n
■ Th is is t h e p re fe rre d a p p ro a ch fo r fra g m e n t e xcisio n .
■ Th e p a t ie n t is p o sit io n e d su p in e o n a ra d io lu ce n t t a b le
w it h t h e le g d ra p e d fre e .
■ A ve rt ica l in cisio n is m a d e fro m t h e a n t e ro su p e rio r ilia c
sp in e e xt e n d in g d ist a lly t o w a rd t h e la t e ra l b o rd e r o f t h e
p a t e lla (TECH FIG 1 A).
■ Th e sa rt o riu s a n d t e n so r fa scia la t a a re id e n t ifie d
(TECH FIG 1 B). Th e fascia is in cise d o ver t h e m ed ial asp ect
o f th e te nso r mu scle , a n d t he m ed ia l b ord e r o f th e te n sor
■ For a posterior Kocher-Langenbeck approach, the patient is
placed prone on a radiolucent fracture table with a distal
femoral traction pin and the knee flexed to 90 degrees to re-
lieve sciatic nerve tension.
■ For a Ganz surgical dislocation, the patient is placed on a ra-
diolucent table with a beanbag in the lateral decubitus position
and the affected leg draped free.
Approach
■ The most difficult decision is determination of the best op-
erative approach.
■ Epstein 2 originally argued that all femoral head fractures
should be approached posteriorly, because the posterior blood
supply to the femoral head had already been damaged during hip
dislocation. This left the anterior capsular blood supply intact.
■ H owever, the anterior capsule and anterior femoral neck
provide very little vascular supply to the femoral head. In
addition, visualization of the anteriorly located femoral
head fracture often is inadequate.
■ This approach is best used when large femoral head frag-
ments remain dislocated posteriorly after reduction of the
hip or with an associated posterior column or posterior wall
fracture.
■ H owever, visualization of the anterior head fragment is
difficult through a posterior approach, and such a frac-
ture may be better treated with a surgical dislocation (see
Techniques section).
■ Swiontkowski6 effectively demonstrated that better visual-
ization of the femoral head was obtained for most Pipkin I and
II femoral head fractures by using the distal limb of an ante-
rior Smith-Peterson approach.
■ N o increased incidence of osteonecrosis was seen, although
a slightly higher risk of heterotopic ossification was observed.
■ A Smith-Peterson approach is currently the most com-
monly used method for fixation, and is the preferred ap-
proach for excision of the fragment.
■ The best visualization of the femoral head can be obtained
through a surgical hip dislocation, as described by Ganz et al.3
■ This approach safely preserves the medial circumflex ar-
terial supply to the femoral head.
■ It also allows the best access to associated injuries such as
posterior acetabular fractures, labral tears, osteochondral
debris, or posteriorly dislocated femoral head fragments.
■ Surgical dislocation also provides improved access to an-
gulate lag screw fixation perpendicular to the femoral head
fracture line.
m u scle is fo llo w ed t o d eve lo p th e in te rval b et we en th e
t en so r a n d sarto riu s m u scles (TECH FIG 1C).
■ Th e t e n so r m u scle is re t ra ct e d la t e ra lly a n d t h e sa rt o riu s
m u scle m e d ia lly.
■ Th e d ire ct a n d in dire ct h e a d s o f t h e re ct u s fe m o ris m u scle
are id e nt ifie d an d a re re t ra ct e d m e dia lly (TECH FIG 1 D).
Th e re is a n o ve rlying fa scia l la ye r t h a t m u st be d ivid e d t o
b e a b le t o se e t h is m u scle . Th e la t e ra l fe m o ra l circu m fle x
ve sse l t ra ve rses t h e in fe rio r p a rt o f t h e w o u n d a n d m a rks
t h e d ist a l a sp e ct o f t h e in cisio n .
 Ch a p t e r 3 7 ORIF OF FEM ORAL HEAD FRACTURES 329

TECHNIQUES
Incision

Fascia over extensor

fasciae latae muscle

Sartorius m.

Lateral

A Fascia over
extensor fasciae
latae muscle

C Medial

Tensor
fasciae
latae

Gluteus Iliocapsularis m.
medius m.

Rectus
femoris m.

Lesser trochanter
Sartorius m.

D E

TECH FIG 1 • A. In cisio n st a rt s fro m t h e a n t e ro su p e rio r ilia c sp in e e xt e n d in g d ist a lly t o w a rd t h e la t e ra l b o rd e r o f t h e

p a t e lla . B. Th e fa scia is in cise d o ve r t h e m e d ia l b o rd e r o f t h e t e n so r m u scle . C. Th e m e d ia l b o rd e r o f t h e t e n so r m u scle
is fo llo w e d t o d e ve lo p t h e in t e rva l b e t w e e n t h e t e n so r m u scle a n d t h e sa rt o riu s m u scle . D. Th e d ire ct a n d in d ire ct h e a d s
o f t h e re ct u s fe m o ris m u scle a re id e n t ifie d a n d re t ra ct e d m e d ia lly. E. Th e ilio ca p su la ris m u scle lie s d e e p t o t h e re ct u s
m u scle . Th is m u scle is sw e p t m e d ia lly t o e xp o se t h e jo in t ca p su le .
 330 Se c t i o n III P E LVI S A N D H IP

■ In m o st p a t ie n t s, a re sid u a l m u scle b e lly, t h e ilio - circu m fe re n t ia lly. Circu m fe re n t ia l visu a liza t io n o f t h e

TECHNIQUES

ca p su la ris m u scle , is d e e p t o t h e re ct u s m u scle fra ct u re is n e ce ssa ry t o co n firm t h a t a d e q u a t e re d u c-

(TECH FIG 1 E). Th is m u scle is sw e p t m e d ia lly, e xp o sin g
t h e ca p su le .
Ca p s u lo t o m y
■ A lo n g it u d in a l in cisio n is m a d e fro m t h e a rt icu la r rim t o
t h e b a se o f t h e fe m o ra l n e ck a lo n g t h e a xis o f t h e
fe m o ra l n e ck. An t e rio rly, a ca p su la r in cisio n is m a d e
a lo n g b o t h t h e a ce t a b u la r rim a n d t h e b a se o f t h e
fe m o ra l n e ck (TECH FIG 2 A). Po st e rio rly, o n ly a ca p su la r
in cisio n a lo n g t h e a rt icu la r rim is m a d e .
■ In cisin g t h e ca p su le p o st e rio rly a lo n g t h e b a se o f t h e
fe m o ra l n e ck p la ce s t h e m e d ia l fe m o ra l circu m fle x a rt e ry
a t risk. Th e m e d ia l fe m o ra l circu m fle x ve sse l, w h ich re st s
in a syn o via l fo ld o n t h e p o st e ro la t e ra l fe m o ra l n e ck, a n d
t h e a ce t a b u la r la b ru m m u st b e p ro t e ct e d . Th e a n t e rio r
a sp e ct o f t h e fe m o ra l n e ck is d e vo id o f va scu la r
st ru ct u re s.
■ If a d d it io n a l e xp o su re is n e ce ssa ry, a p o rt io n o f t h e d ire ct
h e a d o f t h e re ct u s m u scle m a y b e re le a se d .
■ Blu n t re t ra ct o rs a re p la ce d w it h in t h e jo in t ca p su le t o o b -
t a in g o o d e xp o su re o f t h e h e a d fra ct u re (TECH FIG 2 B).
Fr a ct u r e Re d u ct io n a n d Fix a t io n
■ Re d u ct io n o f fra g m e n t is fa cilit a t e d b y cu t t in g t h e lig a -
m e n t u m t e re s.
■ Th e fra g m e n t is e xcise d if it is t o o sm a ll fo r in t e rn a l
fixa t io n .
■ A p o in t e d re d u ct io n cla m p is u se d t o re d u ce t h e d is-
p la ce d fra g m e n t .
■ Ma n y fra ct u re s h a ve a co m p o n e n t o f im p a ct io n in ju ry
o n t h e fe m o ra l h e a d , so t h e fra ct u re m a y n o t ke y in
t io n h a s b e e n o b t a in e d .
■ In so m e ca se s, a n t e rio r d islo ca t io n o f t h e fe m o ra l h e a d
w ill fa cilit a t e b o t h fra ct u re re d u ct io n a n d in se rt io n o f
d e fin it ive fixa t io n .
■ Th e fra ct u re is fixe d w it h re ce sse d 3.5- o r 2.7-m m la g
scre w s o r h e a d le ss se lf-co m p re ssin g scre w s (e g ,
Acu t ra ck [Acu m e d LLC] o r He rb e rt -Wh ip p le scre w s
[Zim m e r In c.]).
■ It is im p o rt a n t t o a sce rt a in t h a t t h e scre w h e a d s a re
re ce sse d w it h in t h e b o n e .
Ga n z Su r g ica l Dis lo ca t io n
■ Th e p a t ie n t is in t h e la t e ra l p o sit io n .
■ Eit h e r a d ire ct la t e ra l in cisio n o r a t ra d it io n a l p o st e ro la t -
e ra l a p p ro a ch is u se d .
■ Th e g lu t e u s m a xim u s is re t ra ct e d p o st e rio rly a n d t h e t e n -
so r fa scia la t a a n t e rio rly.
■ Th e in t e rva l b e t w e e n t h e g lu t e u s m in im u s a n d t h e p iri-
fo rm is is id e n t ifie d , a n d t h e g lu t e u s m in im u s is sh a rp ly
e le va t e d a n t e rio rly.
■ Th e t ro ch a n t e r is o st e o t o m ize d , le a vin g a p o rt io n o f t h e
t ip o f t h e t ro ch a n t e r in t a ct t o p ro t e ct t h e m e d ia l fe m o ra l
circu m fle x ve sse l. Th e o st e o t o m y is o rie n t e d p a ra lle l t o
t h e sh a ft o f t h e fe m u r (TECH FIG 3 A).
■ Th e g lu t e u s m in im u s a n d m e d iu s, t h e t ro ch a n t e ric fra g -
m e n t , a n d t h e va st u s la t e ra lis a n d in t e rm e d iu s m u scle s
a re sh a rp ly e le va t e d a n t e rio rly.
■ Th e d isse ct io n is ke p t su p e rio r t o t h e p irifo rm is m u s-
cle , b e ca u se t h e m e d ia l fe m o ra l circu m fle x ve sse l p e n -
e t ra t e s t h e h ip ca p su le a t t h e in fe rio r m a rg in o f t h e
p irifo rm is.

Femoral
neck
exposed

A B

TECH FIG 2 • A. A ca p su lo t o m y is p e rfo rm e d b y m a kin g a lo n g it u d in a l in cisio n fro m t h e a rt ic-

u la r rim t o t h e b a se o f t h e fe m o ra l n e ck a lo n g t h e a xis o f t h e fe m o ra l n e ck. An t e rio rly, a ca p -
su la r in cisio n is m a d e a lo n g b o t h t h e a ce t a b u la r rim a n d t h e b a se o f t h e fe m o ra l n e ck.
Po st e rio rly, o n ly a ca p su la r in cisio n is m a d e a lo n g t h e a rt icu la r rim . B. Aft e r t h e ca p su lo t o m y is
p e rfo rm e d , b lu n t re t ra ct o rs a re p la ce d a ro u n d t h e fe m o ra l n e ck t o e xp o se t h e fe m o ra l h e a d
a n d n e ck.
 Ch a p t e r 3 7 ORIF OF FEM ORAL HEAD FRACTURES 331

TECHNIQUES
A B C

D E F

G H

TECH FIG 3 • A. Th e t ro ch a n t e ric o st e o t o m y is m a d e p a ra lle l t o t h e sh a ft o f t h e fe m u r. B. Z-sh a p e d ca p su lo t o m y.

C–E. In t ra o p e ra t ive vie w s fo llo w in g su rg ica l d islo ca t io n o f t h e h ip . Th e lig a m e n t u m t e re s w a s t ra n se ct e d t o im p ro ve e xp o -
su re , b u t t h e m e d ia l re t in a cu lu m w a s le ft in t a ct . Th e fra g m e n t is fixe d w it h t h re e h e a d le ss scre w s. No t e t h e a re a o f fe m o ra l
h e a d b o n e lo ss d u e t o im p a ct io n . F,G. Po st e ro su p e rio r la b ra l t e a r is d e m o n st ra t e d . Th e la b ru m is re d u ce d a n d se cu re d w it h
su t u re a n ch o rs. Su rg ica l d islo ca t io n p ro vid e s t h e b e st e xp o su re o f t h e a ce t a b u lu m a n d is o u r p re fe rre d e xp o su re fo r t h is
fra ct u re p a t t e rn . H. Po st o p e ra t ive ra d io g ra p h . Th e t ro ch a n t e ric fra g m e n t is st a b ilize d w it h t w o o r t h re e 3.5-m m co rt ica l
scre w s d ire ct e d in a ce p h a la d t o ca u d a d d ire ct io n .

■ Pla cin g t h e le g in t h e fig u re 4 p o sit io n w it h t h e o p e ra - ■ Th e fe m o ra l h e a d fra g m e n t is re d u ce d o r e xcise d . Th e

t ive -sid e fo o t o n t h e t a b le im p ro ve s e xp o su re o f t h e a n -
t e rio r ca p su le .
■ A Z-sh a p e d ca p su lo t o m y is p e rfo rm e d w it h t h e ce -
p h a la d lim b p o st e rio r a n d t h e ca u d a d lim b a n t e rio r
(TECH FIG 3 B).
■ Th e fe m o ra l h e a d is d islo ca t e d a n t e rio rly.
la b ru m is a sse sse d , a n d is fixe d w it h su t u re a n ch o rs if it is
t o rn (TECH FIG 3 C–H).
■ If a n a sso cia t e d p o st e rio r w a ll fra g m e n t is p re se n t , t h e
h ip is re d u ce d a n d t h e w a ll fra g m e n t re p a ire d .
■ Th e ca p su le is lo o se ly re p a ire d , a n d t h e t ro ch a n t e r is
re a t t a ch e d w it h t w o o r t h re e 3.5-m m co rt ica l scre w s.
332 Se c t i o n III P E LVI S A N D H IP

PEARLS AND PITFALLS

Asso cia t e d in ju rie s
Scia t ic n e rve d ysfu n ct io n
Ma lre d u ct io n
Scre w le n g t h a n d t yp e
Fe m o ra l h e a d va scu la r su p p ly
■ Asso cia t e d fra ct u re s o f t h e fe m o ra l n e ck a n d a ce t a b u lu m a re co m m o n . Re vie w t h e in it ia l in -
ju ry film s a n d p o st –h ip re d u ct io n CT sca n ca re fu lly. Se le ct a n a p p ro p ria t e su rg ica l a p p ro a ch .
■ Su b t le in ju rie s a re co m m o n a ft e r h ip d islo ca t io n . Ca re fu l p re o p e ra t ive m o t o r e xa m in a t io n
w ill fin d su ch d ysfu n ct io n is a re su lt o f t h e in ju ry, n o t o f su rg e ry. Ca re fu l p ro t e ct io n a n d re -
t ra ct io n o f t h e n e rve is e sse n t ia l d u rin g p o st e rio r o r su rg ica l d islo ca t io n a p p ro a ch e s.
■ Th is is a sh e a rin g in ju ry t h at re su lt s in a fe m o ra l h e a d fra ct u re , a rt icu la r ca rt ila ge d a m a ge ,
a n d im pa ct io n in ju ry t o t h e fe m o ra l he a d . It ca n b e d ifficu lt t o o b t a in a circu m fe re nt ia l
a n a t o m ic re d uct io n b eca u se o f t h e im pa ct io n in jury. Circu m fe re n t ia l visu a liza t io n o f t h e fra c-
t u re is n ece ssa ry t o a vo id a la rg e art icu la r st e p -o ff. Th e t e n d e n cy is t o m a lre d u ce t h e p o st erio r
a sp e ct o f t he fra ct u re o w in g t o p o o r e xp o su re an d in co m p le t e visu a liza t io n o f t h e fra ct ure .
■ En su re t h a t t h e scre w s d o n o t p e n e t ra t e in t o t h e jo in t . Th e y sh o u ld b e re ce sse d b e n e a t h t h e
co rt e x o f t h e fe m o ra l h e a d . Use h e a d le ss scre w s ra t h e r t h a n st a n d a rd scre w s, b e ca u se t h e
h e a d o f t h e st a n d a rd scre w w ill d isp la ce t h e b o rd e rs o f t h e t h in fra ct u re fra g m e n t a s t h e
head engages the bone.
■ Drillin g t h e su p e rio r su rfa ce o f t h e fe m o ra l h e a d w it h a 2.0-m m d rill b it sh o u ld p ro d u ce a r-
t e ria l b le e d in g if t h e va scu la r su p p ly t o t h e fe m o ra l h e a d h a s b e e n m a in t a in e d .

POSTOPERATIVE CARE COMPLICATION S

■ Patients are given 24 hours of appropriate antibiotic pro- ■ Posttraumatic arthrosis: 50%
phylaxis. ■ Femoral head osteonecrosis: 20%

■ Deep venous thrombosis prophylaxis is started 24 hours ■ N eurologic injury: 10% (60% of these recover some
postoperatively, and is used before surgery if it has been de- function)
layed more than 24 hours after injury. ■ H eterotopic ossification: 25% to 65% ; higher risk with an-

■ H eterotopic ossification prophylaxis using either 700 cGy of terior approach

radiation or indomethacin 25 mg three times daily is consid- ■ H ip instability

ered in patients with significant damage to the gluteus min- ■ Deep venous thrombosis

imus muscle.
■ Patients are allowed 30 to 40 pounds weight bearing for 8 to
REFEREN CES
12 weeks, then progressed to full weight bearing as tolerated.
■ H ip flexion is limited to 70 degrees for 6 weeks.
■ Pool therapy is started once the incision is dry and the su-
tures are removed.
■ O nce weight bearing is initiated at 12 weeks, more aggres-
sive physical therapy focusing on gait training and quadriceps
and hip abductor strengthening is started.
OUTCOMES
■ Because of the rarity of femoral head fracture-dislocations,
no large prospective trials have compared surgical versus non-
surgical treatment methods.
■ M ost retrospective reviews, including those by both
Epstein 2 and Jacob,4 report less than 50% good or excellent
results at 5 to 10 years of follow-up.
■ Posttraumatic arthrosis is common following a femoral
head fracture, and patients should be warned early of the poor
prognosis.
1. Asghar FA, Karunakar M A. Femoral head fractures: diagnosis, man-
agement, and complication. O rthop Clin N orth Am 2004;35:
463–472.
2. Epstein H C, Wiss DA, Cozen L. Posterior fracture dislocation of the
hip with fracture of the femoral head. Clin O rthop Rel Res
1985;201:9–17.
3. Ganz R, Gill TJ, Gautier E, et al. Surgical dislocation of the adult hip:
A technique with full access to the femoral head and acetabulum
without risk of avascular necrosis. J Bone Joint Surg Br 2001;
83B:1119–1124.
4. Jacob JR, Rao JP, Ciccarelli C. Traumatic dislocation and fracture
dislocation of the hip: A long-term follow-up study. Clin O rthop
Relat Res 1987;214:249–263.
5. Seibenrock KA, Gautier E, Woo AK, Ganz R. Surgical
dislocation of the femoral head for joint debridement and accurate
reduction of fractures of the acetabulum. J O rthop Trauma 2002;
16:543–552.
6. Swiontkowski M F, Thorpe M , Seiler JG, H ansen ST. O perative man-
agement of displaced femoral head fractures: case matched compari-
son of anterior versus posterior approaches for Pipkin I and Pipkin II
fractures. J O rthop Trauma 1992;6:437–442.

Ch a p t e r 38
DEFIN ITION
■ Femoral neck fractures occur in two patient populations.
■ M ost commonly, they happen in older, osteopenic pa-
tients after low-energy trauma, such as falls.
■ When they occur in younger patients with normal bone,
they are usually the result of high-energy trauma, such as a
motor vehicle collision.
■ Femoral neck fractures can be classified by several charac-
teristics. The most important distinguishing feature in regard
to treatment decisions is the degree of displacement.
■ Fractures that are nondisplaced or impacted into valgus
can usually be treated with fixation in situ using percuta-
neous methods.
■ Displaced fractures usually require reduction and fixation
or replacement.
■ The location of the fracture in the femoral neck can be
described as subcapital, transcervical, or basicervical (FIG 1 ).
■ Transcervical femoral neck fractures can be further charac-
terized by the angle of the fracture line with respect to the
perpendicular of the femoral shaft axis. This is the Pauwels
classification (Table 1).
■ The importance of this feature is to recognize high-angle
fractures (more vertical), which have the greater risk of dis-
placement when treated with screws along the neck axis.
AN ATOMY
■ The femoral neck axis forms an angle of about 140 degrees to
the femoral shaft axis. In addition, it is anteverted about 15 de-
grees with reference to the plane of the posterior condyles of the
distal femur.
FIG 1 • De fin it io n o f lo ca t io n fo r fe m o ra l n e ck fra ct u re s.
Fra ct u re s t h ro u g h t h e re d zo n e a re d e scrib e d a s b a sice rvica l, in
t h e ye llo w zo n e t h e y a re t ra n sce rvica l, a n d in t h e g re e n a re a
t h e y a re d e sig n a t e d su b ca p it a l.
Op e n Re d u ct io n a n d In t e r n a l
Fix a t io n a n d Clo s e d Re d u ct io n
a n d Pe rcu t a n e o u s Fix a t io n o f
Fe m o r a l Ne ck Fr a ct u re s
Brian M u llis an d Je f f A n g le n
■ When viewed in both anteroposterior (AP) and lateral radi-
ographic views, the normal contour of the femoral head and
neck forms a gentle S (FIG 2 A,B).
■ The vascular supply of the proximal femur relies on the me-
dial femoral circumflex artery, particularly the posterior branch,
which feeds the retinacula of Weitbrecht. M inor contributions
come from the artery of the ligamentum teres (FIG 2 C,D).
PATHOGEN ESIS
■ Low-energy femoral neck fractures generally are a result of
a fall from standing height in an osteoporotic individual.
■ This is an increasing public health problem, with projec-
tions of 512,000 total hip fractures in the United States by
the year 2040.1
■ H igh-energy (comminuted) femoral neck fractures generally
result from high-speed motor vehicle collision or falls from
greater than 10 feet.
■ These patients frequently have multiple injuries, which
can complicate treatment.
N ATURAL HISTORY
■ N ondisplaced or minimally displaced fractures that are not
surgically stabilized are likely to suffer worsened displacement
owing to the high mechanical forces associated with hip mo-
tion and the instability that comes from comminution of the
cortical bone.
■ The intra-articular location of the femoral neck means that
there is not a well-vascularized soft tissue envelope, and the
fracture is exposed to synovial fluid, which contains enzymes
that lyse blood clot, the required first stage in bone healing. As
a result, femoral neck fracture healing is slowed.
■ In addition, the blood supply comes from tenuous retro-
grade blood flow.
■ Nonunion rate for untreated displaced fractures approaches
100% .
■ N onunion of the femoral neck leads to a shortened limb,
variable restriction in motion, and pain with weight bearing.
■ Fracture of the femoral neck can lead to interruption of the
blood supply to the femoral head due to kinking or disruption
of vessels or tamponade from hemarthrosis.
■ This results in avascular necrosis in about 15% of cases. 2
■ M any surgeons believe that time to treatment is an impor-
tant factor, with delay increasing the incidence. This is diffi-
cult to prove, and the time imperative probably varies from
patient to patient.
■ Femoral neck fractures in the elderly are associated with
about 20% 1-year mortality.4
■ About 50% of patients return to their previous level of func-
tion after surgery.3
333
334 Se c t i o n III PELVIS AND HIP

PATIEN T HISTORY AN D PHYSICAL ■ Internal and external rotation. Pain in the groin is con-
FIN DIN GS cerning for femoral neck fracture but may also be caused by
fractures of the anterior pelvic ring.
■ In most patients with femoral neck fracture, the history will ■ Impaction of the heel of the injured leg. Groin pain that
contain a distinct traumatic episode, after which the patient
did not exist at rest implies hip fracture.
could not ambulate.
■ Physical findings reveal limb shortening, external rota-

tion, and pain on attempted hip motion.
■ In some patients, the onset of pain is more insidious.
■ It is usually associated with weight bearing, and it is lo-
cated in the groin rather than in the buttock or trochanteric
area.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Standard plain radiographs consist of an AP view of the
pelvis and AP and frog-leg lateral films of the hip.
■ An AP traction film with internal rotation can be helpful if

■ In the case of a stress fracture, the history of increased initial films are difficult to interpret in terms of the location of
activity over a short period of time is suggestive. injury or fracture pattern.
■ N ight or rest pain suggests pathologic fracture or impend- ■ If clinical suspicion is high (eg, an elderly patient who can-

ing fracture. not ambulate because of groin pain) but plain radiographs are
■ In highly osteoporotic patients with minor trauma, a history negative, a bone scan or M RI may be obtained for low-energy
of groin pain with weight bearing may be a symptom of occult injuries.
femoral neck fracture, which is a nondisplaced fracture not ■ The bone scan will not turn positive for 24 to 72 hours,

visible on plain radiographs. but the M RI should be diagnostic within hours of injury.
■ Physical examination should include: ■ Some studies have suggested that any multiply injured pa-

■ O bservation of the lower extremities with comparison of
foot position in the supine patient. A shortened, externally
rotated limb indicates fracture.
■ Gait observation. Groin pain on attempted weight bear-
ing or an antalgic gait suggests occult femoral neck fracture.
tient with a high-energy femur fracture should have imaging of
the femoral neck with a CT scan in addition to plain films to
identify minimally displaced femoral neck fractures. H owever,
the CT scan may be false negative as well, and the routine use
of this modality is controversial.

Ta b le 1 Pa u w e ls Cla s s if ica t io n o f Tr a n s ce r v ica l Fe m o r a l Ne ck Fr a ct u r e s

Cla s s if ica t io n Fr a ct u r e Ef f e ct o f
Pla n e Ve r t ica l Fo r ce s
An g le * Ex a m p le o n Fr a ct u r e Sit e Fix a t io n
Pauwels 1 Low, 30 degrees Compression, stable Lag screws in axis of femoral neck

Pauwels 2 30 to 50 degrees Variable Lag screws in axis of femoral neck

Pauwels 3 High, 50 degrees Shear, unstable; tends to At least one lag screw perpendicular
displace into shortened, to fracture plane
varus position

*Fracture plane angle is relative to a line perpendicular to the femoral axis on AP radiograph.
 Ch a p t e r 3 8 ORIF AND CLOSED REDUCTION AND PERCUTANEOUS FIXATION OF FEM ORAL NECK FRACTURES 335

FIG 2 • A,B. AP a n d la t e ra l m o d e l sh o w in g g e n t le
S cu rve o f t h e o u t lin e o f t h e h e a d a n d n e ck. Th is
sm o o t h co n t o u r sh o u ld b e p re se n t a n d sym m e t rica l
o n su p e rio r, in fe rio r, a n t e rio r, a n d p o st e rio r su rfa ce s.
C,D. Va scu la r su p p ly t o t h e fe m o ra l h e a d . Th e m e d ia l
a n d la t e ra l fe m o ra l circu m fle x a rt e rie s a rise fro m t h e
p ro fu n d a fe m o ris a n d fo rm a rin g a ro u n d t h e b a se o f
t h e fe m o ra l n e ck, w h ich is p re d o m in a n t ly e xt ra ca p su -
la r. Fro m t h is rin g , t h e a rt e rie s o f t h e re t in a cu lu m o f
We it b re ch t a sce n d a lo n g t h e fe m o ra l n e ck t o p ro vid e
re t ro g ra d e flo w t o t h e fe m o ra l h e a d . Th e fo ve a l
a rt e ry a rise s fro m t h e o b t u ra t o r a rt e ry a n d su p p lie s a
va ria b le b u t u su a lly m in o r p o rt io n o f t h e fe m o ra l
head.

A B

Ant. sup.
iliac spine Ext. iliac a. Acetabular
Inguinal
labrum
Joint
capsule ligament

Ascending Common
branch femoral a. Synovial Foveolar
membrane
Transverse Obturator
branch Retinacular a.
Lateral
circumflex Medial
femoral a. circumflex
femoral a. Medial
Descending
branch Pectineus m. circumflex
femoral a.
Femur Adductor
longus m.
Deep
C
femoral a. D

DIFFEREN TIAL DIAGN OSIS ■ Buck’s traction or pillow splints may be helpful in reduc-
ing pain.
■ Intertrochanteric, pertrochanteric, or subtrochanteric ■ As soon as pain control is adequate, patients should be mo-
fracture
■ Anterior pelvic ring (ramus) fracture
bilized out of bed to a chair to help prevent the complications
■ H ip dislocation
of bed rest, such as pneumonia, aspiration, skin breakdown,
■ Femoral head fracture
and urinary tract infection.
■ Some valgus impacted fractures may be treated nonopera-
■ Pathologic lesion, including neoplasm or infection

■ Arthritis
tively, particularly if discovered after several weeks, but there
■ Avascular necrosis
is a risk of displacement of up to 46% .
■ N onoperative treatment for these patients should consist
■ Contusion

■ M uscle strain
of mobilization on crutches or a walker. 5
■ Stress fractures may be treated nonoperatively if they are

N ON OPERATIVE MAN AGEMEN T
■ N onoperative treatment may be appropriate in patients who
are nonambulators, neurologically impaired, moribund, or in
extremis.
■ N onoperative treatment should initially consist of bed rest,
appropriate analgesia, protection against decubitus ulcers, and
caught early and are nondisplaced and if the fracture line does
not extend to the tension side or superior neck.
SURGICAL MAN AGEMEN T
■ M ost patients with femoral neck fracture should be consid-
ered for surgical treatment.
■ Displaced femoral neck fractures in some patient po-

appropriate medical supportive treatment. pulations may be better served by hemiarthroplasty or

336 Se c t i o n III PELVIS AND HIP
total hip arthroplasty, which is beyond the scope of this
chapter.
■ This includes elderly patients, osteoporotic patients,
those with neurologic disease, patients with preexisting hip
arthritis, and those with medical illnesses impairing bone heal-
ing or longevity (eg, renal failure, diabetes, malignancy, or an-
ticonvulsant treatment).
■ N ondisplaced fractures, valgus-impacted femoral neck frac-
tures in the elderly, or stress fractures in athletes can be treated
with fixation in situ through percutaneous techniques.
■ O pen reduction and internal fixation is the standard for high-
energy injuries in younger healthy patients with good bone.
■ Closed reduction of a displaced femoral neck fracture in the
young patient is difficult, and one should not accept a less-
than-perfect reduction to avoid an open procedure.
■ The quality of the reduction is the most important
surgeon-controlled factor in outcome.
Preoperative Planning
■ O nce the decision for operative treatment is made, preoper-
ative planning begins with evaluation of patient-specific fac-
tors that may alter the timing or technique for fixation of the
femoral neck fracture.
■ In the elderly population, optimization of medical condi-
tions is advisable, including evaluation of hydration and
cardiac and pulmonary function, and management of
chronic medical conditions. H owever, delay of surgery be-
yond the first 2 to 4 days increases the risk of perioperative
complications and the length of stay.
■ In younger patients, it is important to consider other in-
juries that may affect operative positioning or fixation. For
example, ipsilateral lower extremity injuries at another level
may affect the use of the fracture table.
■ Good-quality radiographs in two planes are necessary to
understand the location and orientation of the fracture. In
some cases, radiographs of the contralateral side may help
select an implant with the correct length, diameter, or neck–
shaft angle.
A B
FIG 3 • A. Pat ient po sit io ning on fractu re t able. Both legs are sup ported in t he ext en ded p osit ion in padde d foot support s. The injured
le g is ke p t in n e u tral a b d u ctio n –ad d u ct io n , w h ile t h e u n in ju red le g is ab d u ct ed t o a llo w p lace me n t o f t h e C-arm b e tw ee n t h e le gs.
The injure d leg ma y b e int ernally rot at ed t o assist w ith re duct ion. B. Fract u re t ab le an d C-arm p o sit io n in g to o b t ain a lat eral view o f
th e fe mo ral neck.
■ The anticipated implants should be verified present before
the case. It is useful to have arthroplasty instruments and im-
plants in the hospital in the event of unexpected findings.
Fortunately, this will rarely be needed.
■ N ondisplaced fractures in the subcapital or transcervical re-
gion can be treated with two or three cannulated screws, but
most surgeons believe that basicervical fractures should be
treated with a fixed-angle device, such as a sliding hip screw or
cephalomedullary nail.
Positioning
■ The patient is positioned on a fracture table with both hips
extended. The contralateral leg is abducted to allow the C-arm
to be positioned between the legs (FIG 3 A).
■ O wing to the risk of compartment syndrome, the surgeon
should avoid using the “ well leg holder,” which puts the
contralateral leg in a hemi-lithotomy position (hip and knee
flexed, elevating the leg).
■ Intraoperative fluoroscopy is used, and good visualization of
the hip and the fracture reduction in both AP and lateral projec-
tions should be verified before preparing the leg (FIG 3B).
■ A closed reduction may sometimes be obtained by applying
gentle traction and internal rotation under fluoroscopic con-
trol (Fig 3A). Vigorous and complicated reduction maneuvers
are unlikely to be effective and should be avoided. If simple,
gentle positioning is not successful in achieving acceptable
position, open reduction should be strongly considered. The
patient should be well relaxed by the anesthesia team.
■ Reduction is anatomic when the normal contours of the
femoral neck are re-established in both the AP and lateral pro-
jections (see Fig 2A,B), the normal neck–shaft angle and neck
length are restored (as judged from a film of the contralateral
hip, or AP pelvis), the relative heights of the femoral head and
trochanter are symmetrical to the contralateral side, and no
gaps are seen in the fracture.
■ If the C-arm images are of poor quality because of patient
obesity or other factors, the surgeon must not assume or hope
it will be better intraoperatively. If adequate visualization to
 Ch a p t e r 3 8 ORIF AND CLOSED REDUCTION AND PERCUTANEOUS FIXATION OF FEM ORAL NECK FRACTURES
assess reduction or implant position is not achievable, open
reduction under direct visualization is the prudent course.
Approach
■ A standard lateral approach is used for percutaneous fixa-
tion of nondisplaced or valgus impacted fractures.
CLOSED REDUCTION AND PERCUTANEOUS FIXATION
■ Th e p a t ie n t is p o sit io n e d o n t h e fra ct u re t a b le a n d re -
d u ct io n is o b t a in e d a s n o t e d a b o ve , C-a rm visu a liza t io n
is ve rifie d , a n d t h e le g a n d h ip is p re p a re d a n d d ra p e d in
a st e rile fa sh io n .
■ Pre o p e ra t ive a n t ib io t ics a re g ive n .
Gu id e w ire a n d Scre w Pla ce m e n t
■ Gu id e w ire s fo r ca n n u la t e d scre w s a re p la ce d in lin e w it h
t h e fe m o ra l n e ck a xis t h ro u g h p o ke h o le s.
■ Th e w ire s a re p la ce d p a ra lle l, u sin g a p a ra lle l d rill
g u id e .
■ Th e st a n d a rd scre w a rra n g e m e n t is a n in ve rt e d t ria n -
g le o f t h re e scre w s.
■ Th e y sh o u ld b e p o sit io n e d p e rip h e ra lly in t h e fe m o ra l
n e ck w it h g o o d co rt ica l b u t t re ss, p a rt icu la rly a g a in st
A B
D E
337
■ If an open reduction is planned, a Smith-Peterson or
Watson-Jones approach may be used according to surgeon
preference to afford visualization of the anterior femoral
neck.
■ The Watson-Jones approach is the senior author’s prefer-
ence and is described below.
TECHNIQUES
t h e in fe rio r a n d p o st e rio r n e ck. St a rt in g p o in t s b e lo w
t h e le sse r t ro ch a n t e r sh o u ld b e a vo id e d o w in g t o risk
o f su b t ro ch a n t e ric fra ct u re p o st o p e ra t ive ly (TECH
FIG 1 A–C).
■ Once the posit ion of the wires is verified in tw o planes by
flu o ro sco py, sma ll (1-cm) full-de p th incision s a re ma d e a t
each guide pin, and the soft tissues are spread to the bone.
■ Th e la t e ra l co rt e x m a y b e d rille d in p a t ie n t s w it h d e n se
bone.
■ Se lf-d rillin g , se lf-t a p p in g ca n n u la t e d scre w s a re p la ce d
b y p o w e r o ve r t h e g u id e w ire s.
■ Wa sh e rs sh o u ld b e u se d in t h e m o re p ro xim a l, m e t a -
p h yse a l lo ca t io n s (TECH FIG 1 D,E).
■ Screw s should b e long eno ugh so tha t all screw t hreads
a re o n th e pro xim a l (h e a d ) sid e o f t h e fra ct u re .
TECH FIG 1 • A. Saw bones la te ral view of t he
p ro xim a l fe m u r sh o w in g co n fig u ra t io n fo r
t h re e p a ra lle l g u id ew ires b efo re p lacem en t o f
can n u lat ed scre ws. Th e wire sta rt in g p o in t s
fo rm a n in ve rt e d t ria n g le . B. Int ra operat ive AP
flu o ro sco p ic vie w sh o w in g p o sit io n a n d d e p t h
o f th e gu id e w ire s. Th e in fe rio r w ire ru n s righ t
alon g t he inferior cort ex of the fem ora l neck—
t h e “calca r” (arro w ). C. Int raope ra tive la te ra l
flu o ro sco p ic vie w sh o w in g g u id e wire p o sitio n .
Th e po ste rio r wire is d ire ct ly a d ja ce n t to a n d
su p p o rt e d b y th e p o st e rio r co rt e x o f t h e n e ck.
Ca re is n e ce ssa ry t o e n su re t h a t th e g u id ew ire
d o e s n o t g o o utsid e o f t h e n e ck a n d t h e n re -
e n te r t he fem o ra l h e a d . D,E. Int raope ra tive
flu o ro sco p ic vie w s d e mo n st ra tin g ca n n u la te d
scre w in se rt io n o ve r g u id e wire s. D. AP view
sh o w in g u se o f wa sh e rs in th is me ta p hysea l lo-
cat io n . E. Lat eral vie w show ing pa ra lle l inse r-
t io n a n d a p p ro p ria te d e p th .
 338 Se c t i o n III PELVIS AND HIP
Art h ro t o m y
TECHNIQUES
■ Ma n y su rg e o n s b e lie ve t h a t a n a rt h ro t o m y sh o u ld b e
p e rfo rm e d t o re lie ve p re ssu re o n t h e b lo o d su p p ly t o t h e
fe m o ra l h e a d d u e t o in t ra ca p su la r b le e d in g . So m e co n -
sid e r t h is t o b e m o st ly im p o rt a n t in yo u n g e r p a t ie n t s
w it h m in im a lly d isp la ce d fra ct u re s, b e ca u se t h e y re a so n
t h a t m o re w id e ly d isp la ce d fra ct u re s h a ve h a d d e co m -
p re ssio n o f t h e in t ra ca p su la r h e m a t o m a b y virt u e o f t h e
in ju ry. Th is is co n t ro ve rsia l.
■ A n o .15 b la d e o n a lo n g h a n d le is p o sit io n e d a t t h e
in fe rio r m a rg in o f t h e b a se o f t h e fe m o ra l n e ck o n
t h e AP flu o ro sco p ic im a g e .
OPEN REDUCTION AND INTERNAL FIXATION THROUGH THE WATSON-
JONES APPROACH
■ Th e p a t ie n t is p o sit io n e d o n t h e fra ct u re t a b le a s n o t e d
a b o ve , flu o ro sco p ic visu a liza t io n is co n firm e d , a n d t h e
le g a n d h ip is p re p a re d a n d d ra p e d in a st e rile fa sh io n .
■ Circu m fe re n t ia l p ro xim a l t h ig h p re p a ra t io n is
im p o rt a n t .
■ Pre o p e ra t ive a n t ib io t ics a re g ive n .
So ft Tissu e Disse ct io n
■ Th e in cisio n is lo ca t e d la t e ra lly o ve r t h e a n t e rio r p o rt io n
o f t h e g re a t e r t ro ch a n t e r.
■ It cu rve s slig h t ly a n t e rio rly a s it e xt e n d s p ro xim a l
fro m t h e t ro ch a n t e r t o w a rd t h e cre st fo r a b o u t 8 t o
10 cm .
■ It e xt e n d s st ra ig h t d ist a lly a b o u t 10 cm fro m t h e
t ro ch a n t e r (TECH FIG 2 A).
■ Th e fa scia la t a is id e n t ifie d a n d in cise d ju st p o st e rio r t o
t h e t e n so r fa scia la t a m u scle .
■ Th is in cisio n t h ro u g h t h e fa scia e xt e n d s t h e le n g t h o f
t h e skin in cisio n (TECH FIG 2 B).
■ Th e a n t e rio r in fe rio r e d g e o f t h e g lu t e u s m in im u s is
id e n t ifie d .
■ Th e in t e rva l b e t w e e n t h e m in im u s a n d t h e jo in t ca p -
su le is d e ve lo p e d .
■ A p o rt io n o f t h e m in im u s in se rt io n o n t h e t ro ch a n t e r
ca n b e g e n t ly re le a se d t o fa cilit a t e re t ra ct io n w it h a
cu rve d b lu n t Ho h m a n n re t ra ct o r.
■ Th e re fle ct e d h e a d o f t h e re ct u s fe m o ris is id e n t ifie d
(TECH FIG 2 C) a n d d ivid e d (TECH FIG 2 D), le a vin g a
st u m p t o re p a ir.
■ A Co b b e le va t o r ca n b e u se d t o cle a n m u scle fib e rs o ff
t h e a n t e rio r ca p su le .
■ Th e ca p su le is in cise d in lin e w it h t h e fe m o ra l n e ck a xis
(TECH FIG 2 E) a n d t h e n re le a se d in a T sh a p e a lo n g t h e
a ce t a b u la r e d g e (TECH FIG 2 F).
■ Blu n t Ho h m a n n re t ra ct o rs ca n b e m o ve d in sid e t h e
ca p su le . Th e su rg e o n m u st t a ke ca re t o b e ve ry g e n -
t le a g a in st t h e p o st e rio r fe m o ra l n e ck (TECH FIG
2 G).
■ Th e fra ct u re sh o u ld b e cle a rly e xp o se d .
■ If n e ce ssa ry, t h e d ist a l p a rt o f t h e ca p su le , w h e re it
in se rt s a n t e rio rly a t t h e b a se o f t h e n e ck, ca n b e
re le a se d , co n ve rt in g t h e T a rt h ro t o m y t o a la zy H (o r
a n I).
■ A sm a ll skin in cisio n is m a d e a t t h is le ve l, a n d t h e so ft
t issu e s a re sp re a d d o w n t o t h e jo in t ca p su le .
■ Wit h flu o ro sco p ic ve rifica t io n o f p o sit io n , a sm a ll ca p -
su lo t o m y is p e rfo rm e d t o a llo w d ra in a g e o f t h e
h e m a t o m a fro m t h e ca p su le .
■ A b lu n t su cke r t ip ca n b e in se rt e d t h ro u g h t h is sm a ll
in cisio n t o e va cu a t e a n y re m a in in g h e m a t o m a .
■ Th is sh o u ld b e d o n e g e n t ly a n d sp a rin g ly, a n d o n ly if
n e ce ssa ry fo r visu a liza t io n , a s it e n t a ils a risk o f in ju ry t o
t h e rin g o f va scu la t u re a t t h e b a se o f t h e fe m o ra l n e ck.
Fra ct u re Re d u ct io n
■ A 4.5-m m Sch a n z p in sh o u ld b e p la ce d in t h e p ro xim a l
fe m o ra l sh a ft a t t h e su b t ro ch a n t e ric le ve l t o fa cilit a t e
re d u ct io n . Th e u se o f a T-h a n d le ch u ck w ill a llo w e a sie r
m a n ip u la t io n o f t h is p in .
■ A 2.5-m m t e rm in a lly t h re a d e d Kirsch n e r w ire is
p la ce d in t h e fe m o ra l h e a d a t t h e a rt icu la r m a rg in t o
se rve a s a jo yst ick in t h e p ro xim a l (h e a d ) fra g m e n t .
So m e t im e s it is n e ce ssa ry t o u se t w o su ch jo yst icks t o
a ccu ra t e ly p o sit io n t h e h e a d , w h ich , b e ca u se o f it s
sp h e rica l n a t u re , m a y b e d ifficu lt t o p o sit io n a lo n g
t h re e a xe s sim u lt a n e o u sly.
■ Re d u ct io n is p e rfo rm e d u n d e r d ire ct visu a liza t io n u sin g
t h e Kirsch n e r w ire a n d Sch a n z p in t o m a n ip u la t e t h e
fra g m e n t s.
■ In t e rn a l ro t a t io n o f t h e sh a ft , a lo n g w it h e xt e rn a l
ro t a t io n a n d a d d u ct io n (va lg u siza t io n ) o f t h e h e a d
fra g m e n t , is u su a lly re q u ire d .
■ Occa sio n a lly a b o n e h o o k u n d e r t h e m e d ia l in fe rio r
p o rt io n o f t h e n e ck w ill h e lp .
■ Th e re d u ct io n is ve rifie d b y ke yin g t h e o p p o sin g co r-
t ica l su rfa ce s o n t h e a n t e rio r, su p e rio r, a n d in fe rio r
n e ck t o g e t h e r u n d e r d ire ct visu a liza t io n . A fin g e r ca n
b e g e n t ly u se d t o fe e l t h e su rfa ce s a n d ve rify a
sm o o t h re d u ct io n w it h o u t g a p s o r t ra n sla t io n . Ha rd
in st ru m e n t s sh o u ld n o t b e u se d fo r t h is t o a vo id d a m -
a g e t o t h e d e lica t e b lo o d ve sse ls o n t h e n e ck.
■ Th e re d u ct io n is t e m p o ra rily st a b ilize d w it h a t le a st t w o
t e rm in a lly t h re a d e d 2.5-m m Kirsch n e r w ire s p la ce d fro m
t h e la t e ra l fe m o ra l co rt e x.
■ It is ve rifie d b y flu o ro sco p y in t w o p la n e s.
■ Wh e n t h e re d u ct io n is a n a t o m ic a n d t e m p o ra rily st a b i-
lize d , d e fin it ive fixa t io n d e vice s (ca n n u la t e d scre w
g u id e w ire s, slid in g h ip scre w , o r ce p h a lo m e d u lla ry n a il
g u id e ) a re p o sit io n e d .
Scre w Pla ce m e n t
■ Scre w fixa t io n is p e rfo rm e d a s d e scrib e d a b o ve fo r p e r-
cu t a n e o u s st a b iliza t io n .
 Ch a p t e r 3 8 ORIF AND CLOSED REDUCTION AND PERCUTANEOUS FIXATION OF FEM ORAL NECK FRACTURES 339

Reflected head of

TECHNIQUES
rectus femoris m.

A D
Tensor fascia lata Anterior capsule

E
Articular cartilage
Gluteus maximus m. of femoral head
Level of greater trochanter
B below the fascia
Posterior edge
Anterior of TFL

Cephalad Caudad

F Femoral neck
Femoral head
C Posterior
Hip joint capsule

TECH FIG 2 • A. La n d m a rks fo r Wa t so n -Jo n e s a p p ro a ch : A SIS,

a n t e rio r su p e rio r ilia c sp in e ; TFL, t e n so r fa scia la t a ; GT, g re a t e r
t ro ch a n t e r; F, fe m u r. Th e cro ssh a t ch e d lin e is t h e in cisio n .
B. In t e rva l fo r Wa t so n -Jo n e s a p p ro a ch , sh o w n h e re b e t w e e n
t e n so r fa scia la t a a n t e rio rly a n d g lu t e u s m a xim u s p o st e rio rly, is
in d ica t e d b y t h e p o sit io n o f t h e fo rce p s. C. Th e a n t e rio r su rfa ce
o f t h e h ip jo in t ca p su le h a s b e e n cle a re d o ff. Th e re t ra ct o r a t
G
t h e t o p o f t h e p ict u re (a n t e rio r o n t h e p a t ie n t ) is u n d e r t h e
t e n so r fa scia la t a , a n d t h e re t ra ct o r t o t h e le ft sid e o f t h e p ic-
t u re (ce p h a la d ) is u n d e r t h e le a d in g e d g e o f t h e g lu t e u s m in im u s. Th e re fle ct e d h e a d o f t h e re ct u s fe m o ris, a t t a ch -
in g o n t h e t o p o f t h e jo in t ca p su le , is g ra sp e d b y t h e fo rce p s. D. Th e re fle ct e d h e a d o f t h e re ct u s fe m o ris h a s b e e n
d ivid e d a n d t a g g e d w it h su t u re . E. Th e sca lp e l is in p o sit io n t o p e rfo rm a rt h ro t o m y o f t h e a n t e rio r ca p su le in lin e
w it h fe m o ra l n e ck. Th e su t u re s a re in t h e p ro xim a l st u m p o f t h e re fle ct e d h e a d o f t h e re ct u s. F. A T-ca p su lo t o m y h a s
b e e n p e rfo rm e d , w it h t h e t ra n sve rse a rm t o w a rd t h e a ce t a b u lu m (p ro xim a l). G. Th e fe m o ra l n e ck is e xp o se d w it h
t h e g e n t le u se o f Ho h m a n n re t ra ct o rs in sid e t h e ca p su le .
 340 Se c t i o n III PELVIS AND HIP
■ Fo r h ig h -an g le t ra n scervica l fra ct u re s (Pau w els 3), a lag
TECHNIQUES
scre w sh o uld be p o sit io n e d in a m o re h orizon t a l o rien ta-
tion , p e rpen d icula r to t h e fra ct ure p la n e , t o p ro vide co m-
p re ssio n, w h ich w ill re sist the t e n de n cy fo r sh e a r fo rces t o
d isp lace the fra ct u re .
■ Alt e rn a t ive ly, a fixe d -a n g le im p la n t su ch a s a slid in g h ip
scre w o r ce p h a lo m e d u lla ry n a il co u ld b e u se d a n d m a y
g ive b e t t e r m e ch a n ica l fixa t io n in a co m m in u t e d fra ct u re
o r Pa u w e ls 3 fra ct u re p a t t e rn .
■ Re d u ct io n a n d im p la n t p o sit io n sh o u ld b e ve rifie d w it h
t h e C-a rm .
CEPHALOMEDULLARY NAIL FIXATION
■ Th e p a t ie n t is p o sit io n e d o n t h e fra ct u re t a b le a s
n o t e d a b o ve , flu o ro sco p ic visu a liza t io n is co n firm e d ,
a n d t h e le g a n d h ip is p re p a re d a n d d ra p e d in a st e rile
fa sh io n .
■ Circu m fe re n t ia l p ro xim a l t h ig h p re p a ra t io n is
im p o rt a n t .
■ Pre o p e ra t ive a n t ib io t ics a re g ive n .
In cisio n a n d Disse ct io n
■ A sm a ll in cisio n , u su a lly 3 t o 4 cm lo n g , is m a d e se ve ra l
ce n t im e t e rs p ro xim a l t o t h e t ip o f t h e g re a t e r t ro ch a n t e r
t o a llo w p a ssa g e o f t h e n a il (TECH FIG 3 ).
■ A p e rio st e a l e le va t o r ca n b e u se d t o sp re a d t h e g lu t e u s
m e d iu s fib e rs in lin e w it h t h e in cisio n .
■ Blu n t d isse ct io n w it h a n e le va t o r o r a fin g e r p ro vid e s a c-
ce ss t o t h e st a rt in g p o in t . Th e t ip o f t h e g re a t e r
t ro ch a n t e r is p a lp a t e d . Th e t e n d o n o f t h e g lu t e u s m e d iu s
a t t a ch in g t o t h e t ro ch a n t e r ca n b e fe lt a n d is p ro t e ct e d .
St a rt in g Po in t a n d Re a m in g
■ Usin g flu o ro sco p y, a st a rt in g p o in t is o b t a in e d fo r t h e
n a il a t t h e m e d ia l e d g e o f t h e g re a t e r t ro ch a n t e r fo r a
t ro ch a n t e ric st a rt in g ce p h a lo m e d u lla ry n a il.
■ Th e st a rt in g p o in t sh o u ld b e ju st la t e ra l t o t h e p iri-
fo rm is fo ssa (TECH FIG 4 A).
TECH FIG 3 • La n d m a rks fo r ce p h a lo m e d u lla ry n a il p la ce -
m e n t . Th e ilia c cre st is m a rke d a n d t h e t ro ch a n t e r is o u t lin e d .
Th e in cisio n is in lin e w it h t h e fe m o ra l sh a ft a n d se ve ra l ce n -
t im e t e rs p ro xim a l t o t h e t ip o f t h e t ro ch a n t e r.
Wo u n d Clo su re
■ Wo u n d clo su re in clu d e s re p a ir o f t h e ca p su le , re st o ra t io n
o f t h e re fle ct e d h e a d o f t h e re ct u s, a n d clo su re o f t h e
fa scia la t a .
■ La ye re d clo su re o f t h e skin a n d st e rile d re ssin g s co m -
p le t e t h e jo b .
■ Po rt a b le ra d io g ra p h s in t h e o p e ra t in g ro o m w it h t h e p a -
t ie n t st ill a sle e p , w it h t h e b a ck t a b le st ill st e rile , a re u se -
fu l t o a vo id n a st y su rp rise s in t h e re co ve ry ro o m .
■ Alt e rn a t ive ly, a n a w l ca n a lso b e u se d t o o b t a in t h e
p ro p e r st a rt in g p o in t ; t h is ca n b e e sp e cia lly u se fu l in
o b e se p a t ie n t s.
■ An a n a t o m ic re d u ct io n o f t h e fe m o ra l n e ck m u st b e
a ch ie ve d b e fo re re a m in g .
■ If a n a n a t o m ic re d u ct io n ca n n o t b e a ch ie ve d b y
clo se d m e a n s, a n o p e n re d u ct io n m u st b e p e rfo rm e d .
■ Th is ca n b e d o n e b y a Sm it h -Pe t e rso n o r Wa t so n -
Jo n e s a p p ro a ch , a s d e scrib e d a b o ve .
■ An a n t iro t a t io n a l p in m a y b e u se d t o m a in t a in re -
d u ct io n (TECH FIG 4 B,C).
■ On ce re d u ct io n h a s b e e n o b t a in e d , t h e e n t ry re a m e r is
in t ro d u ce d (TECH FIG 4 D).
■ Fo r a sh o rt ce p h a lo m e d u lla ry n a il, t h e e n t ry re a m e r is
a ll t h a t is n e e d e d b e fo re n a il p a ssa g e .
■ If a lo n g ce p h a lo m e d u lla ry n a il is b e in g p la ce d , se ria l
re a m in g ca n b e p e rfo rm e d t o 1 t o 1.5 cm o ve r t h e d e -
sire d n a il d ia m e t e r.
Pro xim a l a n d Dist a l In t e rlo ckin g
■ Aft e r t h e n a il is p o sit io n e d a t t h e co rre ct d e p t h , t h e
g u id e w ire in t o t h e fe m o ra l h e a d is p la ce d .
■ Mu lt ip le flu o ro sco p ic im a g e s a re n e e d e d t o m a ke su re
t h e t ip o f t h e g u id e w ire is p la ce d w it h in t h e ce n t e r o f
t h e fe m o ra l h e a d fo r n a ils w it h a sin g le scre w g o in g
in t o t h e h e a d .
■ Ne w e r n a ils w it h m o re t h a n o n e scre w g o in g in t o
t h e h e a d m a y n e ce ssit a t e a d ju st m e n t s t o t h is t e ch -
n iq u e t o a llo w p a ssa g e o f b o t h scre w s (su ch a s p la c-
in g t h e first la g scre w slig h t ly su p e rio r t o ce n t e r
t o a llo w p a ssa g e o f t h e se co n d scre w in fe rio r t o
ce n t e r).
■ A d e p t h g a u g e is u se d t o ch e ck t h e le n g t h o f t h e
g u id e w ire .
■ Fo r ro t a t io n a lly u n st a b le fe m o ra l n e ck fra ct u re s, a n a n -
t iro t a t io n a l g u id e w ire o r scre w ca n b e p la ce d t o p re ve n t
ro t a t io n o f t h e fra ct u re w it h t a p p in g (TECH FIG 5 A).
■ Ma n y n a il syst e m s a llo w a p in t o b e p la ce d t h ro u g h a
sh e a t h a t t a ch e d t o t h e jig , o r h a ve a n a n t iro t a t io n a l
b a r.
■ A re a m e r is t h e n u se d t o o p e n t h e o u t e r co rt e x o f t h e
fe m u r a n d is co n t in u e d in t o t h e h e a d u n d e r flu o ro sco p ic
g u id a n ce .
 Ch a p t e r 3 8 ORIF AND CLOSED REDUCTION AND PERCUTANEOUS FIXATION OF FEM ORAL NECK FRACTURES 341

TECHNIQUES
A C D

TECH FIG 4 • A. In t ra o p e ra t ive AP flu o ro sco p ic vie w

sh o w in g st a rt in g p o in t a t m e d ia l e d g e o f g re a t e r
t ro ch a n t e r, in lin e w it h t h e m id -a xis o f t h e in -
t ra m e d u lla ry ca n a l. B. In t ra o p e ra t ive p h o t o g ra p h
sh o w in g lo n g e r in cisio n d ist a lly u se d t o o b t a in
a n a t o m ic re d u ct io n w it h t e m p o ra ry st a b iliza t io n p in
p la ce d t o m a in t a in re d u ct io n . C. In t ra o p e ra t ive la t e ra l
flu o ro sco p ic vie w sh o w in g p o sit io n o f t h e t e m p o ra ry
st a b iliza t io n p in a n d t h e g u id e w ire . D. In t ra o p e ra t ive
AP flu o ro sco p ic vie w sh o w in g t h e e n t ry re a m e r w it h
B a n t iro t a t io n a l p in m a in t a in in g re d u ct io n o f fra ct u re .

■ Th e re a m e r sh o u ld b e ch e cke d d u rin g p a ssa g e t o e n - ■ Mo st n a il syst e m s h a ve a se t scre w t h a t n e e d s t o b e a d -

su re t h e g u id e w ire is n o t b e in g d rive n in t o t h e p e lvis
a n d t h e re d u ct io n is n o t lo st d u rin g re a m in g .
■ Th e la g scre w is t h e n t a p p e d , a n d flu o ro sco p y is a g a in
u se d t o e n su re t h e re d u ct io n is n o t lo st .
■ Th e la g scre w is p la ce d a n d flu o ro sco p y u n d e rt a ke n in
m u lt ip le vie w s t o ru le o u t p e n e t ra t io n o f t h e su b ch o n -
d ra l su rfa ce .
■ If a d ist a l in t e rlo ck is d e sire d , it is t h e n p la ce d .
va n ce d t o g ive ro t a t io n a l co n t ro l t o t h e la g scre w .
■ If co m p re ssio n is d e sire d , t h e se t scre w t h e n n e e d s t o
b e lo o se n e d , u su a lly a q u a rt e r-t u rn o f t h e scre w -
d rive r, a cco rd in g t o t h e re co m m e n d a t io n s o f t h e in d i-
vid u a l n a il syst e m b e in g u se d .
■ As a b o ve , a p p ro p ria t e film s sh o u ld b e t a ke n w it h t h e p a -
t ie n t a sle e p . Th is m a y in clu d e p la in film s if flu o ro sco p y is
n o t a d e q u a t e (TECH FIG 5 B,C).

TECH FIG 5 • A. An t iro t a t io n a l scre w is p la ce d in

a d d it io n t o g u id e w ire b e fo re t a p p in g w h e n
u sin g a slid in g h ip scre w o r ce p h a lo m e d u lla ry
n a il. B. Pre o p e ra t ive ra d io g ra p h sh o w in g a
d isp la ce d fe m o ra l n e ck fra ct u re . C. Fin a l in t ra o p -
e ra t ive AP flu o ro sco p ic vie w sh o w in g a n a t o m ic
re d u ct io n w it h a n t iro t a t io n a l scre w w it h
ce p h a lo m e d u lla ry n a il. B C
 342 Se c t i o n III PELVIS AND HIP
TECHNIQUES
MINIMALLY INVASIVE FIXATION WITH A SLIDING HIP SCREW
Po sit io n in g , Re d u ct io n , a n d
Gu id e w ire Pla ce m e n t
■ Th e p a t ie n t is p o sit io n e d o n t h e fra ct u re t a b le a s
n o t e d a b o ve a n d in Ch a p t e r TR-8, e xce p t t h a t w e d o n o t
u se a w e ll le g h o ld e r b e ca u se o f risk o f co m p a rt m e n t
syn d ro m e . Occa sio n a lly, in p a t ie n t s w it h a d d u ct io n
co n t ra ct u re , t h e w e ll le g ca n n o t b e a b d u ct e d e n o u g h
w it h t h e h ip e xt e n d e d t o a llo w a cce ss o f t h e C-a rm . In
t h e se ca se s, t h e w e ll le g h o ld e r is u se d a s d e scrib e d in
Ch a p t e r TR-15. Flu o ro sco p ic visu a liza t io n is p e rfo rm e d ,
a n d re d u ct io n is co n firm e d t o b e a cce p t a b le in a ll
p la n e s.
■ In fe m o ra l n e ck fra ct u re s, a s o p p o se d t o in -
t e rt ro ch a n t e ric o r p e rt ro ch a n t e ric fra ct u re s, t h e re d u c-
t io n m u st b e ve rifie d a s a n a t o m ic if o n e is t o e xp e ct st a -
b ilit y a n d h e a lin g .
■ In t h is a p p ro a ch , a s o p p o se d t o t h e t e ch n iq u e d e scrib e d
in Ch a p t e r TR-15, t h e g u id e w ire is in se rt e d p e rcu t a -
n e o u sly b y p o kin g t h ro u g h t h e skin u n d e r t h e g u id a n ce
o f flu o ro sco p y a n d w it h u se o f a n a p p ro p ria t e a n g le
g u id e (TECH FIG 6 A).
■ Th e g u id e w ire is p o sit io n e d in t h e ce n t e r o f t h e fe m o ra l
n e ck a n d h e a d a s d e scrib e d in Ch a p t e r TR-15 (TECH
FIG 6 B).
B B
TECH FIG 6 • A. Pe rcu t a n e o u s in se rt io n o f a g u id e w ire w it h
a n g le g u id e . Th e g u id e is h e ld a lo n g sid e t h e le g a n d flu o ro -
sco p ic vie w s a re o b t a in e d t o ve rify p a ra lle l a lig n m e n t .
B. Flu o ro sco p ic AP im a g e sh o w in g in se rt io n o f g u id e w ire ,
w h ich h a s b e e n st a b b e d t h ro u g h t h e skin .
■ If t h e fra ct u re is ro t a t io n a lly u n st a b le (t ra n sce rvica l, co m -
m in u t e d , w id e ly d isp la ce d b e fo re re d u ct io n ), a n a n t iro -
t a t io n a l w ire o r scre w sh o u ld b e p la ce d u p t h e n e ck
a cro ss t h e fra ct u re t o p re ve n t lo ss o f re d u ct io n (se e Te ch
Fig 5A).
In cisio n a n d Pre p a ra t io n o f Bo n e
■ An in cisio n is m a d e b e g in n in g a t t h e g u id e w ire a n d e x-
t e n d in g d ist a lly fo r 4 t o 5 cm (TECH FIG 7 A).
■ A fu ll-t h ickn e ss skin -t o -b o n e in cisio n is m a d e .
■ So ft t issu e s a re g e n t ly sp re a d w it h a cla m p , a n d a n e l-
e va t o r is u se d t o cle a r t issu e fro m t h e la t e ra l co rt e x
d ist a l t o t h e p in e n t ry sit e fo r t h e le n g t h o f a t w o -
h o le p la t e .
■ Th e g u id e w ire is m e a su re d .
■ Th e re a m e r is t h e n se t t o t h is d e p t h (TECH FIG 7 B).
■ Flu o ro sco p y sh o u ld b e ch e cke d in t e rm it t e n t ly d u rin g
re a m in g b e ca u se t h e g u id e w ire ca n m ig ra t e in t o t h e
p e lvis if b o u n d b y t h e re a m e r.
Im p la n t Pla ce m e n t
■ Th e la g scre w is t h e n p la ce d o ve r t h e g u id e w ire in st a n -
d a rd fa sh io n (TECH FIG 8 ).
■ Th e fe m o ra l n e ck–sh a ft a n g le h a s b e e n se t b y p la ce m e n t
o f t h e g u id e p in , b u t it ca n b e m e a su re d in t ra o p e ra t ive ly
w it h a g u id e t o se le ct t h e a p p ro p ria t e im p la n t .
■ Th is is u su a lly a 135-d e g re e sid e p la t e if p la ce d
co rre ct ly.
■ Th e sid e p la t e is t h e n p la ce d o ve r t h e la g scre w a n d g e n -
t ly w o rke d t h ro u g h t h e so ft t issu e s u n t il it is p la ce d in t o
TECH FIG 7 • A. Aft e r sa t isfa ct o ry p o sit io n o f t h e g u id e w ire
is ve rifie d o n AP a n d la t e ra l flu o ro sco p y, t h e in cisio n is
m a rke d o n t h e skin 4 t o 5 cm in fe rio r t o t h e g u id e w ire . B. Th e
ca n n u la t e d re a m e r is u se d t o p re p a re t h e b o n e fo r t h e la g
scre w .
 Ch a p t e r 3 8 ORIF AND CLOSED REDUCTION AND PERCUTANEOUS FIXATION OF FEM ORAL NECK FRACTURES 343

TECHNIQUES
TECH FIG 8 • AP a n d la t e ra l flu o ro sco p ic
vie w s sh o w in g t h e fin a l re d u ct io n a n d fixa -
A B t io n u sin g a 3-h o le sid e p la t e .

co n t a ct w it h t h e la t e ra l co rt e x. Th e skin is q u it e m o b ile sim p ly re a p p lyin g t h e T-h a n d le scre w d rive r t o t h e la g

a n d e la st ic, a n d w it h a lit t le st re t ch in g t h e p la t e ca n b e
p o sit io n e d e a sily.
■ Fin a l se a t in g ca n b e d o n e w it h lig h t b lo w s o f a m a lle t
w it h t h e a id o f a “ ca n d le st ick” im p a ct io n d e vice .
■ A t w o -h o le p la t e is su fficie n t .
■ If la g scre w w a s n o t p la ce d w it h t h e ke y p a ra lle l t o t h e
fe m o ra l sh a ft , m o st syst e m s a llo w t h is t o b e co rre ct e d b y
scre w a n d t u rn in g t h e p la t e a n d scre w a s o n e u n it u n t il
t h e p la t e fit s a p p ro p ria t e ly.
■ Usu a lly o n ly t w o b ico rt ica l scre w s a re n e e d e d t h ro u g h
t h e sid e p la t e in t o t h e sh a ft .
■ As a b o ve , a p p ro p ria t e film s sh o u ld b e t a ke n w it h t h e p a -
t ie n t a sle e p . Th is m a y in clu d e p la in film s if flu o ro sco p y is
not adequate.

PEARLS AND PITFALLS

Im a g in g ■ Th e p a t t e rn o f in ju ry m u st b e re co g n ize d p re o p e ra t ive ly. A t ra ct io n film w it h in t e rn a l ro t a t io n ca n h e lp w it h t h is, a s
in it ia l p la in film s a re u su a lly e xt e rn a lly ro t a t e d a n d m a y b e d ifficu lt t o in t e rp re t .
■ If t h e clin ica l e xa m in a t io n is su sp icio u s d e sp it e n e g a t ive p la in film s, a scre e n in g MRI is in d ica t e d t o ru le o u t a n o ccu lt
fe m o ra l n e ck fra ct u re .
■ Alt h o u g h co n t ro ve rsia l, a CT sca n o f t h e fe m o ra l n e ck sh o u ld b e co n sid e re d in a ll t ra u m a p a t ie n t s w it h fe m u r
fra ct u re s.
Po sit io n in g ■ Pe lvic ro t a t io n : Eit h e r scisso r le g s w it h t h e fra ct u re t a b le , o r t h e t o rso is le a n e d a w a y fro m t h e a ffe ct e d sid e t o p re -
ve n t p e lvic t ilt .
■ Th e p a t ie n t s sh o u ld b e d ra p e d w id e , fro m t h e lo w e r rib s t o b e lo w t h e kn e e , t o a llo w co m p le t e a cce ss t o t h e fe m u r if
p ro b le m s a rise .
Re d u ct io n ■ In t e rn a l ro t a t io n o f t h e fra ct u re d -sid e le g h o ld e r w ill re d u ce a n t e rio r n e ck d ia st a sis.
■ Gu id e w ire jo yst icks u sin g 2.5-m m t e rm in a lly t h re a d e d Kirsch n e r w ire s a n d Sch a n z p in s ca n b e u se d t o h e lp o b t a in
re d u ct io n (u su a lly u se d w h e n a n o p e n re d u ct io n is n e ce ssa ry).
■ Re d u ct io n is fa cilit a t e d b y co m p le t e m u scle re la xa t io n .
■ An a n a t o m ic re d u ct io n is n e ce ssa ry. An o p e n a p p ro a ch sh o u ld b e u se d if t h e re is a n y q u e st io n t h a t t h e re d u ct io n is
n o t p e rfe ct .
Fixa t io n ■ Th e su rg e o n sh o u ld a vo id st a rt in g scre w s in fe rio r t o t h e le sse r t ro ch a n t e r t o m in im ize t h e risk o f su b t ro ch a n t e ric
fe m u r fra ct u re .
■ Scre w s a re p o sit io n e d a g a in st t h e fe m o ra l n e ck co rt e x, e sp e cia lly in fe rio rly a n d p o st e rio rly.
■ Fo r h ig h -a n g le fra ct u re s (Pa u w e ls t yp e 3), t h e su rg e o n sh o u ld co n sid e r u sin g a n a d d it io n a l h o rizo n t a l scre w , slid in g
h ip scre w , o r ce p h a lo m e d u lla ry n a il.
■ If t h e fra ct u re is co m m in u t e d o r ro t a t io n a lly u n st a b le , t h e su rg e o n sh o u ld co n sid e r p la cin g a slid in g h ip scre w o r
ce p h a lo m e d u lla ry n a il.
■ If u sin g a slid in g h ip scre w o r ce p h a lo m e d u lla ry n a il, t h e t ip –a p e x d ist a n ce sh o u ld b e 25 m m o r le ss, ca lcu la t e d b y
a d d in g t h e d ist a n ce fro m t h e ce n t e r o f t h e fe m o ra l h e a d a t t h e le ve l o f t h e su b ch o n d ra l b o n e t o t h e t ip o f t h e scre w
o n b o t h t h e AP a n d la t e ra l ra d io g ra p h s.

POSTOPERATIVE CARE OUTCOMES

■ In the elderly, mentally competent patient with stable fixa- ■ The 1-year mortality rate is about 20% in the elderly.4
■ About 50% of patients return to their previous level of
tion, weight bearing is allowed as tolerated.
■ For deep vein thrombosis prophylaxis, the length and type function.3
of treatment are controversial, but some form of prophylaxis
should be given at least during the patient’s hospital stay. COMPLICATION S
■ A first-generation cephalosporin is given for 24 hours post- ■ There is a 16% rate of avascular necrosis with displaced
operatively. femoral neck fractures.2
344 Se c t i o n III PELVIS AND HIP
■ There is a 33% rate of nonunion with displaced femoral
neck fractures.2
REFEREN CES
1. Cummings SR, Rubin SM , Black D. The future of hip fractures in the
United States: numbers, costs, and potential effects of postmenopausal
estrogen. Clin Orthop Relat Res 1990;252:163–166.
2. Lu-Yao GL, Keller RB, et al. O utcomes after displaced fractures of
the femoral neck: a meta-analysis of 106 published reports. J Bone
Joint Surg Am 1994;76A:15–25.
3. Pajarinen J, Lindahl J, et al. Pertrochanteric femoral fractures treated
with a dynamic hip screw or a proximal femoral nail. J Bone Joint
Surg Br 2005;87B:76–81.
4. Rogmark C, Johnell O . Primary arthroplasty is better than internal
fixation of displaced femoral neck fractures. Acta O rthop 2006;77:
359–367.
5. Verheyen CC, Smulders TC, van Walsum AD. H igh secondary dis-
placement rate in the conservative treatment of impacted femoral
neck fractures in 105 patients. Arch O rthop Trauma Surg 2005;125:
166–168.
 Ce p h a lo m e d u lla r y Na ilin g o f
Ch a p t e r 39 t h e Pro x im a l Fe m u r
Th o m as A . Ru sse ll
DEFIN ITION
■ Fractures of the proximal femur are usually grouped into
four major types reflecting differences in the anatomic and
physiologic character of these regions:
■ Femoral head fractures
■ Intracapsular femoral neck fractures
■ Pertrochanteric
fractures (also referred to as in-
tertrochanteric and peritrochanteric), which include proxi-
mal extracapsular fractures of the femoral neck region to
the region along the lesser trochanter before the develop-
ment of the medullary canal
■ Subtrochanteric fractures
■ Cephalomedullary nailing is the surgical stabilization of the
fracture with an intramedullary device usually inserted
through the piriformis fossa, the lateral greater trochanter, or
the medial greater trochanter.
■ The cephalic or femoral head portion of the fixation con-
struct is one or more screw or blade devices interlocked with
the nail component of the construct.
■ Cephalomedullary nails are most commonly indicated in ex-
tracapsular peritrochanteric and subtrochanteric fractures.
Although there is occasional overlap of these regions, the per-
sonality of the fracture will be predominantly one of these
major types.
AN ATOMY
■ The transitional anatomy from the femoral head to the sub-
trochanteric region affords very different fracture pathogene-
ses, affecting the surgical opportunity for repair.
■ Intracapsular fractures of the femoral neck are critically
dependent on the vascular supply from the medial femoral
circumflex artery for fracture repair and maintenance of
vascularity of the femoral head to avoid avascular necrosis.
■ Conversely, the well-vascularized pertrochanteric region
is dependent on the structural integrity of an essentially
solid cancellous bone block from the triangle of Ward to the
lesser trochanter, where the solid nature of the structure
changes to a tubular construct with the origin of the femoral
medullary canal (FIG 1 A).
■ Subtrochanteric fractures incur the highest stresses in the
proximal femur owing to their tubular anatomy, which places
high degrees of stress on the implants used for their fixation.
■ The muscular attachments of the gluteus medius in the lat-
eral aspect of the greater trochanter and the iliopsoas insertion
in the lesser trochanter are key determinants in the deforming
forces associated with fracture displacement and functional re-
covery after injury (FIG 1 B).
PATHOGEN ESIS
■ Fractures of the proximal femur fall into three mechanistic
categories:
■ Low-energy same-level falls, predominantly in the senior
population (50 to 80 years), often associated with osteo-
porosis and muscular atrophy
■ H igh-energy trauma in the 18- to 45-year age group from
motor vehicle collisions and falls from greater heights,
resulting in fractures with marked displacement and
comminution
■ Pathologic fractures, often the first indication of a neo-
plastic process
N ATURAL HISTORY
■ To obtain any real hope of ambulatory recovery, surgical
treatment is necessary for complete fractures, as the resulting
deformity of a nonoperatively treated hip invariably results in
significant shortening and varus deformity.
■ Functional recovery is actually very poor despite surgical
treatment of these fractures with conventional techniques in
the 50- to 80-year age group.
■ The American Academy of O rthopaedic Surgeons esti-
mates a 24% mortality rate in patients older than 50 within
1 year after fracture, and only 25% of patients make a full
recovery.2
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Pertinent history for a hip fracture patient focuses on the
mechanism of injury for insight into the potential quality of
bone available for repair and associated injuries in high-energy
trauma.
■ Associated injuries or premorbid diseases may coexist with
the fracture diagnosis. Syncopal episodes resulting in a fall may
bring attention to cardiovascular and neurologic disease states.
■ A history of any tumor or malignant disease, including the
last mammogram and breast examination in women older than
45 and the last prostate examination in men older than 40,
may suggest an underlying pathologic etiology for the fracture.
■ Drug use, either illicit or prescribed, as a confounding and
contributing factor must be sought.
■ Unfortunately, nursing home and institutionalized patients
must be examined for potential neglect and abuse.
■ The physical findings of a displaced hip fracture are short-
ening of the extremity, deformity of rotation compared to the
contralateral extremity, and pain or crepitance with motion at
the hip.
■ Shortening and rotational deformity may be the result of
varus deformity at the hip from associated muscular pull or
telescoping of 100% displaced fragments.
■ Examination should also include the Lippmann test (auscul-
tation). Decreased tone or pitch implies fracture. Sound
conduction through the pelvis and hip from the pelvis is inter-
rupted by any discontinuity from the patella, femur, or pelvis
articulations.
345
346 Se c t i o n IV FEM UR AND KNEE

FIG 1 • A. Ra d io g ra p h ic a n a t o m y
o f t h e p ro xim a l fe m o ra l fra ct u re
zo n e s. No t e g re a t e r t ro ch a n t e r
a n d la t e ra l w a ll a n d le sse r
t ro ch a n t e r a n d m e d ia l w a ll.
B. Mu scle a t t a ch m e n t s in
su b t ro ch a n t e ric fra ct u re s
a cco u n t in g fo r t h e su b se q u e n t
d e fo rm it y o f t h e fra ct u re . B

■ Swelling and discoloration with hematoma are signs of in- ■ Pathologic deformity (ie, Paget disease, fibrous dysplasia of
jury but are usually not acutely present. the hip)
■ Lacerations, M orel-Lavalle lesions, and decubitus ulcers ■ Pubic rami fracture

may complicate the surgical approach. ■ Acetabular fracture

■ Extracapsular proximal femur fractures extravasate blood ■ Contiguous femoral fracture

into the surrounding tissues. ■ H ip fracture-dislocation (rare)

IMAGIN G AN D OTHER DIAGN OSTIC N ON OPERATIVE MAN AGEMEN T

STUDIES
■ Plain radiographs, including an anteroposterior (AP) view of
the pelvis, AP and cross-table lateral views of the affected hip,
and AP and lateral radiographs, are required for diagnosis and
preoperative planning.
■ If a long nail implant is a consideration, AP and lateral radi-
ographs of the affected femur to the knee are required, with
special attention to femoral bow and medullary canal diameter.
■ CT or M RI scans are rarely required for displaced fractures
but may be useful in establishing the diagnosis in nonobvious
fractures and atypical fractures in high-energy trauma patients.
■ If a pathologic etiology is suspected, however, an M RI or
■ N onoperative treatment is frequently the best option in non-
ambulatory or chronic dementia patients with pain control-
lable with analgesics and rest, patients with terminal disease
with less than 6 weeks of life expected, patients with unresolv-
able medical comorbidities that preclude surgical treatment,
and patients with active infectious diseases that preclude inser-
tion of a surgical implant.
■ An exception is incomplete pertrochanteric fractures
diagnosed by M RI, which have been shown to heal with
nonoperative measures in selective patients. 1

PET scan of the body should be considered as part of the ini-

tial workup.
■ Intraoperative or preoperative traction radiography or fluo-

roscopic C-arm views may be helpful in delineating the extent

of complex fractures.
■ Intraoperative length measurements with the C-arm of the

normal femur may be helpful in selecting the correct nail

length in complex fractures (FIG 2 ).

DIFFEREN TIAL DIAGN OSIS

■ Painful arthropathy (osteoarthritis, rheumatoid arthritis,
septic) FIG 2 • Est im a t e o f n a il re q u ire d fro m in t ra o p e ra t ive
■ Established nonunion of the proximal femur ra d io g ra p h o f n o rm a l fe m u r w it h n a il in b o x.
 Ch a p t e r 3 9 CEPHALOM EDULLARY NAILING OF THE PROXIM AL FEM UR 347

■ N onoperative management must include attentive nursing
care with frequent positioning to avoid decubiti, attention to
nutrition and fluid homeostasis, and adequate analgesia or
narcotic pain suppression. Patients may be mobilized from bed
to chair as tolerated, usually after 7 to 14 days, with careful
support and elevation of the affected extremity.
■ Fracture callus at 3 weeks markedly decreases motion-related
pain, and by 6 weeks most patients can be lifted into a wheel-
chair or reclining chair.
■ Ambulatory ability should not be anticipated after nonoper-
ative treatment of displaced fractures.
■ Russell-Taylor type IIA fractures are fractures involving
the greater trochanter and lateral wall but have the possi-
bility of restoration of medial cortical stability. Reverse
obliquity patterns fall into this group. If the greater
trochanter is displaced, open reduction and stabilization
are required. Trochanteric portal cephalomedullary nails
are recommended if a nail technique is preferred. Pi-
riformis nails may not obtain sufficient stability of the
proximal femur. O pen plate and screw reduction with an
indirect reduction technique may be preferred in this group
of patients.
■ Russell-Taylor type IIB fractures are the most unstable frac-

SURGICAL MAN AGEMEN T tures, with fracture extension into the greater trochanteric
■ Surgical management, once selected, should be performed as region, and have lost medial cortical stability. Trochanteric
soon as any correctable metabolic, hematologic, or organ sys- cephalomedullary nails are the preferred nail option for this
tem instabilities have been rectified. Usually this is within the group if a stable nail construct can be obtained, or alterna-
first 24 to 48 hours for most patients. tively a 95-degree angle plate and screws. These are very com-
■ The literature is inconclusive as to increased mortality plex fractures to treat with nail techniques, and new locking
after this time, but patient suffering and hospital efficiencies plate designs may be advised in the future based on future
demand timely intervention. clinical studies.
■ Reverse obliquity patterns and lateral wall fractures oc-
Preoperative Planning
curring in the perioperative period have been identified as
■ Standard AP pelvis and AP hip radiographs are usually
obtained. Cross-table lateral and films in traction are useful if
the hip fracture pattern is complex. H ip fractures are three-
dimensional entities, and this is readily apparent in high-energy
trauma cases. Full-length radiographs of good quality are re-
quired before surgery to evaluate the full extent of damage to
the femur, to estimate the length and diameter of implant selec-
tions, and to avoid neglect of skip lesions or segmental damage
to the femur.
■ Classifications for pertrochanteric and subtrochanteric hip

fractures have not been particularly helpful in clinical situa-

tions, although increased surgical complexity is associated
with unstable fracture patterns.5
■ Unstable characteristics include posteromedial large sepa-

rate fragmentation, basicervical patterns, reverse obliquity

patterns, and displaced greater trochanteric or lateral wall
fractures. IA IB
■ The Evans, Kyle, AO /O TA, and Russell-Taylor classifica-

tions are commonly referred to in the literature.

■ The Russell-Taylor classification assists in implant selection

for the proximal femur by drawing attention to the high-risk

attributes of the proximal femoral anatomy, particularly the
absence or presence of fracture extension into the greater
trochanter (lateral wall), referred to as group I (intact greater
trochanteric region) and group II (fracture extension), and sec-
ondly the absence or presence of medial cortical stability in the
lesser trochanteric region, referred to as type A (stable contact
possible) and type B (fracture instability) (FIG 3 ). 17
■ Russell-Taylor type IA fractures are in reality high diaphy-

seal femoral fractures within 5 cm of the lesser trochanter

and are preferentially treated with conventional interlocking
nails. with the surgeon’s choice of either trochanteric or pir-
iformis entry devices.
■ Russell-Taylor type IB fractures are fractures at the dia-
physeal–metaphyseal junction of the proximal femur with
medial instability due to fracture comminution. The greater
trochanter and lateral wall are intact, and cephalomedullary
nails, either of the reconstruction nail class or gamma nail
class, are indicated, with either a trochanteric or piriformis
entry type of device with the respective portal.
IIA IIB
FIG 3 • Russe ll-Ta ylo r classificat io n . Typ e IA fra ct u re s are in
re ality h ig h d iap h yse a l fe m ora l fra ct u re s wit h in 5 cm of t h e lesse r
tro ch a n t er. Typ e IB fra ctu res a re fra ct ure s at t h e d ia ph ysea l–
me ta p h ysea l ju n ct io n o f th e p ro xim al fem u r w it h med ia l insta bil-
ity due to fract ure co mm inut io n. Type IIA fract ures invo lve t he
g re at e r t ro ch a nt er a n d la te ra l wa ll b u t h a ve t h e p ossibilit y of
re st o rat io n o f m e dial co rtica l st a b ility. Type IIB fra ctures a re th e
mo st u n st ab le fra ctu res, w ith fractu re ext en sio n in to th e grea te r
tro ch a n t eric reg io n , a nd have lost me d ial co rt ica l stab ilit y.
348 Se c t i o n IV FEM UR AND KNEE

high-risk patterns for sliding compression hip screw-type
implant failure, with secondary displacement and failure to
maintain the reduction. This calls into question our ability to
differentiate stable from unstable pertrochanteric fractures.4,12
■ Determination of the preoperative neck–shaft angle and
These implants are designed to have a piriformis portal for in-
sertion, usually with the shaft component straight in the AP
plane, or a trochanteric portal with the shaft component later-
ally angulated proximally.
■ M odern trochanteric designs have moved to a 4-degree

medullary canal diameter is paramount to selection of the cor- proximal bend positioned above the lesser trochanteric re-
rect nail device, as different manufacturers have different gion, which seems to be most compatible with anatomic
neck–shaft angle and diameter nails. Another important con- restoration of the fracture. 11
sideration is nail curvature for long nails. Curved nails with a ■ Reconstruction design nails (two smaller screws into the

1.5- to 2-meter radius are applicable to most situations, but
the surgeon must beware of patients with excessive curvature
or tertiary curves in the distal third of the femur, as distal pen-
etration of long nails has been reported.10
■ Cephalomedullary nailing involves fixation of the femoral
head coupled with an intramedullary shaft implant (FIG 4 ).
head) (Russell-Taylor Reconstruction N ail, TriGen; Smith
& N ephew) have the usual advantage of a smaller head
diameter (average 13 to 15 mm) and may be of a piriformis
or trochanteric portal design, whereas the traditional
trochanteric portal (Gamma; Stryker-H owmedica), IM H S
(Smith & N ephew) nails have a single large-diameter femoral

A B

C D

FIG 4 • Ce p h a lo m e d u lla ry n a il t yp e s fro m Sm it h & Ne p h e w , In c. A. Ga m m a

Cla ss IMHS. B. Pirifo rm is TriGe n Re co n st ru ct io n Na il. C. Tro ch a n t e ric TriGe n
Re co n st ru ct io n Na il. D. In t e g ra t e d In t e rlo ckin g In t e rTa n Na il. (A,D: Co u rt e sy
o f Sm it h & Ne p h e w , In c., Me m p h is, TN.)
 Ch a p t e r 3 9 CEPHALOM EDULLARY NAILING OF THE PROXIM AL FEM UR 349

FIG 5 • A. AP o ve r-t h e -t o p C-a rm

p o sit io n . B. La t e ra l C-a rm p o sit io n
fo r t ru e la t e ra l o f h ip . C. Scisso rs
p o sit io n o f le g s a n d a n g u la t io n o f
C-a rm h e a d fo r t ru e a lig n m e n t .
D. La t e ra l d e cu b it u s p o sit io n w it h
C-a rm . B D

head fixation screw and have proximal shaft diameters around decubitus position will also require adjustment of the C-arm to
16 to 18 mm. correct parallax error (FIG 5 D).
■ N ew-generation trochanteric nails are moving to smaller

geometries of 15.5 to 17 mm in diameter to conserve bone

stock.
■ N ew designs in femoral head fixation are also in use, with spi-
ral blade nail devices for femoral head fixation (TFN , Synthes)
and integrated interlocking two-screw fixation (InterTan, Smith
& Nephew) with the design goal of improving fracture stability.
Approach
■ The surgical approach for the entry is common for all ante-
grade proximal femoral nailing.
■ The incision is usually 3 to 4 cm long and is about 2 cm
proximal to the greater trochanter, centered over the extrapo-
lated middle third of the trochanter.
■ In obese or muscular individuals, this can be referenced

Positioning by a line drawn transversely from the anterior inferior iliac

■ Intramedullary techniques for the proximal femur are best spine and the lateral position of the incision determined by
managed with a modern fracture table with image intensifica- the C-arm true lateral with a radiographic marker on the
tion (C-arm) capabilities. skin (FIG 6 ).
■ Although the lateral decubitus approach may be helpful for ■ This approach should not damage the gluteus medius mus-

reverse obliquity patterns, the supine position is usually pre- cle, so aggressive traction or manipulation through the muscle
ferred because of the ease of setup and radiographic visualiza- should be avoided. The surgeon should always instrument and
tion in a familiar frame of reference. ream the femur with soft tissue protection in mind.
■ We prefer bilateral foot traction with knees in extension with

the legs scissored, although attachment to the fracture table via

skeletal traction through the distal femur or proximal tibia is
used if there are other injuries about the knee, leg, or foot.
■ The operative leg is raised to about 20 to 30 degrees

of flexion and the nonoperative extremity is extended 20 to

30 degrees.
■ The legs are pulled in line with the body to avoid varus

positioning of the hip.

■ The C-arm is brought in from the opposite side with the

base parallel to the operative extremity, centered on the mid-

femur such that the cephalad–caudad movement of the C-
arm gives good visualization of the femoral head and shaft in
AP and lateral views.
■ With this type of setup, the true AP of the hip is usually

obtained with 10 to 20 degrees of rotation of the C-arm over

the top and the true lateral corresponds to about 15 to 30 de- FIG 6 • Skin in cisio n p o sit io n re fe re n cin g t h e a n t e rio r in fe rio r
grees over the horizontal position (FIG 5 A–C). The lateral ilia c sp in e .
 350 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES

FRACTURE REDUCTION
■ Re d u ct io n o f t h e fra ct u re is t a n t a m o u n t t o su cce ss. My
p re fe rre d t e ch n iq u e fo r t h e p ro xim a l fe m u r in vo lve s a
fo u r-st e p t e ch n iq u e .
■ Aft e r a t t a ch m e n t t o t h e fo o t p o sit io n e r o r ske le t a l
t ra ct io n w it h t h e p e rin e a l p o st a t t a ch e d , p o st e rio r
sa g is co rre ct e d a t t h e fra ct u re w it h a fo rce d ire ct e d
fro m p o st e rio r t o a n t e rio r a n d m a in t a in e d .
■ Th e le g is fle xe d t h ro u g h t h e fo o t h o ld e r 20 t o 30 d e -
g re e s fro m n e u t ra l fo r in t e rt ro ch a n t e ric p e rso n a lit y
fra ct u re s a n d 30 t o 40 d e g re e s fo r su b t ro ch a n t e ric
p e rso n a lit y fra ct u re s, m a in t a in in g t h e p o st e rio r-t o -
a n t e rio r re d u ct io n fo rce a t t h e h ip (TECH FIG 1 A).
■ Tra ct io n is a p p lie d t o re st o re le n g t h in lin e w it h t h e
b o d y. No va ru s!
■ The leg is rot at ed t o alig n w it h the p ro xim al frag m en t,
5 to 15 de grees of ext erna l rot at ion for m ost sub-
tro cha n t eric pe rso n a lit y fra cture s a n d 10 t o 15 o f inte r-
n al rot a t io n fo r in t e rtroch a nt eric p erso n alit y fractu re s.
■ Acce p t a b le a lig n m e n t is co n firm e d w it h t h e C-a rm in
b o t h vie w s. Th e su rg e o n e n su re s t h e re is a d e q u a t e ro o m
in t h e p e lvic a n d a b d o m in a l a re a s fo r t h e in se rt io n o f t h e
w ire s, re a m e rs, a n d im p la n t s in re la t io n t o t h e fra ct u re
t a b le . A 3-lit e r b a g o f sa lin e m a y e le va t e t h e p e lvis h ig h
e n o u g h t o a llo w ro o m fo r t h e in st ru m e n t a t io n .
■ Th e re d u ct io n ca n t h e n b e fin e -t u ne d w it h in t ra m e d u lla ry
in st ru m e n t s o r b y p e rcu t a n e o u s jo yst icks o r p u sh e rs
(TECH FIG 1 B,C).
■ If t h e re d u ct io n is n o t a cce p t a b le a t t h is p o in t , t h e
su rg e o n sh o u ld st o p a n d re -e va lu a t e t h e p o sit io n o f t h e
C-a rm a n d t h e a m o u n t o f t ra ct io n (t o o lit t le o r t o o
m u ch ). Th e su rg e o n sh o u ld n o t st a rt re a m in g t h e p ro xi-
m a l fe m u r u n t il re d u ct io n co n t ro l is d e m o n st ra t e d .
■ If re d u ct io n ca n n o t b e o b t a in e d b y jo yst icks a n d p e rcu t a -
n e o u s b o n e h o o ks (TECH FIG 1 D), t h e su rg e o n sh o u ld
p ro ce e d t o o p e n re d u ct io n u sin g t h e lo w e r p o rt io n o f a
Wa t so n -Jo n e s–t yp e a p p ro a ch t o t h e h ip (TECH FIG 1 E–I).
■ Th e su rg e o n sh o u ld a vo id d isse ct in g t h e m e d ia l so ft t is-
su e e n ve lo p e , w h e re t h e va scu la rit y is lo ca t e d . A sin g le
ce rcla g e w ire w ill b e m o st h e lp fu l if t h e re is a co ro n a l
sp lit o f t h e p ro xim a l fra g m e n t . Use o f m u lt ip le ca b le s o r
w ire s is a vo id e d . Th e cla m p s a n d re d u ct io n t o o ls a re
m a in t a in e d a s t h e im p la n t is in se rt e d .

A B

C D E

F G H I

TECH FIG 1 • A. Re d uction m an e uve r w it h fo rce d ire ct e d p ost e rio r t o a n te rio r a t th e fract u re to a lig n a n te rior
co rtice s, fle xio n o f d ista l fra g m e n t to m a t ch p ro xim a l fra g me n t , a n d th e n lo n g it u d in a l t ra ct io n . B. Percu t an e ou s
Sch an z p in as jo yst ick in p ro xim al fra g m en t . C. Pe rcu t an e ou s jo yst ick ecce nt rically place d t o allo w p a ssag e o f re-
ducer. D. Pe rcuta neou s joystick and percut ane ous bo ne hook. E. Op en re d u ct io n Wat so n -Jo n e s w it h tw o clam p s
for irre d ucible h ig h-e n e rgy h ip fra ct ure . F. Open reduction AP ra diograph. G. Open reduction lat eral rad io gra ph.
H,I. AP a n d la te ra l ra d io g rap h s sh o w in g fin al resu lt .
 Ch a p t e r 3 9 CEPHALOM EDULLARY NAILING OF THE PROXIM AL FEM UR 351

PRECISION PORTAL PLACEMENT AND TRAJECTORY CONTROL
■ The rat io nale for t he m inim a lly inva sive cep halo m edu llary
su rg ica l te chn iq u e is b ase d on t hree con ce p t s t o m axim ize
b on e a nd soft t issu e con se rva t ion d u rin g n a il imp lan t a -
tio n and t o m in im ize th e po te nt ia l fo r ma la lig n m e n t 16 :
■ Pre cisio n p o rt a l p la ce m e n t
■ Tra je ct o ry co n t ro l
■ Po rt a l p re se rva t io n
■ A p re cise st a rt in g p o in t is t h e first crit e rio n in e n su rin g
a n a ccu ra t e re d u ct io n o f p ro xim a l fra ct u re s, w h e t h e r t h e
e n t ry p o rt a l is a m o d ifie d t ro ch a n t e ric e n t ry p o rt a l o r a
p irifo rm is p o rt a l a s d e fin e d b y t h e se le ct e d n a il g e o m e -
t ry (TECH FIG 2 A,B).
■ Th e p ro xim a l fe m u r is fille d w it h a so lid ca n ce llo u s b o n e
a rch it e ct u re fro m t h e fe m o ra l h e a d re g io n u n t il t h e le ve l
TECHNIQUES
ju st b e lo w t h e le sse r t ro ch a n t e r, w h e re t h e m e d u lla ry
ca n a l b e g in s.
■ Tra je ct o ry co n t ro l is t h e d e ve lo p m e n t o f a p re cise p a t h
fo r t h e n a il t h ro u g h t h is so lid ca n ce llo u s b o n e , w h ich w ill
re st o re t h e p ro xim a l a lig n m e n t in t h e a n t e ro p o st e rio r
a n d m e d io la t e ra l p la n e s.
■ Th is co rre ct t ra je ct o ry p a ra lle ls t h e a n t e rio r la t e ra l
co rt e x o f t h e p ro xim a l fe m u r a n d a llo w s n a il ju xt a p o -
sit io n a g a in st a so lid co rt ica l st ru ct u re (TECH FIG 2 C).
■ An in co rre ct t ra je ct o ry w ill in d u ce m a la lig n m e n t w it h
n a il in se rt io n a n d re su lt in a n u n st a b le ju xt a p o sit io n
a g a in st ca n ce llo u s b o n e o n ly, fo rcin g t h e n a il t o m i-
g ra t e t o t h e p o st e rio r co rt e x a n d re su lt in g in a fle xio n
d e fo rm it y o f t h e p ro xim a l fra g m e n t (TECH FIG 2 D,E).

A B C

D E

TECH FIG 2 • A. Ra d io g ra p h ic p o sit io n o f e n t ry p o rt a l. Me d ia l p in is m e d ia l t ro ch a n t e ric p o rt a l a n d la t e ra l p in is la t -

e ra l t ro ch a n t e ric p o rt a l. B. La t e ra l ra d io g ra p h ic p ro je ct io n o f p irifo rm is p o rt a l; t ro ch a n t e ric p o rt a ls w ill b e a lig n e d t o
b ise ct t h e fe m o ra l h e a d m o re a n t e rio rly. C. An t e ro la t e ra l t ra je ct o ry fo r n a il in p ro xim a l fe m u r. D,E. In co rre ct n a il t ra -
je ct o ry in p ro xim a l fra g m e n t . D. Ero sio n o f e n t ry p o rt a l ve rsu s co n t ro lle d re a m e d e n t ry p o rt a l. E. Fle xio n d e fo rm it y
fro m p o st e rio rly d ire ct e d p ro xim a l fra g m e n t t ra je ct o ry.

PORTAL ACQUISITION AND PROTECTION

■ On ce t h e co rre ct t ra je ct o ry is e st a b lish e d , t h e p o rt a l a n d
t h e la t e ra l w a ll o f t h e t ro ch a n t e r m u st b e p ro t e ct e d fro m
e ro sio n a n d fra g m e n t a t io n b y t h e su b se q u e n t in st ru -
m e n t s fo r fra ct u re re d u ct io n a n d ca n a l p re p a ra t io n .
■ Typ ica lly, w it h t h e p a t ie n t in a su p in e p o sit io n , t h is
e ro sio n t a ke s p la ce in a p o st e ro la t e ra l d ire ct io n d u r-
in g re a m in g o f t h e p ro xim a l fe m o ra l co m p o n e n t , fu r-
t h e r co n t rib u t in g t o a fle xe d a n d va ru s p o sit io n o f t h e
p ro xim a l fra g m e n t w h e n n a il in se rt io n o ccu rs.
■ A st e p w ise a p p ro a ch t o ca n a l p re p a ra t io n w ill sim p lify
t h e n a il in se rt io n t e ch n iq u e (TECH FIG 3 A–C).
■ Th e re a re t h re e cu rre n t ly p u b lish e d o p t io n s fo r p o rt a l
p la ce m e n t 14 :
■ La t e ra l t ro ch a n t e ric fo r n a ils w it h a p ro xim a l la t e ra l
a n g u la t io n o f m o re t h a n 5 d e g re e s
■ Me d ia l t ro ch a n t e ric p o rt a l fo r n a ils w it h a p ro xim a l
la t e ra l a n g u la t io n o f 4 t o 5 d e g re e s
■ Pirifo rm is p o rt a l fo r st ra ig h t p ro xim a l se g m e n t n a ils
 352 Se c t i o n IV FEM UR AND KNEE

■ Th e g u id e w ire d rill syst e m is in se rt e d w it h so ft t issu e p ro - ■ A ca n n u la t e d rig id re a m e r, p re fe ra b ly w it h m o d u la r

TECHNIQUES

t e ct io n t o t h e re g io n o f t h e g re a t e r t ro ch a n t e r. A 3.2-cm e n d -cu t t in g ca p a b ilit y (TriGe n ), a p p ro xim a t in g t h e

g u id e w ire is in se rt e d a b o u t 5 t o 10 m m in t o b o n e in t h e
la t e ra l a sp e ct o f t h e g re a t e r t ro ch a n t e r.
■ Th is is a p ivo t p in a b o u t w h ich a h o n e yco m b t yp e
o f t a rg e t e r ca n b e a d ju st e d t o p re cise ly p la ce t h e
d e fin it ive g u id e w ire p in a t t h e t ip o f t h e g re a t e r
t ro ch a n t e r.
■ Th e d e fin it ive g u id e w ire sh o u ld b e ju st la t e ra l t o t h e t ip
o f t h e g re a t e r t ro ch a n t e r fo r t h e la t e ra l t ro ch a n t e ric p o r-
t a l, m e d ia l t o t h e t ip o f t h e g re a t e r t ro ch a n t e r fo r t h e
m e d ia l t ro ch a n t e ric p o rt a l (se e Te ch Fig 2A), a n d m e d ia l
t o t h e t ro ch a n t e r o n t h e n a d ir o f t h e su p e rio r fe m o ra l
n e ck fo r t h e p irifo rm is p o rt a l o n t h e AP C-a rm vie w , a n d
a ll p o rt a ls sh o u ld b e ce n t e re d in t h e fe m o ra l n e ck o n t h e
la t e ra l C-a rm vie w .
■ Th e d e fin it ive g u id e w ire sh o u ld b e in se rt e d 10 t o
15 m m in t o t h e t ro ch a n t e r a n d d o e s n o t h a ve t o b e in
co rre ct ca n a l a lig n m e n t a s t h e d e fin it ive t ra je ct o ry
w ill b e o b t a in e d in t h e n e xt st e p .
■ In sertio n o f th e g u id ew ire to o d ee p ly w ill co n strain t h e
rea mer u su ally in t o a varus fracture red uctio n po sition .
This is beca use the flexib ility of the wire and the la teral
appro ach vector of t he hip w ill alwa ys place the w ire in
a varu s po sition w h en n ailin g in a sup in e po sitio n . On e
o f t he re a l a dva nta g e s of the la te ra l po sit io n is allo w-
in g a m o re d irect vect o r ap p ro ach fo r t h e g u id ew ire .
p ro xim a l n a il g e o m e t ry d ia m e t e r, is in t ro d u ce d o ve r
t h e g u id e w ire t h ro u g h t h e p ro t e ct ive sle e ve (TECH
FIG 3 D).
■ Th e rig id re a m e r o r ch a n n e l re a m e r is d ire ct e d t o -
w a rd a p o in t p ro je ct e d in t h e ce n t e r o f t h e m e d u lla ry
ca n a l ju st d ist a l t o t h e re g io n o f t h e le sse r t ro ch a n t e r
(TECH FIG 3 E).
■ Th e re a m e r is a d va n ce d in st e p w ise fa sh io n w h ile
co n firm in g m a in t e n a n ce o f t ra je ct o ry.
■ Aft e r t h e re a m e r h a s b e e n in se rt e d a b o u t 20 m m , it s t ra -
je ct o ry is co n firm e d w it h a la t e ra l C-a rm vie w .
■ Th e re a m e r sh o u ld b e d ire ct e d a lo n g t h e a n t e rio r
co rt e x o f t h e p ro xim a l fe m u r. Th e in se rt io n o f t h e
re a m e r ca n b e a d ju st e d d u rin g re a m in g t o a p p ro xi-
m a t e t h e p o sit io n d e scrib e d a n d is m o st h e lp fu l in
a vo id in g a va ru s p o sit io n o f t h e p ro xim a l fe m u r.
■ On ce t h e ca n a l is re a m e d in su ch a fa sh io n , t h e d ist a l
fe m u r is a d ju st e d w it h t h e fra ct u re t a b le t o a llo w co rre ct
n e ck–sh a ft a n g u la t io n .
■ Th e re a m e r is in se rt e d u n t il it re a ch e s t h e m e d u lla ry
ca n a l ju st b e lo w t h e re g io n o f t h e le sse r t ro ch a n t e r
(TECH FIG 3 F).
■ Th e in n e r re a m e r is re m o ve d a n d t h e o u t e r re a m e r is
m a in t a in e d fo r p ro t e ct io n o f t h e p ro xim a l re a m e r d u rin g
t h e n e xt st e p .

A B C

D E F

TECH FIG 3 • A. En t ry p o rt a l t o o l w it h h o n e yco m b d e sig n t a rg e t e r fo r p in p la ce m e n t (TriGe n , Sm it h & Ne p h e w , In c.,

Me m p h is, TN). B. In se rt io n o f e n t ry p o rt a l t o o l t h ro u g h in cisio n . C. Tw o -p in t e ch n iq u e t h ro u g h h o n e yco m b t a rg e t e r t o p re -
cise ly a cq u ire e n t ry sit e o f p in . D. Ch a n n e l re a m e r in se rt io n t h ro u g h e n t ry p o rt a l t o o l fo r so ft t issu e p ro t e ct io n . E. AP ra d i-
o g ra p h o f t ra je ct o ry fo r m e d ia l t ro ch a n t e ric p o rt a l. F. La t e ra l ra d io g ra p h o f co rre ct a n t e ro la t e ra l p o rt a l w it h ch a n n e l
re a m e r. (A: Co u rt e sy o f Sm it h & Ne p h e w , In c.)
 Ch a p t e r 3 9 CEPHALOM EDULLARY NAILING OF THE PROXIM AL FEM UR 353

FRACTURE REDUCTION AND CANAL PREPARATION
■ A fra ct u re re d u ce r (TriGe n ) o r sim ila r cu rve d ca n n u la t e d
d e vice is in se rt e d t h ro u g h t h e re t a in e d ch a n n e l re a m e r
t o t h e fra ct u re sit e a n d t h re a d e d t h ro u g h t h e fra ct u re
sit e in t o t h e d ist a l fra g m e n t in t ra m e d u lla ry ca n a l, w it h
m a n ip u la t io n in a p p ro p ria t e p la n e s t o a lig n t h e fra ct u re
(TECH FIG 4 A).
■ A lo n g g u id e ro d is in se rt e d t o t h e kn e e if a lo n g n a il is
d e sire d , co n firm in g t h a t t h e w ire d o e s n o t im p in g e o n
t h e a n t e rio r co rt e x d ist a lly.
■ Pre fe ra b ly t h e g u id e ro d sh o u ld b e in se rt e d t o t h e o ld
p h yse a l sca r a n d ce n t e re d o n AP a n d la t e ra l C-a rm
vie w s (TECH FIG 4 B).
■ Th e re d u ce r is re m o ve d a n d t h e g u id e w ire p o sit io n is
m a in t a in e d w it h a n o b t u ra t o r p ro xim a lly.
■ Le n g t h is ch e cke d w it h a n a p p ro p ria t e ru le r, a llo w in g fo r
fra ct u re d ist ra ct io n a n d n a il fin a l p o sit io n .
■ Th e d ia p h yse a l re g io n is re a m e d u p t o 1 m m o ve r t h e d e -
sire d n a il size (u p t o 2 m m fo r e xce ssive a n t e rio r b o w s)
(TECH FIG 4 C).
■ Th e p ro xim a l e xp a n sio n o f t h e n a il sh o u ld h a ve a l-
re a d y b e e n re a m e d w it h t h e e n t ry p o rt a l re a m e r, b u t
t h e su rg e o n sh o u ld a lw a ys co n firm d ia m e t e rs.
■ Th e ch a n n e l re a m e r is re m o ve d a n d t h e se le ct e d n a il is
in se rt e d (TECH FIG 4 D).
TECHNIQUES
■ Fo r lo n g t ro ch a n t e ric n a ils, it is h e lp fu l t o ro t a t e t h e
n a il 90 d e g re e s a n t e rio rly d u rin g t h e first h a lf o f t h e
n a il in se rt io n t o m in im ize h o o p st re sse s in t h e p ro xi-
m a l fe m u r. Aft e r p a rt ia l in se rt io n , t h e n a il is ro t a t e d
t o t h e a n t icip a t e d a n t e ve rsio n re q u ire d fo r fe m o ra l
h e a d fixa t io n .
■ Th e la st 5 cm o f t h e n a il is in se rt e d a ft e r re le a sin g d is-
t ra ct io n su fficie n t fo r fra ct u re a p p o sit io n , m a in t a in -
in g co rre ct ro t a t io n a l a lig n m e n t .
■ Mo st co m m e rcia l g u id e s u se re fe re n ce m a rks t o a lig n
w it h t h e fe m o ra l h e a d o n t h e la t e ra l C-a rm vie w .
Th e se sa m e g u id e s m a y b e u se d fo r C-a rm ve rifica t io n
o f co rre ct d e p t h o f in se rt io n t o a llo w o p t im a l fe m o ra l
h e a d fixa t io n .
■ Th e lo n g g u id e ro d is re m o ve d t o p ro ce e d w it h in t e r-
lo ckin g .
■ Pro xim a l in t e rlo ckin g w ill d e p e n d o n t h e t yp e o f im -
p la n t se le ct e d , b u t m o st d e sig n s re co m m e n d t h a t t h e
scre w b e p la ce d a s clo se t o ce n t e r-ce n t e r p o sit io n a s
p o ssib le .
■ If a se co n d a ry scre w is in clu d e d in t h e n a il d e sig n co n -
st ru ct s (ie , Re co n st ru ct io n o r In t e rTa n ), t h e re is u su -
a lly su fficie n t ro o m fo r t h e se co n d scre w in fe rio rly,
b u t ca re sh o u ld b e e xe rcise d in sm a ll p a t ie n t s.

A B

C D

TECH FIG 4 • A. Insert ion o f redu ce r t hrou gh chan ne l rea m er, lat era l ra diog ra ph ic vie w .
B. Re du ce r d ire ct ed g u id e ro d cen t ere d o n la te ral ra d io g rap h , a vo id in g a nt e rio r d ist al co r-
te x. C. Dia p h ysea l re a min g t h ro u g h ch a n n e l re am e r. D. Na il in sert io n . Fo r t ro ch a n t eric n ail,
t h e su rg eo n m at ch es t h e cu rve o f t h e n ail w it h t h e p ro xim al fe m u r d u rin g in it ia l in sert io n
t o m in im ize h o o p st re ss at e n t ry p o rt al. Th e n a il is ro t a t ed in t o co rrect p o sit io n a ft e r 30%
t o 50% in sert io n .
 354 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES
SINGLE-SCREW OR SINGLE-DEVICE DESIGNS (GAMMA, IMHS, TFN
[SYNTHES, PAOLI, PA])
■ Th e ce n t e r-ce n t e r w ire is in se rt e d t o w it h in 5 m m o f su b -
ch o n d ra l b o n e . Fra ct u re re d u ct io n is co n firm e d a n d t h e
le n g t h t o la t e ra l co rt e x is m e a su re d .
■ If co m p re ssio n is d e sire d (u su a lly 5 m m ), t h e su rg e o n
re a m s fo r t h e scre w a n d se le ct s a scre w 5 m m sh o rt e r
t h a n m e a su re d . Fo r t h e TFN, t h e h e a d is n o t re a m e d .
A B
TWO-SCREW RECONSTRUCTION (TRIGEN)
■ Usin g t h e p ro xim a l t a rg e t in g g u id e a t t a ch e d t o t h e n a il,
t h e su rg e o n in se rt s t h e m o st d ist a l p ro xim a l g u id e w ire
a lo n g t h e fe m o ra l ca lca r w it h in 5 m m o f t h e in fe rio r
fe m o ra l n e ck, ce n t e re d o n t h e la t e ra l C-a rm vie w , t o
w it h in 5 m m o f su b ch o n d ra l b o n e (TECH FIG 6 A).
■ Th ro u g h t h e p ro xim a l t a rg e t in g g u id e a t t a ch e d t o t h e
n a il, t h e su rg e o n in se rt s t h e m o st p ro xim a l g u id e p in ,
w h ich w ill b e clo se t o t h e ce n t e r p o sit io n o f t h e fe m o ra l
h e a d p a ra lle l t o t h e first g u id e p in . It s p o sit io n is co n -
firm e d w it h t h e C-a rm .
A B
TECH FIG 6 • A. Tro ch a n t e ric re co n st ru ct io n n a il w it h in fe rio r d rill p la ce d first a lo n g m e d ia l n e ck. B. In fe rio r la g
scre w p la ce d first . C. La t e ra l ra d io g ra p h ic vie w o f h e a d scre w p o sit io n .
■ Th e su rg e o n in se rt s t h e h e a d fixa t io n scre w o r n a il t o t h e
d e sire d d e p t h ; p o sit io n is co n firm e d o n AP a n d la t e ra l C-
a rm vie w s (TECH FIG 5 A).
■ Th e o p t io n o f co m p re ssio n a n d lo ckin g o f t h e la g scre w
w it h a se t -scre w w it h in t h e n a il is a va ila b le o n se le ct e d
syst e m s (TECH FIG 5 B,C).
TECH FIG 5 • A. Gam m a n ail AP view w ith lat -
e ra l troch a n te ric p o rt a l a n d ce n t e r-ce n te r h e a d
scre w p o sit io n . B. Ru ssell-Ta ylor IIB fractu re
w ith sh o rt In t e rTa n na il AP. C. Lat eral view .
■ Th e su rg e o n re m o ve s t h e in fe rio r g u id e w ire , d rills a n d
re a m s fo r t h e se le ct e d la g scre w fo r t h e syst e m , a n d in -
se rt s t h e in fe rio r scre w (TECH FIG 6 B).
■ Th e sa m e st e p s a re re p e a t e d fo r t h e p ro xim a l scre w , a n d
fin a l fixa t io n is co n firm e d o n AP a n d la t e ra l ra d io g ra p h s
(TECH FIG 6 C).
■ Tra ct io n is re le a se d b e fo re fin a l t ig h t e n in g o f t h e la g
scre w s t o a llo w fra ct u re co m p re ssio n .
C
 Ch a p t e r 3 9 CEPHALOM EDULLARY NAILING OF THE PROXIM AL FEM UR 355

INTEGRATED SCREW CEPHALOMEDULLARY NAIL (INTERTAN)
■ Wh e re a s t h e p re vio u s t e ch n iq u e s fo r fe m o ra l h e a d fix-
a t io n u se d d e vice s t h a t g a in co m p re ssio n b y im p a ct io n
o r co m p re ssio n a g a in st t h e la t e ra l co rt e x, t h is d e vice
u se s a g e a r d rive m e ch a n ism t h a t co m p re sse s t h e
n a il a g a in st t h e e n d o st e a l su rfa ce o f t h e m e d ia l co rt e x
a n d sim u lt a n e o u sly co m p re sse s t h e p ro xim a l fe m o ra l
h e a d a n d n e ck t o t h e m e d ia l su rfa ce o f t h e n a il (se e
Te ch Fig 5B,C).
■ This design conceptua lly im proves rot ational and trans-
lat io n al stab ility to t h e p ro ximal femo ral co nstru ct.
■ The 3.2-m m guide wire is inse rt ed t hrou gh t he proxim al
ta rge ting g uide a n d a dva n ce d in a cen t e r p osit io n o f t h e
fe m ora l he a d t o w it h in 5 m m o f su bch on dra l bo n e, aft e r
co n firm in g co rre ct d e p th a n d a n t e ve rsio n (TECH FIG
7 A–C).
■ Th e in fe rio r la t e ra l co rt e x is d rille d t h ro u g h t h e t a rg e t -
in g g u id e w it h a st e p d rill t o cle a r a w a y b o n e fro m t h e
n a il a t t a ch m e n t sit e fo r t h e g e a r d rive . Th e in fe rio r scre w
h o le is t h e n d rille d t o w it h in 5 m m o f t h e ce n t e r-ce n t e r
g u id e w ire t ip (TECH FIG 7 D).
TECHNIQUES
■ Th e d e ro t a t io n b a r is in se rt e d in t o t h e in fe rio r h o le t o
a u g m e n t fe m o ra l h e a d a n d n e ck st a b ilit y d u rin g la rg e
la g scre w re a m in g (TECH FIG 7 E,F).
■ Th e su rg e o n co n firm s t h e le n g t h fo r t h e la g scre w , su b -
t ra ct in g 5 t o 10 m m fro m t h e m e a su re d le n g t h fo r co m -
p re ssio n if d e sire d .
■ Th e 3.2 w ire is o ve rd rille d w it h t h e 10.5-m m ca n n u -
la t e d d rill, a n d t h e se le ct e d la g scre w is in se rt e d t o
w it h in 5 m m o f su b ch o n d ra l b o n e (TECH FIG 7 G).
■ Th e d e ro t a t io n b a r is re m o ve d a n d t h e co m p re ssio n g e a r
d rive scre w is in se rt e d t h ro u g h t h e g u id e . Tra ct io n is re -
le a se d fro m t h e le g a n d co m p re ssio n is st a rt e d (TECH FIG
7 H–K).
■ Co mp re ssio n t h o ug h th e g ea r d rive d oe s n o t b eg in
u n til th e h e a d o f t h e ge a r d rive scre w co nt a cts t he n ail.
■ Visu a liza t io n o f co m p re ssio n ca n b e co n firm e d b y C-
a rm a n d ca lib ra t io n s o n t h e g u id e .
■ On ce co m p re ssio n is a ch ie ve d , t h e scre w d rive rs a re d isa s-
se m b le d . St a t ic lo ckin g o f t h e scre w a sse m b ly ca n b e
a ch ie ve d w it h t h e in t e g ra t e d se t scre w w it h in t h e n a il.

A B C

D E F

TECH FIG 7 • In t e g ra t e d scre w ce p h a lo m e d u lla ry n a il (In t e rTa n , Sm it h Ne p h e w ,

In c.). A. Pilo t d rill h o le fo r 3.2-m m w ire fo r ce n t e r-ce n t e r p o sit io n . B. AP ra d i-
o g ra p h w it h ra d io lu ce n t a lig n m e n t t o w e r. C. La t e ra l ra d io g ra p h w it h ra d io lu -
ce n t g u id e ce n t e re d o ve r fe m o ra l h e a d . D. In fe rio r scre w h o le fo r d e ro t a t io n b a r
a n d co m p re ssio n scre w . E,F. De ro t a t io n b a r in se rt e d . G. Drill fo r ca n n u la t e d ce n -
G t e r la g scre w . (co n t in u e d )
 356 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES

H I

TECH FIG 7 • (co n t in u e d ) H–J. In se rt io n o f in fe rio r

co m p re ssio n scre w a n d fin a l AP a n d la t e ra l vie w s o f
in t e g ra t e d scre w s e n g a g e d . K. Sch e m a t ic o f in t e -
g ra t e d scre w s a nd n a il in fra ct u re . (K: Co u rt e sy o f
Sm it h & Ne p h e w , In c., Me m p h is, TN.) K

DISTAL INTERLOCKING TECHNIQUE

■ Sh o rt n a ils h a ve d ist a l lo ckin g ca p a b ilit y, u su a lly in a st a -
t ic o r d yn a m ic m o d e w it h m o st m o d e rn d e sig n s. I p re fe r
d yn a m ic lo ckin g .
■ Mo st syst e m s h a ve t h is h o le t a rg e t e d t h ro u g h t h e
p ro xim a l n a il g u id e , a n d a sin g le b ico rt ica l scre w is
u su a lly su fficie n t .
■ Lo n g n a ils h a ve d ist a l lo ckin g ca p a b ilit y w it h e it h e r st a -
t ic h o le s o r a co m b in a t io n o f st a t ic a n d d yn a m ic.
■ Fo r le n g t h -st a b le p ro xim a l fra ct u re s, o n e b ico rt ica l
scre w is su fficie n t in a d yn a m ic m o d e .
■ Co n ve rse ly, fo r se g m e n t a l fra ct u re s o r e xt e n sive co m -
m in u t io n , t w o scre w s m a y b e p re fe rre d .
■ Dist a l in t e rlo ckin g is m o st co m m o n ly d o n e u sin g t h e
sa m e fre e h a n d t e ch n iq u e u se d in t h e co n ve n t io n a l
fe m o ra l in t e rlo ckin g n a il t e ch n iq u e (TECH FIG 8 ).
TECH FIG 8 • Dist a l fre e h a n d t e ch n iq u e fo r lo n g n a ils.

WOUND CLOSURE FOR ALL NAILS

■ Wit h a t t e n t io n t o d e t a il, m in im a l d a m a g e t o t h e m u scle
a n d skin is in cu rre d w it h n a il t e ch n iq u e s, so w o u n d irri-
g a t io n a n d st a n d a rd la ye re d clo su re a re p e rfo rm e d .
 Ch a p t e r 3 9 CEPHALOM EDULLARY NAILING OF THE PROXIM AL FEM UR 357

PEARLS AND PITFALLS

Re d u ct io n in t h e ■ Th e h e ig h t o f t h e p e rin e a l p o st is a d ju st e d t o e ffe ct m e d ia l d isp la ce m e n t o f t h e sh a ft . Th is is
la t e ra l p o sit io n e sp e cia lly h e lp fu l w it h re ve rse o b liq u it y p e rt ro ch a n t e ric p a t t e rn s (Ru sse ll-Ta ylo r IIA).
Re d u ct io n in t h e ■ Th e su rg e o n sh o u ld a vo id p la cin g t h e h ip in va ru s t o g a in e n t ry in t o t h e b o n e . Th is le a d s t o a va ru s
su p in e p o sit io n t ra je ct o ry in t h e p ro xim a l b o n e st o ck, w h ich w ill re cu r w it h n a il in se rt io n .
■ Th e ke y t o re d u ct io n is t h e ro t a t io n o f t h e d ist a l fra g m e n t t o t h e e xt e rn a lly ro t a t e d p ro xim a l
fra g m e n t a n d a p p o sit io n o f t h e a n t e rio r co rt e x o f t h e p ro xim a l a n d d ist a l fra g m e n t s. Th e se t w o
p o in t s w ill a llo w co rre ct io n o f t h e fle xio n a n d m a lro t a t io n d e fo rm it ie s.
■ Aft e r n a il in se rt io n , t h e ro t a t io n a l a lig n m e n t o f t h e p ro xim a l fe m u r m a y ch a n g e , so b e fo re d ist a l
in t e rlo ckin g , t h e su rg e o n sh o u ld ch e ck le n g t h o n t h e la t e ra l C-a rm vie w a n d m a t ch o f co rt e x
a n t e rio rly a n d p o st e rio rly fo r e q u iva le n t t h ickn e ss. I u se a C-a rm –ve rifie d t ru e la t e ra l vie w o f t h e
h ip , m a rk t h e ro t a t io n o f t h e C-a rm o n it s a xis, a n d t h e n m o ve t h e C-a rm t o t h e d ist a l fe m u r a n d
visu a lize a t ru e la t e ra l o f t h e kn e e w it h o ve rla p o f t h e fe m o ra l co n d yle s a n d m a rk t h e ro t a t io n o f
t h e C-a rm . Sim p le su b t ra ct io n o f t h e se t w o va lu e s g ive s m e t h e a p p ro xim a t e a n t e ve rsio n . Fo r m o st
p a t ie n t s, 15 d e g re e s is t h e a ve ra g e , a lt h o u g h so m e Asia n p a t ie n t s h a ve u p t o 30 d e g re e s. Th e n , b y
ro t a t in g t h e d ist a l fra g m e n t , a lig n m e n t is se t a n d t h e n a il is fin a lly fu lly se a t e d .
En t ry p o rt a l ■ Th e m e d ia l t ro ch a n t e ric p o rt a l g re a t ly sim p lifie s t h e a cce ss t o t h e p ro xim a l fe m u r, a n d t h e u se o f
a rig id re a m e r syst e m m in im ize s fa lse t ra je ct o rie s a n d t ro ch a n t e ric ia t ro g e n ic fra ct u re s. Th e su rg e o n
sh o u ld a vo id le t t in g t h e re a m e r la t e ra lize in t h e g re a t e r t ro ch a n t e r a t a n y t im e .
■ Th e m e d ia l t ro ch a n t e ric p o rt a l u se s le ss ra d ia t io n a n d o p e ra t ive t im e a n d is p re fe rre d in t h e su p in e
p o sit io n . 15
Tra je ct o ry co n t ro l ■ Th e co n ce p t o f t ra je ct o ry co n t ro l p la ce s t h e n a il in a p p o sit io n t o t h e a n t e ro la t e ra l co rt e x,
m in im izin g fle xio n d e fo rm it ie s a t t h e fra ct u re sit e , a n d co n se rve s b o n e st o ck p ro xim a lly b y a vo id in g
cu t o u t o f t h e re a m e r p o st e rio rly.
Na il in se rt io n ■ Ro t a t io n o f t h e t ro ch a n t e ric d e sig n n a ils d u rin g t h e first h a lf o f in se rt io n m in im ize s st re ss o n t h e
g re a t e r t ro ch a n t e r a n d m e d ia l co rt e x o f t h e fe m u r b e lo w t h e le sse r t ro ch a n t e ric re g io n in lo n g n a il
d e sig n s.
■ Th e su rg e o n sh o u ld re m e m b e r t o le t o ff t ra ct io n b e fo re fin a l se a t in g o f t h e n a il t o a vo id n a ilin g t h e
fe m u r in d ist ra ct io n .
■ Na ils m u st h a ve st a b ilit y b y co rt ica l co n t a ct in t h e p ro xim a l a n d d ist a l fe m u r. Disru p t io n o f t h e
la t e ra l w a ll p la ce s m o re st re ss o n t h e co n st ru ct a n d sh o u ld b e re co n st ru ct e d se p a ra t e ly fro m t h e
n a il if d isp la ce d , o r a lo ckin g p ro xim a l p la t e m a y b e re q u ire d . Sp e cia l ca re is re q u ire d fo r
Ru sse ll-Ta ylo r IIA a n d B fra ct u re p a t t e rn s.
Pro xim a l scre w ■ Gu id e w ire in se rt io n a n d d rillin g sh o u ld a lw a ys b e p e rfo rm e d w it h a h ig h sp e e d ra t e a n d a slo w fe e d
t a rg e t in g ra t e . Th is m e a n s t h a t t h e g u id e w ire s a n d re a m e rs b e n d a n d ca n b e m isd ire ct e d w it h e xce ssive a xia l
fo rce d u rin g d rillin g .
■ Fo r sin g le -d e vice a n d in t e g ra t e d scre w fe m o ra l h e a d fixa t io n , t h e su rg e o n sh o u ld u se a ce n t e r-ce n t e r
p o sit io n fo r t h e la rg e la g scre w .
■ Fo r t w o -d e vice fe m o ra l h e a d fixa t io n (re co n st ru ct io n ), t h e in fe rio r scre w is p la ce d first a lo n g t h e
m e d ia l ca lca r o f t h e fe m o ra l n e ck; t h is w ill e n su re ro o m fo r t h e p ro xim a l scre w .
Dist a l lo ckin g ■ Dist a l lo ckin g is u su a lly re co m m e n d e d w it h a d yn a m ic sin g le scre w fo r sh o rt a n d lo n g n a ils. Tw o
d ist a l in t e rlo ckin g scre w s a re re co m m e n d e d fo r co m m in u t e d o r se g m e n t a l fra ct u re s.

POSTOPERATIVE CARE diographs at 2 weeks and then monthly thereafter until

■ AP and lateral radiographs of the final construct should be
obtained in the surgical suite before recovering the patient to
assess the construct and ensure stability.
■ If there are adjustments to be made, these are best made
while the patient is still under anesthesia.
■ Radiographs should reveal the entire fracture region, in-
cluding the entire implant construct.
■ Patients are mobilized to a chair upright position the day
after the operative procedure.
■ Ambulation with supervision is allowed, with weight bear-
ing as tolerated with a walker or crutches and emphasis on
heel-strike and upright balance exercises.6
fracture healing is documented and the patients have maxi-
mized ambulatory capabilities, usually by 6 months after the
injury.
■ The surgeon should emphasize good nutrition and hip ab-
ductor exercises bilaterally.
■ Patients must be counseled to report any increased swelling
or respiratory distress as an emergency because of the high risk
of thromboembolic disease.
OUTCOMES
■ Union of these fractures is high (more than 95% ).
■ Functional recovery is poor in many patients, however, with

■ M ultiple trauma or patients with other complications more than 60% of patients failing to recover their preinjury
may have delayed ambulation, but it should begin as soon level of function. 8
as possible to minimize secondary complications. ■ M ortality within the first year in patients older than 55 is

■ Patients are re-evaluated with an examination and ra- 20% to 30% .

358 Se c t i o n IV FEM UR AND KNEE
A B
■ M any patients sustain progressive collapse of the hip into
varus and shortening of the leg with the current generation of
sliding hip screw fixation.9
COMPLICATION S
■ Loss of construct stability is one of the most common com-
plications. It is manifested by collapse of the screw and varus
migration of the femoral head construct, with final cutout fail-
ure in the worst cases.
■ This occurs to a small degree in all cases, as the sliding im-
paction was designed to minimize catastrophic cutout.
■ A center-center position of single-screw devices minimizes
cutout.3
■ N ail cutout is a much more serious complication, involving
loss of fixation of the nail component in the proximal femur
or periprosthetic femoral fracture with short nails; this will re-
sult in reoperation with locking construct plates or 95-degree
blade plates, exchange for longer nails, or even prosthetic re-
placement in severe cases (FIG 7 A).
■ N onunion, though rare (1% in older patients), is usually
treated with total hip replacement and grafting and implant re-
vision in young patients (FIG 7 B).
■ Infection occurs in 1% to 2% of postoperative cases and is
minimized by preoperative antibiotics, usually a cephalosporin
class of antibiotic.
■ In immunocompromised and malnourished patients, stan-
dard care involves isolation and sensitivity testing of the
causative bacteria and appropriate intravenous antibiotics,
in consultation with an infectious disease specialist, and
standard débridement and irrigation for wound care.
■ If the implant is stable, it should be retained. Rarely will
a resection arthroplasty be required.
REFEREN CES
1. Alam A, Willett K, O stlere S. The M RI diagnosis and management of
incomplete intertrochanteric fractures of the femur. J Bone Joint Surg
Br 2005;87B:1253–1255.
2. American Academy of O rthopaedic Surgery website (AAO S.org), H ip
Fractures, 2007.
FIG 7 • Nail failu res. A. Pro xima l screw cu t ou t .
B. Distractio n n o n u n io n w it h sp iral b la d e n ail co n st ru ct .
3. Baumgaertner M R, et al. The value of the tip-apex distance in pre-
dicting failure of fixation of peritrochanteric fractures of the hip. J
Bone Joint Surg Am 1995;77A:1058–1064.
4. Gotfired Y. The lateral trochanteric wall: a key element in the recon-
struction of unstable pertrochanteric hip fractures. Clin O rthop Relat
Res 2004;425:82–86.
5. Jin WJ, Dai LY, Cui YM , et al. Reliability of classification systems for
intertrochanteric fractures of the proximal femur in experienced or-
thopaedic surgeons. Injury 2005;36:858–861.
6. Koval KJ, et al. Postoperative weight-bearing after a fracture of the
femoral neck or an intertrochanteric fracture. J Bone Joint Surg Am
1998;80A:352–356.
7. Lippmann RK. The use of auscultatory percussion for the examina-
tion of fractures. J Bone Joint Surg 1932;14:118.
8. M iller CW. Survival and ambulation following hip fracture. J Bone
Joint Surg Am 1978;60A:930.
9. M oroni A, Faldini C, Pegreffi F, et al. Dynamic hip screw compared
with external fixation for treatment of osteoporotic pertrochanteric
fractures: a prospective randomized study. J Bone Joint Surg Am
2005;87A:753–759.
10. O strum RF, Levy M S. Penetration of the distal femoral anterior cor-
tex during intramedullary nailing for subtrochanteric fractures: a re-
port of three cases. J O rthop Trauma 2005;19:656–660.
11. O strum RF, M arcantonio A, M arburger R. A critical analysis of the
eccentric starting point for trochanteric intramedullary femoral nail-
ing. J O rthop Trauma 2005;19:681–686.
12. Palm H , Jacobsen S, Sonne-H olm S, et al. Integrity of the
lateral femoral wall in intertrochanteric hip fractures: an important
predictor of a reoperation. J Bone Joint Surg Am 2007;89A:
470–475.
13. Pepper J, Russell TA, Sanders R, et al. M inimally invasive in-
tramedullary nail insertion instruments and method. U.S. Patent
5951561, 9/14/1999.
14. Perez EA, Jahangir AA, M ashru RP, et al. Is there a gluteus medius
tendon injury during reaming through a modified medial trochanteric
portal? J O rthop Traumat 2007;21:617–620.
15. Ricci WM , Schwappach J, Tucker M , et al. Trochanteric versus piri-
formis entry portal for the treatment of femoral shaft fracture.
J O rthop Trauma 2006;20:663–667.
16. Russell TA, M ir H R, Stoneback BS, et al. Avoidance of malreduction
in proximal femur fractures: minimally invasive nail insertion tech-
nique. J O rthop Trauma 2008;22:391–398.
17. Russell TA, Taylor JC. Subtrochanteric fractures. In: Browner B, ed.
Skeletal Trauma. Philadelphia: WB Saunders, 1993.
 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 40 Fix a t io n o f Pe r it ro ch a n t e r ic
Hip Fr a ct u re s
M at t h e w E. Oe t g e n an d M ich ae l R. Bau m g ae rt n e r
DEFIN ITION
■ Peritrochanteric hip fractures are defined as extracapsular
hip fractures, always involving the trochanter and frequently
with extension into the subtrochanteric region.
■ These fractures occur after falls in a substantial number of
elderly people (estimated incidence of 250,000 fractures per
year) and represent a growing percentage of healthcare expen-
ditures annually.
■ These fractures require operative intervention to achieve sta-
ble fracture fixation to allow immediate patient mobilization.
AN ATOMY
■ The intertrochanteric region of the hip is notable for the
anatomic transition from the femoral neck to the femoral shaft.
■ The angle subtended by the femoral neck and long axis of
the femoral shaft in the coronal plane (the neck–shaft angle)
is usually between 120 and 135 degrees in adults.
■ Studies have shown that this angle tends to decrease
with age.
■ The average femoral neck is anteverted between 10 and 15
degrees (range 0 to 50 degrees) and slightly translated anteri-
orly (5 to 8 mm) from the axis of the femoral shaft.14
■ The peritrochanteric region of the femur is composed of
multiple thickenings of trabecular bone distributed in com-
pressive and tensile groups.4
■ The thickest and most structural are the primary compres-
sive trabeculae located along the posterior medial aspect of
the femoral neck and shaft, also known as the calcar.
■ M ultiple muscle groups attach to this region of the femur:
■ Iliopsoas: attaches to the lesser trochanter and exerts a
flexion and external rotation force to the hip
■ Abductors and short external rotators: attach to the
greater trochanter
■ Adductors: attach to the femoral shaft distal to the peri-
trochanteric region
■ The blood supply to the peritrochanteric region of the femur
is rich and abundant. The medial and lateral femoral circum-
flex arteries supply the cancellous bone of the trochanteric re-
gion through muscle attachments at the vastus origin and the
insertion of the gluteus medius.
PATHOGEN ESIS
■ In the elderly population most peritrochanteric fractures are
caused by a fall onto the lateral aspect of the hip, whereas high-
energy trauma produces these fractures in younger individuals.
■ N umerous factors, such as structurally weak bone, less
subcutaneous padding, and slowed protective reflexes,
lead to increased forces on the hip with falls in the elderly
population.
■ Pathologic lesions in the peritrochanteric region are not un-
common and may lead to pathologic fractures after relatively
minor trauma.
N ATURAL HISTORY
■ Almost all peritrochanteric hip fractures will heal without
intervention. H owever, owing to the pull of the musculature in
this region, the fracture will heal in gross malalignment, lead-
ing to subsequent functional limitations. 16
■ Early operative intervention of these fractures is undertaken
to ensure fracture union in an anatomic alignment.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ It is important to elicit the cause of the patient’s fall, as
many falls in the elderly population that result in hip fractures
are due to medical comorbidities.
■ Complaints of hip pain before falling may indicate a pre-
existing pathologic process that requires further evaluation.
■ A thorough global musculoskeletal examination of the pa-
tient is necessary because of the high incidence of associated
fractures (especially of the wrist and proximal humerus) in the
elderly population sustaining hip fractures from simple falls.
■ Examination of the soft tissue overlying the lateral hip,
sacrum, and heels is necessary to ensure that no pressure ulcers
or abrasions have occurred in these areas.
■ The classic physical finding in a patient with a peri-
trochanteric hip fracture is a short, externally rotated affected
extremity.
■ Patients may have associated musculoskeletal injuries that
are not discovered until examined because of the distracting
hip injury.
■ H ip rotation assessment: Because of the muscular attach-
ments and gravity, the lower extremity tends to rest externally
rotated with a peritrochanteric hip fracture.
■ Passive log-rolling of the leg will elicit pain (particularly with
internal rotation, which tightens the hip capsule and causes pain
due to the hemarthrosis). This may be an especially helpful find-
ing in occult hip fractures with no obvious fracture deformity.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Plain radiographs consisting of an anteroposterior (AP)
pelvis and cross-table lateral of the injured hip should be ob-
tained initially.
■ A traction radiograph (radiograph taken with gentle manual
traction and internal rotation of the leg) will provide more in-
formation on the fracture pattern and will allow a better com-
parison to the uninjured hip (FIG 1 A,B).
■ A fine-cut (2-mm) CT scan with reconstruction images
(sagittal and coronal) set to bone windows may help assess the
fracture when ipsilateral femoral neck or other fractures are
suspected.
■ M RI is the modality of choice to assess for the presence of
an occult peritrochanteric hip fracture in the setting of normal
radiographs (FIG 1 C).
359
360 Se c t i o n IV FEM UR AND KNEE

surgical site, and patients with severe and irreversible medical

comorbidities precluding operative intervention.
■ N onoperative management consists of two regimens:

■ Early mobilization

■ N o attempt at axial realignment

■ Used for nonambulatory patients and consists of pain

control and early mobilization out of bed to chair as tol-

erated to avoid systemic complications of recumbency
■ Traction

■ Attempted anatomic realignment with nonoperative

management for ambulatory patients

■ Balanced traction for 8 to 12 weeks, with serial radi-
A
ographs to assess healing
■ Progressive weight bearing as the fracture shows signs

of healing

SURGICAL MAN AGEMEN T

■ O nce surgical management is chosen, the timing of interven-
tion becomes important.
■ The balance between medical optimization and early op-

erative management in this mostly elderly patient popula-

tion is delicate.
■ Although a recent study of more than 2600 patients found

that a delay in surgery of up to 4 days did not increase patient

mortality up to 1 year postoperatively, most studies suggest
that delays of more than 2 days may increase patient mortal-
B ity postoperatively.11,17
Preoperative Planning
■ Radiographs are reviewed to determine the fracture pattern.
■ We find the AO /O TA fracture classification system to be

useful and reliable for these fractures. It is divided into groups

based on fracture geometry (FIG 2 ):
■ Group 1 has a single fracture line extending to the me-

dial cortex.
■ Group 2 has more than one fracture line extending to the

medial cortex.
■ Group 3 has a fracture geometry that runs in a more

C transverse or reverse oblique pattern, with the fracture line

exiting the lateral cortex below the vastus ridge.
FIG 1 • A. AP ra d io g ra p h o f a n OTA 31-A1 p e rit ro ch a n t e ric h ip ■ Implant selection for fracture fixation should be guided

fra ct u re . B. Tra ct io n ra d io g ra p h ; n o t e t h e re d u ct io n se e n w it h based on fracture pattern and patient age.

t ra ct io n . C. MRI sca n o f a p a in fu l rig h t h ip sh o w in g a n o ccu lt ■ O TA 31-A1-type fractures have been shown to be fixed
p e rit ro ch a n t e ric fra ct u re (arro w ) n o t se e n o n p la in ra d io g ra p h s. with reliably good results using either a sliding hip screw or
intramedullary device.
■ O TA 31-A2-type fractures have been shown to be

amenable to treatment with either side plate and screw de-

DIFFEREN TIAL DIAGN OSIS vices or intramedullary devices.
■ Femoral neck fracture ■ Recent studies have shown improved patient outcomes
■ Femoral shaft fracture
and better maintenance of fracture alignment with the use
■ Greater trochanter fracture
of intramedullary devices in this type of fracture.12,15
■ Septic hip ■ O TA 31-A3-type fractures have been shown to be treated
■ Lateral compression-type pelvic fracture, with pubic rami
best with intramedullary devices or blade plates.
fractures ■ Sliding hip screw devices are contraindicated in these

fractures because of the high incidence of implant failure.6

N ON OPERATIVE MAN AGEMEN T ■ In a meta-analysis, intramedullary implants were found

■ Early operative management of peritrochanteric fractures is to have a lower failure rate than blade plates when used
associated with decreased patient morbidity and improved pa- to treat this type of fracture pattern and should be consid-
tient function compared to nonoperative management. ered the implant of choice for the elderly patient.6
■ Relative indications for nonoperative management include ■ Preservation of bone stock in the proximal femur is an

nonambulatory or demented patients with little pain, patients important consideration in young patients with this frac-
with active sepsis, patients with skin breakdown around the ture pattern.
 Ch a p t e r 4 0 ORIF OF PERITROCHANTERIC HIP FRACTURES
Peritrochanteric simple Peritrochanteric
(31-A1) multifragmentary
(31-A2)
■ A fixed-angle plate (such as a 95-degree blade plate or
locked plate), as well as a reconstruction-type nail with a
small proximal diameter, will allow for stable fracture fix-
ation, along with preserved proximal femoral bone stock,
which is helpful in cases necessitating later revision open
reduction and internal fixation.
■ The neck–shaft angle of the nonfractured femur should be
measured preoperatively to estimate the reduction to be
achieved (FIG 3 ).
■ Preoperative planning is vital for a satisfactory outcome
when a peritrochanteric fracture is fixed with a blade plate.
■ M ultiple views of the nonfractured, contralateral hip and
femur, as well as multiple traction views of the fractured
hip, are required to properly plan the surgical sequence for
this type of fixation.
Positioning
■ When fixing a peritrochanteric fracture with a sliding hip
screw device, the patient is positioned on a well-padded fracture
table, with the nonfractured leg carefully positioned in flexion
and external rotation in a well leg holder. Alternatively, the pa-
tient may be placed in the “ scissor” position, with the nonfrac-
tured leg extended and supported with a boot. This position is
FIG 3 • AP p e lvis ra d io g ra p h . Th e n e ck–sh a ft a n g le h a s b e e n
d ra w n o n t h e n o n fra ct u re d e xt re m it y.
361
Intertrochanteric
(31-A3) FIG 2 • AO/OTA cla ssifica t io n o f p ro xi-
m a l fe m u r fra ct u re s.
helpful in some patients (eg, obesity, stiff contralateral hip, bi-
lateral injuries) who may not be able to flex and externally ro-
tate the contralateral hip to enable use of a well leg holder.
■ This facilitates access by the fluoroscopic C-arm to the
fractured hip (FIG 4 A).
■ We prefer to secure the affected foot to a well-padded heel
cup with tape, leaving the posteromedial neurovascular bundle
uncompromised. The foot is then dorsiflexed and secured
against a well-padded metatarsal bar to lock the transverse
tarsal joint and allow strong traction and rotational forces to
be transmitted to the fracture (FIG 4 B).
■ Alternatively, if the fracture is to be fixed with a fixed-angle
plate, the patient is placed on a completely radiolucent flat-top
table. The affected hip is bumped up at a 20- to 30-degree
angle and the leg is draped free.
■ The scissors position is another alternative position for fix-
ation of a peritrochanteric hip fracture (FIG 4 C). The patient
is placed supine on a traction table and both feet are secured
in traction boots. The noninjured leg is then extended to allow
a lateral radiograph of the injured hip to be obtained with rel-
ative ease.
■ Some muscular patients may require skeletal traction of the
affected leg through the distal femur or proximal tibia to pro-
vide adequate fracture length and alignment.
Approach
■ Because of the muscular forces exerted on the fracture frag-
ments associated with peritrochanteric hip fractures, perfect
anatomic reduction of the fracture is close to impossible with
indirect methods, especially in the lateral plane, which is often
the most difficult plane to control.
■ Studies have shown, however, that absolute anatomic re-
duction of all fragments of these fractures is not necessary
for a satisfactory functional outcome.13
■ The primary goal of reduction of peritrochanteric hip frac-
tures is to re-establish a normal anatomic alignment between
the proximal head and neck fragment and the distal femoral
shaft in the anteroposterior, lateral, and rotational planes.
■ A lateral approach to the proximal femur is the preferred
approach for open reduction and internal fixation of peri-
trochanteric femur fractures.
 362 Se c t i o n IV FEM UR AND KNEE
B C
TECHNIQUES
INCISION
■ Th e in cisio n is ce n t e re d o ve r t h e la t e ra l a sp e ct o f t h e
fe m u r. It is st a rt e d p ro xim a lly a t t h e p a lp a b le va st u s
rid g e fo r slid in g h ip scre w d e vice s a n d ju st p ro xim a l t o
t h e t ip o f t h e g re a t e r t ro ch a n t e r fo r fixe d -a n g le p la t e s.
■ Th e d ist a l e xt e n t o f t h e in cisio n is m a d e lo n g e n o u g h
t o a llo w a p p lica t io n o f t h e p la t e .
■ Th e in cisio n is ca rrie d t h ro u g h t h e fa scia la t a , a vo id in g
t h e t e n so r m u scle p ro xim a lly a n d a n t e rio rly. Th e va st u s
la t e ra lis fa scia a n d m u scle is in cise d lo n g it u d in a lly 2 t o 3
FRACTURE REDUCTION
■ Wit h t h e p a t ie n t a ccu ra t e ly p o sit io n e d o n t h e fra ct u re
t a b le , t h e fra ct u re is in it ia lly re d u ce d in t h e a n t e ro p o st e -
rio r p la n e w it h a xia l t ra ct io n t o re -e st a b lish fra ct u re
le n g t h a n d p a rt ia lly co rre ct t h e va ru s m a la lig n m e n t
(TECH FIG 1 ).
■ Ab d u ct io n o f t h e le g u su a lly co rre ct s t h e fin a l va ru s
m a la lig n m e n t a n d e st a b lish e s t h e n o rm a l n e ck–sh a ft
a n g le .
■ Int e rn al rot a t io n of t he d ist a l fra g m en t u sua lly co rre ct s
t he e xt e rna l rot a t io n de fo rm it y a n d w ill alig n t h e fe m o ra l
n e ck p ara lle l t o t h e flo o r t o a ssist in e ve n t u a l g uide pin in -
se rt io n , b u t t h is m u st b e co n firm e d u n d e r flu o ro sco p y.
■ In so m e in st a n ce s, e xt e rn a l ro t a t io n o f t h e p ro xim a l
fra g m e n t is n e ce ssa ry t o a ch ie ve re d u ct io n o f t h e ro -
t a t io n a l d e fo rm it y.
FIG 4 • A. Pa t ie n t p o sit io n e d
o n fra ct u re t a b le . B. Ext re m it y
se cu re d w it h h e e l cu p a n d
m e t a t a rsa l b a r t o fa cilit a t e
m a n ip u la t io n . C. Pa t ie n t p o si-
t io n e d o n fra ct u re t a b le in t h e
scisso r p o sit io n .
cm a n t e rio r t o t h e lin e a a sp e ra a n d re t ra ct e d a n t e rio rly.
Ca re is t a ke n t o id e n t ify a n d co n t ro l a n y p e rfo ra t in g ve s-
se ls su p p lyin g t h e va st u s la t e ra lis m u scle .
■ Pro xim a lly, t h e o rig in o f t h e va st u s la t e ra lis is sh a rp ly
re le a se d o ff t h e va st u s rid g e t o a llo w a t ra u m a t ic a n t e -
rio r re t ra ct io n o f t h e m u scle , t o fa cilit a t e la t e ra l
fe m o ra l sh a ft e xp o su re .
■ Ca re sh o u ld b e t a ke n t o a vo id a n y m e d ia l sh a ft d isse c-
t io n t o m a in t a in t h e va scu la t u re t o t h e fra ct u re zo n e .
■ Fra ct u re re d u ct io n is n e xt ch e cke d in t h e la t e ra l p la n e .
Th e se fra ct u re s o ft e n d isp la y a n a p e x-p o st e rio r a n g u la -
t io n . Th is ca n b e co rre ct e d b y p la cin g a cru t ch u n d e r t h e
fe m o ra l sh a ft fo r su p p o rt . Alt e rn a t ive ly, so m e fra ct u re
t a b le s h a ve p a d d e d a t t a ch m e n t s t o su p p o rt t h e t h ig h .
■ Fra ct u re re d u ct io n is re a sse sse d in b o t h t h e a n t e ro p o st e -
rio r a n d la t e ra l p la n e s a n d ch e cke d fo r fra ct u re d isp la ce -
m e n t , n e ck–sh a ft a n g le , n e ck a n t e ve rsio n , ro t a t io n , a n d
fe m o ra l sh a ft sa g , w it h a g o a l o f o b t a in in g a n e a r-
a n a t o m ic re d u ct io n in a ll o f t h e se p la n e s (n o rm a l o r
slig h t va lg u s re d u ct io n , le ss t h a n 20 d e g re e s o f a n g u la -
t io n o n t h e la t e ra l ra d io g ra p h , a n d le ss t h a n 4 m m o f
fra ct u re d isp la ce m e n t ).1
■ If a n e a r-a n a t o m ic clo se d re d u ct io n ca n n o t b e o b t a in e d ,
a fo rm a l o p e n re d u ct io n is n e ce ssa ry.
 Ch a p t e r 4 0 ORIF OF PERITROCHANTERIC HIP FRACTURES 363

TECHNIQUES
A B C

D E F

TECH FIG 1 • Fra ct u re re d u ct io n . A. Pre o p e ra t ive p e rit ro ch a n t e ric fra ct u re .

B. Po sit io n o f t h e fra ct u re a ft e r lo n g it u d in a l t ra ct io n . C. Po sit io n o f t h e fra c-
t u re a ft e r lo n g it u d in a l t ra ct io n a n d a b d u ct io n a p p lie d . D. Po sit io n o f t h e
fra ct u re a ft e r lo n g it u d in a l t ra ct io n , a b d u ct io n , a n d in t e rn a l ro t a t io n a p -
p lie d . E. Po st e rio r fra ct u re sa g . F. Po sit io n o f t h e fra ct u re a ft e r lo n g it u d in a l
t ra ct io n , a b d u ct io n , in t e rn a l ro t a t io n , a n d fle xio n fo rce a p p lie d w it h a
cru t ch u n d e r t h e le g . G. In t ra o p e ra t ive p ict u re o f cru t ch p la ce d u n d e r d ist a l
G fra g m e n t .

GUIDE PIN POSITIONING FOR SLIDING HIP SCREW AND

FRACTURE PREPARATION
■ Th e e n t ra n ce p o in t fo r t h e g u id e p in is se le ct e d o n ce e x-
p o su re o f t h e la t e ra l fe m o ra l co rt e x is co m p le t e d .
■ Th e e n t ra n ce fo r a 135-d e g re e p la t e is t yp ica lly 2 cm
b e lo w t h e va st u s rid g e , o p p o sit e t h e m id p o in t o f t h e
le sse r t ro ch a n t e r, a t t h e le ve l o f t h e fe m o ra l in se rt io n
o f t h e g lu t e u s m a xim u s t e n d o n (TECH FIG 2 ).
■ Th e ent ran ce p o in t fo r t he g uide p in is adju sted 1 cm prox-
imal (for lo wer-an g led d evices) or d istal (for h ig h er-an g led
devices) from the 135-degree st arting point for every
5-deg ree ad ju st ment in th e m easu red n eck–sh aft an g le.
■ The fem ora l an te versio n can be estim at ed by ad vancing a
fre e guide p in b y ha n d up th e a n t erior fe mo ra l n eck a n d
se cu rin g it in t h e a n t e rior a spe ct of the fe m ora l h e a d .
■ Th e co rre ct -a n g le d g u id e is p la ce d a t t h e g u id e p in in se r-
t io n sit e , ce n t e re d in t h e a n t e ro p o st e rio r p la n e o n t h e
fe m o ra l sh a ft a n d se a t e d flu sh t o t h e la t e ra l co rt e x.
■ Th e g u id e p in is a d va n ce d u n d e r flu o ro sco p ic g u id a n ce ,
in b o t h t h e a n t e ro p o st e rio r a n d la t e ra l vie w s, t o e n su re
ce n t ra l p la ce m e n t in t h e fe m o ra l h e a d .
■ If t h e p in is n o t ce n t e re d in t h e h e a d o n b o t h vie w s,
it m u st b e re m o ve d a n d a d ju st e d .
■ Th e fra ct u re re d u ct io n sh o u ld b e re a sse sse d a n d t h e
g u id e a d ju st e d t o e n su re t h a t ce n t ra l g u id e p in p la ce -
m e n t is o b t a in e d .
■ Th e g u id e p in is in se rt e d t o w it h in 5 m m o f t h e jo in t lin e
in b o t h t h e a n t e ro p o st e rio r a n d la t e ra l p ro je ct io n s.
■ Th e in t e ro sse o u s le n g t h o f t h e g u id e p in is m e a su re d
w it h t h e ru le r p ro vid e d in t h e in st ru m e n t se t .
■ Ca re m u st b e t a ke n w h e n d e cid in g o n a la g scre w
le n g t h , e sp e cia lly in h ig h ly u n st a b le fra ct u re s re d u ce d
w it h a su b st a n t ia l a m o u n t o f t ra ct io n . Th is t ra ct io n
ca n ca u se fra g m e n t d ist ra ct io n a n d o ve re st im a t io n o f
la g scre w le n g t h , w h ich w ill b e n o t ice d w h e n t ra ct io n
is e ve n t u a lly re le a se d .
■ Th e g u id e w ire is t h e n a d va n ce d in t o t h e su b ch o n d ra l
b o n e t o e n su re st a b ilit y d u rin g re a m in g .
■ A se co n d g u id e p in ca n t h e n b e a d va n ce d in t o t h e
fe m o ra l h e a d p ro xim a l t o t h e o rig in a l g u id e p in in
 364 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES

A B C

D E F

TECH FIG 2 • Gu id e p in p o sit io n in g a n d fra ct u re p re p a ra t io n . A. Ra d io g ra p h sh o w in g p o sit io n o f g u id e p in a t t h e

le ve l o f t h e le sse r t ro ch a n t e r, ju st b e lo w t h e va st u s rid g e . B. An g le d g u id e a n d g u id e p in in se rt e d p a ra lle l t o g u id e
p in , sh o w in g fe m o ra l a n t e ve rsio n . C. Flu o ro sco p ic im a g e sh o w in g a n t e ve rsio n p in a n d in se rt e d g u id e p in . D. Gu id e
p in a d va n ce d in t o ce n t e r o f t h e fe m o ra l h e a d in t h e AP p ro je ct io n . E. Gu id e p in a d va n ce d in t o ce n t e r o f t h e
fe m o ra l h e a d in t h e la t e ra l p ro je ct io n . F. Trip le re a m e r.

u n st a b le fra ct u re s o r in fra ct u re s t h a t a re re d u ce d in in a d ve rt e n t ly a d va n ce d in t o t h e p e lvis, t h e ch a n n e l is

a n a t o m ic a lig n m e n t u sin g e xce ssive t ra ct io n .
■ Th is p in a ct s a s a d e ro t a t io n a l p in t o e n su re t h a t t h e
p ro xim a l n e ck a n d h e a d fra g m e n t d o e s n o t ro t a t e
w it h re a m in g a n d scre w in se rt io n .
■ A t rip le re a m e r is u se d t o p re p a re t h e ch a n n e l in t h e la t -
e ra l co rt e x, n e ck, a n d h e a d fo r t h e la g scre w a n d sid e
p la t e b a rre l.
■ Th e re a m e r is se t t o 5 m m le ss t h a n t h e m e a su re d la g
scre w le n g t h t o e n su re t h a t t h e su b ch o n d ra l b o n e in
t h e fe m o ra l h e a d is n o t vio la t e d d u rin g re a m in g .
■ Th e t rip le re a m e r is t h e n a d va n ce d a n d w it h d ra w n u n d e r
flu o ro sco p ic g u id a n ce , e n su rin g t h a t t h e g u id e p in is n o t
re a m e d t o it s p ro p e r le n g t h , a n d t h e g u id e p in is n o t
w it h d ra w n w it h t h e re a m e r.
■ Occa sio n a lly t h e in t a ct la t e ra l w a ll o f t h e p ro xim a l
fe m u r m a y b e fra ct u re d b y t h e t rip le re a m e r. If t h is o c-
cu rs, t h e fra ct u re is e sse n t ia lly co n ve rt e d in t o a t ra n s-
ve rse o r re ve rse o b liq u e p a t t e rn , a n d e xce ssive fra ct u re
co lla p se w ill o ccu r if it is fixe d w it h a sim p le slid in g h ip
scre w . In t h e se ca se s, t h e p ro xim a l la t e ra l w a ll m a y b e
b u t t re sse d w it h t h e a d d it io n o f a t ro ch a n t e ric p la t e in
co n ju n ct io n w it h a slid in g h ip scre w o r co n ve rsio n t o a n
in t ra m e d u lla ry d e vice fo r fra ct u re fixa t io n .

IMPLANT INSERTION
■ A t w o - t o fo u r-h o le sid e p la t e is u su a lly ch o se n fo r fixa -
t io n (TECH FIG 3 ).
■ Mu lt ip le clin ica l a n d ca d a ve ric st u d ie s h a ve sh o w n n o
d iffe re n ce in t h e st re n g t h o f im p la n t fixa t io n w it h
sid e p la t e s w it h m o re t h a n fo u r h o le s.3,9
■ Th e im p la n t is se t u p a cco rd in g t o t h e m a n u fa ct u re r’s
sp e cifica t io n s.
■ Th e ca n n u la t e d la g scre w is t h e n in se rt e d o ve r t h e g u id e
p in w it h a ce n t e rin g sle e ve t o e n su re p ro p e r p o sit io n in g .
Ca re fu l sizin g o f t h e la g scre w is re q u ire d , a s n o t e d e a r-
lie r, t o e n su re t h a t fra ct u re co m p re ssio n d o e s n o t le a d t o
e xce ssive scre w le n g t h a n d la t e ra l h a rd w a re p ro m in e n ce .
■ Flu o ro sco p y a n d m a n u a l fra ct u re p a lp a t io n is u se d t o e n -
su re t h a t t h e fra ct u re is n o t d isp la ce d (ro t a t e d ) w h ile t h e
la g scre w is in se rt e d .
■ If t h e fra ct u re is d isp la ce d b y t h e in se rt io n o f t h e la g
scre w , it is re m o ve d , t h e ch a n n e l is t a p p e d , a n d t h e
la g scre w is re in se rt e d .
■ Pe rit ro ch a n t e ric fra ct u re s o f t h e rig h t h ip t e n d t o d is-
p la ce t o a n a p e x-p o st e rio r a n g u la t io n w it h la g scre w in -
se rt io n , w h e re a s le ft h ip fra ct u re s t e n d t o d isp la ce t o a n
a p e x-a n t e rio r a n g u la t io n o w in g t o t h e a n a t o m ic co n fig -
u ra t io n a n d su b se q u e n t t e n sio n in g o f t h e h ip ca p su le
w it h scre w in se rt io n .
 Ch a p t e r 4 0 ORIF OF PERITROCHANTERIC HIP FRACTURES
A B
C D
■ Wit h t h e la g scre w in se rt e d t o t h e d e sire d d e p t h w it h in
t h e fe m o ra l h e a d o n t h e a n t e ro p o st e rio r a n d la t e ra l flu -
o ro sco p ic p ro je ct io n , it s re la t io n t o t h e la t e ra l co rt e x is
ch e cke d t o e n su re p ro p e r le n g t h .
■ Th e sid e p la t e is t h e n slid o ve r t h e la g scre w so it is
se a t e d o n t h e la t e ra l co rt e x, a n d t h e g u id e p in (a n d
d e ro t a t io n a l p in if u se d ) is re m o ve d .
■ Tra ct io n is re le a se d a t t h is p o in t t o a llo w slig h t im p a ct io n
o f t h e fra ct u re in t h e a xia l p la n e .
BLADE PLATE INSERTION
■ Wit h t h e la t e ra l fe m u r a n d t ro ch a n t e ric b lo ck e xp o se d , a
so ft t issu e -sp a rin g re d u ct io n o f t h e t ro ch a n t e ric b lo ck t o
t h e p ro xim a l fe m u r is se cu re d w it h p o in t e d b o n e cla m p s
a n d K-w ire s o r sm a ll la g scre w s a s n e e d e d (TECH FIG 4 ).
■ Gu id e p in s a re t h e n in t ro d u ce d in t o t h is re co n st ru ct e d
se g m e n t t o fa cilit a t e p ro p e r se a t in g o f t h e ch ise l fo r t h e
b la d e p la t e .
■ Th e first p in is p la ce d a n t e rio r t o t h e fe m o ra l n e ck
a n d se cu re d in t o t h e a n t e rio r fe m o ra l h e a d t o
d e m o n st ra t e t h e fe m o ra l a n t e ve rsio n .
■ Th e se co n d p in is p la ce d w it h t h e u se o f a n a n g le d
g u id e , flu o ro sco p y, o r b o t h n e a r t h e t ip o f t h e
g re a t e r t ro ch a n t e r a n d d ire ct e d in t o t h e fe m o ra l
h e a d a t a 90-d e g re e a n g le t o t h e fe m o ra l sh a ft o n ce
t h e fra ct u re h a s b e e n re d u ce d a n d t h e n e ck–sh a ft
a n g le re st o re d .
■ Th e ch ise l is in se rt e d p a ra lle l t o t h e t w o g u id e p in s, ju st
d ist a l t o t h e se co n d p in . Ca re m u st b e t a ke n t o m a in t a in
t h e co rre ct a lig n m e n t o f t h e ch ise l w it h t h e sh a ft o f t h e
fe m u r b e ca u se t h is d e t e rm in e s t h e fle xio n -e xt e n sio n
o f t h e fra ct u re , w h ich is fixe d o n ce t h e b la d e p la t e is
in se rt e d .
■ Th e ch ise l is a im e d t o p a ss t h ro u g h t h e ce n t e r o f t h e
n e ck a n d se a t in t h e in fe rio r p o rt io n o f t h e fe m o ra l
h e a d . Be ca u se o f t h e a n t e rio r t ra n sla t io n o f t h e
365
TECH FIG 3 • Im p la n t in se rt io n .
TECHNIQUES
A. Lag screw a nd side p la te o n in-
se rt e r. B. Placem ent o f sid e plat e.
C. Imp la nt in p la ce. D. Tract ion re-
le ased. E. Fra ct u re a ft er co mp re ssio n.
E
■ Co rt ica l scre w s a re in se rt e d t o se cu re t h e p la t e t o t h e
fe m o ra l sh a ft in t h e u su a l m a n n e r.
■ A co m p re ssio n scre w is t h e n in se rt e d in t o t h e b a rre l
o f t h e la g scre w a n d t ig h t e n e d t o co m p re ss t h e fra c-
t u re in t h e p la n e o f t h e la g scre w , u n d e r flu o ro sco p ic
g u id a n ce .
■ Wit h t h e co m p re ssio n o f t h e fra ct u re co m p le t e , t h e
a lig n m e n t a n d im p la n t p o sit io n a re ch e cke d o n ce a g a in
w it h flu o ro sco p y.
fe m o ra l h e a d o n t h e sh a ft , t h e in se rt io n sit e is in t h e
a n t e rio r h a lf o f t h e t ro ch a n t e r.
■ Th e p o sit io n of t h e ch ise l sh o u ld b e co n st a n t ly ch e cke d
w it h flu o ro sco p y b e fo re a n d d u rin g it s in se rt io n .
■ Th e ch ise l is ca re fu lly re m o ve d a n d t h e a p p ro p ria t e -
le n g t h b la d e p la t e is in se rt e d a n d g e n t ly se a t e d in t o t h e
p ro xim a l fra g m e n t .
■ Th e in se rt io n sh o u ld b e fre q u e n t ly ch e cke d w it h b i-
p la n a r flu o ro sco p y t o e n su re t h a t t h e b la d e fo llo w s
t h e p a t h m a d e b y t h e ch ise l.
■ On ce t h e b la d e is se a t e d , t h e m o st p ro xim a l scre w is
p la ce d t h ro u g h t h e im p la n t in t o t h e m e d ia l co rt e x o f t h e
p ro xim a l fe m o ra l n e ck, rig id ly se cu rin g t h e im p la n t t o
t h e p ro xim a l fra g m e n t .
■ Fra ct u re re d u ct io n is n o w a ch ie ve d b y b rin g in g t h e
p la t e t o t h e sh a ft a n d co n t ro llin g le n g t h a n d ro t a t io n .
■ A fe m o ra l d ist ra ct o r m a y b e u se d o n t h e la t e ra l a sp e ct o f
t h e fe m u r, w it h t h e p ro xim a l p in in t h e h e a d a n d n e ck
fra g m e n t a n d t h e d ist a l p in p la ce d d ist a l t o t h e e n d o f
t h e p la t e .
■ Dist ra ct io n is a p p lie d a cro ss t h e fra ct u re t o g a in fra ct u re
a lig n m e n t a n d le n g t h t h ro u g h so ft t issu e t e n sio n in g
u sin g a n in d ire ct re d u ct io n t e ch n iq u e .
■ A b o n e cla m p is lo o se ly a p p lie d t o t h e d ist a l fe m o ra l
sh a ft fra g m e n t a n d p la t e t o co u n t e ra ct t h e t e n d e n cy
 366 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES

A B C

TECH FIG 4 • Bla d e p la t e in se rt io n .

A,B. Pre o p e ra t ive AP a n d la t e ra l
ra d io g ra p h s o f a 31-A3 fra ct u re in a
28-ye a r-o ld m a n . C. Ch ise l in se rt e d
a ft e r fe m o ra l h e a d a n d n e ck a n d
t ro ch a n t e ric b lo ck w e re se cu re d w it h
la g scre w s. D. In se rt io n o f b la d e p la t e .
D E E. Po st o p e ra t ive AP ra d io g ra p h .

fo r t h e fra ct u re t o b e re d u ce d in t o va ru s w it h t h e ■ Th e p la t e is t h e n fixe d t o t h e sh a ft fra g m e n t s w it h

fe m o ra l d ist ra ct o r.
■ Po in t e d re d u ct io n cla m p s a re u se d t o re d u ce co m m in -
u t e d fra g m e n t s t o t h e p la t e w it h o u t st rip p in g t h e m
o f so ft t issu e a t t a ch m e n t s.
■ Wit h t h e fra ct u re a lig n m e n t a n d le n g t h re st o re d , it is
ch e cke d w it h flu o ro sco p y.
■ If a cce p t a b le , t h e d ist ra ct io n is re d u ce d t o a llo w fra g -
m e n t se t t lin g a n d fra ct u re co m p re ssio n .
scre w s in t h e st a n d a rd m a n n e r, a n d la g scre w s a re in -
se rt e d w h e re t h e p o in t e d re d u ct io n cla m p s w e re p re -
vio u sly p la ce d .
■ Th e fin a l fra ct u re a lig n m e n t a n d le n g t h , a s w e ll a s t h e
fe m o ra l h e a d , a re e xa m in e d w it h flu o ro sco p y t o e n su re
p ro p e r fra ct u re re d u ct io n a n d t o m a ke su re t h a t t h e re
h a s b e e n n o h e a d p e n e t ra t io n b y t h e im p la n t .

WOUND CLOSURE ■ Th e w o u n d is t h e n clo se d in a la ye re d fa sh io n ; t h e m u s-

■ Ag g re ssive d é b rid e m e n t o f d e vit a lize d t issu e is p e r- cle , fa scia , su b cu t a n e o u s t issu e , a n d skin a re re p a ire d
fo rm e d b e fo re w o u n d irrig a t io n . se p a ra t e ly.

PEARLS AND PITFALLS

Pre o p e ra t ive fra ct u re a sse ssm e n t
Fra ct u re re d u ct io n
■ Th e fra ct u re p a t t e rn m u st b e st u d ie d p re o p e ra t ive ly so t h a t t h e p ro p e r d e vice fo r fixa t io n m a y
b e ch o se n . Im p ro p e r u se o f a slid in g h ip scre w in a n OTA t yp e 31-3A fra ct u re , fo r e xa m p le ,
w ill le a d t o a h ig h e r in cid e n ce o f fixa t io n fa ilu re .
■ Fra ct u re re d u ct io n o b t a in in g a n a t o m ic a lig n m e n t is im p o rt a n t . Th e ra t e o f fixa t io n fa ilu re
in cre a se s, n o m a t t e r w h a t fixa t io n m e t h o d is u se d , fo r p o o rly re d u ce d fra ct u re s.
 Ch a p t e r 4 0 ORIF OF PERITROCHANTERIC HIP FRACTURES 367

Im p la n t se le ct io n ■ Me a su re m e n t o f t h e n e ck–sh a ft a n g le o f t h e n o rm a l h ip is im p o rt a n t t o e n su re t h a t t h e
p ro p e r-a n g le d sid e p la t e is u se d . Use o f a n im p ro p e rly a n g le d d e vice w ill p re ve n t ce n t ra l a n d
d e e p p la ce m e n t o f t h e la g scre w in t h e fe m o ra l h e a d a n d w ill in cre a se t h e in cid e n ce o f
fixa t io n fa ilu re .
■ Ma n y d iffe re n t d e vice syst e m s e xist w it h slig h t va ria t io n s o f t e ch n iq u e a n d im p la n t d e sig n .
Fa m ilia rit y w it h t h e se le ct e d d e vice is im p o rt a n t , a n d a t ria l ru n o n a p la st ic b o n e m o d e l ca n
b e h e lp fu l.
La g scre w p o sit io n ■ Po sit io n in g o f t h e la g scre w ce n t ra lly a n d d e e p w it h in t h e fe m o ra l h e a d is o n e o f t h e m o st
im p o rt a n t fa ct o rs t o p ro t e ct a g a in st im p la n t cu t o u t .
■ The t ip–a pex dist ance, a s me asure d on ant eropost erior a nd la te ra l fluoroscop y int raope rat ive ly,
sh o u ld b e u n d e r 25 m m t o sig n ifica n tly d e cre a se t h e in cid e n ce o f fixa t io n fa ilu re 1 (FIG 5 ).

Xap

Dap

Xlat Dlat

FIG 5 • Pro p e r m e a su re m e n t Dtrue D

TAD = ( Xap x ) + ( Xlat x true )
t e ch n iq u e fo r t ip –a p e x d ist a n ce . Dap Dlat

La t e ra l co rt ica l w a ll fra ct u re ■ Ca re fu l h a n d lin g a n d m a in t e n a n ce o f t h e la t e ra l co rt ica l w a ll o f t h e fe m u r in t h e t ro ch a n t e ric

La t e ra l vie w re d u ct io n
Ro t a t io n a l fra ct u re re d u ct io n
re g io n is im p o rt a n t t o p ro vid e a la t e ra l b u t t re ss fo r co n t ro lle d fra ct u re im p a ct io n p o st o p e ra -
t ive ly. Fra ct u re o f t h is st ru ct u re d u rin g im p la n t in se rt io n m a y le a d t o a h ig h e r in cid e n ce o f
fra ct u re co lla p se a n d p o o re r o u t co m e s w h e n a slid in g h ip scre w is u se d fo r fra ct u re fixa t io n .
Wh e n t h is p it fa ll is e n co u n t e re d , re -e st a b lish in g t h e la t e ra l co rt e x is crit ica l a n d ca n b e a c-
co m p lish e d b y a d d in g a t ro ch a n t e ric p la t e t o t h e slid in g h ip scre w o r co n ve rsio n t o a n in -
t ra m e d u lla ry d e vice .
■ Re d u ct io n o f p e rit ro ch a n t e ric fra ct u re s in t h e la t e ra l vie w is d ifficu lt . Gra vit y a n d m u scu la r
p u ll t e n d t o t h e fra ct u re in t o a n a p e x-p o st e rio r o r a p e x-a n t e rio r p o sit io n , re sp e ct ive ly, d e -
p e n d in g o n t h e fra ct u re p a t t e rn . Ca re m u st b e t a ke n t o a sse ss t h e fra ct u re re d u ct io n in t h is
p la n e a n d a d ju st t h e re d u ct io n if it is n o t a n a t o m ic. Po in t e d re d u ct io n cla m p s o r p e rcu t a -
n e o u sly p la ce d jo yst icks ca n a id in t h e re d u ct io n in t h is p la n e w h ile lim it in g so ft t issu e d isru p -
t io n o f t h e fra ct u re .
■ Ro t a t io n a l re d u ct io n o f p e rit ro ch a n t e ric fra ct u re s ca n b e ch a lle n g in g a s w e ll. Ro t a t io n a l re -
d u ct io n o f in t e rt ro ch a n t e ric fra ct u re s is u su a lly st ra ig h t fo rw a rd , a s m o st t im e s t h e re is a
m a jo r fra ct u re lin e t o a sse ss. Su b t ro ch a n t e ric fra ct u re s in yo u n g p a t ie n t s a re o ft e n q u it e co m -
m in u t e d a n d la ck d e fin it ive a n a t o m y t o a ccu ra t e ly ju d g e ro t a t io n a lig n m e n t fro m t h e fra c-
t u re a lo n e . In t h e se ca se s ro t a t io n m a la lig n m e n t o f t h e lim b ca n b e a sse sse d b y a lig n in g t h e
h ip a n d kn e e in t h e a n t e ro p o st e rio r p la n e . Th is w ill e n su re o ve ra ll re d u ct io n o f a n y ro t a t io n a l
m a la lig n m e n t o f t h e lim b .

POSTOPERATIVE CARE ■ Patients are mobilized as soon as their cardiopulmonary

and mental status will safely allow, usually by postoperative
■ Anteroposterior and lateral radiographs of the operative hip
day 1.
should be obtained immediately postoperatively in the recov- ■ Unrestricted immediate postoperative weight bearing is eas-
ery room to assess implant position and fracture reduction and
iest for the patient to comply with, and multiple investigations
to ensure that no iatrogenic femur fracture was produced in-
have shown no increase in fixation failure as a result of this
traoperatively. The entire device should be included in the ra-
postoperative rehabilitation protocol.7
diograph (FIG 6 ).
368 Se c t i o n IV FEM UR AND KNEE

FIG 6 • Po st o p e ra t ive AP a n d la t e ra l ra d io g ra p h s sh o w in g co r-
re ct im p la n t p o sit io n in g a n d n o in t ra o p e ra t ive co m p lica t io n s. B

■ Koval et al8 used gait analysis to show how patients effec-

tively autoregulate their weight bearing postoperatively, with
the patients who had the least-stable fracture patterns preop-
eratively putting the least amount of weight on their legs im-
mediately postoperatively.
■ Patients should be seen 2 weeks postoperatively to check for

uneventful wound healing.

■ Follow-up radiographs should be obtained at 2, 6, and 12

weeks to check for controlled fracture impaction, exclude any

fixation device complications, and assess fracture healing. C

FIG 7 • A. Va ru s co lla p se . B. OTA 31-A1 in t e rt ro ch a n t e ric h ip

OUTCOMES
■ With proper fracture reduction, implant selection, and fixa-
tion device positioning, peritrochanteric hip fractures heal in
up to 98% of cases.
■ O ne-year mortality rates after fixation of peritrochanteric
fra ct u re fixe d w it h a slid in g h ip scre w . C. Fo llo w -u p ra d i-
o g ra p h 6 m o n t h s p o st o p e ra t ive ly sh o w in g se co n d a ry fra ct u re
d isp la ce m e n t .

hip fractures range from 7% to 27% , with most studies find-

ing a rate of 15% to 20% .10
■ M ortality rates depend on both preoperative and postoper-
ative medical complications and condition, as well as preoper-
ative functional status.
■ Postoperative functional status also depends on numerous
■ Longitudinal studies comparing the functional status of pa-
tients before and after hip fracture fixation have documented
that roughly 40% of patients maintain their preoperative level
of ambulation postoperatively.
■ Another 40% of patients have increased dependency on

variables: ambulation devices but remain ambulatory.

■ Socioenvironmental functional status has been shown to ■ Twelve percent of patients become household-only

be of great importance in determining the postoperative ambulators, and 8% of patients become nonambulators
function status of a patient.10 postoperatively. 5
 Ch a p t e r 4 0 ORIF OF PERITROCHANTERIC HIP FRACTURES
COMPLICATION S
■ Loss of proximal fixation is defined as varus collapse of
the proximal fracture fragment with cutout of the lag screw
from the femoral head (FIG 7 A). This complication is seen
in 4% to 20% of fractures, usually within 4 months of
surgery.
■ Although certain fracture patterns have been shown to
have a higher rate of proximal fixation loss, the fracture pat-
tern cannot be controlled by the physician.
■ The placement of the lag screw, on the other hand, can
be controlled by the physician. A central and deep position
with a tip–apex distance of less than 25 mm has been
shown to significantly reduce the incidence of proximal fix-
ation loss. 2
■ N onunion occurs in 1% to 2% of fractures. The low inci-
dence is likely due to the well-vascularized nature of the can-
cellous peritrochanteric region of the hip through which these
fractures develop.
■ Secondary fracture displacement
■ Despite adequate fracture reduction and implant posi-
tioning, fractures may progress to excessive impaction,
with resultant limb shortening and abductor weakening
(FIG 7 B,C). This can lead to suboptimal patient functional
results. This is often seen in cases of unrecognized lateral
wall fractures (either iatrogenically induced by implant
placement or unrecognized from the original trauma).
■ Use of intramedullary fixation devices and vigilant fol-
low-up may help avoid this complication.
■ Infection
■ Wound dehiscence
REFEREN CES
1. Baumgaertner M R, Curtin SL, Lindskog DM , et al. The value of the
tip-apex distance in predicting failure of fixation of peritrochanteric
fractures of the hip. J Bone Joint Surg Am 1995;77A:1058–1064.
2. Baumgaertner M R, Solberg BD. Awareness of tip-apex distance re-
duces failure of fixation of trochanteric fractures of the hip. J Bone
Joint Surg Br 1997;79B:969–971.
369
3. Bolhofner BR, Russo PR, Carmen B. Results of intertrochanteric
femur fractures treated with a 135-degree sliding screw with a two-
hole side plate. J O rthop Trauma 1999;13:5–8.
4. Griffen JB. The calcar femorale redefined. Clin O rthop Relat Res
1982;164:211–214.
5. Koval KJ, Friend KD, Aharonoff GB, et al. Weight bearing after hip
fracture: a prospective series of 596 geriatric hip fracture patients. J
O rthop Trauma 1996;10:526–530.
6. Koval KJ, Sala DA, Kummer FJ, et al. Postoperative weight-bearing
after a fracture of the femoral neck or an intertrochanteric fracture. J
Bone Joint Surg Am 1998;80A:352–356.
7. Koval KJ, Skovron M L, Aharonoff GB, et al. Ambulatory ability after
hip fracture: a prospective study in geriatric patients. Clin O rthop
Relat Res 1995;310:150–159.
8. Kregor PJ, O bremskey WT, Kreder H G, et al. Unstable
pertrochanteric femoral fractures. J O rthop Trauma 2005;19:63–66.
9. M cLoughlin S, Wheeler DL, Rider J, et al. Biomechanical evaluation
of the dynamic hip screw with two- and four-hole sideplates. J
O rthop Trauma 2000;14:318–323.
10. M iller CW. Survival and ambulation following hip fracture. J Bone
Joint Surg Am 1978;60A:930.
11. M oran CG, Wenn RT, Sikand M , et al. Early mortality after hip frac-
ture: is delay before surgery important? J Bone Joint Surg Am
2005;87:483–489.
12. Pajarinen J, Lindahl J, M ichelsson O , et al. Peritrochanteric femoral
fractures treated with a dynamic hip screw or a proximal femoral
nail: a randomised study comparing postoperative rehabilitation. J
Bone Joint Surg Br 2005;87:76–81.
13. Rao JP, Banzon M T, Weiss AB, et al. Treatment of unstable in-
tertrochanteric fractures with anatomic reduction and compression
hip screw fixation. Clin O rthop Relat Res 1983;175:65–71.
14. Ruby L, M ital M A, O ’Connor J, et al. Anteversion of the femoral
neck. J Bone Joint Surg Am 1979;61:46–51.
15. Utrilla AL, Reig JS, M unoz FM , et al. Trochanteric gamma nail and
compression hip screw for trochanteric fractures: a randomized,
prospective, comparative study in 210 elderly patients with a new de-
sign of the gamma nail. J O rthop Trauma 2005;19:229–233.
16. Winter WG. N onoperative treatment of proximal femoral fractures
in the demented, nonambulatory patient. Clin O rthop Relat Res
1987;218:97–103.
17. Z uckerman JD, Skovron M L, Koval KJ, et al. Postoperative compli-
cations and mortality associated with operative delay in older pa-
tients who have a fracture of the hip. J Bone Joint Surg Am 1995;
77A:1551–1556.
 Re t ro g r a d e In t r a m e d u lla r y
Ch a p t e r 41 Na ilin g o f t h e Fe m u r
Lau ra S. Ph ie f f e r an d Ro n ald Lak at o s
DEFIN ITION
■ Retrograde femoral nailing can be defined as any femoral
nailing technique with a distal entry from the condyles or
through an intercondylar, intra-articular starting point.
■ For this chapter, retrograde fem oral nailing will refer to
nails with an intercondylar starting point that extend through
the shaft region to the proximal femur. In certain fracture sit-
uations, shortened nails (supracondylar nails) can be used with
the same starting point for fixation of distal femoral fractures.
AN ATOMY
■ The femoral shaft is tubular in shape over the extent of the
isthmus, gradually flaring infra-isthmally into the distal femur,
which is trapezoidal in cross section.
■ The entry point for the retrograde femoral nail is located at
the distal end of the patellofemoral grove, just anterior to the
posterior cruciate ligament insertion (FIG 1 A).
■ Radiographically, this is located in the midline or just me-
dial to the midline between the condyles on the antero-
posterior (AP) view, and laterally just anterior to the line
of Blumensaat as it meets the trochlear grove (FIG
1 B,C).4,11,13,14,19 This flat articular area has minimal to no
contact with the patella until 120 degrees of flexion.1,4
■ Pertinent proximal anatomy includes neurovascular struc-
tures anterior to the proximal femur, close to interlocking
screw insertion sites. 21
■ The femoral artery is medial to the proximal femur, with
branches that cross the anterior femur more than 4 cm dis-
tal to the lesser trochanter.
■ Branches of the femoral nerve cross more proximal start-
ing 4 cm distal to the piriformis fossa.
■ Damage to neurovascular structures caused by proximal
locking screw insertion can be avoided or minimized by
avoiding medial dissection and with placement at or above
the lesser trochanter (FIG 2 ).
PATHOGEN ESIS
■ Femoral shaft fractures are markers of high-energy
injuries.9,11,12,13,20,24
■ Studies have shown that 38% of trauma patients diagnosed
with a femoral shaft fracture have additional injuries.2,6,7,23
■ In femur fracture patients with associated injuries, the
most common findings are other musculoskeletal injuries
(93% ), thoracic injuries (62% ), head injuries (59% ), ab-
dominal injuries (35% ), and facial injuries (16% ).7
■ Ipsilateral femoral neck fractures occur in 1% to 6% of
all femoral shaft fractures and are initially missed in up to
20% to 50% of cases. 26 Recognition of these injuries be-
fore intramedullary stabilization is important to minimize
potential complications (refer to section on imaging and
other diagnostic studies).
370
■ All trauma patients should undergo the standard advanced
trauma life support (ATLS) examination to rule out associated
life-threatening injuries.
■ Although less common, femoral shaft fractures can occur in
isolated sports injuries and in low-energy injuries associated
with pathologic bone, such as with osteoporosis or metastatic
bone disease.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Pain and deformity of the thigh are usually obvious but may
be obscured in the morbidly obese patient.
■ The fractured limb should be closely examined to avoid
missing any open wounds, particularly in the posterior aspect
of the thigh. Skin abrasions and apparently minor wounds
should be assessed to determine if they communicate with the
fracture.
■ Swelling is a common finding with femoral shaft fractures.
Compartment syndrome of the thigh is rare but can occur.25
■ The entire lower extremity and pelvis needs to be evaluated
because of the high rate of associated musculoskeletal injuries.
■ A thorough neurologic and vascular examination must also
be performed. Although femoral nerve damage is very un-
usual, sciatic nerve damage can occur.3,5,32
■ Associated ligamentous injuries of the knee are common but
may be difficult to assess until definitive stabilization of the
femur has been obtained. Therefore, this examination should
be repeated after nailing the femoral fracture.28,29
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Anteroposterior (AP) and lateral radiographs of the full
length of the femur are essential, as well as formal AP and lat-
eral radiographs of the hip and knee.
■ Lateral knee radiographs should be closely evaluated
for subtle patellar impaction fractures or nondisplaced
fractures.
■ H ip radiographs should be closely examined to rule out
an associated femoral neck fracture, which has been shown
to occur in 1% to 6% of femoral shaft fractures.26
■ Some surgeons recommend a routine CT scan examination
of the femoral neck as part of the trauma scan to rule out a
femoral neck fracture.
■ A reported 20% to 50% of these injuries are missed on
the initial plain radiographic examination.26
■ Because of the high association of missed coronal fractures
in high-energy injuries, a CT scan of the knee should be ob-
tained whenever formal knee radiographs reveal a supra-
condylar distal femur fracture and there is consideration for
retrograde nailing.16
■ Any coronal fractures seen on CT examination should be
considered a contraindication for retrograde nailing owing
 Ch a p t e r 4 1 RETROGRADE INTRAM EDULLARY NAILING OF THE FEM UR 371

Lateral Medial

TG

A B

FIG 1 • A. Dist a l fe m u r vie w e d e n d o n , w it h id e a l st a rt in g p o in t

C BL
fo r re t ro g ra d e fe m o ra l n a ilin g id e n t ifie d (*) ju st a n t e rio r t o t h e
p o st e rio r cru cia t e lig a m e n t in se rt io n . B,C. AP a n d la t e ra l ra d i-
o g ra p h s o f t h e kn e e , w it h t h e in it ia l st a rt in g g u id e w ire p o si-
t io n e d a t t h e id e a l st a rt in g p o in t fo r re t ro g ra d e fe m o ra l n a ilin g .
Th e ra d io g ra p h ic la n d m a rk fo r t h e t ro ch le a r g ro o ve (TG) is in d i-
ca t e d o n t h e AP ra d io g ra p h a n d fo r t h e lin e o f Blu m e n sa a t (BL)
o n t h e la t e ra l ra d io g ra p h .

to the possibility of compromising the distal interlocking ■ Proximally, CT scans can supplement plain radiographs
screw fixation. to determine fracture line extension into the peritrochanteric
region and to check for occult femoral neck fractures.
SURGICAL MAN AGEMEN T ■ Distally, CT imaging is helpful to assess intra-articular ex-

Classifications and Relative Indications tension and to check for coronal plane fractures.16
■ All femoral shaft fractures, as classified by the Winquist
■ It is important to assess the extent of the fracture both prox-
imally and distally with proper radiographs. system,31 are technically suitable for retrograde femoral nail-
ing (FIG 3 ).
■ Retrograde femoral nailing is not considered to be the stan-

dard of care for treatment of more proximal subtrochanteric

fractures, but in certain patient circumstances it may be the
treatment of choice (Table 1).
■ Subtrochanteric fractures with the lesser trochanter and

piriformis fossa intact, Russell-Taylor IA fractures (FIG 4 ),22

Medial Lateral

Proximal Anatomy 0 I II III IV

FIG 2 • Cro ss-se ct io n a l vie w o f t h e p ro xim a l fe m u r, w it h p ro xi- FIG 3 • Win q u ist fe m o ra l sh a ft fra ct u re cla ssifica t io n syst e m .29
m a l in t e rlo ckin g scre w in se rt io n sh o w n a n d p e rt in e n t m e d ia l All fra ct u re p a t t e rn s in t h is syst e m a re a m e n a b le t o re t ro g ra d e
n e u ro va scu la r st ru ct u re s. fe m o ra l n a ilin g .
372 Se c t i o n IV FEM UR AND KNEE

Ta b le 1 Re la t iv e In d ica t io n s f o r Re t r o g r a d e In t r a m e d u lla r y Na ilin g o f t h e Fe m u r

In d ica t io n
All femoral shaft fractures
Pregnancy
Bilateral femur fractures
Floating knee injuries
Polytrauma patient
Unstable spine injuries
Acetabular or pelvic fractures
Ipsilateral hip and femoral
shaft fractures
Ipsilateral femoral shaft
fracture below a total hip
replacement stem
Morbid obesity
Soft tissue wounds about the hip
Ra t io n a le
Shown in multiple studies to have equivalent union rates and outcomes to antegrade intramedullary nailing
Ability to decrease the amount of radiation exposure to the fetus
Decreased overall operative time because the lower extremities can be prepared and draped together, eliminating the need
to reposition for the second procedure
Single surgical approach
Supine positioning without bump allows for multiple surgical team approach to patient.
Supine positioning without bump affords ability to maintain spine precautions throughout the procedure.
Avoids surgical incision about the hip that may limit future surgical approaches
Allows each fracture to be treated with the optimal implant
Short supracondylar retrograde nails can be used to treat the fracture with a minimally invasive technique.
Easier and more limited surgical approach
Avoids surgical approach of compromised soft tissues

may be amenable to retrograde femoral nailing if other pa-

tient factors favor a retrograde approach.
■ Ideally, some proximal medial cortex remains intact to act

as a buttress against the nail.

■ It is important to know how far the proximal interlocking

screw holes are from the tip of the nail in the retrograde nail
system available in your hospital.
■ We recommend being able to obtain two bicortical inter-

locking screws above the most proximal fracture line for

very proximal fractures. If possible, they should be through
holes, not slots, in the nail to provide more stability.
■ If the subtrochanteric fracture has proximal extension, in-

cluding either the lesser trochanter or piriformis fossa, or

both, then proximal interlocking screw fixation of the retro-
grade nail would be compromised and alternative fracture
fixation methods should be considered.
IA IIA ■ Retrograde femoral nailing may be considered in certain

supracondylar distal femoral fractures. We find that M uller’s

AO classification system of distal femoral fractures15 best elu-
cidates which of these fractures can be addressed with retro-
grade femoral nailing (FIG 5 ).
■ Consideration for retrograde femoral nailing can be given

for all extra-articular (A subgroup) fractures.

■ It is important to know the distance between the distal in-

terlocking screw holes and the tip of the nail in the retrograde
nail system available in your hospital.
■ We recommend being able to obtain at least two bicorti-

cal interlocking screws below the most distal fracture line

for distal fractures.
■ N ails with oblique distal interlocking options can be ad-

vantageous because of increased stability and potentially less

screw head prominence.
■ Consideration for retrograde femoral nailing can be given

to simple transverse articular fracture patterns (C-1 and C-2

subgroups).
IB IIB ■ This should be performed with an open medial or lat-

FIG 4 • Ru sse ll-Ta ylo r cla ssifica t io n syst e m o f su b t ro ch a n t e ric eral parapatellar approach to the knee in lieu of a percu-
fe m u r fra ct u re s,22 w it h fra ct u re p a t t e rn s a m e n a b le t o re t ro - taneous approach. Articular reduction must first be ob-
g ra d e fe m o ra l n a ilin g h ig h lig h t e d . tained and then maintained with bicortical screw fixation
 Ch a p t e r 4 1 RETROGRADE INTRAM EDULLARY NAILING OF THE FEM UR 373

placed outside of the planned path for the retrograde nail

(FIG 6 ).
■ Partial articular fractures (all B subgroups) and complex ar-

ticular fractures (C-3 subgroups) should not be considered for

retrograde femoral nailing.
■ Patients with osteoporotic distal fractures may be best

treated with some of the newer fixed-angle plate devices,

owing to concerns of distal interlocking screw purchase.
■ Alternatively, nails designed with multiaxial screws or the

use of supplemental blocking screws may help with aug-

A1 B1 C1
menting fixation.

Contraindications
■ Preoperative knee stiffness preventing 40 to 60 degrees of
flexion
■ Active knee sepsis

■ Grossly contaminated soft tissue wounds about the knee

■ Skeletally immature patients

Preoperative Planning
A2 B2 C2 ■ AP and lateral radiographs are used to measure the diame-
ter of the femoral canal isthmus and thus determine the ap-
proximate nail diameter. M ost intramedullary nail systems
come in diameters ranging from 10 to 13 mm.
■ N ail lengths are often determined intraoperatively but can

be ascertained by imaging the contralateral femur.

■ Radiographs are evaluated to determine the location and

morphology of the fracture; they should be scrutinized for

nondisplaced secondary fracture lines that could become dis-
placed during operative treatment.
■ O ccasionally, fracture fragments may be stuck in the

A3 B3 C3 canal and may need to be pulled out.

■ In the case of fractures that show significant shortening pre-

FIG 5 • Mu lle r’s AO cla ssifica t io n syst e m o f d ist a l fe m o ra l fra c- operatively, it may be difficult to restore length off the fracture
t u re s,15 w it h fra ct u re p a t t e rn s a m e n a b le t o re t ro g ra d e fe m o ra l table.
n a ilin g h ig h lig h t e d .

A
C

FIG 6 • A. Dia g ra m o f la t e ra l a sp e ct o f d ist a l fe m u r, w it h p o t e n t ia l sit e s fo r in t ra -a rt icu la r scre w fixa t io n o u t o f t h e p a t h o f t h e

re t ro g ra d e fe m o ra l n a il id e n t ifie d . B. Dia g ra m o f d ist a l fe m u r e n d o n , w it h p o t e n t ia l sit e s fo r in t ra -a rt icu la r scre w fixa t io n o u t
o f t h e p a t h o f t h e re t ro g ra d e fe m o ra l n a il id e n t ifie d . C. In t ra o p e ra t ive la t e ra l ra d io g ra p h o f a su p ra co n d yla r, in t ra co n d yla r (C1)
d ist a l fe m u r fra ct u re w it h in t ra -a rt icu la r scre w fixa t io n a n d re t ro g ra d e n a il in p la ce .
 374 Se c t i o n IV FEM UR AND KNEE

■A trial reduction should be performed under fluoroscopy included in the preparation in case any femoral neck frac-
before the start of the procedure; the patient must be para- tures are identified after treatment of the femoral shaft
lyzed for the procedure. fracture.
■ If length is difficult to restore manually, then a femoral ■ Radiolucent sterile towels, sheets, or a radiolucent triangle

distractor should be used for the procedure. Placement of are used to create a bump under the knee, allowing for about
the femoral distractor is described in the section on fracture 40 degrees of knee flexion and placing the patella anterior for
reduction. correct rotational alignment.1,14
■ Before preparing and draping the injured limb, the surgeon ■ Intraoperative fluoroscopy should come in from the con-

should examine the contralateral extremity to determine the tralateral side.

patient’s normal leg length and rotation.
■ Femoral length can be evaluated by using a radiographic
ruler and intraoperative fluoroscopy (FIG 7 A).
■ N ormal rotation can be determined by flexing the hip and
knee and checking the patient’s normal internal and exter-
nal rotation of the hip, and by examining the normal resting
position of the foot as the patient lies supine on the operat-
ing room table (FIG 7 B).
Positioning
■ The patient is positioned supine on a radiolucent diving
Approach
■ The knee should be flexed about 40 degrees to avoid injury
to the proximal tibia and the patella. 14
■ Intraoperative fluoroscopy is used to obtain a perfect lateral
of the knee. The line of Blumensaat should be clearly identified
(see Fig 1C).
■ A radiopaque guidewire can be used to identify the center of
the long axis of the femur in order to determine the correct
level of the skin incision.
■ The guide pin is used to center a 1.5- to 2.5-cm incision just

board or flat-top table with no bump under the hip. medial to the midline.
■ The surgeon should ensure that the entire femur, from hip ■ A medial flap is created using subcutaneous dissection. A

to knee, can be imaged on AP and lateral fluoroscopy. medial paratendinous arthrotomy is then made to allow en-
■ The extremity should be draped free from the anterior su- trance of the initial starting guidewire into the intracondylar
perior iliac spine to the ankle. The entire hip should be notch.

C-arm
(intraoperative x-ray)
Position 1 Position 2

Calibrated ruler
for nail system

FIG 7 • A. Sch e m a t ic la t e ra l vie w o f a p a t ie n t o n a ra d io lu ce n t o p e ra t in g

ro o m t a b le , d e p ict in g h o w t o u se a ra d io p a q u e ru le r a n d flu o ro sco p y t o d e -
t e rm in e fe m o ra l le n g t h . B. Sch e m a t ic a n t e rio r vie w o f a p a t ie n t o n t h e o p -
e ra t in g ro o m w it h t h e u n in ju re d h ip a n d kn e e fle xe d , ch e ckin g t h e p a t ie n t ’s
n o rm a l in t e rn a l a n d e xt e rn a l ro t a t io n o f t h e h ip . B
 Ch a p t e r 4 1 RETROGRADE INTRAM EDULLARY NAILING OF THE FEM UR
PLACING THE GUIDEWIRE
■ Th e su rg e o n co n firm s t h e co rre ct p la ce m e n t o f t h e in it ia l
st a rt in g g u id e w ire o n t h e AP a n d la t e ra l flu o ro sco p ic ra -
d io g ra p h s.
■ On t h e lat eral ima g e, t h e in itia l sta rt in g g u id e wire
sh o u ld b e sit u a t e d a t t h e a p e x o f t h e lin e o f
Blu me nsa a t , in line wit h the fe m o ral sh a ft (se e Fig 1C).
■ On t h e AP im a g e , t h e g u id e w ire sh o u ld b e ce n t e re d
o r ju st m e d ia l t o t h e m id lin e in t h e t ro ch le a r g ro o ve ,
in lin e w it h t h e fe m o ra l sh a ft (se e Fig 1B).
■ On t h e AP im a g e , t h e flu o ro sco p e is m o ve d p ro xi-
m a lly t o b e ce rt a in t h e g u id e w ire is d ire ct e d a t t h e
ce n t e r o f t h e ca n a l.
CREATING AND REAMING THE STARTING HOLE
■ Th e in it ia l st a rt in g re a m e r is u se d t o cre a t e t h e st a rt in g
h o le . (Alt e rn a t ive ly, a n a w l o r a st e p d rill ca n b e u se d t o
m a ke t h e st a rt in g h o le u sin g t h e p rin cip le s d e scrib e d
a b o ve .)
FRACTURE REDUCTION
■ Tra ct ion is u se d t o re st o re le n g t h . Th e su rg e o n m u st e n -
su re t h a t a d e q u a t e a n e st h e sia (fu ll p a ra lysis) is e m p lo ye d .
■ Th e re a re m a n y d e fo rm in g m u scle fo rce s, d e p e n d in g o n
t h e le ve l o f t h e fra ct u re . If t h e fra ct u re ca n n o t b e re -
d u ce d b y m a n u a l t ra ct io n , u se o f b u m p s, p u llin g w it h
sh e e t s w ra p p e d a ro u n d t h e p ro xim a l o r d ist a l t h ig h , o r
p u sh in g w it h m a lle t s, t h e n h e re a re so m e o p t io n s.
■ The abdu ctor muscles will abd uct and externally rotate th e
proximal femur after high subtrochanteric and proximal
shaft fractures. Inserting a unicortical 5-mm Schanz pin
through a percutaneous incision in the lateral cortex just
abo ve th e fractu re or in the g reater trochanter can gain
excellen t control of the proximal fracture fragment.
■ Th e ilio p so a s m u scle w ill fle x a n d in t e rn a lly ro t a t e p ro xi-
m a l-t h ird fe m o ra l sh a ft fra ct u re s b y it s p u ll o n t h e le sse r
t ro ch a n t e r. Ag a in , in se rt in g a u n ico rt ica l 5-m m Sch a n z
p in t h ro u g h a p e rcu t a n e o u s in cisio n in t h e la t e ra l co rt e x
ju st a b o ve t h e fra ct u re o r in t h e g re a t e r t ro ch a n t e r ca n
g a in e xce lle n t co n t ro l o f t h e p ro xim a l fra ct u re fra g m e n t .
■ Th e a d d u ct o r m u scle s sp a n m o st sh a ft fra ct u re s a n d
e xe rt a st ro n g a xia l a n d a d d u ct io n fo rce . So m e t im e s m id -
sh a ft t ra n sve rse fra ct u re s ca n b e t h e m o st d ifficu lt t o re -
d u ce . In se rt in g a u n ico rt ica l 5-m m Sch a n z p in t h ro u g h a
p e rcu t a n e o u s in cisio n in t h e la t e ra l co rt e x ju st a b o ve a n d
ju st b e lo w t h e fra ct u re ca n g a in e xce lle n t co n t ro l o f t h e
p ro xim a l a n d d ist a l fra ct u re fra g m e n t s.
PASSING THE GUIDEWIRE
■ On ce th e fract u re is re d u ce d o n t h e AP an d lat era l im ag e s,
th e surge on p a sse s th e g uide w ire t o e n d just be lo w t h e
le vel o f th e p irifo rm is fo ssa .
375
TECHNIQUES
■ Wh e n st a rt in g t o d rill t h e in it ia l g u id e w ire , t h e su r-
g e o n ’s h a n d sh o u ld d ro p slig h t ly t o p re ve n t t h e w ire
fro m fa llin g in t o t h e p o st e rio r cru cia t e lig a m e n t in -
se rt io n ; t h e h a n d is ra ise d o n ce t h e w ire e n t e rs t h e
co rt e x, so a s t o b e in lin e w it h t h e fe m o ra l sh a ft .
■ On ce t h e in it ia l st a rt in g g u id e w ire is ce n t e re d o n t h e
AP a n d la t e ra l im a g e s, t h e w ire is p a sse d in t o t h e d is-
t a l fe m o ra l sh a ft .
■ A so ft t issu e re t ra ct o r is p la ce d o ve r t h e in it ia l st a rt -
in g g u id e w ire t o p ro t e ct t h e p a t e lla r t e n d o n d u rin g
re a m in g .
■ On ce t h e st a rt in g h o le h a s b e e n m a d e , a b e a d e d -t ip
g u id e w ire is p a sse d t o t h e le ve l o f t h e fra ct u re .
■ Dist a l fra ct u re s t e n d t o a n g u la t e in t o re cu rva t u m
t h ro u g h t h e p u ll o f t h e g a st ro cn e m iu s m u scle . Bu m p s
p la ce d u n d e r t h e kn e e t o fle x t h e kn e e ca n h e lp re la x t h e
g a st ro cn e m iu s m u scle . On e ca n a lso u se b lo ckin g scre w s
in d ist a l fra ct u re s t o su rg ica lly cre a t e a n a rro w “ ca n a l” in
t h e m e t a p h yse a l re g io n in lin e w it h t h e ca n a l o f t h e
fe m o ra l sh a ft so t h a t t h e in t ra m e d u lla ry n a il ca n h e lp
w it h re d u ct io n o f t h e fra ct u re .
■ Alt e rn a t ive ly, a fe m o ra l d ist ra ct o r ca n a ssist w it h o b t a in -
in g a n d m a in t a in in g fra ct u re re d u ct io n fo r a fra ct u re a t
a n y le ve l. It ca n b e p la ce d la t e ra lly, in se rt e d p ro xim a lly a t
t h e g re a t e r t ro ch a n t e r a n d d ist a lly in e it h e r t h e p o st e rio r
a sp e ct o f t h e fe m o ra l co n d yle o r in t h e p ro xim a l t ib ia .
Alt e rn a t ive ly, so m e su rg e o n s re co m m e n d a n t e rio r p la ce -
m e n t t o a vo id p o t e n t ia l p o st e rio r a n g u la t io n o f d ist a l
fra ct u re p a t t e rn s.
■ La st ly, so m e fra ct u re s re q u ire o p e n in g o f t h e fra ct u re
sit e t o o b t a in re d u ct io n , w it h t h e fin d in g o f t h e m u scle
in t e rp o se d w it h in t h e fra ct u re . We re co m m e n d la t e ra lly
b a se d in cisio n s u n le ss o t h e rw ise d ict a t e d b y a n o p e n
fra ct u re w o u n d .
■ Re st o ra t io n o f le n g t h a n d co rre ct ro t a t io n ca n b e a s-
se sse d clin ica lly a s w e ll a s ra d io g ra p h ica lly b y clo se ly
scru t in izin g t h e d ia m e t e r o f t h e m e d ia l a n d la t e ra l
fe m o ra l co rt e x, e n su rin g t h e y a re o f e q u a l d ia m e t e r
p ro xim a l a n d d ist a l t o t h e fra ct u re .
■ Th is is d o n e t o e n su re t h a t re a m in g is p e rfo rm e d p a st t h e
le ve l o f t h e le sse r t ro ch a n t e r, sin ce t h e re a m e rs st o p a t
t h e b e a d e d p o rt io n o f t h e g u id e w ire .
 376 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES
REAMING
■ Re a m in g sh o u ld b e g in w it h a n e n d -cu t t in g re a m e r (t yp i-
ca lly size 8 m m o r 9 m m in d ia m e t e r).
■ Fra ct u re re d u ct io n m u st b e m a in t a in e d t h ro u g h o u t t h e
re a m in g p ro ce ss t o m in im ize e cce n t ric re a m in g .
■ Re a m in g sh o u ld b e p e rfo rm e d slo w ly a n d in 0.5-m m in -
cre m e n t s t o p re ve n t t h e rm a l n e cro sis.
■ Th e a p p ro xim a t e n a il d ia m e t e r is se le ct e d b a se d o n t h e
p re o p e ra t ive m e a su re m e n t o f t h e fe m o ra l ist h m u s. Th e
fin a l n a il d ia m e t e r sh o u ld b e se le ct e d b a se d o n t h e size
o f t h e re a m e r t h a t p ro vid e s t h e in it ia l co rt ica l ch a t t e r.
■ Th e ca n a l is re a m e d t o 1.0 t o 1.5 m m o ve r t h e se le ct e d
n a il d ia m e t e r.
■ Na il le n g t h ca n b e d e t e rm in e d m u lt ip le w a ys:
■ A ra d io lu ce n t ru le r ca n b e p la ce d o n t h e a n t e rio r a s-
p e ct o f t h e fe m u r. Th e n a il sh o u ld e n d a b o ve t h e
le ve l o f t h e le sse r t ro ch a n t e r o n t h e AP ra d io g ra p h
a n d sh o u ld b e m e a su re d so t h a t it is d e e p t o t h e
Guidewire A
Clamp Guidewire B
Blumensaat’s
line
*
PLACING THE NAIL
■ On ce t h e n a il size is se le ct e d , t h e n a il is in se rt e d o ve r t h e
g u id e w ire .
■ Mo st cu rre n t syst e m s a llo w t h e b e a d e d -t ip g u id e w ire t o
p a ss t h ro u g h t h e ca n n u la t e d n a il. If a n o ld e r syst e m is
b e in g u se d , t h e n t h e b e a d e d -t ip g u id e w ire m u st b e e x-
ch a n g e d fo r a sm o o t h -t ip g u id e w ire u sin g a n e xch a n g e
tube.
■ If g u id e w ire e xch a n g e is re q u ire d , t h e su rg e o n e n su re s
co rre ct p la ce m e n t o f t h e sm o o t h -t ip g u id e w ire o n t h e
AP a n d la t e ra l im a g e s b e fo re n a il in se rt io n .
■ Th e n a il is in se rt e d o ve r t h e g u id e w ire a n d sh o u ld p a ss
re la t ive ly e a sily.
■ If t h e n a il d o e s n o t a d va n ce e a sily, t h e su rg e o n p e r-
fo rm s a ca re fu l AP a n d la t e ra l flu o ro sco p ic a sse ssm e n t
o f t h e fra ct u re re d u ct io n a n d n a il p la ce m e n t .
■ Na il in se rt io n d e p t h is a sse sse d o n t h e la t e ra l kn e e
ra d io g ra p h .
■ Th e n a il sh o u ld e n d p ro xim a l t o t h e a p e x o f t h e lin e
o f Blu m e n sa a t t o e n su re su b ch o n d ra l p la ce m e n t
(TECH FIG 2 A).
■ Th e su rg e o n co n firm s t h a t fra ct u re le n g t h a n d a lig n m e n t
h a ve b e e n re st o re d o n t h e AP a n d la t e ra l ra d io g ra p h s.
■ Th e su rg e o n co n firm s t h a t t h e n a il le n g t h se le ct e d p u t s
t h e p ro xim a l t ip o f t h e n a il e n d in g a t o r a b o ve t h e le ve l
o f t h e le sse r t ro ch a n t e r (TECH FIG 2 B).
■ Th e n a il is a d va n ce d if t h e p ro xim a l t ip d o e s n o t e n d
a t o r a b o ve t h e le ve l o f t h e le sse r t ro ch a n t e r.
a p e x o f t h e lin e o f Blu m e n sa a t o n t h e la t e ra l vie w
(se e Fig 1C).
■ Alt e rn a t ive ly, a se co n d g u id e w ire o f t h e sa m e le n g t h
ca n b e in se rt e d in t o t h e kn e e t o e n d ju st d e e p t o t h e
a p e x o f t h e lin e o f Blu m e n sa a t o n t h e la t e ra l flu o ro -
sco p ic im a g e .
■ Th is a d d it io n a l g u id e w ire is cla m p e d a t t h e le ve l o f
t h e g u id e w ire a lre a d y in p la ce .
■ Th e p o rt io n d ist a l t o t h e g u id e w ire in p la ce is m e a -
sure d t o e q u a l t h e a m o u n t o f g u id e w ire in t h e
fe m o ra l ca n a l (TECH FIG 1 ).
■ In a d d it io n , m a n y n a ilin g syst e m s h a ve syst e m -sp e cific
m e a su re m e n t g u id e s t h a t a re o u t lin e d in t h e ir t e ch -
n iq u e m a n u a ls.
■ If t h e m e a su re m e n t is b e t w e e n n a il size s, t h e sh o rt e r
n a il is se le ct e d . Le n g t h ca n b e a d d e d w it h a n e n d ca p
if re q u ire d .
TECH FIG 1 • Sch e m a t ic d ia g ra m o f a la t e ra l vie w o f
t h e kn e e , o b t a in in g fe m o ra l le n g t h m e a su re m e n t
u sin g t h e t w o -g u id e w ire t e ch n iq u e . *Th e a m o u n t o f
g u id e w ire B in d ica t e d b y t h e b ra cke t e q u a ls t h e
a m o u n t o f g u id e w ire A in t h e fe m o ra l ca n a l.
■ If t h is le a ve s t h e n a il co u n t e rsu n k, e n d ca p s ca n b e se -
le ct e d t o g a in n a il le n g t h .
■ Ca re m u st b e t a ke n t o re m a in b e lo w t h e p irifo rm is
fo ssa t o a vo id p ro xim a l n a il p ro t ru sio n .
■ Th e n a il is lo cke d d ist a lly u sin g t h e d ist a l in t e rlo ckin g
g u id e s.
■ We t yp ica lly u se o n e la t e ra l-t o -m e d ia l d ist a l in t e rlo ck-
in g scre w fo r t ra n sve rse m id sh a ft fe m o ra l fra ct u re s,
a n d a se co n d a n t e ro la t e ra l-t o -p o st e ro m e d ia l d ist a l
in t e rlo ckin g scre w fo r co m m in u t e d o r d ist a l fe m o ra l
fra ct u re s.
■ Usin g live flu o ro sco p y, t h e flu o ro sco p ic m a ch in e is ro -
t a t e d a b o u t t h e kn e e t o a sse ss t h e le n g t h o f t h e in t e r-
lo ckin g scre w s. Be ca u se o f t h e t ra p e zo id a l sh a p e o f
t h e d ist a l fe m u r, scre w s a re o ft e n p ro m in e n t b u t n o t
w e ll re co g n ize d o n t h e AP ra d io g ra p h .
■ Th e su rg e o n sh o u ld co n sid e r u sin g w a sh e rs, a m e d ia l
lo ckin g n u t , o r a lo ckin g e n d ca p (w h ich lo cks t h e
m o st d ist a l in t e rlo ckin g scre w t o t h e n a il) a s o p t io n s
fo r o st e o p o ro t ic b o n e .
■ On ce d ista l in terlo ckin g screw fixa tio n is co m p let e, t h e
su rg eo n rea ssesse s t h e fra ct u re red u ct io n fluo ro scop ically.
■ If a n y sh o rt e n in g h a s o ccu rre d , le n g t h ca n b e re -
g a in e d b y m a n u a l t ra ct io n o r b y b a ck-sla p p in g t h e
n a il w it h t h e in se rt io n g u id e n a il re m o va l a t t a ch m e n t
(t h e su rg e o n m u st e xe rcise ca u t io n w h e n u sin g t h is
t e ch n iq u e in p a t ie n t s w it h o st e o p o ro t ic b o n e ).
 Ch a p t e r 4 1 RETROGRADE INTRAM EDULLARY NAILING OF THE FEM UR 377

TECHNIQUES
PF

BL
A B

TECH FIG 2 • A. Po st o p e ra t ive la t e ra l ra d io g ra p h o f t h e kn e e , sh o w in g co rre ct re t -

ro g ra d e fe m o ra l n a il in se rt io n d e p t h d e e p t o t h e lin e o f Blu m e n sa a t (BL).
B. Po st o p e ra t ive AP ra d io g ra p h o f t h e h ip , sh o w in g co rre ct re t ro g ra d e fe m o ra l n a il
in se rt io n d e p t h a b o ve t h e le sse r t ro ch a n t e r o f t h e fe m u r b u t b e lo w t h e ra d io g ra p h ic
la n d m a rk fo r t h e p irifo rm is fo ssa (PF).

SCREW FIXATION
■ Pro xim a l in t e rlo ckin g scre w fixa t io n is p e rfo rm e d in t h e
a n t e rio r-t o -p o st e rio r p la n e u sin g t h e fre e h a n d p e rfe ct
circle t e ch n iq u e .7
■ First , a m a g n ifie d AP im a g e o f t h e p ro xim a l fe m u r is
o b t a in e d .
■ Th e flu o ro sco p y m a ch in e is ro t a t e d u n t il t h e p ro xim a l
in t e rlo ckin g h o le is se e n a s a “ p e rfe ct circle ” (a lso
d iscu sse d in Ch a p t e r TR-10, An t e ro g ra d e In t ra m e d u lla ry
Na ilin g o f t h e Fe m u r; Te ch Fig 4, Dist a l in t e rlo ckin g
scre w p la ce m e n t ).
■ A 1-cm in cisio n is m a d e in t h e p ro xim a l a sp e ct o f t h e
t h ig h , a n t e rio rly ce n t e re d o ve r t h e p ro xim a l in t e rlo ckin g
h o le , a s visu a lize d o n t h e AP ra d io g ra p h .
■ Ca re fu l b lu n t d isse ct io n e xp o se s t h e a n t e rio r fe m u r.
■ Th e p ro xim a l fe m u r’s d e n se co rt ica l b o n e m a ke s it d iffi-
cu lt t o st a rt a h o le u sin g a st a n d a rd d rill b it . Th e p o in t e d
so ft t issu e g u id e s fro m la rg e e xt e rn a l fixa t io n syst e m s o r
a p o in t e d d rill b it ca n b e u se d t o p re ve n t slip p in g o ff o f
t h e a n t e rio r co rt e x.
■ Th e fe m o ra l a rt e ry lie s 1 cm m e d ia l t o t h e fe m u r a t t h e
le ve l o f t h e le sse r t ro ch a n t e r, so t h e su rg e o n m u st a vo id
slip p in g o ff t h e fe m u r m e d ia lly.
■ On ce t h e d rill p a sse s t h ro u g h t h e first co rt e x, it is re -
m o ve d fro m t h e d rill b it t o co n firm ra d io g ra p h ica lly t h a t
it w ill p a ss t h o u g h t h e n a il b y t h e a p p e a ra n ce o f a p e r-
fe ct circle w it h in t h e p ro xim a l in t e rlo ckin g h o le .
■ Sm a ll ch a n g e s in t h e d rill a n g le ca n b e m a d e t o e n su re
co rre ct p a ssa g e t h ro u g h t h e in t e rlo ckin g h o le .
■ Wit h a m a lle t , t h e d rill b it ca n b e g e n t ly t a p p e d t h ro u g h
t h e n a il h o le . Th e d rill is t h e n re a t t a ch e d t o co m p le t e
d rillin g t h ro u g h t h e p o st e rio r a sp e ct o f t h e p ro xim a l
fe m u r.
■ Be ca u se o f t he p ro ximit y o f th e sciat ic n erve , care sh ou ld
b e t ake n to e n sure t h at t h e d rill is n o t a d va n ce d t o o fa r
p a st th e po st e rio r corte x.
■ Be fo re re m o vin g t h e d rill, t h e su rg e o n m u st re co n firm
co rre ct ro t a t io n a l a lig n m e n t b y fle xin g t h e h ip a n d kn e e
a n d a sse ssin g t h e h ip ’s in t e rn a l a n d e xt e rn a l ro t a t io n
p ro file .
■ It is co mp a re d wit h th e n o rma l in t ern al an d e xt ern al
ro t a t io n o f t h e co n trala te ra l u n in ju re d h ip t h a t w a s ex-
amine d preo perat ively.
■ Screw le n g th m easu rem en t ca n b e co n firm ed w it h a fro g -
le g la te ra l o r a t ru e la te ra l vie w w it h fle xin g o f t h e h ip t o
cle a r t h e co n tra la t e ra l le g .
■ A sin g le p ro xim a l in te rlo ckin g scre w is a ll th a t is n e e d e d
fo r m ost fracture s.
■ The usua l lengt h o f t he pro xim al int erlo cking scre w is
25 to 35 mm .
■ A se co n d p ro xima l in t e rlo ckin g scre w m a y b e se le ct e d
fo r m ore p ro xim al fra ctu re p a t te rn s.
■ A lo ckin g scre w d rive r sh o u ld b e u se d t o a vo id lo sin g t h e
scre w in t h e p ro xim a l so ft t issu e s. Alt e rn a t ive ly, a su t u re
ca n b e t ie d a ro u n d t h e h e a d o f t h e scre w fo r re t rie va l if
n e ce ssa ry.
■ An in t e rn a lly ro t a t e d m a g n ifie d vie w o f t h e h ip is o b -
t a in e d t o crit ica lly re a sse ss fo r t h e p re se n ce o f a fe m o ra l
n e ck fra ct u re .
 378 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES

WOUND CLOSURE
■ Aft e r w o u n d irrig a t io n , t h e kn e e fa scia l la ye r is clo se d
w it h a 0 o r 1-0 a b so rb a b le su t u re . Th e su b cu t a n e o u s
la ye r is t h e n clo se d w it h 2-0 a b so rb a b le su t u re . Th e skin
ca n t h e n b e clo se d w it h su rg ica l st a p le s.
■ Th e in t e rlo ckin g scre w in cisio n s ca n b e clo se d w it h 2-0
a b so rb a b le su b cu t a n e o u s su t u re s a n d skin st a p le s.
■ So ft d re ssin g s a re a p p lie d .
■ On ce t h e lim b is u n d ra p e d b u t b e fo re m o vin g t h e p a -
t ie n t o ff t h e o p e ra t in g t a b le , it is crit ica l t o a sse ss t h e
a ch ie ve d le n g t h a n d ro t a t io n co m p a re d t o t h e co n t ra la t -
e ra l lim b . If a n y le g -le n g t h d iscre p a n cy o r ro t a t io n a l d e -
fo rm it y is a p p re cia t e d , t h e lim b sh o u ld b e re p re p a re d ,
d ra p e d , a n d co rre ct e d b y ch a n g in g t h e p ro xim a l in t e r-
lo ckin g scre w o r scre w s.
■ A re p e a t e xa m in a t io n o f kn e e st a b ilit y is p e rfo rm e d b e -
fo re le a vin g t h e o p e ra t in g ro o m .

PEARLS AND PITFALLS

Fra ct u re re d u ct io n
Na il in se rt io n :
a vo id in g p o o r
st a rt in g d ire ct io n
Na il in se rt io n :
a vo id in g
slip p in g o ff
Na il in se rt io n :
a vo id in g d ist a l
n a il p ro m in e n ce
Na il in se rt io n :
p ro b le m s w it h
p ro xim a l lo ckin g
scre w s
Use o f d ist a l e n d ca p
Avo id in g d ist a l
in t e rlo ckin g scre w
p ro m in e n ce
Asso cia t e d in ju rie s
Sp e cific fra ct u re
p a t t e rn s
■ Th e su rg e o n sh o u ld re q u e st fu ll re la xa t io n w it h a n e st h e sia t o fa cilit a t e le n g t h re st o ra t io n .
■ Th e su rg e o n sh o u ld b e w a re o f t h e p o t e n t ia l fo r sh o rt e n in g o f t h e fe m u r w it h re t ro g ra d e in se rt io n .
Be fo re p la cin g t h e p ro xim a l in t e rlo ckin g scre w s, t h e su rg e o n sh o u ld scru t in ize t h e in t ra o p e ra t ive ra d i-
o g ra p h s o f t h e fra ct u re sit e t o e n su re t h a t co rre ct le n g t h h a s b e e n o b t a in e d . Le n g t h m a y b e re g a in e d
b y u sin g t h e fe m o ra l d ist ra ct o r, o r b y u sin g t h e g u id e t o b a ck-sla p t h e n a il a ft e r d ist a l in t e rlo ckin g
scre w p la ce m e n t , o r b y m a n u a l t ra ct io n .
■ Th e su rg e o n sh o u ld e n su re t h a t t h e in it ia l st a rt in g g u id e w ire is ce n t e re d in lin e w it h t h e fe m o ra l sh a ft
o n t h e AP a n d la t e ra l im a g e s. Du e t o t h e o ve rh a n g o f t h e p o st e rio r co n d yle s, t h e re is a t e n d e n cy
t o e rr t o o fa r p o st e rio r; b e ca u se o f t h e n o rm a l va lg u s o f t h e d ist a l e n d o f t h e fe m u r, t h e re is a t e n d e n cy
t o a im t o o m e d ia l, a n d a va ru s d e fo rm it y ca n b e cre a t e d .
■ Wh e n st a rt in g t o d rill t h e in it ia l g u id e w ire , t h e su rg e o n sh o u ld d ro p h is o r h e r h a n d slig h t ly t o p re ve n t
t h e w ire fro m fa llin g in t o t h e p o st e rio r cru cia t e lig a m e n t in se rt io n ; t h e h a n d is ra ise d o n ce t h e su rg e o n
e n t e rs t h e co rt e x, so a s t o b e in lin e w it h t h e fe m o ra l sh a ft .
■ Be fo re in se rt in g t h e d ist a l in t e rlo ckin g scre w s, t h e su rg e o n sh o u ld co n firm t h e su b ch o n d ra l p o sit io n
o f t h e n a il o n t h e la t e ra l in t ra o p e ra t ive ra d io g ra p h ju st d e e p t o t h e a p e x o f t h e lin e a t Blu m e n sa a t
(se e Te ch Fig . 2A).
■ Th e p ro xim a l fe m o ra l co rt e x is t h ick a n d st ro n g . It is e a sy t o st rip p ro xim a l lo ckin g scre w s d u rin g t h e ir
in se rt io n . If d ifficu lt ie s a re e n co u n t e re d o n in se rt io n , t h e su rg e o n sh o u ld re p la ce it w it h a n e w scre w .
Th is ca n h e lp a vo id sig n ifica n t issu e s if scre w o r n a il re m o va l is e ve r re q u ire d .
■ So m e syst e m s h a ve a lo ckin g d ist a l e n d ca p t h a t ca n lo ck t h e m o st d ist a l scre w in p la ce ; t h is is a u se fu l
fe a t u re fo r o st e o p o ro t ic b o n e .
■ En d ca p in se rt io n ca n fa cilit a t e in t ra m e d u lla ry n a il re m o va l if a re a m e d e xch a n g e d n a ilin g fo r fe m o ra l
d e la ye d u n io n o r n o n u n io n o ccu rs.
■ As w it h a n y n a il in se rt io n , if a n e n d ca p is u se d , it sh o u ld b e sp e cifica lly m e n t io n e d in t h e o p e ra t ive
n o t e fo r re vie w in t h e e ve n t o f fu t u re scre w o r n a il re m o va l.
■ Be fo re re m o vin g t h e in se rt io n jig , t h e d ist a l fe m u r is ro t a t e d u n d e r live flu o ro sco p y t o e va lu a t e t h e
le n g t h o f t h e d ist a l in t e rlo ckin g scre w s. Scre w le n g t h ch a n g e s a re m a d e if n e ce ssa ry.
■ Accu ra t e m e a su re m e n t fo r lo ckin g scre w s m in im ize s p o st o p e ra t ive h a rd w a re irrit a t io n .
■ Off-a xis scre w s a re u se d w h e n t h e o p t io n is a va ila b le .
■ Th e su rg e o n sh o u ld a lw a ys ch e ck t h e p re o p e ra t ive im a g e s a n d in t ra o p e ra t ive C-a rm im a g e s fo r
ip sila t e ra l fra ct u re s o f t h e fe m o ra l n e ck.
■ Wh e n u sin g a h ip scre w sid e p la t e im p la n t , t h e su rg e o n sh o u ld t ry t o o ve rla p p ro xim a l h a rd w a re fo r
im p ro ve d m e ch a n ica l p ro p e rt ie s.10
■ Ta b le 2 list s a lt e rn a t ive t e ch n iq u e s.

POSTOPERATIVE CARE ■ For most femoral shaft fractures, even those with comminu-
■ Physical therapy for active and passive knee range of motion tion, weight bearing as tolerated can be safely initiated in the
may be started on the first postoperative day, as can ambula- immediate postoperative period.
tion, prescribed based on the fracture pattern and associated ■ Routine postoperative deep vein thrombosis prophylaxis,

injuries. such as low-molecular-weight heparin, may be safely re-

 Ch a p t e r 4 1 RETROGRADE INTRAM EDULLARY NAILING OF THE FEM UR 379

Ta b le 2 Alt e r n a t iv e Te ch n iq u e s

Fr a ct u r e Ty p e
Ipsilateral femoral shaft
and neck fractures
Subtrochanteric femoral
shaft fractures
Periprosthetic fractures
below a hip stem
Supracondylar femur
fractures
Supracondylar femur
fractures with a simple
sagittal fracture
Periprosthetic fractures
above a total knee
Ipsilateral femoral shaft
and tibial shaft fractures
(“floating knee injuries”)
Pr o s
Optimal fixation for each
fracture pattern
Percutaneous treatment
compared to plating
techniques. Lower incidence
of malunion than antegrade
nailing technique.8,17
Percutaneous treatment
compared to plating
techniques
Percutaneous treatment
compared to plating
techniques
Percutaneous treatment
compared to plating
techniques
Percutaneous treatment
compared to plating
techniques
Single approach and
incision for treatment of
both injuries
Co n s
Two separate surgical
procedures and implants
Less stable proximal fixation
Stress riser created between
end of hip stem and nail
Longer times to union.
Less stable implants than
with current locking plate.
Longer times to union.
Less stable implants than
with current locking plate.
Limited points of distal
fixation
None
Te ch n iq u e
Stabilize hip fracture first, using cannulated screws or dynamic
hip screw. Select four-hole side plate to overlap nail placement.
Do not fill distal three holes until after femoral nail is placed.
Select femoral nail length to end at or above lesser trochanter.
Use small lateral incisions at the level of the fracture to place
pointed reduction clamps without muscle stripping in fracture
reduction.
Place two proximal interlocking screws.
Standard technique except for shorter nail insertion.
Judicious use of blocking screws to ensure center placement of
guidewire, reamer, and nail. Important to maintain alignment
during reaming.
As above, with an open parapatellar approach to knee to ensure
anatomic knee reduction. (Refer to Fig 6 for screw placement.)
Preoperatively determine if femoral component has open box
design. Routine nail insertion technique.
Routine insertion technique

sumed on postoperative day 1 and prescribed for 6 weeks ■ Distal interlocking screw prominence is common, and a rel-
thereafter. atively high percentage of patients elect to have these removed
■ Twenty-four hours of antibiotic prophylaxis is standard for as a secondary procedure.17,18,20
closed fractures. Patients with open fractures remain on antibi- ■ M alunions can be avoided when blocking screws are used

otics for 48 hours after the final intraoperative débridement judiciously for the more distal fracture patterns, and close at-
has been performed. tention is paid to ensure that the fracture reduction is first ob-
tained and then maintained during the entire reaming process.
OUTCOMES ■ Shortening and malrotation can be readily assessed at the

■ The long-term effects of retrograde nailing on knee function end of the procedure and corrected immediately by revising
are not known. placement of the proximal interlocking screw or screws.
■ Two prospective, randomized trials comparing reamed ante- ■ Selecting larger-diameter nails based on feedback of cortical

grade and retrograde nailing of femoral shaft fractures showed
no difference in knee pain or knee function at time of fracture
union.17,27 As expected, early postoperative knee pain was
higher in the retrograde femoral nailing groups, but by the
time of union there was no significant difference between the
two approaches.
■ Fracture healing rates seem to be equivalent except in the
more distal supracondylar femur fractures, which have taken
longer to achieve union. The retrograde nailing technique ap-
pears to produce slightly higher malunion rates, with external
rotation, shortening, and distal varus malalignment being the
most common deformities. 18,20,27
COMPLICATION S
■ The most common complications can often be prevented
with meticulous surgical techniques.
■ Paying close attention to the proper nail insertion starting
point and ensuring that the distal portion of the nail remains
subchondral are two key technical points to avoiding poten-
tial knee problems.
chatter during reaming seems to improve union rates when the
retrograde nailing technique is used.
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physeal and distal femoral fractures in Rochester, M innesota,
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3. Britton JM , Dunkerley DR. Closed nailing of a femoral fracture fol-
lowed by sciatic nerve palsy. J Bone Joint Surg Br 1990;72B:318.
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mal intercondylar starting point for retrograde femoral nailing: an
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nail for subtrochanteric fracture stabilization. Clin O rthop Relat Res
1998;348:95–100.
9. Gregory P, DiCicco J, Karpik K, et al. Ipsilateral fractures of the
femur and tibia: treatment with retrograde femoral nailing and un-
reamed tibial nailing. J O rthop Trauma 1996;10:309–316.
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on the mechanical properties of the femur. J Trauma 2003;54:930–935.
11. Herscovici D Jr, Whiteman KW. Retrograde nailing of the femur using
an intercondylar approach. Clin Orthop Relat Res 1996;332:98–104.
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reaming, of fractures of the femoral shaft in multiply injured patients.
J Bone Joint Surg Am 1995;77A:1520–1527.
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tramedullary nailing of fractures of the femoral shaft. J O rthop
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14. M organ E, O strum RF, DiCicco J, et al. Effects of retrograde femoral
intramedullary nailing on the patellofemoral articulation. J O rthop
Trauma 1999;13:13–16.
15. M uller M E, N azarian S, Koch P, Schatzker J. The Comprehensive
Classification of Fractures of Long Bones. Berlin/H eidelberg: Springer
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supracondylar-intercondylar distal femoral fractures and coronal
plane fractures. J Bone Joint Surg Am 2005;87A:564–569.
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retrograde and antegrade femoral intramedullary nailing. J O rthop
Trauma 2000;14:496–501.
18. O strum RF, DiCicco J, Lakatos R, et al. Retrograde intramedullary
nailing of femoral diaphyseal fractures. J O rthop Trauma 1998;12:
464–468.
19. O strum RF. Retrograde femoral nailing: indications and techniques.
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grade nailing of femoral shaft fractures. J O rthop Trauma 2001;15:
161–169.
21. Riina J, Tornetta P III, Ritter C, et al. N eurologic and vascular struc-
tures at risk during anterior-posterior locking of retrograde femoral
nails. J O rthop Trauma 1998;12:379–381.
22. Russell TA. Subtrochanteric fractures of the femur. In: Browner B,
Jupiter JB, Levine A, et al, eds. Skeletal Trauma: Basic Science,
M anagement, and Reconstruction, ed 3. Philadelphia: Saunders, 2003:
1832–1878.
23. Salminen ST, Pihlajamaki H K, Avikainen VJ, et al. Population-based
epidemiologic and morphologic study of femoral shaft fractures. Clin
O rthop Relat Res 2000;372:241–249.
24. Sanders R, Koval KJ, DiPasquale T, et al. Retrograde reamed femoral
nailing. J O rthop Trauma 1993;7:293–302.
25. Schwartz JT Jr, Brumback RJ, Lakatos R, et al. Acute compartment
syndrome of the thigh: a spectrum of injury. J Bone Joint Surg Am
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26. Tornetta P III, Kain M S, Creevy WR. Diagnosis of femoral neck frac-
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27. Tornetta P III, Tiburzi D. Antegrade or retrograde reamed femoral
nailing: a prospective, randomised trial. J Bone Joint Surg Br 2000;
82B:652–654.
28. Vangsness CT Jr, DeCampos J, M erritt PO , et al. M eniscal injury as-
sociated with femoral shaft fractures: an arthroscopic evaluation of
incidence. J Bone Joint Surg Br 1993;75B:207–209.
29. Walling AK, Seradge H , Spiegel PG. Injuries to the knee ligaments
with fractures of the femur. J Bone Joint Surg Am 1982;64A:
1324–1327.
30. Watson JT, M oed BR. Ipsilateral femoral neck and shaft fractures:
complications and their treatment. Clin O rthop Relat Res 2002;399:
78–86.
31. Winquist RA, H ansen ST, Clawson DK. Closed intramedullary nail-
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72A:724–728.
 An t e ro g r a d e In t r a m e d u lla r y
Ch a p t e r 42 Na ilin g o f t h e Fe m u r
Bru ce H. Ziran , Nat alie L. Talb o o , an d Navid M . Ziran
DEFIN ITION
■ A femoral shaft fracture is any fracture of the femoral diaph-
ysis from 5 cm below the lesser trochanter to within 6 to 8 cm
of the distal femoral articular surface.
■ Some fracture lines extend proximal or distal to the shaft
and are therefore not considered shaft fractures.
■ This description is mostly semantic, as the more impor-
tant aspect of definition is understanding the “ personality”
of the fracture.
■ Fractures whose essential element is diaphyseal with
“ extensions” into the outer regions are different than frac-
tures whose essential element is subtrochanteric or supra-
condylar with extension into the diaphysis.
■ In some circumstances there may be enough involvement
of proximal or distal aspects that treatment must change.
■ For the purposes of this chapter, we will focus on fractures
that are amenable to antegrade nailing.10
■ The Abbreviated Injury Scale (AIS) score for an isolated
femoral shaft fracture is three, thus making the Injury Severity
Score for an isolated femoral shaft fracture a nine.
■ O pen fractures are usually graded according to the Gustilo-
Anderson classification, but one must keep in mind that this
classification system was designed for the tibia, a subcuta-
neous bone. Thus, if absorbed energy is considered, theoreti-
cally, significantly more energy would be required to fracture
a femur and disrupt the soft tissue envelope around a femur
than around a tibia. N onetheless, this system is widely em-
ployed in the femur for descriptive purposes.
■ The fracture classification system previously used most com-
monly was the Winquist classification, but it has been modi-
fied and standardized with the AO /O TA classification, which
is the recommended system.16,27
AN ATOMY
■ The femur is the longest bone in the body. It is subject to very
high stresses in the proximal region because of the need to tran-
sition the forces of body weight via a lever arm (femoral neck)
into more axial forces distally. As such, the subtrochanteric
area is subject to very high stresses.14
■ The femur has an anterior bow and is not a circular bone.
■ Anteriorly and laterally there are flattened surfaces, and
posteriorly there is a taper that is confluent with the linea
aspera.
■ The linea aspera is a very thick fascial structure and fre-
quently remains in continuity but separates from the femur.
■ Entrapment of the linea aspera between the fracture ends
may impede closed fracture reduction, especially with simple
fracture patterns. The bone ends may need to be “ unwound”
to effect a reduction.
■ Both anterior and lateral bowing is important to recognize,
especially if abnormal (eg, metabolic bone disease).
■ The anterior bow has an average radius of curvature of
about 120 cm.
■ If there is excessive bowing, good preoperative planning is
needed.
■ Surgical options for such abnormal bowing include plate
fixation or a controlled osteotomy to allow nail placement.16
■ The endosteal diameter is important to recognize, especially
with young or sclerotic bone.
■ N ormal aging and osteoporosis results in a biomechanical
adaptation of enlarged inner diameter. Thus, elderly indi-
viduals may have a larger-diameter femoral shaft with a
thinner cortex. As in other cylindrical tubes, the bending
rigidity of the femur is roughly proportional to the radius to
the fourth power.
■ The vascular supply to the femur is from a nutrient artery
off the second perforating branch of the profunda femoris,
entering posteriorly along the linea aspera.
■ N ormally, periosteal branches supply the outer one quar-
ter to one third of the cortex as the direction of blood flow
is centripetally outward from the medulla to the cortex.
■ O nce fracture occurs, a reversal of blood flow occurs
from the periosteal vessel, radially inward.
■ The linea aspera protects many perforating periosteal ves-
sels, except in severe fractures, and may help explain the high
healing rate of femoral shaft fractures (about 95% ).
■ There are three thigh compartments: anterior, posterior, and
medial.
■ Thigh compartment syndrome may occur and generally
involves the anterior compartment. Frequently, release of
the anterior compartment will relieve pressure.
■ The proximity of the gluteal compartment places it at
risk as well. It should also be considered with compartment
syndromes.
PATHOGEN ESIS
■ Femoral shaft fractures are high-energy injuries in the
young; in the elderly simple falls from ground level are suffi-
cient to fracture the femur.
■ Fracture patterns give clues to the mechanism.
■ For example, a simple transverse fracture with a butterfly
fragment is due to a bending force (eg, T-bone vehicle crash).
■ Spiral fracture patterns are usually due to torsional forces.
■ Indirect high-energy mechanisms, such as a fall from a height
or motor vehicle crashes, will usually incur a significant initial
deformity during the fracture process.
■ The active and passive recoil of the muscle soft tissue en-
velope will decrease the initial displacement. Thus, the extent
of soft tissue injury can be difficult to appreciate.
■ O pen fractures in this setting are usually “ inside-out”
injuries.
■ Direct mechanism fractures are from ballistic injuries, crush
injuries, or other weapons (eg, chainsaw, axe).
■ With these injuries, there may be less initial displacement
of the fracture and soft tissues, but the amount of soft tissue
injury can still be extensive.
381
382 Se c t i o n IV FEM UR AND KNEE
In ballistic injuries, the shock and cavitation can result in
■ ■ The limb should be aligned and placed in a traction device,
extensive tissue necrosis.
■ In both mechanisms, it is important to recognize that the
zone of tissue injury may extend well beyond the fracture site.
N ATURAL HISTORY
■ In the early 20th century, the natural history of femur frac-
tures was poor.
■ The mortality of wartime femur fracture before and dur-
ing World War I was approximately 80% . Serendipitous use
of a wheeled splint for transport off the battlefield resulted in
a precipitous drop in the mortality rate (the Thomas splint
was thus developed).
■ Because surgical techniques were primitive in those times,
fears about infection and surgical complications resulted in
most fractures being treated in traction.
■ The outcome was frequently a shortened, rotated, varus
malunion of the femur.
■ Additional problems such as decubiti, venous thromboem-
bolism, and pulmonary infections with prolonged bed rest re-
sulted in high morbidity and mortality by today’s standards.
■ Kuntschner is considered the father of intramedullary nailing.
■ Kuntschner’s original technique was an open nailing, ex-
posing the fracture site, and in the Western nations, poor
surgical technique resulted in high rates of infection and
nonunion.
■ As a result, this method of fracture care was abandoned
until late into the 1970s.16
■ Kuntschner’s method was resurrected in the United States by
early traumatologists, like S. Hansen and M. Chapman, who
used Kuntschner’s newer technique of “ closed” femoral nailing.
■ The success rate of femoral nailing using closed technique
resulted in low morbidity and began a change in practice to
what we perform today.
■ Early studies outlined the benefits of early reamed femoral
nailing.
■ As survival of more traumatized patients increased, a
subset of patients who may benefit from “ subacute” nailing
developed.
■ Later studies identified patients at risk (eg, pulmonary
injury, incomplete resuscitation, and brain injury) who
benefited from stabilization of life-threatening injuries be-
fore fixation.
■ This reflects the paradigm shift from early total care
(ETC) to damage control orthopedics (DCO ).3,19,22
■ While some have advocated plating in such cases, there have
been no studies demonstrating the superiority of one method
over the other in terms of patient survival.4
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Relevant history includes age, sex, mechanism of injury,
associated injuries, loss of consciousness, weakness, paraly-
sis, or loss of sensation.
■ M etabolic conditions and any musculoskeletal conditions
should be elucidated if possible.
■ Patients should be evaluated according to the advanced
trauma life support (ATLS) guidelines.
■ Particular attention should be given to hypotension, since
femoral shaft fractures can be associated with up to 3 to 4 L
of blood loss. While not solely responsible for hypotension,
femur shaft fractures can be a contributory source.
such as a Sager splint or a Thomas splint.
■ These devices should be removed and replaced with skele-
tal or limb traction because of the risk of skin problems in
the perineal or ischial and ankle areas.
■ It is essential to inspect the affected limb for any open
wounds, swelling, and ecchymosis (see Exam Table for Pelvis
and Lower Extremity Trauma, page 1).
■ The extent of the open wound does not always correlate
with the degree of soft tissue or fascial stripping due to the
fracture.
■ Vascular evaluation should include manual palpation of
the popliteal, posterior tibial, and dorsalis pedis pulses.
■ It is important to understand that a pulse is a pressure
wave and can still be present in the absence of flow.
■ Alternatively, the absence of pulse does not always
mean absence of flow.
■ Use of Doppler and examination of the contralateral
limb are needed.
■ H ypotension with peripheral vasoconstriction may ac-
company such injuries.
■ The limb should be aligned before vascular examination.
■ Asymmetric or absent pulses warrant a measurement of the
ankle-brachial index (ABI).
■ An ABI less than 0.9 is abnormal.
■ Arteriography should be considered to rule out vascular
injury.
■ N eurologic evaluation includes motor and sensory function
of the femoral and sciatic nerve.
■ The femoral nerve may be difficult to examine secondary
to pain associated with the fracture.
■ Sciatic nerve function can be evaluated for both peroneal
and tibial branches.
■ The peroneal branch is tested with ankle and toe dorsi-
flexion and sensation on the top of the foot.
■ Tibial branch function is tested with ankle and toe plan-
tarflexion as well as sensation to the sole of the foot.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ The tenet of imaging a joint above and a joint below should
be followed.
■ Good anteroposterior (AP) and lateral views of the hip,
femur, and knee are required.
■ Such films can be obtained in the operating room but are
essential in planning, since the presence of a femoral neck
fracture or a fracture about the knee will greatly change the
operative tactic.
■ Attempts should be made to get an internal-rotation AP
view of the femoral neck. H owever, with current trauma
algorithms, the commonality of the pelvic CT scan allows
imaging of the femoral neck. The scan should be viewed
before deciding on the surgical tactic.
■ If radiographs are normal but the clinical examination sug-
gests injury (eg, unable to bear weight, pain out of proportion to
injury), coronal MRI imaging may elucidate an occult fracture.
■ CT scanning in these situations may not be sensitive
enough to find such fractures.
■ O ccult femoral fractures may be hard to identify with pre-
operative radiographs.
■ Use of CT scans of the abdomen that go to the level of the
femoral neck have been found to be sensitive enough to
 Ch a p t e r 4 2 ANTEROGRADE INTRAM EDULLARY NAILING OF THE FEM UR
identify such occult femoral neck fractures and should be
done for most cases.23
DIFFEREN TIAL DIAGN OSIS
■ O ther injuries may occur concomitantly with femur frac-
tures, including pelvic fractures, acetabular fractures, femoral
neck fractures, and ligamentous injuries to the knee.
■ If an effusion is present in the knee, the index of suspicion
for a knee injury should be elevated.
■ Distal femur fracture may also occur but may not be radi-
ographically evident, especially in osteoporotic bone.
■ In the absence of a reasonable mechanism, other causes for
fracture such as metabolic bone disease or metastatic (or pri-
mary) fracture should be ruled out.
N ON OPERATIVE MAN AGEMEN T
■ N onoperative management has typically been reserved for
patients who are unfit for surgery, patients who are quadri-
plegic or paraplegic, patients in whom the benefits do not
outweigh the risks, or other precluding factors (eg, active
infection).
■ Truly nondisplaced fractures in a compliant and able patient
may also be treated nonoperatively.
■ Infants and young children may also be treated nonopera-
tively because of their ability to remodel.
■ N onoperative management consists of bed rest and skeletal
traction (either through the distal femur or proximal tibia)
with 20 to 30 lb of weight.
■ Attention should be given to mechanical and pharmaco-
logic venous thromboembolism prophylaxis if this treat-
ment is considered.
SURGICAL MAN AGEMEN T
■ Isolated femur fractures are not urgent. Appropriate evalua-
tion and medical clearance should be performed. It is in the
best interests of the patient and system to stabilize the patient
expeditiously, but when appropriate resources are available
(eg, knowledgeable staff, anesthesia). It is not necessary to sta-
bilize such fractures during off shifts unless indicated for other
reasons (eg, open fracture, polytrauma).
■ Patients with isolated femur fractures should have some
method of traction, pain control, and deep vein thrombosis
prophylaxis while awaiting surgical intervention.
■ Currently, statically locked femoral nailing with limited
reaming is the standard of care.
■ The studies by Brumback et al determined that statically
locked nails do not affect healing and avoid the problems of
malrotation and shortening. Unreamed nails were proposed
to limit effects of canal fill and the theoretical concern of in-
fection. N either concern was proven, and in fact small un-
reamed nails had the same problems as in the tibia: higher
rates of nonunion. Currently, the “ ream to fit” technique is
used.5–9,26
■ In the multiply injured patient (Injury Severity Score of more
than 18), with pulmonary compromise or head injury, fracture
fixation should be delayed until suitably cleared for surgical
intervention, and damage control methods with use of a tem-
porary external fixator should be considered.2,4,17,21
■ Recently, the reamer-irrigator-aspirator has been used to
minimize the pressure-induced embolization from the marrow.
As studies are ongoing, this method may reduce the risks in the
multiply injured patients.
383
■ O pen fractures can be safely nailed if a thorough débride-
ment and irrigation is performed.
■ Absorbable antibiotic beads (calcium sulfate, not calcium
phosphate, mixed with vancomycin or tobramycin) can be
used at the time of definitive closure to provide local antibi-
otic delivery.20
■ In severely contaminated fractures, a staged approach using
temporary antibiotic beads (using polymethylmethacrylate
mixed with vancomycin or tobramycin) and temporary exter-
nal fixation, followed by nailing within 2 weeks (with or with-
out use of absorbable beads), can be employed.
■ Conversion of external fixation to intramedullary nails
can safely be performed within 2 to 4 weeks, as long as there
is no indication of pin tract problems.
■ In such cases, the risk of infection is increased but accept-
able in lieu of prolonged bed rest.
■ Because of deforming forces in proximal fractures, the prox-
imal segment tends to flex and externally rotate.
■ Care should be taken to ensure that the posterior cortex
of the proximal fragment is not inadvertently reamed away.
■ In distal fractures, the distal segment tends to flex at the
knee (recurvatum of fracture).
■ With distal fractures, care should be taken to avoid varus or
valgus reduction. This can occur because the opening of the
medullary canal distally does not have intimate contact with
the nail and does not “ self-align.”
■ Transverse fractures may contain a segment of intact linea
aspera that peels off the posterior aspect and may get entrapped
in the fracture.
■ It can result in shortening that may be difficult to over-
come without either “ unwinding” the fracture or opening
the fracture site.
■ In skeletally mature children, intramedullary nailing offers
the same benefits as in adults.
■ Attention should be paid to adolescents with very valgus
neck angles, as some have hypothesized that this can in-
crease the risk of avascular necrosis of the femoral head.
H owever, with modern implants, a trochanteric starting
point may alleviate such concerns.
■ Skeletally immature children may still be considered for
some form of intramedullary treatment after considering re-
maining growth, type of fracture, and benefits over other
methods of treatment.1,11
Preoperative Planning
■ All films should be reviewed, with particular attention paid
to the presence of an ipsilateral femoral shaft and neck fracture.
■ The overall condition of the patient and any associated in-
juries should be contemplated before embarking on a surgical
tactic.
■ In the presence of pelvic or acetabular fracture, pregnancy,
or obesity, one should consider a more elegant tactic, such as
retrograde nailing, as opposed to antegrade nailing.
■ If suitable, antegrade nailing in the supine position can be
safely performed with proper positioning and knowledge.
■ Several options have to be considered during preoperative
planning. They include:
■ Table: fracture table or radiolucent
■ Position: supine or lateral
■ Entry point: piriformis or trochanteric
■ Type of nail: cephalomedullary or standard
■ Use of traction: skeletal, boot, or manual
384 Se c t i o n IV FEM UR AND KNEE

■ Strong consideration should be given to checking fine cut ■ Supine position

CT scans to search for femoral neck fractures when possible. ■ The supine position may be easier for surgeons to visual-

As part of the operative plan, the femoral neck should also be ize anatomic relationships.
checked radiographically after fixation and prior to leaving the ■ It is more difficult to use supine positioning in obese

operating suite. patients.

■ It may be the preferred position in patients with spinal

Positioning cord injuries or severe chest injuries.

■ It can be used with and without traction.
■ Fracture table
■ Standard fracture tables (eg, those used commonly for hip ■ If the supine (floppy) positioning on a radiolucent table is

fractures) can be used for antegrade femoral nailing but are chosen, it helps to position the patient at the edge of the bed
best used for supine position nailing. with a small bolster under the pelvis.
■ A large and well-padded perineal post should be used. ■ Preparing and draping should include the posterior aspect

■ Traction should be used sparingly and only when of the gluteal area, since crossing the leg over will facilitate
needed. access to the piriformis.
■ The legs should be scissored to facilitate imaging and allow ■ Even with the newer trochanteric entry technique and

for appropriate countertraction. Placing the opposite leg in implants, the ability to manipulate the leg in adduction
lithotomy position can allow rotation of the pelvis when trac- may be useful during the procedure (FIG 1 D).
tion is applied. ■ Lateral position
■ The ability to image all aspects of the femur should be ■ The lateral position facilitates gaining an entry point,

verified before preparing and draping (FIG 1 A). especially with a piriformis starting point in obese
■ Radiolucent tables patients.
■ N ewer tables allow free image intensifier access to the ■ It can be used with and without traction.

■ When using the lateral position, the pelvis is rolled for-

lower extremity.
■ Some of the tables (Jackson table, O SI, California) also
provide traction assemblies. These types of tables are suit-
able for multiple limb operations (FIG 1 B).
■ Our preferred method uses a radiolucent Jackson table with
traction apparatus and lateral positioning (FIG 1C).
ward about 15 degrees to allow lateral imaging of the prox-
imal femur.
■ Care should be taken during positioning for proper
padding and spinal precautions if occult spinal injury may
be present.

A B

C D

FIG 1 • A. Su p in e p o sit io n in g o n a fra ct u re t a b le w it h le g s scisso re d . Slig h t o b liq u it y u sin g a

b u m p u n d e r t h e sa cru m h e lp s w it h h ip visu a liza t io n . B. Su p in e p o sit io n w it h o u t t ra ct io n o n
fla t -t o p t a b le . Th e ip sila t e ra l h ip sh o u ld b e clo se t o t h e e d g e , a n d a b u m p u n d e r t h e sa cru m
w ill h e lp w it h visu a liza t io n . St a n d a rd la t e ra l vie w s o f t h e h ip fo r e n t ry p o in t s ca n b e u se d , b u t
so ca n fro g -le g la t e ra ls. C. La t e ra l p o sit io n w it h t ra ct io n . Ske le t a l t ra ct io n in t h e p ro xim a l
t ib ia o r d ist a l fe m u r ca n b e u se d . Th e p e rin e a l p o st is p ict u re d h e re in t h e p e rin e u m , w h ich is
b e st fo r p ro xim a l fra ct u re s. In fa ct , lit t le t ra ct io n is u su a lly n e e d e d a n d t h e p o st is fre q u e n t ly
p o sit io n e d u n d e r t h e a p e x o f t h e fra ct u re a n d u se d t o o ve rco m e g ra vit a t io n a l sa g g in g . If t ra c-
t io n w ill b e n e e d e d , w e h a ve fo u n d t h a t p la cin g a b la n ke t o n t h e “ d o w n ” le g a n d se cu rin g
t h e co n t ra la t e ra l t h ig h w it h a slin g o f t a p e co u rsin g in a p ro xim a l a n d o b liq u e fa sh io n w ill re -
sist m o d e ra t e a m o u n t s o f t ra ct io n . D. Pre p a ra t io n a n d d ra p in g o f t h e le g u sin g a fla t -t o p
t a b le w it h o u t t ra ct io n sh o u ld in clu d e p o st e rio r se ct io n s o f t h e b u t t o cks. Th e le g ca n b e
cro sse d o ve r t o g a in e a sie r a cce ss t o t h e p irifo rm is st a rt in g p o in t .
 Ch a p t e r 4 2 ANTEROGRADE INTRAM EDULLARY NAILING OF THE FEM UR
■ Traction
■ If traction is used, it frees an assistant and the length and
rotation can be “ set.”
■ If manual traction is used, the length and rotation need to
be checked before final interlocking.
■ Skeletal traction can be via the proximal tibia or distal
femur.
■ The surgeon should be careful if there is any ligamen-
tous instability of the knee, as suggested by a knee effu-
sion or other sign of injury.
■ In such cases, distal femoral traction can be used, and it
can be prepared and draped into the operative field.
■ Use of distal femoral traction can complicate distal in-
terlocking because of the proximity of the traction appa-
ratus with the interlocking site.
SOFT TISSUE DISSECTION
■ Wh e t h e r u sin g a ce p h a lo m e d u lla ry n a il o r p irifo rm is
fo ssa n a il, t h e su rg ica l a p p ro a ch is sim ila r.
■ Th e su rg e o n p a lp a t e s t h e g re a t e r t ro ch a n t e r.
■ Fo r t ro ch a n t e ric e n t ry, t h e skin in cisio n is b a se d a b o u t 4
t o 10 cm a b o ve t h e t ro ch a n t e r in lin e w it h t h e fe m u r.
■ Th e t e n so r fa scia is in cise d a n d t h e g lu t e u s m a xim u s is
g e n t ly se p a ra t e d .
■ Th e t e n d in o u s in se rt io n o f t h e g lu t e u s m e d iu s is fre -
q u e n t ly m o re d ist a l, a n d t h is t e n d o n ca n b e g e n t ly
sp re a d t o id e n t ify a b u rsa l a re a ju st b e lo w t h e m e d iu s
a n d a b o ve t h e m in im u s.
TROCHANTERIC AND PIRIFORMIS FOSSA ENTRY
■ Aft e r so ft t issu e d isse ct io n , t h e t ip o f t h e g re a t e r
t ro ch a n t e r is p a lp a t e d . Th e p irifo rm is fo ssa is p a lp a t e d
m e d ia lly.
■ Th e id e a l st a rt in g p o in t fo r a p irifo rm is fo ssa n a il is in t h e
fo ssa a lo n g t h e m e d ia l u p slo p e o f t h e g re a t e r
t ro ch a n t e r, sin ce t h is is m o st in lin e w it h t h e sh a ft .
■ Th is p o in t m a y va ry b e t w e e n p a t ie n t s a n d sh o u ld b e
co n firm e d w it h in t ra o p e ra t ive flu o ro sco p y.
A B
385
■ Boot traction is a very common alternative.
■ Unlike tibial or femoral skeletal traction, where the
knee is slightly bent, boot traction uses a straight leg
(FIG 1A).
■ Care should be taken to avoid nerve traction injury (eg,
avoid prolonged and excessive traction).
■ Small perineal posts and long durations of traction
have been shown to increase the risk of pudendal nerve
injury.
■ If traction is used, it should be first applied to
determine the “ reducibility” of the fracture. Then it
should be reduced during prepping and applied as
needed.
■ Large and well padded perineal posts should be used
whenever possible.6,15
TECHNIQUES
■ Fo r p irifo rm is e n t ry, t h e in cisio n is m a d e a b o u t a h a n d -
b re a d t h a lo n g t h e lin e b e t w e e n t h e t ro ch a n t e r a n d t h e
p o st e rio r su p e rio r ilia c sp in e .
■ On ce t h e g lu t e u s m a xim u s is g e n t ly se p a ra t e d , t h e
a cce ss t o t h e p irifo rm is is p o st e rio r t o t h e m e d iu s.
■ Th e p irifo rm is fo ssa ca n b e e a sily p a lp a t e d a s a “ d im -
p le d le d g e ” b e h in d t h e t ro ch a n t e r. Th is a n a t o m ic
fe a t u re is u se d d u rin g t h e p e rcu t a n e o u s a p p ro a ch
fo r p ro p rio ce p t ive fe e d b a ck d u rin g p in p la ce m e n t .
■ Th e su rg e o n ca n h a ve a n a ssist a n t a d d u ct t h e e xt re m -
it y t o a id in e xp o sin g t h is sp o t (TECH FIG 1 A).
■ On ce t h e st a rt in g p o in t is id e n t ifie d b y p a lp a t io n a n d
co n firm e d w it h flu o ro sco p y, t h e co rt e x is p e n e t ra t e d
w it h e it h e r a n a w l o r a t h re a d e d Kirsch n e r w ire .
■ Eve ry e ffo rt sh o u ld b e g ive n t o e st a b lish in g a n a ccu -
ra t e st a rt in g p o in t (ie , o n e t h a t is in lin e w it h t h e
fe m o ra l sh a ft ).
TECH FIG 1 • A. AP im a g e o f t h e co rre ct p o si-
t io n o f a g u id e p in fo r p irifo rm is e n t ry.
B. La t e ra l im a g e o f p irifo rm is st a rt in g p o in t .
Th e p in n e e d o n ly st a rt in t h e p irifo rm is; it w ill
fre q u e n t ly co u rse a n t e rio r, a n d ca re sh o u ld b e
t a ke n n o t t o p e n e t ra t e t h e a n t e rio r co rt e x.
Th e rig id re a m e r n e e d o n ly o p e n t h e t o p o f
t h e b o n e fo r a cce ss t o m e d u lla ry ca n a l.
 386 Se c t i o n IV FEM UR AND KNEE

■ If th is is n ot po ssib le, as lo ng as th e ent ry site is co llin ear In t h e se ca se s, p re p a rin g u n d e r t h e b u t t o ck a n d

TECHNIQUES

with the shaft, the pin can be direct ed anteriorly.
■ In t h e se ca se s, ca re sh o u ld b e t a ke n n o t t o p e rfo -
ra t e t h e a n t e rio r co rt e x (TECH FIG 1 B).
■ In su p in e n a ilin g , e sp e cia lly w it h o b e se p a t ie n t s, t h is ca n
b e ve ry d ifficu lt . Ad d u ct io n o f t h e lim b m a y n o t a lw a ys
b e p o ssib le b e ca u se o f b o d y h a b it u s a n d se t u p a n d e sp e -
cia lly w it h p ro xim a l fra ct u re s.■
a cce ssin g fro m a m o re p o st e rio r a p p ro a ch m a y a llo w a c-
ce ss t o t h e fo ssa .
■ The lat eral po sit ioning allows the ea sie st a ccess, wit h very
fe w p ro b lem s. In fa ct , n a ilin g ca n b e p e rfo rm e d p ercu ta -
n e ou sly (d e scrib e d b elo w ) wit h lit tle p ro b le m wh e n using
th e lat e ral po sit ion .

PERCUTANEOUS METHOD OF NAILING

■ Th e p e rcu t a n e o u s m e t h o d o f n a ilin g 29 u se s cu t a n e o u s
la n d m a rks t o id e n t ify t h e id e a l e n t ry sit e , w h ich is u su a lly
a b o u t o n e fu ll h a n d b re a d t h (8 cm ) fro m t h e p o st e rio r
co rn e r o f t h e t ro ch a n t e r t o w a rd s t h e p o st e rio r su p e rio r
ilia c sp in e (TECH FIG 2 A).
■ Th e in cisio n is a st a b w o u n d .
■ A g u id e p in is a d va n ce d t o t h e t ro ch a n t e ric b u rsa (TECH
FIG 2 B).
■ Th e p in is “ ro lle d ” o ff t h e p o st e rio r slo p e o f t h e
t ro ch a n t e r a n d t h e n a d va n ce d d ist a lly a n d a n t e rio rly
(TECH FIG 2 C,D).
■ A ve ry d ist in ct re sist a n ce is fe lt , a s if o n a p e d e st a l o r
le d g e o f b o n e . Th e t ip o f t h e p in p ro vid e s p ro p rio ce p t ive
fe e d b a ck w h e n t h is o ccu rs, a n d it ca n b e fe lt t h a t t h e re
a re st ru ct u re s a n t e rio r a n d m e d ia lly, w h ich co n st it u t e
t h e “ w a lls” o f t h e fo ssa .

A B

C D

TECH FIG 2 • A. Th e cu t a n e o u s sit e fo r p e rcu t a n e o u s n a ilin g , sit u a t e d a b o u t m id w a y a n d

slig h t ly p o st e rio r t o m id p o in t b e t w e e n t ip o f t ro ch a n t e r a n d p o st e rio r su p e rio r ilia c sp in e .
B. Ph o t o g ra p h sh o w in g p in d rive n in t o p irifo rm is via p e rcu t a n e o u s w o u n d . C. Th e p in u su a lly
fin d s t h e t ro ch a n t e ric b u rsa . It is t h e n “ ro lle d ” o ff t h e b a ck a n d a d va n ce d a n t e rio r a n d d ist a l
u n t il a d ist in ct re sist a n ce is fe lt . It sh o u ld re st o n t h e “ le d g e ” o f b o n e kn o w n a s t h e p irifo rm is
fo ssa . D. Th e p in h a s a re sist a n ce t o a n t e rio r a n d d ist a l a d va n ce m e n t b u t ca n m o ve m e d ia l a n d
p o st e rio r. (co n t in u e d )
 Ch a p t e r 4 2 ANTEROGRADE INTRAM EDULLARY NAILING OF THE FEM UR 387

TECHNIQUES
E F

G H

TECH FIG 2 • (co n t in u e d ) E. Th e rig id re a m e r a d va n ce s o ve r t h e p in t o e n t e r t h e p ro x-

im a l fe m u r. Use o f irrig a t io n w ill h e lp p re ve n t so ft t issu e ca t ch in g . F. In se rt io n o f t h e
n a il o ve r t h e g u id e w ire . Wit h u se o f a b e n t g u id e w ire a n d “ re a m -t o -fit ” t e ch n iq u e ,
t h e like lih o o d o f a n in ca rce ra t e d re a m e r is ve ry lo w , a n d e xch a n g e o f t h e g u id e w ire
w it h a ch e st t u b e is n o t n e e d e d (u n le ss a b a ll-t ip g u id e w ire is u se d ). G. In t ra o p e ra t ive
p h o t o o f fin a l w o u n d s. H. En t ry sit e w o u n d s a re u su a lly a b o u t 1.5 cm .

■ At t h is p o in t im a g e ve rifica t io n is p e rfo rm e d . o p e n t h e co rt e x a n d p ro vid e a cce ss t o m e d u lla ry

■ If t h e p in is n o t co a xia l w it h t h e fe m u r, w h a t is m o st
im p o rt a n t is t h a t t h e t ip o f t h e p in is ce n t e re d .
■ Th e p in is a d va n ce d t o e n g a g e t h e co rt e x, a n d t h e n a
9- t o 12-m m rig id re a m e r is u se d t o o p e n t h e p ro xim a l
fe m o ra l co rt e x (TECH FIG 2 E).
■ Th is re a m e r n e e d o n ly b e a d va n ce d e n o u g h t o
co n t e n t s. Ca re sh o u ld b e t a ke n n o t t o re a m t o o
d e e p ly a n d p e rfo ra t e t h e co rt e x o f t h e p ro xim a l
fe m u r a n t e rio rly (se e Te ch Fig 1).
■ Once this ste p is accomplishe d, the remainde r of the p roce-
dure can b e do ne with standard methods, and instruments
are passed via the keyhole skin incision (TECH FIG 2F–H).

TROCHANTERIC ENTRY, GUIDEWIRE PLACEMENT, AND

FRACTURE REDUCTION
■ Aft e r so ft t issu e d isse ct io n (a s d e scrib e d p re vio u sly), t h e
su rg e o n p a lp a t e s t h e t ip o f t h e g re a t e r t ro ch a n t e r a n d
it s a n t e ro p o st e rio r d im e n sio n s.
■ Be ca u se o f t h e in h e re n t a n a t o m y o f t h e p ro xim a l fe m u r,
t h e id e a l st a rt in g sp o t fo r a t ro ch a n t e ric e n t ry n a il is a t
t h e t ip o f t h e g re a t e r t ro ch a n t e r (m e d io la t e ra l) a n d t h e
ju n ct io n o f t h e a n t e rio r o n e t h ird a n d p o st e rio r t w o
t h ird s o f t h e g re a t e r t ro ch a n t e r.
■ Th is sp o t m a y va ry fro m p e rso n t o p e rso n , b u t t h e co r-
re ct st a rt in g p o in t is o n e t h a t is in lin e w it h t h e
fe m o ra l sh a ft .
■ On ce t h e co rre ct st a rt in g sp o t is id e n t ifie d , t h e o u t e r
co rt e x is p e n e t ra t e d w it h e it h e r a n a w l o r a p o in t e d
g u id e w ire (TECH FIG 3 A).
■ In t h is m e t h o d , b e ca u se t h e a b d u ct o r m e ch a n ism is
b e in g sp lit , so ft t issu e p ro t e ct io n is im p o rt a n t .
■ Aft e r t h e st a rt in g p o in t is id e n t ifie d , a g u id e w ire is
p la ce d in t o t h e p ro xim a l fe m u r a n d p a sse d d o w n t h e
ca n a l.
■ Fo rce fu l a n d je rkin g m o t io n s ca n b e a vo id e d b y
firm ly t w ist in g t h e g u id e w ire t h ro u g h t h e ca n ce llo u s
bone.
■ A g e n t le J b e n d a t t h e d ist a l 1 cm o f t h e w ire a llo w s
t h e w ire t o b e “ b o u n ce d ” o ff co rt ice s a n d t o b e
“ st e e re d ” in m e t a p h yse a l a re a s (TECH FIG 3 B).
■ Th e p ro p rio ce p t ive fe e d b a ck o f a w ire p a ssin g a lo n g
t h e m e d u lla ry ca n a l is sim ila r t o t h e se n sa t io n o f
p u sh in g a st ick o n a sid e w a lk.
 388 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES

D F

TECH FIG 3 • A. Th e e nt ry p o in t fo r t h e troch an t e r is u su ally o n th e a nt e rio r on e -t h ird ju n ct ion .

B. Be nt stra ig h t gu id e wire . Th is h elp s t o “ste e r” th e wire in me ta p hyse a l b o ne an d w ill p reven t
re a m e r h e a d s fro m d ise n g a g in g (re le va n t o n ly in m o d u la r d e sig n s). C. Th e “w and.” It is available
o n so me se ts, o r ca n be p e rform e d wit h so me e xt ra ct io n rod s. It is p la ce d o ve r t h e g u id e wire in t o
t h e p roxima l seg m en t , d o w n to t h e le vel o f t h e lesser tro ch an t er. It ca n m an ip u la te t h e p ro xim al
fra g me n t t o a im it in to th e d ist a l se g me n t, a ft e r w h ich t h e g u id e w ire is a d va n ce d in t o t h e d ist a l
fra gmen t. Th is is m uch m o re desira b le t h an stru g g ling w ith m an u al me th o d s. D. F bar. Th is can b e
p la ce d a rou n d t he t h ig h to e ffe ct t he d esire d tran sla t io n . In o u t-o f-p la n e de formit ie s, t h e b a r ca n
fin d t he “ id e a l” o rie n ta tio n a n d e ffe ct a re d u ctio n . E. Th e joyst ick me thod . Sm all te rm inally
t h re ade d w ire s ca n b e d rilled in to t h e co rt ex o f e ach seg m en t a n d u se d t o ma n ip u lat e th e frag -
m en t s in t o red u ct io n . Sma ll e xt ern al fixa to r p in s can also b e u se d an d h ave b ee n p re vio u sly d e-
scrib e d. F. Int ra operat ive ima ge of guidew ire pa ssed across fractu re.

■ If t h e fra ct u re is n o t re d u ce d su fficie n t ly t o e a sily p a ss t o m a n ip u la t e t h e p ro xim a l fra g m e n t a s t h e w ire

t h e w ire a cro ss, t h e re a re se ve ra l t e ch n iq u e s a va ila b le t o
fa cilit a t e re d u ct io n a n d w ire p a ssin g .
■ So m e n a il syst e m s p ro vid e a ca n n u la t e d ro d t h a t is
p la ce d o ve r t h e w ire a n d p a sse d in t o t h e p ro xim a l
fe m u r. Th is rig id w ire h o ld e r fu n ct io n s a s a w a n d
a p p ro a ch e s t h e fra ct u re so t h a t it ca n e a sily b e p a sse d
a cro ss (TECH FIG 3 C).
■ An F o r H b a r, a cru t ch , o r b o t h ca n a lso b e u se fu l t o
m a n ip u la t e t h e p ro xim a l a n d d ist a l fra g m e n t s (TECH
FIG 3 D).
 Ch a p t e r 4 2 ANTEROGRADE INTRAM EDULLARY NAILING OF THE FEM UR
■ So m e t im e s t h e fra ct u re ca n n o t b e p e rfe ct ly re d u ce d , b u t
e n o u g h p ro visio n a l a lig n m e n t ca n b e e st a b lish e d t o p a ss
t h e g u id e w ire .
■ If t h e fractu re is u n stab le an d d ifficu lt to red u ce after
num erous at te mpts, a small incision can be m ade along
th e la t eral thigh o ve r th e fra ct u re a nd t he fra ctu re can
be digit ally reduced and provisionally aligned.
■ In so m e ca se s, t h e in cisio n ca n b e le n g t h e n e d t o a llo w
p la ce m e n t o f “ lo b st e r cla w ” -t yp e cla m p s.
MEASUREMENT AND REAMING
■ On ce t h e g u id e w ire h a s b e e n p la ce d , t h e le n g t h o f t h e
n a il is m e a su re d e it h e r w it h a m e a su rin g d e vice (u su a lly
su p p lie d b y t h e in t ra m e d u lla ry n a il syst e m ) o r b y u sin g a
g u id e w ire o f t h e sa m e le n g t h .
■ Pla cin g t h e se co n d w ire a t t h e e n t ry sit e a n d m e a su r-
in g w h a t is n o t o ve rla p p in g w it h t h e in se rt e d w ire
p ro vid e s n a il le n g t h .
■ Be fo re m e a su rin g , t h e su rg e o n co n firm s t h e p ro xim a l
p o sit io n o f t h e ru le r o n t h e g re a t e r t ro ch a n t e r.
■ Th e su rg e o n sh o u ld m a ke su re t h a t t h e re is n o so ft
t issu e b e t w e e n t h e ru le r a n d t h e t o p o f t h e g re a t e r
t ro ch a n t e r, a s t h is ca n a rt ificia lly in cre a se t h e le n g t h
o f t h e n a il ch o se n .
■ Ave ra g e n a il le n g t h s ra n g e fro m 38 t o 42 cm .
■ Usin g t h e ra d io g ra p h s o f t h e fe m u r, t h e su rg e o n ca n e s-
t im a t e t h e b e g in n in g re a m e r size .
■ Wit h “ t ig h t ” ca n a ls, re a m in g sh o u ld b e g in w it h lo w e r
size s, a n d se q u e n t ia l re a m in g ca n b e g in st a rt in g w it h
t h e lo w e st size a va ila b le (u su a lly 8 o r 9 m m ).
■ Wh e n st a rt in g t o re a m , t h e su rg e o n sh o u ld p a y p a r-
t icu la r a t t e n t io n t o ke e p t h e re a m e r m e d ia l in t h e
NAIL PLACEMENT
■ If a b a ll-t ip p e d w ire is u se d , t h e su rg e o n sh o u ld co n firm
t h a t it ca n b e p u lle d t h ro u g h t h e n a il o r e xch a n g e d fo r a
sm o o t h -t ip w ire .
■ Aft e r t h e n a il h a s b e e n in se rt e d , it s p o sit io n is ch e cke d
d ist a lly, a t t h e fra ct u re sit e , a n d p ro xim a lly n e a r it s in se r-
t io n sit e .
■ Th e su rg e o n e n su re s t h a t t h e n a il is n o t t o o p ro u d
a b o ve t h e g re a t e r t ro ch a n t e r a n d fo ssa .
■ If t h e fra ct u re sit e is d ist ra ct e d , t ra ct io n sh o u ld b e re -
d u ce d o r a d ju st e d t o e ffe ct a sa t isfa ct o ry re d u ct io n .
■ Le n g t h a n d ro t a t io n n e e d t o b e re co n firm e d b e fo re
in t e rlo ckin g . Se ve ra l m e t h o d s ca n b e u se d .12,13,24,25
■ Co rt ica l ch a ra ct e rist ics
■ Th e fe m u r d ia m e t e r is n o t sym m e t ric. Va ria n ce s in
co rt ica l t h ickn e ss ca n b e u se d t o e st im a t e ro t a t io n .
■ Fract u re lin es can b e u sed to est im ate co rrect
rotation.
■ Ra d io g ra p h ic m e t h o d s
■ On e m e t h o d ch e cks t h e t ru e h ip la t e ra l w it h t h e
d ist a l fe m o ra l la t e ra l in t h e in t a ct co n t ra la t e ra l
fe m u r. Th e m e a su re d d iffe re n ce is m irro re d in t h e
fra ct u re d sid e .
■ In ca se s o f co m m in u t io n o r b ila t e ra l fra ct u re s, a n -
o t h e r m e t h o d ca n b e u se d t o d e t e rm in e o r se t t h e
389
■ Ot h e r m e t h o d s in clu d e t h e u se o f u n ico rt ica l “ jo yst ick”
TECHNIQUES
h a lf-p in s fro m a n e xt e rn a l fixa t o r se t (u su a lly a 5-m m
h a lf-p in ). Alt e rn a t ive ly, 3-m m t h re a d e d g u id e p in s ca n
a lso b e u se d (TECH FIG 3 E).
■ Th e g u id e w ire p o sit io n in t h e d ist a l se g m e n t is co n -
firm e d w it h in t ra o p e ra t ive flu o ro sco p y.
■ Th e g u id e w ire sh o u ld b e p a sse d d o w n t o t h e d ist a l
fe m u r p h yse a l sca r a n d sh o u ld b e ce n t e r-ce n t e r o n
b o t h t h e AP a n d la t e ra l vie w s.
p ro xim a l fe m u r t o p re ve n t re a m in g o u t t h e p o st e rio r
o r la t e ra l co rt e x.
■ If t h e re a m e r d o e s n o t p a ss e a sily, t h e su rg e o n sh o u ld
ch e ck it s p o sit io n w it h flu o ro sco p y sin ce t h e re a m e r
m a y b e h it t in g co rt ica l b o n e (u su a lly a n t e rio rly).
■ Re a m in g ca n b e in cre a se d b y 1.0-m m in cre m e n t s u n t il
d ist in ct “ ch a t t e r” is e n co u n t e re d , a ft e r w h ich it sh o u ld
in cre a se in 0.5-m m in cre m e n t s.
■ On ce e n d o st e a l “ ch a t t e r” is e n co u n t e re d , re a m in g sh o u ld
co n t in u e fo r a n o t h e r 1.0 t o 2.0 m m , a n d a n a il d ia m e t e r
o f 1.0 t o 1.5 m m sm a lle r t h a n t h e la rg e st d ia m e t e r
re a m e d sh o u ld b e u se d .
■ Wit h m o d e rn n a il d e sig n s, m o st m a le p a t ie n t s ca n b e
t re a t e d w it h 11- t o 13-m m n a ils a n d m o st fe m a le s
w it h 10- t o 12-m m n a ils.
■ Ca re sh o u ld b e t a ke n w h e n t h e re is a t e n d e n cy fo r a
d e fo rm in g fo rce t o a llo w fo r “ e cce n t ric” re a m in g (e g ,
p ro xim a l fra ct u re s).
■ In t h e se ca se s, w it h o u t a t t e n t io n , e cce n t ric re a m in g
ca n re m o ve co rt ica l b o n e a n d cre a t e d e fe ct s t h a t
re su lt in d e fo rm it y o r a n a il o u t sid e t h e b o n e .
ro t a t io n . A t ru e la t e ra l o f t h e d ist a l fe m u r is o b -
t a in e d , a n d t h e in t e n sifie r is t h e n m o ve d o rt h o g o -
n a l t o t h is p o sit io n , a n d t h e p ro xim a l fe m u r is vi-
su a lize d t o o b t a in a p ro file o f t h e le sse r
t ro ch a n t e r. Th e im a g e s a re sa ve d fo r re fe re n ce ,
a n d m irro re d o n t h e fra ct u re d sid e , o r co n t ra la t -
e ra l sid e if b ila t e ra l.
■ Su rp risin g ly, ro t a t io n a l d e fo rm it ie s a p p e a r t o b e w e ll
t o le ra t e d , w it h a n a ve ra g e o f 28% o f p a t ie n t s h a vin g a
d e fo rm it y o f m o re t h a n 15 d e g re e s.
■ In t e rn a l ro t a t io n is t o le ra t e d b e t t e r t h a n e xt e rn a l
ro t a t io n .
■ In a ll ca se s, a clin ica l e xa m in a t io n o f ro t a t io n o f
b o t h le g s w it h t h e p e lvis su p in e a n d t h e h ip fle xe d t o
90 d e g re e s ca n b e u se d t o e st im a t e sym m e t ry.
■ Un le ss t h e p a t ie n t is in e xt re m is, a ll n a ils sh o u ld b e st a t i-
ca lly lo cke d .
■ Th e o rd e r o f in t e rlo ckin g sh o u ld b e co n sid e re d .
■ In a xia lly st a b le ca se s, t h e d ist a l se g m e n t sh o u ld b e in -
t e rlo cke d , a n d co m p re ssio n a p p lie d b y b a ck-sla p p in g
t h e n a il.
■ In u n st a b le ca se s, t ra ct io n a n d a lig n m e n t sh o u ld b e
m a in t a in e d u n t il in t e rlo ckin g is co m p le t e . Usu a lly d is-
t a l in t e rlo ckin g p re ce d e s p ro xim a l in t e rlo ckin g .5,28
 390 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES

PROXIMAL INTERLOCKING SCREW PLACEMENT

■ Th e re a re g u id e s w it h e a ch syst e m t h a t a llo w p la ce m e n t ■ Un le ss t h e fra ct u re is st a b le , t h e st a t ic scre w h o le
o f p ro xim a l scre w s. In g e n e ra l, a t le a st o n e scre w sh o u ld sh o u ld b e u se d , a n d t h e h o le clo se st t o t h e fra ct u re is
b e p la ce d . p re fe rre d .

DISTAL INTERLOCKING SCREW PLACEMENT

■ Dist a l scre w p la ce m e n t is u su a lly d o n e w it h a fre e h a n d
t e ch n iq u e . Th is ca n b e o n e o f t h e m o st ch a lle n g in g p a rt s
o f t h e ca se fo r so m e su rg e o n s a n d t h e e a sie st fo r o t h e rs.
■ In g e n e ra l, se t u p a n d im a g e p o sit io n in g ca n g re a t ly fa cil-
it a t e t h is p a rt o f t h e p ro ce d u re .
■ Usin g t h e co n ce n t ric circle co n ce p t , t h e im a g e in t e n sifie r
o r t h e le g is ro t a t e d t o o b t a in a p e rfe ct circle .
■ If t h e im a g e is o va l o r sh a p e d like a n e ye , t h e im a g e
in t e n sifie r is n o t p e rp e n d icu la r t o t h e a xis o f t h e n a il,
o r in o t h e r w o rd s, p a ra lle l o r co -a xia l w it h t h e a xis o f
t h e scre w h o le .
■ Th e g o a l is t o a lig n t h e a xis o f t h e im a g e in t e n sifie r
w it h t h a t o f t h e scre w h o le . Ge t t in g p e rfe ct circle s is
t h e first crit ica l st e p .
■ In TECHNIQUES FIGURE 4 A, t h e im a g e in t e n sifie r
is n o t a lig n e d in t h e co ro n a l p la n e (va ru s o r va lg u s
t o t h e fe m o ra l n a il).
■ In TECHNIQUES FIGURE 4 B, t h e im a g e in t e n sifie r
is n o t a lig n e d in t h e a xia l–t ra n sve rse p la n e (ro t a -
t io n a lly t o t h e n a il).
■ In TECHNIQUES FIGURE 4 C, b o t h scre w h o le s in
t h e n a il lin e u p , g ivin g t h e “ p e rfe ct circle ”
w h e re in t h e im a g e in t e n sifie r is co -lin e a r t o t h e
a xis o f t h e scre w h o le in t h e n a il.
■ Ne xt , a d rill o r sca lp e l is u se d t o d e t e rm in e t h e cu t a n e o u s
lo ca t io n fo r a n in cisio n , w h ich sh o u ld g o t h ro u g h t h e fa s-
cia a n d t o b o n e .
■ A d rill is ce n t e re d o ve r t h e h o le a n d h e ld se cu re ly
(TECH FIG 4 D).
■ At t h is p o in t t h e re a re t w o o p t io n s: t h e d rill ca n b e
g e n t ly t a p p e d t o e n g a g e t h e n e a r co rt e x, o r it ca n b e
d rille d .
■ Th e a xis o f t h e d rill b it sh o u ld b e a lig n e d w it h t h e
ce n t e r o f t h e im a g e in t e n sifie r (w h ich is p a ra lle l t o
t h a t o f t h e h o le ). Th u s, if t h e d rill t ip is ce n t e re d
o ve r t h e h o le a n d a lig n e d w it h t h e ce n t e r o f t h e in -
t e n sifie r, it sh o u ld b e co -a xia l w it h t h e a xis o f t h e
h o le .

A B C

TECH FIG 4 • A. Th e p e rfe ct circle m e t h o d fo r fre e h a n d in t e rlo ckin g . If t h e im a g e a p p e a rs a s t w o circle s o ve r-

la p p e d , t h e sh a p e o f a n 8 w ill a p p e a r. Th e ce n t ra l a re a is e llip t ica l a n d in d ica t e s t h a t t h e im a g e in t e n sifie r a xis is
n o t co llin e a r w it h t h e a xis o f t h e scre w h o le s. Th e a p p ro p ria t e co rre ct ive d ire ct io n is p a ra lle l t o t h e sh o rt a xis o f
t h e ce n t ra l e llip se (o r p e rp e n d icu la r t o t h e lo n g a xis). In t h is ca se , t h e co rre ct io n w o u ld b e in t h e co ro n a l p la n e
(p ro xim a l-t o -d ist a l). B. In t h is sit u a t io n , t h e ro t a t io n o f t h e im a g e d o e s n o t m a t ch . It w ill n e e d t o b e co rre ct e d a lo n g
t h e p a t h o f t h e C. C. Th e im a g e o f a p e rfe ct circle . (co n t in u e d )
 Ch a p t e r 4 2 ANTEROGRADE INTRAM EDULLARY NAILING OF THE FEM UR 391

TECHNIQUES
12 mm

~3 nail diameters
36-40 mm

~5.5 nail diameters

65 mm

D E F

TECH FIG 4 • (co n t in u e d ) D. Th e drill p oint sh o uld b e in th e mid dle o f th e circle. Then the axis of the drill can be made co llinear
with that of the image intensifier. E. The drill can pass anterior or post erior to the nail and “feel” pretty good. Care should be
take n to ma ke su re the d rill poin t doe s no t d rift during this mot ion . Proprioce pt ive fee dback will frequ ently indicate when the drill
passes through the na il a nd the con tra la tera l co rte x. If the d rill “kicks” in o ne d ire ctio n (ante rior o r p osterior) it m ay h a ve missed
the na il. If it is n ot a ligne d in the coron al plane , it ma y h it the na il. It is imp ortan t to verify all implan t po sition s befo re leaving t he
operating room. F. A me th od of me a su rin g u sin g th e n a il a s a “ ya rdst ick.” If the dia mete r o f the na il is kno wn , the n the diam ete r
of th e bo ne at the level of the interlockin g ho le can be estimated by seeing h ow man y mu ltip les o f th e n ail will fit in that segment.
With some p ractice th e accuracy of th is tech n iq ue is imp ressive: we estimate o ur accu racy to exceed 90% u sin g th is techn iq ue.

■ On ce t h e d rill is in t o t h e b o n e a n d a d va n ce d , flu o ro - ■ An a lt e rn a t e m e t h o d , w h ich w e h a ve u se d w it h su r-

sco p ic ve rifica t io n sh o u ld b e o b t a in e d , a ft e r w h ich
t h e d rill is a d va n ce d t o t h e fa r co rt e x.
■ If the d rill bit “kicks” or jerks in to a d ifferen t d irectio n
or cannot be advanced, it is likely that it either glanced
off the nail (missed the hole anteriorly or posteriorly) or
is hitting the n ail (pro ximally or distally) (TECH FIG 4E).
■ Me a su re m e n t
■ Th e d rill ca n b e re m o ve d a n d m e a su re d w it h a d e p t h
g a u g e o r in m a n y syst e m s re a d d ire ct ly fro m t h e d rill
g u id e .
p risin g a ccu ra cy, is t o u se t h e kn o w n d ia m e t e r o f t h e
n a il a s a le g e n d .
■ Co m p a rin g t h e w id t h o f t h e fe m o ra l ca n a l a t t h e
le ve l o f t h e scre w h o le w it h t h a t o f t h e n a il a n d e s-
t im a t in g t h e n u m b e r o f n a il w id t h s in t h a t se g -
m e n t a llo w s fo r a n e st im a t e o f t h e scre w le n g t h .
■ Wit h a lit t le p ra ct ice , t h is m e t h o d is fa irly re li-
a b le , e sp e cia lly co n sid e rin g t h a t m a n y co m p a n ie s
p ro vid e scre w s o n ly in 5-m m in cre m e n t s (TECH
FIG 4 F).

PEARLS AND PITFALLS

Pre o p e ra t ive ■ Co rre ct p o sit io n a n d t ra ct io n a re ch o se n b a se d o n p a t ie n t size a n d a ssist a n t a va ila b ilit y.
In t ra o p e ra t ive ■ Aft e r n a il in se rt io n t h e su rg e o n sh o u ld a lw a ys ch e ck lim b ro t a t io n , lim b le n g t h , a n d t h e
fe m o ra l n e ck (ia t ro g e n ic fra ct u re ).

POSTOPERATIVE CARE ■Care should be taken when fracture lines are within 6 to
8 cm of the interlocking sites. In these cases, higher stresses
■ Postoperative radiographs should be obtained to check frac-
can result in complications of the nail or delayed healing,
ture alignment, rotation, and nail and screw placement as well
and weight bearing can be initiated with radiographic initi-
as to ensure the integrity of the femoral neck.
■ A clinical examination for rotation of the hip and a
ation of healing (callus).
■ Patients should be provided with physiotherapy for range of
thorough knee examination are needed to rule out occult knee
motion of the knee and hip and encouraged to exercise the ab-
injury.
■ M ost femoral fractures, irrespective of comminution, can be
ductors as well.
■ Deep vein thrombosis prophylaxis should be considered for
allowed weight bearing as tolerated.
all patients, unless contraindicated.
392 Se c t i o n IV FEM UR AND KNEE

OUTCOMES
■ The femur can be expected to heal in about 95% of cases,
with an infection rate of about 1% (FIGS 2 AND 3 ).
■ Knee motion should return to normal about 12 weeks post-

operatively, but may be limited in head-injured or polytrauma

patients owing to heterotopic bone formation or lack of early
motion.18
■ While healing rates are good, there is almost always an ob-

jective deficit in outcomes, which may or may not be clinically

relevant.
■ O bjective examination can reveal deficits in endurance

and strength, weather-related symptoms, or residual hip,

thigh, and knee pain.
■ M uch like tibial nailing, the causes of such symptoms

have not been well elucidated.

COMPLICATION S
■ Iatrogenic femoral neck fracture
■ Up to 15 degrees of rotational malalignment can be well tol-

erated, but greater than 15 degrees should be corrected.

■ Rotational deformity can be prevented by paying close at-

tention to cortical thickness, since the femur is not perfectly

cylindrical and cortical thickness varies.
■ Angular malalignment can be defined as greater than 5 de-

grees of angulation in coronal or sagittal planes.

■ The overall rate of malalignment is 7% to 11% , with

most angular deformities occurring at the proximal and dis-

tal thirds of the femur.16 FIG 3 • Fin a l ra d io g ra p h s d e m o n st ra t in g fin a l fixa t io n .

■ Up to 1.5 cm of leg-length discrepancy may be well tolerated.

■ Beyond 2 cm, many patients will eventually complain

of symptoms of malalignment (eg, back, knee, or ankle pain).

■ While symptoms should resolve with simple shoe

modifications, most patients are not able to maintain

compliance.
■ Infection is an infrequent but devastating complication. It

can be treated by several methods.

■ If the infection is early and fixation is stable, local and

systemic antibiotic treatment with nail retention may be

considered.
■ If the infection is extensive, a staged procedure should be

considered with use of a temporary custom-fabricated an-

tibiotic-impregnated intramedullary device, possibly an ex-
ternal fixator, and a course of intravenous antibiotics.
■ If the infection is delayed and the fracture is partially

healed, one can also consider an exchange nail with reaming

and placement of a nail of greater size (usually 2 mm).
■ M ost femur fractures should be considered for a combina-

tion of mechanical and pharmacologic prophylaxis against

deep vein thrombosis.
■ Fat emboli are a rare occurrence.

■ Studies on the reamer-irrigator-aspirator are pending.

This device may prevent fat emboli.

■ Decreased hip function and muscle weakness of the hip ab-

ductors and external rotators, along with trochanteric pain,

FIG 2 • Ra d io g ra p h d e m o n st ra t in g in it ia l d a m a g e co n t ro l thigh pain, and limp, may occur.
■ There is a small but definite occurrence of hip dysfunction
m e a su re s u sin g e xt e rn a l fixa t io n . Th e o n e p ro xim a l p in w a s
a d va n ce d t o g a in b ico rt ica l p u rch a se . with femur fractures.
 Ch a p t e r 4 2 ANTEROGRADE INTRAM EDULLARY NAILING OF THE FEM UR
■ While it still occurs with even retrograde nailing, the inci-
dence seems to be greater with antegrade nails, but recent
data using a trochanteric starting point appear promising.
■ Further and more definitive studies are warranted. There
is no superior method.
■ H eterotopic ossification may occur in 9% to 60% of patients,
with the most commonly associated factor being head injury.
■ Failed hardware or refracture usually indicates a nonunion.
In some cases, fracture of locking screws serves to “ autody-
namize” the fracture and healing ensues.
■ There is no need for hardware removal or additional
surgery if the fracture heals with minimal deformity.
■ Stretch injury of the sciatic nerve due to prolonged traction
during intramedullary nailing can be avoided with judicious
use of traction.
■ Treatment consists of expectant and supportive treatments.
■ Pudendal nerve palsy (if intramedullary nailing is performed
on a fracture table) can occur when excessive traction and a
small perineal post are used.
■ M ost femur fractures can be brought to length easily, and
traction should be limited to the time of reduction and nail
passage and interlocking.
■ Use of a large, well-padded perineal post, judicious trac-
tion, or a femoral distractor can avoid this problem.
■ Compartment syndrome of the thigh (especially in intu-
bated, polytrauma victims) may occur, especially with crush
injuries or prolonged hypotension.
■ Clinical signs should be used to dictate treatment, and re-
lease of the anterior compartment is generally sufficient.
■ If compartment pressures are to be monitored, threshold
pressure is 30 or 40 mm H g or one that is based on the pa-
tient’s diastolic blood pressure (within 30 mm H g).
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O rthopedics 2005;28:1182–1186.

Ch a p t e r 43
DEFIN ITION
■ Distal femur fractures are difficult, complex injuries that can
result in devastating outcomes.
■ The distal part of the femur is considered the most distal 9
to 15 cm of the femur and can involve the articular surface.
The intra-articular injury can vary from a simple split to exten-
sive comminution.
■ Articular involvement can lead to posttraumatic arthritis.
■ These fractures constitute 4% to 7% of all femur fractures.
■ If the hip is excluded, they represent nearly one third of
all femur fractures.
■ There is a bimodal distribution defined by the mechanism
of injury (see below).
AN ATOMY
■ The supracondylar area of the femur is the zone between the
femoral condyles and the metaphyseal–diaphyseal junction.
■ The metaphyseal bone has some important structural
characteristics.
■ The predominant bone is cancellous.
■ The cortices are especially thin.
■ There is a wide intramedullary canal.
■ It is also important to understand the unique bony architec-
ture of the distal femur (FIG 1 ).
■ It is trapezoidal in shape, and hence the posterior aspect
is wider than the anterior aspect. There is a gradual decrease
by 25% in the width from posterior to anterior.
■ The medial femoral condyle has a larger anterior-to-
posterior dimension than the lateral side and extends farther
distally.
■ The shaft is in line with the anterior half of the distal
femoral condyles.
Anterior width
Outline of
trapezoid
A Posterior width
FIG 1 • A. Vie w o f t h e d ist a l fe m u r sh o w in g t h e w id e r p o st e rio r a sp e ct a n d t ra p e zo id a l sh a p e . B. La t e ra l vie w o f t h e d ist a l fe m u r; t h e
sh a ft is in lin e w it h t h e a n t e rio r h a lf o f t h e d ist a l fe m o ra l co n d yle s.
394
Op e n Re d u ct io n a n d In t e r n a l
Fix a t io n o f t h e Dis t a l Fe m u r
A n im e sh A g arw al
■ The normal mechanical and anatomic axes of the lower
limb must be understood so that the alignment of the limb can
be re-established (FIG 2 ).
■ The mechanical femoral axis, which is from the center of
the femoral head to the center of the knee, is 3 degrees off
the vertical. The mechanical axis of the entire limb contin-
ues to the center of the ankle.
■ The anatomic femoral axis differs from the mechanical
femoral axis in that there is 9 degrees of valgus at the knee.
This results in an anatomic femoral axis of the lateral distal
femur of 81 degrees or an anatomic femoral axis of the me-
dial distal femur of 99 degrees.
■ The mechanical and anatomic axes of the tibia are for
practical purposes identical, going from the center of the
knee to the center of the ankle.
■ The treatment of distal femur fractures can be complicated
by the various muscle attachments, which can impede or ham-
per proper fracture reduction.
■ The quadriceps and hamstrings result in fracture shorten-
ing; thus, excellent muscle paralysis must be obtained for
proper reduction.
■ The medial and lateral gastrocnemius results in posterior
angulation and displacement of the distal segment. The
distal femur “ extends,” resulting in an apex posterior
deformity. If an intercondylar extension is present, rota-
tional deformities of the individual condyles can occur
(FIG 3 A,B).
■ The adductors, specifically the adductor magnus, which
inserts onto the adductor tubercle of the medial femoral
condyle, can lead to a varus deformity of the distal segment
(FIG 3 C).
■ The neurovascular structures about the knee are at risk
when an injury of the distal femur occurs.
1/
2
B

Vertical axis
Mechanical axis
3°
Anatomic axis
6°
81° 99°
Knee joint axis
FIG 2 • Me ch a n ica l a n d a n a t o m ic a xe s o f t h e lo w e r e xt re m it y;
t h e 9 d e g re e s o f va lg u s a t t h e kn e e is n o t e d .
■ At the canal of H unter, roughly 10 cm proximal to the
knee on the medial side, the superficial femoral artery enters
the popliteal fossa (FIG 3 C).
■ Posterior to the knee, both the popliteal artery and the
tibial nerve are at risk at the fracture site (FIG 3 D).
PATHOGEN ESIS
■ As mentioned, there is a bimodal distribution in terms of age
in the epidemiology of distal femur fractures. This relates to
the mechanism of injury.
■ H igh-energy and low-energy injuries occur.
■ H igh-energy injuries usually are from motor vehicle acci-
dents and occur in the young patient. There is a direct im-
pact onto the flexed knee, such as from the dashboard.
These patients often have associated injuries such as a hip
fracture or dislocation or vascular or nerve injury. These
high-energy injuries generally result in comminuted frac-
tures, mostly of the metaphyseal region. The comminution
can be articular as well.
Ch a p t e r 4 3 ORIF OF THE DISTAL FEM UR 395
■ Low-energy injuries usually occur in the elderly patient
who falls from a standing height. The axial loading is ac-
companied by either varus or valgus with or without rota-
tion. The osteoporotic bone in these individuals leads to
fracture. The fracture pattern can vary from the most simple
extra-articular type to the most complex intra-articular in-
jury. O wing to the gastrocnemius complex, an apex poste-
rior deformity of the condyles occurs as the fragments are
flexed because of the muscle attachment.
N ATURAL HISTORY
■ Fractures of the distal femur that have intra-articular displace-
ment can lead to severe posttraumatic arthritis if left untreated.
■ O perative treatment has led to a 32% decrease in poor
outcomes. 9
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Direct physical examination of the knee with a distal femur
fracture is limited primarily because of pain and the obvious
nature of the injury.
■ The patient presents with a swollen and tender knee after
either a fall or some high-energy trauma (motor vehicle or
motorcycle accident).
■ A large hemarthrosis is present.
■ Any attempts at range of motion result in severe pain, and
significant crepitus is usually noted with palpation.
■ If there is concern for an open knee joint, the joint can be in-
jected after a sterile preparation to see whether the knee joint
communicates with any wound.
■ The physical examination is directed primarily at ascertaining
the neurovascular status of the lower limb and determining
whether any associated injuries exist, especially the hip (see Exam
Table for Pelvis and Lower Extremity Trauma, pages 1 and 2).
■ If there are any small wounds or tenting of the skin ante-
riorly, the fracture should be considered as being open.
■ It is important to check for pulses.
■ If diminished or absent, pulses should be assessed with
Doppler.
■ The ankle-brachial indices should be obtained if there is
a concern for arterial injury.
■ Any side-to-side difference or value less than 0.9 war-
rants an arteriogram.
■ N erve function should be checked. Sensation and both ac-
tive dorsiflexion and plantarflexion must be assessed.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ The initial imaging study is always plain radiographs.
Anteroposterior (AP) and lateral radiographs of the knee
should be obtained initially.
■ Traction films should be obtained if there is severe com-
minution of either the metaphysis or articular surface. This
aids in the preoperative planning.
■ Dedicated knee films should always be obtained in the as-
sessment of distal femur fractures. Additionally, the entire
femur, to include the hip and knee, should be imaged to
look for possible extension and associated injuries and to
allow for preoperative planning (FIG 4 ).
■ In cases of severe comminution, radiographs of the con-
tralateral knee can aid in preoperative planning as well.
396 Se c t i o n IV FEM UR AND KNEE

Medial femoral
condyle

A
Lateral femoral
B condyle

C D

FIG 3 • A. Pa t ie n t w it h a g ra d e IIIA o p e n d ist a l fe m u r w it h e xt ru d e d fra g m e n t ; t h e “ e xt e n sio n ” o f t h e fe m o ra l co n d yle s is o u t lin e d .

B. Pa t ie n t w it h a d ist a l fe m u r fra ct u re w it h in t e rco n d yla r e xt e n sio n sh o w in g t h e su b t le ro t a t io n a l d e fo rm it ie s o f t h e in d ivid u a l
co n d yle s. C. Th e m u scle fo rce s a re sh o w n o n t h e d ist a l fe m u r, a s is t h e fe m o ra l a rt e ry a n d ve in e n t e rin g t h e ca n a l o f Hu n t e r (arro w ).
Th e a d d u ct o r m a g n u s in se rt s o n t h e a d d u ct o r t u b e rcle , le a d in g t o a va ru s d e fo rm it y o f t h e d ist a l se g m e n t . D. A la t e ra l im a g e o f t h e
sa m e p a t ie n t w it h t h e p o p lit e a l a rt e ry a n d t ib ia l n e rve d ra w n in t o sh o w t h e re la t ive p ro xim it y t o t h e fra ct u re e n d s.
 Ch a p t e r 4 3 ORIF OF THE DISTAL FEM UR 397

FIG 4 • A–C. Pa t ie n t w it h a sp ira l d ist a l-

t h ird fe m u r fra ct u re t h a t a p p e a rs t o b e
e xt ra -a rt icu la r. A. In t h e AP ra d io g ra p h ,
t h e kn e e is n o t fu lly visu a lize d . B. A d e d -
ica t e d kn e e AP ra d io g ra p h sh o w s t h e
sp ira l d ist a l-t h ird fe m u r fra ct u re .
No t e t h e in t ra -a rt icu la r in ju ry a n d t h e
g a p a t t h e fra ct u re (arro w s). C. La t e ra l
vie w o f t h e kn e e . Ag a in n o t e t h e co ro -
n a l fra ct u re o f t h e m e d ia l fe m o ra l
co n d yle (t yp e B3). D–F. Pla in ra d io g ra p h s
o f a p a t ie n t w it h a g ra d e II o p e n d ist a l
fe m u r fra ct u re . G,H. Pa t ie n t w it h a
clo se d fe m u r fra ct u re t h a t w a s in it ia lly
t h o u g h t t o b e e xt ra -a rt icu la r.

A B

C D E

F G H
398 Se c t i o n IV FEM UR AND KNEE

A B C

FIG 5 • A. Axia l CT im a g e o f p a t ie n t
in Fig u re 4A–C co n firm in g t h e t yp e
B3 fra ct u re o f t h e m e d ia l fe m o ra l
co n d yle . B. Axia l CT im a g e o f t h e
p a t ie n t in Fig u re 4D–F. C–E. CT im -
a g e s o f t h e p a t ie n t in Fig u re 4G,H
sh o w t h e n o n d isp la ce d in t e rco n d yla r
sp lit a s w e ll a s t h e lo w la t e ra l fra c-
t u re lin e a n d e xt e n sive p o st e rio r
D E m e t a p h yse a l co m m in u t io n (t yp e C2).

■ A dedicated CT scan is an important adjunct to the preop- ■ Coronal and sagittal reconstructions should be requested.
erative planning when there is articular involvement (FIG 5 ). ■ Three-dimensional images can be created from most

■ Generally, extra-articular distal femur fractures do not require CT scans. This can also aid in the preoperative planning
a CT scan. However, it has been shown that coronal fractures (FIG 6 A,B).
may be missed on plain films, and thus there is a low threshold ■ Subtle sagittal-plane rotational malalignment between

for obtaining a CT scan for fractures of the distal femur.4 condyles can be assessed (FIG 6 C).
■ If the fracture pattern warrants a temporary bridging ■ If associated soft tissue injury is suspected, such as ligamen-

external fixator, it is best to obtain the CT scan after place- tous tears or tendon ruptures, then M RI may be indicated.
ment of such a fixator for better definition. Routine use of M RI, however, is not needed.

A B C

FIG 6 • AP (A) a n d la t e ra l (B) vie w s o f a 3D CT re co n st ru ct io n o f t h e p a t ie n t in Fig u re 3B w it h a d is-

t a l fe m u r fra ct u re . Th e fra ct u re is w e ll d e fin e d . C. An o b liq u e 3D CT re co n st ru ct io n vie w sh o w in g
t h e sa m e p a t ie n t a n d t h e ro t a t io n a l m a la lig n m e n t b e t w e e n co n d yle s.
 Ch a p t e r 4 3 ORIF OF THE DISTAL FEM UR 399

DIFFEREN TIAL DIAGN OSIS

■ Proximal tibia fracture
■ Femoral shaft fracture
■ Septic knee
■ Patella fracture
■ Anterior cruciate ligament rupture
■ Knee dislocation

N ON OPERATIVE MAN AGEMEN T

■ There are few relative indications for nonoperative manage-
ment of distal femur fractures: A1 B1 C1
■ Poor overall medical condition

■ Patient has severe comorbidities and is too sick for

surgery.
■ Patient has extremely poor bone stock.

■ Spinal cord injury (paraplegia or quadriplegia)

■ Some special situations may warrant nonoperative care

on case-by-case basis.
■ N ondisplaced or minimally displaced fracture

■ Select gunshot wounds with incomplete fractures

■ Extra-articular and stable

■ Unreconstructable

■ Lack of experience by the available surgeon or lack of

A2 B2 C2
equipment or appropriate facility to adequately treat the
injury. Transfer is indicated in these situations; otherwise,
nonoperative treatment may be the only option.
■ There are several methods for nonoperative treatment.

■ Skeletal traction

■ Cast bracing

■ Knee immobilizer

■ Long-leg cast

■ There are acceptable limits for nonoperative management:

■ 7 degrees of varus or valgus

■ 10 degrees of anterior or posterior angulation. A flex-

ion deformity is less well tolerated than an extension

deformity. A3 B3 C3
■ Up to 1 to 1.5 cm of shortening
FIG 7 • AO/OTA cla ssifica t io n fo r d ist a l fe m u r fra ct u re s (t yp e s
■ 2 to 3 mm of stepoff at the joint surface
33A, B, a n d C).

SURGICAL MAN AGEMEN T

■ The goal of any treatment, nonoperative or operative, is to
maintain or restore the congruity of the articular surface and AO/OTA Cla s s if ica t io n o f
restore the length and alignment of the femur and subsequently
Ta b le 1 Fe m o r a l Fr a ct u r e s
the limb.
■ O nce surgery is deemed appropriate for the patient and the
Cla s s if ica t io n De s cr ip t io n
Type A Extra-articular
particular injury, the surgical technique options available are A1 Simple or two-part fracture
determined by the particular fracture pattern. A2 Metaphyseal butterfly or wedge fracture
■ Distal femur fractures have been classified several ways.
A3 Metaphysis is comminuted
■ The AO /O TA classification is probably the most widely
Type B Partial articular
accepted classification system and allows some guidance on B1 Sagittal-plane fracture of the lateral femoral
which techniques are best (FIG 7 , Table 1). condyle
■ Treatment also must be determined based on factors other B2 Sagittal-plane fracture of the medial femoral
than the classification alone. condyle
■ The degree of comminution and injury to both the articu- B3 Any frontal or coronal plane fracture of the
condyle (Hoffa type)
lar surface and bone
■ The amount of fracture displacement
Type C Intra-articular
C1 Simple articular split and metaphyseal injury
■ The soft tissue injury
(T or Y fracture configuration)
■ Associated injuries, other fractures, and injury to neu-
C2 Simple articular split with comminuted
rovascular structures metaphyseal injury
■ Patient’s overall condition and injury to other organ sys- C3 Comminuted articular with varying metaphyseal
tems. This may affect the timing of surgery or the position- injury
ing of the patient.
400 Se c t i o n IV FEM UR AND KNEE
■ There are several principles for the surgical management of
distal femur fractures
■ The articular surface must be reduced anatomically, which
usually requires direct visualization through an open expo-
sure (arthrotomy). Simple intra-articular splits may be treated
with closed reduction and percutaneous fixation.
■ The extra-articular injury should be dealt with using indi-
rect reduction techniques as much as possible to maintain a
biologic soft tissue envelope. Avoidance of stripping of the
tissues, especially on the medial side, is ideal.
■ The surgeon must re-establish the length, rotation, and
alignment of the femur and the limb.
■ The soft tissue injury and bone quality may dictate treat-
ment decisions.
Fixation Choices
■ External fixation
■ A temporary bridging external fixator across the knee
joint can be used if temporary stabilization is required before
definitive fixation. This is usually the case where definitive
open reduction and internal fixation is planned. This could
be in cases where the soft tissues prevent immediate fixation.
■ Definitive management with bridging or nonbridging ex-
ternal fixation can be used for unreconstructable joints, very
severe soft tissue injuries, or severe osteopenia.
■ Intramedullary nailing
■ This can be performed fairly acutely; temporary bridging
external fixation is not necessary.
■ Antegrade intramedullary nailing has been described and
can be used for distal fractures with a large enough distal
segment to allow for two locking screws. M alalignment has
been a problem, as has adequate fixation. 1,2
■ Retrograde intramedullary nailing can be used in the fol-
lowing cases.
■ All extra-articular type A fractures greater than 4 cm
from the joint. This minimal length of the distal femur al-
lows for multiplanar interlocking in the distal fragment.
■ Type C1 or C2 fractures where the articular fracture can
be anatomically reduced closed or with limited exposure.
Percutaneous screws are used for the articular injury.
■ Periprosthetic fractures around a total knee arthroplasty
with an “ open box” femoral component.
A B
■ M ost surgeons prefer to use a long nail, but short supra-
condylar nails are available as well. M ultiple-hole short
supracondylar nails have fallen out of favor.
■ Plate fixation
■ O pen reduction and internal fixation with plates can be
used for all types A and C fractures but is ideal for the fol-
lowing injuries:
■ Very distal type A fractures within 4 cm of the knee joint
■ All articular type C fractures, but always for C3 types
■ Periprosthetic fractures about a “ closed box” femoral
component of a total knee arthroplasty
■ The partial articular type B1 or B2 if an antiglide plate
is needed
■ Plate options (preferred to least preferred; fixed-angle de-
vices preferred)
■ Fixed-angle locking plates (percutaneous jigs are ad-
vantageous and allow for minimally invasive techniques)
■ 95-degree condylar screw
■ 95-degree blade plate
■ N onlocking plates with or without medial support
(medial plate or external fixation)
■ Limited internal fixation
■ Limited fixation with screws only can be used for partial
articular type B, especially type B3.
■ The amount of open reduction required depends on the
adequacy of closed reduction techniques and obtaining an
anatomic reduction of the joint surface.
■ H eadless screws are useful for type B3 fractures in which
the screws have to penetrate the joint surface (FIG 8 ).
■ Countersinking the screw heads can also be performed.
Preoperative Planning
■ Surgical timing can be affected by:
■ Soft tissue issues
■ M edical condition of the patient
■ Adequacy of available operative team
■ Availability of implants
■ The approach must take the following issues into con-
sideration:
■ The ability to incorporate lacerations in open fractures
into the incision (FIG 9 ) can be useful and should be consid-
ered. H owever, this is not always necessary or possible.
FIG 8 • A. La t e ra l ra d io g ra p h o f p a -
t ie n t w it h a g ra d e II o p e n d ist a l m e -
d ia l fe m o ra l co n d yle fra ct u re (t yp e
B3). Th e Ho ffa fra g m e n t is o u t lin e d .
B. Po st o p e ra t ive ra d io g ra p h a ft e r fix-
a t io n w it h h e a d le ss scre w s, b u rie d u n -
d e rn e a t h t h e su b ch o n d ra l b o n e .

A B
■ Soft tissue dissection should be limited.
■ Adequate exposure is important to anatomically restore
the articular surface.
■ Restoration of limb “ anatomy” must be accomplished and
allow early range of motion.
■ Stable internal fixation and length and sizes of implants
should be templated. Radiographs of the injury can be tem-
plated with implant templates to ensure that proper lengths
are available. A tentative plan of the fixation construct can
be drawn on the image. Additionally, “ preop planning” of
the operating room should be performed; this includes a dis-
cussion with the operative team about the positioning and
equipment needed for the procedure.
■ The need for bone grafting should be assessed (eg, iliac
crest bone graft versus allograft or bone graft substitutes).
■ Fracture fragments and the anticipated fixation construct
should be templated.
■ The surgeon should check for coronal plane fractures of
the condyles (also known as H offa fragments) (see Figs 4C
and 5).
■ Associated injuries may affect the treatment options.
■ An ipsilateral hip or more proximal shaft fracture may
alter the implant choice. A longer plate may be needed to
address both injuries, or consideration to overlap implants
may be warranted to avoid a stress riser.
■ An associated proximal tibia fracture may alter the ap-
proach used. A more lateral incision incorporating a lazy S
incision for the proximal tibia injury may be required.
Positioning
■ A radiolucent table should be used to allow adequate visu-
alization with a C-arm.
■ The patient is placed supine with a hip bump.
■ The rotation of the proximal segment of the fracture (hip)
should be aligned before patient preparation.
■ Using the C-arm, the profile of the lesser trochanter
with the corresponding knee (patella) straight up is deter-
mined on the uninjured side (FIG 1 0 A,B).
■ The injured hip is imaged and internally rotated by the
hip bump so that duplication of the profile of the normal
side is achieved. The size of the bump may be adjusted as
needed for the amount of rotation required.
Ch a p t e r 4 3 ORIF OF THE DISTAL FEM UR 401
FIG 9 • A. Pa t ie n t w it h o p e n d ist a l fe m u r fra ct u re a n d
t ra u m a t ic o b liq u e la ce ra t io n a ft e r d é b rid e m e n t , b rid g -
in g e xt e rn a l fixa t io n , a n d clo su re . B. In co rp o ra t io n o f
t h e la ce ra t io n in t o a m o d ifie d m id lin e a p p ro a ch .
■ The injured knee is placed in the patella-up position to
confirm rotation.
■ This technique is helpful in comminuted metaphyseal
fractures where the rotation is difficult to assess or in
cases where the metaphyseal component will not be di-
rectly visualized.
■ Even though the distal segment is not in “ fixed” rota-
tion, this technique is useful to minimize the chance of a
malrotation during definitive fixation.
■ A sterile tourniquet is used unless a temporary fixator pre-
vents its placement.
■ A large bump or a sterile triangle is used under the knee.
■ This allows for knee flexion, relaxing the gastrocsoleus
complex and facilitating the reduction.
■ A sterile and removable one is most useful.
■ The C-arm is brought in from the opposite side.
■ It should be angled so that it is parallel with the femoral
shaft.
■ A notch view is useful for screw trajectories in the distal
femur (FIG 1 0 C,D).
Approach
■ The best-known approach for the treatment of distal femur
fractures has been the straight lateral approach (FIG 1 1 ).
■ This is suitable for all fracture types, mostly types A and C1.
■ The incision may curve distally toward the tibial tubercle,
and osteotomy may be performed.
■ N ewer approaches include a lateral inverted U to allow
better access to the joint and to allow for plate placement.
■ The minimally invasive lateral approach can be used for cer-
tain fractures and implants.
■ The joint must be visualized, reduced, and stabilized.
■ The placement of the plate on the shaft is done submus-
cularly, and reduction and fixation are done percutaneously
under fluoroscopic guidance.
■ This is ideal for the LISS plate or plating system with tar-
geting devices for the screws in the plate.
■ A modified anterior approach (the swashbuckler) has been
described by Starr et al. 7
■ This involves a midline incision.
■ A lateral parapatellar arthrotomy is done with elevation
of the vastus lateralis as in the lateral approach.
402 Se c t i o n IV FEM UR AND KNEE

A B
Pins penetrating
through medial
cortex

FIG 1 0 • A. C-a rm vie w o f t h e u n in -

ju re d kn e e w it h p a t e lla fo rw a rd fa c-
in g . B. Th is is fo llo w e d b y im a g in g
o f t h e ip sila t e ra l h ip t o o b t a in t h e
le sse r t ro ch a n t e r p ro file (o u t lin e d ).
A sim ila r p ro file sh o u ld b e re cre a t e d
o n t h e in ju re d sid e w it h t h e h ip
b u m p . C. Po sit io n in g o f t h e C-a rm
re la t ive t o t h e fle xe d kn e e t o o b t a in Guide pin penetrating
a n o t ch vie w t o e va lu a t e fo r g u id e into notch and back
p in p e n e t ra t io n in t h e p o st e rio r a s- into medial femoral
p e ct . D. Th e re su lt in g C-a rm im a g e . D condyle

■ A medial parapatellar arthrotomy can be used for retro- ■ It can be used in type C3 fractures if a second plate is
grade intramedullary nailing or limited screw fixation. being used (in conjunction with a lateral approach).
■ M ini-arthrotomy is used for the retrograde nail. ■ A total knee approach has been described by Schatzker. 6

■ Type B injuries may require a formal arthrotomy. ■ This is extremely helpful for type C2 or C3 fractures.

■ A medial approach has been described. ■ It is used for plates but can be used for retrograde in-

■ This is appropriate for type B2 and B3 fractures. tramedullary nailing once the articular surface is recon-
structed.
■ A midline approach is used.

■ An extended medial parapatellar arthrotomy is done.

■ This allows exposure of the condyles for articular

reduction.
■ A midline incision with a lateral parapatellar arthrotomy is

my preferred exposure for type C fractures.

■ A midline approach is used.

■ A lateral parapatellar arthrotomy is done.

■ Proximal extension is made into the quadriceps tendon,

enough to repair to itself.

■ M edial dislocation of patella is done.

■ This allows exposure of the condyles for articular reduc-

FIG 1 1 • Skin in cisio n fo r a la t e ra l a p p ro a ch . tion and easier lateral plate insertion.

 Ch a p t e r 4 3 ORIF OF THE DISTAL FEM UR 403

TECHNIQUES
TEMPORARY BRIDGING EXTERNAL FIXATION
■ A la rg e e xt e rn a l fixa t io n syst e m is u se d . Re d u ct io n o f t h e Me t a p h yse a l
A sm a ll b u m p is p la ce d u n d e r t h e kn e e t o p la ce t h e kn e e Co m p o n e n t
■

in slig h t fle xio n .

■ Gro ss re d u ct io n o f t h e m e t a p h yse a l co m p o n e n t o f t h e
■ Th e in ju re d e xt re m it y is b ro u g h t o u t t o le n g t h w it h m a n -
fra ct u re sh o u ld b e p e rfo rm e d w it h t ra ct io n a n d m a n ip u -
u a l t ra ct io n .
la t io n o f t h e p in s.
■ Tw o o r t h re e 5-m m Sch a n z p in s a re p la ce d in t h e t ib ia in
■ Th e fra ct u re sh o u ld b e b ro u g h t o u t t o le n g t h .
a n a n t e rio r-t o -p o st e rio r d ire ct io n ju st m e d ia l t o t h e cre st
■ In t ra o p e ra t ive ly, t h e o p p o sit e le g ca n b e u se d t o h e lp
t o e n su re in t ra m e d u lla ry p la ce m e n t .
d e t e rm in e le n g t h .
■ Tw o o r t h re e 5-m m Sch a n z p in s a re p la ce d in t h e fe m o ra l
■ Postop era tively, a scanogram can be used t o de te r-
sh a ft in a n a n t e rio r-t o -p o st e rio r d ire ct io n .
mine wh eth e r th e len g th h as b e en reg a in ed b efo re d e-
■ Th e se sh o u ld b e p la ce d o u t o f t h e zo n e o f so ft t issu e
finit ive fixat io n if t h ere is e xt e n sive co mm in u t ion , b ut
in ju ry if p o ssib le .
th is is n ot alw a ys n eed ed (TECH FIG 2). Alt h o u gh the
■ Th e p in s a re p la ce d w h ile t h e lim b is o u t t o le n g t h so
knee ma y be som ew hat flexed, t he scan ogram can still
t h a t t h e q u a d rice p s is n o t “ ske w e re d ” in a sh o rt e n e d
b e o b ta in ed an d t he fe mo ra l len g t h d et erm in ed as o p-
p o sit io n .
p o se d t o t h e en t ire le g le ng t h .
■ Th e p in s ca n b e p la ce d o u t sid e o f t h e a n t icip a t e d
■ Th e ro t a t io n sh o u ld b e ch e cke d o n ce a g a in b e fo re lo ck-
p la t e lo ca t io n . Th is, h o w e ve r, h a s n o t b e e n e m p iri-
in g t h e e xt e rn a l fixa t o r co n st ru ct , a s d e scrib e d a b o ve
ca lly fo u n d t o b e a p ro b le m . In m y e xp e rie n ce
u n d e r p o sit io n in g . Th e sa m e t e ch n iq u e sh o u ld b e p e r-
p la t e s h a ve o ft e n o ve rla p p e d w it h p in sit e s a n d
fo rm e d u n d e r st e rile co n d it io n s.
t h e re h a s n o t b e e n a n a sso cia t e d p ro b le m w it h in -
■ Va ru s–va lg u s a lig n m e n t sh o u ld b e a sse sse d b e fo re fin a l
fe ct io n s.
t ig h t e n in g a s w e ll.
■ Pin p la ce m e n t in t h e t ib ia m a y b e a lt e re d if a d d it io n a l
■ Th is ca n b e d o n e b y u sin g t h e Bo vie co rd in t ra o p e ra -
u se s o f su ch p in s a re n e e d e d , su ch a s t ra ct io n fo r a n a s-
t ive ly a n d a sse ssin g t h e m e ch a n ica l a xis o f t h e lim b b y
so cia t e d a ce t a b u la r fra ct u re (TECH FIG 1 A).
flu o ro sco p ica lly e va lu a t in g fro m t h e h ip t o t h e a n kle
■ Th e b a rs ca n b e co n fig u re d in m a n y w a ys, a ll o f
w it h t h e co rd ce n t e re d a t t h e fe m o ra l h e a d a ll t h e
w h ich p ro vid e t e m p o ra ry st a b iliza t io n a cro ss t h e
w a y t o t h e a n kle .
kn e e jo in t . I p re fe r a d ia m o n d co n fig u ra t io n (TECH
■ Th e p o in t a t w h ich t h e co rd cro sse s t h e kn e e a llo w s
FIG 1 B).
o n e t o ju d g e t h e va ru s–va lg u s a lig n m e n t .

TECH FIG 1 • A. Brid g in g kn e e e xt e rn a l fix-

a t io n in p a t ie n t w it h a sso cia t e d a ce t a b u la r
fra ct u re ; t h e t ib ia l p in w a s u se d fo r t ra ct io n
p u rp o se s a s w e ll. B. A d ia m o n d co n fig u ra -
A t io n fo r b rid g in g kn e e e xt e rn a l fixa t io n .
 404 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES
A B
TECH FIG 2 • AP ra d io g ra p h (A) a n d sca n o g ra m (B) sh o w in g t h a t le n g t h w a s re -e st a b lish e d w it h
t h e e xt e rn a l fixa t o r.
OPEN REDUCTION AND INTERNAL FIXATION OF THE DISTAL FEMUR WITH
LOCKING PLATES (TYPE C FRACTURES)
■ Th is t e ch n iq u e ca n b e u se d re g a rd le ss o f t h e lo ckin g
p la t e syst e m u se d . Ea ch syst e m ’s t e ch n iq u e g u id e sh o u ld
b e re vie w e d b e fo re u se , a s e a ch syst e m h a s it s o w n id io -
syn cra sie s. Va ria t io n s in p la t e a p p lica t io n a s w e ll a s re -
d u ct io n t o o ls a n d t e ch n iq u e s a re u n iq u e t o e a ch syst e m .
■ Th e t e m p o ra ry e xt e rn a l fixa t o r is p re p a re d u sin g a
“ d o u b le -d o u b le ” t e ch n iq u e .
■ The fixat or is first prepa re d w ith a Bet adin e “ scru b”
(7.5% p o vid o n e –io d in e ) so lu t io n fo llo w e d b y a
Be t a d in e “ p a in t ” (10% p o vid o n e –io d in e ) so lu t io n
(Be ta –Bet a prepa ra tion), follow ed by th e e xt re mit y,
wit h a se cond Bet a–Bet a pre parat ion.
■ Th e su rg e o n t h e n d o e s a n a lco h o l p re p a ra t io n , fo l-
lo w e d b y io d in e fo r t h e fixa t o r, fo llo w e d b y a lco h o l
a n d io d in e o n t h e skin .
■ Th is h a s b e e n su cce ssfu l in o u r p ra ct ice a n d a llo w s fo r
m a in t e n a n ce o f t ra ct io n d u rin g t h e p re p a ra t io n a n d
a id s in t h e a ct u a l su rg e ry, fu n ct io n in g a s a fe m o ra l
d ist ra ct o r. (Ch lo rh e xid in e is u se d in io d in e -a lle rg ic
p a t ie n t s.)
■ An a lt e rn a t ive is t o co m p le t e ly re m o ve t h e fixa t o r
co m p o n e n t s, e xce p t t h e p in s, a n d w a sh , st e rilize , a n d
t h e n re a sse m b le t h e fixa t o r o n t h e p a t ie n t a ft e r t h e
le g h a s b e e n p re p a re d .
■ If t h e re is n o t e m p o ra ry b rid g in g e xt e rn a l fixa t o r, t h e
m e t a p h yse a l co m p o n e n t o f t h e fra ct u re ca n b e re d u ce d
a n d b ro u g h t o u t t o le n g t h w it h a fe m o ra l d ist ra ct o r, a
t e m p o ra ry sim p le e xt e rn a l fixa t o r, o r m a n u a l t ra ct io n if
a d e q u a t e h e lp is a va ila b le .
■ Ro t a t io n o f t h e p ro xim a l se g m e n t ca n b e m a n ip u -
la t e d w it h t h e d e vice u se d .
Mid lin e Ap p ro a ch w it h a n Ext e n d e d
La t e ra l Pa ra p a t e lla r Art h ro t o m y
■ A st ra ig h t in cisio n is m a d e d ire ct ly a n t e rio r a b o u t 5 cm
p ro xim a l t o t h e su p e rio r p o le o f t h e p a t e lla a n d d ist a lly
t o t h e le ve l o f t h e t ib ia t u b e rcle (TECH FIG 3 A).
■ Th e la t e ra l skin fla p is d e ve lo p e d t o a llo w fo r a la t e ra l
p a ra p a t e lla r a rt h ro t o m y (TECH FIG 3 B).
■ Th e a rt h ro t o m y is p e rfo rm e d , e n su rin g a cu ff o f t issu e o n
t h e la t e ra l a sp e ct o f t h e p a t e lla fo r re p a ir a s w e ll a s m e -
d ia lly o n t h e q u a d rice p s (TECH FIG 3 C).
■ Th e p a t e lla ca n b e su b lu xe d m e d ia lly o r in ve rt e d w it h
kn e e fle xio n t o a llo w e xp o su re o f t h e co n d yle s (TECH
FIG 3 D).
■ Ad d it io n a lly, a b lu n t Ho h m a n n re t ra ct o r ca n b e
p la ce d o n t h e m e d ia l sid e a t t h e le ve l o f t h e co n d yle
t o re t ra ct t h e p a t e lla .
■ Th e ca p su le is su b p e rio st e a lly e le va t e d o ff t h e la t e ra l
fe m o ra l co n d yle t o a llo w fo r p la ce m e n t o f t h e p la t e .
■ The lat eral collat eral ligam ent is pre se rved because th e
d isse ctio n is lim it e d to th e a n te rior t wo th irds of t he
la te ra l fem o ral co n d yle an d p lat e p lacem en t is u su ally
p ro xima l to t he la te ra l e p ico n d yle .

A B
C D
■ Th e m e d ia l sid e in t h e m e t a p h yse a l re g io n is le ft u n d is-
t u rb e d a s m u ch a s p o ssib le .
Re d u ct io n o f t h e Art icu la r Su rfa ce
■ Th e jo in t is e va lu a t e d t o d e t e rm in e co m m in u t io n .
■ Jo in t re co n st ru ct io n is t h e n p e rfo rm e d w it h d ire ct re d u c-
t io n . Ea ch co n d yle is fu lly a sse sse d first fo r sm a lle r fra c-
t u re fra g m e n t s, w it h t h e g o a l o f re st o rin g e a ch co n d yle
a n a t o m ica lly. Sm a ll-d ia m e t e r scre w s (le ss t h a n 3.0 m m )
m a y b e u se d a n d ca n b e co u n t e rsu n k u n d e rn e a t h t h e a r-
t icu la r su rfa ce .
■ La rg e co ro n a l fra ct u re fra g m e n t s a re b e st t re a t e d w it h
co u n t e rsu n k 3.5- t o 4.5-m m la g -t yp e scre w s. We u se
h e a d le ss scre w s.
■ On ce e a ch co n d yle is t h o u g h t t o b e re st o re d , o r if a sim -
p le fra ct u re p a t t e rn is p re se n t , t h e co n d yle s sh o u ld b e re -
d u ce d t o e a ch o t h e r u sin g a la rg e p o in t e d re d u ct io n fo r-
ce p s (TECH FIG 4 A–C).
■ Ea ch fra g m e n t ca n b e ro t a t e d re la t ive t o a n o t h e r; t h is
m u st b e a d d re sse d a s d iscu sse d b e fo re .
■ Th e b e st w a y t o a sse ss t h is is u n d e r d ire ct visu a liza -
t io n a n d e va lu a t in g t h e re d u ct io n a t t h e t ro ch le a r re -
g io n o f t h e p a t e llo fe m o ra l jo in t .
Ch a p t e r 4 3 ORIF OF THE DISTAL FEM UR 405
TECHNIQUES
TECH FIG 3 • Pat ient w it h grade II o pen dis-
t al fem u r fra ct u re (also sh o wn in Fig s. 4D–F,
5B, an d 6). A. St ra ig h t m id lin e in cisio n . B.
Late ra l skin fla p is d eve loped. C. Art h ro t o my
is st arte d a nd t he n e xt ende d proxim ally int o
t h e q u ad te nd o n (d ashe d line). D. Th e a rth ro-
t o m y is co mp le te d an d t h e co n d yle s are visu -
a lize d w ith m e dia l sub lu xa tion o f the p a t ella .
■ Ad d it io n ally, p re o p e rat ive e va lu a t io n a sse ssin g t h e lat -
eral rad iogra ph can g uide t h e su rgeo n. Int rao pe ra t ive
flu o ro sco p y t o rea sse ss t he la t e ra l vie w is a lso u se fu l.
■ Te m p o ra ry Kirsch n e r w ire s o r t h e g u id e p in s fo r t h e lo ck-
in g scre w s fo r t h e p la t e ca n b e u se d fo r a d d it io n a l st a b i-
liza t io n o f t h e t w o co n d yle s (TECH FIG 4 D).
De fin it ive Fixa t io n o f t h e Co n d yle s
■ Th is ca n b e a cco m p lish e d o u t sid e t h e p la t e first a n d su p -
p le m e n t e d w it h scre w s t h ro u g h t h e p la t e . Th e a re a
a ro u n d t h e p ro p o se d p la t e , t h e “ p e rip h e ry,” ca n b e u se d
fo r t h e scre w p la ce m e n t t o a vo id in t e rfe re n ce w it h t h e
p la t e p la ce m e n t it se lf.
■ If t h is is d o n e , t h e n t h e m e t a p h yse a l fra ct u re d o e s n o t
n e ce ssa rily h a ve t o b e p ro p e rly re d u ce d b e fo re in it ia l
scre w p la ce m e n t .
■ Scre w s ca n a lso b e p la ce d fro m m e d ia l t o la t e ra l t o a vo id
in t e rfe re n ce w it h t h e p la t e .
■ De fin it ive fixa t io n ca n b e a cco m p lish e d t h ro u g h t h e
p la t e a lso (se e n e xt ).
■ If t h is is d o n e , t h e m e t a p h yse a l co m p o n e n t sh o u ld b e
re d u ce d t o e n su re t h e p ro p e r fle xio n –e xt e n sio n a lig n -
m e n t o f t h e sh a ft w it h t h e co n d yle s.
 406 Se c t i o n IV FEM UR AND KNEE

TECH FIG 4 • Th e co n d yle s a re re d u ce d u n d e r d ire ct visu a liza t io n (A) a n d

TECHNIQUES

co n firm e d w it h AP (B) a n d la t e ra l (C) in t ra o p e ra t ive flu o ro sco p ic im a g e s.

D. Gu id e p in s t h ro u g h t h e p la t e t e m p la t e o r scre w t ra je ct o ry g u id e a re
u se d t o t e m p o ra rily st a b ilize t h e in t e rco n d yla r sp lit .

B C D

■ Th is w ill e n su re t h a t t h e p la t e is co llin e a r w it h t h e cu ra t e p la ce m e n t o f t h e p la t e d ist a lly, a n d in it ia l g u id e -

sh a ft o n ce fixe d t o t h e d ist a l se g m e n t . Ot h e rw ise , a
m a lre d u ct io n in t h e sa g it t a l p la n e w ill o ccu r.
■ Th e t e m p o ra ry Kirsch n e r w ire s ca n b e le ft in p la ce t o
st a b ilize t h e jo in t .
Re d u ct io n o f t h e Sh a ft t o t h e Dist a l
Se g m e n t
■ On ce t h e a rt icu la r su rfa ce is t e m p o ra rily st a b ilize d o r re -
d u ce d , t h e re d u ct io n o f t h e sh a ft t o t h e d ist a l se g m e n t
sh o u ld b e p e rfo rm e d b e fo re p la t e a p p lica t io n .
■ Th is ca n b e t e m p o ra rily st a b ilize d w it h Kirsch n e r w ire s o r
St e in m a n n p in s.
■ Alt e rn a t ive ly, p re cise ly p la ce d b u m p s u n d e rn e a t h t h e
d ist a l se g m e n t ca n b e u se d t o co rre ct t h e e xt e n sio n o f
t h e d ist a l se g m e n t a n d a lig n it w it h t h e sh a ft .
■ Ad ju st m e n t o r lo o se n in g o f t h e t e m p o ra ry e xt e rn a l fixa -
t o r ca n a id in re d u ct io n if n e e d e d .
■ Th e p la t e ca n t h e n b e p la ce d su b m u scu la rly.
■ Aft e r p la cin g t h e in it ia l g u id e w ire p a ra lle l t o t h e jo in t
Pla ce m e n t o f t h e Pla t e
■ Ea ch fixe d -a n g le p la t in g syst e m is d e sig n e d t o h e lp re -
e st a b lish t h e va lg u s a lig n m e n t o f t h e d ist a l fe m u r.
■ Th e scre w s in t h e d ist a l p o rt io n o f t h e p la t e a re d e -
sig n e d t o b e p a ra lle l t o t h e jo in t su rfa ce .
■ Th u s, t h e in it ia l g u id e w ire s fo r t h e se scre w s sh o u ld b e
p la ce d p a ra lle l a n d co n firm e d b y flu o ro sco p y.
■ A d ist a l “ jo in t w ire ” ca n b e p la ce d t o b e t t e r e va lu -
a t e t h is (TECH FIG 5 A).
■ Pla cin g t h e d ist a l scre w s p a ra lle l t o t h e jo in t w ill h e lp
e n su re t h a t w h e n t h e sh a ft is b ro u g h t t o t h e p la t e ,
t h e a n a t o m ic a xis o f t h e fe m u r is re st o re d .
■ A d ist a l scre w t ra je ct o ry g u id e is p ro vid e d fo r so m e sys-
t e m s (TECH FIG 5 B). Th is ca n b e u se d t o h e lp e n su re a c-
w ire s ca n b e p la ce d t h ro u g h t h is.
■ Once t he w ires are p lace d, th e gu ide can b e rem o ve d
and rep lace d w it h t he pla t e, using t he w ires as a g uide .
■ Ho w e ve r, t h e sh a ft p o rt io n o f t h e p la t e re q u ire s su b -
m u scu la r in se rt io n , a n d t h u s t h e p la t e ca n n o t b e
b ro u g h t t o a n a p p ro p ria t e p o sit io n t o a llo w t h is t o
o ccu r.
■ To so lve t h is, t h e g u id e w ire s ca n b e d rive n t h ro u g h
t h e m e d ia l sid e o f t h e kn e e , w h ich is d ist a l e n o u g h t o
b e sa fe (TECH FIG 5 C).
■ Th e p la t e ca n t h e n b e in se rt e d su b m u scu la rly a n d t h e
g u id e w ire s d rive n b a ck t h ro u g h t h e p la t e la t e ra lly,
t h u s a lig n in g t h e p la t e t o t h e d ist a l se g m e n t a n d e n -
su rin g p ro p e r scre w t ra je ct o ry a n d p la t e p la ce m e n t
(TECH FIG 5 D,E).
■ A sin g le g u id e w ire in a ce n t ra l h o le w ill st ill a llo w
fle xio n –e xt e n sio n p la ce m e n t o f t h e p la t e if t h is n e e d s
t o b e a d ju st e d .
d ist a lly, a n d e n su rin g t h e fra ct u re is re d u ce d , t h e su r-
g e o n sh o u ld o b t a in flu o ro sco p ic visu a liza t io n o f t h e
p la t e p ro xim a lly o n t h e sh a ft t o e n su re t h a t t h e p la t e is
o n t h e b o n e (TECH FIG 5 F,G).
■ To e n su re p la ce m e n t o f t h e p la t e o n t h e b o n e
b o t h p ro xim a lly a n d d ist a lly, it is b e st t o st a b ilize
t h e p la t e d ist a lly (w h e re e xp o su re is) u sin g a
g u id e w ire in t h e ce n t e r h o le . Th is a llo w s fo r a p ivo t
p o in t a ro u n d w h ich t h e a n t e ro p o st e rio r p o sit io n in g
o f t h e p la t e ca n b e m a n ip u la t e d fo r t h e sh a ft .
Flu o ro sco p y t o im a g e t h e la t e ra l is t h e n u se d t o e n -
su re p la ce m e n t .
■ On ce t h e a n t e ro p o st e rio r p o sit io n is o b t a in e d , t h e
p la t e is st a b ilize d p ro xim a lly.
 Ch a p t e r 4 3 ORIF OF THE DISTAL FEM UR 407

TECHNIQUES
A B C

D E F

TECH FIG 5 • A. Dist a l re fe re n ce p in is p la ce d t o e n su re t h a t t h e p ro xim a l

p in is p a ra lle l t o t h e jo in t . B. Clin ica l p ict u re d e p ict in g t h e g u id e . C. Diffe re n t
p a t ie n t sh o w in g t h e p e n e t ra t io n o f t h e m e d ia l sid e w it h t h e g u id e w ire s t o
a llo w p la t e p la ce m e n t . D,E. Th e p la t e is p la ce d w it h a d d it io n a l g u id e p in s in
p la ce . F,G. La t e ra l in t ra o p e ra t ive flu o ro sco p ic im a g e s e n su re p ro p e r p la t e
G p la ce m e n t o n t h e fe m u r b e fo re scre w in se rt io n .

■ Th e p la t e sh o u ld b e t e m p o ra rily st a b ilize d t o t h e b o n e ■ If a t a rg e t in g g u id e is use d , t h e n a so ft t issu e g u id e for

p ro xim a lly.
■ Be fo re t h e t e m p o ra ry st a b iliza t io n , t h e le n g t h a n d ro -
t a t io n m u st b e ch e cke d . Id e a lly, if t h e t e m p o ra ry fix-
a t o r is in p la ce , t h e se t w o p a ra m e t e rs h a ve b e e n
m a in t a in e d d u rin g t h e co u rse o f t h e o p e ra t io n .
■ If n o scre w t a rg e t in g g u id e is p re se n t , a p e rcu t a n e o u s
p ro visio n a l fixa t io n p in ca n b e u se d t o st a b ilize t h e
p la t e .
t h e m o st p ro xim a l h o le is p la ce d p e rcu t a n e o u sly a n d a
d rill b it o r g u id e w ire is u se d t o st a b ilize t h e p la t e .
■ Ag a in , t h e fle xio n –e xt e n sio n re d u ct io n sh o u ld b e
ch e cke d .
■ Th is p ro ce d u re cre a t e s o u r “ b o x” co n st ru ct , w h ich
a id s in t h e p la ce m e n t o f scre w s t h ro u g h t h e t a rg e t in g
d e vice (if u se d ) a n d in t e m p o ra ry st a b iliza t io n o f t h e
fra ct u re co n st ru ct .
 408 Se c t i o n IV FEM UR AND KNEE
Scre w Pla ce m e n t
TECHNIQUES
■ If t h e in t e rco n d yla r sp lit is g o in g t o b e st a b ilize d b y
scre w s t h ro u g h t h e p la t e , p a rt ia lly t h re a d e d scre w s o r
o ve rd rille d fu lly t h re a d e d scre w s sh o u ld b e u se d first t o
p ro vid e in t e rfra g m e n t a ry co m p re ssio n .
■ Sp e cia lly d e sig n e d co n ica l scre w s fo r ce rt a in syst e m s
e xist , o r la rg e p a rt ia lly t h re a d e d scre w s ca n b e u se d
(la rg e r t h a n 4.5 m m ). Th is a lso co m p re sse s t h e p la t e
to the bone.
■ On ce t h e a rt icu la r in ju ry is a d d re sse d , a t le a st t w o a d d i-
t io n a l lo ckin g scre w s sh o u ld b e p la ce d in t o t h e d ist a l se g -
m e n t t o se cu re t h e p la t e a n d t h e a lig n m e n t .
■ Th e t ra je ct o ry o f d ist a l lo ckin g scre w s ca n b e a sse sse d
o n t h e n o t ch vie w t o e n su re t h a t p e n e t ra t io n
A B
At t a ch in g t h e Dist a l Se g m e n t t o
t h e Sh a ft
■ Th e d ist a l se g m e n t is n o w fixe d a n d ca n b e a t t a ch e d t o
t h e sh a ft .
■ If t h e re is m a la lig n m e n t in t h e co ro n a l p la n e b u t t h e
sa g it t a l p la n e a lig n m e n t is re d u ce d , t h e sh a ft ca n b e
A B
TECH FIG 7 • Th e “ w h irlyb ird ” d e vice is t ig h t e n e d a n d t h e b o n e p u lle d t o t h e p la t e .
t h ro u g h t h e in t e rco n d yla r n o t ch d o e s n o t o ccu r
(TECH FIG 6 ; se e Fig 10C fo r C-a rm se t u p a n d p o sit io n
fo r t h is im a g e ).
■ Be fo re p la cin g t h e lo ckin g scre w s, t h e le n g t h , ro t a -
t io n , a n d a lig n m e n t m u st b e ch e cke d a g a in if n o fix-
a t o r o r d ist ra ct o r is in p la ce h o ld in g t h e fra ct u re
a lig n m e n t .
■ Th e p la t e ca n b e lo cke d t o t h e d ist a l se g m e n t a n d
t h e n u se d t o m a n ip u la t e t h e d ist a l se g m e n t re la t ive
t o t h e sh a ft fo r t h e fle xio n –e xt e n sio n re d u ct io n .
■ Th is, h o w e ve r, is p re d ica t e d o n p ro p e r d ist a l a lign -
m e n t o f t h e p la t e . Ot h e rw ise , o n ce t h e p la t e is
fixe d t o t h e d ist a l se g m e n t in a m a lp o sit io n a n d
t h e fra ct u re re d u ce d , t h e p la t e m a y b e a n t e rio r o r
p o st e rio r o n t h e sh a ft .
TECH FIG 6 • Pa t ie n t se e n in Fig u re 10C,D,
w it h t h e g u id e w ire n o w p u lle d b a ck a n d a n
a p p ro p ria t e ly size d scre w p la ce d .
“ p u lle d ” t o t h e p la t e b y m e a n s o f va rio u s t h re a d e d d e -
vice s o r a n o n lo ckin g scre w t h a t ca n b e p la ce d fre e h a n d
u n d e r flu o ro sco p ic g u id a n ce o r t h ro u g h a t a rg e t in g jig
(TECH FIG 7 ).
C
 Ch a p t e r 4 3 ORIF OF THE DISTAL FEM UR 409

Pla ce m e n t o f Ad d it io n a l Scre w s ■ Th e re st o ra t io n o f t h e m e ch a n ica l a xis ca n b e ch e cke d

■ On ce p ro p e r re d u ct io n o f t h e fra ct u re is t e m p o ra rily
a ch ie ve d a n d t h e p la t e in p ro p e r p o sit io n , a d d it io n a l
scre w s ca n b e p la ce d .
■ If t h e t a rg e t in g scre w g u id e is u se d , p e rcu t a n e o u s lo ck-
in g scre w s ca n b e p la ce d t h ro u g h t h e so ft t issu e d rill o r
scre w g u id e s (TECH FIG 8 A–C).
■ If n o t a rg e t in g g u id e is a va ila b le , flu o ro sco p ic g u id a n ce
a n d a p e rcu t a n e o u s m e t h o d ca n b e u se d fre e h a n d .
■ De p e n d in g o n t h e syst e m , lo ckin g d rill g u id e s ca n b e
p la ce d fre e h a n d t o e n su re p ro p e r t ra je ct o ry o f t h e d rill
so t h a t lo ckin g scre w s ca n b e u se d .
■ If t h at is n o t th e case, n o n lo ckin g screw s sh o u ld b e p laced .
■ Exp e rie n ce is re q u ire d fo r t h e fre e h a n d p e rcu t a n e o u s
m e t h o d ; o t h e rw ise , a n o p e n a p p ro a ch t o t h e sh a ft
sh o u ld b e p e rfo rm e d .
■ Th e fin a l co n st ru ct sh o u ld b e ch e cke d w it h flu o -
ro sco p y o n t h e la t e ra l a sp e ct a s w e ll (TECH FIG 8 D,E).
TECHNIQUES
in t ra o p e ra t ive ly a ft e r t e m p o ra ry st a b iliza t io n (p re -
fe rre d ) o r d e fin it ive st a b iliza t io n u sin g t h e Bo vie co rd .
■ TECHNIQUES FIGURE 8 F–H sh o w t h e re p a ir a ft e r d e -
fin it ive st a b iliza t io n .
■ Th e e xa ct n u m b e r o f scre w s in e a ch fra g m e n t h a s ye t t o
b e d e t e rm in e d in t h e lit e ra t u re , b u t w e p re fe r t o h a ve a t
le a st five scre w s in e a ch fra g m e n t if p o ssib le a t t h e e n d
o f fixa t io n .
■ A lo n g e r w o rkin g le n g t h in t h e sh a ft ca n b e u se d , a n d
n o t a ll h o le s n e e d t o b e fille d .
■ Th e re is e vid e n ce t h a t in yo u n g p a t ie n t s w it h g o o d
b o n e , n o lo ckin g scre w s a re n e e d e d in t h e d ia p h ysis.
■ Mu lt ip le lo ckin g scre w s a re u se d in t h e e p ip h ysis b e -
ca u se o f t h e sh o rt le n g t h o f t h e se d ist a l fra g m e n t s.
■ Th e la rg e st scre w s a va ila b le fo r t h e e p ip h ysis sh o u ld
b e u se d .

A C

B D E

TECH FIG 8 • A. Ta rg e t in g g u id e fo r p ro xim a l scre w s. B. C-a rm im a g e o f scre w s p la ce d . C. St a b in cisio n s u se d fo r

p e rcu t a n e o u s m e t h o d . D,E. Pla t e p la ce m e n t o n t h e la t e ra l a sp e ct is co n firm e d . (co n t in u e d )
 410 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES

F G H

TECH FIG 8 • (co n t in u e d ) F–H. Alig n m e n t is ch e cke d in t ra o p e ra t ive ly w it h t h e Bo vie co rd . Th e m e ch a n ica l a xis fro m
t h e ce n t e r o f t h e fe m o ra l h e a d t h ro u g h t h e m id d le o f t h e kn e e t o t h e m id d le o f t h e a n kle is co n firm e d .

Bo n e Gra ft in g u se d t o h e lp m in im ize b le e d in g a n d im p ro ve visu a liza -

■ Th e m e t a p h yse a l co m m in u t io n m a y re q u ire b o n e g ra ft -
in g in ca se s o f o p e n fra ct u re s w it h b o n e lo ss.
■ Th e e xa ct t yp e a n d n e e d va ry a n d sh o u ld b e b a se d o n
t h e su rg e o n ’s e xp e rie n ce (TECH FIG 9 ).
■ He m o st a sis is a ch ie ve d t h ro u g h o u t t h e p ro ce d u re o r
a ft e r t h e t o u rn iq u e t is re le a se d . A t o u rn iq u e t ca n b e
t io n , e sp e cia lly fo r a rt icu la r re co n st ru ct io n . Oft e n a st e r-
ile t o u rn iq u e t is u se d b e ca u se o f t h e t e m p o ra ry b rid g in g
e xt e rn a l fixa t o r t h a t is in p la ce .
■ Aft e r a d e q u a t e irrig a t io n (b e fo re b o n e g ra ft o r su b st i-
t u t e p la ce m e n t if u se d ), a d ra in is p la ce d in t h e kn e e
jo in t a n d b ro u g h t o u t la t e ra lly.

A B C

TECH FIG 9 • A. Pa t ie n t w it h sig n ifica n t m e t a p h yse a l b o n e lo ss fro m a n o p e n in ju ry sh o w n o n CT sca n . B. Th e p o st -

fixa t io n ra d io g ra p h sh o w s t h e vo id . C. Pla ce m e n t o f Ost e o se t b e a d s im p re g n a t e d w it h va n co m ycin (o ff-la b e l u se )
t o fill t h e vo id a n d p ro vid e o st e o co n d u ct ive m a t e ria l fo r h e a lin g .
 Ch a p t e r 4 3 ORIF OF THE DISTAL FEM UR 411

St a n d a rd Wo u n d Clo su re ■ Th e knee is flexed an d extend ed fully to en su re resto ratio n

TECHNIQUES
of m otion as well as to break any adhesions in the quadri-
■ Clo su re o f t h e a rt h ro t o m y is p e rfo rm e d w it h fig u re 8 0
cep s t ha t ma y h ave forme d while t he t em po ra ry b ridging
Vicryl su t u re s. Th is is re in fo rce d b y a ru n n in g 2-0
extern al fixat or h ad b een in p lace (TECH FIG 1 0 B,C).
Fib e rw ire su t u re (TECH FIG 1 0 A). ■ Th e fin a l ra d io g ra p h s a re t a ke n in t h e o p e ra t in g ro o m
■ Th e su b cu t a n e o u s t issu e is clo se d w it h 2-0 Vicryl.
(TECH FIG 1 0 D,E).
■ Th e skin is clo se d w it h st a p le s, a s a re t h e p e rcu t a n e o u s
st a b in cisio n s.

TECH FIG 1 0 • A. Clo su re o f t h e a rt h ro t o m y. B,C.

Fu ll fle xio n a n d e xt e n sio n o f t h e kn e e a ft e r d e fin i-
t ive fixa t io n a n d clo su re . As se e n in fin a l AP (D) a n d
la t e ra l (E) ra d io g ra p h s, t h e m e t a p h yse a l co m m in u -
t io n is b rid g e d a n d le ft u n d ist u rb e d .

C D E

OPEN REDUCTION AND INTERNAL FIXATION OF THE DISTAL FEMUR WITH

LOCKING PLATES (TYPE A OR NONDISPLACED TYPE C1 OR C2)
■ Th is t e ch n iq u e ca n b e u se d re g a rd le ss o f t h e lo ckin g
p la t e syst e m u se d . Ea ch syst e m ’s t e ch n iq u e g u id e sh o u ld
b e re vie w e d b e fo re u se , a s e a ch syst e m h a s it s o w n id io -
syn cra sie s. Va ria t io n s in p la t e a p p lica t io n a s w e ll a s re -
d u ct io n t o o ls a n d t e ch n iq u e s a re u n iq u e t o e a ch syst e m .
■ Se e co m m e n t s a b o ve re g a rd in g t e m p o ra ry u se o f a n e x-
t e rn a l fixa t o r o r d ist ra ct o r.
Lim it e d La t e ra l Ap p ro a ch
■ A la t e ra l in cisio n m e a su rin g a b o u t 5 t o 6 cm is m a d e
st a rt in g a t t h e le ve l o f t h e jo in t a n d e xt e n d in g p ro xi-
m a lly in lin e w it h t h e sh a ft . Th e d ist a l e xt e n t is cu rve d
slig h t ly t o w a rd t h e t ib ia l t u b e rcle , a s in t h e la t e ra l a p -
p ro a ch (TECH FIG 1 1 A,B).
■ Th e ilio t ib ia l b a n d is in cise d in lin e w it h t h e skin in cisio n
(TECH FIG 1 1 C).
■ Th e d isse ct io n is ca rrie d d o w n t o t h e la t e ra l fe m o ra l
co n d yle . Th e la t e ra l a sp e ct is e xp o se d e n o u g h fo r p la t e
p la ce m e n t (TECH FIG 1 1 D).
■ A Co b b e le va t o r is u se d t o cre a t e a p la n e su b m u scu la rly
u p t h e la t e ra l sh a ft o f t h e fe m u r fo r p la ce m e n t o f t h e
p la t e .
 412 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES

C
B

TECH FIG 1 1 • Pa t ie n t w it h clo se d d is-

t a l fe m u r fra ct u re (a lso sh o w n in Fig s.
4G,H a n d 5C–E). A. Lim it e d la t e ra l in -
cisio n , w it h t h e t ib ia l t u b e rcle
A
m a rke d . B. Skin in cisio n sh o w in g t h e
ilio t ib ia l b a n d . C. In cisio n o f t h e
ilio t ib ia l b a n d . D. Exp o su re o f t h e la t -
D e ra l a sp e ct o f t h e fe m u r.

St a b ilizin g t h e Art icu la r Su rfa ce ■ Te m p o ra ry Kirsch n e r w ire s o r g u id e w ire s fro m a ca n n u -

la t e d syst e m ca n b e p la ce d fo r a d d it io n a l st a b ilit y (TECH
■ Fo r n o n d isp la ce d t yp e C1 o r C2 fra ct u re s, t h e first p rio r-
FIG 1 2 C,D).
it y is t o st a b ilize t h e a rt icu la r su rfa ce . ■ All cla m p s, Kirsch n e r w ire s, o r g u id e w ire s sh o u ld
■ Visu a liza t io n o f t h e jo in t m a y b e a cco m p lish e d w it h
b e p la ce d o u t sid e t h e zo n e o f p la t e a p p lica t io n (TECH
p la ce m e n t o f a b lu n t Ho h m a n n re t ra ct o r (o r sim ila r Z re -
FIG 1 2 E,F).
t ra ct o r) (TECH FIG 1 2 A). ■ De fin it ive fixa t io n o f t h e co n d yle s sh o u ld b e p e rfo rm e d
■ A re d u ct io n fo rce p s is p la ce d a n t e rio rly t o h o ld t h e re -
(se e t e ch n iq u e d e scrip t io n a b o ve ) (TECH FIG 1 2 G).
d u ct io n (TECH FIG 1 2 B).

A C

B D F

TECH FIG 1 2 • A. Visu a liza t io n o f t h e jo in t fo r a rt icu la r re d u ct io n . B. C-a rm im a g e o f re d u ct io n fo rce p s

h o ld in g t h e in t e rco n d yla r sp lit re d u ce d . C,D. Clin ica l p h o t o g ra p h s w it h fo rce p s fo llo w e d b y g u id e w ire s fo r
scre w p la ce m e n t . E,F. La t e ra l vie w s sh o w in g p in s a n d w ire s o u t sid e t h e zo n e fo r e it h e r p la t e a p p lica t io n
o r in t ra m e d u lla ry n a il. Th e a n t e rio r a n d p o st e rio r p la ce m e n t o f t h e p in s is se e n . (co n t in u e d )
 Ch a p t e r 4 3 ORIF OF THE DISTAL FEM UR 413

TECHNIQUES
G

TECH FIG 1 2 • (co n t in u e d ) G. De fin it ive fixa t io n o f t h e

co n d yle s w it h 4.5-m m p a rt ia lly t h re a d e d ca n n u la t e d scre w s.
TECH FIG 1 3 • Ad ju n ct ive t e m p o ra ry fixa t io n w it h St e in m a n n
p in s t o re d u ce t h e sh a ft t o t h e d ist a l co n st ru ct ; p in s a g a in a re
p la ce d o u t sid e o f t h e a re a fo r p la t e a p p lica t io n .

Re d u ct io n o f t h e Dist a l Se g m e n t a n d
Pla t e Pla ce m e n t
■ Re d u ct io n o f t h e d ist a l se g m e n t t o t h e sh a ft ca n b e p e r-
fo rm e d u sin g t e m p o ra ry St e in m a n n p in s (TECH FIG 1 3 ).
■ Th e p la t e ca n n o w b e a p p lie d in a su b m u scu la r fa sh io n
(se e Pla ce m e n t o f t h e Pla t e , a b o ve ).

Wo u n d Clo su re
■ Fin a l ra d io g ra p h s a re t a ke n in t h e o p e ra t in g ro o m
(TECH FIG 1 4 ).
■ St a n d a rd w o u n d clo su re is u n d e rt a ke n , a s d e scrib e d in
t h e p re vio u s se ct io n .

Re t ro g ra d e Na ilin g
■ Re fe r t o Ch a p t e r TR-9 o n re t ro g ra d e n a ilin g o f t h e
fe m u r. A B

TECH FIG 1 4 • Fin a l AP a n d la t e ra l ra d io g ra p h s re ve a l t h a t

t h e p o st e rio r a n d m e d ia l m e t a p h yse a l co m m in u t io n is le ft
u n d ist u rb e d .

PEARLS AND PITFALLS

Art icu la r re d u ct io n
Pla t e a p p lica t io n
So ft tissu e h an d lin g
■ Dire ct o p e n re d u ct io n sh o u ld b e u se d .
■ It ca n b e o u t sid e t h e p la t e o r t h ro u g h t h e p la t e .
■ Scre w s sh o u ld b e o u t o f t h e w a y o f t h e p la t e o r n a il .
■ Th e in it ia l g u id e w ire t h ro u g h t h e ce n t ra l h o le in t h e p la t e sh o u ld b e p a ra lle l t o t h e jo in t . Nin e t y-five
d e g re e s is b u ilt in t o t h e p la t e . If lo ckin g scre w s a re p la ce d p a ra lle l t o t h e jo in t , t h e n o n ce t h e p la t e is
re d u ce d t o t h e sh a ft , t h e p ro p e r a lig n m e n t is re st o re d .
■ Ro t a t io n m u st b e co n t in u a lly a sse sse d .
■ Th e fra ct u re sh o u ld b e re d u ce d in t h e sa g it t a l p la n e b e fo re t e m p o ra ry fixa t io n o r cre a t io n o f a “ b o x
co n st ru ct ” w it h t h e p la t e .
■ In co m m in u t e d ca se s, a sca n o g ra m o r o p p o sit e -sid e fe m u r film w it h a ru le r ca n b e o b t a in e d t o h e lp
d e t e rm in e t h e le n g t h .
■ The surg eon shou ld avoid stripping the soft t issues m ed ia lly. Th is w ill obvia te t he n eed fo r b one gra ft ing.
■ Th e p la t e sh o u ld b e p la ce d su b m u scu la rly.
414 Se c t i o n IV FEM UR AND KNEE

Te m p o ra ry b rid g in g
e xt e rn a l fixa t o r
Pe rip ro st h e t ic fra ct u re s
De fo rm it y p re ve n t io n
Va lg u s d e fo rm it y
Va ru s d e fo rm it y
Ext e n sio n d e fo rm it y
■ An y co n st ru ct ca n b e u se d .
■ Th e p in s a n d b a rs sh o u ld b e p la ce d in a m a n n e r su ch t h a t t h e fixa t o r co u ld b e u se d in t ra o p e ra t ive ly a s
a fe m o ra l d ist ra ct o r t o h o ld t h e re d u ct io n , a llo w in g t h e p la t in g t o o ccu r.
■ Th e fixa t o r p in s in t h e fe m u r sh o u ld b e p la ce d w h ile t ra ct io n is a p p lie d t o t h e lim b so a s t o m a xim ize
t h e le n g t h o f t h e q u a d rice p s. Th is w ill e n su re t h a t d ifficu lt y re g a in in g le n g t h is n o t a sso cia t e d w it h
“ ske w e rin g ” o f t h e q u a d rice p s.
■ Th e su rg e o n sh o u ld e n su re t h a t t h e fe m o ra l co m p o n e n t w ill a llo w a n in t ra m e d u lla ry n a il (e g , t h e
fe m o ra l b o x is o p e n ).
■ If t h e co m p o n e n t is st e m m e d , t h e n t h e su rg e o n sh o u ld m a ke su re t h a t ca b le s a re a va ila b le t o h e lp
su p p le m e n t fixa t io n ; u n ico rt ica l lo cke d scre w s m a y n o t b e su fficie n t fo r fixa t io n .
■ Pla cin g t h e in it ia l g u id e w ire t h ro u g h t h e “ ce n t ra l” h o le fo r p la t e fixa t io n p a ra lle l t o t h e jo in t e n su re s
p ro p e r a lig n m e n t o f t h e p la t e re la t ive t o t h e sh a ft . Th e p la t e s a re d e sig n e d t o re cre a t e t h e n o rm a l
a n a t o m ic re la t io n sh ip o f t h e d ist a l fe m u r t o t h e sh a ft . Ad d it io n a lly, a cla m p ca n b e p la ce d o n t h e d ist a l
fra g m e n t a n d h e ld in t h e p ro p e r p o sit io n a s t h e p la t e is a p p lie d w h ile a d h e rin g t o t h e sa m e p rin cip le
a s o u t lin e d a b o ve .
■ In a sim ila r fa sh io n , a va ru s d e fo rm it y ca n b e p re ve n t e d b y t h e sa m e t e ch n iq u e ; h o w e ve r, o n ce t h e
p la t e is fixe d t o t h e d ist a l se g m e n t in it s p ro p e r a lig n m e n t t o t h e d ist a l se g m e n t , a n o n lo ckin g scre w
ca n b e u se d in t h e sh a ft t o “ su ck” t h e p la t e t o t h e b o n e , re su lt in g in co rre ct io n o f t h e va ru s.
■ Be ca u se o f t h e p u ll o f t h e g a st ro cn e m iu s co m p le x, t h e d ist a l fra g m e n t t e n d s t o fle x d o w n w a rd , re su lt -
in g in a re la t ive “ e xt e n sio n ” d e fo rm it y a t t h e m e t a p h ysis. To p re ve n t t h is t h e kn e e is fle xe d a s m u ch a s
fe a sib le t o a llo w fo r o p e ra t ive fixa t io n , a n d a b u m p d ire ct ly u n d e rn e a t h t h e a p e x o f t h e d e fo rm it y ca n
h e lp p re ve n t t h e d e fo rm in g fo rce s.

POSTOPERATIVE CARE ■ Patients are prescribed physical therapy for range of motion
and strengthening at 2 weeks.
■ The goal of stable fixation is to allow early range of motion.
M y preference is a hinged knee brace locked in extension for OUTCOMES
2 weeks, at which time the wound is healed and full motion is
then started.
■ Results are good to excellent in 50% to 96% of cases.3,5,9
■ Average range of motion is about 110 to 120 degrees.
■ A continuous passive motion machine can be used.
■ About 70% to 80% of patients can walk without aids.
■ Cold therapy products can be used.
■ It is difficult to compare the results of studies in the
■ A drain is used for 48 hours postoperatively.

■ Deep vein thrombosis prophylaxis may be indicated for cer- literature.9

■ There is no universally accepted classification.
tain patients:
■ There are varying indications.
■ O bese
■ Different grading systems are used.
■ M ultiply injured
■ N ot all authors adhere to the same principles.
■ H istory of previous deep vein thrombosis

■ Patient who may not be mobile enough despite an isolated

injury COMPLICATION S
■ We provide 2 weeks of deep vein thrombosis prophylaxis ■ N eurovascular injuries
for all patients and then reassess in terms of mobility if it is ■ Can occur from initial trauma

an isolated injury. O therwise, with significant risk factors or ■ Rare after surgery

indications for deep vein thrombosis prophylaxis, a full 6- ■ Infection

week course is prescribed. ■ 0% to 10% rate after open reduction and internal

■ Early protected weight bearing fixation

■ Toe-touch weight bearing for 6 to 8 weeks for plate ■ Predisposing factors:

fixation ■ H igh-energy injuries

■ Followed by partial weight bearing for 4 to 6 weeks for ■ O pen fractures

plate fixation ■ Extensive dissection

■ Followed by full weight bearing ■ Prolonged operative time

■ Immediate weight bearing can be indicated for fixation of ■ Inadequate fixation

type A fractures with intramedullary nailing if the fracture ■ N onunion

pattern is stable and not comminuted. ■ 0% to 6% rate after open reduction and internal
■ For type C fractures treated with intramedullary nailing fixation
and screw fixation for the articular component, toe-touch ■ Predisposing factors:

weight bearing or non-weight bearing for 6 to 8 weeks is ad- ■ Bone loss or defect (FIG 1 2 A)

equate, followed by full weight bearing. ■ H igh-energy injuries

■ In all cases, progression of weight bearing is based on ra- ■ Soft tissue stripping

diographic evidence of healing. ■ Loss of osseous vascularity

 Ch a p t e r 4 3 ORIF OF THE DISTAL FEM UR 415

A B C

FIG 1 2 • A. Pa t ie n t in Fig u re 3A a ft e r d é b rid e m e n t o f n o n via b le e xt ru d e d b o n e a n d p la ce m e n t o f e xt e rn a l fixa t o r.

Th e se g m e n t a l b o n e lo ss is se e n . B,C. No n u n io n o f a C3 d ist a l fe m u r fra ct u re w it h su b se q u e n t h a rd w a re fa ilu re .

■ Inadequate stabilization ■ Posttraumatic arthritis occurs in 0% to 30% of cases.

■ N o bone graft ■ Predisposing factors:

■ Infection ■ Severe articular comminution

■ M alunion ■ Cartilage loss

■ M ore common with nonsurgical treatment, which results ■ Cartilage impaction or damage

in varus and recurvatum ■ Surgical factors:

■ O perative treatment with newer locking plates can result ■ Failure of anatomic reduction

■ M alalignment of fracture
in valgus.
■ Treatment required to restore mechanical axis:

■ Supracondylar osteotomy

■ Stable fixation
REFEREN CES
■ Early range of motion
1. Dominguez I, Rodrigez EM , De Pedro M oro JA, et al. Antegrade nail-
ing for fractures of the distal femur. Clin O rthop Relat Res 1998;
■ H ardware failure occurs in 0% to 13% of cases 350:74–79.
(FIG 1 2 B,C). 8 2. Leung KS, Shen WY, M ui LT, et al. Interlocking intramedullary nail-
■ Predisposing factors: ing for supracondylar and intercondylar fractures of the distal part of
■ Comminution of metaphyseal area the femur. J Bone Joint Surg Am 1991;73A:332–340.
■ O lder age 3. M arkmiller M , Konrad G, Sudkamp N . Femur-LISS and distal
■ Very distal fracture
femoral nail for fixation of distal femoral fractures: are there differ-
ences in outcome and complications? Clin O rthop Relat Res 2004;
■ Premature loading or weight bearing
426:252–257.
■ N onunion
4. N ork SE, Segina DN , Aflatoon K, et al. The association between
■ Infection supracondylar-intercondylar distal femoral fractures and coronal
■ Knee stiffness: almost all patients exhibit some loss of plane fractures. J Bone Joint Surg Am 2005;87A:564–569.
motion 5. Rademakers M V, Kerkhoffs GM M J, Sierevelt IN , et al. Intra-articu-
■ Protruding hardware
lar fractures of the distal femur: a long-term follow-up study of sur-
gically treated patients. J O rthop Trauma 2004;18:213–219.
■ Articular malreduction
6. Schatzker J. Fractures of the distal femur revisited. Clin O rthop Relat
■ Adhesions
Res 1998;347:43–56.
■ Intra-articular 7. Starr AJ, Jones AL, Reinert CM . The “ Swashbuckler” : a modified an-
■ Ligamentous–capsular contractures terior approach for fractures of the distal femur. J O rthop Trauma
■ M uscle scarring 1999;13:138–140.
■ Treatment may consist of any of the following or combi- 8. Vallier H A, H ennessey TA, Sontich JK, et al. Failure of LCP condy-
lar plate fixation in the distal part of the femur: a report of six cases.
nation of: J Bone Joint Surg Am 2006;88A:846–853.
■ M anipulation
9. Z lowodzki M, Bhandari M, M arek DJ, et al. Operative treatment of
■ Arthroscopic lysis
acute distal femur fractures: systematic review of 2 comparative studies
■ Formal quadricepsplasty and 45 case series (1989 to 2005). J Orthop Trauma 2006;20:366–371.
 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 44 Fix a t io n o f t h e Pa t e lla
J. Be n jam in Sm u ck e r an d Jo h n K. So n t ich
DEFIN ITION
■ The patella, the largest sesamoid bone, is a key part of the
knee extensor mechanism and provides leverage to the quadri-
ceps mechanism. Fractures of the patella have the potential to
disrupt the extensor mechanism.
■ Fractures of the patella also affect the knee joint itself by in-
terrupting the articular surface.
■ M anagement of patellar fractures must restore any disrup-
tion of the extensor mechanism while ensuring minimal dis-
ruption of the articular surface.
■ Stellate or comminuted, transverse, vertical, apical or infe-
rior pole, and sleeve fractures are common descriptive terms
used in the classification of patellar fractures.
AN ATOMY
■ The articular surface is composed of medial and lateral
facets, with the medial facet having the most variability in size
and shape. H orizontal ridges further subdivide the medial and
lateral facets. An odd facet lies at the most medial aspect of the
articular surface. The distal pole of the undersurface is extra-
articular (FIG 1 ).
■ The superior pole of the patella serves as an attachment for
the quadriceps tendon. The most superficial portion of the
quadriceps tendon courses over the anterior patellar surface
and is contiguous with the patellar tendon. The patellar ten-
don courses from the apex of the patella to the tibial tubercle.
■ The patellar retinaculum is composed of thickenings of
the fascia lata of the thigh in addition to the aponeurosis of the
vastus medialis and lateralis.13 In addition to stabilizing the
patella, the retinaculum acts as a secondary extensor.
Anterior surface Posterior (articular) surface
Superior pole
(base)
Lateral Medial
facet facet
Odd facet
Inferior pole
(apex)
416
■ Multiple arteries about the knee supply a peripatellar plexus,
although the main intraosseous blood supply is from a distal-to-
proximal direction.14
■ The patella acts to increase the moment arm of the extensor
mechanism by displacing the quadriceps tendon anteriorly.
This increased moment arm is most critical during terminal ex-
tension, when the quadriceps is otherwise at a mechanical dis-
advantage.9
■ Due to the small contact area of the articular surface and
the high level of compressive forces generated by the extensor
mechanism, the contact stress on the patellofemoral joint has
been estimated to be higher than any other major weight-
bearing joint. 5
PATHOGEN ESIS
■ Fractures of the patella may result from direct force to the
anterior knee, indirect forces transmitted through the extensor
mechanism, or a combination of both.
■ The patella is particularly susceptible to injury from direct
blows given its small amount of tissue covering and its
prominence.
■ The portion of the patella articulating with the femur moves
from distal to proximal with increasing degrees of flexion. The
fracture pattern for direct blows to the patella has been shown
to correspond to the articulating portion of the patella at the
time of injury, thus corresponding to the amount of knee flex-
ion at time of injury.1
■ Indirect forces causing fracture can be caused by unantici-
pated and rapid flexion of the knee while the quadriceps is also
firing. Fractures from an indirect mechanism tend to be less
comminuted than those from direct trauma.5
FIG 1 • Pa t e lla r a n a t o m y. Th e m a jo r fa ce t s in clu d e t h e
m e d ia l, la t e ra l, a n d o d d fa ce t s. Th e m e d ia l a n d la t e ra l
fa ce t s a re fu rt h e r su b d ivid e d b y su b t le h o rizo n t a l rid g e s.

N ATURAL HISTORY
■ Depending on the type of fracture and involvement of the
retinaculum, various amounts of long-term extensor weakness
can be expected. The long-term effect on range of motion is
likewise dependent upon fracture pattern and displacement.
■ There is an increased incidence of osteoarthritis of the knee
after patellar fracture. The increased rate of arthritis may be
both from initial cartilage injury and posttraumatic arthritis
due to articular cartilage incongruity.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Physical examination findings are as follows:
■ O ften a defect can be palpated in the patella.
■ N ew onset of joint effusion after injury localizes injury to
within the capsule of the knee. A knee effusion may not be
present if there is disruption of the retinaculum, allowing
hematoma to escape from the joint capsule.
■ The placement of the patella and palpation of defects with
the patella, quadriceps tendon, or patellar tendon can help
differentiate between patellar fracture and ligamentous ex-
tensor disruption.
■ Pain can limit the ability to test for active extension of the
knee or for extensor lag. Introduction of local anesthesia
after aspiration of hematoma can aid in assessment of exten-
sor function. The surgeon should note any extravasation of
local anesthetic to evaluate intra-articular extension of skin
defects.
■ Aspiration: The surgeon notes the amount of fluid aspi-
rated. The presence of fat lobules in the syringe signifies a
fracture extending into the knee capsule.
■ Patients with patellar fractures are able to actively extend
the knee in marginal or longitudinal fracture types or with
intact secondary extensors (ie, retinaculum). Knee extension
is usually not possible with displaced transverse fractures.
■ H istory is critical in determining a direct versus indirect
cause of fracture. Patella fractures caused by a high-energy di-
rect cause (ie, head-on motor vehicle accident with dashboard
injury) are often associated with other injuries to the knee.
■ Peripheral pulses and neurologic function must be
examined.
■ Knee stability should be evaluated. Patella fractures may be
accompanied by cruciate ligament injury.
■ O pen fractures will require urgent operative management
30 o
45 o
A
Ch a p t e r 4 4 ORIF OF THE PATELLA 417
and are associated with an increased rate of nonunion and in-
fection.17 O pen fractures also connote higher energy and an
increased likelihood of associated injury.
■ Physical examination must include a thorough secondary
survey for other associated injuries. Distal femur fractures and
acetabular injuries are commonly associated in high-energy
motor vehicle accidents owing to transfer of force through the
flexed knee.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Anteroposterior (AP) and lateral views of the knee and an
axial view of the patella provide sufficient information for
nearly all fracture types.
■ In the trauma setting, the M erchant view 11 is the best toler-
ated (FIG 2 A).
■ A bipartite patella, arising from failed fusion of patellar os-
sification centers, can be mistaken for a fracture. Bipartite
patellae are most commonly located superolaterally and
occur more frequently in males. In 40% of individuals with a
bipartite patella, the contralateral patella will also be
bipartite7 (FIG 2 B,C).
■ The normal Insall-Salvati ratio (height of the patella over
the distal from the inferior pole to the tibial tubercle) is about
1.0.8 Values less than 1 represent patella alta and possible
patellar tendon rupture. Patella alta may also be seen in patel-
lar sleeve fractures in the pediatric population.
DIFFEREN TIAL DIAGN OSIS
■ Q uadriceps rupture
■ Patellar tendon rupture
■ Bipartite patella
■ Ligamentous or meniscal injury
■ Distal femur or tibial plateau fracture
■ Inflammatory arthritis or septic arthritis
■ O steochondral injury
■ Patellar dislocation or retinacular injury
N ON OPERATIVE MAN AGEMEN T
■ Fractures must meet two criteria to be managed
nonoperatively:
■ N o associated extensor mechanism disruption
■ Less than 2 mm of displacement of the articular surface or
less than 3 mm separation of the fracture fragments.3,6 (Less
FIG 2 • A. In t h e Me rch a n t vie w , t h e kn e e is a llo w e d
t o b e n d t o 45 d e g re e s a n d t h e x-ra y b e a m is a n g le d
a t 30 d e g re e s t o t h e h o rizo n . Th e x-ra y ca sse t t e is
p la ce d p e rp e n d icu la r t o t h e le g o n t h e p ro xim a l t ib -
ia l d ia p h ysis. (co n t in u e d )
418 Se c t i o n IV FEM UR AND KNEE
B C
displacement is tolerated by some authors in the presence of
transverse fractures.4 )
■ The described period of immobilization varies.
H istorically, patients were kept in a long-leg cast for 4 to 6
weeks. Current nonoperative management involves early
functional treatment.
■ O ur preference for nonoperative treatment includes partial
weight bearing with crutches and a hinged knee brace.
■ The leg is maintained in extension for 2 weeks, 0 to 45 de-
grees of flexion for 2 weeks, and 0 to 90 degrees for 2
weeks, followed by full motion for 2 weeks.
■ After this 8-week course, full weight bearing is allowed.
■ N onoperative management of appropriate fractures results
in good overall results, with loss of flexion the most common
complication.4,5
SURGICAL MAN AGEMEN T
■ O perative treatment is the preferred treatment for the major-
ity of fractures not meeting the nonoperative criteria outlined
above. Treatment is aimed at anatomic reconstruction of the ar-
ticular surface and restoration of the extensor mechanism.
■ O pen reduction and internal fixation is the treatment of
choice.
■ Cases with severe comminution of the inferior or superior
pole may be considered for partial patellectomy.
■ Total patellectomy is reserved for cases of severe comminu-
tion involving most of the patella in which reconstruction of
an articular surface is not possible.
■ M ethods involving arthroscopy or external fixation have
not gained widespread use.
■ Soft tissue must be respected as there exists only a thin soft
tissue envelope covering the patella. This care for soft tissue
begins in the emergency department. Splints or knee immobi-
lizers must be accompanied by copious padding to minimize
complications from pressure.
Preoperative Planning
■ O perative timing is dictated by patient condition, presence
of open fractures, and condition of the soft tissues.
FIG 2 • (co n t in u e d ) B,C. Bip a rt it e p a t e lla . No t e t h e
cla ssic su p e ro la t e ra l p o sit io n o f t h is m u lt ip a rt it e
p a t e lla a n d t h e scle ro t ic m a rg in s.
■ Fracture imaging is reviewed.
■ Examination under anesthesia is critical, as evaluation of co-
existing ligamentous injuries is often limited by patient pain
prior to surgery. Lachman, pivot shift, posterior drawer, and
varus–valgus testing should be undertaken before preparing
the surgical site.
■ Concomitant injuries may be addressed in the same
surgery.
Positioning
■ Patients are placed in the supine position on a radiolucent
table.
■ If a tourniquet is used, it must be placed as proximally
as possible on the thigh. The quadriceps must not be
trapped under the tourniquet, as this may retract the patella
superiorly, hindering fracture reduction. The knee is flexed
to 90 degrees before elevating the tourniquet. If the retinacu-
lum is disrupted and the superior patella is high-riding, the
quadriceps should be pulled distally before inflating the
tourniquet. 18
Approach
■ Longitudinal or transverse incisions may be made.
■ We use a longitudinal approach to facilitate exposure and
allow extension to the tibial tubercle for wire augmentation
when needed. A longitudinal approach may be better tolerated
for future reconstructive surgeries and may therefore be bene-
ficial in elderly patients or patients with preexisting
osteoarthritis.
■ A transverse approach follows the skin lines and may be
preferable cosmetically. A transverse approach minimizes
risk of injury to the infrapatellar branch of the saphenous
nerve.
■ Dissection is carried through the patellar bursa to expose the
fracture site. H ematoma is often encountered upon opening
bursa. H ematoma is cleared from the fracture site with copious
irrigation and small curettes. The fracture line is followed to the
retinacular tissue; the surgeon identifies the superior and infe-
rior leaves of retinaculum and tags them for later repair.

TENSION BAND WIRING
■ Te n sio n b a n d w irin g ca n b e u se d t o st a b ilize t ra n sve rse
fra ct u re p a t t e rn s. Mo re co m p le x fra ct u re p a t t e rn s ca n
u se a t e n sio n b a n d co n st ru ct if t h e fra ct u re ca n b e co n -
ve rt e d t o a t ra n sve rse p a t t e rn b y fixa t io n o f sm a lle r
co m m in u t e d p ie ce s w it h scre w s o r Kirsch n e r w ire s.
Te n sio n b a n d co n st ru ct s m a y a lso b e u se d fo r m o re d ist a l
p o le fra ct u re s, w it h Kirsch n e r w ire s p la ce d m o re clo se ly
t o g e t h e r t o ca p t u re t h e fra g m e n t .
■ Tw o 1.6- t o 2.0-m m Kirsch n e r w ire s w ill sp a n t h e fra ct u re
in p a ra lle l (TECH FIG 1 A). Th e y ca n b e in t ro d u ce d
t h ro u g h t h e fra ct u re sit e in t o t h e p ro xim a l fra g m e n t in a
re t ro g ra d e fa sh io n o r in t o t h e d ist a l fra g m e n t in a n a n -
t e g ra d e fa sh io n .
■ Th e Kirsch n e r w ire is d e live re d u n t il flu sh w it h t h e
fra ct u re lin e , a n d t h e fra ct u re re d u ct io n is o b t a in e d
a n d h e ld w it h p a t e lla r re d u ct io n cla m p s o r We b e r
cla m p s.
■ Fra ct u re re d u ct io n is ch e cke d b y p a lp a t in g t h e a rt icu -
la r su rfa ce w it h a Fre e r e le va t o r (o r b y fin g e r p a lp a -
t io n if t h e re n t in t h e re t in a cu lu m a llo w s). Wh e n e n -
co u n t e re d , sm a ll a rt icu la r fra g m e n t s w it h o u t a t -
t a ch e d su b ch o n d ra l b o n e m a y b e d isca rd e d .
De p re sse d a rt icu la r fra g m e n t s a re g e n t ly re d u ce d b y
a Fre e r e le va t o r.
■ On ce t h e fractu re is su fficien t ly re d u ce d , t h e Kirsch n er
wire is delive re d t hrough t he opposite fract ure frag men t.
■ A la t e ra l flu o ro sco p ic vie w m a y h e lp t o e n su re a p -
p ro p ria t e fra ct u re re d u ct io n a n d Kirsch n e r w ire
p la ce m e n t .
A B
TECH FIG 1 • Te n sio n b a n d fixa t io n . A. Fra ct u re re d u ct io n is m a in t a in e d w it h a We b e r cla m p w h ile Kirsch n e r w ire s a re
p a sse d . B. A la rg e a n g io ca t h is u se d fo r e a se o f w ire p la ce m e n t d e e p t o Kirsch n e r w ire s a n d b e n e a t h t h e q u a d rice p s t e n -
d o n . (co n t in u e d )
Ch a p t e r 4 4 ORIF OF THE PATELLA 419
TECHNIQUES
■ Id e a lly, t h e Kirsch n e r w ire s w ill b e a b o u t 5 m m b e lo w t h e
a n t e rio r su rfa ce o f t h e p a t e lla . 12 Th e Kirsch n e r w ire
sh o u ld b e clip p e d t o le a ve ro u g h ly 1 cm o f p ro m in e n ce
b e lo w t h e in fe rio r p o le o f t h e p a t e lla .
■ A 1.0-m m -t h ick ce rcla g e w ire is p a sse d ju st d e e p t o t h e
Kirsch n e r w ire s, a b u t t in g t h e su p e rio r p o le o f t h e
p a t e lla . Ca re m u st b e t a ke n t o le a ve lit t le t o n o in t e rve n -
in g so ft t issu e b e t w e e n t h e su p e rio r p a t e lla a n d t h e t e n -
sio n b a n d .
■ A 16-g a u g e a n g io ca t h m a y b e p a sse d t h ro u g h t h e
q u a d rice p s m e ch a n ism a n d t h e w ire a d va n ce d
t h ro u g h t h e ca t h e t e r t o a id in p la ce m e n t o f t h e w ire
(TECH FIG 1 B).18
■ Th e ce rcla g e w ire is p a sse d d ist a lly in a sim ila r
fa sh io n , e n su rin g t h e w ire a b u t s t h e d ist a l p o le o f t h e
p a t e lla .
■ Th e w ire is lo o p e d a ro u n d t h e a n t e rio r a sp e ct o f t h e
p a t e lla .
■ Alt e rn a t ive ly, t h e w ire m a y b e crisscro sse d in a fig u re
8 p a t t e rn .
■ Prio r t o t e n sio n in g , t h e su rg e o n ve rifie s t h a t t h e
Kirsch n e r w ire s ca p t u re t h e ce rcla g e w ire .
■ To e n su re e ve n t e n sio n in g , a t w o -lo o p t e n sio n in g t e ch -
n iq u e is u se d . A t w ist is m a d e in t h e ce rcla g e w ire o n
t h e o p p o sit e sid e o f t h e t w o fre e e n d s o f t h e w ire .
Th e fre e e n d s a re g e n t ly t w ist e d . Th e se t w o lo o p s
a re se q u e n t ia lly t ig h t e n e d w it h a la rg e n e e d le d rive r
(TECH FIG 1 C). Th e lo o p is lift e d t o t e n sio n t h e w ire
a n d t h e n t w ist e d . 18
 420 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES

C D

TECH FIG 1 • (co n t in u e d ) C. He a vy n e e d le d rive rs a re u se d sim u lt a n e o u sly t o t e n sio n t h e

ce rcla g e w ire . D. La t e ra l vie w o f t h e fin a l co n st ru ct a ft e r ca p t u rin g t h e ce rcla g e w ire in
t h e b e n t e n d o f t h e Kirch n e r w ire s.

■ Wire s a re se q u e n t ia lly t e n sio n e d u n t il a p p ro p ria t e ■ Re t in acu la r d e fe ct s a re rep aire d wit h ab so rb ab le b ra id ed

co m p re ssio n is visu a lize d a n d p a lp a t e d a t t h e fra c-
t u re sit e .
■ The en ds of t he t w ist s are clippe d, b ent o ver, a nd ta mp ed
in to b o n e to min im ize p ro min e n ce .
■ Th e su p e rio r p o rt io n o f t h e Kirsch n e r w ire is b e n t a n d
t h e n cu t , le a vin g a h o o k t o ca p t u re t h e ce rcla g e w ire .
Th e Kirsch n e r w ire is ro t a t e d a n d t a m p e d in t o t h e su p e -
rio r p o le o f t h e p a t e lla . Th e in fe rio r t ip o f t h e w ire is cu t
t o a vo id e xce ssive le n g t h w it h in t h e p a t e lla t e n d o n w h ile
le a vin g e n o u g h w ire t o m a in t a in p o sit io n o f t h e ce rcla g e
w ire (TECH FIG 1 D).
su t ure, a crit ica l st ep in rest o rin g th e exten sor m echanism.
■ Th e t o u rn iq u e t is d e fla t e d a n d h e m o st a sis o b t a in e d . A
su ct io n d ra in is p la ce d a s n e e d e d a n d t h e w o u n d is
clo se d w it h b u rie d a b so rb a b le su t u re s fo llo w e d b y sim -
p le n ylo n su t u re s.
■ A w e ll-p a d d e d st e rile d re ssin g is a p p lie d w it h p a d d in g
o ve r t h e le g fro m t h e m a lle o li t o t h e p ro xim a l t h ig h . A
kn e e im m o b ilize r is p la ce d .

MODIFIED TENSION BAND WITH CANNULATED SCREWS

■ As a d vo ca t e d b y Ca rp e n t e r e t a l, ca n n u la t e d scre w s m a y
b e u se d in p la ce o f Kirsch n e r w ire s in a t e n sio n b a n d co n -
st ru ct fo r t ra n sve rse fra ct u re p a t t e rn s (TECH FIG 2 A–C).
Th is co n st ru ct h a s sh o w n t o b e su p e rio r b io m e ch a n ica lly
t o t h e Kirsch n e r w ire t e n sio n b a n d co n st ru ct , re sist in g
la rg e r fo rce s a n d re su lt in g in le ss fra ct u re g a p in g
w it h lo a d s. 5
■ Re d u ct io n is o b t a in e d a s d e scrib e d a b o ve , w it h t h e
g u id e -w ire s fo r t h e 4.0- o r 4.5-m m p a rt ia lly t h re a d e d
ca n n u la t e d scre w s u se d in p la ce o f Kirsch n e r w ire s.
■ Scre w s a re p la ce d o ve r t h e g u id e w ire s u sin g a la g
t e ch n iq u e a n d a re le ft sh o rt o f t h e d ist a l co rt e x. A la t -
e ra l flu o ro sco p ic vie w is h e lp fu l in ve rifyin g scre w
p la ce m e n t .
 Ch a p t e r 4 4 ORIF OF THE PATELLA 421

TECHNIQUES
A B

C D

TECH FIG 2 • A–D. Ra d io g ra p h s o f ca n n u la t e d scre w a n d t e n sio n b a n d co n st ru ct . A. La t e ra l ra d io g ra p h d e m o n st ra t -

in g a t ra n sve rse p a t e lla r fra ct u re . B. AP vie w o f fin a l scre w a n d ce rcla g e co n st ru ct . C. La t e ra l vie w sh o w in g t h a t t h e
scre w t h re a d s a re slig h t ly p ro m in e n t a n d n o t e n t ire ly w it h in b o n e . D. Fin a l co n st ru ct o f ca n n u la t e d scre w w it h ce r-
cla g e w ire . Th e t h re a d s re m a in e n t ire ly w it h in b o n e .

■ A 0.8-m m (18-g a u g e ) w ire is p a sse d t h ro u g h a sin g le ■ Aft e r b rin g in g t h e t w o e n d s o f t h e w ire t o g e t h e r, a t w o -

ca n n u la t e d scre w , lo o p e d b a ck o ve r t h e a n t e rio r su r- lo o p t ig h t e n in g t e ch n iq u e is u se d a s d e scrib e d a b o ve ,
fa ce o f t h e p a t e lla , a n d a d va n ce d t h ro u g h t h e se co n d a n d t h e t w ist s a re b u rie d (TECH FIG 2 D).
scre w . Alt e rn a t ive ly, 1.6-m m ca b le ca n b e p la ce d
t h ro u g h 4.5-m m ca n n u la t e d scre w s.

INTERFRAGMENTARY SCREWS WITHOUT TENSION BANDING

■ Alt h o u g h o cca sio n a lly u se d w it h t e n sio n b a n d co n st ru ct s
t o co n ve rt co m p le x fra ct u re p a t t e rn s in t o t ra n sve rse p a t -
t e rn s, scre w fixa t io n ca n a lso b e u se d a lo n e (TECH FIG 3 ).
Th is co n st ru ct is p a rt icu la rly su it e d fo r sim p le fra ct u re
p a t t e rn s w it h a rt icu la r d isp la ce m e n t a n d a n in t a ct
re t in a cu lu m .
■ La g scre w fixa t io n is o ft e n t h e m e t h o d o f ch o ice fo r lo n -
g it u d in a l fra ct u re s re q u irin g o p e ra t ive m a n a g e m e n t .
La g scre w fixa t io n fo r t ra n sve rse fra ct u re s is a lso a su it -
a b le o p t io n , e sp e cia lly in p a t ie n t s w it h g o o d b o n e st o ck.
Mu lt ip le b io m e ch a n ica l st u d ie s h a ve sh o w n t w o co rt ica l
la g scre w s t o b e n e a rly a s st ro n g a s2 o r st ro n g e r t h a n 5
t e n sio n b a n d a lo n e .
■ Aft e r o b t a in in g re d u ct io n w it h p o in t e d fo rce p s, 3.5-m m
o r 4.5-m m co rt ica l scre w s a re u se d in la g g in g fa sh io n
a cro ss fra ct u re sit e s.
■ Clo su re a n d re t in a cu la r re p a ir a re u n d e rt a ke n a s d e -
scrib e d a b o ve .
 422 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES
A B
TECH FIG 3 • Ra d io g ra p h s o f la g scre w co n st ru ct . A,B. AP a n d la t e ra l in ju ry film s. C. Po st o p e ra t ive ra -
d io g ra p h . No t e b ico rt ica l scre w p u rch a se .
PARTIAL PATELLECTOMY
■ Pa rt ia l p a t e lle ct o m y is o ft e n a d vo ca t e d fo r co m m in u t e d
fra ct u re s o f t h e p a t e lla w h e n a p o rt io n o f t h e p a t e lla is
sig n ifica n t ly co m m in u t e d . Oft e n t h is co m m in u t io n o c-
cu rs a t t h e p a t e lla r p o le , w it h in fe rio r p o le fra ct u re s
b e in g m o re co m m o n .
■ Aft e r a st a n d a rd a p p ro a ch a s a b o ve , t h e co m m in u t e d
fra ct u re fra g m e n t s a re id e n t ifie d . If re st o ra t io n o f t h e
co m m in u t e d sit e is n o t p o ssib le , t h e co m m in u t e d fra g -
m e n t s a re re m o ve d . Pre se rva t io n o f a s la rg e a p o rt io n o f
t h e a rt icu la r su rfa ce a s p o ssib le is crit ica l.
■ Mu lt ip le lo n g it u d in a l d rill h o le s a re m a d e t h ro u g h t h e
re m a in in g p o rt io n o f t h e p a t e lla su ch t h a t t h e e n t ra n ce
p o in t o f t h e t e n d in o u s a t t a ch m e n t w ill b e a s n e a r t o t h e
A B
C
a rt icu la r su rfa ce a s p o ssib le . Th e a m o u n t o f h o le s is e q u a l
t o t h e n u m b e r o f su t u re s p lu s o n e .
■ No n a b so rb a b le su t u re w it h a t e n d o n g ra sp in g st it ch is
u se d t o a t t a ch t h e a d ja ce n t t e n d o n (u su a lly p a t e lla r t e n -
d o n ) t h ro u g h t h e d rill h o le s. Su t u re is t ie d w it h t h e kn e e
in n e u t ra l o r h yp e re xt e n sio n (TECH FIG 4 ).
■ Re pa ir ma y be a u gm en t ed b y a t en sio n b an d co nstru ct
th ro u g h th e p ate lla a n d t ib ial t ub e rcle o r b y Mersile ne
t a p e , a lt h o u g h w e d o n o t co m m o n ly p e rfo rm su ch
augm ent at ion.
■ Re t in a cu lu m is re p a ire d w it h a b so rb a b le su t u re .
■ Clo su re is a s d e scrib e d a b o ve .
TECH FIG 4 • Pa rt ia l p a t e lle ct o m y. A. Co m m in u t e d d ist a l p o le
o f p a t e lla fra ct u re , a n id e a l fra ct u re p a t t e rn fo r t h e co n st ru ct .
B. Su t u re p la ce m e n t p rio r t o t e n sio n in g a n d t yin g . Tw o su -
t u re s a n d t h re e d rill h o le s a re u se d .

PEARLS AND PITFALLS
Th e su rg e o n sh o u ld e n su re t h a t t e n sio n b a n d w ire s h a ve lit t le
t o n o in t e rve n in g t issu e b e t w e e n t h e w ire a n d t h e p a t e lla
w h e n p a ssin g u n d e r t h e Kirsch n e r w ire s a t t h e p ro xim a l a n d
d ist a l p o le s.
Ca n n u la t e d scre w s m u st b e le ft sh o rt o f t h e fa r co rt e x if u se d
w it h a t e n sio n b a n d co n st ru ct . In co n t ra st , w h e n u sin g scre w in
a la g g in g fa sh io n , b ico rt ica l p u rch a se a ffo rd s a b e t t e r co n st ru ct .
There is a de lica t e b a la nce be tw e e n e a rly ra ng e of m o tio n to
prom ot e b et te r lo ng -t e rm ra ng e o f m otio n a nd pro te ct io n o f
fixa tion to a void loss o f re du ct io n.
Wh e n p o ssib le , co m p le x fra ct u re p a t t e rn s a re co n ve rt e d in t o
sim p le r o r t ra n sve rse p a t t e rn s.
POSTOPERATIVE CARE
■ Passive knee range of motion and gentle active range of mo-
tion begins once soft tissue healing is ensured. We use an abun-
dance of padding postoperatively underneath any bracing until
postoperative soft tissue swelling resolves.
■ Patients are allowed to bear partial weight with crutches
and the knee fully extended in a knee immobilizer or hinged
knee brace immediately postoperatively.
■ We prefer 2 weeks with the knee in extension, 2 weeks of
knee flexion from 0 to 60 degrees, and 2 weeks of full knee
flexion in a hinged knee brace.
■ Full weight bearing out of a brace is allowed once signs of
fracture healing are evident on postoperative imaging, and not
before 6 weeks.
■ Although straight leg raising and quadriceps sets with the
knee extended may begin immediately postoperatively, quadri-
ceps strengthening with resistance is held until signs of fracture
healing appear.
■ For fracture fixation deemed unstable during intraoperative
range of motion, initiation of knee motion may be held until
fracture healing is evident.
■ Rehabilitation must keep in mind the compressive forces on
the patella during knee flexion. Compressive forces are greater
than three times body weight during stair climbing and reach
nearly eight times body weight while squatting.10
OUTCOMES
■ O utcomes depend on maintenance of fracture reduction.
■ In a review of 320 patients with patellar fractures (212
treated nonoperatively) with a mean follow-up of 8.9 years,
Bostrum 3 reported that 24% of patients did not consider
themselves fully recovered; moderate or severe pain persisted
in 31% of patients. The range of mobility was normal in 90%
of patients, with the majority of restriction of motion in el-
derly patients. N inety-one percent of patients had fracture
union.
■ Functional outcomes after long-term follow-up of tension
band wiring have been reported to be the same as age-matched
standards.15
Ch a p t e r 4 4 ORIF OF THE PATELLA 423
■ Th is co m m o n e rro r ca n ca u se fra ct u re sit e d ist ra ct io n . Wh e n
t h e fra ct u re is lo a d e d , t h e fra g m e n t s ca n d isp la ce o n t h e
Kirsch n e r w ire u n t il t h e t e n sio n b a n d b e co m e s t a u t .5
■ Pro t ru sio n o f t h e scre w p a st t h e d ist a l co rt e x cre a t e s a st re ss
rise r in t h e t e n sio n b a n d .5 Ad d it io n a lly, t h e t e n sio n b a n d d o e s
co n t a ct t h e scre w t ip ra t h e r t h a n t h e b o n e , le sse n in g co m -
p re ssio n fo rce s o n t h e b o n e t h ro u g h t h e t e n sio n co n st ru ct .
■ Passive ran g e -of-mo t io n exe rcise s o u g h t t o b e gin as so on as
su rge o n co m fo rt allo w s. In tra o p e ra tive kne e ra ng e o f mo tio n
resu ltin g in ga p in g at t h e fra ctu re sit e a nd p o or intrao p erat ive
b o n e st o ck m ay lea d to th e de cisio n for d e la ye d p assive ra ng e
o f mot io n.
■ Fixa t io n o f lo n g it u d in a l co m m in u t e d fra g m e n t s w it h
in t e rfra g m e n t a ry scre w s o ft e n a llo w s t h e fra ct u re p a t t e rn t o
b e t re a t e d a s a sim p le r t ra n sve rse p a t t e rn .
COMPLICATION S
■ The historical complication rate of operative intervention
for patellar fractures varies in the literature. Although a recent
study on perioperative complications reported a rate of
25% ,16 historical rates are much lower. 3
■ Infection rates are low and can be minimized by the use of
perioperative antibiotics and careful soft tissue handling. Few
postoperative infections are deep infections involving the
joint.3,16
■ Patients often note palpable hardware, given the thin overly-
ing tissue. Although we do not routinely remove hardware, pa-
tients in whom the hardware becomes symptomatic may have
hardware removal after fracture consolidation. H ardware re-
moval rates have varied in the literature from 10% to 60%
with tension band constructs.15,16
■ Smith et al16 reported fracture displacement of more than 2
mm in 22% of patients treated with tension band wiring. All
patients with significant displacement requiring reoperation
were weight bearing without bracing between 3 and 5 weeks.
In the remainder of cases with loss of fixation, the most com-
mon cause was technical error.
■ N onunion with tension band techniques is a rare compli-
cation, occurring in less than 1% of fractures fixed in this
manner. 5
■ Decreased knee range of motion is another possible compli-
cation. Flexion is more commonly lost than extension. At
times this loss of motion can be due to intra-articular adhe-
sions and can benefit from arthroscopic release.
■ As with many intra-articular fractures, osteoarthritis devel-
ops in the injured extremity at a rate greater than that of the
uninjured extremity. Reported rates of osteoarthritis vary
greatly.
REFEREN CES
1. Atkison PJ, H aut RC. Injuries produced by blunt trauma to the
human patellofemoral joint vary with flexion angle of the knee. J
O rthop Res 2001;19:827–833.
2. Benjamin J, Bried J, Dohm M , et al. Biomechanical evaluation of var-
ious forms of fixation of transverse patellar fractures. J O rthop
Trauma 1987;1:219–222.
424 Se c t i o n IV FEM UR AND KNEE
3. Bostrum A. Fracture of the patella: a study of 422 patellar fractures.
Acta O rthop Scand Suppl 1972;143:3–80.
4. Braun W, Wiedemann M , Ruter A. Indications and results of nonop-
erative treatment of patellar fractures. Clin O rthop Relat Res
1993;289:197–201.
5. Carpenter JE, Kasman R, M atthews LS. Fractures of the patella. J
Bone Joint Surg Am 1993;75A:1550–1561.
6. Edwards B, Johnell O , Redlund-Johnell L. Patellar fractures: a 30-
year follow-up. Acta O rthop Scand 1989;60:712–714.
7. Green WT. Painful bipartite patellae: a report of three cases. Clin
O rthop Relat Res 1975;110:197–200.
8. Insall J, Goldberg V, Salvati E. Recurrent dislocation of the high-
riding patella. Clin O rthop Relat Res 1972;88:67–69.
9. Kaufer H . M echanical function of the patella. J Bone Joint Surg Am
1971;53A:1551–1560.
10. M atthews LS, Sonstegard DA, H enke JA. Load-bearing characteristics
of the patellofemoral joint. Acta Orthop Scand 1977;48:511–516.
11. M erchant AC, M ercer RL, Jacobsen RH , et al. Roentgenographic
analysis of patellofemoral congruence. J Bone Joint Surg Am 1974;
56A:1391–1396.
12. N erlich M , Weigel B. Patella. In: Ruedi TP, M urphy WM , eds. AO
Principles of Fracture M anagement. N ew York: Thieme, 2000:
487–501.
13. Reider B, M arshall JL, Koslin B, et al. The anterior aspect of the
knee joint: an anatomical study. J Bone Joint Surg Am 1981;63A:
351–356.
14. Scapinelli R. Blood supply of the human patella: its relation to is-
chaemic necrosis after fracture. J Bone Joint Surg Br 1967;49B:
563–570.
15. Schemitsch EH , Weinberg J, M cKee M D, et al. Functional outcome
of patella fractures following open reduction and internal fixation. J
O rthop Trauma 1999;13:279.
16. Smith ST, Cramer KE, Karges DE, et al. Early complications in the
operative treatment of patella fractures. J O rthop Trauma 1997;
11:183–187.
17. Torchia M E, Lewallen DG. O pen fractures of the patella. J O rthop
Trauma 1996;10:403–409.
18. Wilber JH . Patellar fractures: open reduction internal fixation. In:
Wiss DA, ed. M aster Techniques in O rthopaedic Surgery: Fractures.
Philadelphia: Lippincott Williams & Wilkins, 1998:335–346.
 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 45 Fix a t io n o f Bico n d y la r Tib ia l
Pla t e a u Fr a ct u re s
To b y M . Risk o an d W illiam M . Ricci
DEFIN ITION
■ Bicondylar tibial plateau fractures involve both medial and
lateral plateaus.
■ Schatzker type 5 fractures (FIG 1 A,B) involve both condyles
without complete dissociation from the shaft. Thus, a portion
of the joint is still attached to the shaft. They are usually
amenable to medial and lateral buttress plate fixation.
■ Schatzker type 6 fractures (FIG 1 C,D) involve both condyles
with complete dissociation of the articular segment from the
shaft.
■ Lateral fractures with associated posterior medial fragments
should be distinguished from other bicondylar types, as they
often require posteromedial fixation independent from lateral
fixation and may be representative of fracture-dislocation (see
Fig 3).
AN ATOMY
■ In the loaded knee, the medial plateau bears about 60% to
75% of the load. 7,8
■ The medial plateau is larger than the lateral plateau (FIG 2 ).
■ The medial plateau is concave, the lateral plateau convex.
■ Stronger, denser subchondral bone is found on the medial
side due to increased load.
■ The lateral plateau is higher than the medial plateau. The
medial proximal tibial angle is 87 degrees relative to the
anatomic axis of the tibia (range 85 to 90 degrees).6
■ The proximal posterior tibial angle is 81 degrees relative to
anatomic axis of the tibia (range 77 to 84 degrees).6
■ The iliotibial band inserts on the tubercle of Gerdy.
■ The anterior cruciate ligament attaches adjacent and medial
to the tibial eminence. It acts to resist anterior translation of
the tibia relative to the femur. Recognizing a fracture fragment
that contains this attachment can be important to re-establish
stability to the knee.
■ The posterior cruciate ligament attaches about 1 cm below
the joint line on the posterior ridge of the tibial plateau and a
few millimeters lateral to the tibial tubercle.
■ The function of the posterior cruciate is to resist posterior
tibial translation of the tibia relative to the femur. This acts
as the central pivot of the knee.
■ The medial collateral ligament resists valgus force.
■ The medial collateral ligament originates on the medial
femoral epicondyle and inserts on the medial tibial condyle.
■ The lateral collateral ligament resists varus force and exter-
nal rotation of the femur.
■ The lateral collateral ligament originates on the lateral
epicondyle of the femur and attaches to the fibular head.
■ The menisci, medial and lateral, are crescent-shaped fibro-
cartilaginous structures that act to dissipate the load on the
tibial plateau, deepen the articular surfaces of the plateau, and
help lubricate and provide nutrition to the knee.
■ The medial meniscus is more C-shaped and the lateral
meniscus is more circular in shape.
■The lateral meniscus is more mobile than the medial
meniscus.
PATHOGEN ESIS
■ Bicondylar tibial plateau fractures are typically caused by a
high-energy mechanism with associated injury to surrounding
soft tissue.
■ The mechanism responsible for injury is primarily an axial
force, which may be associated with a varus or valgus moment.
■ With a valgus force, the lateral femoral condyle is driven
wedge-like into the underlying lateral tibial plateau.5
■ The size of the fracture fragments depends on multiple
factors, including localization of the impact, the magnitude
of the axial force producing the fracture, the density of the
bone, and the position of the knee joint at the moment of
trauma.
■ Ligament injuries have been found to occur in 20% to 77%
of tibial plateau fractures.3,4
■ Repair of ligament injuries at the time of fracture fixa-
tion is controversial. Some advocate ligamentous repair at
the time of fracture fixation, while others feel that if the
fracture can be reduced there is no need for early ligamen-
tous repair.
N ATURAL HISTORY
■ Joint incongruity can predispose to arthrosis.
■ Inadequate fracture stability can lead to varus–valgus
collapse.
■ Joint stiffness
■ Joint instability can result from associated ligament injury.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Generally, a bicondylar injury pattern is caused by a high-
energy mechanism. It may also be seen with a low-energy mech-
anism, such as a fall from standing height or in an older patient
with osteoporosis.
■ The patient will complain of a painful swollen knee and
will have difficulty bearing weight on the extremity.
H emarthrosis will be present if the capsule has not been
disrupted.
■ The patient history should include details of the injury mech-
anism, preinjury ambulatory status, and any previous injury and
disability.
■ A complete examination is required to rule out other in-
juries. The vascular status of the limb proximal and distal to
the injury requires evaluation.
■ If there is an abnormality on palpation pulses, a vascular
consult may be needed.
■ The ankle–brachial index of the extremity, along with ultra-
sound examination of the leg, can be helpful in fully evaluating
the possibility of vascular injury, which occurs in about 2% of
these fractures.1,9 The patient is evaluated for compartment
425
 426 Se c t i o n IV FEM UR AND KNEE

A B

FIG 1 • A,B. AP a n d la t e ra l vie w s o f a Sch a t zke r t yp e

5 b ico n d yla r t ib ia l p la t e a u fra ct u re . C,D. AP a n d la t -
e ra l vie w s o f a Sch a t zke r t yp e 6 b ico n d yla r t ib ia l
C D p la t e a u fra ct u re .

Anterior Posterior
cruciate ligament cruciate ligament

Lateral Medial
meniscus collateral
ligament
Lateral
collateral Medial
ligament Patellar ligament
meniscus

Lateral Medial
condyle condyle
Lateral
of tibia of tibia Anterior meniscus
Gerdy’s cruciate ligament
tubercle Tibial
tuberosity Medial
collateral
ligament

Medial
meniscus
Lateral
collateral
Posterior ligament
A B cruciate ligament

FIG 2 • AP (A) a n d a xia l (B) vie w s o f t h e t ib ia sh o w in g t h e re le va n t a n a t o m y.

 Ch a p t e r 4 5 ORIF OF BICONDYLAR TIBIAL PLATEAU FRACTURES
syndrome by palpating the lower extremity compartment for
swelling and passively extending the muscles in the lower ex-
tremity, noting any increase in pain.
■ The strength of dorsiflexion and eversion will help evaluate
the peroneal nerve. It is important to examine and document
peroneal nerve function before surgery because of the possibil-
ity of a stretch injury. M otor and sensory function of the nerve
proximal and distal to the injury should be assessed.
■ A thorough ligament examination of the knee is needed, al-
though this can be difficult preoperatively owing to difficulty
differentiating ligamentous from bony instability.
■ Examination of the knee ligaments should therefore take
place after operative stabilization and before the patient is
awake in the operating room.
■ Soft tissues need careful inspection before definitive surgi-
cal intervention can take place. The surgeon should note
where surgical incisions will be located when evaluating the
soft tissue.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Anteroposterior (AP) and lateral radiographs of the knee
and tibia, and oblique views of the knee (FIG 3 A–C).
A B
D E
427
■ CT scan with sagittal and coronal reconstruction is helpful
to define complex fracture patterns and to plan surgical tactics
(FIG 3 D,E).
■ M RI is useful in evaluating ligament and meniscal injury
around the knee.4
DIFFEREN TIAL DIAGN OSIS
■ Unicondylar tibia fracture
■ Patella fracture
■ Ligament injury at the knee
■ Proximal tibial shaft fracture
■ Extensor mechanism disruption
N ON OPERATIVE MAN AGEMEN T
■ A fracture brace, a long-leg cast, or both may be used to
treat low-energy nondisplaced fractures.
■ These require close observation to ensure progressive
malalignment (particularly varus) does not occur.
■ A long-leg cast, a fracture brace, or both can be used in treat-
ing low-energy, minimally displaced fracture patterns. It may
also be used if patient factors (eg, comorbidities, functional
status) would make operative intervention inappropriate.
C
FIG 3 • Bico n d yla r t ib ia l p la t e a u
fra ct u re in clu d in g p o st e rio r m e d ia l
fra g m e n t . A. AP vie w . B. Ob liq u e
vie w . C. La t e ra l vie w . D. CT sa g it t a l
re co n st ru ct io n sh o w in g p o st e rio r
m e d ia l fra g m e n t . E. Axia l CT sh o w -
in g la t e ra l a n d p o st e rio r m e d ia l
fra g m e n t s.
 428 Se c t i o n IV FEM UR AND KNEE
SURGICAL MAN AGEMEN T
Preoperative Planning
■ The surgeon should thoroughly review all preoperative imag-
ing studies.
■ A surgical approach is planned that affords adequate expo-
sure for reduction and stabilization of the fracture.
■ Single lateral, dual incisions and occasionally a posterior
approach are most common.
■ Single anterior incisions with stripping should be avoided
if medial and lateral exposure is required.
■ A tactic for fracture reduction is planned based on preoper-
ative imaging.
■ Consideration should be given as to whether a femoral
distractor will be useful.
■ In bicondylar fracture patterns, joint distraction is mar-
ginal with use of a femoral distractor, as distraction takes
place through the fracture rather than across the joint.
■ The surgeon should decide which part of the bicondylar
pattern to stabilize first. By approaching the posteromedial
side first and obtaining the reduction on the medial side be-
fore approaching the lateral tibial plateau, the surgeon may
help prevent stabilizing the knee in varus. If the medial side
can be reduced percutaneously and the fracture pattern is
amenable to lateral locked plating only, the surgeon may be
able to avoid dual incisions. These decisions can be made in
preoperative planning.
■ Patient positioning should be planned to ease surgical ex-
posure. It is usually supine, except when a posterior or postero-
medial approach is required. If a posterior approach is required
the patient should be positioned prone.
■ Implant selection: single lateral locking plate or lateral lock-
ing and posteromedial plate.
■ The surgeon should consider whether a nonsterile or sterile
tourniquet is required.
■ Imaging: The C-arm should be placed on the contralat-
eral side of the patient for the lateral exposure. If the sur-
geon will start with the posteromedial exposure, the C-arm is
on the ipsilateral side of the patient. The monitor is posi-
tioned for comfortable viewing, usually toward the head of
the bed.
■ The surgeon should consider a staged protocol with provi-
sional spanning external fixation for high-energy bicondylar
injuries with significant soft tissue swelling. O pen reduc-
tion and internal fixation can be done when swelling has
subsided.
TECHNIQUES
POSTEROMEDIAL APPROACH
■ Th e in cisio n is st a rt e d 1 cm p o st e rio r t o t h e p o st e ro m e -
d ia l e d g e o f t h e t ib ia l m e t a p h ysis (TECH FIG 1 A).
■ Th e sa p h e n o u s ve in a n d n e rve sh o u ld b e ca re fu lly
a vo id e d d u rin g t h e su p e rficia l d isse ct io n .
■ De e p d isse ct io n co n t in u e s t o e xp o se t h e p e s a n se rin e
t e n d o n s (TECH FIG 1 B), w h ich ca n b e m o b ilize d a n t e -
rio rly a n d p o st e rio rly.
■ If m o re p ro xim a l e xt e n sio n o f t h e in cisio n is n e e d e d ,
t h e su rg e o n ca n p ro ce e d p o st e rio r a n d p a ra lle l t o t h e
p e s a n se rin e t e n d o n s.
FIG 4 • Su p in e p o sit io n in g fo r fixa t io n o f b ico n d yla r t ib ia l p la -
t e a u fra ct u re s sh o u ld p ro vid e fo r u n h in d e re d AP a n d la t e ra l flu -
o ro sco p ic ra d io g ra p h s a n d b o t h m e d ia l a n d la t e ra l a p p ro a ch e s.
Positioning
■ The patient is placed supine with the contralateral limb se-
cured to a radiolucent or fracture table, with a bump under the
ipsilateral hip (removed for medial approach) (FIG 4 ).
■ N onsterile high thigh tourniquet
■ C-arm on contralateral side with the monitor near the head
of the bed
Approach
■ A midline approach with medial and lateral exposure has been
associated with high complication rates and should be avoided.
■ When medial and lateral exposure is required, an antero-
lateral exposure with the addition of a posteromedial ap-
proach is therefore preferred.
■ An anterolateral approach is the standard approach for
most tibial bicondylar fractures. It allows for direct exposure
of lateral meniscus and intra-articular fractures and for place-
ment of lateral plates.
■ M etaphyseal fracture components are best treated indi-
rectly, especially when comminuted, to maximally preserve
biologic potential for healing.
■ The medial condyle can be stabilized with lateral locking
plates, provided multiple locking screws engage the medial
fragment.
■ Bicondylar fractures with displaced medial articular involve-
ment require more direct reduction and stabilization, usually
via a posteromedial exposure.
■ Soft tissue dissection should be limited with a dual incision
technique.
■ A minority of fractures, those with a bicondylar posterior
shearing injury pattern, may benefit from a direct posterior
exposure.
■ Th e m e d ia l g a st ro cn e m iu s is e a sily d isse ct e d fro m t h e
p o st e ro m e d ia l t ib ia .
■ Su b p e rio st e a l d isse ct io n sh o u ld b e lim it e d t o t h e fra ct u re
m a rg in s t o a id in co n firm a t io n o f t h e re d u ct io n .
■ Th e p la t e sh o u ld b e slig h t ly u n d e rco n t o u re d t o
h e lp b u t t re ss t h e p o st e ro m e d ia l fra g m e n t (TECH FIG
1 C,D).
 Ch a p t e r 4 5 ORIF OF BICONDYLAR TIBIAL PLATEAU FRACTURES 429

TECHNIQUES
A B

C D

TECH FIG 1 • A. Skin in cisio n fo r p o st e rio r m e d ia l a p p ro a ch t o t ib ia l p la t e a u . B. De e p

d isse ct io n fo r t h e p o st e rio r m e d ia l a p p ro a ch in clu d e s e xp o su re o f t h e p e s a n se rin e t e n -
d o n s, w h ich a re p re se rve d . AP (C) a n d la t e ra l (D) p o st o p e ra t ive ra d io g ra p h s sh o w in g
la t e ra l p lu s p o st e ro m e d ia l p la t e fixa t io n o f a b ico n d yla r t ib ia l p la t e a u fra ct u re .

LATERAL EXPOSURE
■ Th e su rg e o n id e n t ifie s a n d m a rks la n d m a rks (t u b e rcle o f
Ge rd y, t ib ia l cre st , p a t e lla , fib u la r h e a d ).
■ Th e lo w e r e xt re m it y is e xsa n g u in a t e d a n d t h e t o u rn iq u e t
in fla t e d t o a b o u t 300 m m Hg .
■ To u rn iq u e t u se is o p t io n a l.
■ Th e skin in cisio n is m a rke d . Th e in cisio n sh o u ld b e g in d is-
t a lly a b o u t 2 cm la t e ra l t o t h e t ib ia l cre st , cu rvin g o ve r
t h e t u b e rcle o f Ge rd y, t h e n p ro ce e d in g su p e rio rly o ve r
t h e fe m o ra l e p ico n d yle (TECH FIG 2 A).
■ Th e skin is in cise d a lo n g t h e m a rke d in cisio n . Th e su r-
g e o n sh a rp ly d isse ct s t o fa scia w it h o u t d e t a ch in g su b cu -
t a n e o u s fa t fro m t h e fa scia (TECH FIG 2 B).
■ Th e fib e rs o f t h e ilio t ib ia l b a n d a re sp lit lo n g it u d in a lly
p a ra lle l t o t h e skin in cisio n w it h o u t d isru p t in g t h e ca p -
su le (TECH FIG 2 C).
■ Th e ilio t ib ia l b a n d is e le va t e d fro m t h e t u b e rcle o f Ge rd y
a n t e rio rly a n d p o st e rio rly.
■ If re q u ire d fo r la t e ra l a rt icu la r re d u ct io n , a la t e ra l sub -
m e n sica l a rt h ro t o m y is m a d e b y in cisin g t h e ca p su le h o r-
izo n t a lly, in clu d in g t h e co ro n a ry liga m e n t (TECH FIG 2 D).
■ Th e m e n iscu s is e le va t e d a n d in sp e ct e d fo r t e a rs.
■ Th e su rg e o n d ire ct ly visu a lize s in t ra -a rt icu la r fra ct u re
fra g m e n t s la t e ra lly a n d o b t a in s re d u ct io n .
■ Th e m e t a p h yse a l fra ct u re s sh o u ld b e in d ire ct ly re -
d u ce d w it h flu o ro sco p ic g u id a n ce .
■ Pre lim in a ry re d u ct io n m a y b e h e ld w it h Kirsch n e r
w ire fixa t io n o r a la rg e p e ria rt icu la r re d u ct io n fo rce p .
■ Sim u lt a n e o u s e xp o su re o f t h e m e d ia l sid e m a y b e
re q u ire d if m e d ia l re d u ct io n is n o t o b t a in e d b y in d i-
re ct m e t h o d s.
 430 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES

A B

C D

TECH FIG 2 • A. La n d m a rks (p a t ella , t ib ia l t u b e rcle , t u b ercle o f Ge rd y, a n d fib u la ) fo r t h e a n t e -

rio r la t e ra l a p p ro a ch . B. An t e rio r lat e ra l a p p ro a ch su p e rficia l d isse ct io n . C. De e p lat e ra l e xp o su re
w it h ilio t ib ia l ba n d in cise d p a ra lle l t o it s fib e rs ce nt e re d o ve r t u b e rcle o f Ge rd y. D. Su b m e n sica l
a rt h ro t o m y p ro vid e s d ire ct a ccess t o t h e la t era l a rt icula r su rfa ce .

FIXATION
■ A la t e ra lly a p p lie d p la t e is u se fu l t o su p p o rt la t e ra l sp lit
fra g m e n t s a n d t o su p p o rt d e p re sse d a rt icu la r fra g m e n t s
(via t h e ra ft e ffe ct o f m u lt ip le p ro xim a l scre w s p la ce d
su b ch o n d ra lly).
■ Su p p o rt o f t h e m e d ia l sid e ca n b e p ro vid e d via a
la t e ra l p la t e w h e n t h e m e d ia l fra g m e n t is o f su ffi-
cie n t size a n d lo ca t io n t h a t m u lt ip le scre w s fro m
t h e la t e ra l p la t e e n g a g e t h e m e d ia l fra g m e n t (TECH
FIG 3 ).
■ Lo ckin g scre w s p ro vid e su p e rio r re sist a n ce t o m e d ia l
su b sid e n ce a n d a re p re fe rre d t o n o n lo ckin g scre w s
fo r t h is a p p lica t io n .

A B C

TECH FIG 3 • Bico nd yla r t ib ia l p la t e a u fra ctu re . Preo p era t ive AP (A) an d la te ra l (B) ra d io gra p hs a n d CT sca n (C).
(co n t in u e d )
 Ch a p t e r 4 5 ORIF OF BICONDYLAR TIBIAL PLATEAU FRACTURES
D E
TECH FIG 3 • (co n t in u e d ) D,E. AP an d lat eral rad io g rap h s after t reat m en t
w ith a sin gle la t e ra l lo ckin g p la te .
■ Wh e n co m p re ssio n is re q u ire d b e t w e e n t h e m e d ia l a n d
la t e ra l fra g m e n t , n o n lo cke d la g scre w s sh o u ld b e u se d
b e fo re p la cin g lo cke d scre w s a cro ss t h e fra ct u re lin e .
■ Wh en t h e m ed ial fra g me n t is o f su ch size an d lo cat io n
th a t m u lt iple lo cked scre ws fro m a la t era l p la te ca n no t en -
g age th is frag m e nt , se pa ra t e me d ia l fixa t ion is req u ire d .
■ Th is is m o st co m m o n ly t h e ca se w it h p o st e rio r m e d ia l
fra g m e n t s t h a t a re a m e n a b le t o se p a ra t e p o st e ro m e -
d ia l b u t t re ss p la t e fixa t io n .
■ Su b ch o n d ra l d e fe ct s sh o u ld b e g ra ft e d w it h a llo g ra ft ,
a u t o g ra ft , o r b o n e su b st it u t e .
■ It m a y b e h e lp fu l in so m e ca se s t o u se a llo g ra ft b o n e
cro u t o n s t o h e lp re d u ce d e p re sse d fra ct u re fra g m e n t s b y
POSTERIOR APPROACH (POSTERIOR SHEARING FRACTURE)
■ An S-sh a p e d in cisio n st a rt s m id lin e su p e rio rly a n d e x-
t e n d s m e d ia l d ist a lly. Th e in cisio n is ce n t e re d o n t h e
p o p lit e a l fo ssa , w it h t h e t ra n sve rse co m p o n e n t m a d e a t
t h e jo in t lin e (TECH FIG 4 A,B).
■ Th e su rg e o n id e n t ifie s a n d p ro t e ct s t h e co m m o n p e r-
o n e a l n e rve , p o p lit e a l a rt e ry a n d ve in , t ib ia l n e rve , a n d
m e d ia l su ra l cu t a n e o u s n e rve (TECH FIG 4 C).
■ Fu ll-t h ickn e ss fa scio cu t a n e o u s fla p s a re ra ise d .
■ Th e la t e ra l h e a d o f t h e g a st ro cn e m iu s is d isse ct e d b lu n t ly
a n d it s b lo o d su p p ly p ro t e ct e d d ist a lly. Th e t e n d o n is d i-
vid e d p ro xim a lly, le a vin g a st u m p fo r re p a ir.
431
TECHNIQUES
im p a ct in g t h e g ra ft t h ro u g h a co rt ica l w in d o w in fe rio r
t o t h e a rt icu la r su rfa ce .
■ A t a m p is u se d t o im p a ct t h e g ra ft a lo n g t h e in fe rio r
su rfa ce o f t h e d e p re sse d fra g m e n t a n d e le va t e t h e
fra g m e n t t o it s p ro p e r p o sit io n .
■ On ce t h e a rt icu la r su rfa ce h a s b e e n re d u ce d a n d fin a l fix-
a t io n a ch ie ve d , t h e n t h e m e n iscu s m a y b e re p a ire d if
needed.
■ Mo st o f t h e m e n isca l in ju rie s a re p e rip h e ra l rim t e a rs a n d
m a y b e re p a ire d in a h o rizo n t a l m a t t re ss fa sh io n t o t h e
ca p su le .
■ La ye re d clo su re o f t h e la t e ra l w o u n d is d o n e w it h a la t -
e ra l d ra in .
■ Th e la t e ra l g a st ro cn e m iu s is re t ra ct e d m e d ia lly (TECH
FIG 4 D).
■ Th e p o p lit e u s a n d so le u s o rig in a re e le va t e d o ff t h e p o s-
t e ro m e d ia l a sp e ct o f t h e p ro xim a l t ib ia .
■ Th e a rt icu la r su rfa ce is e le va t e d t h ro u g h t h e fra ct u re sit e
a n d t h e re d u ct io n a sse sse d w it h flu o ro sco p y.
■ A 3.5-m m p la t e is co n t o u re d t o b u t t re ss t h e fra g m e n t s.
La g scre w t e ch n iq u e is u se d t o co m p re ss t h e fra g m e n t s
(TECH FIG 4 E,F).
 432 Se c t i o n IV FEM UR AND KNEE

TECH FIG 4 • A,B. Axia l an d sag it t al CTs d e mo n st ra tin g p o ste rio r sh earin g in ju ry.
TECHNIQUES

C. Post erio r S-shaped incision sta rt ing midline supe riorly, transve rse at th e jo in t line, and
ext end in g to the me dial sid e in t he dista l aspect of t he incision. D. Th e lat eral gast rocne-
miu s is re lea se d afte r ide n tifica tio n o f ne u rova scu la r stru ctu res an d eleva te d m edially.
E,F. Po st operat ive AP a nd la te ra l ra diographs de mon st ra ting poste rior pla ting.

C E F

PEARLS AND PITFALLS

Do n o t re ly o n a la t e ra l lo cke d p la t e t o p re ve n t va ru s co lla p se
o f b ico n d yla r fra ct u re s w it h p o st e ro m e d ia l a rt icu la r
co m p o n e n t s.
Po st e ro m e d ia l in t ra -a rt icu la r t ib ia l fra g m e n t s n e e d b u t t re ss
p la t e s t o p re ve n t va ru s co lla p se e ve n w it h n e w e r lo ckin g
p la t e t e ch n o lo g y.
Wh e n t h e m e d ia l fra g m e n t is o f su ch size a n d lo ca t io n t h a t
m u lt ip le lo cke d scre w s fro m a la t e ra l p la t e ca n n o t e n g a g e
t h is fra g m e n t , se p a ra t e m e d ia l fixa t io n is re q u ire d . Th is is
m o st co m m o n ly t h e ca se w it h p o st e rio r m e d ia l fra g m e n t s
t h a t a re a m e n a b le t o se p a ra t e p o st e ro m e d ia l b u t t re ss p la t e
fixa t io n .
Fa ilu re t o re co g n ize m e n isca l in ju ry a n d re p a ir.
■ A la t e ra lly a p p lie d p la t e is u se fu l t o su p p o rt la t e ra l sp lit
fra g m e n t s (via b u t t re ss e ffe ct ) a n d t o su p p o rt d e p re sse d
a rt icu la r fra g m e n t s (via a ra ft e ffe ct o f m u lt ip le p ro xim a l
scre w s p la ce d su b ch o n d ra lly).
■ Su p p ort o f t h e m e d ia l sid e ca n b e p ro vid e d via a la t e ra l p la t e
w h e n t h e m e d ia l fra g m e n t is o f su ch a size a n d lo ca t io n
t h a t m u lt ip le scre w s fro m t h e la t e ra l p la t e e n g a g e t h e
m e d ia l fra g m e n t . Lo ckin g scre w s p ro vid e su p e rio r re sist a n ce
t o m e d ia l su b sid e n ce a n d a re p re fe rre d t o n o n lo ckin g scre w s
fo r t h is a p p lica t io n .
■ Wh e n co m p re ssio n is re q u ire d b e t w e e n t h e m e d ia l a n d
la t e ra l fra g m e n t s, n o n lo cke d scre w s sh o u ld b e u se d b e fo re
p la cin g lo cke d scre w s a cro ss t h e fra ct u re sit e .
 Ch a p t e r 4 5 ORIF OF BICONDYLAR TIBIAL PLATEAU FRACTURES
POSTOPERATIVE CARE
■ Use of a continuous passive motion (CPM ) device should be
started immediately after surgery at about 0 to 40 degrees.
Flexion is advanced 5 to 10 degrees during each of three 2-
hour sessions per day, with the goal being 0 to 90 degrees be-
fore hospital discharge.
■ Deep vein thrombosis prophylaxis is considered with low-
molecular-weight heparin, aspirin, or Coumadin and a sequen-
tial compression device on the contralateral limb.
■ Initial home physical therapy concentrates on restoring range
of motion with closed-chain active range-of-motion exercises.
■ Toe-touch weight bearing is permitted for 6 to 12 weeks de-
pending on radiographic and clinical healing response.
■ Weight bearing is advanced and strengthening exercises are
initiated upon fracture healing, usually about 8 to 12 weeks
postoperatively.
OUTCOMES
■ Satisfactory articular reduction (step-off or gap of 2 mm or
less) in 62.1% of cases2
■ 91.2% had satisfactory coronal plane alignment
■ 72.1% had satisfactory sagittal plane alignment
■ According to Barei et al, 2 bicondylar tibial plateau fractures
have a significant negative effect on leisure activities, employ-
ment, and general mobilization. Significant residual dysfunc-
tion was observed out to 51 months postoperatively when
compared with the general population.2
■ Decreased arc of motion compared to the uninvolved
extremity
COMPLICATION S
■ Compartment syndrome
■ Infection (7% to 8.4% )1
433
■ Superficial and deep wound complications
■ Residual knee joint instability
■ Removal of hardware due to local discomfort
■ Deep vein thrombosis
■ Arthrosis
■ Loss of motion
REFEREN CES
1. Barei DP, N ork SE, M ills WJ, et al. Complications associated with in-
ternal fixation of high energy bicondylar plateau fractures utilizing a
two-incision technique. J O rthop Trauma 2004;18:649–657.
2. Barei DP, N ork SE, M ills W, et al. Functional outcomes of severe bi-
condylar fractures treated with dual incisions and medial and lateral
plates. J Bone Joint Surg Am 2006;88A:1713–1721.
3. Delamarter RB, H ohl M , H opp E. Ligament injuries associated with
tibial plateau fractures. Clin O rthop Relat Res 1990;250:226–233.
4. Gardner M J, Yacoubian S, Geller D, et al. The incidence of soft
tissue injury in operative tibial plateau fractures: a magnetic re-
sonance imaging analysis of 103 patients. J O rthop Trauma 2005;
19:79–84.
5. H su R, H imeno S, Coventry M , et al. N ormal axial alignment of the
lower extremity and load-bearing distribution at the knee. Clin
O rthop Relat Res 1990;255:215–227.
6. Kennedy J, Bailey W. Experimental tibial-plateau fractures. J Bone
Joint Surg Am 1968;50A:1522–1534.
7. Lachiewicz PF, Funcik T. Factors influencing the results of open re-
duction and internal fixation of tibial plateau fractures. Clin O rthop
Relat Res 1990;259:210–215.
8. M orrison JB. The mechanics of the knee joint in relation to normal
walking. J Biomech 1970;3:51–66.
9. O ttolenghi C. Vascular complications in injuries about the knee joint.
Clin O rthop Relat Res 1982;165:148–156.
10. Paley D. Principles of Deformity Correction. Berlin: Springer-Verlag,
2002.
11. Rasmussen P. Tibial condyle fractures. J Bone Joint Surg Am 1973;
55A:1331–1349.
 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 46 Fix a t io n o f La t e r a l Tib ia l
Pla t e a u Fr a ct u re s
Ph ilip p Ko b b e an d Han s Ch rist o p h Pap e
DEFIN ITION
■ Tibial plateau fractures are intra-articular fractures that
may result in a malalignment of the articular surface and bear
the risk of subsequent arthritis.
AN ATOMY
■ The tibial plateau consists of three osseous structures: the
lateral plateau, the medial plateau, and the intercondylar
eminence.
■ The lateral plateau is smaller and convex, whereas the
medial plateau is larger and slightly concave. Both plateaus
are covered by a meniscus, which serves as a shock absorber
and improves the congruency of the femorotibial joint.
■ The lateral plateau sits slightly higher than the medial
joint surface, forming an angle of 3 degrees of varus with re-
spect of the tibial shaft. This is helpful in identifying the lat-
eral plateau on the lateral radiograph.
■ The anatomy of the tibial plateau leads to an eccentric
load distribution in which the lateral plateau bears 40% of
the knee’s load.1 This asymmetric weight bearing results in
increased medial subchondral bone formation and a
stronger, denser medial plateau.
■ The intermediate, nonarticular intercondylar eminence
serves as the tibial attachment of the anterior and posterior
cruciate ligaments.
■ The stability of the knee joint is based on the cruciate lig-
aments, the collateral ligaments, and the capsule.
■ The tibial tuberosity and the tubercle of Gerdy are bony
prominences located in the subcondylar region for insertion of
the patellar tendon and the iliotibial tract, respectively. These
landmarks are important for planning surgical incisions.
PATHOGEN ESIS
■ Several anatomic factors have been thought to contribute to
the higher incidence of lateral as opposed to medial plateau
fractures.
■ The relative softness of the subchondral bone of the lat-
eral plateau, the valgus axis of the lower extremity, and the
susceptibility of the leg to a medially directed force all lead
to a prevalence of lateral plateau fractures in low-energy
injuries.1
■ Tibial plateau fractures are due to either direct trauma to
the proximal tibia and knee joint or to indirect axial forces.
■ The most frequent mechanism causing a lateral plateau
fracture is a direct trauma to the proximal tibia and knee
joint. This induces a valgus force and drives the lateral
femoral condyle into the soft lateral tibial plateau.
■ Indirect axial forces often develop in high-energy injuries
and may be associated with complex tibial plateau fractures.
■ Twisting injuries account for only 5% to 10% of tibial
plateau fractures and are most commonly sports injuries (eg,
skiing).
434
■ Split or wedge fractures occur in younger patients, whereas
depression fractures occur more frequently in older patients with
osteoporotic bone, which is less able to withstand compression.
N ATURAL HISTORY
■ The natural history of lateral tibial plateau fractures de-
pends on the degree of articular depression and knee stability.8
Knee instability may result from the fracture itself but may
also result from accompanying injuries like meniscal injuries
or rupture of cruciate or collateral ligaments.
■ For nondisplaced or minimally displaced fractures, the prog-
nosis is favorable,3,5,6,17,19,22 but displaced fractures, espe-
cially in combination with knee instability, tend to result in
early posttraumatic arthritis.
■ M eniscal injuries have been reported in up to 50% of tibial
plateau fractures. M eniscal injuries are a major determinant of
prognosis because meniscal integrity is important for joint sta-
bility and may compensate for articular incongruity.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ The physical examination should always include a thorough
assessment of the soft tissue envelope.
■ The marginal soft tissue envelope of the proximal tibia predis-
poses to open fractures and development of tissue necrosis. It is
important to assess severe soft tissue injury because it may not
allow primary plating of the fracture, requiring external fixation.
■ A compartment syndrome may result from continuous hem-
orrhage through the metaphysis into the area of the tibial shaft.
■ Clinical findings indicating a manifest compartment syn-
drome include pain, paresthesia, paresis, pain with stretch, in-
tact pulses, and pink skin coloring.
■ Such findings require immediate fasciotomy.
■ An imminent compartment syndrome requires repeated or
continuous compartment pressure monitoring.
■ A pressure difference between the diastolic pressure and the
compartment pressure of less than 30 mm H g is considered
to be a manifest compartment syndrome,15 which requires
fasciotomy.
■ The neurovascular status of the extremity must be carefully
evaluated, although concomitant injuries of neurovascular
structures are rare in proximal tibia fractures.
■ Palpation of peripheral pulses
■ Doppler ultrasound
■ An ankle-brachial index less than 0.9 indicates that vascu-
lar injury is very likely.
■ Impaired sensorimotor status may indicate compartment
syndrome; impaired dorsal flexion may indicate direct per-
oneal nerve injury.
■ Examination of knee stability is difficult because of pain, so
it should be tested under anesthesia. Assessment of knee
stability may be difficult on initial examination because of
 Ch a p t e r 4 6 ORIF OF LATERAL TIBIAL PLATEAU FRACTURES
intracapsular hematoma and pain. Varus and valgus stress ra-
diographs of the knee in near-full extension can be performed
with sedation or under general anesthesia. Widening of the
femoral–tibial articulation of more than 10 degrees indicates
ligamentous insufficiency.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Plain anteroposterior (AP) and lateral radiographs should be
centered on the knee, with the AP view angled 10 degrees in a
craniocaudal direction to approximate the posterior slope of
the plateau.
■ The standard tool in analyzing tibial plateau fractures is
the three-dimensional CT scan, because the number and de-
gree of isolated fractures are often underestimated on plain
radiographs. 13
■ Although M RI evaluates both osseous and soft tissue in-
juries, it has not yet become a standard tool in analyzing tibial
plateau fractures. It may be helpful in identifying meniscal and
ligamentous injuries.
■ In selected cases (eg, no CT diagnostics available), stress ra-
diographs may be helpful in making decisions about surgical
management.
DIFFEREN TIAL DIAGN OSIS
■ Ligamentous injuries of the knee
■ Knee dislocation
■ M eniscal injury
■ Bone bruise
■ Compartment syndrome
N ON OPERATIVE MAN AGEMEN T
■ For nondisplaced or minimally displaced fractures, the indi-
cations for surgical treatment are controversial and vary
widely in the literature. The range of acceptance for articular
depression varies from 2 mm to 1 cm.3,5,6,17,19,22
■ N ondisplaced or minimally displaced tibial plateau fractures
with stability of the knee joint can be managed nonopera-
tively, provided that the patient is compliant.
■ Partial weight bearing in a hinged fracture brace for 8 to
12 weeks with regular radiographic controls is recommended.
■ Isometric quadriceps exercises and progressive passive,
active-assisted, and active range-of-knee motion exercises are
recommended to avoid substantial muscle atrophy.
■ Failure to maintain reduction with nonoperative management
is an indication for surgical fracture stabilization. Therefore, fre-
quent surveillance radiographs are required for the management
of these patients.
SURGICAL MAN AGEMEN T
■ The primary management of tibial plateau fractures is usu-
ally dictated by the soft tissue injury and by the fracture type.
■ Absolute indications for surgery are displaced fractures,
open fractures, fractures with vascular or neurologic lesions,
fractures with compartment syndrome, and fractures with val-
gus instability.
■ The goals in the surgical treatment of tibial plateau fractures
are restoration of articular surface, axis, meniscal integrity, and
stability to avoid or postpone posttraumatic arthritis. Fracture
stability allows early rehabilitation and supports long-term full
recovery.
435
■ The degree of soft tissue injury and the general condition of
the patient are important factors in surgical decision making.
■ If there is severe soft tissue damage, an open fracture, or
a polytraumatized patient, a temporary external fixator is
applied. Definitive fracture stabilization with open reduc-
tion and internal fixation is delayed until soft tissue damage
or the patient’s critical condition has been resolved.
Preoperative Planning
■ Review of radiographs, CT, M RI
■ Surgical approach and placement of implants
■ Depression fractures with continuity of the lateral cortex
require only screw osteosynthesis.
■ Whether a cortical window is required depends on the de-
gree and location of impaction. Condylar widening is a good
radiologic sign for the requirement of articular elevation with
a pestle via a cortical window.
■ M eniscal and ligamentous injuries require open joint or
arthroscopic surgery.
■ The surgeon should consider the need of bone grafting (iliac
crest bone graft, bone graft substitute) when severe depression
of the plateau is obvious.
■ For surgical decision making, a separate classification of the
fracture and degree of soft tissue injury is important.
■ O pen fractures are classified according to Gustilo et al. 4
■ The soft tissue injury is classified according to Tscherne
and O estern.21
■ The AO /O TA classification for proximal tibial fractures
distinguishes between extra-articular, partial-articular, and
complete-articular fractures, and further subdivides based on
the level of comminution (Table 1).
■ Schatzker’s classification distinguishes between lateral and
medial plateau fractures (Table 2).
■ In general, types I through III are low-energy injuries af-
fecting the lateral plateau.
■ Types IV through VI involve increasingly higher-energy
injuries mostly affecting the medial plateau in combination
with ligamentous injuries.19
Positioning
■ Supine position
■ Bolster under knee to improve internal rotation: the knee
should be slightly bent (about 30 degrees) to reduce tension of
collateral ligaments (FIG 1 )
AO Cla s s if ica t io n f o r
Ta b le 1 Pr o x im a l Tib ia l Fr a ct u r e s
Cla s s if ica t io n De s cr ip t io n
AO-41-A Extra-articular fractures
AO-41-B Partial intra-articular fractures
B1 Split fracture of the lateral plateau
B2 Depression fracture of the lateral plateau
B3 Split-depression fracture of the lateral plateau
AO-41-C Complete articular fractures
C1 Simple bicondylar fracture with simple
metaphyseal fracture
C2 Simple bicondylar fracture with comminuted
metaphyseal fracture
C3 Comminuted articular and metaphyseal fracture
 436 Se c t i o n IV FEM UR AND KNEE

with preservation of all anatomic structures and minimal soft

Ta b le 2 Sch a t zk e r ’s Cla s s if ica t io n
tissue and osseous devitalization. It can be summarized as:
■ Elevation of the meniscus

Ty p e De s cr ip t io n ■ Reduction of the fracture

I Split fracture of the lateral tibial plateau ■ Temporary retention with Kirschner wire or small frag-
II Split-depression fracture of the lateral tibial plateau
ment lag screw
III Pure central depression fracture of the lateral tibial plateau ■ Final stabilization with lag screws, conventional plate, or
IV Split (type A) or depression (type B) fracture of the medial
plateau angular stable plate
■ The incision must be planned to avoid implant location di-
V Bicondylar tibial plateau fracture
VI Comminuted tibial plateau fracture with dissociation between rectly underneath the skin incision. Important landmarks are
the metaphysis and the diaphysis the joint line, the tubercle of Gerdy, the tibial tubercle, the
fibula head, and the lateral femoral epicondyle (FIG 2 ).
■ The standard approach for lateral tibial plateau fractures

■ Tourniquet to minimize blood loss and to improve fracture is the anterolateral approach, which provides excellent expo-
visualization sure of the lateral plateau and allows good soft tissue cover-
■ Radiolucent operating table to allow intraoperative use of age of the implant, especially after minimally invasive plate
fluoroscopy and image intensification application.
■ The posterolateral approach is indicated for fractures of the
■ Contralateral leg placed in leg carrier

■ Ipsilateral iliac crest is prepared and draped if bone graft is lateral posterior plateau.
needed.
Approach
■The surgical approach for lateral tibial plateau fractures de-
mands good visualization of the lateral plateau, combined

FIG 1 • Le g p o sit io n t o re d u ce co lla t e ra l lig a m e n t t e n sio n . FIG 2 • La n d m a rks fo r skin in cisio n .

TECHNIQUES

ANTEROLATERAL APPROACH
■ A st ra ig h t o r a h o cke y-st ick in cisio n (a b o u t 10 cm ) w it h ■ Th e t ib ia lis a n t e rio r m u scle is e le va t e d o ff t h e p ro xi-
t h e kn e e in 30 d e g re e s o f fle xio n is m a d e . m a l t ib ia t o t h e le ve l o f t h e ca p su le a n d t h e co ro n a ry
■ Th e in cisio n is e xt e n d e d d o w n t h ro u g h t h e ilio t ib ia l lig a m e n t is in cise d (TECH FIG 1 ).
b a n d p ro xim a lly a n d t h e fa scia o f t h e a n t e rio r co m p a rt - ■ To e xp o se t h e la t e ra l t ib ia l p la t e a u , t h e la t e ra l m e n is-
m e n t d ist a lly. cu s is ra ise d w it h h o ld in g su t u re s a ft e r in cisio n o f t h e
co ro n a ry lig a m e n t .
■ Th e size o f t h e fra g m e n t is cru cia l fo r t h e d e cisio n o f
Iliotibial band w h e t h e r so ft t issu e is st rip p e d o ff. Fo r sm a ll fra g -
Tibia Released m e n t s n o t a llo w in g co m p re ssio n , st rip p in g t h e d is-
extensor p la ce d fra g m e n t fo r b u t t re ss p la t in g is in d ica t e d .
muscles

Capsule of
tibiofibular joint

TECH FIG 1 • An t e ro la t e ra l a p p ro a ch .
 Ch a p t e r 4 6 ORIF OF LATERAL TIBIAL PLATEAU FRACTURES 437

TECHNIQUES
POSTEROLATERAL APPROACH
■ A lo n g it u d in a l in cisio n is m a d e a lo n g t h e p ro xim a l fib u la ■ Aft e r e xp o su re o f t h e p e ro n e u s n e rve , o st e o t o m y o f
(TECH FIG 2 ). fib u la h e a d is p e rfo rm e d .
■ Th e e xt e n so r m u scle s a re m o b ilize d fro m t h e t ib ia l ■ At t h e e n d o f su rg e ry t h e fib u la r h e a d is re fixa t e d b y
p la t e a u . t e n sio n b a n d w irin g o r scre w fixa t io n .

Tibia

Fibula

Collateral
ligament
Attachment of
biceps femoris m. TECH FIG 2 • Po st e ro la t e ra l a p p ro a ch .

REDUCTION
■ Ca re fu l t re a t m e n t o f so ft t issu e a n d p e rio st e u m is ■ Disp la ce d fra g m e n t s a re re d u ce d w it h re d u ct io n t o o ls.
m a n d a t o ry. ■ Re d u ct io n is t e m p o ra rily m a in t a in e d w it h Kirsch n e r
■ Re d u ct io n is a id e d b y lig a m e n t o t a xis a n d ca re fu l m a n ip - w ire s o r la g scre w s (TECH FIG 3 ).
u la t io n . An e xt e rn a l fixa t o r o r a d ist ra ct o r m a y b e a h e lp -
fu l t o o l.

A B C

TECH FIG 3 • A. Te m p o ra ry re t e n t io n o f fra ct u re re d u ct io n w it h Kirsch n e r w ire . B. Alig n m e n t o f a n g u la r st a b le p la t e .

C. Fin a l st a b iliza t io n w it h a n g u la r st a b le p la t e .

REDUCTION OF IMPACTED SEGM ENTS

■ Im p re ssio n fra ct u re s n e e d t o b e e le va t e d w it h a p e st le ,
w h ich m a y b e in se rt e d t h ro u g h a d ist a l t ib ia l b o n e
w in d o w (TECH FIG 4 ).
■ Ele va t io n is a ch ie ve d b y ca re fu lly e xe rt in g p u n ch e s o n
t h e p e st le (e g , w it h a h a m m e r) u n d e r flu o ro sco p y u n t il
t h e co n t o u r o f t h e a rt icu la r su rfa ce is re -e st a b lish e d .
■ In ca se s o f se ve re b o n e lo ss, t h e d e fe ct m u st b e fille d
w it h b o n e g ra ft o r b o n e su b st it u t e .
 438 Se c t i o n IV FEM UR AND KNEE
TECHNIQUES

TECH FIG 4 • Use o f b o n e w in d o w t o re d u ce a rt icu la r im p a ct io n .

MENISCAL REPAIR
■ Me n isca l in t e g rit y is im p o rt a n t fo r st a b ilit y a n d t o a vo id
p o st t ra u m a t ic a rt h rit is.
■ Pe rip h e ra l lo n g it u d in a l le sio n s o f t h e a n t e rio r a n d in t e r-
m e d ia t e p a rt o f t h e m e n iscu s a re fixa t e d u sin g t h e
“ o u t sid e -in su t u re ” t e ch n iq u e .
■ Pe rip h e ra l lo n g it u d in a l le sio n s o f t h e p o st e rio r m e n iscu s
a re fixa t e d u sin g t h e “ a ll-in sid e ” t e ch n iq u e t o a vo id in -
ju ry t o t h e n e u ro va scu la r st ru ct u re s in t h e p o p lit e a l a re a .
■ Co m p le x m e n isca l le sio n s in t h e a va scu la r a re a re q u ire
re se ct io n .

OSTEOSYNTHESIS
Im p la n t s Pu re Sp lit Fra ct u re s o f t h e La t e ra l
■ Im p la n t s m a y in clu d e ca n ce llo u s scre w s, co n ve n t io n a l Pla t e a u (AO-41-B1 o r Sch a t zke r I)
p la t e s, o r, m o st re ce n t ly, a n g u la r st a b le p la t e s. ■ Fo r fixa t io n , t w o la rg e p a rt ia lly t h re a d e d ca n ce llo u s
■ If t h e lat eral m et ap h yseal sh ell is in ta ct , a lag scre w w it h a b o n e scre w s w it h w a sh e rs ca n b e u se d (TECH FIG 5 ).
wa she r or a t hre e-hole conve ntion al plat e in th e ant iglide
p osit io n is usu a lly su fficie n t.
■ Mu lt ifra g m e n t a ry fra ct u re s o r fra ct u re s w it h se ve re b o n e
lo ss u su a lly re q u ire p la t e o st e o syn t h e sis.
■ Pre fo rm e d lo ckin g o r n o n lo ckin g p la t e s a llo w a n e xa ct
a lig n m e n t a n d re t e n t io n o f t h e fra ct u re .
■ A m in im a lly in va sive t e ch n iq u e b y slid in g t h e p la t e w it h
t h e a im in g d e vice u n d e rn e a t h t h e m u scle m a y b e
se le ct e d . Th e scre w s ca n b e a p p lie d b y st it ch in cisio n s.

Lo ckin g Pla t e s
■ In m u lt ifra g m e n t a ry fra ct u re s o r fra ct u re s w it h se ve re
b o n e lo ss, a n e vid e n ce -b a se d a d va n t a g e o f lo ckin g p la t e s
ve rsu s n o n lo ckin g p la t e s h a s n o t b e e n re p o rt e d in t h e
lit e ra t u re .
■ Ho w e ve r, lo ckin g p la t e s in t h e se t yp e s o f p la t e a u fra c-
t u re s a re a d visa b le fo r t h e fo llo w in g re a so n s:
■ An g u la r st a b le p la t e s re q u ire le ss b o n e g ra ft co m -
p a re d t o co n ve n t io n a l p la t e s in fra ct u re s w it h se ve re
b o n e lo ss.
■ Th e st a b ilit y o f a n g u la r st a b le p la t e s d o e s n o t d e -
p e n d o n frict io n b e t w e e n t h e p la t e a n d t h e b o n e , so
le ss co m p re ssio n o f t h e p e rio st e u m , w it h co n se -
q u e n t b e t t e r b lo o d su p p ly t o t h e fra ct u re a re a , is TECH FIG 5 • St a b iliza t io n o f B1 o r Sch a t zke r I fra ct u re w it h
a ch ie ve d . t w o la g scre w s a n d t w o -h o le p la t e in a n t ig lid e p o sit io n .
 Ch a p t e r 4 6 ORIF OF LATERAL TIBIAL PLATEAU FRACTURES 439

■ In o st e o p e n ic p a t ie n t s a t h ird ca n ce llo u s b o n e scre w w it h w h e re a s in ca se o f fra g m e n t a t io n a la t e ra l b u t t re ss p la t e

TECHNIQUES
w a sh e r is re co m m e n d e d in a n a n t ig lid e p o sit io n ; a la t - is u se d (TECH FIG 6 ).
e ra l b u t t re ss p la t e is u se d in ca se o f fra g m e n t a t io n .
Sp lit -De p re ssio n Fra ct u re o f t h e
Pu re De p re ssio n Fra ct u re s o f t h e La t e ra l Pla t e a u (AO-41-B3 o r
La t e ra l Pla t e a u (AO-4 1-B2 o r Sch a t zke r II)
Sch a t zke r III) ■ Th e d e p re ssio n is e le va t e d b y w o rkin g t h ro u g h t h e sp lit
■ Th e d e p re ssio n is e le va t e d t h ro u g h a co rt ica l w in d o w co m p o n e n t a n d d e p o sit io n o f b o n e g ra ft (TECH FIG 7 ).
a n d st a b ilize d w it h t w o su b ch o n d ra l ca n ce llo u s b o n e ■ Th re e p o sit io n scre w s a re pla ce d su b ch o n d ra lly t o su p po rt
scre w s. In ca se s o f se ve re b o n e lo ss, b o n e g ra ft o r b o n e t h e im p a ct ed jo in t su rface (ra ft in g ) an d a lo ckin g p la t e o r
g ra ft su b st it u t e m a y a lso b e n e e d e d fo r st a b iliza t io n . b u t t re ss p lat e is a p p lie d .
■ In o st e o p e n ic p a t ie n t s, a t h ird ca n ce llo u s b o n e scre w
w it h w a sh e r is re co m m e n d e d in a n a n t ig lid e p o sit io n ,

TECH FIG 6 • St a b iliza t io n o f B2 o r Sch a t zke r III fra ct u re w it h TECH FIG 7 • St a b iliza t io n o f B3 o r Sch a t zke r II fra ct u re w it h
la g scre w s a n d w a sh e rs. (Fro m Sch e e rlin ck T, Ng CS, b u t t re ss p la t e .
Ha n d e lb e rg F, e t a l. Me d iu m -t e rm re su lt s o f p e rcu t a n e o u s,
a rt h ro sco p ica lly-a ssist e d o st e o syn t h e sis o f fra ct u re s o f t h e t ib -
ia l p la t e a u . J Bo n e Jo in t Su rg Br 1998;80:959–964.)

PEARLS AND PITFALLS

Me n isca l re p a ir
Art icu la r d e p re ssio n
Bo n e g ra ft in g
So ft t issu e a sse ssm e n t
■ Me n isca l re p a ir is cru cia l t o re d u ce t h e in cid e n ce o f d e g e n e ra t ive ch a n g e s a ft e r t ib ia l p la t e a u fra ct u re s.
Eve n a fa ile d m e n isca l re p a ir t h a t re q u ire s su b se q u e n t m e n isco t o m y ca n b e b rie fly p ro t e ct ive t o t h e
u n d e rlyin g ca rt ila g e .19
■ Art icu la r d e p re ssio n is a m a jo r d e t e rm in a n t o f p o st t ra u m a t ic a rt h rit is. Aft e r su rg ica l m a n a g e m e n t , n o
a rt icu la r d e p re ssio n sh o u ld b e o b vio u s. Ho w e ve r, se co n d a ry a rt icu la r d e p re ssio n m a y o ccu r d u e t o lo ss
o f fixa t io n . To p re ve n t se co n d a ry a rt icu la r d e p re ssio n , su fficie n t b o n e g ra ft o r b o n e g ra ft su b st it u t e
sh o u ld b e u se d t o st a b ilize t ib ia l p la t e a u d e p re ssio n fra ct u re s. Ho w e ve r, t ib ia l p la t e a u d e p re ssio n fra ct u re s
w it h a p o o r ra d io g ra p h ic re co n st ru ct io n m a y st ill b e a sso cia t e d w it h a g o o d fu n ct io n a l o u t co m e
if m e n isca l in t e g rit y is p re se rve d .
■ Exce ssive so ft t issu e st rip p in g m a y in cre a se t h e risk fo r in fe ct io n a n d n o n u n io n . Th e re fo re , m in im a lly
in va sive t e ch n iq u e s w it h t h e le a st p o ssib le so ft t issu e st rip p in g a n d so ft t issu e irrit a t io n sh o u ld b e u se d .
■ Ilia c cre st b o n e g ra ft in g is t h e t re a t m e n t o f ch o ice t o m a in t a in t h e re d u ct io n o f d e p re sse d t ib ia l p la t e a u
fra g m e n t s. Bo n e su b st it u t e s su ch a s co ra llin e h yd ro xya p a t it e a n d ca lciu m -p h o sp h a t e ce m e n t s h a ve a lso
b e e n su cce ssfu lly u se d .
■ So ft t issu e a sse ssm e n t is a n e a sy b u t p ivo t a l st e p in t h e m a n a g e m e n t o f t ib ia l p la t e a u fra ct u re s. An e xce l-
le n t re d u ct io n a n d fixa t io n m a y b e co m p ro m ise d b y in fe ct io n se co n d a ry t o in a d e q u a t e a sse ssm e n t o f t h e
su rro u n d in g so ft t issu e st a t u s. Fra ct u re s w it h se ve re so ft t issu e im p a irm e n t b e n e fit fro m e xt e rn a l st a b iliza -
t io n a n d se co n d a ry o p e n re d u ct io n a n d in t e rn a l fixa t io n .
440 Se c t i o n IV FEM UR AND KNEE
POSTOPERATIVE CARE
■ Rehabilitation must be planned individually and depends on
patient age, bone quality, type of osteosynthesis, and concomi-
tant injury.
■ N inety degrees of flexion should be achieved by 7 to 10 days.
■ Toe-touch weight bearing is recommended for 4 to 8 weeks,
with progression thereafter according to radiographic findings.
■ Impression fractures of the lateral plateau managed with a
minimally invasive angular plate are allowed weight bearing
about 12 weeks after surgery.
■ Early mobilization and range-of-motion exercises are key to
the successful treatment of proximal tibia fractures to avoid
later knee stiffness and muscle wasting.
OUTCOMES
■ The outcome depends mostly on knee stability, joint con-
gruity, meniscal integrity, and correct axis.
■ A favorable outcome has been reported for surgically
treated low-energy tibial plateau fractures.20 For split and
split-depression fractures, adequate surgical techniques yield
more than 90% good and excellent results.14
■ H owever, concomitant injuries of ligaments and menisci can
compromise the outcome. Therefore, maintaining menisci and
ligamentous stability is important.8
■ Satisfactory functional results can be obtained in the face of
poor radiographic results, however, and may be due to preser-
vation of the meniscus and its ability to bear the load of the
lateral compartment.7,10
COMPLICATION S
■ Early complications
■ The incidence of wound infection appears to correlate with
the amount of hardware implanted and ranges from 0% to
32% for fractures managed with the buttress technique.23
■ Deep vein thrombosis rates are reported to be 5% to 10% ,
and pulmonary embolus occurs in 1% to 2% of patients.2,12
■ Late complications
■ Loss of fixation with axial malalignment and valgus
deformity11,19
■ M alunion as a consequence of inadequate reduction or
loss of reduction 9
■ Posttraumatic arthrosis, which may result from the initial
chondral damage or may be related to residual joint
incongruity8,18
REFEREN CES
1. Berkson EM , Virkus WW. H igh-energy tibial plateau fractures. J Am
Acad O rthop Surg 2006;14:20–31.
2. Blokker CP, Rorabeck CH , Bourne RB. Tibial plateau fractures: an
analysis of the results of treatment in 60 patients. Clin O rthop Relat
Res 1984;193–199.
3. DeCoster TA, N epola JV, el Khoury GY. Cast brace treatment of
proximal tibia fractures: a ten-year follow-up study. Clin O rthop
Relat Res 1988;196–204.
4. Gustilo RB, M endoza RM , Williams DN . Problems in the manage-
ment of type III (severe) open fractures: a new classification of type
III open fractures. J Trauma 1984;24:742–746.
5. H ohl M . Tibial condylar fractures. J Bone Joint Surg Am 1967;49A:
1455–1467.
6. H ohl M , Luck JV. Fractures of the tibial condyle; a clinical and ex-
perimental study. J Bone Joint Surg Am 1956;38A:1001–1018.
7. H onkonen SE. Indications for surgical treatment of tibial condyle
fractures. Clin O rthop Relat Res 1994;199–205.
8. H onkonen SE. Degenerative arthritis after tibial plateau fractures. J
O rthop Trauma 1995;9:273–277.
9. H onkonen SE, Jarvinen M J. Classification of fractures of the tibial
condyles. J Bone Joint Surg Br 1992;74:840–847.
10. Keogh P, Kelly C, Cashman WF, et al. Percutaneous screw fixation of
tibial plateau fractures. Injury 1992;23:387–389.
11. Koval KJ, H elfet DL. Tibial plateau fractures: evaluation and treat-
ment. J Am Acad O rthop Surg 1995;3:86–94.
12. Lachiewicz PF, Funcik T. Factors influencing the results of open re-
duction and internal fixation of tibial plateau fractures. Clin O rthop
Relat Res 1990;210–215.
13. Liow RY, Birdsall PD, M ucci B, et al. Spiral computed tomography
with two- and three-dimensional reconstruction in the management
of tibial plateau fractures. O rthopedics 1999;22:929–932.
14. Lobenhoffer P, Schulze M , Gerich T, et al. Closed reduction/percuta-
neous fixation of tibial plateau fractures: arthroscopic versus fluoro-
scopic control of reduction. J O rthop Trauma 1999;13:426–431.
15. M cQ ueen M M , Court-Brown CM . Compartment monitoring in tib-
ial fractures: the pressure threshold for decompression. J Bone Joint
Surg Br 1996;78B:99–104.
16. M orrison JB. The mechanics of the knee joint in relation to normal
walking. J Biomech 1970;3:51–61.
17. Rasmussen PS. Tibial condylar fractures: impairment of knee joint
stability as an indication for surgical treatment. J Bone Joint Surg Am
1973;55A:1331–1350.
18. Saleh KJ, Sherman P, Katkin P, et al. Total knee arthroplasty after
open reduction and internal fixation of fractures of the tibial plateau:
a minimum five-year follow-up study. J Bone Joint Surg Am 2001;
83A:1144–1148.
19. Schatzker J, M cBroom R, Bruce D. The tibial plateau fracture: the
Toronto experience 1968–1975. Clin Orthop Relat Res 1979;94–104.
20. Stevens DG, Beharry R, M cKee M D, et al. The long-term functional
outcome of operatively treated tibial plateau fractures. J O rthop
Trauma 2001;15:312–320.
21. Tscherne H , O estern H J. [A new classification of soft-tissue damage
in open and closed fractures (author’s transl)]. Unfallheilkunde
1982;85:111–115.
22. Whitesides TE, Heckman M M. Acute compartment syndrome: update
on diagnosis and treatment. J Am Acad Orthop Surg 1996;4:209–218.
23. Young M J, Barrack RL. Complications of internal fixation of tibial
plateau fractures. O rthop Rev 1994;23:149–154.
 Ch a p t e r 47 Ex t e r n a l Fix a t io n o f t h e Tib ia
J. Tracy W at so n
DEFIN ITION
■ Indications for external fixation of the tibial shaft in trauma
applications include the treatment of open fractures with ex-
tensive soft tissue devitalization and contamination. O ther in-
dications include the stabilization of closed fractures with
high-grade soft tissue injury or compartment syndrome.
■ For patients with multiple long bone fractures, external
fixation has been used as a method for temporary, if not
definitive, stabilization.
■ With the introduction of circular and hybrid techniques,
indications have been expanded to include the definitive
treatment of complex periarticular injuries, which include
high-energy tibial plateau and distal tibial pilon fractures.
■ Contemporary external fixation systems in current clinical
use can be categorized according to the type of bone anchor-
age used.
■ This is achieved either using large threaded pins, which are
screwed into the bone, or by drilling small-diameter transfix-
ion wires through the bone. The pins or wires are then con-
nected to one another through the use of longitudinal bars or
circular rings.
■ The distinction is thus between monolateral external fix-
ation (longitudinal connecting bars) and circular external
fixation (wires connecting to rings).
■ Acute trauma applications primarily use monolateral frame
configurations and are the focus of techniques described here.
■ The first type of monolateral frame comes with individual
separate components: separate bars, attachable pin–bar
clamps, bar-to-bar clamps, and Schanz pins (FIG 1 A). These
“ simple monolateral” frames allow for a wide range of flex-
ibility with “ build-up” or “ build-down” capabilities.
■ The second type of monolateral frame is a more con-
strained type of fixator that comes preassembled with a
multipin clamp at each end of a long rigid tubular body. The
telescoping tube allows for axial compression or distraction
of this so-called monotube-type fixator (FIG 1 B).
■ For diaphyseal injuries, the most common type of fixator
application is the monolateral type of frame using large pins.
■ Simple monolateral fixators have the distinct advantage of
allowing individual pins to be placed at different angles and
varying obliquities while still connecting to the bar. This is
helpful when altering the pin position avoid areas of soft tis-
sue compromise (ie, open wounds or severe contusion).
■ The advantage of the monotube-type fixator is its simplic-
ity. Pin placement is predetermined by the multipin clamps.
Loosening the universal articulations between the body and
the clamps allows these frames to be easily manipulated to
reduce a fracture.
■ M any high-energy fractures involve the metaphyseal re-
gions, and transfixion techniques using small tensioned wires
are ideally suited to this region. They have better mechanical
stability and longevity than traditional half-pin techniques.
■ Small tensioned wire circular frames or hybrid frames can
be useful in patients with severe tibial metaphyseal injuries
that occur in concert with other conditions such as soft tis-
sue compromise or compartment syndrome, or in patients
with multiple injuries (FIG 1 C,D).
AN ATOMY
■ The bulk of the tibia is easily accessible in that most of the
diaphyseal portion is subcutaneous.
■ Also, the hard cortical bone found in this location is ide-
ally suited to the placement of large Schanz pins, which
achieves excellent mechanical fixation.
■ The cross-sectional anatomy of the diaphysis and the lat-
eral location of the muscular compartments allow place-
ment of half-pins in a wide range of subcutaneous locations.
This facilitates pin placement “ out of plane” to each other,
which helps achieve overall frame stability (FIG 2 ).
■ The proximal and distal periarticular metaphyseal regions
of the tibia are also subcutaneous except for their lateral sur-
faces. The bone in these locations is primarily cancellous, with
thin cortical walls.
■ The mechanical stability achieved with half-pins depends
on cortical purchase and therefore may not be adequate for
fixation in this cortex-deficient region.
■ Excellent stability is afforded in these areas by using
small-diameter tensioned transfixion wires in conjunction
with circular external fixators.
PATHOGEN ESIS
■ O pen tibial diaphyseal fractures are primarily candidates for
closed intramedullary nailing, but there are occasions when
external fixation is indicated.
■ External fixation is favored when there is significant con-
tamination and severe soft tissue injury or when the fracture
configuration extends into the metaphyseal–diaphyseal
junction or the joint itself, making intramedullary nailing
problematic.
■ The choice of external fixator type depends on the location
and complexity of the fracture, as well as the type of wound
present when dealing with open injuries.
■ The less stable the fracture pattern (ie, the more com-
minution), the more complex a frame needs to be applied to
control motion at the bone ends.
■ If possible, weight bearing should be a consideration.
■ If periarticular extension or involvement is present, the
ability to bridge the joint with the frame provides satisfac-
tory stability for both hard and soft tissues.
■ It is important that the frame be constructed and applied
to allow for multiple débridements and subsequent soft tis-
sue reconstruction. This demands that the pins are placed
away from the zone of injury to avoid potential pin site
contamination with the operative field.
441
442 Se c t i o n V LEG
A B
C D
■ Fractures treated with external fixation heal with external
bridging callus. External bridging callus is largely under the
control of mechanical and other humoral factors and is highly
dependent on the integrity of the surrounding soft tissue enve-
lope. This type of fracture healing has the ability to bridge
large gaps and is very tolerant of movement.
■ M icromotion with the external fixator construct has been
found to accentuate fracture union. It results in the develop-
ment of a large callus with formation of cartilage due to the
greater inflammatory response caused by increased micro-
movement of the fragments.
■ There appears to be a threshold at which the degree of mi-
cromotion becomes inhibitory to this overall remodeling
process, however, so hypertrophic nonunion can result from
an unstable external frame.
FIG 1 • A. Simp le m o n o lat eral fo u r-p in
fra m e w ith a d o u b le -sta ck co n n e ct in g
b ar to in crea se fra me st ab ilit y. B. La rg e
m o n o t u b e fixat o r sp an n in g th e an kle fo r
a se ve re p ilo n fra ct u re . This wa s a pp lied
t o t em p o rize th e so ft tissu e s b efo re
d e fin it ive o pe n sta b iliza t io n o f t h e
injury. C,D. Sma ll te nsio ned w ire circular
fixa to r u se d fo r d e fin it ive m a n a g e m e n t
o f a d ista l tib ia l p e ria rticu la r fra ct ure
w ith pro xim a l sh a ft e xte n sio n .
■ Temporary spanning fixation for complex articular injuries
is used routinely. The ability to achieve an initial ligamento-
taxis reduction substantially decreases the amount of injury-
related swelling and edema by reducing large fracture gaps.
■ It is important to achieve an early ligamentotaxis reduc-
tion: a delay of more than a few days will result in an inabil-
ity to disimpact displaced metaphyseal fragments.
■ O nce the soft tissues have recovered, formal open reduc-
tion and internal fixation can be accomplished with relative
ease as the operative tactic can be directed to the area of
articular involvement.
■ Application of these techniques in a polytrauma patient is
valuable when rapid stabilization is necessary for a patient in
extremis. Simple monolateral or monotube fixators can be
placed rapidly across long bone injuries, providing adequate
 Ch a p t e r 4 7 EXTERNAL FIXATION OF THE TIBIA 443

A B

C D E

FIG 2 • A–D. Cro ss-se ct io n a l a n a t o m y o f t h e t ib ia a t a ll le ve ls. Th e p ro xim a l cro ss-se ct io n d e m o n st ra t e s t h e a b ilit y t o a ch ie ve a t le a st

120 d e g re e s o f p in d ive rg e n ce in t h is re g io n w it h p ro g re ssive ly sm a lle r d ive rsio n a n g le s a s t h e p in s a re p la ce d d ist a lly. It is im p o rt a n t
t o a vo id t e t h e rin g o f a n y m u scu lo t e n d in o u s st ru ct u re s. To a cco m p lish t h is, p in s a re p la ce d p rim a rily a lo n g t h e su b cu t a n e o u s b o rd e r o f
t h e t ib ia . E. Mo d e l sh o w in g sim ila r p in p la ce m e n t a vo id in g t h e a n t e ro la t e ra l a n d p o st e rio r m u scu la r co m p a rt m e n t s. Po st e rio r co rt e x
p in p ro t ru sio n is m in im a l t o a vo id d a m a g in g a n y p o st e rio r n e u ro va scu la r st ru ct u re s.

stabilization to facilitate the management and resuscitation of

the polytrauma patient (FIG 3 ).

N ATURAL HISTORY
■ The stability of all monolateral fixators is based on the con-
cept of a simple “ four-pin frame.”
■ Pin number, pin separation, and pin proximity to the frac-

ture site, as well as bone bar distance and the diameter of the
pins and connecting bars, all influence the final mechanical
stability of the external fixator frame.
■ Large pin monolateral fixators rely on stiff pins for frame

stability. O n loading, these pins act as cantilevers and produce

FIG 3 • Po lyt ra u m a p a t ie n t w it h b ila t e ra l t e m p o ra ry t ib ia l fixa -
t o rs. Ext e rn a l fixa t io n o n t h e rig h t sid e sp a n s a n o p e n t ib ia l
sh a ft fra ct u re w it h a n ip sila t e ra l fo re fo o t in ju ry. Th e le ft le g
a n d a n kle re g io n is sp a n n e d w it h a t e m p o ra ry t ria n g u la r fra m e .
eccentric loading characteristics. Shear forces are regarded
as inhibitory to fracture healing and bone formation, and
this may be accentuated with pins placed in all the same orien-
tation.
■ After stable frame application, the soft tissue injury can be
addressed. O nce the soft tissues have healed, conversion to de-
finitive internal fixation can be safely accomplished. In some
cases the external device is the definitive treatment. Dynamic
444 Se c t i o n V LEG

FIG 4 • A. Ext e n sive o p e n g ra d e 3b in ju ry

d ict a t e s ju d icio u s p in p la ce m e n t t o a vo id p la c-
in g p in s d ire ct ly in t o t h e o p e n w o u n d .
B. Lo ca t io n o f la rg e la ce ra t io n in t h is g ra d e 3a
in ju ry d e t e rm in e s va ria b le p in p la ce m e n t o f t h is
t w o -p in sp a n n in g fixa t o r fo r a co m p le x t ib ia l
sh a ft fra ct u re . An in t e rca la ry p in is a d d e d t o
A p ro vid e a d d e d st a b ilit y t o t h is t e m p o ra ry fra m e .

weight bearing is initiated at an early stage once the fracture is brachial indices, compartment pressure evaluation, or a
deemed stable. formal arteriogram.
■ In fractures that are highly comminuted, weight bearing is ■ Evaluation of compartment pressures is often indicated in

delayed until visible callus is achieved and sufficient stability open fractures and closed high-energy fractures with severe
has been maintained. As healing progresses, active dynamiza- soft tissue contusion.
tion of the frame may be required to achieve solid union. ■ Evaluation of soft tissues and grading of the open fracture

■ Dynamization converts a static fixator, which seeks to neu-
tralize all forces including axial motion, and allows the passage
of forces across the fracture site. As the elasticity of the callus
decreases, bone stiffness and strength increase and larger loads
can be supported. Thus, axial dynamization helps to restore
cortical contact and to produce a stable fracture pattern with
inherent mechanical support. This is accomplished by making
adjustments in the pin–bar clamps with simple monolateral fix-
ators or in releasing the body on a monotube-type fixator.
with regard to the size, orientation, and location of the open
wounds aid in decision making about pin placement and the con-
figuration of the fixator to allow access to open wounds (FIG 4).
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Imaging of the tibia should include at least two orthogonal
views, anteroposterior and lateral.
■ Radiographs of the knee and ankle are necessary to eval-

■ Bony healing is not complete until remodeling of the frac-

uate any articular fracture involvement or associated knee
ture has been achieved. At this stage, the visible fracture lines or ankle subluxation or dislocation.
in the callus decrease and subsequently disappear. The fixator ■ Identifying any occult fracture lines aids in the preopera-

can be removed at this point. tive planning of potential pin placement.

■ M any patients with high-energy tibial fractures have asso-

PATIEN T HISTORY AN D PHYSICAL ciated foot injuries, and views of the foot and ankle are nec-
FIN DIN GS essary to identify this injury pattern.
■ H istory should focus on the mechanism of injury. ■ Traction radiographs of articular injuries of the tibia are use-

■ Determining whether the injury was high energy versus ful to identify the nature and orientation of metaphyseal frag-
low energy gives the surgeon an idea of the extent of the soft ments as well as degree of articular impaction. This aids in
tissue zone of injury and will help determine the possible lo- determining whether a joint-spanning fixator is necessary.
cation of fixation pins. ■ Distraction CT scans should be obtained after the knee-

■ Determining the location of the accident is helpful in cases
of open fracture (ie, open field with soil contamination vs. slip
and fall on ice and snow).
■ These parameters give the surgeon an idea as to the extent
of intraoperative débridement that might be required to cleanse
the wound and the necessary antibiotic coverage for the injury.
■ The neurovascular status should be documented, specifically
the presence or absence of the anterior and posterior tibial
pulses at the ankle.
■ A weak or absent pulse may be an indication of vascular
or ankle-spanning fixator has been applied. These studies
indicate the effectiveness of the ligamentotaxis reduction. This
allows the surgeon to determine the preoperative plan for
definitive fixation once the soft tissues have recovered (FIG 5 ).
SURGICAL MAN AGEMEN T
■ The surgical decisions relate to the configuration of the ex-
ternal device to be applied. These generally will fall into two
categories of treatment options.
■ The first category is a temporary device intended to allow

injury and may dictate further evaluation with ankle– the soft tissues to recover or the patient’s overall condition to
 Ch a p t e r 4 7 EXTERNAL FIXATION OF THE TIBIA 445

A B C

FIG 5 • A,B. Sp a n n in g t w o -p in fixa t o r t e m p o ra rily st a b ilizin g a co m p le x p ilo n fra ct u re . C. CT sca n in t h e fra m e p ro vid e s va lu -
a b le in fo rm a t io n t o d e t e rm in e t h e p re o p e ra t ive p la n fo r in t e rn a l fixa t io n .

improve until definitive fixation of the injury can be safely

carried out.
■ Temporary frames include knee- or ankle-spanning fixa-

tors used in cases of periarticular injuries requiring ligamen-

totaxis reduction and relative stabilization, and simple
frames spanning a tibial shaft fracture in the case of a poly-
trauma patient who needs emergent stabilization of injuries.
These frames are later converted to intramedullary nails
once the patient can undergo additional surgery.
■ They are simplistic and not intended for long-term treat-

ment times.
■ Definitive treatment fixators are primarily applied to dia-

physeal injuries with severe soft tissue compromise (open and

A
closed).
■ These devices are maintained throughout the entire treat-

ment period to allow access to soft tissues and facilitate

secondary procedures such as rotational or free flap cover-
age as well as delayed bone grafting.
■ These frames are more involved and are intended to re-

main in place for the entire treatment period.

Preoperative Planning
■ Evaluation of injury radiographs should identify any distal
or proximal articular extension into the knee or ankle joint.
■ Location of the primary fracture is noted in terms of proxi-

mal or distal locations to help decide on a particular fixator

construct and to help determine if a joint-spanning fixator is
required.
Positioning
■ The patient’s entire lower extremity is elevated using bumps
or a beanbag patient positioner under the ipsilateral hip (FIG 6 ).
This elevates the tibia off the operating table.
B
FIG 6 • Th e in ju re d lim b is e le va t e d u sin g a b u m p o r b e a n b a g
p a t ie n t p o sit io n e r p la ce d u n d e r t h e ip sila t e ra l h ip . Th is a llo w s
t h e in ju re d le g t o b e visu a lize d w it h o u t in t e rfe re n ce fro m t h e
o p p o sit e “ d o w n ” le g . A st e rile b u m p is u se d t o su p p o rt t h e
a n kle , a llo w in g 360-d e g re e a cce ss t o t h e in ju re d t ib ia a n d p ro -
vid in g cle a ra n ce fo r a n y fixa t o r co n fig u ra t io n n e ce ssa ry.
 446 Se c t i o n V LEG

■ The foot can be supported with a sterile bump, thus sus-
pending the limb and allowing full 360-degree access and visu-
alization of the limb.
■ Elevating the limb positions the nonoperative leg below
the operative limb, which aids in placing out-of-plane pins
as well as circular frame components.
■ The image intensifier is positioned opposite the operative
knee, which is important when applying a knee-spanning fix-
ator for a severe tibial plateau fracture.
Approach
■ The integrity of the pin–bone interface is a critical factor in
determining the longevity of an applied external fixation pin.
■ Pin insertion technique is important in achieving an infec-

leg. This aids in fluoroscopic visualization of the femur and tion-free, stable pin–bone interface and thus maintaining
frame stability.
TECHNIQUES

PIN INSERTION TECHNIQUE

■ Th e co rre ct in se rt io n t e ch n iq u e in vo lve s in cisin g t h e skin
d ire ct ly a t t h e sid e o f p in in se rt io n .
■ Aft e r a g e n e ro u s in cisio n is m a d e , d isse ct io n is ca rrie d d i-
re ct ly d o w n t o b o n e a n d t h e p e rio st e u m is in cise d w h e re
a n a t o m ica lly fe a sib le (TECH FIG 1 A).
■ A sm a ll Pe n fie ld -t yp e e le va t o r is u se d t o g e n t ly re fle ct
t h e p e rio st e u m o ff t h e b o n e a t t h e sit e o f in se rt io n
(TECH FIG 1 B). Ext ra n e o u s so ft t issu e t e t h e rin g a n d
n e cro sis is a vo id e d b y m in im izin g so ft t issu e a t t h e sit e o f
in se rt io n .
■ A t ro ca r a n d d rill sle e ve a re a d va n ce d d ire ct ly t o b o n e ,
m in im izin g t h e a m o u n t o f so ft t issu e e n t ra p m e n t t h a t
m ig h t b e e n co u n t e re d d u rin g p re d rillin g (TECH FIG
1 C,D). A sle e ve sh o u ld a lso b e u se d if a se lf-d rillin g p in
is se le ct e d .
■ Aft e r p re d rillin g , a n a p p ro p ria t e -size d e p t h o f p in is a d -
va n ce d b y h a n d t o a ch ie ve b ico rt ica l p u rch a se . An y o f-
fe n d in g so ft t issu e t e t h e rin g sh o u ld b e re le a se d w it h a
sm a ll sca lp e l (TECH FIG 1 E,F).

TECH FIG 1 • Pro p e r p in in se rt io n t e ch n iq u e .

A. A g e n e ro u s in cisio n is m a d e o ve r t h e lo ca t io n
o f t h e p in sit e . B. A sm a ll e le va t o r is u se d t o e l-
e va t e a ll so ft t issu e s, in clu d in g t h e p e rio st e u m ,
E o ff t h e b o n e t o h e lp a vo id t h e t e t h e rin g o f e x-
ce ssive so ft t issu e s d u rin g p re d rillin g a n d p in in -
se rt io n . C. A t ro ca r is a d va n ce d t o b o n e t o p ro -
t e ct t h e so ft t issu e s. D. Th e p in sit e is p re d rille d
t h ro u g h t h e t ro ca r t o a vo id in ca rce ra t in g a n d
t e t h e rin g so ft t issu e s. E,F. A T-h a n d le in se rt io n
ch u ck is u se d t o h a n d -t o rq u e t h e p in in t o p o si-
F t io n , a ch ie vin g p u rch a se in b o t h t h e n e a r a n d
A fa r co rt ice s.
 Ch a p t e r 4 7 EXTERNAL FIXATION OF THE TIBIA 447

MONOLATERAL FOUR-PIN FRAME APPLICATION FOR
TIBIAL SHAFT FRACTURE
■ Co n t e m p o ra ry sim p le m o n o la t e ra l fixa t o rs h a ve cla m p s
t h a t a llo w in d e p e n d e n t a d ju st m e n t s a t e a ch p in –b a r in -
t e rfa ce , a llo w in g w id e va ria b ilit y in p in p la ce m e n t ,
w h ich h e lp s t o a vo id a re a s o f so ft t issu e co m p ro m ise .
■ Be ca u se o f t h is fe a t u re , sim p le fo u r-p in p la ce m e n t
m a y b e ra n d o m o n e it h e r sid e o f t h e fra ct u re .
Op t io n 1
■ Th e in it ia l t w o p in s a re first in se rt e d a s fa r a w a y fro m t h e
fra ct u re lin e a s p o ssib le in t h e p ro xim a l fra ct u re se g m e n t
TECHNIQUES
a n d a s d ist a l a s p o ssib le in t h e d ist a l fra ct u re se g m e n t
(TECH FIG 2 A).
■ A so lit a ry co n n e ct in g ro d is a t t a ch e d clo se t o t h e b o n e t o
in cre a se t h e rig id it y o f t h e syst e m .
■ Lo n g it u d in a l t ra ct io n is a p p lie d a n d a g ro ss re d u ct io n is
a ch ie ve d (TECH FIG 2 B–F).
■ Th e in t e rm e d ia t e p in s ca n t h e n b e in se rt e d u sin g t h e p in
fixa t io n cla m p s a t t a ch e d t o t h e ro d t o a ct a s t e m p la t e s
w it h d rill sle e ve s a s g u id e s.
■ Th e se p in s sh o u ld n o t e n cro a ch o n t h e o p e n w o u n d o r
se ve re ly co n t u se d skin in t h e im m e d ia t e zo n e o f in ju ry.

A B C

D E F

TECH FIG 2 • Placement of a simple four-pin monolateral fixator. A. Two pins are placed on either side of the
fracture as far from the fracture as possible. A connecting bar is then attached to the two pins (B) and a gradual
reduction is performed (C–F). Two pins are then placed as close to the fracture as possible on either side, after lon-
gitudinal traction has accomplish ed a red uction. Th e inn er p ins are then attached and the redu ction is fin e-tun ed .
 448 Se c t i o n V LEG

■ Aft e r p la ce m e n t o f t h e se t w o a d d it io n a l p in s, t h e ■ Th e t w o p ro xim a l p in s a re co n n e ct e d t o a so lit a ry b a r

TECHNIQUES

re d u ct io n ca n b e a ch ie ve d w it h m in im a l d ifficu lt y b y a n d t h e d ist a l t w o p in s a re co n n e ct e d t o a so lit a ry b a r.

a d d it io n a l m a n ip u la t io n o f t h e fra ct u re .
■ On ce sa t isfa ct o ry re d u ct io n h a s b e e n a cco m p lish e d ,
t h e cla m p s a re t ig h t e n e d a n d re d u ct io n is co n firm e d via
flu o ro sco p y.
Op t io n 2
■ Alt e rn a t ive ly, a ll t h e fixa t io n p in s ca n b e in se rt e d in d e -
p e n d e n t o f e a ch o t h e r, w it h t w o p in s p ro xim a lly a n d t w o
p in s d ist a lly (TECH FIG 3 ).
■ Bo t h p ro xim a l a n d d ist a l b a rs a re t h e n u se d a s re d u ct io n
t o o ls t o m a n ip u la t e t h e fra ct u re in t o a lig n m e n t .
■ On ce re d u ct io n h a s b e e n a ch ie ve d , a n a d d it io n a l b a r-
t o -b a r co n st ru ct b e t w e e n t h e t w o fixe d -p in co u p le s is
co n n e ct e d .
■ Re d u ct io n is co n firm e d u n d e r flu o ro sco p y.

A B C D E

TECH FIG 3 • Alt e rn a t ive m e t h o d fo r sim p le fo u r-p in

m o n o la t e ra l fixa t o r. A,B. On ce t h e b a r is a t t a ch e d ,
t w o in t e rca la ry cla m p s ca n b e p o sit io n e d a s t e m p la t e s
fo r t h e p la ce m e n t o f t h e in t e rio r p in s. C. Fin a l co n -
st ru ct a ft e r in t e rio r p in p la ce m e n t . D. Th e p ro xim a l
a n d d ist a l t w o p in s ca n b e a t t a ch e d t o e a ch o t h e r b y
a so lit a ry b a r. Th e se b a rs ca n t h e n b e u se d a s t o o ls t o
re d u ce t h e fra ct u re . E. Th e t w o b a rs a re t h e n co n -
n e ct e d b y a so lit a ry b a r a n d t h e fra ct u re re d u ct io n is
m a in t a in e d . F,G. Clo se d fra ct u re w it h a sso cia t e d co m -
p a rt m e n t syn d ro m e is re d u ce d a n d st a b ilize d u sin g a
F fo u r-p in fixa t o r w it h a sin g le co n n e ct in g b a r.

MONOTUBE FOUR-PIN FRAME APPLICATION FOR TIBIAL SHAFT FRACTURE
■ Use o f t h e la rg e m o n o t u b e fixa t o rs fa cilit a t e s ra p id
p la ce m e n t o f t h e se d e vice s, w it h t h e fixe d -p in co u p le
a ct in g a s p in t e m p la t e s (TECH FIG 4 ).
■ Tw o p in s a re p la ce d t h ro u g h t h e fixa t o r-p in co u p le p ro x-
im a l t o t h e fra ct u re . Th e y a re in se rt e d p a ra lle l t o e a ch
A B C D
E F
Ch a p t e r 4 7 EXTERNAL FIXATION OF THE TIBIA 449
TECHNIQUES
o t h e r a t fixe d d ist a n ce s se t b y t h e p in cla m p it se lf. Th e se
a re u su a lly o rie n t e d a lo n g t h e d ire ct m e d ia l o r a n t e ro -
m e d ia l fa ce o f t h e t ib ia l sh a ft .
■ On ce t h e p in s a re in se rt e d , t h e p in cla m p is t ig h t e n e d
t o se cu re t h e m in p la ce .
TECH FIG 4 • A. Tibia l sh a ft fra ct u re w it h d is-
p la ce m e n t . B. Mo n o t u b e fixa t o r a d ju st e d t o
le n g t h a n d o rie n t a t io n, w it h a ll b a ll jo in t s a n d
t h e t e le sco p in g ce n t ra l b o d y lo o se n e d . C.
Pro xim a l t w o p in s a p p lie d u sin g p in co u p le a s
t e m p la t e . D. Dist a l p in s in se rt e d a n d fra ct ure
re d u ce d w it h a ll b a ll jo in t s lo cke d t o m a in t a in
re d u ct io n . Te le sco p in g b o d y is a lso lo cke d t o
m a in t a in a xia l a lig n m e n t . E,F. In ju ry a n d re d u c-
t io n ra d iog ra p h s u sin g a la rg e -b o d y m o n o t u b e
fixa t o r fo r a n o p e n co m m in u t e d t ib ia l sh a ft
fra ct u re .
 450 Se c t i o n V LEG
■ Th e m o n o t u b e b o d y is t h e n a t t a ch e d t o t h e p ro xim a l p in
TECHNIQUES
co u p le a n d lo n g it u d in a l t ra ct io n a p p lie d t o a ch ie ve a
“ g ro ss” re d u ct io n . Th e fixa t o r b o d y a n d d ist a l m u lt ip in
cla m p a re o rie n t e d a lo n g t h e sh a ft o f t h e t ib ia .
■ Th e p ro xim a l a n d d ist a l b a ll jo in t s sh o u ld b e fre e ly
m o va b le w it h t h e t e le sco p in g b o d y e xt e n d e d .
■ Tw o p in s a re p la ce d t h ro u g h t h e p in co u p le d ist a l t o t h e
fra ct u re a n d t ig h t e n e d .
■ Ca re m u st b e t a ke n t o a llo w a d e q u a t e le n g t h o f t h e
m o n o t u b e fra m e b e fo re fin a l re d u ct io n a n d t ig h t e n -
in g o f t h e b o d y.
■ Usin g the pro xima l a nd d ista l p in clamps as redu ctio n aid s,
the fracture is manually reduced. The proximal and distal
ball joints are then tightened, accomplishing a reduction.
■ At t h is p o in t , t h e t e le sco p in g b o d y ca n b e e xt e n d e d o r
co m p re sse d t o d ia l in t h e a xia l a lig n m e n t . Wh e n le n g t h
KNEE-SPANNING FIXATOR OF TIBIAL PLATEAU FRACTURE
■ Tw o Sch a n z p in s a re p la ce d a lo n g t h e a n t e ro la t e ra l
t h ig h . Th e se p in s a re p la ce d in t h e m id sh a ft re g io n o f t h e
fe m u r (TECH FIG 5 ).
■ Tw o Sch a n z p in s a re t h e n in se rt e d in t o t h e m id sh a ft a n d
d ist a l t ib ia .
A B
C D
is a ch ie ve d , t h e b o d y co m p o n e n t is t ig h t e n e d t o m a in -
t a in a xia l le n g t h .
■ Mo n o t u b e b o d ie s h a ve a ve ry la rg e d ia m e t e r, w h ich lim -
it s t h e a m o u n t o f sh e a rin g , t o rsio n a l, a n d b e n d in g m o ve -
m e n t s o f t h e fixa t io n co n st ru ct .
■ Axia l co m p re ssio n is a ch ie ve d b y re le a sin g t h e t e le -
sco p in g m e ch a n ism .
■ Dyn a m ic w e ig h t b e a rin g is in it ia t e d a t a n e a rly st a g e
o n ce t h e fra ct u re is d e e m e d st a b le .
■ In fra ct u re s t h a t a re h ig h ly co m m in u t e d , w e ig h t b e a r-
in g is d e la ye d u n t il visib le ca llu s is a ch ie ve d a n d su ffi-
cie n t st a b ilit y h a s b e e n m a in t a in e d .
■ The t elescopic b ody allow s dynam ic movem ent in an a xial
d ire ct io n , w h ich is a st im u lu s fo r e a rly pe rio st e a l h e aling .
■ Ap p ly t h e t ib ia l p in s fa r e n o u g h a w a y fro m t h e d ist a l
e xt e n sio n o f t h e p ro xim a l t ib ia su ch t h a t a n y fu t u re
in cisio n s re q u ire d t o p e rfo rm d e fin it ive o p e n re d u c-
t io n a n d in t e rn a l fixa t io n o f t h e p la t e a u fra ct u re
w o u ld n o t im p in g e o n t h e p in s.
TECH FIG 5 • A,B. Op e n t ib ia l
p la t e a u st a b ilize d w it h kn e e -
sp a n n in g fixa t o r. Tw o p in s
e a ch a b o ve (d ist a l fe m u r) a n d
b e lo w (m id t ib ia ) t h e fra ct u re
a re a p p lie d . Tw o b a rs co n n e ct
e a ch p in co u p le . Lo n g co n n e ct -
in g b a rs a re t h e n u se d t o
co n n e ct e a ch p in co u p le , m a in -
t a in in g t h e re d u ce d fra ct u re .
C,D. On e sin g le b a r co n n e ct s
t h e t w o p in s p ro xim a l t o t h e
p la t e a u fra ct u re a n d t h e t w o
p in s d ist a l t o t h e fra ct u re .

■ A so lit a ry b a r ca n t h e n b e u se d t o sp a n a ll p in s.
■ Lo n g it u d in a l t ra ct io n is a p p lie d a n d re d u ct io n co n -
firm e d u n d e r flu o ro sco p y.
■ Slig h t fle xio n o f t h e kn e e is m a in t a in e d a n d a ll co n -
n e ct io n s a re t ig h t e n e d t o m a in t a in t h e lig a m e n t o -
t a xis re d u ct io n .
■ Alt e rn a t ive ly, t h e p ro xim a l t w o fe m u r p in s ca n b e co n -
n e ct e d u sin g a sin g le b a r a n d t h e t w o t ib ia l p in s w it h a
ANKLE-SPANNING FIXATOR FOR TIBIAL PILON FRACTURE
■ Tw o Sch a n z p in s a re p la ce d in t o t h e m id sh a ft t ib ia l re -
g io n (TECH FIG 6 ).
■ Avo id a n y co m p ro m ise d so ft t issu e s a n d p o ssib le fra c-
t u re e xt e n sio n if sp a n n in g t h e a n kle fo r a se ve re p ilo n
fra ct u re w it h sh a ft e xt e n sio n .
■ A ce n t ra lly t h re a d e d t ra n sfixio n p in is t h e n p la ce d
t h ro u g h t h e ca lca n e a l t u b e ro sit y fro m m e d ia l t o la t e ra l,
a vo id in g t h e p o st e rio r t ib ia l a rt e ry.
■ Th e a p p ro p ria t e lo ca t io n fo r t h is p in is 1.5 cm a n t e rio r
t o t h e p o st e rio r a sp e ct o f t h e h e e l a n d 1.5 cm p ro xi-
m a l t o t h e p la n t a r a sp e ct o f t h e h e e l.
■ Th is lo ca t io n is co n firm e d via flu o ro sco p y.
A B
TECH FIG 6 • An kle -sp a n n in g fixa t o rs b rid g in g se ve re p ilo n fra ct u re s. A. Tw o p in s a re p la ce d in t o t h e d ist a l t ib ia , p ro xim a l
e n o u g h t o b e o u t o f t h e zo n e o f in ju ry. A ca lca n e a l t ra n sfixio n p in is p la ce d t h ro u g h t h e ca lca n e a l t u b e ro sit y a n d su b se -
q u e n t m e d ia l-la t e ra l t ria n g u la t io n co n n e ct in g b a rs a re a t t a ch e d . Lo n g it u d in a l t ra ct io n is a p p lie d a n d a ll b a rs a re t ig h t e n e d
t o m a in t a in re d u ct io n . B,C. A fo re fo o t p in is p la ce d in t o t h e se co n d m e t a t a rsa l t o m a in t a in t h e fo o t in a n e u t ra l p o sit io n
a n d a vo id e q u in u s co n t ra ct u re .
TWO-PIN FIXATOR: TEMPORARY STABILIZATION FOR TIBIAL SHAFT, PILON,
OR PLATEAU FRACTURES
■ Th is is a t e m p o ra ry fra m e d e sig n e d fo r ra p id d ist ra ct io n
a n d g ro ss re d u ct io n u se d fo r a ll t yp e s o f t ib ia l p a t h o lo g y.
■ A proximal centrally threaded tra nsfixion pin is applied one
fingerbreadth proximal to the tip of the proximal fibula. It
is inserted from late ral to medial (TECH FIG 7A,B).
■ Alt e rn a t ive ly, t h is p in ca n b e p la ce d in t o t h e d ist a l
fe m u r a t t h e le ve l o f t h e m id p a t e lla a lo n g t h e m id la t -
e ra l co n d yle o f t h e fe m u r.
■ A se co n d t ra n sfixio n p in is p la ce d t h ro u g h t h e ca lca n e a l
t u b e ro sit y, sim ila r t o t h e a n kle -sp a n n in g fra m e d e scrib e d
a b o ve .
Ch a p t e r 4 7 EXTERNAL FIXATION OF THE TIBIA 451
se co n d b a r. Th e se t w o b a rs ca n t h e n b e m a n ip u la t e d
TECHNIQUES
t o a ch ie ve a re d u ct io n o f t h e p la t e a u , a n d a t h ird
b a r co n n e ct in g t h e p ro xim a l fe m o ra l a n d d ist a l t ib ia l
b a rs is t h e n a t t a ch e d a n d t ig h t e n e d t o m a in t a in t h e
re d u ct io n .
■ A la rg e m o n o t u b e fixa t o r ca n a lso b e u se d in t h is fa sh io n
t o sp a n t h e kn e e a n d m a in t a in a t e m p o ra ry re d u ct io n .
■ A so lit a ry b a r is co n n e ct e d t o t h e t ib ia l p in s.
■ Me d ia l a n d la t e ra l b a rs a re t h e n co n n e ct e d t o e a ch sid e
o f t h e h e e l p in , m a kin g a t ria n g u la r co n fig u ra t io n .
■ Lo n g it u d in a l t ra ct io n is ca rrie d o u t t o o b t a in le n g t h ,
a n d ca re is t a ke n t o a ch ie ve a p p ro p ria t e a n t e ro p o st e -
rio r re d u ct io n .
■ To m a in t a in a p la n t ig ra d e fo o t a n d t o m a in t a in a lig n -
m e n t , a p in is p la ce d in t o t h e b a se o f t h e first o r se co n d
m e t a t a rsa l.
■ Th is fo re fo o t p in is t h e n co n n e ct e d t o t h e m a in fra m e
w it h a co n n e ct in g b a r a n d t h e fo o t is h e ld in n e u t ra l
d o rsifle xio n .
C
■ Tw o lo n g co n n e ct in g b a rs a re t h e n a t t a ch e d t o t h e p in s
o n e a ch sid e o f t h e le g .
■ Lo n g it u d in a l t ra ct io n is a p p lie d a n d a g ro ss re d u ct io n
is a ch ie ve d .
■ In so m e circu m st a n ce s, a t h ird p in is p la ce d in t o t h e t ib -
ia l sh a ft a n d a t t a ch e d t o o n e o f t h e lo n g it u d in a l b a rs b y
a t h ird co n n e ct in g b a r (TECH FIG 7 C,D). Th is is d o n e t o
a d d st a b ilit y t o t h is ve ry sim p le fra m e .
 452 Se c t i o n V LEG
TECHNIQUES

A B C

TECH FIG 7 • A,B. App lication of sp ann ing two -p in fixato r

“t raveling tractio n” with att achmen t o f m edial an d lateral
bars. This is used as a very t em porary frame to stabilize a
variety o f co nd itio n s. C,D. Two-pin fixat or used to stabilize
a severe p lateau fractu re. A th ird pin was in sert ed in to th e
distal third of the tibia t o provide additional stability. The
fra me is p rep a re d d ire ctly into th e o pe ra tive field at th e
time of se co nd a ry su rge ry to d efin itive ly st abilize th e fra c-
ture usin g a m ed ia l but tre ss p la te . D

PEARLS AND PITFALLS

Pin p la ce m e n t lo ca t io n
Pin in se rt io n t e ch n iq u e
Te m p o ra ry fra m e s re q u ire a d ju n ct ive
sp lin t in g o f kn e e , le g , a n kle , a n d fo o t .
■ Are a s o f so ft t issu e co m p ro m ise , o p e n w o u n d s, a n d o ccu lt fra ct u re lin e s a s id e n t ifie d o n
CT sca n s sh o u ld b e a vo id e d . Th is p re ve n t s a n y a sso cia t e d p in t ra ct in fe ct io n fro m in vo lv-
in g t h e fra ct u re sit e . Th e fra m e m u st b e co n st ru ct e d a n d a p p lie d t o a llo w fo r m u lt ip le
d é b rid e m e n t s, su b se q u e n t so ft t issu e re co n st ru ct io n , a n d d e fin it ive se co n d a ry in t e rn a l
fixa t io n co n ve rsio n s. Th u s, t h e p in s m u st b e p la ce d a w a y fro m t h e zo n e o f in ju ry t o
a vo id p o t e n t ia l p in sit e co n t a m in a t io n w it h t h e o p e ra t ive fie ld .
■ Ad e q u a t e skin re le a se is p ro vid e d t o a vo id t e t h e rin g o r b u n ch in g o f so ft t issu e s a ro u n d
p in s. Pin s a re o ve rw ra p p e d w it h sm a ll g a u ze w ra p t o p ro vid e a st a b le p in –skin in t e rfa ce
a n d t o a vo id e xce ssive p in –skin m o t io n a n d d e ve lo p m e n t o f t issu e n e cro sis a n d in fe ct io n .
■ Te m p o ra ry sp a n n in g fra m e s a re n o t e xce ssive ly rig id a n d re q u ire a d d it io n a l sp lin t in g t o
m a in t a in t h e fo o t in n e u t ra l a n d t o a vo id t h e d e ve lo p m e n t o f e q u in u s co n t ra ct u re s.

POSTOPERATIVE CARE
■ A compressive dressing should be applied to the pin sites im-
mediately after surgery to stabilize the pin–skin interface and
thus minimize pin–skin motion, which can lead to the develop-
ment of necrotic debris.
■ Compressive dressings can be removed within 10 days to
2 weeks, once the pin sites are healed.
■ If appropriate pin insertion technique is used, the pin sites
will completely heal around each individual pin. O nce healed,
only showering, without any other pin cleaning procedures, is
necessary.
■ Removal of a serous crust around the pins using dilute hy-
drogen peroxide and saline may occasionally be necessary.
■ O intments should not be used for pin care. They tend to
inhibit the normal skin flora and alter the normal skin bacte-
ria and may lead to superinfection or pin site colonization.
■ If pin drainage does develop, pin care should be provided
three times per day.

■ This may also involve rewrapping and compressing the
offending pin site in an effort to minimize the abnormal
pin–skin motion.
■ Following a standardized protocol that involves preclean-
ing the external fixator frame, followed by alcohol wash,
sequential povidone–iodine preparation, paint, and spray
with air drying followed by draping the extremity and fixa-
tor directly into the operative field, additional surgery can be
safely performed without an increased rate of postoperative
wound infection.
■ Definitive treatment with an external fixator demands closed
scrutiny of the radiographs to ensure that the fracture has com-
pletely healed before frame removal. Various techniques have
been described, including CT scans, ultrasound, and bone den-
sitometry, to determine the adequacy of fracture healing.
■ In general, the patient should be fully weight bearing with
minimal pain at the fracture site. The frame should be fully
dynamized such that the load is being borne by the patient’s
limb rather than by the external fixator.
OUTCOMES
■ Staged management of high-energy tibial plateau and tibial
pilon fractures using spanning external fixation to allow the
recovery of soft tissues has reduced the overall rates of soft tis-
sue complications. With secondary plating procedures after
soft tissue recovery, infection rates have been reported to be
less than 5% for complex plateau fractures and less than 7%
for complex pilon fractures.
■ N o severe complications related to the temporary external
fixator alone have been reported.
■ Immediate external fixation followed by early closed inter-
locking nailing has been demonstrated to be a safe and effective
treatment for open tibial fractures if early (less than 21 days
after injury) conversion to intramedullary nailing is performed.
■ Early soft tissue coverage and closure is the primary deter-
minant of delayed infection, highlighting the need for effective
soft tissue management and early closure of open injuries.
■ Definitive treatment of open tibial fractures with external
fixation has a higher rate of malunion compared with in-
tramedullary nailing. N o difference in union rates is noted.
Slightly higher rates of infection are noted in the external fix-
ation group.
■ The severity of the soft tissue injury rather than the choice
of implant appears to be the predominant factor influencing
outcome. External fixation is preferentially used in patients
with the most severe soft tissue injuries or wound conta-
mination.
COMPLICATION S
■ Wire and pin site complications include pin site inflamma-
tion, chronic infection, loosening, or metal fatigue failure.
■ M inor pin tract inflammation requires more frequent pin
care, consisting of daily cleansing with mild soap or half-
strength peroxide and saline solution.
Ch a p t e r 4 7 EXTERNAL FIXATION OF THE TIBIA 453
■ O ccasionally an inflamed pin site with purulent discharge
will require antibiotics and continued daily pin care.
■ Severe pin tract infection consists of serous or seropurulent
drainage in concert with redness, inflammation, and radi-
ographs showing osteolysis of both the near and far cortices.
■ O nce osteolysis occurs with bicortical involvement, the
offending pin should be removed immediately, with débride-
ment of the pin tract.
■ Late deformity after removal of the apparatus usually pre-
sents as a gradual deviation of the limb. This often occurs if
the patient and surgeon become “ frame weary,” which results
in frame removal before healing is complete.
■ O ne should always err on the conservative side and leave
the frame on for an extended time to ensure that the fracture
has healed.
■ When late deformity occurs, it usually has an unsatisfactory
outcome unless collapse is detected early and the frame is re-
applied.
■ If untreated, the resulting malunion requires secondary
osteotomy procedures.
■ Early detection of delayed union often requires adjunctive
bone grafting for previously open shaft fractures.
REFEREN CES
1. Augat P, Burger J, Schorlemmer S, et al. Shear movement at the frac-
ture site delays healing in a diaphyseal fracture model. J O rthop Res
2003;21:1011–1017.
2. Behrens F, Johnson W. Unilateral external fixation: methods to in-
crease and reduce frame stiffness. Clin O rthop Relat Res 1989;(241):
48–56.
3. Chao EY, Aro H T, Lewallen DG, et al. The effect of rigidity on frac-
ture healing in external fixation. Clin O rthop Relat Res 1989;
(241):24–35.
4. Egol KA, Tejwani N C, Capla EL, et al. Staged management of high-
energy proximal tibia fractures (O TA type 41): the results of a
prospective, standardized protocol. J O rthop Trauma 2005;19:
448–455.
5. Green SA. Complications of External Skeletal Fixation: Causes,
Prevention, and Treatment. Springfield, IL: Charles C Thomas, 1981.
6. H aidukewych GJ. Temporary external fixation for the management
of complex intra- and periarticular fractures of the lower extremity. J
O rthop Trauma 2002;16:678–685.
7. H enley M B, Chapman JR, Agel J, et al. Treatment of type II, type
IIIA, and III B open fractures of the tibial shaft: a prospective com-
parison of unreamed interlocking intramedullary nails and half-pin
external fixators. J O rthop Trauma 1998;12:1–7.
8. Kenwright J, Richardson JB, Cunningham JL, et al. Axial movement
and tibial fractures: a controlled randomised trial of treatment. J
Bone Joint Surg Br 1991;73B:654–659.
9. M arsh JL, Bonar S, N epola JV, et al. Use of an articulated external
fixator for fractures of the tibial plafond. J Bone Joint Surg Am
1995;83A:733–736.
10. Sirkin M , Sanders R, DiPasquale T, et al. A staged protocol for soft
tissue management in the treatment of complex pilon fractures. J
O rthop Trauma 1999;13:78–84.
11. Watson JT, Anders M , M oed BR. Bone loss in tibial shaft fractures:
management strategies. Clin O rthop Relat Res 1995;316:1–17.
12. Watson JT, M oed BR, Karges DE, et al. Pilon fractures: treatment
protocol based on severity of soft tissue injury. Clin O rthop Relat Res
2000;375:78–90.
 In t r a m e d u lla r y Na ilin g
Ch a p t e r 48 o f t h e Tib ia
M ark A . Le e an d Bre t t D. Crist
DEFIN ITION
■ Intramedullary nailing (IM N ) techniques typically are used
for closed and open displaced diaphyseal tibial fractures.
■ With additional techniques described in this chapter, the indi-
cations for intramedullary nailing can be extended to proximal
and distal metaphyseal tibia fractures, including those associ-
ated with simple articular involvement.
AN ATOMY
■ The triangular-shaped proximal tibia is most narrow me-
dially, and the proximal medial cortex tibia is obliquely
oriented to the frontal plane. The medullary canal of the
tibia exits at the margin of the lateral articular facet. As a re-
sult of this complex proximal anatomy, there is less sagittal
plane space for an intramedullary nail within the tibia meta-
physis with a medial or central insertion path, and the an-
terior medial metaphyseal cortex can deflect the nail and
create a valgus deformation. Thus, lateral start sites are more
favorable.
■ The patellar tendon inserts on the tibial tubercle and ex-
tends the proximal fracture segment in proximal fracture pat-
terns. This displacement is accentuated with further flexion of
the knee, which typically is required to attain the proper start-
ing point for intramedullary nailing (FIG 1 A).
■ Gerdy’s tubercle—the origin of the anterior compartment
muscles and insertion site of the iliotibial band—is palpable
along the proximal lateral tibia. The anterior compartment
muscles and the iliotibial band contribute to shortening and the
valgus deformity that is typically seen with proximal fractures.
■ The anterior tibial crest corresponds to the vertical lateral
surface of the tibia. When it is palpable, it is an excellent ref-
erence for the anatomic axis and nail path (FIG 1 B).
■ The anteromedial tibial surface is subcutaneous and often is
the site of traumatic open wounds.
■ The anterior neurovascular bundle and tibialis anterior ten-
don are at risk with anterior-to-posterior distal interlocking
screw paths; internal rotation of the nail may decrease the risk
of iatrogenic nerve injury4 (FIG 1 C).
■ The H offa fat pad and intermeniscal ligament are commonly
injured during nail insertion, especially during lateral parap-
atellar and patellar tendon-splitting approaches.29,35
PATHOGEN ESIS
■ Tibial shaft fractures may occur from high-energy mech-
anisms of injury, as when a pedestrian is struck by a motor
vehicle. M any fractures, however, result from low-energy
mechanisms such as simple falls in elderly patients or those
with poor bone quality, or sports-related injuries (usually in
soccer players) in young patients.6
■ In this low-energy fracture group, elderly patients are
more likely to have comminuted and open fractures due to
simple falls.
454
N ATURAL HISTORY
■ The long-term outcome of tibial malunion is not clearly de-
fined in the trauma literature.
■ A weak association is seen between a tibial shaft fracture
malunion and ipsilateral knee and ankle arthritis 14,21,34
■ Knee pain is reported in up to 58% of cases after in-
tramedullary nailing. This pain typically is anterior, associated
with activity, and exacerbated by kneeling activities.7,13
■ Knee pain improves in about 50% of patients after hard-
ware removal.7
■ Attempts to detect a correlation between start sites and
knee pain have been inconclusive, and a comparative evalu-
ation between traditional start sites and newer start sites (ie,
suprapatellar) has yet to be completed.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Understanding the mechanism of injury and the environ-
ment in which the injury occurred is important for evaluating
a patient’s risk for associated injuries and compartment syn-
drome. In open fractures, it can help determine the choice of
prophylactic antibiotic therapy.
■ All patients who sustain tibial shaft fractures from high-energy
mechanisms should undergo standard advanced trauma and life
support (ATLS) protocol to have a thorough examination for
life- and other limb-threatening injuries. Seventy-five percent of
patients with open tibia fractures have associated injuries.2
■ To evaluate a patient’s risk for potential complications, other
medical conditions should be investigated, eg, a history of
diabetes mellitus, renal disease, inflammatory arthropathies, to-
bacco use (which increases healing time by up to 40% ), and pe-
ripheral vascular disease.5
■ It also is important to find out about the patient’s normal ac-
tivities and employment requirements to give them a reasonable
expectation for when they will be able to resume those activities.
■ Pain at the fracture site, swelling, and deformity are com-
mon findings in patients with tibial shaft fractures.
■ A thorough examination of the skin is important to avoid
missing open fracture wounds.
■ Evaluation of the soft tissue envelope for abrasions, contu-
sions, and fracture blisters can help determine whether defini-
tive treatment can be done primarily or if a staged or delayed
approach is required.
■ A thorough neurovascular examination is critical to avoid
the devastating complications associated with compartment
syndrome, which can occur in both closed and open fractures
(see Chap. TR-17).
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Full-length (orthogonal) anteroposterior (AP) and lateral
plain radiographs are necessary to adequately evaluate the

80°
10°–15°
A B
Path of neutral nail
Neurovascular bundle
Extensor hallucis
longus
Fibula
Flexor hallucis
longus
Achilles tendon
C risk o f a rt e ria l in ju ry.
tibia and fibula for concurrent fractures or dislocation and any
preexisting deformity or implants.
■ O rthogonal radiographic views of the knee and ankle are
required to rule out articular involvement.
■ Axial CT scan can be used for proximal and distal fractures
to rule out intra-articular fracture extension.
■ N ondisplaced fracture lines are common.
■ Gunshot wounds may merit CT evaluation to rule out
intra-articular bullet fragments.
■ M RI is not useful for most diaphyseal or metadiaphyseal
fractures
■ Ankle–brachial or ankle–arm indices after fracture reduc-
tion should be used to rule out vascular injuries in severely dis-
placed fractures or fractures with severe soft tissue injury.
Values of less than 0.9 may be indicative of vascular injury, re-
quiring further investigation.20
■ Compartment pressure evaluation with a commercially
available hand-held single-stick monitor or with a side-ported
Ch a p t e r 4 8 INTRAM EDULLARY NAILING OF THE TIBIA 455
Anterior
compartment
Lateral
compartment
Deep posterior
compartment
Superficial posterior
compartment
Path of intentionally
rotated nail
Tibialis anterior
Tibia
FIG 1 • A. Th e m e t a p h yse a l se g -
m e n t e xt e n d s w it h kn e e fle xio n
se co n d a ry t o t h e p u ll o f t h e
p a t e lla r t e n d o n . B. Th e a n t e rio r
t ib ia l cre st is p a lp a b le a n d re p re -
se n t s t h e ve rt ica l la t e ra l b o rd e r
o f t h e t ib ia . Pa lp a t io n o f t h e
Posterior tibial cre st ca n h e lp a id in st a rt in g
artery and nerve w ire o rie n t a t io n . C. An t e rio r
n e u ro va scu la r st ru ct u re s a re a t
risk d u rin g a n t e rio r p la ce m e n t
o f d ist a l in t e rlo ckin g b o lt s; in t e r-
n a l ro t a t io n m a y d e cre a se t h e
catheter connected to a pressure monitor (using the arterial
line set-up) is indicated in patients who have severe or increas-
ing swelling and are not able to comply with physical exami-
nation and questioning (see Chap. TR-17).
■ O bserve for early signs of compartment syndrome in all
patients with tibial diaphyseal fractures.
■ O pen fracture does not preclude development of compart-
ment syndrome.
■ M easure the pressure difference between the diastolic
pressure and the intracompartmental pressure—a differen-
tial value of less than 30 mm H g is considered an indication
for a four-compartment fasciotomy.19
N ON OPERATIVE MAN AGEMEN T
■ N onoperative management is indicated in ambulatory pa-
tients for closed and open fractures that do not require flap cov-
erage and that do not present with excessive initial shortening
or unacceptable angulation when a cast is applied (FIG 2 ).
456 Se c t i o n V LEG

FIG 2 • A-C. An o b liq u e d ia p h yse a l t ib ia l sh a ft fra ct u re t re a t e d

A B C n o n o p e ra t ive ly t o u n io n . (Co u rt e sy o f Pa u l To rn e t t a III, MD.)

■ An intact fibula with an axially unstable fracture pattern(ie, The lateral radiograph is the most accurate to use for
■

short oblique, butterfly, comminuted) is at risk of shortening measuring the appropriate nail length.
and varus and is a relative contraindication to nonoperative ■ M easuring the narrowest diameter on the AP and lat-

management. eral views will determine the appropriate nail diameter

■ A higher rate of malunion and nonunion with nonoperative and whether intramedullary reaming will be necessary.
management is seen in higher-energy fractures.3,11 ■ O rthogonal radiographs of the uninjured tibia can be used

■ Joint stiffness, especially hindfoot, is common with all forms as templates for determining the appropriate length, align-
of prolonged immobilization.8,24 ment, and rotation in comminuted fractures or open fractures
■ Initial treatment includes 2 weeks of a long leg splint, then with bone loss.
a long-leg cast for 2 to 4 weeks.
■ When the initial swelling has subsided, the patient is grad-
Positioning
uated to a patellar tendon or functional brace with weight ■ Supine positioning is standard.
■ A fracture table can be used with boot traction, calcaneal
bearing allowed and encouraged.
■ Radiographs are evaluated at 1- to 2-week intervals over traction, or an arthroscopy leg holder that supports the leg and
the first month of treatment to confirm maintenance of ac- provides mechanical traction when no assistants are available.
ceptable alignment. H owever, knee hyperflexion is difficult, and the guidewire in-
sertion angle is suboptimal for proximal fractures18 (FIG 3 A).
■ The patient is placed on the radiolucent table in one of the
SURGICAL MAN AGEMEN T following positions:
Classification and Relative Indications ■ Supine with the leg free (FIG 3 B)

■ Tibia fractures usually are classified according to the ■ M echanical traction is helpful to achieve reduction

AO /O TA classification (Table 1). when the leg is draped free (FIG 3 C,D).
■ Several relatively well-accepted indications and contraindi- ■ The proximal posterior transfixion pin (FIG 3 E) is in-

cations have been established for the intramedullary nailing of serted medial to lateral and parallel to the tibial plateu.
tibia fractures (Table 2). ■ The distal transfixion pin (FIG 3 F) is inserted parallel

■ A thorough evaluation of the patient’s soft tissue envelope will to the plafond and inferior to the projected end of the
determine when the patient can proceed with definitive fixation. nail.
■ Complete orthogonal radiographs of the entire tibia and ■ Supine with the leg flexed over a bolster or radiolucent

fibula are important to determine whether the patient’s in- triangle (FIG 3 G)
tramedullary canal is large enough to accommodate an in- ■ M aximizing knee flexion makes it easier to attain a

tramedullary nail and identify any pre-existing deformity that start site and to determine the optimal insertion vector
may preclude nail placement. Complete radiographs also iden- (which approaches a parallel path with the anterior tibial
tify any proximal or distal articular involvement. border).
■ Preoperative measurement of the intramedullary canal ■ Semi-extended position

and the length of the tibia will help determine which size ■ For proximal fractures, extending the knee to 20 to 30

nail can be used. degrees of flexion counters the pull of the patellar tendon
 Ch a p t e r 4 8 INTRAM EDULLARY NAILING OF THE TIBIA 457

Ta b le 1 Th e AO/OTA Cla s s if ica t io n o f Dia p h y s e a l Tib ia l Fr a ct u r e s

Cla s s if ica t io n De s cr ip t io n Illu s t r a t io n Cla s s if ica t io n De s cr ip t io n Illu s t r a t io n

42-A Simple 42-B3 Fragmented wedge

42-A1 Spiral

42-C Complex

42-A2 Oblique ( 30 degrees) 42-C1 Spiral

42-A3 Transverse ( 30 degrees) 42-C2 Segmented

42-B Wedge
42-C3 Irregular
42-B1 Spiral wedge

42-B2 Bending wedge

458 Se c t i o n V LEG

and helps reduce the flexion deformity that is typical for

Re la t iv e In d ica t io n s
these fractures.28 Either a radiolucent triangle or bolster
a n d Co n t r a in d ica t io n s f o r
Ta b le 2 In t r a m e d u lla r y Na ilin g
can be used (FIG 3 H).
o f Tib ia l Fr a ct u r e s 2 ,2 7 Approach
■ Use fluoroscopy to determine which approach will allow the
Relat ive Indicat ions starting point to be placed just medial to the lateral tibial spine
• High-energy mechanism
on the AP view and at the anterior articular margin on the lat-
• Moderate to severe soft tissue injury precluding cast or brace
• Angular deformity 5 to 10 degrees
eral view.29
■ For diaphyseal and distal metaphyseal fractures, any of the
• Rotational deformity 5 to 10 degrees
• Shortening 1 cm following approaches is appropriate. As mentioned earlier, the
• Displacement 50% patient’s anatomy can be used to determine which approach
• An ipsilateral fibula fracture at the same level allows for appropriate starting point placement.
• An intact fibula ■ M edial parapatellar

• Compartment syndrome ■ Transpatellar tendon. (This approach may be avoided by

• Ipsilateral femoral fracture some surgeons due to previous retrospective series that
• Inability to maintain reduction showed an increased likelihood of knee pain with this ap-
• Older age, inability to manage with cast or brace
proach.13,23 H owever, other retrospective series and more
Cont raindicat ions
• Intramedullary canal diameter 6 mm
recent prospective trials have found no association between
• Gross contamination of intramedullary canal knee pain and the surgical approach used.)7,31–33
■ Lateral parapatellar
• Severe soft tissue injury where limb salvage is uncertain
■ Proximal metaphyseal fractures
• Preexisting deformity precluding nail insertion
• Ipsilateral total knee arthroplasty or knee arthrodesis ■ The lateral parapatellar approach allows for guidewire

• Significant articular involvement and nail placement in the more lateral position, which is
• Previous cruciate ligament reconstruction beneficial in countering the valgus deformity associated with
these fractures. It also allows intramedullary nailing in the
familiar hyperflexed knee position.

B C D

FIG 3 • A. Th e fra ct u re d le g is p o sit io n e d in ca lca n e a l ske le t a l t ra ct io n o n t h e fra c-

t u re t a b le . Th is p ro vid e s e xce lle n t m e ch a n ica l t ra ct io n b u t lim it s lim b m o b ilit y, e sp e -
cia lly kn e e fle xio n . B. Th e kn e e is fle xe d o ve r a p o sit io n in g t ria n g le in p re p a ra t io n
fo r t h e su rg ica l a p p ro a ch . C,D. Th e t ib ia l fra ct u re is d ist ra ct e d a n d re d u ce d u sin g a
m e ch a n ica l d ist ra ct io n d e vice w it h p ro xim a l a n d d ist a l h a lf-p in s. (co n t in u e d )
 Ch a p t e r 4 8 INTRAM EDULLARY NAILING OF THE TIBIA 459

E F G H

FIG 3 • (co n t in u e d ) E. A p o st e rio rly p o sit io n e d h a lf-p in ca n b e p la ce d b e h in d t h e p ro je ct e d n a il p a t h . F. A d ist a l h a lf-p in p la ce d ju st

o ve r a n d p a ra lle l t o t h e p la fo n d ca n b e h e lp fu l fo r a lig n in g t h e d ist a l fra g m e n t a n d lie s in fe rio r t o t h e p ro je ct e d e n d o f t h e n a il. G.
Th e kn e e is m a xim a lly fle xe d o ve r t h e t ria n g le t o a llo w fo r t h e p ro p e r st a rt in g w ire in se rt io n a n g le . H. Typ ica l se t u p fo r se m i-e xt e n d e d
n a ilin g w it h a sm a ll b o lst e r fo r lim it e d kn e e fle xio n a n d e a sy a cce ss t o t h e lim b fo r re d u ct io n a n d im a g in g .

■ The semi-extended position allows for reduction of the ■ If the suprapatellar approach is being performed, a su-
flexion deformity associated with these fractures. peromedial or superior midline is used and special instru-
■ The limited or formal medial parapatellar may be used mentation is required.
if the surgeon is unfamiliar with the suprapatellar ap- ■ All of the surgical approaches are performed with the

proach and special instrumentation is not available. knee in the semi-extended position.

TECHNIQUES
SURGICAL APPROACH
Me d ia l Pa ra p a t e lla r Te n d o n ■ Th e re t in a cu lu m is t h e n sp lit , a n d t h e p a t e lla r t e n d o n is
re t ra ct e d la t e ra lly.
Ap p ro a ch ■ Do n o t in cise t h e ca p su le .
■ Pa lp a t e a n d m a rk t h e m e d ia l b o rd e r o f t h e p a t e lla r t e n -
d o n (TECH FIG 1 , lin e A ).
■ In cise t h e skin a t t h e m e d ia l b o rd e r o f t h e p a t e lla r
Tra n sp a t e lla r Te n d o n Ap p ro a ch
tendon.
■ Pa lp a t e a n d m a rk t h e m e d ia l a n d la t e ra l b o rd e r o f t h e
■ Fu ll-t h ickn e ss skin fla p s a re d e ve lo p e d . p a t e lla r t e n d o n , t h e in fe rio r b o rd e r o f t h e p a t e lla , a n d
■ Disse ct io n is ca rrie d d o w n t o t h e re t in a cu lu m . t h e t ib ia l t u b e rcle (TECH FIG 1 , lin e B).
■ Incise th e skin st art in g a t the inferior m argin of t he pa te lla
an d co n tin u e d istally in t he m idd le o f the p at ellar t end o n .
■ Fu ll-t h ickn e ss skin fla p s a re d e ve lo p e d .
■ In cise t h e p a ra t e n o n in t h e m id lin e , a n d e le va t e m e d ia l
a n d la t e ra l fla p s t o id e n t ify t h e m a rg in s o f t h e p a t e lla r
tendon.
■ Ma ke a sin g le fu ll-t h ickn e ss in cisio n in t h e m id lin e o f t h e
p a t e lla r t e n d o n . Do n o t in cise t h e ca p su le a n d a vo id in -
ju rin g t h e m e n isci a t t h e in fe rio r m a rg in o f t h e in cisio n .

La t e ra l Pa ra p a t e lla r Te n d o n
Ap p ro a ch
■ Pa lp a t e a n d m a rk t h e la t e ra l b o rd e r o f t h e p a t e lla r t e n -
d o n (TECH FIG 1 , lin e C).
■ In cise t h e skin a t t h e la t e ra l b o rd e r o f t h e p a t e lla r
tendon.
■ Fu ll-t h ickn e ss skin fla p s a re d e ve lo p e d .
TECH FIG 1 • Op t io n s fo r surg ica l in cisio n s in re la t io n t o t h e
p a t e lla a n d p a t e lla r t e n d o n . A. Me d ia l p a ra p a t e lla r t e n d o n
■ Disse ct io n is ca rrie d d o w n t o t h e re t in a cu lu m .
in cisio n. B. Tra n sp a t e lla r t e n d o n in cisio n . C. La t e ra l p a ra p a t e l-
■ Th e re t in a cu lu m is t h e n sp lit , a n d t h e p a t e lla r t e n d o n is
la r t en d o n . D. Su p e ro m e d ia l t e n d o n in cisio n . E. Su p ra pa t e lla r re t ra ct e d m e d ia lly.
incision . ■ Do n o t in cise t h e ca p su le .
 460 Se c t i o n V LEG
TECHNIQUES
A B
28
Se m i-Ext e n d e d Po sit io n
M e d ia l Pa r a p a t e lla r Ap p r o a ch
■ Eit h e r a st a n d a rd m id lin e o r lim it e d m e d ia l skin in cisio n
ca n b e u se d (TECH FIG 2 ).
■ Fu ll-t h ickn e ss skin fla p s a re d e ve lo p e d .
■ Th e d ist a l p o rt io n o f t h e q u a d rice p s t e n d o n is in cise d ,
le a vin g a 2-m m cu ff o f t e n d o n m e d ia lly fo r la t e r re p a ir.
■ A fo rm a l m e d ia l a rt h ro t o m y is d o n e e xt e n d in g a ro u n d
t h e p a t e lla , le a vin g a 2-m m cu ff o f ca p su le a n d re t in a cu -
lu m fo r la t e r re p a ir, a n d co n t in u in g a lo n g t h e m e d ia l
b o rd e r o f t h e p a t e lla r t e n d o n .
30
Su p r a p a t e lla r Ap p r o a ch
■ Th e su p ra p a t e lla r a p p ro a ch re q u ire s sp e cia l n a il in se rt io n
in st ru m e n t a t io n a s w e ll a s ca n n u la s fo r g u id e p in p la ce -
m e n t a n d re a m in g .
■ Th e skin in cisio n is m a d e a t t h e su p e ro m e d ia l e d g e o f t h e
p a t e lla (TECH FIG 3 ).
■ Fu ll-t h ickn e ss skin fla p s a re d e ve lo p e d .
TECH FIG 3 • A p a rt ia l m e d ia l p a ra p a t e lla r a rt h ro t o m y t h a t is
ca rrie d in t o t h e in t e rm e d iu s a llo w s e n o u g h su b lu xa t io n o f t h e
p a t e lla t o p e rfo rm se m i-e xt e n d e d n a ilin g . (Co u rt e sy o f Pa u l
To rn e t t a III, MD.)
TECH FIG 2 • A. A fo rm a l fu ll m e d ia l p a ra p a t e lla r a p -
p ro a ch a llo w s fo r e a sy p a t e lla r su b lu xa t io n a n d st a rt sit e
lo ca liza t io n b u t re q u ire s sig n ifica n t d isse ct io n . B. Th e a l-
t e rn a t ive is a lim it e d m e d ia l a p p ro a ch . (B: Co u rt e sy o f
Pa u l To rn e t t a III, MD.)
■ Ma ke a su p e ro m e d ia l a rt h ro t o m y la rg e e n o u g h t o
p la ce t h e sp e cia l in st ru m e n t a t io n .
■ An a lt e rn a t ive skin in cisio n ca n b e m a d e e xt e n d in g fro m
t h e m id lin e o f t h e su p e rio r p o le o f t h e p a t e lla p ro xim a lly
(se e TECH FIG 1 , lin e E).
■ Fu ll-t h ickn e ss skin fla p s a re d e ve lo p e d .
■ In cise t h e q u a d rice p s t e n d o n in t h e m id lin e , e xt e n d -
in g p ro xim a lly fro m t h e su p e rio r p o le o f t h e p a t e lla ,
a n d m a ke a n a rt h ro t o m y.
St a n d a rd In t ra m e d u lla ry Na ilin g
In it ia l Gu id e w ir e Pla ce m e n t
■ Dra p e t h e le g fre e , in clu d in g t h e p ro xim a l t h ig h .
Dra p in g t h e le g m o re d ist a lly ca n lim it kn e e fle xio n d u e
t o b u n ch in g o f t h e d ra p e s.
■ Fle x t h e kn e e o ve r a b o lst e r o r ra d io lu ce n t t ria n g le
■ A p a d d e d t h ig h t o u rn iq u e t ca n b e a p p lie d a n d in -
fla t e d d u rin g t h e su rg ica l a p p ro a ch , b u t it m u st n o t
b e in fla t e d d u rin g re a m in g b e ca u se o f t h e risk o f
t h e rm a l in ju ry t o t h e in t ra m e d u lla ry ca n a l. Fo r t h is
re a so n , a t h ig h t o u rn iq u e t is u su a lly o m it t e d .
■ Th e st a rt in g g u id e w ire is p la ce d o n t h e skin a n d ra d i-
o g ra p h ica lly a lig n e d w it h t h e a n a t o m ic a xis a n d in lin e
w it h t h e la t e ra l t ib ia l sp in e o n a t ru e AP flu o ro sco p ic
im a g e . Th e skin ca n b e m a rke d a lo n g t h e g u id e w ire p a t h
t o a llo w visu a liza t io n o f t h e a n a t o m ic a xis w it h o u t flu o -
ro sco p y (TECH FIG 4 A).
■ Th e a p p ro p ria t e su rg ica l a p p ro a ch is p e rfo rm e d .
■ Th e kne e is ma xima lly fle xed , and t he gu id ew ire is aligne d
w ith th e a n a t o mic a xis o f th e t ib ia .
■ Typ ica lly, a ch ie vin g a n a p p ro p ria t e in se rt io n ve ct o r
w ill re q u ire t h e w ire t o b e p u sh e d a g a in st t h e p a t e lla
o r t h e p e rip a t e lla r t issu e s.
■ Th e a n t e rio r t ib ia l cre st is p a lp a t e d fo r fro n t a l p la n e w ire
a lig n m e n t .
■ La t e ra l p la n e flu o ro sco p y is n e ce ssa ry t o p la ce t h e w ire
a t t h e p ro xim a l a n d su p e rio r a sp e ct o f t h e “ fla t sp o t ”
a n d n e a r p a ra lle l w it h t h e a n t e rio r t ib ia l co rt ica l lin e
(TECH FIG 4 B).
■ Th e g u id e w ire is d ire ct e d 8 t o 10 cm in t o t h e m e t a p h ysis.
■ Gu id e w ire p o sit io n is ve rifie d in t h e AP a n d la t e ra l
p la n e s.
■ Th e fro n t a l p la n e w ire p o sit io n sh o u ld b e in lin e w it h
t h e a n a t o m ic a xis a n d p ro xim a lly sh o u ld b e ju st m e -
d ia l t o t h e la t e ra l t ib ia l sp in e . La t e ra l a lig n m e n t
sh o u ld b e n e a rly p a ra lle l w it h t h e a n t e rio r t ib ia l co r-
t e x, a n d a ll e ffo rt s sh o u ld b e m a d e t o a vo id a p o st e -
rio rly d ire ct e d ve ct o r (TECH FIG 4 C).

B
A C
Cre a t in g a n d Re a m in g
t h e St a rt in g Ho le
■ The opening reamer (matchin g the proximal nail diameter)
is introdu ce d via a tissu e slee ve and inserte d while ca re fully
maintaining knee hyperflexion and biplanar alignment.
■ If t h e kn e e is a llo w e d t o e xt e n d o r p o st e rio r p re ssu re is
n o t m a in t a in e d o n t h e t issu e sle e ve , t h e st a rt in g h o le
w ill b e co m e e n la rg e d a n t e rio rly, a n d t h e p ro xim a l a n t e -
rio r co rt e x w ill b e vio la t e d .
■ Im p re cise re a m in g t e ch n iq u e le a d s t o a n t e rio riza t io n
o f t h e n a il a n d vio la t io n o f t h e p ro xim a l a n t e rio r
co rt e x (TECH FIG 5 ).
TECH FIG 5 • If fle xio n is n o t m a in t a in e d d u rin g re a m in g , o r
re a m in g is st a rt e d b e fo re e n t ra n ce in t o t h e st a rt in g h o le , t h e
a n t e rio r t ib ia l co rt e x w ill b e vio la t e d b y t h e re a m e r, a n d a n
a n t e rio r n a il p a t h w ill b e p ro d u ce d .
Ch a p t e r 4 8 INTRAM EDULLARY NAILING OF THE TIBIA 461
TECHNIQUES
TECH FIG 4 • A. Markin g th e skin a lo n g t h e crest ca n a s-
sist in a lig ning th e guide wire w ith t he pa th o f t he in-
tram edu lla ry ca nal an d lesse n t he ne ed for fluo roscop ic
guidance. B. Id e al p ro ximal ext ra a rt icu la r st art sit e as see n
on lat eral fluoroscopic ima ge; t his is ne ar th e art icular
ma rgin. C. An id e al in se rt io n vecto r ap p ro ach es a p a ra llel
pat h w it h ant erior corte x and m inim izes the likelihood of
frag men t ext ension w it h seat ing of the nail.
■ Pla ce a 15-d e g re e b e n d 2 cm fro m t h e d ist a l e xt e n t o f t h e
b a ll-t ip p e d g u id e w ire t o a llo w fo r d ire ct io n a l co n t ro l
d u rin g w ire a d va n ce m e n t .
■ Alt e rn a t ive ly, a st ra ig h t b a ll-t ip p e d g u id e wire ca n b e
u se d w it h an in tram ed u lla ry re d uct io n in st ru me n t (eg ,
a ca nnulat ed finge r de vice ), w hich can p re cisely direct
th e w ire a nd sim p lify p assag e acro ss t h e fract u re.
■ A b a ll-t ip p e d g u id e w ire is in t ro d u ce d in t o t h e p ro xim a l
se g m e n t , a n d t h e kn e e is slig h t ly e xt e n d e d fo r fra ct u re
re d u ct io n a n d in st ru m e n t a t io n .
Fra ct u re Re d u ct io n
Sim p le M id d le Dia p h y s e a l Fr a ct u r e s
(Tr a n s v e r s e o r Sh o r t Ob liq u e )
■ Ma n u a l t ra ct io n w it h g ro ss m a n ip u la t io n w ill re d u ce sim -
p le t ra n sve rse m id -d ia p h yse a l fra ct u re s.
■ Me d ia lly-b a se d e xt e rn a l fixa t io n o r d ist ra ct io n w it h a
la rg e u n ive rsa l d ist ra ct o r is h e lp fu l fo r re d u ct io n w h e n
n o a ssist a n t s a re a va ila b le , in la rg e p a t ie n t s, o r w h e n
u se d fo r p ro visio n a l fixa t io n .
■ Mu scu la r p a ra lysis o ft e n is h e lp fu l.
■ Pla ce m e n t o f p e rcu t a n e o u s p o in t e d re d u ct io n fo rce p s
ca n b e h e lp fu l in o b liq u e a n d sh o rt o b liq u e p a t t e rn s t o
a ch ie ve a n a t o m ic o r n e a r-a n a t o m ic re d u ct io n .
■ In t ro d u ce a sm a ll o r la rg e p o in t e d cla m p u n d e r flu o -
ro sco p ic g u id a n ce t o d e t e rm in e t h e a p p ro xim a t e
cla m p a p p lica t io n a n g le (TECH FIG 6 A–C).
■ Typ ica lly, t h e sp ike o n t h e d ist a l fra g m e n t is p o st e ro -
la t e ra l.
Hig h ly Co m m in u t e d M id d le Dia p h y s e a l
Fr a ct u r e s
■ Ha ve co m p a riso n ra d io g ra p h ic im a g e s o f t h e u n in ju re d
e xt re m it y a va ila b le t o b e u se d a s a t e m p la t e fo r le n g t h
a n d ro t a t io n a l re d u ct io n la n d m a rks.
 462 Se c t i o n V LEG
TECHNIQUES

A B C

TECH FIG 6 • Re d u ct io n o f a sim p le m id d le d ia p h yse a l fra ct u re . A. Po in t e d re -

d u ct io n cla m p s ca n b e p la ce d t h ro u g h sm a ll st a b in cisio n s. B. Use flu o ro sco p y
t o lo ca lize cla m p p o sit io n a n d d e t e rm in e id e a l cla m p in cisio n lo ca t io n s.
C. Pe rcu t a n e o u s cla m p s ca n a ccu ra t e ly re d u ce a n d st a b ilize o b liq u e fra ct u re s
b e fo re n a il in t ro d u ct io n .

■ Me ch a n ica l t ra ct io n w it h m e d ia lly b a se d h a lf p in fixa t io n co m p le t e d b e ca u se t h e y re p re se n t a la rg e a m o u n t o f

is ve ry h e lp fu l.
■ A la rg e e xt e rn a l fixa t o r o r la rg e u n ive rsa l d ist ra ct o r is
e q u a lly e ffe ct ive .
■ Th e p ro xim a l h a lf-p in is p la ce d p o st e rio rly a n d p a ra l-
le l t o t h e t ib ia l p la t e a u (TECH FIG 7 A).
■ Th e d ist a l h a lf p in is p la ce d ju st a b o ve a n d p a ra lle l t o
t h e p la fo n d (TECH FIG 7 B).
■ Th e in t ra m e d u lla ry re d u ct io n t o o l a va ila b le in m o st n a il
o r re a m e r se t s ca n b e u se d t o m a n ip u la t e t h e p ro xim a l
fra g m e n t in o rd e r t o a d va n ce t h e t o o l a cro ss t h e fra c-
t u re w h ich a ch ie ve s fra ct u re re d u ct io n a n d g u id e w ire
p la ce m e n t .
Op e n M id d le Dia p h y s e a l Fr a ct u r e s
■ La rg e se g m e n t a l a n d b u t t e rfly fra g m e n t s t h a t a re co m -
p le t e ly d e vit a lize d a n d vo id o f so ft t issu e a t t a ch m e n t s
sh o u ld b e re m o ve d a n d cle a n e d o f co n t a m in a t io n .
■ Th e se p ie ce s ca n t h e n b e re in t ro d u ce d in t o t h e fra ct u re
sit e a n d u se d t o p e rfo rm a n a t o m ic o p e n re d u ct io n
fo llo w in g p a ssa g e o f t h e in t ra m e d u lla ry ro d a n d in t e r-
lo ckin g . Th e se p ie ce s sh o u ld b e re m o ve d a ft e r fixa t io n is
n o n via b le m a t e ria l in a h ig h -risk w o u n d .
■ Occa sio n a lly, a n o st e o t o m e is re q u ire d t o fre e n e a r-
circu m fe re n t ia l fra g m e n t s (TECH FIG 8 A–C).
■ If re d u ct io n is d ifficu lt , a sm a ll-fra g m e n t u n ico rt ica l p la t e
ca n b e u se d t o m a in t a in t h e re d u ct io n d u rin g re a m in g
a n d n a il p la ce m e n t . On ce in t e rlo ckin g is co m p le t e d , t h e
p la t e sh o u ld b e re m o ve d (TECH FIG 8 D).
Pa ssin g t h e Gu id e w ire
■ On ce o p t im a l AP a n d la t e ra l p la n e re d u ct io n is a ch ie ve d ,
t h e w ire is a d va n ce d p a st t h e le ve l o f t h e fra ct u re . Ve rify
t h a t t h e w ire is w it h in t h e ca n a l o n b o t h t h e AP a n d la t -
e ra l vie w s t o a vo id a d va n cin g t o o fa r a n d d a m a g in g e x-
t ra m e d u lla ry st ru ct u re s.
■ In m e t a d ia p h yse a l fra ct u re s, t h e w ire m u st b e ce n t e re d
in t h e m e t a p h yse a l se g m e n t .
■ In p ro xim a l a n d d ist a l fra ct u re s, b lo ckin g scre w s o r
h a lf-p in s m a y b e re q u ire d t o e n su re ce n t ra lize d p o si-
t io n in g o f t h e g u id e w ire (TECH FIG 9 A,C,D).
■ On ce ce n t ra lize d , t h e b a ll-t ip p e d w ire m u st b e im p a ct e d
in t o t h e su b ch o n d ra l b o n e o f t h e t ib ia l p la fo n d a t t h e

TECH FIG 7 • Re d u ct io n o f a h ig h ly co m m in u t e d m id -
d le d ia p h yse a l fra ct u re . A. A p o st e rio rly p o sit io n e d
h a lf-p in w it h a la rg e fe m o ra l d ist ra ct o r is h e lp fu l fo r
fra ct u re re d u ct io n a n d d o e s n o t b lo ck n a il p a ssa g e . B.
A h a lf-p in p la ce d ju st a b o ve t h e a n kle jo in t lie s b e lo w
A B t h e p ro je ct e d e n d o f t h e n a il.
 Ch a p t e r 4 8 INTRAM EDULLARY NAILING OF THE TIBIA 463

TECHNIQUES
A

B C D

TECH FIG 8 • Re d u ct io n o f a n o p e n m id d le d ia p h yse a l fra ct u re . A. A la rg e se g m e n t o f st rip p e d

co rt ica l b o n e h a s b e e n re m o ve d a n d cle a n e d o n t h e b a ck t a b le . B. Th e co rt ica l fra g m e n t h a s b e e n
p la ce d in t o t h e fra ct u re sit e a n d cla m p e d in re d u ce d p o sit io n t o re d u ce t h e fra ct u re a n a t o m ica lly.
C. In t ra o p e ra t ive im a g e o f t h e fra ct u re w it h t h e fra ct u re fra g m e n t cla m p e d in re d u ce d p o sit io n ;
n o t e t h a t t h is fra g m e n t w ill b e re m o ve d a ft e r re a m in g a n d n a il p a ssa g e . D. Un ico rt ica l p la t e s a re
u se fu l fo r m a in t a in in g re d u ct io n d u rin g n a il p a ssa g e .

le ve l o f t h e p h yse a l sca r. Th is d e cre a se s t h e risk o f in a d - ■ Alt e rn a t ive ly, in se rt in g a g u id e w ire o f t h e sa m e

ve rt e n t ly re m o vin g t h e g u id e w ire d u rin g re a m in g .
■ Na il le n g t h m e a su re m e n t ca n n o w b e p e rfo rm e d u sin g
su p p lie d le n g t h g a u g e s, a n d sh o u ld b e ve rifie d w it h
la t e ra l flu o ro sco p ic m e a su re m e n t (TECH FIG 9 B). Th e
la t e ra l vie w is u se d b e ca u se it is m o re a ccu ra t e in d e t e r-
m in in g t h e le ve l o f t h e a rt icu la r su rfa ce a n d a vo id in g
n a il p ro m in e n ce .
le n g t h t o t h e n a il e n t ry sit e a n d t h e n m e a su rin g t h e
le n g t h d iffe re n t ia l b e t w e e n w ire s a lso p ro vid e s a n
a ccu ra t e m e a su re m e n t (TECH FIG 9 C). Ho w e ve r, t h is
in t ro d u ce s t h e sig n ifica n t co st o f a se co n d g u id e w ire .
■ De vice m a n u fa ct u re rs su p p ly n a ils in va ria b le in cre m e n t s.
Wh e n a le n g t h m e a su re m e n t fa lls in b e t w e e n le n g t h s,
ch o o se t h e sh o rt e r le n g t h . A t h re a d e d e n d ca p (u su a lly 5,
10, a n d 15 m m ) ca n b e u se d if it is d e sire d t o b rin g t h e
n a il t o t o p o f t h e ca n a l o p e n in g .
■ Le a vin g t h e n a il co u n t e rsu n k b e lo w t h e b o n e su rfa ce
d o e s n o t co m p ro m ise st a b ilit y in m id d le a n d d ist a l fra c-
t u re s, b u t m a y co m p lica t e fu t u re n a il e xt ra ct io n .

A B
TECH FIG 9 • A. A d rill b it is u se d t o e n su re t h e g u id ew ire is
p laced cen tra lly in t h e d ist a l se g m en t o f th is d ist a l m et a d ia p h y-
se al fra ctu re. B. Th e nail le ng th g u id e is p u she d t o th e o p en in g
o f t h e t ib ia an d verifie d w ith la t era l flu o ro sco p ic ima g in g .
Re a m in g t h e Ca n a l
■ Be fore re a min g , estim a t e t h e n arro we st can al d iam et er
u sin g b ot h AP an d la te ra l p la in ra d iog ra p h s. Alt e rn a t ive ly,
int ra me dullary re am er set s t ypically have a ra dioluce nt
ru le r th a t a llo ws fo r in tra o p e ra tive flu o ro sco p ic ve rifica -
t io n , wh ich sh o u ld b e d o n e o n b o t h t h e AP an d la te ra l
vie ws. Th e ca n al typ ically is rea me d a t least 1 m m o ver t he
ist hm ic diam et er to m inimize t he risk of nail inca rcerat io n.
■ Re a m in g sh o u ld b e g in w it h a n e n d -cu t t in g re a m e r—t h e
8.5- o r 9-m m size in m o st syst e m s.
■ Re a m e r h e a d s sh o u ld b e e va lu a t e d b e fo re in se rt io n a n d
sh o u ld b e sh a rp a n d fre e o f d e fe ct s.
■ In se rt t h e re a m e r h e a d in t o t h e p ro xim a l m e t a p h ysis
w it h t h e kn e e in m a xim a l fle xio n b e fo re a p p lyin g p o w e r
t o a vo id d ist o rt in g t h e e n t ra n ce h o le (TECH FIG 1 0 A).
■ Re a m e rs a re a d va n ce d a t a slo w p a ce u n d e r fu ll p o w e r.
■ If t h e re a m e r sh a ft s a re n o t so lid , b u t a re w o u n d , b e
su re t o a vo id u sin g re ve rse w h e n d rillin g , b e ca u se
t h a t w o u ld ca u se t h e re a m e rs t o u n w in d if re sist a n ce
is e n co u n t e re d w it h in t h e IM ca n a l.
 464 Se c t i o n V LEG
■ Ca re m u st b e t a ke n n o t t o in a d ve rt e n t ly e xt ra ct t h e
TECHNIQUES
g u id e w ire w h e n t h e re a m e rs a re re m o ve d .
■ Mu lt ip le t e ch n iq u e s a re u t ilize d . First , m a n u a l d o w n -
w a rd p re ssu re ca n b e a p p lie d t o t h e w ire w it h sp e cia l-
ize d in st ru m e n t s, m e d icin e cu p s, o r cle a n in g ca n n u la s
(TECH FIG 1 0 B).
■ On ce t h e re a m e r h a s cle a re d t h e o p e n in g , it ca n b e
cla m p e d a n d h e ld in p o sit io n (TECH FIG 1 0 C).
■ Fo r t h e m in im a lly re a m e d t e ch n iq u e , a sin g le e n d -cu t -
t in g re a m e r (u su a lly 9 m m ) is p a sse d d o w n t h e ca n a l t o
e n su re t h e sm a lle st d ia m e t e r n a il ca n p a ss t h ro u g h t h e
n a rro w e st se g m e n t o f t h e in t ra m e d u lla ry ca n a l.
■ In an e ffort to m in imize the rm al dam ag e t o th e e nd o ste al
co rte x, re a m in g sh o u ld b e d isco n t in u e d w it h in 0.5 t o
1 m m of he aring t he ream er he ad cat ching (“chat te r” ) on
th e en d ost e a l cort e x.
■ Ca re a lso sh o u ld b e u se d w h e n t h e re a re b u t t e rfly o r
o b liq u e fra ct u re fra g m e n t s. Co n t in u e d re a m in g a ft e r
e n co u n t e rin g “ ch a t t e r” m a y re su lt in ia t ro g e n ic co m -
m in u t io n a n d lo ss o f re d u ct io n .
Un re a m e d Te ch n iq u e
■ St a n d a rd p re p a ra t io n t e ch n iq u e is u se d fo r t h e st a rt in g
h o le , a n d t h e fra ct u re is re d u ce d .
■ Pre cise e va lu a t io n o f t h e la t e ra l ist h m ic d ia m e t e r is re -
p e a t e d , a n d a sm a ll-d ia m e t e r n a il is se le ct e d , t yp ica lly in
t h e 7- t o 9-m m ra n g e .
■ A g o o d g u id e lin e is t o u se a n a il 1 m m t o 1.5 m m sm a lle r
t h a n t h e n a rro w e st m e a su re o f t h e ist h m u s o n t h e la t e ra l
ra d io g ra p h .
■ If la t e ra l p la n e im a g in g is su g g e st ive o f ca n a l d ia m e t e r
ve ry clo se t o n a il size , a sin g le p a ss w it h a n e n d cu t t in g
re a m e r u su a lly is p e rfo rm e d t o d e cre a se t h e p o ssib ilit y o f
n a il in ca rce ra t io n .
A B
TECH FIG 1 0 • A. Ma in t e n a n ce o f m a xim a l kn e e fle xio n p ro t e ct s t h e e n t ra n ce h o le fro m b e in g in a d ve r-
t e n t ly e n la rg e d b y t h e re a m e r. B. If t h e g u id e w ire is ro t a t in g d u rin g re a m in g , it m u st b e h e ld d o w n a s t h e
re a m e r is p u lle d b a ck t o a vo id in a d ve rt e n t re m o va l o f t h e g u id e w ire . C. A cla m p ca n b e u se d t o g ra sp t h e
g u id e w ire w h e n t h e re a m e r h e a d cle a rs t h e so ft t issu e s.
■ Th e n a il is in se rt e d a n d im p a ct e d in st a n d a rd fa sh io n . If
sig n ifica n t re sist a n ce is e n co u n t e re d w h e n t h e n a il
re a ch e s t h e ist h m u s, t h e n a il is re m o ve d t o a vo id in ca r-
ce ra t io n o r ia t ro g e n ic fra ct u re p ro p a g a t io n . A re a m e r
0.5 t o 1.0 m m la rg e r t h a n t h e n a il is p a sse d d o w n t h e
ca n a l, a n d n a il p a ssa g e is a t t e m p t e d a g a in .
Na il In se rt io n
■ Aft e r t h e n a il in se rt io n h a n d le is a t t a ch e d , p a ss a d rill
t h ro u g h t h e p ro xim a l scre w in se rt io n a t t a ch m e n t a n d
scre w in se rt io n ca n n u la s b e fo re in se rt in g t h e n a il t o e n -
su re a ccu ra t e a lig n m e n t o f t h e a t t a ch m e n t .
■ Ma in t a in n a il ro t a t io n d u rin g in se rt io n b y a lig n in g t h e
ce n t e r o f t h e in se rt io n h a n d le w it h t h e t ib ia l cre st ; co n -
sid e r in t e rn a l ro t a t io n o f t h e n a il if d ist a l a n t e ro p o st e rio r
in t e rlo ckin g b o lt s a re d e e m e d n e ce ssa ry.
■ Ma in t a in kn e e h yp e rfle xio n d u rin g n a il in se rt io n t o
m in im ize t h e risk o f p o st e rio r co rt ica l a b u t m e n t a n d
ia t ro g e n ic fra ct u re .
■ Im p a ct t h e n a il t o t h e fin a l d e p t h u sin g la t e ra l p la n e
flu o ro sco p y.
In t e rlo ckin g Bo lt In se rt io n
■ In sim p le t ra n sve rse fra ct u re s, p la ce d ist a l in t e rlo cks first
t o a llo w fo r b a ck-sla p p in g fo r in t e rfra g m e n t a ry co m -
p re ssio n a n d g a p m in im iza t io n .
■ Usu a lly, d ist a l in t e rlo ck b o lt s a re p la ce d m e d ia l t o
la t e ra l.
■ Positio n the leg in slig ht extension an d stable neutral
rotation.
■ Ro t a t e t h e C-a rm t o la t e ra l im a g in g p o sit io n a n d p u ll t h e
t u b e b a ck a w a y fro m t h e m e d ia l sid e o f t h e le g t o a llo w
fo r d rill p la ce m e n t .
C

■ Ro t a t e t h e le g a n d C-a rm in d ivid u a lly a n d se q u e n t ia lly t o
cre a t e a p e rfe ct circle im a g e ; o p t im ize t h is vie w b e fo re
d rillin g a t t e m p t s (TECH FIG 1 1 A).
■ Aft e r lo ca lizin g t h e in t e rlo ckin g h o le u sin g a cla m p a n d
flu o ro sco p y, m a ke a n in cisio n la rg e e n o u g h t o p la ce t h e
lo ckin g b o lt . Use b lu n t cla m p d isse ct io n u n t il t h e co rt e x
is re a ch e d .
■ Use a sh a rp d rill p o in t a n d p la ce t h e ce n t e r o f t h e p o in t
in t h e ce n t e r o f t h e circle
■ Ho ld t h e d rill o b liq u e ly t o t h e n a il a xis t o sim p lify
re p o sit io n in g (TECH FIG 1 1 B).
■ On ce t h e ce n t ra l lo ca t io n is a ch ie ve d ; a lig n h a n d a n d
d rill w it h im a g in g a xis.
■ Flu o ro sco p e s w it h la se r a lig n m e n t g u id e s ca n b e h e lp -
fu l t o a ssist w it h a lig n m e n t b y ce n t e rin g t h e la se r o n
t h e skin in cisio n a n d t h e n p la cin g t h e la se r in t h e ce n -
t e r o f t h e b a ck o f t h e d rill w h e n p re p a rin g t o d rill t h e
h o le (TECH FIG 1 1 C).
■ Drill t o t h e m id -sa g it t a l p o in t in t h e t ib ia . Th e n d ise n -
g a g e t h e d rill fro m t h e d rill b it a n d ch e ck t h e flu o ro -
sco p ic im a g e .
■ If t h e d rill is a ccu ra t e ly p o sit io n e d in t h e ce n t e r
o f t h e h o le , a d va n ce t h e d rill b it w it h p o w e r
t h ro u g h t h e fa r co rt e x; a vo id b ro a ch in g t h e fa r
co rt e x b y im p a ct in g w it h a m a lle t t o a vo id ia t ro -
g e n ic fra ct u re .
A B
TECH FIG 1 1 • A. A p e rfe ct ly ro t a t e d la t e ra l flu o ro sco p ic im a g e w ill a p p e a r a s a p e rfe ct circle a n d
sh o u ld b e a ch ie ve d b e fo re d rillin g is a t t e m p t e d . B. Th e d rill p o in t m u st b e a lig n e d in t h e ce n t e r
o f t h e p e rfe ct circle b e fo re d rillin g . C. Th e la se r a lig n m e n t g u id e ca n b e h e lp fu l fo r lo ca lizin g t h e
skin in cisio n .
PROXIMAL METAPHYSEAL TIBIA FRACTURES
■ As d escrib ed in t h e a n at o my sect io n , p ro xim al m et ap h y-
se a l t ib ia fra ct u re s h a ve a t e n d e n cy t o b e d isp la ce d in va l-
g u s and flexion . Ma lu n io n occu rs in u p t o 84% o f p ro xim a l
t ib ia fract u res t h at u n d erg o in t ra me d u llary n a ilin g .5
■ In a d d it io n t o t h e t e ch n ica l t ricks t h a t w e w ill d iscu ss,
n a il d e sig n ca n b e im p o rt a n t in a vo id in g m a lu n io n .5
Na ils w it h a m o re p ro xim a l b e n d a re le ss like ly t o ca u se
d isp la ce m e n t o f t h e fra ct u re .10 Na il d e sig n s w it h o b liq u e
p ro xim a l lo ckin g b o lt o p t io n s h a ve b e e n sh o w n t o p ro -
vid e m o re b io m e ch a n ica l st a b ilit y t h a n d e sig n s w it h
t ra n sve rse lo ckin g b o lt s a lo n e .
Ch a p t e r 4 8 INTRAM EDULLARY NAILING OF THE TIBIA 465
■ Drill t h e se co n d in t e rlo ck h o le u sin g t h e sa m e
TECHNIQUES
t e ch n iq u e b u t m a in t a in in g a p a ra lle l a xis w it h t h e
first su cce ssfu l d rill p a ssa g e .
■ Re p la ce t h e d rill w it h t h e a p p ro p ria t e d e p t h g a u g e
a n d ch e ck a n AP im a g e b e fo re scre w le n g t h se le ct io n .
■ On ce in te rlo ck le n g th s an d p o sit io n a re ve rified , “ b ack
slap p in g ” can o ccu r to o p t imize co mp ressio n .
■ Usin g t h e slo t t e d m a lle t a t t a ch m e n t o n t h e in se r-
t io n h a n d le , su p e rio rly d ire ct e d m a lle t b lo w s ca n
b e u se d w h ile p re ssu re is a p p lie d t o t h e fo o t in
o rd e r t o co m p re ss t h e fra ct u re sit e . Flu o ro sco p y
sh o u ld b e u se d t o m o n it o r t h e a m o u n t o f co m -
p re ssio n a n d t h e n a il p o sit io n p ro xim a lly. If “ b a ck
sla p p in g ” is p la n n e d , t h e n a il sh o u ld b e slig h t ly
o ve rin se rt e d t o a vo id n a il p ro m in e n ce a ft e r co m -
p re ssio n is p e rfo rm e d .
■ Pla ce p ro xim a l in t e rlo cks t h ro u g h d rill g u id e s.
■ Be ca u se t h e t ib ia is a t ria n g le , o b liq u e vie w s m a y
b e u se d t o m o re a ccu ra t e ly ju d g e scre w le n g t h fo r
t ra n sve rse lo ckin g b o lt m e a su re m e n t .
■ If o b liq u e lo ckin g b o lt s a re ch o se n p ro xim a lly,
o b liq u e flu o ro sco p ic vie w s sh o u ld b e u se d p rio r t o
in se rt io n h a n d le re m o va l t o a vo id p la cin g lo n g
scre w s t h a t a re p a rt icu la rly sym p t o m a t ic o n t h e
m e d ia l sid e o f t h e kn e e a n d t o a vo id in ju ry t o t h e
p e ro n e a l n e rve p o st e ro la t e ra lly.
C
■ Se ve ra l cu rre n t n a ilin g syst e m s a llo w a fixe d a n g le t o b e
cre a t e d b e t w e e n t h e n a il a n d t h e p ro xim a l lo ckin g b o lt
b y in se rt in g a n e n d ca p t h a t cre a t e s a n in t e rfe re n ce fit
w it h t h e p ro xim a l lo ckin g b o lt , a n d o t h e rs h a ve m e ch a -
n ism s t o a llo w t h e scre w t o lo ck in t o t h e n a il.
■ Use o f a va rie ty o f t h e t ech n iq u es d e scrib e d in t h e fo l-
low ing se ct io ns below ofte n is required t o a chie ve and
m ain t ain fro n t al an d sa g itt al p lan e red u ctio n . Th e m o st
im porta nt elem en t is t he prop er st art ing site and guide-
w ire in se rt io n ve cto r. Po ste rio rly d ire ct e d in se rt ion a ng le s
w ill a cce nt u a t e p ro xim al fra g m e n t e xt e n sio n w it h n ail
 466 Se c t i o n V LEG
pa ssag e rega rd le ss of na il d e sign . Me d ia l d evia tio n o f th e
TECHNIQUES
gu id ew ire w ill le a d t o a b ut m e n t a g a in st th e st ee p me d ial
co rtex a n d lead t o valg u s a n g u lat io n at t h e fra ct u re sit e
w ith nail in se rtio n .
La t e ra l Pa ra p a t e lla r Te n d o n
Ap p ro a ch
■ Aft e r co m p le t in g t h e la t e ra l p a ra p a t e lla r a p p ro a ch d e -
scrib e d , t h e st a n d a rd p a t ie n t p o sit io n in g is u se d .
■ Th e la t e ra l p a ra p a t e lla r a p p ro a ch a llo w s t h e g u id e p in t o
b e m o re e a sily p la ce d ju st m e d ia l t o t h e la t e ra l t ib ia l
sp in e o n t h e AP vie w a n d a lo n g t h e la t e ra l co rt e x t o co r-
re ct t h e va lg u s a n g u la t io n .
■ If a t ru e AP vie w is n o t o b t a in e d a n d t h e le g is e xt e r-
n a lly ro t a t e d , t h e st a rt in g p o in t w ill b e m o re m e d ia l
t h a n d e sire d . 5
■ It is im p o rt a n t t o g e t e n o u g h kn e e fle xio n o ve r t h e ra d i-
o lu ce n t t ria n g le o r b o lst e r t o a llo w fo r t h e g u id e p in t o
b e p la ce d a s p ro xim a l a s p o ssib le a n d p a ra lle l a lo n g t h e
a n t e rio r t ib ia l co rt e x t o h e lp co rre ct t h e t yp ica l fle xio n
d e fo rm it y. 22
Se m i-e xt e n d e d Te ch n iq u e
■ Th e b e n e fit o f t h e se m i-e xt e n d e d t e ch n iq u e fo r p ro xim a l
m e t a d ia p h yse a l fra ct u re s is t h a t t h e le g p o sit io n h e lp s
n e u t ra lize t h e a sso cia t e d fle xio n d e fo rm it y.28
■ Th e p a t ie n t is p la ce d in t h e se m i-e xt e n d e d p o sit io n a s
d e scrib e d e a rlie r.
■ Th e o p e n m e d ia l p a ra p a t e lla r a p p ro a ch ca n b e u se d (se e
TECH FIG 1 , lin e C).
■ Usin g t h e p re vio u sly d e scrib e d su rg ica l a p p ro a ch , t h e
p a t e lla is su b lu xa t e d t o a llo w fo r g u id e p in p la ce -
m e n t , re a m in g , a n d n a il p la ce m e n t , w it h t h e kn e e re -
m a in in g in t h e se m i-e xt e n d e d p o sit io n .
■ No sp e cia l in st ru m e n t s a re re q u ire d .
■ Su p ra p a t e lla r a p p ro a ch 30
■ Eit h e r t h e su p e ro m e d ia l o r d ire ct su p e rio r a p p ro a ch
is u se d .
■ Sp e cia l in st ru m e n t a t io n is re q u ire d ; w h ich in st ru m e n -
t a t io n is n e e d e d d e p e n d s o n t h e sp e cific syst e m u se d .
A B
TECH FIG 1 2 • A. Su p ra p a t e lla r a p p ro a ch : A sp e cia lly-d e sign e d ca n n u la is u se d t o su b lu x t h e p a t e lla a nd p a ss t h ro u g h t h e
p a t e llo fe m o ra l jo in t a n d is p o sit io n e d a t t h e a p p ro p ria t e st a rt in g p o in t . B. Th e g u id e p in is a d va n ce d a p p ro p ria t e ly a n d
t h e ca n n u la is u se d fo r t h e o p e n in g re a m e r, g u id e w ire p la ce m e n t , a n d in t ra m e d u lla ry re a m in g —b u t n o t n a il in se rt io n.
Lo n g re a m e r e xt e n sio n s a re h e lp fu l fo r in t ra m e d u lla ry re a m in g . C. A sp e cia lize d, lo n g in se rt io n h a n d le is re q u ire d for
su p ra p a t e lla r t e ch n iq u e s t o re a ch t h e t ib ia l st a rt sit e .
■ Th e p a t e lla is su b lu xa t e d u sin g a n e lo n g a t e d ca n n u la
(TECH FIG 1 2 A).
■ Th e ca n n u la is a d va n ce d t o t h e st a n d a rd st a rt in g
p o in t u sin g flu o ro sco p y.
■ Th e g u id e p in is p la ce d in t h e st a n d a rd p o sit io n
(TECH FIG 1 2 B).
■ Th e t yp ica l st e p s—u sin g t h e o p e n in g d rill, p la cin g t h e
g u id e w ire , a n d re a m in g —a re a ll co m p le t e d t h ro u g h
t h e e lo n g a t e d ca n n u la .
■ St a n d a rd in t ra m e d u lla ry re a m e rs ca n b e u se d b u t
re a m e r e xt e n sio n s a re h e lp fu l, e sp e cia lly in t a lle r
p a t ie n t s.
■ Fra ct u re re d u ct io n a n d p a ssin g o f t h e g u id e w ire a re
p e rfo rm e d b e fo re re a m in g .
■ A sp e cia l e lo n g a t e d n a il in se rt io n h a n d le is re q u ire d
fo r n a il in se rt io n (TECH FIG 1 2 C).
■ Pro xim a l lo ckin g b o lt in se rt io n is d o n e u sin g t h e a im -
in g a rm .
■ Dist a l lo ckin g b o lt s a re p la ce d u sin g t h e st a n d a rd
fre e h a n d t e ch n iq u e , a s p re vio u sly d e scrib e d .
Ad ju n ct Re d u ct io n a n d Fixa t io n
Te ch n iq u e s
Blo ck in g /Pö lle r Scr e w s
■ Scre w s ca n b e p la ce d a cro ss t h e in t ra m e d u lla ry ca n a l t o
cre a t e a “ fa lse ” co rt e x in t h e m e t a p h yse a l a re a t h a t
n a rro w s t h e p o t e n t ia l sp a ce fo r t h e n a il. Th is a id s in
b o t h fra ct u re re d u ct io n a s t h e n a il is b e in g p la ce d a n d
m a in t e n a n ce o f t h e re d u ct io n o n ce t h e n a il is
se a t e d . 15,26
■ Lo ckin g b o lt s fo u n d in t h e n a ilin g se t o r scre w s m a d e
fro m t h e sa m e m e t a l a s t h e n a il sh o u ld b e u se d .
■ Blo ckin g scre w s ca n e it h e r b e p la ce d p rio r t o in it ia l n a il
in se rt io n o r, if t h e n a il is in se rt e d a n d re sid u a l d e fo rm it y
e xist s, t h e n a il ca n b e re m o ve d a n d b lo ckin g scre w s ca n
b e in se rt e d .
■ Co ro n a l a n d sa g it t a l p la n e co rre ct io n ca n b e p e r-
fo rm e d b y p la cin g a scre w a t t h e co n ca vit y o f t h e
d e fo rm it y.
C
 Ch a p t e r 4 8 INTRAM EDULLARY NAILING OF THE TIBIA 467

TECHNIQUES
A B C

TECH FIG 1 3 • A. A b lo ckin g scre w p o sit io n e d ju st la t e ra l t o t h e id e a l n a il p a t h t o p re ve n t va l-

g u s d e fo rm a t io n . B. A p o st e rio r b lo ckin g scre w lim it s p ro xim a l fra g m e n t e xt e n sio n b y lim it in g
t h e e ffe ct ive a n t e rio r-t o -p o st e rio r ca n a l d ia m e t e r. B,C. Ob liq u e a n d m e d ia l t o la t e ra l in t e rlo ckin g
b o lt s a re p la ce d t h ro u g h t h e n a il.

■ To correct valgu s, t he scre w is pla ced lat erally 3.5 m m co m p re ssio n p la t e , p e lvic re co n st ru ct io n , o r
(TECH FIG 1 3A). To co rre ct la te ra l pla n e e xt e n sio n, o n e -t h ird t u b u la r) is a p p lie d m o re p o st e rio rly a n d fixe d
th e scre w is p la ce d p o st e riorly (TECH FIG 13B). w it h t w o o r t h re e u n ico rt ica l scre w s o n e it h e r sid e o f
■ Th e a p p ro p ria t e ly size d d rill b it is p la ce d w it h flu o ro - t h e fra ct u re t h a t a re lo n g e n o u g h t o m a in t a in t h e
sco p ic a ssist a n ce . re d u ct io n , b u t a vo id im p e d in g t h e p a ssa g e o f t h e in -
■ Th e a p p ro p ria t e ly size d scre w re p la ce s t h e d rill b it . t ra m e d u lla ry re a m e rs a n d n a il (TECH FIG 1 4 ).
■ Th e g u id e w ire is t h e n in se rt e d a n d se a t e d d ist a lly.
■ In t ra m e d u lla ry re a m in g is n e ce ssa ry t o e n su re t h e n a il Ip sila t e ra l Tib ia l Pla t e a u Fra ct u re
fo llo w s t h e n e w ly cre a t e d p a t h . La g Scr e w Fix a t io n f o r Sim p le Fr a ct u r e s
■ Wh e n a scre w t h a t b lo cks t h e w a y is e n co u n t e re d , ■ Re d u ce a n d co m p re ss t h e a rt icu la r su rfa ce w it h p e ria rt ic-
sim p ly p u sh t h e re a m e r h e a d p a st t h e scre w w it h -
u la r re d u ct io n fo rce p s t h ro u g h sm a ll in cisio n s m e d ia lly
o u t re a m in g . Th is a vo id s d u llin g t h e re a m e r h e a d
a n d la t e ra lly.
a n d p o t e n t ia lly d isp la cin g t h e b lo ckin g scre w . ■ Pro visio n a lly fix t h e a rt icu la r fra ct u re w it h a t le a st t w o K-
■ On ce p a sse d t h e scre w , re su m e re a m in g .
w ire s o r ca n n u la t e d scre w g u id e w ire s t h a t a re p a ra lle l t o
■ Aft e r re a m in g is co m p le t e , in se rt t h e in -
t h e a rt icu la r su rfa ce .
t ra m e d u lla ry n a il.
■ If t h e d isp la ce m e n t h a s n o t b e e n co rre ct e d , it w ill
b e n e ce ssa ry t o re m o ve t h e n a il, a n d a d d it io n a l
scre w s m a y b e a d d e d . Re a m in g a n d re in se rt io n o f
t h e g u id e -w ire a re re q u ire d b e fo re re -in se rt in g
t h e n a il.
■ In t e rlo ckin g b o lt s t h ro u g h t h e n a il a re p la ce d in t h e
st a n d a rd fa sh io n (TECH FIG 1 3 B,C).

M e d ia l Un ico r t ica l Pla t e

■ If t h e m e t a p h yse a l fra ct u re ca n b e re d u ce d b u t e a sily d is-
p la ce s w it h ch a n g e s in p o sit io n o f t h e e xt re m it y, a m e -
d ia l u n ico rt ica l p la t e ca n b e u se d .22
■ A m e d ia l o r p o st e ro m e d ia l (m o re p ro xim a lly) skin in ci-
sio n is ce n t e re d a t t h e fra ct u re sit e .
■ Fu ll-t h ickn e ss skin fla p s a re d e ve lo p e d . If t h e p e s a n se r-
in u s t e n d o n s a re e n co u n t e re d , t h e y ca n b e e le va t e d
a n t e rio rly.
■ Aft e r t h e fra ct u re is re d u ce d in t h e co ro n a l a n d sa g it t a l TECH FIG 1 4 • A p o st e ro m e d ia l u n ico rt ica l p la t e m a in t a in s re -
p la n e s, a p la t e o f t h e a p p ro p ria t e le n g t h p la t e (e it h e r d u ct io n w it h o u t im p e d in g n a il p a ssa g e .
 468 Se c t i o n V LEG
TECHNIQUES
A B
TECH FIG 1 5 • A p ro xim a l t ib ia fra ct u re w it h a sim p le a rt icu la r sp lit is st a b ilize d w it h in d e p e n d e n t la g scre w fixa t io n
a n d in t ra m e d u lla ry n a ilin g . (Co u rt e sy o f Pa u l To rn e t t a III, MD.)
■ Eit h e r ca n n u la t e d o r so lid co re scre w s ca n b e u se d fo r la g
scre w fixa t io n (TECH FIG 1 5 ).
■ If t h e re is co m m in u t io n , a vo id o ve r-co m p re ssin g t h e a r-
t icu la r su rfa ce .
■ Avo id p la cin g scre w s a n t e rio rly w h e re t h e n a il w ill b e
in se rt e d .
A B
DISTAL METADIAPHYSEAL TIBIA FRACTURES: FIBULAR FIXATION
■ Ob liq u e fra ct u re p a t t e rn s, w h ich o ft e n a re e n co u n t e re d ,
a re a m e n a b le t o p e rcu t a n e o u s cla m p re d u ct io n (TECH
FIG 1 7 A).
■ Ha lf-p in jo yst icks a re h e lp fu l fo r m a n ip u la t in g a n d re -
d u cin g t h e d ist a l fra ct u re se g m e n t (se e Fig 3E).
■ With a fib u la fract u re n e ar t h e level o f t h e t ib ia l frac-
tu re, fibula r fixa t io n ca n be h e lpfu l in a chievin g re d u ct io n
(TECH FIG 1 7B). Th e soft t issues m ust be tole ra nt o f a lat -
era l or post erolat eral ap proa ch to fibu la , how ever.
■ Sim p le t ra n sve rse fra ct u re s ca n b e fixe d w it h in-
tra m e du lla ry t e chn iq ue using fle xible t ita n iu m n ails,
typ ica lly 2.5 mm in d ia me te r, o r 3.5 m m int ra me d u llary
scre w fixa tion .
C D
La t e r a l Tib ia l Pla t e a u Pla t e 1 6
■ Re d u ce a n d p ro visio n a lly fix t h e t ib ia l p la t e a u co m p o -
n e n t a s d e scrib e d in Ch a p t e rs TR-13 a n d TR-14.
■ Because of the difficulty of placing bicortical screw s in the
me tap hyseal an d d ia physeal areas wit ho u t imp ed ing n ail
in sertio n, a lo ckin g p late sh o uld b e co n sid ered , sin ce un i-
cort ica l locking scre ws a re a va ila b le d ist a lly (TECH FIG 16).
TECH FIG 1 6 • A la t e ra l t ib ia l p la t e a u p la t e ca n b e u se d
w it h a n in t ra m e d u lla ry n a il w it h ip sila t e ra l p la t e a u a n d sh a ft
fra ct u re s.
■ Pla t e fixa t io n a lo n g t h e la t e ra l o r p o st e ro la t e ra l su r-
fa ce is u se d m o st o ft e n .
■ An a t o m ic re st o ra t io n o f le n g t h a n d ro t a t io n is crit ica l
fo r a ccu ra t e re st o ra t io n o f t ib ia l le n g t h , e sp e cia lly
w it h co m m in u t e d t ib ia l fra ct u re p a t t e rn s o r w h e n t ib -
ia l b o n e lo ss is p re se n t .
■ Me d ia lly-b a se d e xt e rn a l fixa t io n o r u n ive rsa l d ist ra c-
t o r p la ce m e n t w it h h a lf-p in p la ce m e n t ju st a b o ve t h e
a rt icu la r su rfa ce o f t h e a n kle jo in t o r w it h fixa t io n
in t o t h e m e d ia l ca lca n e u s o ft e n is h e lp fu l t o a id in t h e
re d u ct io n o f t h e t ib ia fra ct u re , e ve n in t h e p re se n ce
o f st a b le fib u la r fixa t io n .

A B
PEARLS AND PITFALLS
St a rt in g p o in t
Ce n t e rin g t h e g u id e w ire
Me a su rin g n a il le n g t h
Fe m o ra l d ist ra ct o r o r e xt e rn a l
fixa t o r fo r re d u ct io n
Un ico rt ica l p la t e s fo r re d u ct io n
Blo ckin g scre w s/Pö lle r scre w s
Po st e rio r m a lle o lu s
POSTOPERATIVE CARE
■ Weight bearing as tolerated, unless there is articular in-
volvement
■ Posterior splint or cam walker
■ Early range of motion
■ Suture removal at 2 to 3 weeks postoperatively
■ Strengthening after at 6-week clinic visit
■ Consider a quadriceps-specific program.
■ After the 6-week visit, return clinic visits are made at 6- to
8-week intervals until the bone is clinically and radiographi-
cally healed.
OUTCOMES
■ Long-term follow-up of patients treated nonoperatively re-
veals persistent functional deficits and dysfunction, including
stiffness, pain, and loss of muscle power. 8,17,24,25
Ch a p t e r 4 8 INTRAM EDULLARY NAILING OF THE TIBIA 469
TECHNIQUES
TECH FIG 1 7 • A. Dist a l o b liq u e fra ct u re s ca n b e e ffe ct ive ly
re d u ce d w it h p e rcu t a n e o u s cla m p a p p lica t io n . B. An a t o m ic
fib u la r re d u ct io n o ft e n ca n a lig n a t ib ia l fra ct u re in n e a r-
a n a t o m ic p o sit io n .
■ Th e st a rt in g p o in t sh o u ld b e a t t h e a n t e rio r a rt icu la r m a rg in a n d ju st m e d ia l t o t h e la t e ra l
t ib ia l sp in e . St a rt in g t o o m e d ia l a n d d ist a l fo r p ro xim a l m e t a p h yse a l fra ct u re s re su lt s in a
va lg u s a n d fle xe d m a lu n io n .
■ Ce n t e r t h e g u id e w ire d ist a lly o n t h e AP a n d la t e ra l vie w s. If n o t ce n t e re d , t h e n a il w ill
fo llo w t h e p a t h o f t h e re a m e r a n d g u id e w ire , w h ich w ill m a lre d u ce t h e fra ct u re .
■ Me a su re o n t h e la t e ra l vie w . Me a su rin g o n t h e AP vie w w ill p o t e n t ia lly le a d t o a n a il t h a t
is t o o lo n g , w it h a rt icu la r p ro m in e n ce ca u sin g kn e e p a in o r a rt icu la r su rfa ce d a m a g e .
■ Ha lf-p in s ca n b e p la ce d o u t sid e o f t h e p a t h o f t h e n a il. Th e b e st p o sit io n s a re p o st e rio r in
t h e p ro xim a l t ib ia a n d d ist a lly ve ry clo se t o t h e su b ch o n d ra l b o n e o f t h e t ib ia l p la fo n d .
Pla ce m e n t o f t h e p ro xim a l p in t o o a n t e rio rly a n d t h e d ist a l p in t o o p ro xim a lly m a y im p e d e
re a m in g a n d n a il in se rt io n .
■ Me t a d ia p h yse a l p la t e s co n t rib u t e t o st a b ilit y a n d m a in t e n a n ce o f re d u ct io n , a n d re m o va l
ca n le a d t o lo ss o f re d u ct io n a ft e r n a il p a ssa g e . Dia p h yse a l re d u ct io n p la t e s; h o w e ve r,
sh o u ld b e re m o ve d t o p re ve n t rig id fixa t io n o f t h e fra ct u re g a p .
■ Use in t e rlo ckin g b o lt s fro m n a il in st ru m e n t a t io n ra t h e r t h a n sm a ll fra g m e n t scre w s t o
a vo id scre w b re a ka g e d u rin g n a il p a ssa g e .
■ Do n o t re m o ve scre w s, b e ca u se t h e y p ro vid e st a b ilit y a n d h e lp m a in t a in re d u ct io n .
■ Use ca u t io n w h e n u sin g a d rill b it b e ca u se it is p ro n e t o b re a ka g e d u rin g n a il in se rt io n , a n d
re m o va l a ft e r n a il p a ssa g e m a y d e st a b ilize t h e co n st ru ct .
■ Crit ica lly e va lu a t e t h e p o st e rio r m a lle o lu s in d ist a l d ia p h yse a l a n d m e t a p h yse a l fra ct u re s
p re -, in t ra -, a n d p o st o p e ra t ive ly.
■ If a p o st e rio r m a lle o la r fra ct u re o r a rt icu la r in vo lve m e n t is m isse d , a n kle su b lu xa t io n o r
d isp la ce m e n t o f t h e a rt icu la r su rfa ce ca n o ccu r w it h w e ig h t b e a rin g .
■ Anterior knee pain is common (50% to 60% ), and patients
should be informed of this preoperatively.7,13
■ This knee pain is more common in young patients. It typ-
ically is mild and may be exacerbated by kneeling, squat-
ting, or running
■ Its occurrence is not dependent on surgical approach.
■ N ail removal leads to pain resolution in about one half of
patients and decreased pain in another one fourth. 7
■ At late follow-up after tibial nailing, patients’ function is
comparable to population norms, but objective and subjective
evaluation shows persistent sequelae, including knee pain, per-
sistent swelling, muscle weakness, and arthritis—many of
which are not insignificant.
■ M alunion has an unclear association with development of
arthritis.
■ Some authors have associated even mild deformity with
increased risk of osteoarthritis.14,34
470 Se c t i o n V LEG

COMPLICATION S5,27 5. Cannada LK, Anglen JO , Archdeacon M T, et al. Avoiding complica-

tions in the care of fractures of the tibia. J Bone Joint Surg Am
Infection 2008;90A:1760–1768.
■ Closed fractures: about 1% 6. Court-Brown C, M cBirnie J. The epidemiology of tibial fractures.
■ O pen fractures J Bone Joint Surg Br 1995;77B:417–421.
7. Court-Brown CM , Gustilo T, Shaw AD. Knee pain after in-
■ Type I: 5%
tramedullary tibial nailing: Its incidence, etiology, and outcome.
■ Type II: 10%
J O rthop Trauma 1997;11:103–105.
■ Type III: over 15%
8. Digby JM , H olloway GM , Webb JK. A study of function after tibial
■ Condition of the soft tissues is key for risk of infection and cast bracing. Injury 1983;14:432–439.
for outcome. 9. Govender S, Csimma C, Genant H K, et al. Recombinant human
bone morphogenetic protein-2 for treatment of open tibial fractures:
N onunion A prospective, controlled, randomized study of four hundred and
fifty patients. J Bone Joint Surg Am 2002;84A:2123–2134.
■ Closed fractures: 3%
10. H enley M B, M eier M , Tencer AF. Influences of some design parame-
■ O pen fractures: about 15% , and may be higher, depending
ters on the biomechanics of the unreamed tibial intramedullary nail.
on the soft tissue injury J O rthop Trauma 1993;7:311–319.
■ Risk factors
11. H ooper GJ, Keddell RG, Penny ID. Conservative management or
■ Unreamed smaller-diameter nails with smaller locking closed nailing for tibial shaft fractures. A randomised prospective
bolts are associated with delayed or nonunion and an in- trial. J Bone Joint Surg Br 1991;73B:83–85.
12. Jones AL, Bucholz RW, Bosse M J, et al. Recombinant human BM P-
creased risk of locking bolt breakage.
■ Closed fractures carry a risk of severe soft tissue injury,
2 and allograft compared with autogenous bone graft for reconstruc-
tion of diaphyseal tibial fractures with cortical defects: a randomized,
eg, internal degloving. controlled trial. J Bone Joint Surg Am 2006;88A:1431–1441.
■ O pen fractures may be accompanied by severe soft tissue
13. Keating JF, O rfaly R, O ‘Brien PJ. Knee pain after tibial nailing.
injury. J O rthop Trauma 1997;11:10–13.
■ Delayed bone grafting may be warranted for treatment 14. Kettelkamp DB, H illberry BM , M urrish DE, et al. Degenerative
of bone loss. arthritis of the knee secondary to fracture malunion. Clin O rthop
■ The use of RhBM P-2 is FDA-approved in open tibia
Relat Res 1988;234:159–169.
15. Krettek C, M iclau T, Schandelmaier P, et al. The mechanical effect of
fractures.9 It decreases the nonunion rate by 29% , and de- blocking screws (“ Poller screws” ) in stabilizing tibia fractures with
creased secondary interventions. BM P-2 combined with short proximal or distal fragments after insertion of small-diameter
allograft for delayed bone grafting procedures in tibia intramedullary nails. J O rthop Trauma 1999;13:550–553.
fractures with cortical defects have shown a similar rate 16. Kubiak EN , Camuso M R, Barei DP, et al. O perative treatment of ip-
of healing to autograft with the benefit of decreased silateral noncontiguous unicondylar tibial plateau and shaft fractures:
combining plates and nails. J O rthop Trauma 2008;22:560–565.
donor site morbidity.12
17. Kyro A, Lamppu M , Bostman O . Intramedullary nailing of tibial
■ Compartment syndrome
shaft fractures. Ann Chir Gynaecol 1995;84:51–61.
■ Fracture pattern—transverse
18. M cKee M D, Schemitsch EH , Waddell JP, et al. A prospective, ran-
■ H ost factors
domized clinical trial comparing tibial nailing using fracture table
■ Tobacco use traction versus manual traction. J O rthop Trauma 1999;13:463–469.
■ M edications: bisphosphonates, nonsteroidal anti- 19. M cQ ueen M M , Christie J, Court-Brown CM . Acute compartment
syndrome in tibial diaphyseal fractures. J Bone Joint Surg Br
inflammatory drugs
■ Diabetes mellitus
1996;78B:95–98.
20. M ills WJ, Barei DP, M cN air P. The value of the ankle-brachial index
■ Vascular disease
for diagnosing arterial injury after knee dislocation: A prospective
■ M alnutrition—albumin level lower than 34 g/L and a
study. J Trauma 2004;56:1261–1265.
lymphocyte count below 1500/mm 3 21. M ilner S, Greenwood D. Degenerative changes at the knee and ankle
■ Infection related to malunion of tibial fractures. J Bone Joint Surg Br 1997;
79B:698.
Malunion 22. Nork SE, Barei DP, Schildhauer TA, et al. Intramedullary nailing of
proximal quarter tibial fractures. J Orthop Trauma,2006;20:523–528.
■ O ccurs in up to 37% of all tibial nailing procedures
■ M alunion is seen in as many as 84% of patients with
23. O rfaly R, Keating JE, O ’Brien PJ. Knee pain after tibial nailing: does
the entry point matter? J Bone Joint Surg Br 1995;77B:976–977.
proximal metaphyseal tibia fractures. 24. Pun WK, Chow SP, Fang D, et al. A study of function and residual
■ These can be avoided with proper surgical techniques.
joint stiffness after functional bracing of tibial shaft fractures. Clin
O rthop Relat Res 1991;267:157–163.
25. Puno RM , Teynor JT, N agano J, et al. Critical analysis of results of
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1. Althausen PL, N eiman R, Finkemeier CG, et al. Incision placement 1986;212:113–121.
for intramedullary tibial nailing: an anatomic study. J O rthop 26. Ricci WM , O ’Boyle M , Borrelli J, et al. Fractures of the proximal
Trauma 2002;16:687–690. third of the tibial shaft treated with intramedullary nails and block-
2. Baumgartner M , Tornetta P, eds. O rthopaedic Knowledge Update: ing screws. J O rthop Trauma 2001;15:264–270.
Trauma 3. Rosemont, IL: American Academy of O rthopaedic 27. Schmidt A, Finkemeier CG, Tornetta P. Treatment of closed tibia
Surgeons, 2005. fractures. In: Tornetta P, ed. Instructional Course Lectures: Trauma.
3. Bone LB, Sucato D, Stegemann PM , et al. Displaced isolated fractures Rosemont, IL: American Academy of O rthopaedic Surgeons,
of the tibial shaft treated with either a cast or intramedullary nailing. 2006:215–229.
An outcome analysis of matched pairs of patients. J Bone Joint Surg 28. Tornetta P III, Collins E. Semiextended position of intramedullary
Am 1997;79A:1336–1341. nailing of the proximal tibia. Clin O rthop Relat Res 1996;328:
4. Bono CM , Sirkin M , Sabatino CT, et al. N eurovascular and tendi- 185–189.
nous damage with placement of anteroposterior distal locking bolts 29. Tornetta P III, Riina J, Geller J, Purban W. Intraarticular anatomic
in the tibia. J O rthop Trauma 2003;17:677–682. risks of tibial nailing. J O rthop Trauma 1999;13:247–251.
 Ch a p t e r 4 8 INTRAM EDULLARY NAILING OF THE TIBIA
30. Tornetta P, Steen B, Ryan S. Tibial metaphyseal fractures: N ailing in
extension. O rthopaedic Trauma Association Annual M eeting,
Denver, O ctober 16–18, 2008.
31. Vaisto O , Toivanen J, Kannus P, et al. Anterior knee pain after in-
tramedullary nailing of fractures of the tibial shaft: An eight-year fol-
low-up of a prospective, randomized study comparing two different
nail-insertion techniques. J Trauma 2008;64:1511–1516.
32. Vaisto O , Toivanen J, Kannus P, et al. Anterior knee pain and thigh
muscle strength after intramedullary nailing of a tibial shaft fracture:
An 8-year follow-up of 28 consecutive cases. J O rthop Trauma
2007:21:165–171.
471
33. Vaisto O , Toivanen J, Paakkala T, et al. Anterior knee pain after in-
tramedullary nailing of a tibial shaft fracture: an ultrasound study of
the patellar tendons of 36 patients. J O rthop Trauma
2005;19:311–316.
34. van der Schoot DK, Den O uter AJ, Bode PJ, et al. Degenerative
changes at the knee and ankle related to malunion of tibial fractures.
15-year follow-up of 88 patients. J Bone Joint Surg Br
1996;78:722–725.
35. Weninger P, Schultz A, Traxler H , et al. Anatomical assessment of the
H offa fat pad during insertion of a tibial intramedullary nail: com-
parison of three surgical approaches. J Trauma 2009;66:1140–1145.
 Fa s cio t o m y o f t h e Le g f o r
Ch a p t e r 49 Acu t e Co m p a r t m e n t Sy n d ro m e
Ge o rg e Part al, A n d re w Fu re y, an d Ro b e rt O’To o le
DEFIN ITION
■ Compartment syndrome remains one of the most devastat-
ing orthopedic conditions. The potential clinical sequelae and
medicolegal implications of a possible missed compartment
syndrome make it one of the most important entities in all of
orthopedic surgery.2
■ Compartment syndrome is a condition, with numerous
causes, in which the pressure within the osteofascial compart-
ment rises to a level that exceeds intramuscular arteriolar
pressure, resulting in decreased blood flow to the capillaries,
decreased oxygen diffusion to the tissue, and ultimately cell
death. This is a true orthopaedic emergency.
■ The clinical sequelae of a missed compartment syndrome
can be life- and limb-threatening. M yonecrosis can lead to
acute renal failure and multiorgan failure if not appropriately
managed.20
■ Richard von Volkmann first documented nerve injury and
subsequent contracture from compartment syndrome in 1872
following a supracondylar fracture.
■ In 1906, Dr. H ildebrand was the first to apply the term
“ Volkmann ischemic contracture” to define the end result of
any untreated compartment syndrome.
■ In 1909, Dr. Thomas described the major causes of com-
partment syndrome (fractures being the predominant
cause) after reviewing the 112 cases published up to that
date.
■ The first to suggest that fasciotomy may help prevent con-
tracture was Dr. M urphy in 1914.
■ It was not until 1967 that Seddon, Kelly, and Whitesides
described the existence of four compartments in the lower
leg and the need to decompress more than just the anterior
compartment.
■ Any situation that leads to an increased pressure within the
compartment may result in a compartment syndrome.
■ The impermeable fascia prevents fluid from leaking out of
the compartment and also prevents an increase in volume
that could reduce pressure within the compartment.
■ The incidence of compartment syndrome is 7.3 per 100,000
males and 0.7 per 100,000 females.
■ In those cases, the most common cause was fracture fol-
lowed by soft tissue injury.
■ M cQ ueen et al found that the incidence of compartment
syndrome was nearly equal for both high- and low-energy
injuries and that open wounds did not decompress the com-
partments and were not protective.13,14
■ This chapter describes acute compartment syndrome, in
contrast to exertional compartment syndrome.
■ Exertional compartment syndrome is a transient chronic
condition brought on by exercise. Unlike acute compart-
ment syndrome, exertional compartment syndrome is not an
emergency and its treatment is beyond the scope of this
chapter.
472
AN ATOMY
■ The lower leg has four compartments: the anterior, lateral,
superficial posterior, and deep posterior (FIG 1 , Table 1).
■ The anterior compartment is bound anteriorly by fascia, lat-
erally by the anterior intermuscular septum, and posteriorly by
the interosseous membrane between the fibula and tibia.
■ The four muscles in this compartment are the tibialis an-
terior, extensor digitorum longus, extensor hallucis longus,
and peroneus tertius.
■ The neurovascular bundle includes the deep peroneal
nerve and the anterior tibial artery.
■ The deep peroneal nerve provides sensation to the first
dorsal web space of the foot and motor function to all the
muscles in the anterior compartment.
■ The anterior tibial artery travels in this compartment just
anterior to the tibiofibular interosseous membrane and con-
tinues in the foot as the dorsalis pedis artery.
■ The lateral compartment is bordered anteriorly by the fas-
cia, posteriorly by the posterior intermuscular septum, and
medially by the fibula.
■ There are only two muscles of the lateral compartment:
the peroneus longus and the peroneus brevis.
■ The major nerve supply to the lateral compartment is the
superficial peroneal nerve, which supplies the two muscles
of the compartment. The nerve supplies sensation to the
dorsum of the foot, except the first dorsal web space.
■ Since the deep peroneal nerve courses proximally around
the fibular head, both the deep and superficial peroneal
nerves travel within this compartment.
■ There are no main vessels in this compartment, and the
muscles receive their blood supply from the peroneal and
anterior tibial arteries.
■ The deep posterior compartment contains the flexor digi-
torum longus, tibialis posterior, and flexor hallucis longus
muscles.
■ Although it is not considered a separate compartment, the
tibialis posterior muscle can have its own fascial covering.
■ The deep posterior compartment contains the main neu-
rovascular bundle of the posterior compartment, which con-
sists of the tibial nerve, posterior tibial artery and vein, and
peroneal artery and vein.
■ The superficial posterior compartment contains the gastroc-
nemius, soleus, and plantaris muscles, which are supplied by
branches of the tibial nerve, posterior tibial artery, and per-
oneal arteries.
■ There is no major artery that travels in this compartment.
PATHOGEN ESIS
■ Although the exact pathophysiology is not completely under-
stood, the premise of the syndrome is either a decrease in the
space available for the tissues within the fixed compartment or
an increase in the size of the tissues within the compartment.
 Ch a p t e r 4 9 FASCIOTOM Y OF THE LEG FOR ACUTE COM PARTM ENT SYNDROM E 473

Tibialis anterior m.
Extensor hallucis
longus m.
t e r io r e n t
Extensor digitorum A n p a r tm
m
longus m. co Deep posterior
compartment
Lateral incision
Peroneus brevis
and longus m.
compar tment
Lateral

Medial
incision

Flexor hallucis
longus m. Flexor digitorum
longus m.
Soleus m. Su
pe
r f ic t
ia l p t m en Tibialis posterior m. FIG 1 • Cro ss-se ct io n o f t h e lo w e r
osterior compar
le g a t m id -t ib ia l le ve l.

Ta b le 1 Co m p a r t m e n t s o f t h e Lo w e r Le g

Co m p a r t m e n t M u s cle s M a jo r Ar t e r ie s Ne r v e s
Anterior Tibialis anterior Anterior tibial Deep peroneal
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
Lateral Peroneus brevis None Superficial peroneal
Peroneus longus Deep peroneal (proximal in leg)
Deep posterior Posterior tibialis Posterior tibial Tibial
Flexor hallucis longus Peroneal
Flexor digitorum longus
Superficial posterior Gatrocnemius None None
Soleus

■ Either case can result in an increase in pressure above a the pressure within the veins, resulting in their collapse or an
critical value. increase in the venous pressure.17
■ Increased fluid content and swelling of damaged muscles ■ The final event is cellular anoxia and necrosis. 20

can be caused by the following: ■ During necrosis there is an increase in the intracellular cal-

■ Bleeding into the compartment (from fractures, large ves-
sel injury, or bleeding disorders)
■ Fractures are the most common cause of compartment
syndrome. It is estimated that 9.1% of tibial plateau frac-
tures develop compartment syndrome.3
cium concentration coupled with a subsequent shift of water
into the tissue, causing the tissue to swell further, adding to
the pressure.4 This “ capillary leakage” adds to the increased
pressure in the compartment, thus creating a vicious cycle.
■ The effects on muscle and nerve function are time-dependent.

■ Blunt trauma is the second most common cause, ac- ■ Prolonged delay results in greater loss of function.

counting for 23% of cases.14 ■ After sustained elevation of compartment pressures greater

■ Increased capillary permeability (eg, burns, ischemia, than 6 to 8 hours, nerve conduction is blocked.10 In an animal
exercise, snake bite, drug injection, intravenous fluids) study, irreversible muscle damage occurred after 8 hours.22
■ Decreased compartment size can be caused by the following: ■ The exact pressure at which change within the compartment

■ Burns occurs has been subject to debate and has evolved over time.
■ Tight circumferential wrapping, dressings, casts ■ Initially, the pressure of 30 mm H g was reported to be the

■ Localized external pressure, such as lying on the limb for maximum pressure above which irreversible muscle damage
an extended period of time or from pressure on the “ well occurred.27
leg” in the lithotomy position on the fracture table ■ Currently, clinicians have recognized the importance of

■ Elevated pressure prevents perfusion of the tissue from the the patient’s blood pressure when considering the compart-
capillaries and results in anoxia and necrosis. ment pressure and use an absolute difference between dias-
■ The impermeable fascia prevents fluid from escaping, tolic blood pressure and compartment pressure of
causing a rise in compartment pressure such that it exceeds 30 mm H g as a gauge.
474 Se c t i o n V LEG
■ Animal studies have highlighted the importance of the sys-
temic pressures relative to the compartment pressure.
■ H eckman et al found that irreversible ischemic changes
occurred when the compartment pressure was elevated
within 30 mm H g of the mean arterial pressure and within
20 mm H g of the diastolic pressure.27
■ Studies on limb ischemia at the University of Pennsylvania
had similar conclusions.
■ They coined the term “ delta P” referring to the difference
between the mean arterial pressure minus the compartment
pressure, with a lower number reflecting less blood flow.1
■ They found that cellular anoxia and death occur with
pressure within 20 mm H g of the mean arterial pressure;
however, at pressures within 40 mm H g there was re-
duced oxygen tension but no evidence of anoxia, and aer-
obic metabolism persisted.
■ M cQ ueen and Court-Brown used the cutoff of compart-
ment pressure within 30 mm H g of the diastolic blood pres-
sure as a fasciotomy threshold.13
■ There were no adverse clinical outcomes from not re-
leasing compartments with pressures more than 30 mm H g
from the diastolic blood pressure, and this has come to be
the value currently used most often as a threshold for com-
partment syndrome.
N ATURAL HISTORY
■ The outcome of compartment syndrome depends on loca-
tion and time to intervention.
■ Six hours of ischemia is currently the accepted upper limit
of viability. Rorabeck and M acnab reported almost com-
plete recovery of the limb function if fasciotomies are per-
formed within 6 hours of the onset of symptoms.21
■ M uscle undergoes irreversible change after 8 hours of
ischemia, whereas nerves can have irreversible damage after
as short as 6 hours.10
■ Compartment syndrome may have broad effects on multiple
systems.
■ As muscle necrosis occurs, myoglobin, potassium, and
other metabolites are released into circulation.
■ As a result, several metabolic conditions can arise, includ-
ing myoglobinuria, hypothermia, metabolic acidosis, and hy-
perkalemia. In turn, these biochemical phenomena can cause
renal failure, cardiac arrhythmias, and potentially death.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ The use of physical examination findings to diagnose com-
partment syndrome has not been well validated. 26 H owever,
physical examination findings are widely used in clinical
practice.
■ The key to successful handling of compartment syndrome
is early diagnosis and treatment. Therefore, the orthopedic
surgeon must be familiar with the signs and symptoms of the
diagnosis and perform a detailed documented history and
physical.
■ The patient’s history is critical. Certain aspects of the pa-
tient’s history may make the syndrome more likely.
■ The existence of any of the following characteristics
should heighten the surgeon’s suspicion: high-energy mech-
anism, a patient on anticoagulation, or a patient with a tight
circumferential dressing.
■ A patient will often not demonstrate all of the classic “ six Ps” :
pain, paresthesias, pulselessness, pallor, paralysis, and pressure.
■ Pulselessness has recently been regarded as less of an indi-
cator; patients can suffer extensive compartment syndrome
with normal pulses.
■ Likewise, pallor reflects loss of arterial flow and is rarely
present on physical examination.
■ Perhaps the most sensitive and earliest sign of compartment
syndrome is pain with passive stretch of the muscles of the
compartment.4
■ Pain out of proportion to the injury is also an early symp-
tom of the diagnosis.
■ Pain may be absent if compartment syndrome is already
established and nerve injury has occurred.
■ Since small fiber nerves are affected first, light touch will
be affected before pressure and proprioception.
■ The ability to use pain as an indicator may be diminished in
patients unable to sense pain or communicate with the care-
givers; in this situation the surgeon must use other means to
make the diagnosis.
■ Patients in whom pain may be difficult to ascertain include
those with head injuries, those using ethanol or drugs, those who
are intubated or sedated, those who have major distracting in-
juries such as a long bone fracture, those receiving large amounts
of pain medicine, or any other factor that might alter the pa-
tient’s ability to accurately sense and communicate pain levels.
■ Pain perception may also be altered due to anesthesia, and
some reports suggest that patients receiving epidural anesthe-
sia are four times more likely to develop compartment syn-
drome than those receiving other forms of pain control.19
■ This type of anesthesia results in a sympathetic nerve
blockade, thereby increasing the blood flow, compounding
the local tissue pressures and extremity swelling.
■ Similarly, local anesthesia combined with narcotics has been
shown to increase the risk of compartment syndrome.6,19,20
■ Paresthesia can be a useful, but confusing, symptom of com-
partment syndrome.
■ It has been shown, however, that nerve function is altered
after only 2 hours of ischemia; therefore, it represents a po-
tentially early symptom.8
■ With increased pressure in a compartment, the sensory
nerves will be affected first, followed by the motor nerves
(eg, in the anterior compartment, the deep peroneal nerve is
affected quickly, and patients will report loss of sensation
between the first two toes).
■ Paralysis is often less useful since it may be caused by is-
chemia, guarding, pain, or a combination of these factors, par-
ticularly in patients with a distracting extremity injury such as
a tibial shaft fracture.
■ Serial examinations are critical. All complaints should be in-
vestigated thoroughly, and all findings should be carefully
documented in the chart such that subsequent examiners can
refer to the record as a tool for diagnosis (see Exam Table for
Pelvis and Lower Extremity Trauma, page 1).
■ M easurement of the compartment pressure
■ Stryker pressure monitor is most common (FIG 2 ).
■ Arterial line (16- to 18-gauge needle) is easy to do in the
operating room, but the pressure measured with a simple
needle is thought to be 5 to 19 mm H g higher than the pres-
sure measured with a side port or wick catheter. 16
■ Pressure values should be recorded for all four compart-
ments. Typically each compartment is checked twice. If there
 Ch a p t e r 4 9 FASCIOTOM Y OF THE LEG FOR ACUTE COM PARTM ENT SYNDROM E 475

A C
FIG 2 • Stryker in traco mpartmental p ressu re mo nitor. A. Qu ick p ressure mon ito ring
kit containing the intracompartmental pressure monitor, a prefilled saline syringe, a
dia phragm cha mbe r (transd ucer), a nd a ne edle. B. The assembled pressure monitor.
To assemble the monitor kit, the needle is attached to the tapered end of t he t apered
cha mb er ste m (tra nsd uce r). Th e b lu e ca p fro m th e p re fille d syrin ge is re move d a nd
the syrin ge is screwe d into th e re main ing en d o f th e tran sducer, wh ich is a Luer-lo ck
con n ectio n. Th e cove r of th e mon ito r is op en e d. The tra nsd uce r is p la ce d in side the
well (black surface down). The snap cover is closed. Next, the clear end cap is pulled
off the syrin ge e nd, and the mo nitor is read y to use . To prime th e monito r, the ne e dle
is h eld at 45 d egrees up fro m the ho rizon tal an d th e syrin ge plu ng er is p ush ed slo wly
to purge air from the syring e. Th e mo nito r is then tu rne d o n. The assemb led monitor
is tilted at th e app roximate inten ded an gle of in sertion of the needle in to th e skin .
The zero button is pressed to zero the display. The needle is then inserted into the ap-
propria te lo ca tion in the comp artme nt. C. The intracompartmental pressure monitor
need le h a s side po rts to preven t soft tissu e fro m co llap sin g a round th e n e edle op en -
in g. Th is is different fro m a regu lar n eed le that has on ly on e o pening at the end .

is a fracture, the value is checked near and far from the frac-
ture. The contralateral limb can be checked as a control.
■ Delta P (diastolic blood pressure minus intracompartmen-
tal pressure) is measured.
■ A delta P less than 30 mm H g is generally accepted as
an indication for fasciotomy. Compartment syndrome is
typically a clinical diagnosis and does not need measure-
ment of the pressure before performance of fasciotomy.
■ Compartment pressure checks should be reserved for pa-
tients who are difficult to examine, such as sedated patients
that either the flexor or extensor hallucis longus is firing.
“ N VI” is also not useful as it does not state the exact muscle
groups that were tested.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ The diagnosis of compartment syndrome is typically made
clinically. There are, however, adjunct investigations that can
be used to confirm or rule out the diagnosis.
■ O nce a patient is diagnosed with compartment syndrome,

or those with equivocal examination findings. fasciotomies should be performed emergently. Any workup
■ Tight compartments are an important indicator of compart- that could delay this process should be undertaken with great
ment syndrome. The deep posterior compartment cannot be caution.
palpated directly because of its location deep to the superficial ■ If the patient cannot provide clinical clues because he or she

posterior compartment. is sedated or for other reasons, or if the diagnosis is in ques-

■ Pain with passive range of motion is one of the earliest and tion, compartment pressures can be measured.
most important signs of compartment syndrome. ■ Several techniques to measure compartment pressures have

■ Decreased light touch is reported to be one of the first indica-
tors of compartment syndrome. Light touch is a better indicator
since it indicates change in the ability of the nerves to detect a
threshold force, as opposed to two-point discrimination, which
is a test of nerve density and may not change until later in the
been described, including the Whiteside infusion technique,
the Stic technique, the Wick catheter technique, and the slit
catheter technique. The two most commonly used techniques
are the Whiteside side port needle and the slit catheter device.
■ There are numerous commercially available digital pres-

process. sure monitors that are frequently used as well.

■ M uscle force should be documented in all compartments ■ The exact pressure that defines compartment syndrome is

when ruling out compartment syndrome. Documenting that still debatable, although a measured pressure should be taken
patient “ wiggles toes” is not adequate as this indicates only with reference to the diastolic blood pressure. 13
476 Se c t i o n V LEG

■ M cQ ueen et al did a prospective study on 116 tibial shaft due to the direct toxic effect of the venom and the inflamma-
fractures that were monitored continuously for 24 hours. tory response.
They set the criterion for compartment release at a differ- ■ In these cases, antivenom should be administered; this has

ence between diastolic and compartment pressures of less been shown to decrease limb hypoperfusion.
than 30 mm H g. Following this criterion, a total of three
had fasciotomies and none of the sample had late sequelae N ON OPERATIVE MAN AGEMEN T
of compartment syndrome 9 months later.
■ The indications to measure compartment pressures include
■ All patients suspected of having acute compartment syn-
drome should have emergent fasciotomies performed in the
the following: one or more signs or symptoms of compartment
operating room or at the bedside.
syndrome and a confounding factor (eg, local anesthesia), un- ■ “ N onoperative” treatment of acute compartment syndrome
reliable examination with firmness in an injured extremity,
is never appropriate, as this is a life- and limb-threatening in-
prolonged hypotension and a swollen extremity with firmness,
jury whose successful treatment is based on limiting the time
and spontaneous increase in pain after having received ade-
until fasciotomy is performed.
quate analgesia. ■ N onoperative treatment of compartment syndrome is re-
■ The technique of measuring compartment pressures must be
served for patients presenting very late after a missed com-
mastered by the surgeon.
■ Inexperience with the technique may lead to inaccurate
partment syndrome who already have irreversible muscle
necrosis.
data and potentially missed compartment syndrome. ■ O ne school of thought is that these patients should not be
■ When measuring the pressure, the surgeon must be famil-
débrided, as it will only increase the chance of infection.
iar with the local anatomy and able to accurately measure ■ This is controversial and applies only to chronic, missed
all of the compartments.
■ Location of the measurement is important.
compartment syndrome.
■ There is consensus that all acute compartment syndromes
■ H eckman et al reported the highest pressures were within
should be treated operatively with fasciotomies.
5 cm of the fracture site; pressures decreased as the measure- ■ Since ischemic injury is the basis for compartment syndrome,
ments were taken distally and proximally to the fracture.27
additional oxygen should be administered to the patient diag-
They recommended that pressures be measured close to and
nosed with compartment syndrome because it will increase
both distal and proximal to the fracture in all compart-
slightly the blood partial pressure of oxygen (PO 2 ).
ments. The highest measurement is compared to the dias- ■ The surgeon must ensure that the patient is normotensive,
tolic blood pressure and interpreted accordingly.
■ Lab studies should include a complete metabolic profile, a
as hypotension reduces perfusion pressure and leads to fur-
ther tissue injury.
complete blood count with differential, creatine phosphoki- ■ Any circumferential bandages or casts should be removed in
nase, urine myoglobin, serum myoglobin, urinalysis (which
patients at risk for development of compartment syndrome.
may be positive for blood but negative for red blood cells, in- ■ Compartment pressure falls by 30% when a cast is split
dicating myoglobin in the urine due to rhabdomyolysis), and a
on one side and by 65% when a cast is spread after splitting;
coagulation profile (prothrombin time, partial thromboplastin
splitting the padding reduces the pressure by an additional
time, IN R).
■ O btaining a complete laboratory panel should not delay
10% , complete removal of the cast by another 15% . There
could be a total of 85% to 90% reduction in pressure by
operative treatment in a diagnosed case of compartment
just taking off the cast.28
syndrome. ■ Elevating the limb level above the heart decreases limb mean

arterial pressure without changing the intracompartmental

DIFFEREN TIAL DIAGN OSIS pressure. The affected extremity should not be elevated.
■ Compartment syndrome is diagnosed in a patient with either: ■ As shown by Styf and Wiger, after an elevation of 35 cm,

■ Suspicious clinical findings as discussed above, or the mean perfusion pressure decreased by 23 mm H g but the
■ Pressure in a compartment within 30 mm H g of the dias- intracompartmental pressure stayed the same.28
tolic blood pressure ■ Intravenous fluids should be given to decrease the chance of

■ O ther diagnoses to consider: kidney damage from myoglobin.

■ N ormal pain response secondary to fracture or other ■ The “ crush syndrome” is a sequela of muscle necrosis (ie,

trauma high creatine phosphokinase level, above 20,000 IU) and

■ Low pain tolerance secondary to preoperative substance manifests as nonoliguric renal failure, myoglobinuria, olig-
abuse uria, shock, acidosis, hyperkalemia, and cardiac arrhythmias.
■ M uscle rupture ■ Treatment is supportive, with ventilatory support, hydra-

■ Deep venous thrombosis and thrombophlebitis tion, correction of acidosis, and dialysis.
■ Cellulitis ■ It is important in this situation to decrease the metabolic

■ Coelenterate and jellyfish envenomations load by preventing ongoing tissue necrosis and débriding all
■ N ecrotizing fasciitis dead tissue.
■ Peripheral vascular injury ■ The use of narcotics should be closely recorded and monitored

■ Peripheral nerve injury in any patient suspected of having compartment syndrome.

■ Rhabdomyolysis ■ The use of local, spinal, or epidural anesthesia for postop-

■ O f special note, in the case of envenomations, recent studies erative pain control is generally discouraged in patients at
have shown that compartment syndrome is multifactorial and high risk for compartment syndrome as it limits the ability
that fasciotomy may not prevent myonecrosis, which may be of the clinician to do serial examinations.
 Ch a p t e r 4 9 FASCIOTOM Y OF THE LEG FOR ACUTE COM PARTM ENT SYNDROM E
SURGICAL MAN AGEMEN T
■ All patients with acute compartment syndrome should be
treated with emergent fasciotomies of the affected compart-
ments, as compartment syndrome is limb-threatening as well
as potentially life-threatening if allowed to progress to my-
onecrosis and renal failure.
■ Time to diagnosis and surgical treatment of compartment
syndrome is critical, as nerve damage after 6 hours of ischemia
may be irreversible.
■ Patients with compartment syndrome should be given the
highest priority and treated as an operative emergency.
■ Fasciotomy of the involved compartment is the standard of
care for compartment syndrome.
■ In a trauma setting, typically all four compartments of the
leg are released, regardless of evidence of involvement of the
other compartments.
■ Fasciotomies should ideally be performed in the operating
room.
■ If the patient is too ill to be transported to the operating
room or there is no operating room available, fasciotomies
can be performed at the bedside in as sterile an environment
as possible.
■ The only contraindication to fasciotomy in the face of a
compartment syndrome is delayed presentation, in which a pa-
tient with missed compartment syndrome presents more than
24 to 48 hours after irreversible injury has set in.
■ O perative treatment is hypothesized to increase infection.
■ It is often difficult to know when a compartment syndrome
occurred, however, so in situations in which it is unclear, it is
probably wise to release the compartments.
■ O ne school of thought is that if the compartment syndrome
has run its course, fasciotomies should not be performed un-
less the pressure in the compartment is within 30 mm H g of
diastolic pressure.
■ Fasciotomies are also often performed in a prophylactic
manner for any patient with an ischemic limb for more than 6
hours to prevent reperfusion injury.
DOUBLE-INCISION TECHNIQUE
An t e ro la t e ra l In cisio n
■ Th e a n t e ro la t e ra l in cisio n d e co m p re sse s t h e a n t e rio r a n d
la t e ra l co m p a rt m e n t s.
■ Th e a n t e ro la t e ra l in cisio n is m a d e h a lfw a y b e t w e e n
t h e fib u la a n d t h e cre st o f t h e t ib ia a n d lie s ju st
a b o ve t h e in t e rm u scu la r se p t u m d ivid in g t h e a n t e rio r
a n d la t e ra l co m p a rt m e n t s (TECH FIG 1 A).
■ Fa scio t o m ie s h a ve a lso b e e n a cco m p lish e d t h ro u g h sm a ll
in cisio n s. Ho w e ve r, w e p re fe r u sin g g e n e ro u s in cisio n s t o
a llo w fo r fu ll d e co m p re ssio n o f t h e co m p a rt m e n t s.
■ We re co m m e n d in cisio n s t h a t a re t yp ica lly a t le a st
15 t o 20 cm b o t h m e d ia lly a n d la t e ra lly.
■ A sm a ll t ra n sve rse in cisio n is p e rfo rm e d t o id e n t ify
t h e in t e rm u scu la r se p t u m , a ft e r w h ich scisso rs a re
u se d t o sp lit t h e fa scia o f t h e a n t e rio r a n d la t e ra l
co m p a rt m e n t s.
■ Ca re m u st b e t a ke n t o a vo id in ju rin g t h e su p e rficia l
p e ro n e a l n e rve b y m a kin g se p a ra t e in cisio n s in e a ch
co m p a rt m e n t a n d n o t cu t t in g t h e in t e rm u scu la r se p -
t u m (TECH FIG 1 B–F).
477
Preoperative Planning
■ O nce compartment syndrome is diagnosed, every effort
should be directed at getting the patient to the operating room
as quickly as possible for fasciotomies.
■ All further workup should be deferred until fasciotomies
are complete, except workup that is needed for a potential
life-threatening injury.
■ There is little preoperative planning required for this com-
ponent of the patient’s treatment.
■ Radiographs should be reviewed to rule out fractures or dis-
locations; however, additional radiographs can be taken in the
operating room after fasciotomies have been completed.
■ O nly essential preoperative workup should be done before
the patient is taken to the operating room, and the case should
certainly not be delayed for additional, nonessential radi-
ographic workup.
Positioning
■ The patient is usually positioned supine on the operating
room table to facilitate fasciotomies. A small bump may be
placed under the affected hip.
■ The leg is prepared in a sterile fashion and a thigh tourni-
quet is applied but not inflated.
Approach
■ Two separate techniques have been used for decompression
of the lower leg compartments.
■ The two-incision technique is the most commonly used
method, but a one-incision technique involving a lateral
(perifibular) approach also exists.
■ The two-incision technique is more straightforward and
requires less experience to ensure a complete compartment
release and therefore is typically advocated.
■ Some have argued that the one-incision technique may be
useful in defined anterior tibial artery injuries to help pre-
vent loss of anterior skin.
TECHNIQUES
Po st e ro m e d ia l In cisio n
■ Th e p o st e ro m e d ia l a p p ro a ch d e co m p re sse s t h e su p e rfi-
cia l a n d d e e p p o st e rio r co m p a rt m e n t s.
■ Th e in cisio n lie s a b o u t 2 cm p o st e rio r t o t h e p o st e rio r
t ib ia l m a rg in (TECH FIG 2 A).
■ Ca re is t a ke n t o a vo id in ju ry t o t h e sa p h e n o u s ve in
a n d n e rve , w h ich a re re t ra ct e d a n t e rio rly.
■ A sm a ll t ra n sve rse in cisio n is m a d e t o a llo w visu a liza t io n
o f t h e in t e rm u scu la r se p t u m b e t w e e n t h e d e e p a n d su -
p e rficia l p o st e rio r co m p a rt m e n t s, a ft e r w h ich t h e fa scia
o f e a ch is in cise d lo n g it u d in a lly in lin e w it h t h e in cisio n
(TECH FIG 2 B–E).
■ The de ep poste rior com pa rt me nt is initially rele ased dis-
t a lly, a n d t h e n t h e scisso rs a re o rie n t e d p ro xim a lly
th ro ug h a n d u nd e r t h e so le u s b rid g e.
■ It is cru cia l t o re le a se t h e so le u s a t t a ch m e n t t o t h e t ib ia
m o re t h a n h a lfw a y. Also , t h e fa scia o ve r t h e p o st e rio r
t ib ia l m u scle sh o u ld b e re le a se d .
■ On e u se fu l t ip is t o ke e p t h e t ip s o f t h e scisso rs a w a y
fro m m a jo r n e u ro va scu la r st ru ct u re s.
 478 Se c t i o n V LEG
TECHNIQUES

D
C

E F

TECH FIG 1 • La t e ra l in cisio n o f t h e t w o -in cisio n t e ch n iq u e . A. Th e a n t e ro la t e ra l in cisio n is m a d e h a lfw a y b e t w e e n t h e fib u la

a n d t h e t ib ia l cre st o ve rlyin g t h e in t e rm u scu la r se p t u m d ivid in g t h e a n t e rio r a n d la t e ra l co m p a rt m e n t s. B. Clo se -u p p ict u re o f
t he fa scio t o m y sit e a ft e r skin in cisio n b e fo re fa scia is o p e n , sh o w in g t h e in t e rm u scu la r se p t u m b e t w e e n t h e la t e ra l a n d a n t e -
rio r co m p a rt m e n t s a s w e ll a s t h e co u rse o f t h e su p e rficia l p e ro n e a l n e rve . C. Wit h a kn ife , a sm a ll t ra n sve rse in cisio n is m a d e
o ve r t h e in t e rm u scu la r se p t u m . Ca re is t a ke n t o a vo id in ju ry t o t h e su p e rficia l p e ro n e a l n e rve . D. Th e su rg e o n in se rt s t h e t ip s
o f t h e scisso rs in t o t h e sm a ll re n t in t h e fa scia , a n d ke e p in g t h e t ip s o f t h e scisso rs u p a n d a w a y fro m t h e su p e rficia l p e ro n e a l
n e rve , t h e su rg e o n in cise s t h e fa scia o ve r t h e a n t e rio r co m p a rt m e n t d ist a lly. E. Th e scisso rs a re t u rn e d w it h t h e t ip s p ro xim a lly,
a n d t h e fa scia o f t h e a n t e rio r co m p a rt m e n t is re le a se d p ro xim a lly. F. Th e t ip s o f t h e scisso rs a re t h e n in se rt e d in t o t h e re n t cre -
a t e d in t h e fa scia o f t h e la t e ra l co m p a rt m e n t . Ke e p in g t h e t ip s o f t h e scisso rs u p a n d a w a y fro m t h e su p e rficia l p e ro n e a l n e rve ,
t he su rg e o n re le a se s t h e fa scia o ve r t h e la t e ra l co m p a rt m e n t p ro xim a l a n d d ist a l.
 Ch a p t e r 4 9 FASCIOTOM Y OF THE LEG FOR ACUTE COM PARTM ENT SYNDROM E
C
E de e p stru ct u res.
ONE-INCISION TECHNIQUE
■ Th e o n e -in cisio n t e ch n iq u e o ft e n re q u ire s m o re ca re fu l
d isse ct io n a ro u n d m a jo r n e u ro va scu la r st ru ct u re s a n d
ca n p ro ve t o b e m o re ch a lle n g in g . Fo r t h is re a so n it is le ss
o ft e n u se d .
■ A st ra ig h t la t e ra l in cisio n is cre a t e d t h a t o rig in a t e s ju st
p o st e rio r a n d p a ra lle l t o t h e fib u la a t t h e le ve l o f t h e
fib u la r h e a d (p ro t e ct in g t h e p e ro n e a l n e rve ) t o a p o in t
a b o ve t h e t ip o f t h e la t e ra l m a lle o lu s (TECH FIG 3 A).
479
TECHNIQUES
B
TECH FIG 2 • Me d ia l in cisio n o f t h e tw o -in cisio n t e ch n iq u e .
A. Th e m edial incision lies abo ut 2 cm poste rior t o th e post e-
rio r t ib ia l m a rg in . B. Ca re is ta ke n t o a vo id in ju ry t o t h e
sa p h e n o u s ve in . Th e p ict u re sh o w s th e p o st e rio r b o rd e r o f
t h e tib ia e xp o sed a lo n g wit h th e d eep a n d su p e rficia l p o st e-
rio r co mp a rt m e n t s. Th e t ip s o f t h e d isse ctin g scisso rs lie o n
t h e d e ep p o st erio r co m p artm en t . C. A sm all tran sve rse in ci-
sio n is m a d e t o id e n t ify t h e in te rm u scu la r se p t u m b e t w e e n
t h e d e ep an d su p erficia l p o ste rio r co m p artm en t s. Dissectin g
scisso rs a re u se d t o re le a se t h e fa scia o ve r t h e d e e p p o st e rio r
co m p a rt me n t p ro xima lly a n d d ista lly. Pro xim a lly t h e fa scia is
re le a se d u n d e r t h e so le u s b rid g e . Scisso rs a re sh o w n u n d e r
t h e fa scia o f t h e su p erficial p o sterio r co m p artm en t. D. The
de e p an d su p erficia l com pa rt me n ts a re re le a se d . Th e sup er-
ficia l p o st e rio r co mp a rtm e n t lo o ks h e a lt h y, wh e re a s t h e
de e p po st e rio r co m p artm e n t is d u sky. The t ip s o f the cla mp
lie unde r t he soleus bridg e, which also need s t o be released
fro m it s o rig in o n th e tib ia . E. The surgeon relea se s t he
sole u s b rid ge u sin g e lectro cau t ery, takin g care t o p ro t ect t he
■ Po st e rio r t o t h e fib u la , a cce ss is g a in e d t o t h e d e e p a n d
su p e rficia l p o st e rio r co m p a rt m e n t s (TECH FIG 3 B).
■ Th e fa scia b e t w e e n t h e so le u s a n d fle xo r h a llu cis
lo n g u s is id e n t ifie d d ist a lly a n d re le a se d p ro xim a lly t o
t h e le ve l o f t h e so le u s o rig in (TECH FIG 3 C).12
■ An t e rio r t o t h e fib u la , t h e a n t e rio r a n d la t e ra l co m p a rt -
m e n t s a re d e co m p re sse d , t a kin g ca re t o a vo id in ju ry t o
t h e su p e rficia l p e ro n e a l n e rve .
 480 Se c t i o n V LEG
TECHNIQUES
A Gastrocsoleus mass C longus
Flexor hallucis
longus m.
Extensor
digitorum
Soleus m.
longus m.
Tibialis
anterior
B Gastrocnemius m.
MUSCLE DÉBRIDEMENT
■ Re g a rd le ss o f t h e ch o ice o f fa scio t o m y p e rfo rm e d , d e vi-
t a lize d m u scle is d é b rid e d a s n e ce ssa ry.
■ Mu scle via b ilit y is a sce rt a in e d b y t h e p re se n ce o f
h e a lt h y co lo r a n d t h e a b ilit y t o co n t ra ct w h e n p in ch e d
g e n t ly o r t o u ch e d w it h t h e e le ct ro ca u t e ry.
■ Ne cro t ic m u scle se rve s n o fu n ct io n a n d m u st b e re -
m o ve d e ve n t u a lly, a s it w ill fo rm a cu lt u re m e d iu m
fo r in fe ct io n a ft e r fa scio t o m y.
■ Ext e n sive d é b rid e m e n t is n o t t yp ica lly u n d e rt a ke n u n t il
t h e se co n d lo o k a t 36 t o 72 h o u rs, w h e n m u scle via b ilit y
is m o re re a d ily d e t e rm in e d .
CLOSURE OF FASCIOTOMIES
■ Fa scio t o m ie s a re t yp ica lly n o t clo se d a cu t e ly b e ca u se t h e
skin it se lf ca n co n st rict m u scle .
■ Mo st o ft e n fa scio t o m y w o u n d s a re e it h e r p a cke d w it h
m o ist d re ssin g s (TECH FIG 4 A) o r co ve re d w it h a st e rile
va cu u m sp o n g e a n d ke p t u n d e r su ct io n u n t il t h e n e xt
d é b rid e m e n t (TECH FIG 4 B).
■ Fo llo w in g a lo w e r le g fa scio t o m y, a u se fu l t e ch n iq u e h a s
b e e n t h e sh o e la ce clo su re , w h ich in vo lve s u sin g a ve sse l
lo o p a n d skin st a p le s t o g ra d u a lly clo se la rg e a re a s o f
g a p in g skin .
■ Th is a llo w s g ra d u a l a p p ro xim a t io n o f t h e skin e d g e s
o ve r t h e co u rse o f se ve ra l d a ys, t h u s p o t e n t ia lly o b vi-
a t in g t h e n e e d fo r a skin g ra ft (TECH FIG 4 C).
Peroneus Fibula Interosseous
longus membrane
Tibia
Flexor hallucis
TECH FIG 3 • On e -in cisio n t e ch n iq u e . A. Sch e m a t ic sh ow in g
t h e in cisio n la t e ra lly ju st p o st e rio r a n d p a ra lle l t o t h e fib u la .
Ag a in , ca re is t a ke n t o a vo id in ju ry t o t h e su p e rficia l p e r-
o n e a l n e rve . B. Cro ss-se ct io n o f t h e m id -t ib ia sh o w in g d is-
se ct io n p o st e rio r t o t h e fib u la , a llo w in g a cce ss t o t h e d e e p
a n d su p e rficia l p o st e rio r co m p a rt m e n t s. He re t h e fa scia b e -
t w e e n t h e so le u s a n d fle xo r h a llu cis lo n g u s is id e n t ifie d d is-
t a lly a n d re le a se d p ro xim a lly t o t h e le ve l o f t h e so le u s o rig in .
C. Sch e m a t ic sh o w in g a cce ss t o t h e po st e rio r t ib ia a n d t h us
re le a se o f t h e d e e p p o st e rio r co m p a rt m e n t . Disse ct io n a n t e -
rio r t o t h e fib u la w ill a llo w id e n t ifica t io n o f t h e in t e rm u scu -
la r se p t u m b e t w e e n t h e la t e ra l a n d a n t e rio r com p a rt m e n t s.
Th e fa scia o ve rlyin g t h e se t w o co m p a rt m e n t s is re le a se d
p ro xim a lly a n d d ist a lly w it h t h e t ip s o f d isse ct in g scissors,
t a kin g ca re t o a vo id in ju ry t o t h e su p e rficia l p e ro n e a l n e rve .
■ Wh e n fa scio t o m ie s a re p e rfo rm e d in t h e se t t in g o f fra c-
t u re s, t h e fra ct u re s a re st a b ilize d w it h e it h e r in t e rn a l o r
e xt e rn a l fixa t io n , w h ich e lim in a t e s t h e n e e d fo r co n st ric-
t ive ca st s a n d a llo w s a cce ss fo r clin ica l e xa m in a t io n , re -
p e a t p re ssu re m e a su re m e n t s, a n d w o u n d ca re .
■ Fixa t io n o f fra ct u re s m a y t rig g e r co m p a rt m e n t syn -
d ro m e s t h ro u g h t ra ct io n a n d re a m in g .
■ If t w o su rg ica l w o u n d s a re p re se n t , t h e su rg e o n sh o u ld
a t t e m p t t o clo se t h e m e d ia l w o u n d se co n d a rily b e fo re
t h e la t e ra l.
■ Th e la t e ra l sid e o f t h e le g h a s b e t t e r so ft t issu e co ve r-
a g e a n d co n se q u e n t ly is e a sie r t o skin g ra ft o ve r if
o n e o f t h e w o u n d s ca n n o t b e clo se d .
■ So m e t im e s sm a ll re la xin g in cisio n s a ro u n d t h e fa s-
cio t o m y w o u n d ca n d e cre a se t h e t e n sio n , e n h a n cin g t h e
ch a n ce o f h e a lin g (TECH FIG 4 D).
 Ch a p t e r 4 9 FASCIOTOM Y OF THE LEG FOR ACUTE COM PARTM ENT SYNDROM E 481

TECHNIQUES
A B

C D

TECH FIG 4 • Clo su re o f fa scio t o m ie s. A. Mo ist d re ssin g s co ve rin g t h e fa scio t o m y w o u n d . B. St e rile

va cu u m syst e m a p p lie d t o t h e fa scio t o m y sit e , w it h va cu u m su ct io n se t b e t w e e n 100 a n d 125 m m Hg .
C. Sm a ll re la xin g in cisio n s m a d e a ro u n d t h e fa scio t o m y sit e t o re le a se t e n sio n a n d a llo w a n e a sie r clo -
su re . D. Bo o t la ce t e ch n iq u e fo r a p p ro xim a t in g t h e e d g e s o f a fa scio t o m y w o u n d .

PEARLS AND PITFALLS

■ Me d ico le g a l p it fa lls: Wh e n in d o u b t , t h e su rg e o n sh o u ld ■ In 1993 t h e a ve ra g e lit ig a t io n a w a rd w a s $280,000 fo r e ig h t
m e a su re a n d d o cu m e n t p re ssu re in a ll co m p a rt m e n t s o f t h e ca se s o f m isse d co m p a rt m e n t syn d ro m e (in a ll e ig h t n o
in vo lve d e xt re m it y. Th e su rg e o n sh o u ld cle a rly d o cu m e n t in co m p a rt m e n t p re ssu re s w e re e ve r m e a su re d ).24
t h e p a t ie n t ’s ch a rt t h a t t h e p a t ie n t d o e s n o t h a ve
co m p a rt m e n t syn d ro m e a t t h is t im e if t h e clin ica l e xa m in a t io n
fin d in g s a n d p re ssu re s a re n e g a t ive .
■ Th e su rg e o n sh o u ld co n sid e r t h e p o ssib ilit y o f e q u ip m e n t ■ Ne e d le s ca n b e m isp la ce d in t e n d o n s, fa scia , o r w ro n g
e rro r. co m p a rt m e n t . All p re ssu re re a d in g s m u st b e in t e rp re t e d
w it h in t h e co n t e xt o f t h e clin ica l p re se n t a t io n .
■ Th e su rg e o n sh o u ld fu lly re le a se a ll fo u r co m p a rt m e n t s a lo n g
w it h t h e so le a l le a sh a n d p o st e rio r t ib ia l fa scia .
■ No t ig h t p o st o p e ra t ive d re ssin g s sh o u ld b e u se d .
■ Skin ca n ca u se in cre a se d p re ssu re , so t h e su rg e o n sh o u ld n o t
clo se a cu t e ly.

POSTOPERATIVE CARE tive section regarding administration of supplemental oxygen,

■ O nce decompressed, the extremity should be covered in a
bulky dressing, splinted with the foot in neutral, and elevated
above the level of the heart to promote venous drainage and
reduce interstitial fluid.
■ The foot should be splinted in neutral to prevent equinus
contracture.
■ The patient must be closely monitored for the systemic effects
of compartment syndrome. See the discussion in the nonopera-
intravenous hydration, mannitol, and hyperbaric oxygen.
■ Intravenous hydration is important to help prevent rhab-
domyolysis, as discussed in the nonoperative treatment
section.
■ The timing of skin closure varies depending on the cause
and severity of compartment syndrome.
■ M ost fasciotomies can be closed in 5 to 7 days.
■ If the skin is not easily closed secondarily, a split-
thickness skin graft is often needed to prevent excessive
482 Se c t i o n V LEG
granulation and to lessen exposure of muscle and tendon. A
flap may be needed if nerves, vessels, or bone is exposed.
■ If delayed primary closure is planned, small relaxing inci-
sion can be done.
■ H yperbaric oxygen has been used because it reduces tissue
edema through oxygen-induced vasoconstriction while main-
taining and increasing oxygen perfusion.
■ H owever, its opponents argue that hyperbaric oxygen leads
to reperfusion injury following compartment syndrome.
■ O ther agents that have been found to affect recovery from
compartment syndrome include allopurinol and oxypurinol,
superoxide dismutase, deferoxamine, and pentafraction of hy-
droxyethyl starch. These agents are antioxidants and scavenge
for damaging free radicals.
OUTCOMES
■ O utcomes are generally poor if the compartment syndrome
is diagnosed and treated in a delayed fashion. Results are bet-
ter with earlier treatment.
■ In a study by Sheridan et al, 50% of patients were decom-
pressed within 12 hours and 50% were decompressed after
12 hours.23 Sixty-eight percent of the patients decompressed
within 12 hours had normal leg function, whereas only 8% of
the delayed group had normal function.
■ If untreated, Volkmann ischemic contractures develop, lead-
ing to claw toes, weak dorsiflexors, sensory loss, chronic pain,
and eventually amputation.
COMPLICATION S
■ M ost patients (77% ) complain of altered sensation within
the margins of the wound.13
■ Forty percent report dry, scaly skin, 33% pruritus, 30% dis-
colored skin, 25% swollen extremity, 26% tethered scars,
13% recurrent ulcerations, 13% muscle herniation, 10% pain
related to the wound, and 7% tethered tendons.
■ Severe prolonged tissue ischemia resulting in necrosis of the
muscles leads to fibrosis of the muscles and contracture that
may continue over a period of several weeks.
■ This is known as Volkmann ischemic contracture.
■ The late sequelae of compartment syndrome are weak dor-
siflexors, claw toes, sensory loss, chronic pain, and eventually
amputation.
■ Delayed fasciotomy after 12 hours has a reported infection
rate of 46% and an amputation rate of 21% .23
■ The complication rate for delayed fasciotomies is also
much higher (54% ) than that for early fasciotomies (4.5% ).
Therefore, the current recommendation is that if the com-
partment syndrome has existed for more than 24 to 48 hours
and the compartment pressures are not within 30 mm H g of
diastolic pressure, supportive treatment for acute renal fail-
ure should be considered, the skin is not violated, and plans
should be made for a later reconstruction.
REFEREN CES
1. Bernot M , Gupta R, H eppenstall RB. The effect of antecedent is-
chemia on the tolerance of skeletal muscle to increased interstitial
pressure. J O rthop Trauma 1996;10:555–559.
2. Bhattacharyya T, Vrahas M S. The medical-legal aspects of compart-
ment syndrome. J Bone Joint Surg Am 2004;86:864–868.
3. Blick SS, Brumback RJ, Poka A, et al. Compartment syndrome in
open tibial fractures. J Bone Joint Surg Am 1986;68A:1348–1353.
4. Bucholz RW, H eckman JD. Rockwood and Green’s Fractures in
Adults. Philadelphia: Lippincott Williams & Wilkins, 2001:331–352.
5. Due Jr J, N ordstrand K. A simple technique for subcutaneous fas-
ciotomy. Acta Chir Scand 1987;153:521–522.
6. Dunwoody JM , Reichert CC, Brown KL. Compartment syndrome as-
sociated with bupivacaine and fentanyl epidural analgesia in pediatric
orthopaedics. J Pediatr O rthop 1997;17:285–288.
7. Fitzgerald AM , et al. Long-term sequelae of fasciotomy wounds. Br J
Plastic Surg 2000;53:690–693.
8. Garfin SR, M ubarak SJ, H argens AR, et al. Q uantitation of skeletal-
muscle necrosis in a model compartment syndrome. J Bone Joint Surg
Am 1981;63A:631–636.
9. Gulli B, Templeman D. Compartment syndrome of the lower extrem-
ity. O rthop Clin N orth Am 1994;25:677–684.
10. H argens AR, Romine JS, Sipe JC, et al. Peripheral nerve conduction
block by high muscle-compartment pressure. J Bone Joint Surg Am
1979;61A:192–200.
11. H yder N , Kessler S, Jennings AG, et al. Compartment syndrome in
tibial shaft fracture missed because of local nerve block. J Bone Joint
Surg Br 1996;78B:499–500.
12. Kelly RP, Whitesides Jr TE. Transfibular route for fasciotomy of the
leg. J Bone Joint Surg Am 1967;49A:1022–1023.
13. M cQ ueen M M , Christie J, Court-Brown CM . Acute compartment
syndrome in tibial diaphyseal fractures. J Bone Joint Surg Br 1996;
78B:95–98.
14. M cQ ueen M , Gaston P, Court-Brown M C. Acute compartment syn-
drome: who is at risk? J Bone Joint Surg Br 2000;82B:200–203.
15. M eyer RS, White KK, Smith JM , et al. Intramuscular and blood pres-
sures in legs positioned in the hemilithotomy position. J Bone Joint
Surg Am 2002;84A:1829–1835.
16. M oed BR, Thorderson PK. M easurement of intracompartmental
pressure: a comparison of the slit catheter side-ported needle, and
simple needle. J Bone Joint Surg Am 1993;75A:231–235.
17. M orrow BC, M awhinney IN , Elliott JR. Tibial compartment
syndrome complicating closed femoral nailing: diagnosis delayed by
epidural analgesic technique: case report. J Trauma 1994;37:
867–868.
18. M ubarak SJ, H argens AR, O wen CA, et al. The wick catheter tech-
nique for measurement of intramuscular pressure. J Bone Joint Surg
Am 1976;58A:1016–1020.
19. M ubarak SJ, Wilton N C. Compartment syndrome and epidural anal-
gesia. J Pediatr O rthop 1997;17:282–284.
20. O lson SA, Glasgow RR. Acute compartment syndrome in the lower
extremity musculoskeletal trauma. J Am Acad O rthop Surg 2005;13:
436–444.
21. Rorabeck CH . The treatment of compartment syndromes of the leg.
J Bone Joint Surg Br 1984;66B:93–97.
22. Rorabeck CH , Clarke KM . The pathophysiology of anterior tibial
compartment syndrome: an experimental investigation. J Trauma
1978;18:299.
23. Sheridan GW, M atsen FA. Fasciotomy in the treatment of acute com-
partment syndrome. J Bone Joint Surg Am 1976;58A:112–115.
24. Templeman D, Varecka T, Schmidt R. Economic costs of missed
compartment syndromes. Presented at the Annual M eeting, American
Academy of O rthopaedic Surgeons, San Francisco, 1993.
25. Tornetta P III, Templeman D. Compartment syndrome associated
with tibial fracture. AAO S Instr Course Lect 1997;46:303–308.
26. Ulmer T. The clinical diagnosis of compartment syndrome of the lower
leg: are clinical findings predictive of the disorder? J Orthop Trauma
2002;16:572–577.
27. Whitesides TE, H eckman M M . Acute compartment syndrome: up-
date on diagnosis and treatment. J Am Acad O rthop Surg 1996;4:
209–218.
28. Wiger P, Blomqvist G, Styf J. Wound closure by dermotraction after
fasciotomy for acute compartment syndrome. Scand J Plast Reconstr
Surg H and Surg 2000;34:315–320.
 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 50 Fix a t io n o f Pilo n Fr a ct u re s
Co ry A . Co llin g e an d M ich ae l Prayso n
DEFIN ITION
■ In orthopedic surgery, the terms pilon and plafond have
been loosely translated and interchangeably used to describe
the weight-bearing portion of the distal tibial articular surface.
■ These injuries account for about 1% of all lower extremity
fractures and 5% to 10% of tibial fractures.
■ M ost orthopedic surgeons will encounter these injuries dur-
ing the course of their practice; thus, a basic understanding of
their characteristics and their management possibilities is im-
portant for any practicing orthopedist exposed to trauma.
■ O pen reduction with internal fixation (O RIF), even if
through a limited approach, remains the basis by which most
plafond fractures are operatively stabilized.
■ As established by Ruëdi and Allgöwer, 11 the goals of any
surgery for plafond fractures should include precise articular
reconstruction, restoration of extremity length and alignment,
stable fracture fixation, and early joint motion.
■ Despite its widespread application in this respect, open treat-
ment presents some difficulties in the management of these
fractures because it can compromise the thin soft tissue enve-
lope surrounding the distal tibia.
■ M odern techniques in fracture care are useful in minimizing
complications associated with such open treatment in this
unique location.
AN ATOMY
■ Pilon fractures involve the weight-bearing articular surface
of the distal tibia. In about 90% of cases, there is an associated
distal fibula fracture.
■ The talus is predominantly cartilage-covered and sits in the
ankle mortise beneath the tibial pilon. It is restrained medially
and laterally by the malleoli.
PATHOGEN ESIS
■ The mechanism of injury for articular fractures of the distal
tibia usually involves some degree of axial compression as the
dense talus impacts into the tibia’s distal articular surface.
■ The distinction between fracture patterns is thus attributed
to a number of other associated variables, such as the amount
of rotational force involved, foot (talus) position during load-
ing, bone quality, and energy of impact.
■ H ighly comminuted articular injuries usually occur because
of high-energy axial loading forces, while spiral fractures with
minimal articular injury are presumed to result from lower-
energy rotational forces. True bending injuries are seen less
commonly and may be caused by low- or high-energy causes.
■ Despite the absence of a clear spectrum of injury severity, an
estimation of the energy involved in a plafond fracture can be
assumed from aspects other than the tibial fracture pattern it-
self (eg, history, soft tissue injury, associated injuries).
■ About 20% to 40% of plafond fractures are open, reflecting
the severity of the injury and the need for aggressive soft tissue
management.
■ Associated injuries should be carefully investigated because
5% to 10% of plafond fractures are bilateral, 30% of patients
have ipsilateral lower extremity injuries, and 15% have in-
juries to the spine, pelvis, or upper extremities.
■ Although a number of injury combinations are possible in
the distal tibia, characteristic patterns can often be identified.
Understanding the pattern of injury is critical to formulating
an optimal treatment plan.
■ Lower-energy metaphyseal or diaphyseal involvement of the
tibia is spiral in nature with a cortical spike that can guide the
reduction.
■ M etaphyseal comminution just above the articular plafond
is frequently produced under high-energy axial loading, as the
talus impacts into the corresponding weight-bearing surface of
the tibia. In such injuries, the anterior plafond is often com-
minuted and impacted into the adjacent metaphysis.
■ The degree of anterior articular plafond involvement is re-
lated to foot (talus) dorsiflexion at the time of impact.
■ The O rthopaedic Trauma Association’s Committee for Co-
ding and Classification has developed its alphanumeric system
from the AO /ASIF. 8 This alphanumeric system is popular
among fracture surgeons and is used in most current reports of
fracture treatment.
■ Distal tibial fractures are designated as types 43-A, B, and
C, with further subgrouping based on specific fracture charac-
teristics (FIG 1 ).
■ The three major types—A (extra-articular), B (partial
articular), and C (intra-articular extension with complete
separation between the articular fracture fragments and the
tibial shaft)—are further divided into subgroups based on
the amount of fracture comminution, articular depression,
and overall displacement.
■ Cole et al 3 mapped 38 consecutive AO /O TA 43-C3 (com-
plex articular) plafond fractures with CT scans and found
that all plafond fractures in this category exited the
tibiofibular joint laterally and at two separate locations me-
dially to create a coronally oriented Y pattern with three
major fragments (FIG 2 A). There were also varying amounts
of articular comminution anterolaterally or anteromedially
(FIG 2 B).
■ The three “ major” plafond fragments seen in comminuted
complete articular (AO /O TA 43-C) injuries can be described
as follows:
■ First, a posterior plafond fragment develops with a frac-
ture line exiting 1 to 4 cm proximal to the articular surface
(in partial articular injuries [AO /O TA 43-B], the posterior
plafond often remains intact).
■ An anterolateral plafond fracture fragment of varying size
separates with its anteroinferior tibiofibular ligament attach-
ment. This anterolateral tubercle of Chaput requires fixation
to restore the anatomy and function of the syndesmosis
complex.
■ A medial malleolar fracture is identified as the third char-
acteristic fragment.
483
484 Se ct i o n VI FOOT AND ANKLE

Tibia/Fibula Tibia/Fibula Tibia/Fibula

Distal, extra-articular Distal, partial articular Distal, complex articular
43-A 43-B 43-C

Metaphyseal Pure split Articular simple,

simple metaphyseal simple
43-A1 43-B1 43-C1

Metaphyseal Split Articular simple,

wedge depression metaphyseal
multifragmentary
43-A2 43-B2 43-C2

Metaphyseal Multifragmentary Articular

complex depression multifragmentary
43-A3 43-A3 43-C3

FIG 1 • In t h e Ort h o p e d ic Tra u m a Asso cia t io n ’s a lp h a n u m e ric cla ssifica t io n , d ist a l t ib ia

fra ct u re s (OTA 43) a re g ro u p e d in t o t yp e s 43-A (e xt ra -a rt icu la r), 43-B (p a rt ia l-a rt icu la r), a n d
43-C (co m p le t e -a rt icu la r). Ea ch t yp e is su b g ro u p e d b a se d o n sp e cific fra ct u re ch a ra ct e rist ics.

A B
FIG 2 • A,B. CT im ag es fro m 43-C3 p la fon d injuries d e m on stra t in g t yp ical
fra ct u re p a t te rn s w ith a n t e ro la t e ra l, m e d ia l ma lle o lu s, a n d p o ste ro m e d ia l
fra g m e n t s. Va ria b le a m o u n t s o f ce n tra l o r a n te ro ce n t ra l a rt icu la r im p a ctio n
a nd co mm in u t io n a re co mm o n ly se en .
■ Isolated osteochondral fragments of variable size are
often encountered (typically central to anterolateral in loca-
tion; Fig 2B) and constitute the remaining portion of the ar-
ticular surface.
■ H igh-energy injuries often result in fracture extension into
the tibial diaphysis with fibula fractures proximal to the artic-
ular level.
■ Finally, the syndesmosis will be functionally disrupted, sec-
ondary to the fibula fracture and anterolateral plafond separa-
tion. The syndesmosis anatomy and function can be restored by
fixation of both the fibula and anterolateral plafond. Therefore,
tibiofibular syndesmotic screw fixation is rarely required.
FIG 3 • Lo w -e n e rg y sp ira l 43-A t yp e fra ct u re .
Ch a p t e r 5 0 ORIF OF PILON FRACTURES 485
■ In contrast to high-energy patterns, rotational injuries
(FIG 3 ) cause spiral fractures of the distal tibia and fibula orig-
inating at the articular level. Intra-articular injury, if present,
is typically simple and without comminution or impaction.
N ATURAL HISTORY
■ O n one end of the spectrum, high-energy vertical compres-
sion injuries result in comminuted articular fractures with
compromised surrounding soft tissues. O n the other end, low-
energy rotational injuries with minimal axial compression pro-
duce more straightforward spiral fractures with less soft tissue
damage and a more favorable prognosis.
■ Where a particular fracture pattern falls within this spec-
trum can often predict the eventual outcome of the injury.
■ Unfortunately, determining the outcomes from these frac-
tures is not straightforward as existing classification systems
fail to clearly distinguish the spectrum of injury, making a fair
comparison of published outcomes difficult to achieve.
■ What is clear is that the surgeon maintains an important role
in affecting the final outcome of these injuries, principally by
designing a treatment plan that accomplishes the surgical goals
set out above while minimizing the risks of complications.
■ Established variables that clearly affect outcome include
avoiding complications while restoring a congruent articular
surface and the axial alignment of that articular surface rela-
tive to the shaft.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ The injury history is usually clear and often involves a fall
from heights, a motor vehicle crash, a motorcycle crash, or a
sports injury. O ccasionally, a patient will simply miss a step on
stairs or a curb; this atypical history should initiate an investi-
gation for osteoporosis.
■ These patients are usually injured by high-energy means
and should be evaluated as trauma patients and according
to ATLS protocols.
■ All associated injuries must be identified and formulated
into the global treatment plan.
■ Low-energy mechanisms should alert the surgeon to suspect
osteoporosis and initiate an osteoporosis evaluation.
486 Se ct i o n VI FOOT AND ANKLE
Ts ch e r n e a n d Go t ze n Gr a d in g
Ta b le 1 Sy s t e m f o r Clo s e d Fr a ct u r e s
Gr a d e De s cr ip t io n
0 Little or no soft tissue injury
1 Superficial abrasion and mild to moderately severe fracture
configuration
2 Deep, contaminated abrasion with local contusional
damage to skin or muscle and moderately severe fracture
configuration
3 Extensive skin contusion or crushing or muscle destruction
and severe fracture
■ Comorbidities such as diabetes mellitus, vascular disease,
tobacco use, chronic immune or inflammatory diseases, and
others may affect treatment and risk stratification. The med-
ication profile should be assessed for blood thinners, anti-
inflammatories, and others that may affect surgical risk or
bone metabolism.
■ A meticulous examination with special attention to soft tis-
sue and neurovascular status is important in the evaluation
and classification of these fractures (Tables 1 and 2).
■ With wound complication rates having a historic poten-
tial of 50% ,7,14 recognition and appropriate management of
the soft tissue injury cannot be overemphasized.
■ The physician should inspect for wounds, swelling, blis-
ters, ischemic skin, and chronic skin and vascular changes.
■ The physician should identify open fractures and establish
the “ personality” of the injury.
■ Areas of swelling or ecchymosis, breaks in the integu-
ment, and the presence or absence of fracture blisters should
be identified and documented preoperatively.
■ A careful vascular examination is important in evaluating
patients with high-energy pilon injuries, as arterial compro-
mise appears to be more common than previously appreciated
(which may help explain the relatively high complication rates
seen with early O RIF).
■ Findings of vascular compromise may be subtle (such as a
one-vessel injury [eg, anterior tibial artery]) owing to collat-
eral or retrograde flow patterns. Arterial compression
testing (Allen test) about the ankle or the addition of angiog-
raphy to CT may be a useful tool to further evaluate the
local vasculature.
■ Rarely, compartment syndrome may also occur, creating the
need for urgent operative intervention.
Gu s t ilo a n d An d e r s o n Sy s t e m
Ta b le 2 f o r Gr a d in g Op e n Fr a ct u r e s
Gr a d e Ty p e o f Wo u n d So f t Tis s u e
Tr a u m a Size In ju r y
I Low energy 1 cm Minimal
II Intermediate energy 1 cm Moderate
III High energy 10 cm Severe, with crushing
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ The diagnosis of tibial plafond fracture is initially evaluated
with three radiographic views of the ankle (anteroposterior
[AP], mortise, and lateral; FIG 4 A,B).
■ These views should be repeated after all “ reductions,” in-
cluding application of temporizing external fixation.
■ CT scans have been clearly shown to improve a surgeon’s
understanding of the injury (FIG 4 C) and are critical to preop-
erative planning for complex injuries.15
■ For displaced, comminuted pilon fractures, the best time to
obtain a CT scan is after temporizing external fixation is per-
formed (FIG 4 D), when the fracture is brought out to length
with traction. This tends to grossly reduce many parts of the
fracture, making the pathoanatomy of the injury more under-
standable (FIG 4 E,F).
■ The addition of angiography to CT is sometimes useful for
assessing the arterial tree of the distal leg before plafond recon-
struction, if vascular injury is suspected (FIG 4 G). O ccult vas-
cular injuries, especially of the anterior tibial artery, are not
uncommon in patients with high-energy plafond fractures.
DIFFEREN TIAL DIAGN OSIS
■ Tibial shaft fracture
■ Ankle fracture or dislocation
■ Talus fracture
N ON OPERATIVE MAN AGEMEN T
■ N onoperative treatment should be reserved for nondis-
placed or minimally displaced fractures that are determined to
be stable and have little comminution and soft tissue injury.
■ This scenario is uncommon, however, as the amount of en-
ergy necessary to fracture the tibial plafond typically results
in significant fracture displacement and resultant instability.
■ Some consideration may be given to nonoperative treat-
ment in the infirm or neuropathic patient, although the risks
of splinting or casting are often greater than for operative
treatment.
■ Attempts at casting or splinting unstable plafond fractures in
patients considered to be poor candidates for operative treat-
ment (eg, elderly, diabetes, vasculopathy) are fraught with risks
for progressive deformity, skin breakdown, and amputation.
■ The presence of other musculoskeletal injuries becomes a
strong indication for surgical treatment to the tibia as sur-
gical stabilization may allow for easier mobilization and
rehabilitation.
■ Reasonable nonoperative treatment options include non-
weight bearing with casting or bracing until radiographic signs
of healing are visualized.
■ Regular follow-up radiographic vigilance is recommended
to ensure that articular congruity and axial alignment of the
lower leg remain satisfactory.
■ Protected weight bearing must be individualized in each
case, but usually at least 10 to 12 weeks is necessary to safely
expect alignment to be maintained.
SURGICAL MAN AGEMEN T
■ Displaced tibial plafond fractures generally require surgery.
O RIF is the preferred method of treatment for such displaced
fractures to achieve the goals previously outlined by Ruëdi and
Allgöwer.11
 Ch a p t e r 5 0 ORIF OF PILON FRACTURES 487

A B C

E F

FIG 4 • 43-C3 t ib ia l p la fo n d in ju ry. A,B. AP a n d la t e ra l in ju ry ra d io g ra p h s.

C. CT sca n . D. “ Tra ve llin g t ra ct io n ” —e a rly a n kle -sp a n n in g e xt e rn a l fixa t o r.
E,F. Ra d io g ra p h s o f a n kle a ft e r clo se d re d u ct io n a n d a p p lica t io n o f e xt e rn a l
fixa t o r. G. Th re e -d im e n sio n a l re co n st ru ct io n o f CT a n g io g ra m d e m o n st ra t -
G in g d e ficie n t flo w t h ro u g h a n t e rio r t ib ia l a rt e ry.
488 Se ct i o n VI FOOT AND ANKLE
■ O RIF is reserved for fractures where the soft tissues allow
such a surgery within a reasonable time frame (ie, 5 to 21 days
from the injury) as determined by the surrounding soft tissue
appearance.
■ Low-energy fractures with little comminution or soft tissue
compromise may be acceptable for immediate, open surgical
stabilization. In most cases, however, the degree of soft tissue
injury is not fully appreciated at the time of presentation, and
waiting for soft tissues to declare the extent of their injury may
be prudent in these situations.
■ Early application of ankle-spanning external fixation or
“ travelling traction” and staged O RIF of the plafond has been
successful at reducing major complication rates from 50% to
0% to 10% .9,13
■ A simple external fixation construct linking the tibial diaph-
ysis (proximal to area of proposed plate placement) to the
calcaneus suffices for the temporary fixator in most cases
(FIG 4 D).
■ This method brings the limb out to length and allows the
tissues to “ recover” under more physiologic conditions.
■ If profound plantarflexion of the foot exists after reduc-
tion of the talus beneath the plafond and restoration of
length, a pin can be placed in the first or fifth metatarsal (or
both) to optimize positioning of the foot in neutral.
■ An associated fibular fracture is often stabilized in the initial
setting along with temporizing external fixation until defini-
tive O RIF is appropriate.
■ If the fibula is to be repaired in this manner, its reduction
must be anatomic or there may be difficulty with reducing
the tibia at the time of staged pilon reconstruction.
■ The patient should return at regular intervals between 5
days and 3 weeks after injury to schedule and undergo defini-
tive tibial fixation.
■ The return of skin wrinkles, blister epithelialization, and im-
provement in ecchymosis are several parameters to observe
when staging the open tibial procedure.
■ In most cases, the external fixation is removed at the time of
internal stabilization.
Preoperative Planning
■ Understanding the personality of the injury, including soft
tissue problems, patient problems, and the fracture configura-
tion, is critical to formulating an optimal treatment plan.
FIG 5 • Pre o p e ra t ive p la n fo r t ib ia l p la fo n d fra ct u re
re co n st ru ct io n .
■ Preoperative planning allows the surgeon to work through
the case “ on paper” while minimizing risk and often prevent-
ing unnecessary delays during the surgery.
■ A preoperative tracing (FIG 5 ) can help with instrumenta-
tion needs, surgical approaches, anticipated reduction meth-
ods, and implant strategies (selection and placement).
■ CT data often allow the surgeon to choose the optimal ap-
proach to address the articular pathology and apply implants
(eg, anteromedial versus anterolateral approaches for most
AO /O TA 43-C fractures).
Positioning
■ M ost pilon fractures are approached anteriorly; thus, the
patient is typically positioned supine on a radiolucent table.
■ A roll behind the hip may help control external rotation of
the leg during surgery.
■ Tourniquet control is often helpful to allow for visualiza-
tion, particularly of the ankle joint.
■ The preparation and draping is carried above the knee to
make the Gerdy tubercle region available if any autogenous
bone graft is needed.
■ The temporary external fixation pins are incorporated into
the preparation and draping. These pins are used intraopera-
tively for distraction through the external fixator itself or, al-
ternatively, through a universal (femoral) distractor. The pin
sites are isolated with Ioban.
■ Such distraction is helpful in obtaining reduction and provi-
sional stabilization of the articular surface and can also be
used during initial plate placement and screw fixation.
■ For posteromedial approaches the patient may still be posi-
tioned supine, but in this case the surgeon may desire the leg
to be externally rotated, and a bump under the contralateral
hip may be helpful.
■ When the posterolateral approach is used, the patient is best
positioned prone (or lateral) to allow the surgeon comfortable
access to the posterior leg.
Approach
■ Although historically a single “utilitarian” approach was pop-
ular in the reconstruction of the tibial plafond, a variety of surgi-
cal approaches are currently used to treat these fractures (FIG 6).
■ In principle, less dissection and soft tissue retraction, as
well as optimal implant placement, should be possible using
more direct approaches.
■ As with other complex injuries, the selection of an approach
that addresses the personality of each injury is recommended
for plafond fractures.
■ These more customized approaches should adhere to the fol-
lowing principles:
■ Effective soft tissue handling
■ M aintenance of a reasonable skin bridge between inci-
sions (especially if these incisions are long or extensile)
■ Placing skin incisions directly over bone should be avoided
if possible. Thus, if skin problems occur, resultant tissue de-
fects can be reconstructed with a simple skin graft or fasciocu-
taneous flap as opposed to a free soft tissue transfer.
■ H oward et al6 recently reported a series of 46 plafond frac-
tures in 42 patients in which 106 skin incisions were used, cre-
ating 60 skin bridges. The mean skin bridge size was 5.9 cm;
only 16% were greater than 7 cm. All incisions other than two
healed uneventfully, and no deep infections or skin bridge
compromises were recorded.
 Ch a p t e r 5 0 ORIF OF PILON FRACTURES 489

Anterior tibial Deep peroneal n.

artery and vein
Tibialis anterior tendon
Extensor hallucis longus
Anteromedial
Extensor digitorum communis approach
Anterolateral
Tibia
approach

Saphenous v.
Fibula
Peroneus
longus m.
Peroneus
brevis m.
Posterolateral Posteromedial
approach approach
Sural n. Posterior tibial
artery and vein FIG 6 • Ap p ro a ch e s t o t h e t ib ia l p la fo n d a re
Sural v. p ro b a b ly b e st t a ilo re d t o m a t ch t h e in ju ry
Tibial n.
p a t t e rn . Mo re t h a n 90% o f p la fo n d fra c-
Flexor hallucis t u re s a re w e ll a p p ro a ch e d a n t e rio rly (a n -
longus m. t e ro m e d ia lly o r a n t e ro la t e ra lly), b u t o t h e r
Achilles tendon a p p ro a ch e s a re so m e t im e s u se fu l.

ANTEROMEDIAL APPROACH
■ Th e t ra d it io n a l “ AO,” o r a n t e ro m e d ia l, a p p ro a ch t o t h e
t ib ia l p ilo n u se s a n a n t e ro m e d ia l in cisio n d ire ct e d lo n g i-
t u d in a lly a ce n t im e t e r o r so la t e ra l t o t h e a n t e rio r t ib ia l
cre st a n d cro ssin g in a g e n t le o b liq u e fa sh io n o ve r t h e
t ib ia lis a n t e rio r t e n d o n t o a llo w fo r ca re fu l m e d ia l co l-
u m n e xp o su re (TECH FIG 1 ).
■ We u se t h is a n t e ro m e d ia l a p p ro a ch fo r in ju rie s in
w h ich t h e b u lk o f t h e a rt icu la r in ju ry is m e d ia l a n d
TECHNIQUES
t h e a n t e rio r co rt e x fra ct u re p ro p a g a t e s m e d ia lly
a lo n g t h e d ist a l t ib ia .
■ Acce ssin g t h e fa r la t e ra l jo in t su rfa ce u sin g t h is a p -
p ro a ch re q u ire s a fa irly vig o ro u s re t ra ct io n o f t h e a n t e -
rio r a n kle so ft t issu e s (a sm a ll a n t e ro la t e ra l in cisio n ca n
so m e t im e s b e u se d co n co m it a n t ly w it h t h e a n t e ro m e -
d ia l a p p ro a ch t o re d u ce o r st a b ilize t h e a n t e ro la t e ra l
fra g m e n t ).

TECH FIG 1 • A–C. Im a g in g o f 43-C3 p la fo n d in -

ju ry w it h a n t e ro m e d ia l co rt ica l sp lit a llo w in g
b e st a cce ss t o in ju ry t h ro u g h a n t e ro m e d ia l
A B a p p ro a ch . (co n t in u e d )
 490 Se ct i o n VI FOOT AND ANKLE
TECHNIQUES
TECH FIG 1 (co n t in u e d ) • D. Th e a n t e ro m e d ia l a p p ro a ch . Th e in cisio n is
lo ca t e d o ve r t h e a n t e rio r co m p a rt m e n t , la t e ra l o f t h e p a lp a b le cre st o f
D t h e t ib ia a n d cu rvin g g e n t ly m e d ia lly a t t h e a n kle jo in t .
ANTEROLATERAL APPROACH
■ Ma ny surgeo ns ha ve recen tly begu n using an a ntero late ral
app roach for p lafon d injuries in which th e essen tial fea-
tures of the injury are more laterally located (TECH FIG 2).
■ Th is a p p ro a ch t o t h e a n kle h a s b e e n n ice ly d e scrib e d
b y He rsco vici e t a l. 5
■ Th e d isse ct io n p ro ce e d s ju st la t e ra l t o t h e e xt e n so r d ig i-
t o ru m lo n g u s a n d p e ro n e u s t e rt iu s. Th e a n t e rio r t ib ia l
n e u ro va scu la r b u n d le re m a in s m e d ia l.
■ Su p e rficia l p e ro n e a l n e rve b ra n ch e s w ill b e e n co u n t e re d
a n d sh o u ld b e p ro t e ct e d .
■ If a n arro w skin b rid g e o ccu rs b et we en th is ap p ro ach an d
th e fib ular in cisio n , t his a p p roa ch sho u ld be ke p t sh o rt
(e g, 4 t o 5 cm) a nd used for t he articular reduction.
■ Disse ct io n is fu ll t h ickn e ss a n d ca rrie d m e d ia l t o t h e t ib -
ia lis a n t e rio r t e n d o n so a s n o t t o cre a t e m u lt ip le t issu e
d isse ct io n p la n e s.
■ Carefu l h an d lin g o f t h e su b cu t an eou s tissu e is ma n dat ory.
■ Th e p a ra t e n o n o f t h e t ib ia lis a n t e rio r t e n d o n sh o u ld n o t
b e d isru p t e d .
■ Ext e n sive p e rio st e a l st rip p in g o f fra ct u re fra g m e n t s is
a vo id e d a n d fra g m e n t s a re ca re fu lly h in g e d o n t h e ir
so ft t issu e a t t a ch m e n t s t o p re se rve t h e ir va scu la rit y.
■ Hin g in g o p e n t h e a n t e rio r fra g m e n t s like a b o o k u sin g a
sm a ll la m in a sp re a d e r re ve a ls t h e in vo lve m e n t a n d d is-
p la ce m e n t o f t h e ce n t ra l a n d p o st e rio r a rt icu la r p la fo n d
a n d m e t a p h ysis.
■ On ce t h e e xt e n t o f t h e fra ct u re is a p p re cia t e d , re d u ct io n
a n d fixa t io n ca n b e p e rfo rm e d .
■ In so m e ca se s, t h e a rt icu la r in ju ry ca n b e a d d re sse d
t h ro u g h a sm a ll a n t e ro la t e ra l a p p ro a ch a n d a t t a ch m e n t
o f t h e re co n st ru ct e d a rt icu la r se g m e n t t o t h e in t a ct d ia -
p h ysis is a cco m p lish e d b y in se rt in g a n a n t e ro la t e ra l su b -
m u scu la r o r a n t e ro m e d ia l su b cu t a n e o u s p la t e .
■ Pro xim a l fixa t io n ca n t h e n b e a p p lie d in a m o re
“ o p e n ” m a n n e r o u t sid e t h e zo n e o f in ju ry.
■ Alt e rn a t ive ly, if t h e fib u la a n d p la fo n d a re b e in g re -
p a ire d a t t h e sa m e o p e ra t ive visit , a sin g le g e n t ly cu rve d
skin in cisio n p la ce d o ve r t h e syn d e sm o sis ca n b e u se d t o
a cce ss b o t h b o n e s.
■ He re , t o o , t h e su p e rficia l p e ro n e a l n e rve w ill b e e n -
co u n t e re d a n d sh o u ld b e p ro t e ct e d .
 Ch a p t e r 5 0 ORIF OF PILON FRACTURES 491

TECHNIQUES
A B

TECH FIG 2 • A–C. Im a g in g o f

43-C3 p ilo n fra ct u re w it h m o st ly
a n t e ro la t e ra l in ju ry p a t h o lo g y.
D. An t e ro la t e ra l a p p ro a ch . Th is is
a m o d ifica t io n o f Bo h le r’s in cisio n ,
in lin e w it h t h e fo u rt h m e t a t a rsa l
a n d e xt e n d in g p ro xim a lly b e -
t w e e n t h e t ib ia a n d fib u la . D
 492 Se ct i o n VI FOOT AND ANKLE
TECHNIQUES
POSTEROMEDIAL AND POSTEROLATERAL APPROACHES
■ Ad d it io n a l a p p ro a ch e s in clu d e t h e p o st e ro m e d ia l a n d
p o st e ro la t e ra l a p p ro a ch e s.
■ These m et hods are no t comm only em ployed but ma y
b e mo st use fu l in co mb in a tion w ith ot he r a p p ro a ch e s.
■ Bo t h a llo w fo r m in im a l a cce ss t o t h e a rt icu la r su rfa ce
su ch t h a t co m p le x in t ra -a rt icu la r in ju rie s a re n o t w e ll
a d d re sse d t h ro u g h t h e se a p p ro a ch e s a lo n e .
■ Th e y a re e ffe ct ive , h o w e ve r, fo r a id in g in re d u ct io n
o f h a rd -t o -re d u ce p o st e rio r fra g m e n t s a n d a p p lyin g
sm a ll b u t t re ss p la t e s t h a t m a y im p ro ve t h e fixa t io n
st a b ilit y o f in d ivid u a l p o st e rio r a rt icu la r se g m e n t s.
■ Th e p o st e ro m e d ia l a p p ro a ch u se s a skin in cisio n p o st e -
rio r t o t h e m e d ia l fa ce o f t h e t ib ia a n d re q u ire s m o b iliza -
t io n o f (a n d in h e re n t risk t o ) t h e p o st e rio r t ib ia l t e n d o n
a n d p o st e rio r t ib ia l n e u ro va scu la r b u n d le (se e Fig 6).
■ Th e re a re e sse n t ia lly t h re e in t e rva ls t o a cce ss t h e p o s-
t e ro m e d ia l t ib ia via t h is a p p ro a ch , d e p e n d in g o n t h e
fra ct u re co n fig u ra t io n a n d h o w fa r p o st e rio r t h e su r-
g e o n m u st re a ch :
■ An t e rio r t o t h e p o st e rio r t ib ia l t e n d o n
TECH FIG 3 • Th e p o st e ro la t e ra l a p p ro a ch u se s t h e in t e rva l b e t w e e n t h e p e r-
o n e a l a n d e xt e n so r h a llu cis lo n g u s m u scle s a n d a llo w s fo r w id e e xp o su re o f
t h e p o st e rio r d ist a l t ib ia . Acce ss t o t h e fib u la ca n a lso b e e a sily g a in e d t h ro u g h
t h is in cisio n .
REDUCTION AND FIXATION OF THE FIBULA
■ Co n sid e ra t io n a b o u t p la cin g a n d t im in g o f t h e fib u la r re -
p a ir m u st b e t h o u g h t fu l t o p re ve n t lim it in g a p p ro a ch e s
t o t h e t ib ia .
■ Th e fib u la is o ft e n re d u ce d a n d fixe d first t o in d ire ct ly re -
d u ce t h e t ib ia fra ct u re . It is so m e t im e s re p a ire d a t t h e
t im e o f t h e e xt e rn a l fixa t o r a p p lica t io n d u rin g st a g e d
t re a t m e n t .
■ In t h is co n t e xt , t h e fib u la m u st b e w e ll re d u ce d o r t h e
t ib ia l re d u ct io n w ill b e im p a ire d .
■ If st a g e d t re a t m e n t is e m p lo ye d w it h e xt e rn a l fixa t io n
a p p lie d a t a re fe rrin g h o sp it a l, m o st t e rt ia ry ce n t e rs
p re fe r t h e fib u la t o re m a in u n fixe d , t h u s a llo w in g fo r
■ Be t w e e n t h e p o st e rio r t ib ia l a n d t h e fle xo r d ig it o -
ru m co m m u n is t e n d o n s
■ Be t w e e n t h e fle xo r d ig it o ru m co m m u n is t e n d o n
a n d t h e p o st e rio r t ib ia l n e u ro va scu la r b u n d le
■ Th e re t in a cu lu m is in cise d a n d re p a ire d a t t h e t im e o f
w o u n d clo su re .
■ Th e p o st e ro la t e ra l a p p ro a ch t o t h e d ist a l t ib ia cre a t e s
so m e lo g ist ica l p ro b le m s a s t h e p a t ie n t is b e st p o sit io n e d
p ro n e (o r la t e ra l).
■ Th e skin in cisio n is p la ce d 1 t o 2 cm p o st e rio r t o a
st a n d a rd fib u la r in cisio n a n d ca n e a sily b e co m b in e d
w it h fib u la r re p a ir.
■ Th is a p p ro a ch u se s t h e in t e rva l b e t w e e n t h e p e r-
o n e a l t e n d o n s a n d fle xo r h a llu cis lo n g u s (TECH
FIG 3 ). Fa irly e xt e n sile a n d sa fe e xp o su re t o t h e p o s-
t e rio r a sp e ct o f t h e d ist a l t ib ia is p o ssib le u sin g t h is
a p p ro a ch .
■ Th e p o st e rio r co rt e x fra ct u re is u su a lly fa irly sim p le
a n d ca n b e u se d t o g a u g e re d u ct io n . Sm a ll o r m in i-
fra g m e n t b u t t re ss p la t e s a re o ft e n u se fu l h e re .
m a xim a l fle xib ilit y fo r t h e su rg e o n p ro vid in g d e fin it ive
t re a t m e n t .
■ If se p arat e ap p ro a ch e s are t o b e u se d fo r tib ia l a n d fib u -
la r re p air, th e fib u lar in cisio n is o fte n m ad e m o re p o st eri-
o rly t h an fo r m o st fibu la r re pa irs t o ma in ta in a n o ptim a l
d ist an ce fro m a n t icipa t e d a n te ro m e d ia l or a n t e rolat eral
in cisio n s.
■ Th e p o st e ro la t e ra l a p p ro a ch t o t h e d ist a l fib u la is a lso a
g o o d o p t io n b e ca u se it fa lls b e t w e e n t h e m a jo r d ist rib u -
t io n s o f t h e su ra l a n d su p e rficia l p e ro n e a l n e rve s. Th e
p a t ie n t ca n b e d isch a rg e d a n d re m a in m o b ile fo r d a ily
a ct ivit ie s w h ile a w a it in g so ft t issu e im p ro ve m e n t .
 Ch a p t e r 5 0 ORIF OF PILON FRACTURES 493

ARTICULAR REDUCTION AND FIXATION OF THE PILON
■ Th e first p rio rit y in ORIF o f co m p le x a rt icu la r in ju rie s,
su ch a s w it h p ilo n fra ct u re s, is a ccu ra t e re a lig n m e n t o f
t h e jo in t su rfa ce a n d rig id in t e rn a l fixa t io n .
■ On ce st a b ilize d , t h e a rt icu la r se g m e n t ca n t h e n b e a t -
t a ch e d t o t h e t ib ia l d ia p h ysis t h ro u g h o p e n o r m in im a lly
in va sive p la t in g (o r e xt e rn a l fixa t io n ).
■ Ma n y t ime s, re d u ct io n o f t h e a rticu la r se g me n t a n d re d u c-
tion of the m e t a dia p h ysis a re p e rforme d simu lt a ne o usly.
■ No n re co n st ru ct a b le lo o se b o d ie s a re d é b rid e d .
■ Re g a rd le ss o f t h e a p p ro a ch ch o se n a s t h e m o st a p p ro p ri-
a t e b y t h e su rg e o n , ca re fu l a n d p re cise a rt icu la r re co n -
st ru ct io n m u st b e a ch ie ve d .
TECHNIQUES
■ Le ss t h a n 2 m m o f a rt icu la r in co n g ru it y is t yp ica lly
co n sid e re d a cce p t a b le .
■ Wit h jo in t d ist ra ct io n (fe m o ra l d ist ra ct o r o r e xt e rn a l fix-
a t o r), t h e a n t e rio r t w o t h ird s o f t h e jo in t sh o u ld b e re a d -
ily a cce ssib le t h ro u g h a n a n t e rio r a p p ro a ch .
■ A la m in a sp re a d e r is o ft e n h e lp fu l fo r “ b o o kin g o p e n ”
ve rt ica l co rt ica l fra ct u re s t o a cce ss im p a ct e d a rt icu la r
fra g m e n t s (TECH FIG 4 A–D).
■ On e a rt icu la r fra g m e n t is re co n st ru ct e d t o a n o t h e r u n t il
a ll im p o rt a n t fra g m e n t s a re a d d re sse d .
■ So m e t im e s t h e t a la r d o m e ca n b e u se d a s a t e m p la t e fo r
a rt icu la r p la fo n d re d u ct io n .

A B C

D E F

TECH FIG 4 • A–C. Im a g in g o f a t yp ica l 43-A3 p la fo n d in ju ry. (Th e a a n d b in C co rre sp o n d t o t h e fra g m e n t la b e l-

in g in E.) D. Th e a n t e rio r co rt ica l sp lit is o p e n e d like a b o o k a n d h e ld w it h a la m in a sp re a d e r. Disse ct io n is lim it e d
t o t h a t n e ce ssa ry fo r re d u ct io n a n d p la t in g . Dire ct visu a liza t io n o f t h e a n t e rio r t w o t h ird s o f t h e jo in t is t yp ica lly
a va ila b le a n d m a y b e e n h a n ce d w it h u se o f a d ist ra ct o r (o r e xt e rn a l fixa t o r). E. In so m e e xt re m e ca se s su ch a s t h is,
m a jo r a rt icu la r fra g m e n t s a re re co n st ru ct e d w it h Kirsch n e r w ire s, m in i-fra g m e n t scre w s, o r a b so rb a b le p in s o n t h e
b a ck t a b le . F. Cla m p s a n d p ro visio n a l fixa t io n w it h Kirsch n e r w ire s ca n b e p la ce d t h ro u g h t h e w o u n d s o r p e rcu t a -
n e o u sly (ca re fu lly).
 494 Se ct i o n VI FOOT AND ANKLE
■ Th is re co n st ru ct io n sh o u ld b e p ro visio n a lly st a b ilize d
TECHNIQUES
w it h m u lt ip le Kirsch n e r w ire fixa t io n (TECH FIG 4 E).
■ Dire ct visu a liza t io n o f t h e jo in t a n d ra d io g ra p h ic g u id -
a n ce sh o u ld b e crit ica lly e va lu a t e d .
■ Th e p o st e rio r p la fo n d ca n b e d ifficu lt t o re d u ce fro m a n
a n t e rio r-b a se d e xp o su re . An kle p o sit io n in g o ft e n a ffe ct s
t h e p o sit io n o f t h is fra g m e n t .
■ So m e t im e s, w ire jo yst ick m a n ip u la t io n o r t h e u se o f a
sh a rp p ick o r ca re fu l p o in t e d cla m p a p p lica t io n is n e c-
e ssa ry t o o b t a in a n a d e q u a t e re d u ct io n o f p o st e rio r
fra g m e n t s.
■ Po st e rio r a p p ro a ch e s m a y a lso b e n e ce ssa ry, e sp e -
cia lly if d isp la ce d p o st e rio r fra ct u re lin e s e xit “ lo w ”
(ie , t h e y d o n o t e xt e n d p ro xim a lly).
EXTRA-ARTICULAR (METAPHYSEAL) REDUCTION AND FIXATION
OF THE PILON
■ On ce t h e a rt icu la r re d u ct io n is co m p le t e d , re a t t a ch in g
t h e d ist a l a rt icu la r se g m e n t t o t h e d ia p h ysis is a cco m -
p lish e d (in m a n y ca se s, t h is is d o n e sim u lt a n e o u sly).
■ We p re fe r p la t e fixa t io n , a lt h o u g h so m e su rg e o n s u se
e xt e rn a l fixa t io n a ft e r a lim it e d ORIF o f t h e a rt icu la r
su rfa ce .
■ Cu rre n t ly, “ a n a t o m ica lly” co n t o u re d lo w -p ro file , sm a ll-
fra g m e n t p la t e s (w it h lo ckin g ca p a b ilit y) d e sig n e d fo r
t h e d ist a l t ib ia a re a va ila b le fro m m o st im p la n t ve n d o rs.
■ Th e a n a t o m ic d e sig n o f t h e se im p la n t s a ffo rd s a sa t -
isfa ct o ry m a t ch t o t h e a n t e ro m e d ia l o r a n t e ro la t e ra l
(TECH FIG 5 ) su rfa ce o f t h e d ist a l t ib ia .
A B
■ Pro visio n a l w ire s ca n b e u se d a s g u id e w ire s fo r ca n n u -
la t e d scre w s if n e e d e d .
■ Sm a ll a n d m in i-fra g m e n t scre w s a re u se fu l a n d sh o u ld b e
p la ce d b e fo re re m o va l o f t h e p ro visio n a l w ire s.
■ On ce a rt icu la r re co n st ru ct io n is co m p le t e , t h e d isim -
p a ct e d m e t a p h yse a l a re a is e va lu a t e d fo r b o n e g ra ft in g
n e e d s.
■ Fo r a u t o g ra ft , t h e Ge rd y t u b e rcle re g io n is e a sily a cce ssi-
b le a n d le ss p a in fu l t h a n t h e ilia c cre st a n d ca n p ro vid e
a n a d e q u a t e a m o u n t o f g ra ft in m o st ca se s.
■ If a d d it io n a l g ra ft is re q u ire d o r t h e p a t ie n t d o e s n o t
w a n t t o risk a u t o g ra ft m o rb id it y, a syn t h e t ic g ra ft o r a l-
lo g ra ft ch ip s a re u su a lly a su it a b le a lt e rn a t ive (o p e ra t ive
co n se n t sh o u ld re fle ct t h e p o t e n t ia l fo r g ra ft u se ).
■ Tra d it io n a lly, w e h a ve u se d t h e sm a ll fra g m e n t p la t e s,
w h ich a llo w e a sy a n d p re cise co n t o u rin g fo r a n a p p ro p ri-
a t e b o n y fit .
■ No n lo ckin g scre w s a re u se d first t o b rin g t h e p la t e in
clo se a p p o sit io n t o b o n e t o m in im ize t h e p la t e ’s p ro m i-
n e n ce a g a in st t h e so ft t issu e s.
■ Su b se q u e n t in se rt io n o f lo ckin g scre w s, cre a t in g a “ h y-
b rid ” in t e rn a l fixa t io n co n st ru ct , is d e t e rm in e d b a se d o n
fa ct o rs su ch a s b o n e q u a lit y, co m m in u t io n , a n d e xp e ct e d
t im e t o h e a lin g .
■ An a n t e rio r p la t e lo ca t io n is o ft e n b e st fo r n e u t ra liza t io n
o r b u t t re ssin g o f co m p le x in t ra -a rt icu la r fra ct u re s.
TECH FIG 5 • A,B. La g scre w s a re u se d a n d
a n t e rio r p la t in g is p e rfo rm e d t o o p t im ize fixa -
t io n o f t h e a rt icu la r se g m e n t w it h a ra ft o f
a n t e rio r–p o st e rio r scre w s. Au t o g ra ft fro m t h e
t u b e rcle o f Ge rd y w a s u se d a b o ve t h e d isim -
p a ct e d a rt icu la r su rfa ce , b u t a llo g ra ft o r su b st i-
t u t e s m a y b e u se d . (co n t in u e d )
 Ch a p t e r 5 0 ORIF OF PILON FRACTURES 495

TECHNIQUES
TECH FIG 5 (co n t in u e d ) • C,D. Ra d io g ra p h s
sh o w a p p e a ra n ce im m e d ia t e ly p o st o p e ra -
C D t ive ly.

WOUND CLOSURE AND CARE

■ On ce in t ra o p e ra t ive ra d io g ra p h s re ve a l a sa t isfa ct o ry re -
d u ct io n a n d p o sit io n o f im p la n t s, t h e in cisio n is clo se d .
■ Re t in a cu la r la ye rs a re re a p p ro xim a t e d t o co ve r t h e u n -
d e rlyin g b o n e a n d im p la n t s.
■ A d ra in m a y b e co n sid e re d t o m in im ize p re ssu re o n t h e
in cisio n lin e fro m flu id a ccu m u la t io n u n d e r t h e w o u n d .
■ Th e su b cu t a n e o u s la ye r is clo se d w it h a n a b so rb a b le su -
t u re b e fo re skin clo su re .
■ We use fine (4-0) nylon interrup ted su tures and atraumatic
soft tissue handling during wound closure (TECH FIG 6).
■ Clo sin g t h e a n t e ro m e d ia l in cisio n w it h o u t t e n sio n is crit -
ica lly im p o rt a n t . An y su b st a n t ia l t e n sio n o n t h e a n t e rio r
skin e d g e s a ft e r clo su re w ill like ly re su lt in so m e d e g re e
o f so ft t issu e n e cro sis. Ra re ly, a cco m p lish in g t h is st e p
m a y re q u ire re la xa t io n o f t h e la t e ra l in cisio n o r a re t u rn
t rip t o t h e o p e ra t in g ro o m fo r d e la ye d clo su re .
■ A lig h t ly co m p re ssive b u lky d re ssin g a n d sp lin t a re a p -
p lie d w it h t h e a n kle in n e u t ra l p o sit io n .
■ Fin a lly, e le va t io n is re su m e d b e fo re le a vin g t h e o p e ra t -
in g ro o m t o m in im ize sw e llin g .

TECH FIG 6 • Wo u n d clo su re is a ch ie ve d u sin g a t ra u m a t ic t e ch n iq u e , w it h t h e

su p e rficia l la ye rs clo se d u sin g fin e n ylo n su t u re .

PEARLS AND PITFALLS

Min im izin g risk fo r m a jo r
co m p lica t io n s
■ Be fo re m o d e rn m e t h o d s o f so ft t issu e h a n d lin g , o p e n t re a t m e n t o f h ig h -e n e rg y t ib ia l p la fo n d
fra ct u re s w a s d ire ct ly a sso cia t e d w it h h ig h co m p lica t io n ra t e s (a b o u t 50% ).
■ Ma n y o f t h e se co m p lica t io n s a re p re ve n t a b le ; t h u s, t ib ia l p ilo n fra ct u re s p re se n t t h e o rt h o p e d ic
su rg e o n w it h a re a l o p p o rt u n it y t o in flu e n ce a p a t ie n t ’s u lt im a t e o u t co m e .
■ Co n t e m p o ra ry fra ct u re t re a t m e n t p rin cip le s (e g , st a g e d t re a t m e n t p ro t o co ls, t a ilo re d su rg ica l
a p p ro a ch e s, ca re fu l so ft t issu e h a n d lin g , in d ire ct re d u ct io n , a n d b io lo g ic fixa t io n ) h a ve re d u ce d
t h e ra t e o f co m p lica t io n s t o a n a cce p t a b le le ve l (a b o u t 0% t o 10% ) fo r t h e se fra ct u re s.
496 Se ct i o n VI FOOT AND ANKLE

Su rg ica l g o a ls ■ As e st a b lish e d b y Rü e d i a n d Allg ö w e r, t h e g o a ls o f su rg e ry fo r p ilo n fra ct u re s in clu d e p re cise a r-

So ft t issu e m a n a g e m e n t
Art icu la r re d u ct io n t ricks
Me t a p h yse a l re d u ct io n t ricks
Fixa t io n p ro b le m s
t icu la r re co n st ru ct io n , re st o ra t io n o f e xt re m it y le n g t h a n d a lig n m e n t , st a b le fra ct u re fixa t io n ,
a n d e a rly jo in t m o t io n .
■ Th e a vo id a n ce o f co m p lica t io n s is crit ica l t o co n sist e n t ly a ch ie vin g o p t im a l clin ica l re su lt s.
■ Th e so ft t issu e s m u st b e q u ie sce n t a t t h e t im e o f p la fo n d o p e n re d u ct io n a n d in t e rn a l fixa t io n .
■ St a g e d t re a t m e n t p ro t o co ls, t a ilo re d su rg ica l a p p ro a ch e s, ca re fu l so ft t issu e h a n d lin g , a n d in d i-
re ct re d u ct io n sh o u ld b e u se d ro u t in e ly fo r t h e se in ju rie s.
■ Th e a rt icu la r re d u ct io n is o f p a ra m o u n t im p o rt a n ce a n d is u su a lly p e rfo rm e d first , fo llo w e d b y
t h e m e t a p h yse a l–d ia p h yse a l re d u ct io n .
■ Lo n g it u d in a l t ra ct io n w it h a n e xt e rn a l fixa t o r o r fe m o ra l d ist ra ct o r a llo w s fo r in d ire ct fra ct u re
re d u ct io n a n d jo in t visu a liza t io n .
■ Art icu la r fra g m e n t s m a y b e d isim p a ct e d w it h sm a ll o st e o t o m e s o r e le va t o rs. Th e se fra g m e n t s
sh o u ld b e ke p t a s t h ick a s p o ssib le , a n d vo id s cre a t e d b y d isim p a ct io n sh o u ld u su a lly b e g ra ft e d .
■ Sm a ll, irre p a ra b le fre e fra g m e n t s sh o u ld b e re m o ve d .
■ A w e ll-p o sit io n e d t a la r d o m e m a y b e u se fu l a s a t e m p la t e t o re d u ce a rt icu la r fra g m e n t s.
■ Mu lt ip le Kirsch n e r w ire s a n d ca re fu lly p la ce d p o in t e d cla m p s m a y h e lp fu l in g a in in g a n d m a in -
t a in in g re d u ct io n .
■ Fra ct u re re d u ct io n sh o u ld b e ca re fu lly scru t in ize d u sin g d ire ct visu a liza t io n a n d ra d io g ra p h y
b e fo re a n d a ft e r fixa t io n so t h a t ch a n g e s ca n b e m a d e b e fo re d e fin it ive fixa t io n o r le a vin g t h e
o p e ra t in g ro o m .
■ Oft e n re d u cin g t h e jo in t fra g m e n t s w ill sim u lt a n e o u sly re a lig n t h e m e t a p h ysis.
■ Po in t e d cla m p s, sm a ll p u sh p la t e s, a n d la g scre w s a re ve ry u se fu l fo r t h e m e t a p h yse a l re d u ct io n .
■ Axia l a lig n m e n t m u st b e ca re fu lly scru t in ize d clin ica lly a n d ra d io g ra p h ica lly.
■ A w e ll-re p a ire d fib u la is a n e xce lle n t g u id e fo r re st o rin g t ib ia l le n g t h .
■ 2.4-, 2.7-, a n d 3.5-m m la g scre w s a n d o cca sio n a lly a b so rb a b le p in s a re u se fu l fo r fixa t io n o f t h e
a rt icu la r fra g m e n t s. Th e se a re o ft e n p la ce d in su b ch o n d ra l b o n e t o g a in o p t im a l st a b ilit y o f o s-
t e o ch o n d ra l fra g m e n t s.
■ An a t o m ica lly co n t o u re d p ilo n p la t e s w it h lo ckin g ca p a b ilit y a re n ice t o o ls fo r u se in co m p le t e
a rt icu la r in ju rie s o r o st e o p o ro t ic b o n e b u t a re n o t a lw a ys n e ce ssa ry (o r d e sira b le ).

POSTOPERATIVE CARE ■ M ore modern techniques of plafond fracture management

have led to much more satisfactory complication rates for
■ Elevation of the extremity should continue for the next few
pilon fractures.
weeks to protect the incisions. ■ Sirkin et al13 retrospectively analyzed a staged protocol
■ Patient education is important to maximize understanding
for management of 56 C-type plafond fractures treated
of wound risks and compliance with elevation and other post-
using a protocol of immediate (within 24 hours) stabiliza-
operative treatments.
■ Aggressive respiratory care and supplemental oxygen are
tion of the fibula fracture with temporary spanning external
fixation of the tibia across the ankle joint. Formal open re-
continued until the patient is fully awake and off intravenous
construction of the tibial fracture with plating was per-
narcotics (respiratory depressants).
■ Immobilization is maintained for about 10 to 14 days or
formed when soft tissues normalized (average 13 days).
Three patients developed deep infections (6% ) and five pa-
until the incisions have healed adequately.
■ At the time of suture removal, ankle range-of-motion exer-
tients had superficial necrosis that was well treated with
local wound care and oral antibiotics.
cises are taught, and the limb is placed in a removable fracture ■ Patterson and Cole9 published results of a similar two-
brace.
■ Strict non-weight bearing is continued, with advancement in
staged technique for the treatment of C3 plafond fractures.
Twenty-one patients underwent early fibular fixation
weight bearing made when radiographic evidence of fracture
and placement of a spanning external fixator. After an
consolidation is adequate, typically at 10 to 12 weeks after
average of 24 days, patients underwent O RIF of the
surgery.
plafond fractures. There were no infections or soft tissue
complications.
OUTCOMES ■ There are a few limited studies that have compared staged

■ The philosophy for open reduction and rigid internal fixa- O RIF to other methods for treating tibial plafond fractures.
tion of plafond fractures is a direct extension of Ruëdi and ■ Blauth et al2 retrospectively compared results of three dif-

Allgöwer’s original recommendations.11 ferent management protocols for severe plafond fractures
■ H istorically, early poor results with O RIF were primarily re- (92% 43-C fractures):
lated to the disruption of the soft tissue envelope and not the ■ Primary O RIF (n 15, reserved for patients with
fixation of the bony fracture itself.7,14 closed fractures without severe soft tissue trauma)
■ These failures were the result of the inherent fragility of ■ Primary minimally invasive osteosynthesis of the artic-

the thin soft tissue envelope in this area, misunderstandings ular surface with long-term (minimum of 4 weeks)
of the soft tissue injury severity, overly aggressive soft tissue transarticular external fixation of the ankle (n 28)
stripping during surgery, and the use of prominent, large ■ Two-stage procedure with primary minimally invasive

fragment implants for stabilization. osteosynthesis of the articular surface and ankle-spanning

external fixation, followed by staged subcutaneous plat-
ing (n 8)
■ While the incidence of wound infection did not differ
significantly among the three groups, this study found
that patients who had undergone two-stage surgery did
better in terms of pain, ankle motion, activities of daily
living, and the need for secondary arthrodesis compared
to the other groups.
■ Babis et al1 retrospectively compared 50 tibial plafond
fractures treated by O RIF to 17 patients treated with mini-
mally invasive osteosynthesis or external fixation. They
found that three parameters significantly influenced results:
the severity of fracture, the quality of surgical reduction,
and the procedure by which the fracture was managed
(O RIF did better).
■ H arris et al4 compared functional outcomes after oper-
ative treatment of 43-B or C plafond fractures with O RIF
(n 63) versus limited open articular reduction and wire
ring external fixation (n 16). The greatest impairment in
outcome was noted after type C3 fractures regardless of
the method of treatment employed. O RIF was associated
with fewer complications and less posttraumatic arthritis
than external fixation, but this finding possibly reflected a
selection bias, as open injuries and the more severely com-
minuted fractures were all managed with external fixation.
■ Two studies have reported intermediate or long-term patient
outcomes after O RIF of tibial plafond fractures.
■ Sands et al12 reported on 30 patients who completed the
SF-36 more than 18 months after O RIF of a tibial plafond
fracture. There were deficits in every SF-36 subcategory,
with the largest differences in outcomes seen in the areas of
physical function and physical role function.
■ Pollak et al10 similarly evaluated 80 patients with the SF-
36 more than 2 years after O RIF of a pilon injury. They also
found diminished scores in all eight functional domains of
the SF-36, including markedly abnormal scores for physical
function, physical role function, and bodily pain. They also
reported that 35% of patients reported substantial ankle
stiffness, 29% had persistent swelling, and 33% described
ongoing pain. O f the participants who had been employed
before the injury, 43% were not working at final follow-up.
COMPLICATION S
■ Tibial pilon fractures are often complex injuries that have a
high potential for complications if not managed thoughtfully.
■ As many of these complications are somewhat pre-
ventable, tibial plafond fractures present the orthopedic
surgeon with an opportunity to improve a patient’s ulti-
mate outcome.
■ While we cannot alter the severity of a particular injury,
appropriate surgical timing and soft tissue handling, along
with exact articular reduction and stable fixation to allow
for early motion, offer the best chance of obtaining good
results with few complications for patients with these
fractures.
■ Wound problems resulting from these procedures should be
treated aggressively to prevent deep infection.
■ Superficial marginal wound necrosis can be successfully
managed with local wound care with or without oral
antibiotics.
■ Full-thickness necrosis (eschar) can be followed as well in
reliable patients who can be followed closely and educated to
Ch a p t e r 5 0 ORIF OF PILON FRACTURES 497
return immediately for any wound problems. O nce the eschar
begins to detach or drain (becomes “ unstable” eschar), it will
need to be removed immediately and débrided and antibiotics
given. If healing beneath the eschar is inadequate at the time
of its unroofing, the patient may require formal débridement
and soft tissue coverage with a simple skin graft, fasciocuta-
neous flap, or free soft tissue transfer, depending on the area
and size of the wound and how much “ biology” will be nec-
essary to aid healing and prevent infection.
■ Anteromedial wounds of this sort are more problematic
than anterolateral wounds or others, because the underlying
tibia and fracture will be exposed in the anteromedial case.
■ Established deep infection is a limb-threatening problem
and usually requires intravenous antibiotics, staged surgeries
including external fixation support, soft tissue coverage (often
through free-tissue transfer), and possibly late bone grafting.
■ Importantly, not all patients are good candidates for such
complex reconstructive procedures. In these cases, early
below-the-knee amputation is a useful means for restoring pre-
dictable function in an expeditious manner.
■ M alunion typically occurs in varus and usually occurs if
malalignment is accepted or unrecognized or union is not
achieved or fixation fails.
■ Prevention is important and should focus on providing
adequate initial and ongoing medial column support against
an intact, plated, or healed fibula.
■ Some surgeons avoid fixation of the fibula entirely. This
method is typically coupled with external fixation for the tibia
fracture after limited open articular reconstruction.
■ Avoiding fibular stabilization, however, does not convinc-
ingly decrease and perhaps even increases the chance of an-
gular deformity. Also, maintaining appropriate length is
more difficult with the use of external fixation alone.
■ M alalignment of the tibia or fibula may adversely affect
ankle function and result in painful ankle arthrosis.
■ M ost authors use less than 5 degrees of varus–valgus and
less than 5 or 10 degrees of recurvatum–procurvatum as a
limit for acceptable alignment.
■ M alunion surgery is typically associated with adjustment
of the fixation and requires careful preoperative planning
and perhaps referral to a surgeon with experience in post-
traumatic reconstruction.
■ N onunion or delayed union occurs in about 5% or more of
patients and may occur in combination with malalignment.
■ Injury and host factors are implicated in problems with
union of the tibial pilon.
■ Significant metaphyseal comminution, open fractures, and
bone loss are factors prone to causing healing problems; ad-
junctive measures should be considered in these cases.
■ Smoking cessation and avoidance of nonsteroidal anti-
inflammatory medications should be routinely discussed
with patients to decrease the likelihood of these compli-
cations.
■ Immediate or early staged (4 to 8 weeks) bone grafting may
advance tibial metaphyseal healing in high-risk fractures.
External bone stimulation can also be considered early (for
acceleration of fresh fracture healing) or late (as an adjunct to
nonunion surgery) in the treatment course.
■ Treatment of an established distal tibial nonunion re-
quires a comprehensive plan including consideration of the
soft tissues, local biology and mechanics, presence of infec-
tion, condition of the ankle joint, and others.
498 Se ct i o n VI FOOT AND ANKLE
■ Repair frequently requires realignment of the limb axis,
followed by rigid fixation with or without bone grafting.
■ Posttraumatic arthritis should be addressed by an initial
course of conservative care. Ankle arthrodesis (method by sur-
geon preference) is often chosen once nonoperative treatment
measures have been exhausted. Recent advances in total ankle
arthroplasty may hold promise in carefully selected patients,
but this is not currently recommended.
■ Rarely, a primary arthrodesis is considered for limb salvage
in severe fractures in which the articular surface cannot be
salvaged.
■ The combination of metaphyseal nonunion and ankle arthri-
tis is particularly difficult because the intercalary segment of
tibia (between the nonunion site and the ankle joint) is often
small and of poor bone quality.
■ Treatment options for this condition include amputation
(especially if infection is present), resection with distraction
osteogenesis, or internal fixation spanning both the nonunion
and arthritic ankle along with bone grafting.
REFEREN CES
1. Babis GC, Vayanos ED, Papaioannou N , et al. Results of surgical
treatment of tibial plafond fractures. Clin O rthop Relat Res 1997;
341:99–105.
2. Blauth M , Bastian L, Krettek C, et al. Surgical options for the treat-
ment of severe tibial pilon fractures: a study of three techniques. J
O rthop Trauma 2001;5:153–160.
3. Cole PA, M ehrle RK, Bhandari M . The pilon map: assessment of
fracture lines and comminution zones in AO C3 type pilon fractures.
O rthopedic Trauma Association annual meeting, H ollywood, FL,
O ctober 8–10, 2004.
4. H arris AM , Patterson BM , Sontich JK, et al. Results and outcomes
after operative treatment of tibial plafond fractures. Foot Ankle Int
2006;27:256–265.
5. H erscovici D Jr, Sanders RW, Infante A, et al. Bohler incision: an ex-
tensile anterolateral approach to the foot and ankle. J Orthop Trauma
2000;14:429–432.
6. H oward JL, Agel J, Barei D, et al. Challenging the dogma of the 7-cm
rule: a prospective study evaluating incision placement and wound
healing for tibial plafond fractures. O rthopaedic Trauma Association
annual meeting, Phoenix, AZ , O ctober 5–7, 2006.
7. M cFerran M A, Smith SW, Boulas H G, et al. Complications encoun-
tered in the treatment of pilon fractures. J O rthop Trauma
1992;6:195–200.
8. O rthopedic Trauma Association Committee for Coding and
Classifications. Fracture and dislocation compendium. J O rthop
Trauma 1996;10(supp 1):56–60.
9. Patterson MJ, Cole JD. Two-staged delayed open reduction and inter-
nal fixation of severe pilon fractures. J Orthop Trauma 1999;13:
85–91.
10. Pollak AN, M cCarthy ML, Bess RS, et al. Outcomes after treatment of
tibial plafond fractures. J Bone Joint Surg Am 2003;85A:1893–1900.
11. Ruëdi T, Allgö wer M . Fractures of the lower end of the distal tibia:
surgical management by limited internal fixation and articulated dis-
traction. Injury 1969;1:92–99.
12. Sands A, Grujic L, Byck DC, et al. Clinical and functional outcomes
of internal fixation of displaced pilon fractures. Clin O rthop Relat
Res 1998;347:131–137.
13. Sirkin M . Sanders R, DiPasquale T, et al. A staged protocol for soft
tissue management on the treatment of complex pilon fractures. J
O rthop Trauma 1999;13:78–84.
14. Teeny SM , Wiss DA. O pen reduction and internal fixation of tibial
plafond fractures: variables contributing to poor results and compli-
cations. Clin O rthop Relat Res 1993;292:108–117.
15. Tornetta P III, Group J. Axial computed tomography of pilon frac-
tures. Clin O rthop Relat Res 1996;323:273–276.
 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 51 Fix a t io n o f In d ire ct An k le
Fr a ct u re s
Ke n n e t h A . Eg o l
DEFIN ITION
■ The ankle is a modified hinge joint, which relies on a con-
gruently reduced mortise to provide optimal function.
■ M aintenance of normal tibiotalar contact is essential if one
is to maintain function.
■ Surgical treatment of displaced, unstable ankle fractures
centers on anatomic restoration of the bony and ligamentous
relationships that make up the ankle mortise.
■ This chapter will focus on the treatment of a specific pattern
of injury to the ankle, specifically the bimalleolar fracture
pattern.
AN ATOMY
■ The anatomy of the distal tibia and ankle joint must be
taken into account when considering ankle fractures. As the
tibial shaft flares in the supramalleolar region, the dense corti-
cal bone changes to metaphyseal cancellous bone (FIG 1 A).
■ The shape of the tibial articular surface is concave, with dis-
tal extension of the anterior and posterior lips.
■ This surface has been called the tibial plafond, which is
French for ceiling.
■ The talar dome is wedge-shaped and sits within the mortise.
It is wider anteriorly than posteriorly.
■ The medial end of the tibia is the medial malleolus.
■ The medial malleolus is composed of the anterior and
posterior colliculi, separated by the intercollicular groove
(FIG 1 B).
■ The anterior colliculus is the narrower and most distal
portion of the medial malleolus and serves as the origin of
the superficial deltoid ligaments.
■ The intercollicular groove and the posterior colliculus,
which is broader than the anterior colliculus, provide the
origin of the deep deltoid ligaments.
■ The insertions of the deltoid ligaments (medial tubercle of
the talus, navicular tuberosity, and sustentaculum tali) can
also be considered part of the medial malleolar osteoliga-
mentous complex.
■ The lateral malleolus is the distal end of the fibula. It ex-
tends about 1 cm distal and posterior compared to the medial
malleolus.
■ The syndesmotic ligament complex unites the distal fibula
with the distal tibia. The following ligaments make up the syn-
desmotic complex: the anteroinferior tibiofibular ligament, the
posteroinferior tibiofibular ligament, the inferior transverse
ligament, and the interosseous ligament (FIG 1 C).
PATHOGEN ESIS
■ The majority of bimalleolar ankle fractures are secondary to
rotation of the body about a supinated or pronated foot. They
are best defined by the classification of Lague-H ansen (FIG 2 ).
■ The supination–external rotation pattern of ankle fracture is
divided into four stages.
■ The stage 1 injury is tearing of the anterior inferior
tibiofibular ligaments.
■ As the external rotation force continues laterally, a spiral
fracture of the fibula occurs. O n lateral radiograph, the frac-
ture line will pass from the anteroinferior cortex to the pos-
terosuperior cortex.
■ The third stage occurs when the posteroinferior tibiofibu-
lar ligaments avulse or fracture off the posterior malleolus.
■ The final stage results in a medial malleolar osteoligamen-
tous complex injury with either a deep deltoid ligament tear
or a fracture of the medial malleolus.
■ The pronation–external rotation variant also has four
stages. Because of the pronated position of the foot at injury,
however, the medial structures are injured in the early stages.
■ The fibula fracture pattern seen with this mechanism is
usually suprasyndesmotic, and the fracture pattern is an an-
terosuperior-to-posteroinferior fracture line as seen on the
lateral radiograph.
■ The supination–adduction pattern is heralded by a low
transverse fibular fracture and a vertical shearing pattern me-
dially. This pattern is also associated with tibial plafond
impaction.
■ Finally, the pronation–abduction pattern is identified by the
avulsion of the medial malleolus and a transverse or laterally
comminuted fibular fracture above the syndesmosis secondary
to a direct bending moment.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Most patients who present with ankle pain following trauma
will describe a twisting type of injury. Less frequently they will
report a direct blow to the ankle.
■ Proper medical history should include the patient’s current
comorbid medical conditions, such as peripheral vascular dis-
ease, diabetes, or peripheral neuropathy.
■ Physical examination should center on inspection, palpa-
tion, and neurovascular examination.
■ It is important to note any gross deformity, which may
signify dislocation. If dislocation is present, the ankle should
be reduced and splinted as soon as possible to prevent skin
tenting and neurovascular compromise.
■ Inspection for any open wound about the ankle is critical as
well. O pen fractures imply a surgical urgency. Swelling, ecchy-
mosis, and tenderness about the malleoli should be recorded.
■ For patients with a supination–external rotation pattern iso-
lated fibula fracture who present with an intact mortise, the
gravity stress examination can be revealing. M ore than 5 mm
of medial clear space widening in association with a lateral
malleolus fracture signifies an unstable pattern.
■ Pain at the ankle along the syndesmosis during a squeeze
test implies injury to the syndesmosis.
■ The proximal fibula, knee, and tibia should also be exam-
ined. Palpation of pulses, detection of capillary refill, and a
499
500 Se c t i o n VI FOOT AND ANKLE

Tibia

Fibula
Anterior
colliculus

Talonavicular
ligament
Tibiotalar joint
Superficial Posterior
deltoid colliculus
Talus
ligament
Deep
deltoid
ligament

A B

Tibia Transverse
ligament
Interosseous
membrane
Posteroinferior
tibiofibular
Anteroinferior ligament
tibiofibular
Posterior
ligament
talofibular
ligament FIG 1 • A. Bo n y a n a t o m y in t h e su p ra -
m a lle o la r re g io n o f t h e d ist a l t ib ia .
Calcaneofibular B. An a t o m y o f t h e m e d ia l a sp e ct o f t h e
ligament a n kle jo in t . C. Lig a m e n t o u s a n a t o m y
C a b o u t t h e a n kle jo in t .

careful neurosensory examination must be documented prior ■ Restoration of medial ankle stability depends on the size
to manipulation. and location of the medial malleolar fragment.
■ The size of the medial fragment is key to stability.

IMAGIN G AN D OTHER DIAGN OSTIC ■ Anterior collicular fractures will have only the superficial

STUDIES deltoid attached. In about 25% of supination–external rota-

■ Radiographic examination includes the ankle trauma series: tion type 4 injuries there will be an associated deep deltoid
anteroposterior (AP), lateral, and mortise view (FIG 3 A–C). rupture. Thus, fixation of this fragment will not enhance
■ In patients with isolated lateral malleolar fractures with clin- stability.
ical signs of medial injury, or if there is any question of ankle ■ The lateral radiograph is the key. If the fragment is

stability in a supination–external rotation fracture pattern, a
manual external rotation stress radiograph should be obtained
to assess for instability.
■ The tibia is held internally rotated 15 degrees with the
ankle in dorsiflexion to produce a gentle external rotation
moment at the ankle under fluoroscopy (FIG 3 D).
■ M ore than 5 mm of medial clear space widening in asso-
greater than 2.8 cm wide, the deep deltoid will be attached
and stability is restored. If the fragment is less than 1.7 cm
wide, then stability is not restored with fixation. For frac-
tures in between, an intraoperative external rotation stress
examination should be performed following malleolar
fixation.
■ CT scanning may be helpful in assessing posterior malleolar

ciation with a lateral malleolus fracture signifies an unstable fragment size in rotational ankle fractures.
pattern (FIG 3 E). ■ M RI may have some utility if there is an isolated lateral

■ If clinically warranted, full-length tibia–fibula radiographs malleolus fracture with signs of medial injury and an equivo-
should be obtained. cal stress examination.
 Ch a p t e r 5 1 ORIF OF INDIRECT ANKLE FRACTURES 501

Supination–adduction Supination–external ■ Lateral process talus fracture

injuries rotation injuries ■ Anterior process calcaneus fracture
■ Subtalar dislocation

N ON OPERATIVE MAN AGEMEN T

■ Ankle fractures in which the ankle mortise remains stable
II can be treated nonoperatively.
II IV ■ Isolated lateral malleolus fractures without evidence of
I I and III
or medial-sided injury are considered supination external rota-
or
IV tion type 2 injuries and can be treated with functional brac-
I ing and weight bearing as tolerated.
■ Unstable patterns such as supination–external rota-

tion type 4, either ligamentous or a true bimalleolar or

trimalleolar ankle fracture, can also be treated nonoperatively
in patients who are poor surgical candidates (eg, insulin-
dependent diabetics), who have severe soft tissue problems, or
who do not wish to undergo surgical stabilization.
Pronation–external Pronation–adduction ■ If nonoperative treatment is chosen, it is crucial to en-

rotation injuries injuries sure anatomic mortise reduction throughout treatment until
healing.
■ Unstable injuries should be treated in a well-molded short-

III leg cast and checked on a weekly basis to ensure continued

mortise reduction.

III
I
SURGICAL MAN AGEMEN T
I II and
or II ■ Any fracture of the ankle in which there is residual talar
or IV
I I tilt or talar subluxation such that the ankle mortise is
not anatomically reduced is an indication for surgical
stabilization.

FIG 2 • Th e La g u e -Ha n se n cla ssifica t io n o f a n kle fra ct u re s.
Preoperative Planning
■ Surgical anatomy should be reviewed prior to entering
the operating room, including the bony and ligamentous
structures.
■ The neurovascular anatomy about the ankle should be re-

DIFFEREN TIAL DIAGN OSIS viewed, including the course of the saphenous vein medially
■ Ankle sprain and the superficial peroneal nerve laterally.
■ Lateral malleolus fracture ■ Equipment to be used includes a small fragment plate and

■ Bimalleolar ankle fracture screw set, large pelvic reduction clamps, small-diameter
■ Trimalleolar ankle fracture Kirschner wires, and 3.5- to 4.0-mm cannulated screw sets. If

A B C

FIG 3 • Ra d io g ra p h ic e va lu a t io n w it h a n a n kle t ra u m a se rie s: AP (A), la t e ra l (B), a n d m o rt ise (C) vie w s. (co n t in u e d )

 502 Se c t i o n VI FOOT AND ANKLE

FIG 3 • (co n t in u e d ) Clin ica l (D) a n d ra d io g ra p h ic

(E) d e m o n st ra t io n o f a p h ysicia n -a ssist e d e xt e rn a l ro t a -
D E t io n st re ss e xa m in a t io n o f t h e a n kle .

the nature of the fracture is still in question, radiographic stress
examination may be performed under anesthesia.
Positioning
■ The patient is positioned supine with a small bump under
the ipsilateral hip to ease access to the fibula.
■ A pneumatic tourniquet can be applied to the affected thigh
■ In rare cases, if a posterior approach is chosen, the patient
may be placed in the prone position to allow access to the
posterior tibia via the posterolateral approach.
Approach
■ The fibula is approached via a direct lateral incision.
■ The medial malleolus is approached via a gently curved an-

if desired for use during the surgical procedure. The affected teromedial incision.
limb is prepared and draped free. ■ Direct access to the posterior malleolus can be obtained

■ The bump may be removed after lateral fixation for easier through a posterolateral approach to the fibula.
access to the medial side.
TECHNIQUES

DIRECT LATERAL APPROACH TO THE FIBULA

Exp o su re
■ Th e in cisio n is ke p t ju st o ff t h e p o st e rio r b o rd e r o f t h e
fib u la b u t m a y b e a d ju st e d slig h t ly b a se d o n so ft t issu e
co n sid e ra t io n s (TECH FIG 1 A).
■ De e p e r t issu e s a re in cise d in lin e w it h t h e skin in cisio n
(TECH FIG 1 B).
■ Ca re m u st b e t a ke n p ro xim a lly in t h e w o u n d t o a vo id
in ju ry t o t h e su p e rficia l p e ro n e a l n e rve , w h ich cro sse s

A B

TECH FIG 1 • Surgical approach to the

fib u la , d ire ct la t e ra l. A. Skin in cisio n
marke d out just a lon g the posterio r bor-
d er of the fibu la, centered a bo ut the le ve l
o f the fracture. B. In cisio n th ro ugh the
p ero neal (lateral compartme nt) fa scia, e x-
p osing the fra ctu re site. C. Id entificatio n
o f the sup erficial perone al ne rve a s it
C crosses proximally in th e woun d.
 Ch a p t e r 5 1 ORIF OF INDIRECT ANKLE FRACTURES 503

t h e fie ld a b o u t 7 cm p ro xim a l t o t h e d ist a l t ip o f t h e ■ If t h e cla m p s m a ke it d ifficu lt t o p la ce a la g scre w , p ro vi-

fib u la (TECH FIG 1 C).
■ Ne xt , t h e p e ro n e a l fa scia is d ivid e d a n d t h e p e ro n e a l t e n -
d o n s a n d m u scu la t u re a re re t ra ct e d p o st e rio rly.
■ Wit h g e n t le e le va t io n o f t h e p e rio st e u m a b o u t t h e
fra ct u re sit e , t h e fib u la sh o u ld b e e xp o se d .
■ Ca re sh o u ld b e t a ke n t o a vo id e xce ssive st rip p in g o f
fra ct u re fra g m e n t s a s w e ll a s ia t ro g e n ic d isru p t io n o f
t h e syn d e sm o t ic lig a m e n t s a s t h e y in se rt a n t e rio rly o n
t h e fib u la .
La t e ra l Pla t in g
■ Fo llo w in g e xp o su re o f t h e fra ct u re , t h e first st e p in vo lve s
cle a n in g t h e fra ct u re sit e (TECH FIG 2 A), fo llo w e d b y
fra ct u re re d u ct io n .
■ Usu a lly re d u ct io n is a ffo rd e d b y a sm a ll “ lio n ja w ” cla m p
o r p o in t e d re d u ct io n fo rce p s.
■ If re d u ct io n is d ifficu lt , m a n u a l t ra ct io n w it h p ro n a -
t io n a n d e xt e rn a l ro t a t io n w ill a ffo rd fra ct u re a lig n -
m e n t in su p in a t io n –e xt e rn a l ro t a t io n p a t t e rn s.
■ Ca re sh o u ld b e t a ke n t o a vo id p la cin g cla m p s o ve r
fra ct u re sp ike s t o p re ve n t in a d ve rt e n t co m m in u t io n
(TECH FIG 2 B).
TECHNIQUES
sio n a l Kirsch n e r w ire s m a y b e p la ce d a cro ss t h e fra ct u re
a n d t h e cla m p s re m o ve d (TECH FIG 2 C).
■ At t h is p o in t , if a la t e ra l p la t e is ch o se n , t h e la g scre w is
p la ce d in t h e a n t e rio r-t o -p o st e rio r d ire ct io n , p e rp e n d ic-
u la r t o t h e fra ct u re .
■ If a p o st e rio r p la t e (a n t ig lid e ) is ch o se n , t h e la g scre w
is p la ce d t h ro u g h t h e p la t e in a p o st e rio r-t o -a n t e rio r
d ire ct io n .
■ In e it h e r ca se , t h e n e a r co rt e x is o ve rd rille d w it h a
3.5-m m d rill b it , fo llo w e d b y d rillin g o f t h e fa r co rt e x
w it h a 2.5-m m d rill b it (TECH FIG 2 D).
■ The le ngth of t he screw is mea su re d and a se lf-ta pping
3.5-mm screw is place d acro ss t he fra ct ure in t he screw
tra ck.
■ Ne xt a o n e -t h ird t u b u la r p la t e is p la ce d d ire ct ly la t e ra l
o n t h e fib u la (n e u t ra liza t io n ).
■ Th e p ro xim a l scre w h o le s a re fille d w it h b ico rt ica l
3.5-m m scre w s a ft e r d rillin g w it h t h e 2.5-m m d rill b it
(TECH FIG 2 E).
■ Dista lly, unicortical ca ncello us scre ws a re p laced , with care
not to penetrate the distal tibia–fibula joint (TECH FIG 2 F).
■ Th e w o u n d is clo se d (TECH FIG 2 G).

A B C

D E F

TECH FIG 2 • A. Cle a n in g t h e fra ct u re sit e w it h a sm a ll cu re t t e . B An e xa m p le o f

cla m p p la ce m e n t a cro ss t h e fib u la r fra ct u re sit e . Ca re is t a ke n n o t t o co m m in u t e t h e
fra ct u re sp ike . C. La g scre w p la ce m e n t , o ve rd rille d w it h a 3.5-m m b it p ro xim a lly. D.
Th is is fo llo w e d b y d rillin g o f t h e fa r co rt e x w it h a 2.5-m m d rill. E. A n e u t ra liza t io n
p la t e is a p p lie d t o t h e la t era l su rfa ce o f t h e fib u la . F. Exa m p le o f d ist a l scre w p e n -
G e t ra t io n t o b e a vo id e d . G. Wo u n d clo su re .

ANTEROMEDIAL APPROACH TO THE MEDIAL MALLEOLUS

Exp o su re ■ An in cisio n is m a d e p a ra lle l t o t h e sa p h e n o u s ve in
t h a t is e it h e r co n ca ve a n t e rio r o r co n ca ve p o st e rio r t o
■ Th e m e d ia l m a lle o lu s is a p p ro a ch e d via a g e n t ly cu rve d
a llo w visu a liza t io n o f t h e a n t e ro m e d ia l jo in t .
a n t e ro m e d ia l in cisio n (TECH FIG 3 A).
 504 Se c t i o n VI FOOT AND ANKLE
TECHNIQUES
A
B TECH FIG 4 • A. Redu ctio n is achieved with a po inted reduction
TECH FIG 3 • A. Fo r a m e d ia l-sid e in ju ry, t h e skin in cisio n is
cu rve d a b o u t t h e m e d ia l m a lle o lu s. B. Fra ct u re sit e is e xp o se d
a n d cle a n e d o f h e m a t o m a a n d t h e t a la r d o m e is in sp e ct e d fo r
sig n s o f ch o n d ra l in ju ry.
■ Aft e r d isse ct io n o f t h e skin , t h e su b cu t a n e o u s t issu e s
sh o u ld b e ca re fu lly d isse ct e d t o p re ve n t in ju ry t o t h e
sa p h e n o u s ve in a n d n e rve .
■ With t h e d issect io n ca rried d o w n sh arp ly t o th e b o n e, t h e
p erio st eum is e le vat e d fo r 1 m m p ro xim a lly a n d d ista lly.
■ Th e fra ct u re sh o u ld b e b o o ke d o p e n t o a llo w visu a l in -
sp e ct io n o f t h e t a la r d o m e fo r ch o n d ra l in ju ry.
■ Th e jo in t a n d m e d ia l g u t t e r sh o u ld b e irrig a t e d t h ro u g h
t h e fra ct u re fo r a n y lo o se h e m a t o m a o r d e b ris t h a t m a y
im p e d e re d u ct io n (TECH FIG 3 B).
Op e ra t ive St a b iliza t io n
■ Fo llo w in g e xp o su re , t h e m e d ia l m a lle o la r fra g m e n t
(u su a lly o n e la rg e p ie ce ) ca n b e re d u ce d w it h t h e a id
o f a d e n t a l t o o l o r sm a ll p o in t e d re d u ct io n cla m p
(TECH FIG 4 A).
■ The fragm en t can be provisionally st abilize d w ith sma ll-
d iame te r Kirsch n er wires p lace d in pa ra lle l (TECH FIG 4B).
■ Aft e r ra d io g ra p h ic d o cu m e n t a t io n o f t h e re d u ctio n a n d
wire place me nt , cannula ted screw s of appropriat e lengt h
ma y be pla ce d o ve r th e wire s a fte r drillin g of t h e o u t
POSTEROLATERAL APPROACH TO THE TIBIA
■ Dire ct a cce ss t o t h e p o st e rio r m a lle o lu s fra ct u re (TECH
FIG 5 A) ca n b e o b t a in e d t h ro u g h t h e p o st e ro la t e ra l a p -
p ro a ch t o t h e fib u la (TECH FIG 5 B).
■ Th e in t e rva l b e t w e e n t h e Ach ille s a n d t h e p e ro n e a l
m u scle is d e ve lo p e d (TECH FIG 5 C).
A
clamp. B. Gu ide wire s for can nula ted scre ws are pla ce d a cro ss
the fracture.
co rtice s wit h a ca n n u la t e d d rill. Alt e rn a tive ly, n o n ca n n u -
la te d screw s ma y b e u sed in d ep e n d en t o f th e p ro visio n al
st a b iliza tio n.
■ Usu a lly, a 4.0-m m p a rt ia lly t h re a d e d ca n ce llo u s scre w
ca n b e p la ce d . If t h e fra g m e n t is sm a ll, h o w e ve r, 3.5- o r
3.0-m m ca n n u la t e d scre w s a re n o w a va ila b le .
■ Mo re re ce n t st u d ie s h a ve a d vo ca t e d fo r t h e u se o f
t w o b ico rt ica l 2.7-m m scre w s p la ce d in la g m o d e .
■ Tw o scre w s a re re co m m e n d e d fo r ro t a t io n a l co n t ro l. If
t h e fra g m e n t is t o o sm a ll, h o w e ve r, o n e scre w m a y su f-
fice o w in g t o t h e in h e re n t st a b ilit y o f t h e u n d u la t in g
fra ct u re lin e .
■ Co u n t e rsin kin g t h e scre w h e a d s m e d ia lly m a y h e lp t o
a lle via t e p a in fu l p ro m in e n t h a rd w a re .
■ Co m m in u t e d fra ct u re s t h a t a re n o t a m e n a b le t o scre w
fixa t io n m a y b e n e fit fro m a sm a ll b u t t re ss p la t e o r a “ su -
t u re t e n sio n b a n d ” t e ch n iq u e u sin g t h e d e lt o id lig a m e n t
fo r fixa t io n .
■ Th e su t u re o r w ire t e n sio n b a n d is a n ch o re d a b o u t a
m o re p ro xim a l scre w p la ce d p a ra lle l t o t h e a rt icu la r
su rfa ce .
■ Th e fle xo r h a llu cis lo n g u s is t a ke n o ff t h e fib u la d o w n
t o t h e in t e ro sse o u s m e m b ra n e , a n d t h e n t h e re st o f
t h e d e e p p o st e rio r co m p a rt m e n t is t a ke n o ff t h e p o s-
t e rio r t ib ia (TECH FIG 5 D).

B
C su it e d fo r fra ct u re s in vo lvin g la rg e p o rt io n s
A D
POSTERIOR MALLEOLUS FIXATION
■ If a n a d e q u a t e re d u ct io n ca n b e a ch ie ve d via clo se d ,
in d ire ct re d u ct io n , t h e fra ct u re ca n b e st a b ilize d w it h
ca n n u la t e d la g scre w s p la ce d in t h e a n t e rio r-t o -p o st e rio r
d ire ct io n .
■ If an o pen ap proach is used for red uctio n, screws placed
posterior to anterior may be placed across the fracture site.
Ch a p t e r 5 1 ORIF OF INDIRECT ANKLE FRACTURES 505
TECHNIQUES
TECH FIG 5 • Dire ct p o st e rio r p la t in g is w e ll
o f t h e p o st e rio r m a lle o lu s. A. Po st re d u ct io n
la t e ra l ra d io g ra p h sh o w in g a p o st e rio r
m a lle o lu s fra ct u re in vo lvin g m o re t h a n o n e
t h ird o f t h e a rt icu la r su rfa ce . B. Pa t ie n t in
p ro n e p o sit io n , in cisio n b e t w e e n Ach ille s
a n d p o st e rio r fib u la b o rd e r. C. Acce ss is
via t h e in t e rva l b e t w e e n t h e fle xo r h a llu cis
lo n g u s a n d t h e p e ro n e a l m u scle b e lly.
D. Po st e rio r m a lle o la r fra g m e n t fo llo w in g
fib u la r p la t in g .
■ If t h e fra ct u re fra g m e n t is o f su fficie n t size , a n a n t ig lid e
p la t e (o n e -t h ird t u b u la r) m a y b e p la ce d w it h u n d e rco n -
t o u rin g o f t h e p la t e t o p ro vid e a sa t isfa ct o ry b u t t re ss
e ffe ct (TECH FIG 6 ).
TECH FIG 6 • Po st o p e ra t ive AP a n d la t e ra l ra d i-
o g ra p h s d e m o n st ra t in g p o st e rio r p la t in g o f t h e
t ib ia t o b u t t re ss t h e p o st e rio r m a lle o la r fra ct u re
fra g m e n t .
 506 Se c t i o n VI FOOT AND ANKLE
TECHNIQUES

POSTERIOR PLATING OF THE FIBULA

■ In t h is ca se , t h e su rg ica l a p p ro a ch is sim ila r t o t h e la t e ra l
p la t in g t e ch n iq u e .
■ Wh e n a p p lica t io n o f a p o st e rio r o r a n t ig lid e p la t e is ch o -
se n , p la ce m e n t o f a la g scre w is o p t io n a l.
■ My p re fe rre d m e t h o d is t o a p p ly t h e p la t e a lo n g t h e fla t
p o st e rio r su rfa ce o f t h e b o n e , u sin g it a s a re d u ct io n a id
w it h a b o n e re d u ct io n cla m p (TECH FIG 7 A).
■ I p re fe r t o p la ce a p o st e rio r-t o -a n t e rio r–d ire ct e d la g
scre w t h ro u g h t h e p la t e .
■ Be ca u se o f t h e b io m e ch a n ica l p ro p e rt ie s o f t h is p la t e
co n st ru ct , t h is la g scre w is o p t io n a l.
■ Ne xt , a t le a st t w o o r t h re e b ico rt ica l scre w s a re p la ce d in
t h e p la t e . A b ico rt ica l scre w p la ce d p o st e rio r t o a n t e rio r
in t h e d ist a l scre w is o p t io n a l.
■ If a p o st e rio r p la t e is a p p lie d , t h e p ro xim a l scre w s a re
p la ce d b ico rt ica lly fro m p o st e rio r t o a n t e rio r, b o t h p ro x-
im a l a n d d ist a l t o t h e fra ct u re . Th is is a n a d va n t a g e in o s-
t e o p o ro t ic b o n e (TECH FIG 7 B).

TECH FIG 7 • An a lt e rn a t ive fo r p la t e p la ce -

m e n t is a lo n g t h e p o st e rio r b o rd e r o f t h e
fib u la . A. In t h is co n st ru ct t h e im p la n t is a n
a n t ig lid e p la t e . B. Th e la g scre w ca n b e p la ce d
fro m p o st e rio r t o a n t e rio r w it h b ico rt ica l p u r-
A B ch a se a ch ie ve d in e a ch scre w .

SYNDESMOSIS FIXATION
■ Aft e r st a b iliza t io n o f t h e m e d ia l a n d la t e ra l sid e s o f t h e ■ Th e scre w sh o u ld n o t b e p la ce d in la g m o d e .
a n kle , syn d e sm o t ic in t e g rit y sh o u ld b e a sse sse d . ■ If a la t e ra l p la t e is u se d , t h e scre w is p la ce d t h ro u g h
■ Th e Co t t o n t e st in vo lve s p ro vid in g a la t e ra l fo rce o n o n e o f t h e d ist a l h o le s.
t h e fib u la w it h a b o n e h o o k o r b o n e cla m p (TECH ■ If a p o st erio r p lat e is u sed , t h e syn d e sm o sis scre w w ill
FIG 8 A). likely b e p la ced o u tsid e t h e p lat e o n t h e lat eral co rt ex.
■ La t e ra l d isp la ce m e n t t h a t a llo w s m o re t h a n a fe w m il-
lim e t e rs o f t ib io fib u la r w id e n in g is co n sid e re d p a t h o -
lo g ic a n d a n in d ica t io n fo r syn d e sm o t ic fixa t io n .
■ Th e la t e ra l ra d io g ra p h sh o u ld b e scru t in ize d t o a s-
se ss t h e re la t io n sh ip o f t h e fib u la t o t h e a rt icu la r
su rfa ce o f t h e a n kle jo in t . In g e n e ra l, o n a t ru e la t -
e ra l vie w o f t h e a n kle , t h e t ip o f t h e fib u la sh o u ld b e
a n t e rio r t o t h e p o st e rio r b o rd e r o f t h e d ia p h yse a l
t ib ia , b u t co m p a riso n s t o t h e co n t ra la t e ra l a n kle ca n
A
b e a sse sse d .
■ With a b o lst er b eh in d t h e a n kle, a la rg e te n ta cu lu m clam p
is p lace d a cro ss th e tib io fib u lar jo in t , w it h o n e tin e o n t h e
d ist al t ibia a n d t h e o t h er o n t h e fib u la (TECH FIG 8B).
■ Re d u ct io n is co n firm e d o n t h e AP, m o rt ise , a n d la t e ra l
ra d io g ra p h ic vie w s.
■ Wh ile d o rsifle xio n o f t h e t a lu s h a s b e e n re co m m e n d e d in
t h e p a st t o p re ve n t o ve rt ig h t e n in g o f t h e syn d e sm o sis,
m o re re ce n t st u d ie s h a ve sh o w n t h a t it is virt u a lly im p o s-
sib le t o o ve rt ig h t e n a n a n a t o m ica lly re d u ce d m o rt ise .
■ Fixat io n ch o ices ran g e fro m o n e o r t w o scre ws, wit h t h re e B
o r four cortices d rilled a nd 3.5-m m o r 4.5-m m scre w d ia m -
TECH FIG 8 • A. Th e Co t t o n t e st is p e rfo rm e d fo llo w in g fib u -
ete rs used. Alt hough t he size and nu mbe r o f screw s re- la r fixa t io n b y p u llin g la t e ra lly w it h a h o o k o r cla m p t o a sse ss
ma in con trove rsia l, som e p a ra me te rs a re ag ree d o n. t h e in t e g rit y o f t h e syn d e sm o sis. B. Re d u ct io n a n d st a b iliza -
■ Th e scre w sh o u ld b e p la ce d 1.5 t o 2 cm p ro xim a l a n d t io n o f t h e syn d e sm o sis is a ch ie ve d w it h a cla m p p la ce d a cro ss
p a ra lle l t o t h e jo in t . t h e d ist a l t ib io fib u la r jo in t a n d a b u m p p la ce d u n d e r t h e le g .
 Ch a p t e r 5 1 ORIF OF INDIRECT ANKLE FRACTURES 507

PEARLS AND PITFALLS

Da m a g e o r e n t ra p m e n t o f
su p e rficia l p e ro n e a l n e rve
Fa ilu re t o o b t a in fib u la r le n g t h
Pre se n ce o f o st e o p o ro t ic b o n e
In t ra -a rt icu la r h a rd w a re
p e n e t ra t io n
Ma lre d u ct io n o f t h e
syn d e sm o sis
Pe ro n e a l t e n d in it is a n d
p a in fu l h a rd w a re
■ Ca re m u st b e t a ke n t o e xp o se a n d m o b ilize t h e n e rve p ro xim a lly if in t h e su rg ica l fie ld (FIG
4 A ). Th is w ill h e lp m in im ize t h e ch a n ce o f d a m a g e d u rin g su rg e ry a n d clo su re .
■ Th is w ill le a d t o p e rsist e n t m e d ia l w id e n in g .
■ A p la t e is u se d t o p u sh t h e d ist a l fra g m e n t w it h a la m in a r sp re a d e r. Th e d ist a l t ib io fib u la r
a n a t o m ic re la t io n sh ip is a sse sse d a n d t h e co n t ra la t e ra l a n kle is u se d fo r co m p a riso n .
■ Su p p le m e n t a ry Kirsch n e r w ire s
■ Mu lt ip le syn d e sm o sis scre w s
■ Po st e rio r-p la ce d fib u la p la t e
■ Lo cke d p la t e
■ Ca re fu l in t ra o p e ra t ive ra d io g ra p h ic a sse ssm e n t is im p o rt a n t .
■ Dist a l scre w s in t h e la t e ra l fib u la r p la t e m u st b e u n ico rt ica l.
■ AP ra d io g ra p h is b e st t o e va lu a t e m e d ia l m a lle o lu s fixa t io n .
■ Bo lst e r is p la ce d u n d e r a n kle , n o t fo o t . Th is w ill ca u se a n t e rio r d isp la ce m e n t (FIG 4 B).
■ A g o o d la t e ra l ra d io g ra p h is o b t a in e d t o a sse ss re d u ct io n .
■ It is im p o ssib le t o o ve rt ig h t e n a n a n a t o m ica lly re d u ce d syn d e sm o sis.
■ La t e ra lly p la ce d fib u la r h a rd w a re is a sso cia t e d w it h a h ig h e r in cid e n ce o f p a in fu l h a rd w a re .
■ Po st e rio rly p la ce d fib u la r fixa t io n is a sso cia t e d w it h a h ig h e r in cid e n ce o f p e ro n e a l
t e n d in it is.

A B

FIG 4 • A. Id e n t ifica t io n a n d p ro t e ct io n o f t h e su p e rficia l p e ro n e a l n e rve

w it h in t h e a n t e rio r fla p . B. CT sca n sh o w in g m a lre d u ct io n o f t h e
syn d e sm o sis.

POSTOPERATIVE CARE OUTCOMES

■ All ankles should be splinted in the neutral position and
elevated for at least 24 hours postoperatively.
■ We remove the splint at 10 to 14 days and remove the sutures.
■ Patients are then placed into a removable functional brace
that allows them to begin early active-assisted and passive
range of ankle motion.
■ O ne year after ankle fracture surgery, patients generally
do well, with most experiencing little or mild pain and few
restrictions in functional activities. They have significant
improvement in function compared with 6 months after
surgery.
■ Younger age, male sex, absence of diabetes, and a lower

■ Patients are also allowed to begin isometric strengthening American Society of Anesthesia class are predictive of
exercises. functional recovery at 1 year following ankle fracture
■ All patients are kept non-weight bearing for at least 6 weeks. surgery.
■ At 6 weeks patients are progressed to weight bearing as tol- ■ It is important to counsel patients and their families on

erated based on radiographic criteria. the expected outcome after injury with regard to functional
■ Weight bearing can be delayed for slow healing and recovery.
presence of a syndesmotic screw. In general we do not alter ■ Looking specifically at elderly patients (older than 60

the weight-bearing status because of syndesmotic injury or years), functional outcomes steadily improved over 1 year
routinely remove the syndesmosis screw, but we advise pa- of follow-up, albeit at a slower rate than in the younger
tients of the possibility of screw breakage following weight patients.
bearing. ■ O ur results suggest that operative fixation of unstable

■ Patients are restricted from operating an automobile for ankle fractures in the elderly can provide a reasonable func-
9 weeks following right-sided ankle fracture. tional result at the 1-year follow-up.
 508 Se c t i o n VI FOOT AND ANKLE
A B
COMPLICATION S
■ M inor complications include epidermolysis (FIG 5 A), su-
perficial infection, and peroneal tendinitis with painful
hardware.
■ M ajor problems include nonunion (FIG 5 B), hardware fail-
ure, deep infection, and compartment syndrome.
REFEREN CES
1. Egol KA, Amirtharajah M , et al. Ankle stress test for predicting the
need for surgical fixation of isolated fibular fractures. J Bone Joint
Surg Am 2004;86A:2393–2398.
2. Egol KA, Dolan R, et al. Functional outcome of surgery for fractures
of the ankle: a prospective, randomised comparison of management in
a cast or a functional brace. J Bone Joint Surg Br 2000;82B:246–249.
3. Egol KA, Sheikhazadeh A, et al. Lower-extremity function for driving
an automobile after operative treatment of ankle fracture. J Bone
Joint Surg Am 2003;85A:1185–1189.
4. Egol KA, Tejwani N C, et al. Predictors of short-term functional out-
come following ankle fracture surgery. J Bone Joint Surg Am 2006;
88A:974–979.
FIG 5 • A. Skin n ecro sis an d slo u g h fo llo win g su rg ical
int erve nt io n. B. CT sca n d e mo n st ra tin g fib u la r
n o nu n io n a t 6 m o nt h s fo llo win g o p e n re d u ction a nd
int ernal fixa tion of a pron at io n–ab duct ion injury.
5. Lauge-H ansen N . Fractures of the ankle. II. Combined experimental-
surgical and experimental-roentgenologic investigations. Arch Surg
1950;60:957–985.
6. M cConnell T, Creevy W, et al. Stress examination of supination ex-
ternal rotation-type fibular fractures. J Bone Joint Surg Am 2004;
86A:2171–2178.
7. M ichelson JD. Fractures about the ankle. J Bone Joint Surg Am
1995;77A:142–152.
8. Pankovich AM , Shivaram M S. Anatomical basis of variability in in-
juries of the medial malleolus and the deltoid ligament. II. Clinical
studies. Acta O rthop Scand 1979;50:225–236.
9. Park SS, Kubiak EN , et al. Stress radiographs after ankle fracture: the
effect of ankle position and deltoid ligament status on medial clear
space measurements. J O rthop Trauma 2006;20:11–18.
10. Pettrone FA, Gail M , et al. Q uantitative criteria for prediction of the
results after displaced fracture of the ankle. J Bone Joint Surg Am
1983;65A:667–677.
11. Phillips WA, Schwartz H S, et al. A prospective, randomized study of
the management of severe ankle fractures. J Bone Joint Surg Am
1985;67A:67–78.
12. Tornetta P III. Competence of the deltoid ligament in bimalleolar
ankle fractures after medial malleolar fixation. J Bone Joint Surg Am
2000;82A:843–848.
 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 52 Fix a t io n o f Ta lu s Fr a ct u re s
David E. Karg e s
DEFIN ITION
■ Fractures of the talus are severe injuries affecting ankle and
hindfoot joint function.
■ Displaced fractures of the talus are a surgical challenge to or-
thopedic surgeons. The injuries are infrequent and the fracture
anatomy is partially concealed by adjacent osseous structures.
■ O pen reduction and internal fixation is generally manda-
tory to restore talar anatomy precisely.
■ O utcomes of talus fractures correlate with injury severity.
These results include ankle and subtalar joint stiffness, post-
traumatic arthrosis, and osteonecrosis of the talus.
AN ATOMY
■ Two anatomic factors play significant roles in the outcome
of talus fractures.
■ Sixty percent of the bone is covered by articular cartilage,
significantly limiting extraosseous perfusion to the bone.
■ Disruption of circulation to the talus correlates with open
or comminuted talus fractures, leading to an increased risk of
avascular necrosis. The blood supply to the talar body enters
through the inferior talar neck via the artery of the tarsal
canal. This key vessel originates from the posterior tibial
artery. Secondary blood supply to the body is derived from
the deltoid branch of the posterior tibial artery, entering the
talar body along its medial surface. Circulation to the neck,
head, and lateral body is supplied via the dorsalis pedis, tarsal
sinus, and lateral tarsal sinus arteries. This last artery is an
anastomosis between the peroneal and dorsalis pedis arteries.
■ The talus has seven articulations.
■ Three main surfaces articulate with the plafond and lateral
malleolus, while three surfaces articulate with the calcaneus.
■ The final articulation of the talar head with the tarsal
navicular represents an important articulation for midfoot
motion.
■ Predictable stiffness with range of motion and posttraumatic
arthritic changes is experienced with severe fractures of the
talus.
PATHOGEN ESIS
■ Fractures of the talus present in varying patterns depending
on the mechanism of injury.
■ Fractures of the talar head are intra-articular and the result
of axial load to the talonavicular joint with the foot positioned
in plantarflexion.
■ These fractures constitute up to 10% of all fractures of
the talus.
■ They are uncommon but must be looked for in the event
of an isolated subtalar dislocation.
■ Talar neck fractures occur in the frontal plane and result
from dorsiflexion of the foot against the anterior lip of the dis-
tal tibia. The fracture begins transversely along the medial talar
neck due to an associated supination force to the hindfoot.
The fracture line extends laterally. The fracture may be extra-
articular, intra-articular, or a combination of both. With in-
creased energy, the hindfoot supination force generates a
fracture of the medial malleolus of the ankle.
■ After completion of the neck fracture, continued hyper-
dorsiflexion and axial load to the body of the talus may
force dislocation of the talar body posteriorly, disrupting
significant extraosseous circulation.
■ Fractures of the body of the talus involve up to 23% of talus
fractures. The mechanism of injury is the same for body frac-
tures as for fractures of the talar neck.
■ Fracture patterns of the body of the talus include coronal,
sagittal, horizontal shear, and crush fractures of the weight-
bearing surface.
■ Process fractures of the talar body are described by
anatomic location.
■ Lateral and posterior process fractures are sustained by
inversion and eversion mechanisms of the ankle, respec-
tively. These fractures are often missed on plain film radi-
ographs of the ankle and diagnosed as ankle sprains.
■ H awkins classified lateral process fractures into avul-
sion, isolated, and comminuted types.
■ Posteromedial and posterolateral process fractures lie to
each side of the flexor hallucis longus tendon. These are
commonly intra-articular fractures of the inferior surface of
the posterior talus.
N ATURAL HISTORY
■ The postoperative prognosis for any displaced talus fracture
should be guarded because of significant postinjury potential
for complication.
■ Fractures of the head of the talus are commonly nondis-
placed because of powerful capsular and talonavicular liga-
mentous attachments.
■ Displaced fractures of the talar head have a 10% inci-
dence of osteonecrosis and can lead to secondary posttrau-
matic arthrosis.
■ Fractures of the neck of the talus are defined as fractures an-
terior to the lateral process of the talus. H awkins’ work on
vertical fractures of the neck of the talus helped clarify injury
of vascular perfusion to the bone by delineating three types of
fractures of the neck of the talus.
■ The type I fracture is nondisplaced. Disruption of blood
flow is limited to the anterolateral region of the bone. I rec-
ommend a computed tomography (CT) scan to confirm no
displacement of the fracture before diagnosing a type I frac-
ture. H istorically, H awkins reported a 13% incidence of os-
teonecrosis in type I injuries (FIG 1 A).
■ In the type II talar neck fracture there is displacement of the
talar dome fragment, which is routinely posterior, often de-
picting clear subluxation of the talar body. Blood flow to the
medial body and head is preserved. The type II talar neck frac-
ture has a 20% to 50% risk of avascular necrosis (FIG 1 B).
509
510 Se c t i o n VI FOOT AND ANKLE
A B
FIG 1 • Ha w kin s cla ssifica t io n o f t a la r fra ct u re s. A. Typ e I: d isru p t io n o f
a n t e ro la t e ra l p e rfu sio n . B. Typ e II: m e d ia l p e rfu sio n in t a ct . C. Typ e III: a ll
D so u rce s o f b lo o d flo w in ju re d . D. Typ e IV: d islo ca t io n o f a ll a rt icu la t io n s.
■In the type III injury, the transverse fracture of the talar
neck is associated with dislocation of the talar body. The
incidence of osteonecrosis of the talar body is 50% to
100% . All major perfusion to the body of the talus is dam-
aged (FIG 1 C).
■ A type IV injury of the talar neck has been documented; it
is a type III fracture-dislocation with associated talonavicular
dislocation.2 All extraosseous blood flow to the talus is con-
sidered disrupted. The value of the Hawkins classification is
that it allows the orthopedic surgeon to predict what to expect
with a specific talar neck injury. O pen reduction and rigid in-
ternal fixation is the recommended treatment (FIG 1 D).
■ Talar body fractures are defined as fractures extending into
or posterior to the lateral process.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ Fractures of the talus are commonly associated with vehicu-
lar trauma and falls.
■ The relationship of severe lower extremity trauma and
airbags is well known. After airbag deployment, the torso
and lower extremities are directed toward the floor panel of
the car.
■ I believe that the incidence of high-energy hindfoot trauma
will increase over time. Globally, transport related injuries
remain the leading cause of disability from injury. By 2020,
traffic injuries will increase from a current 9th position to
3rd disability-adjusted life years lost.
■ The history and the clinical status of the talar injury must be
carefully recorded because the injury severity is likely to corre-
late with the long-term patient outcome.
■ O n the initial examination the physician should note pain,
motion, crepitus, deformity, soft tissue swelling, open frac-
tures, and associated fractures of adjacent bones to the foot
and ankle and should perform a complete neurovascular
evaluation of the extremity.
C
■ Detailed documentation of the talus fracture pattern and
local soft tissue injury is paramount.
■ Soft tissue local pressure phenomenon, commonly found
anterolaterally in closed type III fractures of the talar neck,
may precipitate full-thickness pressure necrosis of the skin if
not decompressed early.
■ Severe swelling of the ankle is common in the acute frac-
ture of the talus and may progress to fracture blister forma-
tion, precluding safe execution of operative incisions.
■ The physician should examine the skin for swelling, ecchy-
mosis, fracture blisters, and deformity; these are signs of a
closed fracture.
■ A closed injury with mild or moderate swelling (bony
landmarks palpable) indicates talar neck type I and II frac-
tures and process fractures.
■ A closed injury with severe swelling indicates talar neck
type III and IV fractures and body fractures.
■ O pen fractures will be apparent by the transverse, medial,
or supramalleolar traumatic laceration of the ankle. Lateral,
posterior, and plantar wounds are uncommon.
■ The physician should perform vascular, neurosensory, and
myotendinous examinations of the foot and ankle.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Three plain radiographic views are necessary to radiographi-
cally evaluate talus fractures: anteroposterior (AP), mortise (15-
degree internal rotation view), and lateral images of the ankle.
■ The AP and mortise views of the ankle demonstrate align-
ment of the talar body in the ankle mortise. The lateral view
depicts the sagittal outline of the talus.
■ The Canale view is used to assess varus or valgus malalign-
ment of the talar neck, particularly with H awkins type I and
II injuries. The knee must be flexed and the foot in equinus
and everted, with the x-ray tube directed 15 degrees caudad
(FIG 2 A).

A B
FIG 2 • Ra d io lo g y o f t a la r fra ct u re s. A. Ca n a le vie w sh o w in g m e d ia l a n d la t e ra l t a la r n e ck p ro visio n a lly re d u ce d .
B. La t e ra l p ro ce ss fra ct u re le ss o b vio u s o n p la in film . C. La t e ra l p ro ce ss fra ct u re a s sh o w n o n CT sca n .
■ Because of the high-energy nature of fractures of the talus,
AP and oblique views of the foot should be a standard addition
to the three-view plain film ankle protocol so as not to miss as-
sociated midfoot and forefoot injuries (FIG 2 B).
■ Computed tomography (CT) provides important additional
information to the three-view plain film series of the ankle.
Thirty-degree coronal and paraxial CT imaging is important
to confirm H awkins type I fractures of the talar neck and plan
treatment of talar body fractures with extension posterior to
the lateral process. Reconstructions of both sagittal and coro-
nal CT studies provide valuable information about incremen-
tal pathoanatomy of the entire talus, medial to lateral and
anterior to posterior, respectively. In addition, confirmation of
a process fracture that is not clearly viewed by plain film is eas-
ily diagnosed by CT (FIG 2 C).
DIFFEREN TIAL DIAGN OSIS
■ Process fracture of the talus
■ Lateral process fracture
■ M edial process fracture
■ H ead of talus fracture
■ N eck of talus fracture
■ Body of talus fracture
■ N eck and body of talus fracture
■ Fracture-dislocation of talus
■ Involving body
■ Involving neck and body
■ Extruded talus
(Any of these injuries to the talus may be open fractures, af-
fecting management.)
N ON OPERATIVE MAN AGEMEN T
■ Fractures of the talus include a spectrum of injury patterns
ranging from isolated regions of the talus (eg, lateral process)
to severely comminuted talus fractures involving all parts of
bone, making nonoperative management inappropriate.
■ H igh-energy injury mechanisms that cause talus frac-
tures precipitate fracture displacement and joint surface
incongruity.
Ch a p t e r 5 2 ORIF OF TALUS FRACTURES 511
C
■ M edial and lateral process fractures, minimally displaced
(less than 2 mm) and involving less than 1 cm of bone, are
commonly managed nonoperatively.
■ These injuries are treated acutely in well-padded, com-
pressive dressings with posterior splints and non-weight
bearing. Swelling and immediate pain in the ankle improve
significantly by 7 to 10 days. The patient is subsequently
converted to a short-leg non-weight-bearing cast for 6
weeks, followed by progressive range of ankle and subta-
lar motion and return to weight bearing in a removable
fracture-boot.
■ If the process fracture is severely comminuted, precluding
surgical reconstruction, the same initial and definitive non-
operative management is employed.
■ Isolated fractures of the head of the talus without disloca-
tion and without displacement are largely stable fractures.
These injuries require plain radiographic evaluation of both
the ipsilateral foot and ankle to confirm the isolated nature of
the injury. I recommend CT scanning (axial and transverse
views of foot and ankle) of this injury to rule out associated
midfoot pathology.
■ Acutely, an isolated, nondisplaced talar head fracture is
splinted for 7 to 10 days with subsequent short-leg casting in
neutral plantarflexion with non-weight bearing for 4 weeks.
Intermittent daily ankle and subtalar motion with Achilles
tendon stretching should follow with application of a remov-
able fracture boot. The patient remains non-weight bearing
until 6 to 8 weeks after injury. N ext, progressive weight bear-
ing, range of motion, stretching, and strengthening of the en-
tire lower extremity are recommended.
■ The H awkins type I fracture of the neck of the talus is a
nondisplaced talar neck fracture. The talus remains anatomi-
cally positioned in the ankle and subtalar joint with minimal
potential for disruption of perfusion to the bone.
■ A subgroup of these injuries may present with displace-
ment of the talar neck on initial injury plain radiographs.
After closed manipulation of the fracture in plantarflexion,
the talar neck fracture may reduce. A true H awkins type I
talar neck fracture will not displace even with gentle dorsi-
flexion. The type I fracture strongly warrants a CT scan,
512 Se c t i o n VI FOOT AND ANKLE
with sagittal reconstruction, to confirm anatomic alignment
of the talar neck.
■ If there is displacement of the neck fracture, the injury
must be reclassified as a type II, which requires surgical
treatment to obtain, and maintain, the reduction.
■ Truly nondisplaced fractures of neck of the talus can be
treated nonoperatively in a short-leg non-weight-bearing cast
for 6 to 8 weeks. Close follow-up is recommended to watch
for any displacement of the neck fracture. At 6 to 8 weeks
after the injury, progressive weight bearing, range of motion,
stretching, and strengthening are initiated.
■ Injury forces precipitating fractures of the dome of the talus
are universally severe, causing articular displacement, and are
an indication for surgery. O pen fractures of the talus, even
with no displacement, are best managed with rigid surgical
stabilization to allow for wound care and early motion.
SURGICAL MAN AGEMEN T
■ The timing of operative management of talus fractures has
been an area of controversy, specifically whether the displaced
talus fracture is an orthopedic emergency.
■ O ne recent study indicates that orthopedic trauma sur-
geons do not believe a displaced fracture of the neck of the
talus is an orthopedic emergency.
■ H owever, it is important to differentiate the potential of
vascular injury to the talar body from soft tissue and neu-
rovascular compromise of the foot because of injury to the
talus. In particular, fracture-dislocation of the body of the
talus is associated with compromised blood flow to the bone,
the threat of pressure phenomenon to the skin, and possible
tibial nerve dysfunction.
■ The acute severity of soft tissue swelling or the impact
of an open hindfoot wound may preclude safe, immediate
reconstruction of the talus fracture after reduction of the
dislocation.
■ Foot and ankle external fixation is a suitable treatment op-
tion, with staged definitive fixation applied accordingly.
■ Any open talus fracture must be treated as an orthopedic
emergency.
■ Preoperative antibiotics may be selected on the basis of
wound contamination. These include a cephalosporin and
possibly gentamicin. Penicillin is added if gross or farm con-
tamination is present. All patients should receive a tetanus
toxoid booster.
■ The patient is taken to the operating room and after soft
tissue débridement the wound receives at least 3 to 9 L of
normal saline using pulsed lavage.
■ At this time, in addition to partial or complete fixation of
the talus fracture, provisional foot and ankle external fixa-
tion may be used to provide soft tissue and osseous stabiliza-
tion before delayed closure.
■ Regarding general guidelines for fractures of the body, neck,
and head of talus fractures, surgical management is indicated
with fracture displacement, malalignment, subluxation, dislo-
cation, or instability.
■ Recent studies indicate that displacement or malalign-
ment will have a negative impact on foot function. Two
millimeters of fracture displacement has been shown to af-
fect subtalar joint mechanics.
■ There is less agreement regarding surgical indications for
process fractures of the talus. Acute, displaced fractures with
large fragments showing extension into the subtalar joint by
CT imaging are best treated with open reduction and internal
fixation.
■ A displaced fracture of the neck of the talus is one of the
most common indications for surgery on the talus. The frac-
ture is known to start, in the coronal plane, along the medial
neck and extend laterally until completion.
■ There are two common types of neck fractures: an extra-
articular pattern and an intra-articular type that extends into
the subtalar joint.
■ The displaced extra-articular vertical neck fracture is
routinely amenable to closed reduction by applying dor-
sal-to-plantar pressure on the head of the talus asso-
ciated with longitudinal traction and plantarflexion of
the forefoot. Immediate reduction of this fracture dimin-
ishes concerns for soft tissue, neurovascular, and osseous
compromise.
■ The intra-articular pattern is less likely to cooperate with
closed manipulation owing to the obliquity of the fracture
as it extends posterior into the subtalar joint. This fracture
pattern is more deserving of immediate or early surgery.
■ For patients with severe open fractures of the talus, or
closed injuries in which soft tissue compromise precludes im-
mediate open management, temporizing external fixation may
be effective.
■ The goals of temporary external fixation are to maintain
the length of the talus for reconstruction, facilitate soft tis-
sue management, and restore general alignment. External
fixation is rarely definitive management for talus fractures.
■ Displaced, open or closed, fractures benefit most from
rigid internal fixation for bone healing and early motion.
H owever, a recent report evaluating results of the extruded
talus identified definitive external fixation as an option to
manage the purely dislocated talus. This is an excellent
treatment option to stabilize the ankle and subtalar and
talonavicular articulations of the talus.
Preoperative Planning
■ O perative planning for talus fractures requires evaluation of
imaging studies to clearly understand the relationships of all
major fracture fragments.
■ A preoperative CT scan of the fracture is standard when
confronted with a comminuted talar neck or body fracture.
The surgeon must become familiar with the morphology of
the bone and its many contours to facilitate reconstruction.
■ Intraoperative visibility and access to talar fragments are rou-
tinely challenging, but these variables can be largely facilitated
by correct patient positioning, surgical approaches, adequate
operating room lighting (headlamp), attention to reduction
techniques, and implants selected. All play a key role in preop-
erative planning.
■ The principles of open treatment are restoring articular con-
gruity, maximizing the revascularization potential of the bone,
and allowing early motion of the ankle and subtalar joints.
■ The use of a radiolucent table and a headlamp promotes
optimal visualization.
■ A tray of fine-tipped, sharp and strong bone elevators, dental
probes, Freer elevators, small bone clamps, mini/small lamina
spreaders, and small distractors or external fixation equipment
is routinely needed not only for talus fracture fixation but also
all fine articular fracture reconstructions.

■ Small interfragmentary (3.5 mm) cortical screw fixation and
mini-fragment (2.7 or 2.0 mm) screw/plate instrumentation is
commonly needed for talus fracture fixation.
■ An extra-long mini-screw (2.7 or 2.0 mm) inventory is
recommended, with screws up to 60 mm long.
■ The use of mini-implants is particularly helpful when recon-
structing comminuted fractures.
■ Contemporary mini-fragment systems are predominantly
stainless steel.
■ Some authors have suggested using titanium implants
to allow use of magnetic resonance imaging to assess
osteonecrosis.
■ O steochondral fragments too small for mini-fragment fix-
ation can be fixed with bioabsorbable pegs or headless artic-
ular screws.
Positioning
■ Displaced fractures of the head, neck, body, and lateral
process of the talus are best reconstructed with the patient in
the supine position.
■ Supine positioning allows medial, anterolateral, and di-
rect lateral incisions to be performed with ease (FIG 3 A,B).
■ Intraoperative fluoroscopy is conveniently performed with
the patient in this universal position.
■ The patient should have an adequate bump placed preop-
eratively under the ipsilateral gluteal region to avoid exter-
nal rotation of the ankle.
■ Fractures of the posterior body of the talus are performed
through posteromedial or posterolateral surgical approaches.
These approaches are achieved most efficiently with the pa-
tient in the prone position (FIG 3 C).
A C
Ch a p t e r 5 2 ORIF OF TALUS FRACTURES 513
■ The prone or lateral recumbent position is effective for
occasional posterior-to-anterior fixation associated with
minimal or no displacement of the fracture.
■ A radiolucent table without attachments at the foot al-
lows for all required radiographic views.
Approach
Medial and Anterolateral Approach
■ Anatomic reduction of displaced head, neck, and body frac-
tures requires visualization of both medial and lateral surfaces
of the talus. A medial and anterolateral (two-incision) ap-
proach effectively prevents a malreduction of the articular sur-
faces and neck.
■ A surgeon’s initial impression of the dual-incision approach
to talus fractures may be perceived to disregard the biology of
the bone and its limited extraosseous blood supply. With at-
tention to detail, neither the plantar nor the direct dorsal
blood supply to the talus is violated.
■ Landmarks for the medial incision are the dorsomedial tip
of the medial malleolus extended, in line with the axis of the
foot to the tarsal navicular (FIG 4 A).
■ This incision is 5 mm dorsal to the axis of the posterior
tibial tendon.
■ Its extension continues just distal to the navicular tuberos-
ity, allowing exposure of the medial surface of the talar
head, neck, and distal body.
■ The approach may be lengthened in both directions to im-
prove visibility.
■ The anterolateral incision is parallel and 5 to 6 cm lateral to
the medial approach (FIG 4 B).
FIG 3 • A. Su p in e p o sit io n fo r m e d ia l a n d a n t e ro la t e ra l
a p p ro a ch e s. B. Su p in e p o sit io n fo r d ire ct la t e ra l
a p p ro a ch . C. Pro n e p o sit io n fo r p o st e rio r a p p ro a ch .
514 Se c t i o n VI FOOT AND ANKLE
Medial talar
Anterior tibial
neck fracture
tendon sheath
Posterior tibial
A tendon sheath
FIG 4 • A. Me d ia l a p p ro a ch . B. An t e ro la t e ra l a p p ro a ch .
■This incision should begin just medial or in line with the
syndesmosis of the ankle.
■ The lateral neck of the talus is difficult to access and recon-
struct if the incision is made too lateral.
■ If comminution of the lateral process is to be addressed,
the incision can be shifted slightly lateral.
■ After completing the skin incision, the surgeon must beware
of the lateral branch of the superficial peroneal nerve when in-
cising deep to the subcutaneous tissues.
■ The lateral retinaculum must be sharply incised, and the ex-
tensor digitorum tendons are retracted medially, exposing the
extensor digitorum brevis muscle.
■ The muscle belly is reflected distally off its proximal origin,
allowing easy access to the lateral capsule of the talus.
■ The lateral capsulotomy is made in line with the axis of the
neck of the talus.
■ Anatomic reduction of complex talus fractures is achieved
by working from side to side through both incisions.
Transmalleolar Approach
■ An important modification of the medial approach to the
talus is the medial malleolar osteotomy. In displaced body or
complex talar neck fractures, the procedure may be greatly
facilitated by this increased exposure.
■ I prefer to continue the medial incision longitudinally, di-
rectly in line with the axis of the medial malleolus, extending
just proximal to the supramalleolar region (FIG 5 A).
■ After exposing the malleolus, without violating the perios-
teum, the distal tip of the anterior and posterior colliculus of
the medial malleolus must be predrilled (FIG 5 B) and tapped
retrograde for two parallel, 3.5-mm interfragmentary cortical
or 4.0-mm partially threaded cancellous screws.
■ An oblique osteotomy directed toward the shoulder of the me-
dial ankle mortise is performed using a very thin oscillating saw
blade.
■ This osteotomy is incomplete, advancing only to the level
of the medial subchondral bone.
■ The osteotomy is completed by gentle levering of a thin
wide osteotome on the inner cortex (FIG 5 C).
Lateral head Extensor digitorum
of talus tendon
Lateral talar Sinus tarsi
B neck fracture
■ At this time, an anterior and partial posterior capsulotomy
of the medial malleolus is needed to allow inferior mobiliza-
tion of the malleolus. The deltoid vessels perfusing the medial
body of the talus are protected with gentle retraction.
■ Patients requiring this transmalleolar approach will rou-
tinely benefit from the associated anterolateral incision for op-
timal visualization of the proximal neck and body of the talus
during reconstruction.
Posterior Approach
■ An isolated posterior body fracture of the talus or dis-
placed H awkins type III fracture may require a posterome-
dial or posterolateral approach for fracture reduction and
management.
■ The incision is longitudinal, beginning at the midpoint of
the calcaneus and extending a fingerbreadth medial or lateral
to the Achilles tendon for approximately 6 to 8 cm (FIG 6 ).
■ When making the incision through the deep posterior com-
partment fascia, the surgeon must take care to identify and
gently retract the medial neurovascular structures.
■ The posterior tibial nerve and artery may be tethered over
a posteriorly dislocated talar body fragment in a H awkins
type III fracture-dislocation, warranting extreme caution
during the approach.
■ After safely retracting the nerve and artery, the flexor hallu-
cis longus (FH L) tendon represents a landmark directly poste-
rior to the body of the talus.
■ The FH L tendon is then retracted laterally to begin the
reconstruction.
Lateral Approach
■ Lateral process fractures of the talus are easily accessed
using a direct lateral approach.
■ A longitudinal 6- to 8-cm direct lateral incision is started 3 cm
proximal to the distal tip of the lateral malleolus of the fibula,
extending anteriorly in a curvilinear incision, in line with the
axis of the foot.
■ The lateral retinaculum and subtalar capsule are incised lon-
gitudinally, exposing the lateral process fracture (FIG 7 ).
 Ch a p t e r 5 2 ORIF OF TALUS FRACTURES 515

90°

C
Medial malleolus Comminuted Plafond of
A reflected plantarly dome of talus distal talus
FIG 5 • A. Tra n st e ct a l m e d ia l m a lle o la r o st e o t o m y. B. Pre d rillin g o f m e d ia l m a lle o lu s. C. Ma lle o la r o st e o t o m y co m p le t e .

FIG 6 • A. Poste rom ed ia l incision. B. Flexo r

h allu cis lo n g u s co n cealin g p o st erio r t alu s.
C. Hem art h ro sis o f p o st erio r cap su le.

Posterior tibial
nerve

B C
Flexor hallus Posterior capsule
longus tendon of ankle
 516 Se c t i o n VI FOOT AND ANKLE
Lateral
subtalar
joint
FIG 7 • Fre e r e le va t o r is u se d t o re d u ce t h e la t e ra l p ro ce ss o f
t h e t a lu s fra g m e n t .
TECHNIQUES
OPEN REDUCTION AND INTERNAL FIXATION OF THE NECK OF THE TALUS
Re d u ct io n
■ Aft e r co m p le t io n o f t h e m e d ia l a p p ro a ch , lim it e d sh a rp
d isse ct io n is p e rfo rm e d o n ly a lo n g t h e m e d ia l n e ck a n d
h e a d t o re m o ve e xt ra o sse o u s so ft t issu e a t t a ch m e n t s a n d
e xp o se t h e t a la r b o d y, n e ck, a n d h e a d a n d t h e t a lo n a vic-
u la r jo in t .
■ Th e m e d ia l fra ct u re lin e is co m m o n ly fo u n d t o h a ve co m -
m in u t io n t h a t a ffe ct s u n d e rst a n d in g o f t h e t ru e le n g t h
a n d a lig n m e n t o f t h e m e d ia l co lu m n o f t h e b o n e .
■ In se rt in g a m in i-la m in a sp re a d e r t o g e n t ly d isim p a ct
t h e m e d ia l t a la r n e ck fra ct u re a llo w s re st o ra t io n o f
le n g t h a n d a lig n m e n t o f t h e m e d ia l a n d d o rsa l su r-
fa ce o f t h e n e ck.
■ An a t o m ic a lig n m e n t is a ch ie ve d u sin g t h e d e n t a l
p ro b e a n d sm a ll e le va t o rs a s re d u ct io n t o o ls.
■ If t h e t a la r n e ck fra ct u re is in t ra -a rt icu la r w it h e xt e n sio n
in t o t h e su b t a la r jo in t , t h e b o d y fra g m e n t ro u t in e ly a s-
su m e s a fle xe d , m a lro t a t e d p o sit io n .
■ To d e ro t a t e t h e t a la r b o d y’s fle xe d p o sit io n , t h e su r-
g e o n sh o u ld firm ly se cu re a p e rcu t a n e o u s 4.0-m m
e xt e rn a l fixa t io n h a lf-p in in t o t h e b o d y fra g m e n t
t h ro u g h a p o st e ro la t e ra l st a b in cisio n , a ct in g a s a
jo yst ick.
Tria l Fixa t io n
■ On ce t h e t a la r n e ck is re d u ce d , t h e n e xt st e p is t o a d -
va n ce a sin g le sm o o t h Kirsch n e r w ire re t ro g ra d e t h ro u g h
t h e t a la r h e a d , d ire ct e d a cro ss t h e fra ct u re in t o t h e p o s-
t e rio r b o d y, t o h o ld t h e p o sit io n o f t h e m e d ia l t a la r n e ck
fra ct u re .
■ If n o b o n y re d u ct io n ke ys a re visib le a lo n g t h e m e -
d ia l t a la r n e ck, d u e t o co m m in u t io n , t h e m in i-la m in a
sp re a d e r is in se rt e d in t h e fra ct u re m e d ia lly w h ile
t h e su rg e o n p a t ie n t ly re d u ce s t h e m e d ia l t a la r n e ck
a lig n m e n t .
■ Ta la r n e ck flu o ro sco p y is n e ce ssa ry t o e va lu a t e t ra n sla -
t io n a n d a lig n m e n t o f t h e fra ct u re . Th is im p o rt a n t st e p
e st a b lish e s t h e t ru e le n g t h a n d a lig n m e n t o f t h e m e d ia l
t a la r n e ck.
■ Ag a in , a re t ro g ra d e sm o o t h o r t h re a d e d w ire is a d -
va n ce d a cro ss t h e fra ct u re .
■ Th e su rg e o n t h e n e xp o se s t h e la t e ra l n e ck o f t h e t a lu s.
■ Th e e xt ra -a rt icu la r fra ct u re lin e re ve a ls t h e la t e ra l
sh o u ld e r o f t h e t a la r d o m e .
■ Co m m in u t io n is ra re ; t h e fra ct u re s a re sim p le , d iscre t e
p a t t e rn s t h a t re d u ce re la t ive ly e a sily b y ro t a t in g
a ro u n d t h e m e d ia l Kirsch n e r w ire .
■ Aft e r re d u ct io n , a re t ro g ra d e Kirsch n e r w ire is a d va n ce d
t h ro u g h t h e la t e ra l t a la r h e a d a n d a cro ss t h e fra ct u re ,
p ro visio n a lly fixin g t h e la t e ra l sid e o f t h e t a lu s fra ct u re .
■ In t ra o p e ra t ive flu o ro sco p y is p e rfo rm e d t o co n firm t h e
p re cise re d u ct io n o f t h e fra ct u re .
■ Clo se a t t e n t io n is p a id t o t h e Ca n a le im a g e o f t h e
t a la r n e ck t o b e su re t h e re is n o m a la lig n m e n t o f t h e
n e ck fra g m e n t .
Scre w Fixa t io n
■ De fin it ive fixa t io n o f t h e m e d ia l t a la r n e ck fra ct u re is
a ch ie ve d b y g e n t ly su b lu xin g t h e m e d ia l t a lo n a vicu la r
jo in t t o e xp o se t h e a rt icu la r su rfa ce o f t h e t a la r h e a d
(TECH FIG 1 ).
■ A co u n t e rsu n k in t e rfra g m e n t a ry 3.5-m m scre w is a d -
va n ce d t o t h e p o st e rio r b o d y o f t h e t a lu s.
■ La t e ra lly, ve ry d e n se co rt ica l b o n e a lo n g t h e p ro xim a l
n e ck p re se n t s a n e xce lle n t e xt ra -a rt icu la r lo ca t io n fo r a d -
va n cin g a se co n d in t e rfra g m e n t a ry scre w .
■ Fra ct u re p a t t e rn s o f t h e t a lu s m a ke it d ifficu lt t o in se rt
p a ra lle l in t e rfra g m e n t a ry scre w s.
■ Th e m e d ia l scre w is e a sily d ire ct e d p o st e ro la t e ra lly
a n d t h e la t e ra l scre w p o st e ro m e d ia lly.
■ Th is p a t t e rn o f fixa t io n h a s n e ve r b e e n fo u n d t o a f-
fe ct h e a lin g .
Pla t e Fixa t io n
■ Ta la r n e ck fra ct u re s t h a t a re n o t a m e n a b le t o in t e rfra g -
m e n t a ry scre w s b e ca u se o f co m m in u t io n p e rfo rm w e ll
w it h m in i-p la t e fixa t io n .
■ Fo u r- o r five -h o le 2.0-m m m in i-p la t e s a re e a sily co n -
t o u re d a n d a p p lie d a lo n g e it h e r t h e m e d ia l o r la t e ra l
n e ck su rfa ce s fo r fixa t io n in t h e se ca se s (TECH FIG 2 ).
■ Plat e fixat ion is especia lly helpful in cases wit h lat eral
co m min u t io n , o r w h e n th e la t e ra l sh o u ld e r is p ro xim a l
to the fra ct u re .
 Ch a p t e r 5 2 ORIF OF TALUS FRACTURES 517

TECHNIQUES
B C

TECH FIG 1 • A. Bo n e m o d e l h ig h lig h t in g m e d ia l in t ra -a rt icu la r, la t e ra l

e xt ra -a rt icu la r, a n d p o st e rio r scre w fixa t io n . B. Ha w kin s t yp e II fra ct u re .
A C. Po st o p e ra t ive fixa t io n .

TECH FIG 2 • Bo n e m o d e l d e p ict in g m in i-p la t e a n d scre w fixa -

t io n o f t a la r n e ck fra ct u re .

OPEN REDUCTION AND INTERNAL FIXATION OF THE NECK OF THE TALUS

WITH A DISLOCATED TALAR BODY
■ Ta la r n e ck fra ct u re s w it h a sso cia t e d p o st e rio r d islo ca t io n
o f t h e b o d y fra g m e n t (Ha w kin s t yp e III) p re se n t a n in -
cre a se d ch a lle n g e t o t h e su rg e o n .
■ Fra ct u re -d islo ca t io n o f t h e b o d y a n d t a la r h e a d
fra g m e n t s (Ha w kin s t yp e IV) is a se ve re p a n t a la r
in ju ry, b u t re d u ct io n o f t h e t a lo n a vicu la r jo in t is
e a sily a ch ie ve d t h ro u g h m e d ia l a n d a n t e ro la t e ra l
a p p ro a ch e s.
Re d u ct io n o f t h e Bo d y Fra g m e n t
■ Re d u ct io n o f t h e b o d y fra g m e n t is a n im m e d ia t e g o a l
w it h e it h e r in ju ry t yp e t o d im in ish st re t ch o n n e u ro va s-
cu la r st ru ct u re s a n d d e co m p re ss lo ca l p re ssu re p h e n o m -
e n o n o f t h e skin e n ve lo p e .
■ Th e b o d y co m m o n ly d islo ca t e s p o st e ro m e d ia lly b e -
ca u se o f t h e re t a in e d t e t h e r fro m t h e d e e p d e lt o id
lig a m e n t . Ho w e ve r, t h e b o d y m a y d islo ca t e d ire ct ly
p o st e rio rly o r p o st e ro la t e ra lly.
■ A o p e n Ha w kin s t yp e III fra ct u re -d islo ca t io n a llo w s t h e
su rg e o n a cce ss t o t h e b o d y fra g m e n t t h ro u g h t h e co m -
m o n t ra n sve rse m e d ia l t ra u m a t ic w o u n d .
■ A clo se d Ha w kin s III in ju ry m a y w a rra n t a p o st e ro -
m e d ia l o r p o st e ro la t e ra l in cisio n t o a cce ss t h e b o d y
fra g m e n t if it ca n n o t b e re t rie ve d t h ro u g h t h e m e -
d ia l a p p ro a ch .
■ An a sso cia t e d m e d ia l o r la t e ra l m a lle o la r fra ct u re o f t h e
a n kle h e lp s re d u ct io n o f t h e t a la r b o d y d islo ca t io n im -
m e n se ly, p a rt icu la rly w it h d isru p t io n o f t h e syn d e sm o t ic
lig a m e n t .
■ Re d u ct io n o f t h e d islo ca t e d b o d y fra g m e n t m a y b e a t -
t e m p t e d in t h e e m e rg e n cy ro o m u sin g ra d io g ra p h ic in -
fo rm a t io n a n d co n scio u s se d a t io n .
■ A w e ll-co n t ro lle d , sin g le a t t e m p t a t clo se d re d u ct io n
is re a so n a b le .
■ Th e h in d fo o t is p o sit io n e d in e q u in u s a n d t h e su b t a -
la r jo in t is d ist ra ct e d b y g rip p in g t h e h e e l a n d a p p ly-
in g t ra ct io n .
 518 Se c t i o n VI FOOT AND ANKLE
■ Ne xt , t h e d islo ca t e d t a la r b o d y fra g m e n t is p u sh e d
TECHNIQUES
a n t e rio rly.
■ Th e m a in t e t h e r, if o n e e xist s, t o t h e d islo ca t e d
t a la r b o d y fra g m e n t is t h e d e e p d e lt o id lig a m e n t
m e d ia lly. If in t a ct , t h e d e e p d e lt o id lig a m e n t ,
w h ich is sh o rt a n d n o n e la st ic, a llo w s fo r lit t le
m o t io n , m in im izin g t h e yie ld o f su cce ssfu l clo se d
re d u ct io n .
■ If t h e clo se d re d u ct io n is u n su cce ssfu l, m a n ip u la t io n a n d
re d u ct io n u n d e r g e n e ra l a n e st h e sia is re co m m e n d e d im -
m e d ia t e ly in t h e o p e ra t in g ro o m .
Pe rcu t a n e o u s Re d u ct io n
■ A p e rcu t a n e o u s re d u ct io n ca n b e a n e ffe ct ive a n d q u ick
n e xt st e p , p a rt icu la rly if t h e d islo ca t e d t a la r b o d y is a sin -
g le fra g m e n t .
■ Wit h t h e p a t ie n t in t h e su p in e p o sit io n , a la rg e , firm
st e rile b u m p m u st b e p o sit io n e d u n d e r t h e ca lf o f t h e
p a t ie n t .
■ A 4-m m e xt e rn a l fixa t io n h a lf-p in is a d va n ce d t h ro u g h
t h e p o st e rio r t u b e ro sit y o f t h e ca lca n e u s, in lin e w it h t h e
lo n g a xis o f t h e b o n e , t o t h e su b ch o n d ra l su rfa ce o f t h e
a n t e rio r p ro ce ss o f t h e ca lca n e u s.
■ Ne xt , a m e d ia l-t o -la t e ra l 4-m m h a lf-p in is a d va n ce d
a cro ss t h e d e n se su b ch o n d ra l d ist a l t ib ia b ico rt ica lly.
OPEN REDUCTION AND INTERNAL FIXATION OF THE BODY OF THE TALUS
■ Re co n st ru ct io n o f t a la r b o d y fra ct u re s is b e st p e rfo rm e d
u sin g d u a l m e d ia l a n d a n t e ro la t e ra l a p p ro a ch e s w it h t h e
a d d it io n o f t h e m e d ia l m a lle o la r o st e o t o m y.
■ Un le ss t h e fra ct u re lin e is t ra n sve rse a n d ve ry a n t e -
rio r, a llo w in g re a so n a b le a cce ss b y a st a n d a rd d u a l
a p p ro a ch , a t ra n sm a lle o la r a p p ro a ch is p la n n e d .
■ Fra ct u re p a t t e rn s t o t h e b o d y o f t h e t a lu s o ccu r in b o t h
sa g it t a l a n d co ro n a l p la n e s. Re g a rd le ss o f t h e fra ct u re
p la n e , t h e p rin cip le is t o w o rk t h ro u g h t h e fe n e st ra t io n
p ro vid e d b y t h e m e d ia l m a lle o la r o st e o t o m y, u sin g fin e -
t ip p e d d e n t a l p ro b e s, re d u cin g t h e p o st e rio r p o rt io n o f
t h e b o d y t o t h e a n t e rio r b o d y fra g m e n t s.
A B
TECH FIG 3 • A. Bo n e m o d e l d e p ict in g t a la r n e ck a n d d o m e fra ct u re (AP vie w ). B. Bo n e m o d e l d e p ict in g t a la r n e ck
a n d d o m e fra ct u re (la t e ra l vie w ). C. CT im a g e o f co ro n a l t a la r b o d y fra ct u re . (co n t in u e d )
■ A fin a l 4-m m h a lf-p in is m a n u a lly, a n d ca re fu lly, a d -
va n ce d d e e p in t o t h e b o d y o f t h e t a lu s t h ro u g h a 1.5-cm
lo n g it u d in a l in cisio n .
■ Th e ra t io n a le o f t h e p in p la ce m e n t sh o u ld b e cle a r.
■ Th e lo n g ca lca n e a l p in h a s t e rrific m e ch a n ica l a d va n t a g e
w it h t ra ct io n t o t h e t o rn p o st e rio r ca p su le o f t h e a n kle .
■ Th e su rg e o n d ist ra ct s t h e d ist a l t ib ia l a n d ca lca n e a l p in
w h ile a su rg ica l a ssist a n t a t t e m p t s t o re d u ce t h e t a la r
b o d y a n t e rio rly u sin g t h e h a lf-p in a s a jo yst ick.
Re d u ct io n o f t h e Ta la r Do m e
Fra g m e n t
■ Re d u ct io n o f t h e t a la r d o m e fra g m e n t , re ca lcit ra n t t o a
p e rcu t a n e o u s re d u ct io n , m u st b e d o n e u sin g a m e d ia l
a p p ro a ch .
■ Th e p e rcu t a n e o u s 4-m m h a lf-p in s sh o u ld b e m a in -
t a in e d fo r u se in t h e o p e n re d u ct io n .
■ Aft e r co m p le t io n o f t h e m e d ia l a p p ro a ch , a la m in a
sp re a d e r o r m e d iu m fe m o ra l d ist ra ct o r is a p p lie d m e -
d ia lly, d ist ra ct in g t h e jo in t .
■ Th e p o st e rio r t a la r b o d y h a lf-p in is u se d t o le ve r t h e
body fragment into a reduced position within the joint.
■ On ce t h e h e a d , n e ck, a n d b o d y fra g m e n t s a re re d u cib le ,
re co n st ru ct io n is p e rfo rm e d b y la g scre w o r m in i-p la t e
a n d scre w fixa t io n .
■ Sm a ll, sm o o t h Kirsch n e r w ire s a re in se rt e d fro m m e d ia l
a n d la t e ra l p o rt a ls, p ro visio n a lly fixin g t h e b o d y.
■ Asso cia t e d fra ct u re s o f t h e n e ck o f t h e t a lu s a re p ro vi-
sio n a lly fixe d a ft e r re d u ct io n o f t h e b o d y fra ct u re .
■ In t e rfra g m e n t a ry, co u n t e rsu n k, m in i-scre w s (2.7 o r
2.0 m m ) a re se q u e n t ia lly in se rt e d , fixin g t h e b o d y
fra g m e n t .
■ He a d le ss scre w s ca n a lso b e u se d fo r t h is fra ct u re .
■ Fin a lly, co u n t e rsu n k, in t e rfra g m e n t a ry sm a ll fra g -
m e n t (3.5 m m ) scre w s o r m in i-p la t e a n d scre w co n -
st ru ct s a re u se d t o fix t h e t a la r n e ck fra ct u re (TECH
FIG 3 ).
C

D E
TECH FIG 3 • (co n t in u e d ) D. Po st o p e ra t ive fixa t io n o f t a la r b o d y fra ct u re re q u irin g m e d ia l m a lle o la r o st e o t o m y.
E. Po st o p e ra t ive la t e ra l vie w o f t a la r b o d y fra ct u re . F. Po st o p e ra t ive Ca n a le vie w o f t a lu s.
OPEN REDUCTION AND INTERNAL FIXATION OF THE POSTERIOR BODY OF
THE TALUS
■ Disp la ce d , in t ra -a rt icu la r p o st e rio r t a la r b o d y fra ct u re s
p re se n t la rg e ly in t h e co ro n a l p la n e (TECH FIG 4 ).
■ I p re fe r t o p o sit io n t h e p a t ie n t p ro n e , o n a st e rile
b u m p , a n d a cce ss t h e fra ct u re t h ro u g h t h e p o st e ro m e -
d ia l a p p ro a ch .
■ Be fo re in fla t io n o f a t o u rn iq u e t , I re co m m e n d in se rt in g
m e d ia l, d ist a l-t h ird t ib ia l a n d ca lca n e a l e xt e rn a l fixa t io n
h a lf-p in s. Th is w ill a llo w fo r a p p lica t io n o f a sm a ll
fe m o ra l d ist ra ct o r, w h ich a id s in a n kle a n d su b t a la r jo in t
d ist ra ct io n .
■ A h e a d la m p w o rn b y t h e o p e ra t in g su rg e o n a id s visu a l-
iza t io n in t h is a p p ro a ch .
A
B D
Ch a p t e r 5 2 ORIF OF TALUS FRACTURES 519
TECHNIQUES
F
■ Na rro w Ho h m a n n re t ra ct o rs a re g e n t ly a p p lie d m e d ia lly
a n d la t e ra lly w it h in t h e a n kle jo in t , re t ra ct in g t h e p o st e -
rio r t ib ia l n e rve a n d a rt e ry a n d FHL t e n d o n , re sp e ct ive ly.
Th is a llo w s e xp o su re o f t h e p o st e rio r t a la r fra g m e n t .
■ Th e fra ct u re is re d u ce d u sin g d e n t a l p ro b e s.
■ Sm o o t h Kirsch n e r w ire s a re in se rt e d , p o st e rio r t o a n -
t e rio r, p ro visio n a lly fixin g t h e fra ct u re .
■ Th e fra ct u re is fixe d e it h e r b y in t e rfra g m e n t a ry, p a ra lle l
scre w fixa t io n o r a w e ll-co n t o u re d m in i-p la t e a n d in t e r-
fra g m e n t a ry scre w s.
■ Th e p o st e rio r m in i-p la t e is co n t o u re d in a cu rvilin e a r
fa sh io n t o se cu re ly b u t t re ss t h e p o st e rio r t a lu s.
E
TECH FIG 4 • A. Pre o p e ra t ive CT
im a g e o f p o st e rio r t a lu s fra ct u re .
B. Poste ro med ia l longitu dinal inci-
sio n . C. Int raop erat ive locat ion of
h alf-p in s t o assist in an kle an d su b ta -
la r joint distraction. D. In trao p e ra tive
m in i-p lat e fixa tio n . E. Posto p e ra tive
la te ra l view .
 520 Se c t i o n VI FOOT AND ANKLE
TECHNIQUES
OPEN REDUCTION AND INTERNAL FIXATION OF THE LATERAL PROCESS OF
THE TALUS
■ Op e n re d u ct io n a n d in t e rn a l fixa t io n o f fra ct u re s o f t h e
la t e ra l p ro ce ss o f t h e t a lu s m a y b e p e rfo rm e d w it h t h e
p a t ie n t p o sit io n e d e it h e r su p in e o r d ire ct la t e ra l.
■ In t u it ive ly, t h e p a t ie n t sh o u ld b e su p in e if o t h e r
su rg e ry is t o b e p e rfo rm e d o n t h e fo o t a n d a n kle .
■ Aft e r co m p le t in g t h e la t e ra l a p p ro a ch , t h e su rg e o n ca re -
fu lly e va lu a t e s t h e la t e ra l p ro ce ss fra ct u re (TECH FIG
5 A,B).
■ I g e n t ly d isp la ce t h e fra ct u re a n d a sse ss t h e co n d it io n
o f t h e su b t a la r jo in t .
■ Sm a ll fra g m e n t s a re co m m o n ly d e vo id o f so ft t issu e
a t t a ch m e n t s. On ly ve ry sm a ll fra g m e n t s sh o u ld b e
re m o ve d .
■ La rg e r fra g m e n t s, e ve n t h o se w it h o u t so ft t issu e a t -
t a ch m e n t s, a re n e e d e d t o re st o re t h e st ru ct u re o f t h e
A B
TECH FIG 5 • La t e ra l p ro ce ss fra ct u re o f t a lu s. A. Pre o p e ra t ive CT im a g e .
B. In t ra o p e ra t ive vie w o f fra ct u re . C. In t ra o p e ra t ive vie w o f fixa t io n .
D D. Po st o p e ra t ive im a g e .
EXTERNAL FIXATION
■ A t a lu s d e vo id o f so ft t issu e a t t a ch m e n t s sh o u ld b e im -
m e d ia t e ly p la ce d in a Ba cit ra cin so lu t io n a n d t ra n sp o rt e d
t o t h e o p e ra t in g ro o m .
■ Aft e r p re p a ra t io n a n d d ra p in g , t h e t a lu s is p la ce d in t w o
o r t h re e Ba cit ra cin a n d sa lin e b a t h s a n d g e n t ly scru b b e d
b e fo re re im p la n t a t io n .
■ A fo o t a n d a n kle e xt e rn a l fixa t o r m u st b e co n st ru ct e d
(TECH FIG 6 ).
■ In it ia lly, t w o 4-m m e xt e rn a l fixa t io n h a lf-p in s a re in -
se rt e d b ico rt ica lly in t o t h e a n t e rio r d ist a l t h ird o f t h e
t ib ia .
la t e ra l p ro ce ss in a n y clo se d fra ct u re o f t h e la t e ra l
p ro ce ss o f t h e t a lu s.
■ An y a n t e rio r o r p o st e rio r o st e o ch o n d ra l fra g m e n t s a re
re d u ce d a n d p ro visio n a lly fixe d w it h sm a ll, sm o o t h
Kirsch n e r w ire s.
■ A Fre e r e le va t o r is h e lp fu l t o d e t e rm in e t h e a n a t o m ic
su b t a la r jo in t lin e .
■ Fin a l re d u ct io n o f t h e d ire ct la t e ra l fra g m e n t s o f t h e
la t e ra l p ro ce ss is p ro visio n a lly fixe d b y Kirsch n e r
w ire s.
■ Iso la t e d la t e ra l p ro ce ss fra ct u re s a re b e st fixe d b y in t e r-
fra g m e n t a ry m in i-scre w fixa t io n .
■ Co m m in u t e d fra ct u re s sh o u ld b e b u t t re sse d b y m in i-
scre w a n d p la t e fixa t io n t o re sist d isp la ce m e n t a g a in st
a xia l lo a d s t o t h e p ro ce ss (TECH FIG 5 C,D).
C
■ A 4-m m h a lf-p in is in se rt e d b ico rt ica lly in t o t h e b a se
o f t h e first a n d fift h m e t a t a rsa ls.
■ Fin a lly, a 4-m m h a lf-p in , o r t ra n sfixio n p in , is a d -
va n ce d fro m m e d ia l t o la t e ra l, b ico rt ica lly, t h ro u g h
t h e t u b e ro sit y o f t h e ca lca n e u s.
■ An e xt e rn a l fixa t io n ro d co n n e ct s t h e t w o m e t a t a rsa l
b a se p in s, fo rm in g a m id fo o t u n it . It is im p o rt a n t t o le a ve
e xce ss ro d o n e a ch e n d o f t h e m id fo o t u n it fo r fu rt h e r
t ib ia l-ro d a t t a ch m e n t .
■ Ne xt , a n iso la t e d , lo n g e xt e rn a l fixa t io n ro d is a t t a ch e d
t o t h e m e d ia l e n d o f t h e m id fo o t u n it a n d t o t h e d ist a l
 Ch a p t e r 5 2 ORIF OF TALUS FRACTURES 521

t ib ia l h a lf-p in , re st o rin g n e u t ra l p la n t a rfle xio n o f t h e ■ Fin a lly, e xt e rn a l fixa t io n ro d s a re a d d e d , co n n e ct in g t h e

a n kle .
■ A se cond, long e xternal fixa tio n rod is atta che d to the la t-
eral end o f the midfoot rod and conn ected to the proximal
tibial pin, controlling ankle varus and assisting dorsiflexion.
TECHNIQUES
ca lca n e a l p in t o b o t h t h e m e d ia l, m id fo o t ro d a n d e it h e r
t ib ia l h a lf-p in fo r in cre a se d fra m e rig id it y a n d p o ssib ly t o
d ist ra ct t h e su b t a la r jo in t .

A C

TECH FIG 6 • A. Fo o t –a n kle e xt e rn a l fixa t io n

fra m e m o d e l u sin g 4-m m h a lf-p in s.
At t a ch m e n t s: d ist a l t h ird o f t h e t ib ia , ca lca -
n e u s, b a se o f first a n d fift h m e t a t a rsa ls.
B. Op e n p e rit a la r d islo ca t io n . C. Ap p lica t io n
B D o f fo o t –a n kle fra m e . D. De la ye d clo su re .

PEARLS AND PITFALLS

Avo id a m e d ia l a p p ro a ch t o t h e n e ck ■ Th e t u b e ro sit y o f t h e t a rsa l n a vicu la r is a n im p o rt a n t la n d m a rk id e n t ifyin g t h e p la n t a r
o f t h e t a lu s p la n t a r t o t h e in se rt io n lim it t o t h e m e d ia l a p p ro a ch . Im m e d ia t e sw e llin g o b scu re s p a lp a t io n o f t h is la n d m a rk.
o f t h e p o st e rio r t ib ia l t e n d o n .
Th e n e ck o f t h e t a lu s is a lig n e d ■ Th e a n t e ro la t e ra l su rg ica l a p p ro a ch sh o u ld n o t b e la t e ra l t o t h e syn d e sm o sis u n le ss t o
e cce n t rica lly m e d ia l in t h e h in d fo o t . a d d re ss fixa t io n o f t h e la t e ra l p ro ce ss o f t h e t a lu s o r d é b rid e m e n t o f su b t a la r
co m m in u t io n .
A m e d ia l m a lle o la r o st e o t o m y ■ Th e o st e o t o m y sh o u ld b e m a d e a t t h e le ve l o f t h e jo in t u sin g a t h in sa w b la d e . Th e
p e rfo rm e d d ist a l t o t h e sh o u ld e r su rg e o n sh o u ld p ro t e ct t h e so ft t issu e s p o st e rio r t o t h e m a lle o lu s d u rin g t h e o st e o t o m y.
o f t h e m e d ia l a n kle m o rt ise
g ive s p o o r visu a liza t io n o f
t h e t a la r d o m e .
Be w a re o f fixin g t h e n e ck o f t h e ■ Th e su rg e o n sh o u ld vie w t h e Ca n a le im a g e in t ra o p e ra t ive ly w it h C-a rm flu o ro sco p y
t a lu s in va ru s m a la lig n m e n t . (fle xe d kn e e , e ve rt e d fo o t in e q u in u s a n d C-a rm t u b e d ire ct e d 15 d e g re e s ca u d a d ).
Me d ia l scre w fixa t io n o f t a la r n e ck ■ Th e su rg e o n sh o u ld a vo id m e d ia l p e rcu t a n e o u s fixa t io n o f t a la r n e ck fra ct u re s.
fra ct u re s, n o t co u n t e rsu n k in t h e
t a la r h e a d , co m m o n ly a ch ie ve s p o o r
fixa t io n in t h e m e t a p h yse a l b o n e .
Do n o t u se p o st e rio r-t o -a n t e rio r ■ Po st e rio r-t o -a n t e rio r fixa t io n d o e s n o t a llo w re d u ct io n o f a d isp la ce d fra ct u re .
scre w fixa t io n , w it h t h e p a t ie n t in
t h e p ro n e p o sit io n , fo r a d isp la ce d
t a la r n e ck fra ct u re .
522 Se c t i o n VI FOOT AND ANKLE
POSTOPERATIVE CARE
■ The goal of operative and nonoperative treatment of talus
fractures is to achieve bone union and restore hindfoot function.
■ Return to preinjury status is commonly not achieved sec-
ondary to posttraumatic arthrosis and joint stiffness, but
good functional outcomes are attained even in the most se-
vere cases of talar neck and body fractures.
■ Immediate postoperative treatment requires application of
sterile ankle dressings and a well-padded, short-leg dressing
with a posterior plaster splint.
■ The ankle is positioned in neutral plantarflexion. Rigid
internal fixation safely allows early postoperative ankle and
subtalar motion.
■ Before hospital discharge, the patient is taught to perform
daily dressing changes and application of a foot and ankle
compression Ace wrap to control swelling.
■ The patient is to wear a removable short-leg fracture boot
and remain absolutely non-weight bearing for 8 weeks.
■ The fracture boot should be worn during the night for the
initial 3 to 4 weeks after surgery to prevent an early Achilles
tendon contracture.
■ Active ankle and subtalar motion exercises are recom-
mended.
■ Immediate outpatient physical therapy after a talus injury
routinely leads to excessive pain and ankle swelling.
■ H owever, upper and contralateral lower extremity
strengthening may be valuable during the initial, subacute,
6-week postinjury period.
■ Partial avascular necrosis of the lateral dome of the talus is
common. This may be seen because only the medial deep deltoid
blood supply to the talar body remains intact after the injury.
■ The H awkins sign is an early subchondral radiolucent line
indicating blood supply to the body of the talus. Its presence,
seen on an AP radiograph at 6 to 8 weeks, indicates bone re-
sorption, which is an active process requiring vascularity.
■ Fortunately, patients with isolated regional osteonecrosis
of the talar dome rarely experience late collapse.
■ The lack of a H awkins sign does not confirm osteonecro-
sis and may not be confirmed by plain radiographs until up
to 3 months after the injury.
■ There are no data to support extended periods of non-
weight bearing in patients with partial avascular necrosis.
Currently, the impact of weight bearing on the progression
of osteonecrosis is unknown. Procedures designed to revas-
cularize the talus, such as core decompression, are not rec-
ommended.
■ Protected weight bearing with a patellar tendon-bearing
brace to alleviate axial load to the hindfoot and refraining
from repetitive-loading sports are reasonable early concerns
to discuss with the patient.
■ I recommend formal outpatient physical therapy starting at
6 weeks after surgery. The patient is non-weight bearing for
2 weeks, performing passive range of motion of the ankle
and subtalar joints, isometrics of the leg, and possibly pool
therapy.
■ At 8 weeks, progressive weight bearing, strengthening, pro-
prioception, and range-of-motion exercises ensue.
■ Patients routinely display increased swelling of the injured
extremity with weight bearing.
■ Application of a 20- to 30-mm H g compression stocking
helps reduce swelling.
■ By 3 months the patient should be weaned from the fracture
boot and the transition made to an ankle brace applied within
a shoe.
■ Physical therapy can easily continue for up to 3 months
with these injuries.
■ The patient must be counseled on the importance of long-
term exercise after the end of formal physical therapy.
■ N onoperative management of talus fractures requires cast
immobilization for 6 weeks.
■ After cast immobilization, the injury should be treated
with a removable fracture boot and an outpatient physical
therapy protocol.
■ Progression to weight bearing is determined accordingly.
■ Follow-up postoperative management requires a three-view
plain radiographic ankle series.
OUTCOMES
■ If the patient does not develop a complication of a talus frac-
ture or its management, requiring secondary reconstructive
surgery, the functional outcome should be considered a success.
■ Recent data evaluating the surgical timing of talus frac-
tures maintain that the time to surgery does not correlate
with outcome. There is no association between delay of op-
erative management and avascular necrosis. This makes a
strong case for provisional external fixation of reduced talus
fractures as immediate treatment, particularly if the condi-
tion of soft tissues does not allow early open management.
■ Risk factors that lead to lower functional outcomes in-
clude comminution, a higher H awkins classification, open
fracture, and associated ipsilateral lower extremity injuries.
■ O steonecrosis of the talus, posttraumatic arthrosis, joint
stiffness, and varus malalignment can have a negative impact
on the outcome.
■ The incidence of avascular necrosis of the talar body has
been shown to increase with the severity of injury. The
H awkins sign has an accuracy of 75% . This sign is considered
a good predictor of a vascularized talar dome; however, the
absence of a H awkins sign does not necessarily indicate pro-
gression of avascular necrosis.
■ Recent studies evaluating talar neck fractures identify
an overall 50% incidence of avascular necrosis, with evi-
dence of collapse of the talar dome in 31% of the cases.
■ Posttraumatic arthrosis secondary to these injuries is
more common than avascular necrosis and most often pre-
sents in the subtalar joint.
■ Ankle arthrosis does not occur as an isolated outcome;
it is seen in association with subtalar arthritis.
■ Recent reports of talar body fractures show a 20% rate of
early superficial wound complications. All patients were
treated effectively with oral antibiotics and local wound
care. Thirty-eight percent of cases developed avascular
necrosis. Evidence of talar dome collapse presented in half
of these cases by 14 months after the injury. Patients with
talar dome fractures with osteonecrosis and posttraumatic
arthrosis had the lowest functional scores.
■ N o consensus exists regarding the most appropriate treat-
ment of the extruded talus. This is a rare injury with an in-
tuitively poor prognosis.
■ A recent study evaluating reimplantation of the talus
promoted the consideration of retaining the talus if possi-
ble. In the study, 8 patients had pure dislocations and 11

presented with various major and minor fracture patterns
associated with talar extrusion. All fractures and disloca-
tions were stabilized and no wound was allowed to granu-
late to closure. Talar collapse occurred within 1 year in all
eight patients with major fractures. At an average of 42
months follow-up, there were two infections. Seven pa-
tients required secondary surgical procedures, including
hardware removal, ankle arthroplasty with subtalar fu-
sion, ankle fusion, bone grafting, débridement, and flap re-
visions. The authors clearly did not experience a high in-
fection rate, supporting their conclusion that reimplanta-
tion is an effective solution to the challenging problem of
traumatic talectomy.
COMPLICATION S
■ Fractures of the talus have known complications associated
with soft tissue and fracture healing, malunion, arthrosis, and
avascular necrosis.
■ O pen fractures must be managed by a standard protocol
including débridement, prophylactic antibiotics, fracture
stabilization, and delayed closure.
■ Soft tissue complications associated with talus fractures are
predominantly superficial.
■ If full-thickness slough occurs, however, a formal wound
débridement is mandatory, followed by rotational or free
flap coverage.
■ The incidence of delayed union or nonunion of fractures of
the talar neck varies in the literature between 0% and 10% . The
presence of avascular necrosis is a primary cause of nonunion.
N onunion of the talar neck fracture may also result from poor
fixation.
■ If the cause of nonunion is unclear, the nonunion should
be studied by magnetic resonance imaging or CT scan.
Every effort should be made to revise fixation with autoge-
nous bone graft when possible.
■ N onunion due to total osteonecrosis of the body of the
talus requires removal of the body fragment and a tibiocal-
caneal fusion.
■ N onoperative management of comminuted lateral or pos-
teromedial process fractures can be unpredictable.
■ If pain persists long after the patient has returned to full
weight bearing and radiographic or CT imaging suggests
nonunion, surgical resection of these fragments is routinely
helpful. Pain is commonly linked to fibrous nonunion of
these avulsion fragments.
■ M alunion of the talus is predominantly due to varus
malalignment. M alalignment of the talar neck is best prevented
using dual medial and anterolateral approaches in combination
Ch a p t e r 5 2 ORIF OF TALUS FRACTURES 523
with the Canale image intraoperatively when performing the pa-
tient’s initial surgery.
■ Subtalar and ankle arthrosis is the most common complica-
tion associated with fractures of the talus. The incidence of
subtalar arthrosis is greatest.
■ Arthritic symptoms can be managed effectively with non-
steroidal anti-inflammatories. The hindfoot is also benefited
by custom ankle bracing. The patellar tendon-bearing brace
can effectively unload weight to the injured ankle, giving the
patient increased relief.
■ If symptoms of arthrosis are not improved nonopera-
tively, the patient should be evaluated by selective hindfoot
and ankle lidocaine injection. Relief of joint pain, whether
unifocal or bifocal, will allow the surgeon to counsel the pa-
tient on further reconstructive treatment.
REFEREN CES
1. Burgess AR, Dischinter PC, O ’Q uinn TD, et al. Lower extremity in-
juries in drivers of airbag-equipped automobiles: clinical and crash re-
construction correlations. J Trauma 1995;38:509–516.
2. Canale ST, Kelly FB. Fractures of the neck of the talus: long-term
evaluation of 71 cases. J Bone Joint Surg Am 1978;60A:143–156.
3. Cedell CA. Rupture of the posterior talotibial ligament with avulsion of
a bone fragment from the talus. Acta Orthop Scand 1974;45:454–461.
4. Comfort TH , Behrens F, Gaither DW, et al. Long-term results of dis-
placed talar neck fractures. Clin O rthop Relat Res 1985;81–87.
5. Elgafy H, Ebrahelm NA, Tile M, et al. Fractures of the talus: experience
of two level one trauma centers. Foot Ankle Int 2000;21:1023–1029.
6. H aliburton RA, Sullivan CR, Kelly PJ, et al. The extra-osseous and
intra-osseous blood supply to the talus. J Bone Joint Surg Am 1958;
40A:115.
7. H awkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am
1970;52A:991–1002.
8. Lindvall E, H aidukewych G, DiPasquale T, et al. O pen reduction and
internal fixation of isolated, displaced talar neck and body fractures.
J Bone Joint Surg Am 2004;86A:2229–2234.
9. M cCrory P, Blading C. Fractures of the lateral process of the talus.
Clin J Sport M ed 1996;6:124–128.
10. M ulfinger GL, Trueta J. Blood supply to the talus. J Bone Joint Surg
Br 1970;52B:160–167.
11. Patel R, VanBergyk A, Pinney S. Are displaced talar neck fractures
surgical emergencies? A survey of orthopaedic trauma experts. Foot
Ankle Int 2005;26:378–381.
12. Pleuriau PB, Browkaw DS, Jelen BA, et al. Plate fixation of talar neck
fracture: preliminary review of a new technique in 23 patients.
J O rthop Trauma 2002;16:213–219.
13. Sanders DW, Busam M , H attwick E, et al. Functional outcomes fol-
lowing displaced talar neck fractures. J O rthop Trauma 2004;18:
265–270.
14. Smith C, N ork S, Sangeorzan B. The extruded talus: results of reim-
plantation. J Bone Joint Surg Am 2006;88A:2418–2424.
15. Vallier H , N ork S, Benirschke S, et al. Surgical treatment of talar
body fractures. J Bone Joint Surg 2003;85A:1716–1724.
 Su r g ica l Tre a t m e n t o f
Ch a p t e r 53 Ca lca n e a l Fr a ct u re s
Jam e s B. Carr
DEFIN ITION
■ An intra-articular calcaneus fracture is an injury that in-
volves the joint surfaces of the calcaneus, usually with dis-
placement.
■ A fracture-dislocation of the calcaneus occurs when the pos-
terior facet dislocates from beneath the talus and ends up dis-
placed beneath the fibula. It carries a poor prognosis if treated
nonoperatively.
■ “ Soft tissue” damage refers to the injury to the skin, adipose,
tendinous, muscular, and nerve structures that surround the cal-
caneus and ranges from mild bruising to near-amputation in
open fractures.
■ Fracture blisters and varying degrees of skin contusion
occur most commonly.
■ “ Wrinkle sign” refers to the skin wrinkles that appear
when the injury swelling response is resolving.
■ A primary fracture line is one that occurs early in the mech-
anism of the calcaneal fracture. There are two that occur, and
if their pathogenesis is understood, this can explain the major-
ity of the pathology observed. This will be defined further in
the Pathogenesis section.
AN ATOMY
■ The calcaneus is the largest bone in the foot. It has a com-
plex shape that makes exact surgical reconstruction difficult.
■ The calcaneus functions to transmit weight-bearing forces of
the leg into the foot.
■ The calcaneus has a shock absorber function by assisting in
mobility of the ankle and subtalar joints, thus allowing the
foot to accommodate to variations in terrain.
■ The calcaneus has four articular facets that produce this
mobility: posterior, anterior, middle, and cuboid. Exact artic-
ular alignment is required for full function of this four-joint
complex.
■ The internal structure of the calcaneus reflects its weight-
bearing role.
■ There is particularly dense trabecular bone in the juxta-
articular regions, especially below the posterior facet (the
thalamic trabecular system).
■ The tendo Achilles insertion also has dense trabecular
bone.
■ Cortical bone of 3 to 4 mm in thickness occurs in the
superior-medial region (sustentaculum area) and in the
superior-lateral strut of bone that runs between the cuboid
and posterior facets (anterolateral fragment). These regions
of cortical bone will come into play when discussing the in-
ternal fixation of the calcaneus (FIG 1 ).
■ The soft tissues of the calcaneus are easily damaged by
trauma. M anagement of this injury component is essential to
avoid iatrogenic surgical complications.
524
PATHOGEN ESIS
■ Despite the seemingly infinite varieties of fractures that occur,
stereotypic fracture lines, fragments, and displacements can be
recognized.
■ The calcaneus is fractured by a combination of shear and
compression forces generated by the talus descending upon the
calcaneus.
■ Two primary fracture lines occur.
■ The first occurs in the angle of Gissane and divides
the calcaneus into anterior and posterior fragments. It
can split either the middle or anterior facet, and the frac-
ture continues on the lateral wall in an inverted Y shape
(FIG 2 ).
■ The second fracture divides the calcaneus into medial and
lateral halves and shears the posterior facet into two or
more fragments.
■ As the talus continues to compress the calcaneus, the
lateral half of the posterior facet is impacted into the body
of the calcaneus, with the recoil producing a step-off in
the posterior facet.
■ This same fracture line commonly continues into the
cuboid facet and, in combination with the first primary
fracture line, produces the anterolateral fragment and su-
peromedial fragment.
■ In this way, these two fracture lines produce fracture
components that include the superomedial fragment, an-
terolateral fragment, posterior facet, and tuberosity.
■ Characteristic displacements of these components occur.
■ The tuberosity is driven up between the pieces of the pos-
terior facet, can tilt into valgus or varus, and is usually
translated laterally.
■ The lateral posterior facet fragments are impacted and ro-
tated plantarly into the body of the calcaneus (FIG 3 A).
■ The posterior facet breaks into one of three patterns,
which form the basis of the Sanders classification:
■ Sanders II: two main pieces (FIG 3 B)
■ Sanders III: three main pieces (FIG 3 C)
■ Sanders IV: multifragmentary
■ The superomedial fragment retains alignment to the talus
by means of its ligamentous attachments but can be subtly
displaced by overlap with the anterior process. This overlap
occurs along the primary fracture line that occurs in the
sinus tarsi.
■ The anterolateral fragment displaces superiorly a variable
amount. It typically extends into the cuboid facet, with
varying degrees of displacement (FIG 3 D).
■ The lateral calcaneal wall is displaced outward in the area of
the trochlear tubercle. This, in combination with tuberosity
translation, accounts for the heel widening and peroneal im-
pingement that occur.
 Ch a p t e r 5 3 SURGICAL TREATM ENT OF CALCANEAL FRACTURES 525

Posterior
facet
Superomedial fragment
of calcaneus

FIG 1 • A la t e ra l ra d io g ra p h o f a ca lca n e u s sp e cim e n se c-

t io n e d in t h e sa g it t a l p la n e . Th e t ra b e cu la r syst e m s a re visu a l-
ize d a n d n u m b e re d 1 t h ro u g h 4. Th e d e n se st b o n e is in t h e
ju xt a -a rt icu la r re g io n s. Th ick co rt ica l b o n e a lso is p re se n t in
t h e a n t e ro la t e ra l fra g m e n t a n d m e d ia l w a ll in t h e su st e n t a cu -
Tuberosity
la r re g io n . 1, t h a la m ic t ra b e cu la r syst e m ; 2, a n t e rio r a p o p h y-
se a l t ra b e cu la r syst e m ; 3, a n t e rio r p la n t a r t ra b e cu la r syst e m ;
4, p o st e rio r p la n t a r.
FIG 2 • Pa t t e rn o f ca lca n e a l fra ct u re -d islo ca t io n a n d re d u ct io n .

■ The first fracture types recognized were the joint depression separates the fractured joint surface from the tuberosity
and tongue-type patterns, which are readily identified on a lat- (FIG 4 ).
eral heel radiograph. ■ Because of this anatomy, certain tongue fractures have a

■ The tongue fracture maintains a connection between the large portion, or even the entire posterior facet, in continu-
tuberosity and the posterior facet, while the joint depression ity with the tuberosity (AO -O TA 73 C1). Thus, reduction of

A B C

FIG 3 • A. Th e p o st e rio r fa ce t d isp la ce s a n d ro t a t e s in a p la n t a r d ire ct io n

(arro w ). B,C. CT sca n s sh o w in g a Sa n d e rs II fra ct u re w it h a la rg e su p e ro -
m e d ia l fra g m e n t (B) a n d a Sa n d e rs III fra ct u re (C). D. Th e p rim a ry fra c-
t u re lin e e xt e n d s in t o t h e ca lca n e a l cu b o id fa ce t . Th e a n t e ro la t e ra l fra g -
m e n t is re p re se n t e d b y t h e m o st la t e ra l p ie ce (arro w ). (D: Co u rt e sy o f
D Pa u l To rn e t t a III, MD.)
526 Se c t i o n VI FOOT AND ANKLE
Anterolateral
fragment
Superomedial
fragment
Posterior
facet
Tuberosity
A B
FIG 4 • Ca lca n e u s fra ct u re p a t t e rn s: t o n g u e (A) a n d jo in t d e p re ssio n (B).
the tuberosity will reduce indirectly the posterior facet and
restore the angle of Bohler. This particular pattern is well
suited for small incision or percutaneous techniques.
■ Reduction of a joint depression pattern is best performed
with an open reduction.
N ATURAL HISTORY
■ An intra-articular fracture of the calcaneus is a serious in-
jury that will diminish foot function.
■ N onoperative treatment is with early motion and delayed
weight bearing 6 to 8 weeks after injury. This method has the
least chance of iatrogenic injury.
■ In a classic review by Lindsay and Dewar, only 17% of pa-
tients had no foot symptoms with long-term follow-up.
■ The loss of ability to perform manual labor is common, with
an average time off work of 4 to 6 months for laborers.
■ Loss of subtalar motion to varying extents will occur.
■ Tibiotalar impingement and anterior ankle pain can be pro-
duced if the crush deformity is severe enough.
■ It can take 18 to 24 months for the foot symptoms to max-
imally improve after this injury. M ost improvement occurs in
the first 12 months.
■ The key concept here is that patients who continue to im-
prove symptomatically can be observed until maximum im-
provement occurs.
■ A recent randomized, prospective study found that the need
for late subtalar arthrodesis is five to six times greater if non-
operative treatment is used on all injuries. The overall rate was
approximately 17% .
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ The history is typically one of a fall or vehicle crash.
O ccasionally in a diabetic, a seemingly trivial ankle sprain-type
mechanism can occur. Important risk factors for operative
treatment complications include smoking, diabetes, peripheral
vascular disease, and steroid use. The foot and ankle are visu-
ally inspected.
■ Swelling is graded as mild, moderate, or severe.
■ O perative treatment in the face of severe soft tissue
swelling is prone to wound healing complications.
Anterolateral
fragment
Superomedial
fragment
Posterior
facet
Tuberosity
■ Fracture blisters are graded as fluid-filled or blood-filled. If
unhealed, fracture blisters are a source of skin bacterial colo-
nization. Blood-filled blisters denote a deeper dermal injury.
■ Skin contusion is noted.
■ If present, the wrinkle sign is noted. It means the swelling
is resolving and surgical incisions are less likely to experi-
ence complications.
■ O pen wounds are noted.
■ The physician palpates the foot and ankle, looks for spine
injuries or ipsilateral fractures, and performs a secondary sur-
vey for other injuries.
■ Spine injuries are said to accompany up to 10% of all cal-
caneal fractures.
■ The physician assesses for compartment syndrome, includ-
ing passive flexion and extension of the toes, tenseness of the
foot swelling, and compartment pressure measurement.
■ Positive results are degree of pain elicited and pressures
within 30 mm of diastolic blood pressure.
■ Compartment syndrome can occur in 5% to 10% of all
calcaneal fractures.
■ The physician performs a neurologic examination to check
the sensory function of foot and toes, including light touch and
pinprick.
■ Calcaneal fractures can damage the posterior tibial nerve
and occasionally sensory nerves. Findings may be altered
with compartment syndrome.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Anteroposterior and lateral (FIG 5 A,B) foot radiographs
are the initial screening study.
■ The axial (H arris) view should also be obtained (FIG 5 C).
This view will demonstrate the medial wall and show the re-
lation of the superomedial fragment to the tuberosity.
■ Broden views are radiographs that focus on the subtalar
joint. They are taken with the foot internally rotated, and
the x-ray beam angled to varying degrees cephalad (FIG
5 D,E). By using different degrees of cephalad angulation,
different parts of the posterior facet may be imaged. They
are best used intraoperatively to judge the reduction of the
posterior facet and the medial wall of the calcaneus.
 Ch a p t e r 5 3 SURGICAL TREATM ENT OF CALCANEAL FRACTURES 527

A B

C D E

FIG 5 • A,B. La t e ra l ra d io g ra p h s sh o w in g a se ve re ly d isp la ce d t o n g u e -t yp e Sa n d e rs II fra ct u re o f t h e ca lca n e u s w it h m id -

fo o t d islo ca t io n (A) a n d a Sa n d e rs III fra ct u re (B). C. Th e a xia l Ha rris vie w d e m o n st ra t e s d isp la ce m e n t o f t h e m e d ia l w a ll
(arro w ). Re d u ct io n o f t h is p a t h o a n a t o m y is t h e b a sis fo r t h e m e d ia l a p p ro a ch . D. Bro d e n vie w s a re o b t a in e d b y ce n t e r-
in g t h e x-ra y b e a m o n t h e p o st e rio r fa ce t , in t e rn a lly ro t a t in g t h e fo o t , a n d d ire ct in g t h e b e a m ce p h a la d . E. As t h e b e a m
is a im e d ce p h a la d , m o re a n t e rio r p o rt io n s o f t h e p o st e rio r fa ce t a re visu a lize d . Also n o t e t h e m e d ia l w a ll o n p ro file . As
t h e x-ra y is t ilt e d m o re , t h e vie w b e co m e s a t ru e Ha rris a xia l vie w (if t h e in t e rn a l ro t a t io n is re m o ve d ).

■ If the fracture is displaced, a computed tomography (CT)
scan is recommended to define the anatomy (see Fig 3B,C).
■ A CT scan with biplanar cuts and reconstructions is
recommended. This will best delineate the fragments and
displacements.
■ The recommended nonoperative treatment is compression
wrapping, early motion, and delayed weight bearing at 6 to 8
weeks after injury. This offers the least iatrogenic risk to the
patient while optimizing chances for subtalar motion.
■ O nce weight bearing is started, the patient continues with

range-of-motion exercises.
DIFFEREN TIAL DIAGN OSIS ■ Strengthening of the foot and ankle muscles is added as

■ Fracture of the talus fracture consolidation progresses.

■ Lateral process of talus fracture ■ A well-cushioned shoe usually offers the best pain relief.

■ Fracture of the midfoot (eg, navicular fracture) Two different shoe sizes may be needed in extreme cases.
■ Severe ankle sprain ■ A rocker-bottom sole can be added to assist with the toe-

■ Subtalar dislocation off stance phase of gait.

■ Stress fractures of the calcaneus can masquerade as a soft ■ A double upright brace with a rocker-bottom-soled shoe can

tissue disorder of the hindfoot (eg, plantar fasciitis). assist ambulation in patients with severe injury who have im-
pairment upon fracture healing.
N ON OPERATIVE MAN AGEMEN T ■ N onoperative treatment is not recommended for calcaneal

■ The indications for nonoperative treatment include poste- fracture dislocations, as a painful deformed foot is practically
rior facet displacement less than 2 mm, and medical conditions guaranteed if it is left unreduced.
such as peripheral vascular disease or diabetes.
■ Some surgeons consider smoking a relative contraindica- SURGICAL MAN AGEMEN T
tion; it certainly predisposes to a higher wound complication ■ The displaced intra-articular calcaneal fracture presents a
rate. difficult challenge.
■ Severe fracture blisters or closed soft tissue injury can pre- ■ Foot pain and stiffness are common even with the best of

clude operative treatment, although open reduction and treatment, and iatrogenic problems such as infection can result
internal fixation can be performed as late as 4 weeks after in loss of limb in extreme circumstances, and at the least pre-
injury. dispose to a poor result.
528 Se c t i o n VI FOOT AND ANKLE
■ Thus, a careful, individualized approach is recommended,
with a priority on avoiding iatrogenic problems while attain-
ing an anatomic alignment of the calcaneus.
■ Indications include displacement of the posterior facet of
more than 2 mm, and calcaneus fracture dislocation.
■ Research shows that certain patient groups, such as those
receiving worker’s compensation, are predisposed to a poor
result with operative treatment, but that does not obviate
the benefits of obtaining anatomic foot alignment and less-
ening the chances of late subtalar fusion.
■ O perative restoration of at least the calcaneal shape should
be considered for fractures with severe displacement (eg,
tuberosity displaced superiorly behind the ankle joint), as late
reconstructions can be difficult.
■ The choice of any surgical approach or technique should al-
ways have the goal of total anatomic restoration, although ex-
treme comminution can compromise attainment of this goal.
Preoperative Planning
■ O nce operative treatment has been elected, the surgical
approach is chosen based on a number of factors, including
the surgeon’s training and experience and the pathoanatomy
present.
■ The timing is in general when the wrinkle sign develops,
typically 7 to 14 days after injury. Fracture blisters should be
epithelialized.
■ The injury pathoanatomy is analyzed first by looking at
the posterior facet pattern (Sanders II, III, or IV), displace-
ment, and location of the primary fracture line in the poste-
rior facet.
■ Fractures that are more medial are more difficult to visu-
alize, and more fragments involving the posterior facet are
more difficult to fixate anatomically.
■ Fractures that separate the entire posterior facet and
have a tongue pattern are amenable to percutaneous Essex-
Lopresti techniques.
■ Conversely, joint depression fractures require open reduc-
tion of the posterior facet.
■ A highly comminuted Sanders IV fracture may alter the
goals to restoration of the calcaneal body shape and primary
fusion.
■ The other fracture components to be analyzed for displace-
ment are the superomedial fragment, anterolateral fragment,
and tuberosity. The surgical plan should address each of these
pathologies for reduction strategy and fixation.
■ The typical reduction order is first to correct any superome-
dial fragment subluxation.
■ N ext, the superomedial fragment is reduced and held to
the tuberosity.
■ The posterior facet is then reduced and fixed.
■ Finally, the anterolateral fragment is reduced and fixed.
■ The size and integrity of the superomedial fragment is criti-
cal, as fixation techniques largely center on screw placement
into its substance. A small or comminuted superomedial frag-
ment makes rigid fixation harder to achieve and may call for
alternative techniques.
■ Restoration of the superomedial fragment to the tuberos-
ity will restore the calcaneal shape and make room for re-
duction of the displaced posterior facet fragments.
■ The superomedial fragment may be incarcerated in the
sinus tarsi and subtly subluxated. This is recognized by the
preoperative CT scan on the sagittal reconstructions, and by
the lack of congruence of the superomedial fragment with
the undersurface of the talus.
■ Failure to correct this subluxation makes posterior
facet reduction very difficult.
■ The anterolateral fragment should key into location just in
front of the reduced posterior facet and restores lateral column
length.
■ It can be fixed with either lag screws into the superome-
dial fragment, or a mini-fragment plate. Some of the perime-
ter plates have a small extension to pull this fragment into
place.
■ The fixation chosen depends on the approach taken.
Fractures splitting the posterior facet will require lag screws
inserted from lateral to medial; they range in size from 2 to
4 mm, depending on the fractures present.
■ Sanders III fractures are converted into two major pieces
with the use of countersunk mini-fragment screws that fix
the intermediate piece to the more medial piece.
■ Extra-long mini-fragment screws are desirable to reach
the medial cortical bone.
■ The plate chosen depends on the approach.
■ The extensile lateral approach will require some type of
low-profile “ perimeter” plate.
■ Strategic placement of small and mini-fragment plates,
and occasionally lag screws alone, is used in small-incision
techniques.
■ Plans must be made for imaging, most typically fluoroscopy.
This will allow control of the AP, lateral, axial, and Broden
views intraoperatively.
■ Arthroscopy can also help visualize the posterior facet,
especially in its anterior portions.
Positioning
■ The extensile lateral approach is performed in the lateral de-
cubitus position with the injured foot on top. A thigh tourni-
quet is applied.
■ The fluoroscope is brought in from the side opposite the sur-
geon regardless of the surgical approach.
■ The same position can be used for percutaneous manipu-
lations of tongue fractures. This allows conversion to the ex-
tensile lateral approach, as recommended by Tornetta.
■ Small-incision approaches are performed supine with a
bump under the ipsilateral hip. A tourniquet is placed but not
routinely inflated.
■ For small-incision techniques, the patient is pulled down
to the end of the table. The point of the heel should project
slightly beyond the end of the bed. This allows for place-
ment of axially directed implants.
■ If used, the arthroscope is placed with the monitor on the
same side as the C-arm, toward the head of the bed.
Approach
■ Small-incision techniques will address most calcaneal
pathologies but require a firm understanding of the fragments,
displacements, and deforming forces present.
■ They are ideally suited to Sanders II fractures with a large
superomedial fragment and only mild to moderate posterior
facet displacement.
■ The extensile lateral approach is applicable to all fracture
patterns and displacements. Its use in open fractures warrants
caution with respect to soft tissue complications.
 Ch a p t e r 5 3 SURGICAL TREATM ENT OF CALCANEAL FRACTURES 529

PERCUTANEOUS REDUCTION AND FIXATION OF TONGUE FRACTURE
■ If p e rfo rm e d a cu t e ly, p e rcu t a n e o u s re d u ct io n s ca n b e
t e ch n ica lly e a sie r a n d d o n o t in cre a se t h e risk o f in fe c-
t io n in m y e xp e rie n ce .
■ If t h e re is a n y q u e st io n , t h e su rg e o n sh o u ld u se t h e
p re se n ce o f t h e w rin kle sig n a n d h e a lin g o f fra ct u re
b list e rs.
■ Th is t e ch n iq u e is id e a lly in d ica t e d fo r t o n g u e p a t t e rn s
t h a t h a ve a la rg e p e rce n t a g e o f t h e p o st e rio r fa ce t
co n n e ct e d t o t h e t u b e ro sit y (Sa n d e rs IIC) (TECH
FIG 1 A).
TECHNIQUES
■ Th e t e ch n iq u e ca n b e u se d fo r Sa n d e rs IIA a n d IIB p a t -
t e rn s, b u t t h e fa ce t re d u ct io n is m o re d ifficu lt if d o n e
p e rcu t a n e o u sly.
■ I p re fe r t o p e rfo rm t h is su rg e ry su p in e , w it h t h e a d d it io n
o f a sin u s t a rsi in cisio n fo r fa ilu re o f t h e p e rcu t a n e o u s
re d u ct io n .
■ To rn e t t a p re fe rs t h e la t e ra l p o sit io n , w it h co n ve rsio n
t o t h e e xt e n sile la t e ra l a p p ro a ch if p e rcu t a n e o u s m a -
n ip u la t io n s a re u n su cce ssfu l.

A B

C D

E F G

TECH FIG 1 • A. A d isp la ce d t o n g u e fra ct u re d e m o n st ra t e s t h e t yp ica l d isp la ce m e n t a n d lo ca t io n o f a n in ju ry

a m e n a b le t o p e rcu t a n e o u s re d u ct io n . Th e a n t e rio r p ro ce ss is n o t co m m in u t e d . Th e m e d ia l fra g m e n t w a s sm a ll.
B. In t ro d u ct io n o f a la rg e sm o o t h p in t o m a n ip u la t e t h e fra ct u re . No t e t h e in co m p le t e re d u ct io n in t h e a n g le o f
Gissa n e , a n d p o st e rio rly w h e re t h e t o n g u e fra ct u re e xit s. C. Mu lt ip le w ire s fo r ca n n u la t e d scre w s h a ve b e e n
p la ce d . Th e a n t e rio r p ro ce ss is n o t co m m in u t e d a n d ca n b e u se d fo r scre w p u rch a se . D. Re d u ct io n o b t a in e d a n d
scre w p la ce m e n t . E–G. Fo r t h is Sa n d e rs II fra ct u re , a ft e r re p a ir o f t h e n a vicu la r fra ct u re , a sm a ll in cisio n w a s
m a d e in t h e p la n t a r la t e ra l fo o t , lo ca lizin g t h e a re a b e n e a t h t h e a n g le o f Gissa n e . E. A 5-m m p in w a s p la ce d
o n a Syn t h e s (Pa o li, PA) T-h a n d le d ch u ck. Th e p in w a s t h e n p la ce d t h ro u g h t h e st a b in cisio n a n d a d va n ce d ju st
in sid e t h e la t e ra l w a ll o f t h e ca lca n e u s. At t h e sa m e t im e , a ca n n u la t e d scre w g u id e w ire w a s p la ce d in t h e p la n -
t a r p o rt io n o f t h e ca lca n e u s. F. Wit h t h e m a n ip u la t in g p in a p p lyin g a firm u p w a rd p re ssu re w it h t h e fo o t p la n -
t a rfle xe d , t h e w ire w a s d rive n fro m t h e t u b e ro sit y in t o t h e t o n g u e fra g m e n t . Th is w a s re p la ce d w it h a 4.0-m m
ca n n u la t e d scre w . G. A se co n d ca n n u la t e d scre w w a s p la ce d fro m t h e la t e ra l ca lca n e u s in t o t h e su p e ro m e d ia l
fra g m e n t .
 530 Se c t i o n VI FOOT AND ANKLE
■ Th e p a t ie nt is p la ce d su p in e w it h a ge n e ro u s b u m p u n d e r
TECHNIQUES
t h e ip sila t e ra l hip t o a ssist a cce ss t o t h e h e e l.
■ 0.25% Ma rca in e w it h e p in e p h rin e is in je ct e d in t o t h e
fra ct u re h e m a t o m a a n d so ft t issu e s. A p o p lit e a l b lo ck is
a lso p la ce d b y t h e a n e st h e sia t e a m . Th e co m b in a t io n o f
t h e se t w o b lo cks w ill a llo w fo r o u t p a t ie n t su rg e ry m a n -
a g e m e n t o f t h is in ju ry.
■ A 1/8 St e in m a n n p in is in t ro d u ce d in t o t h e ca lca n e u s
fro m t h e p o st e rio r t u b e ro sit y in t o t h e re g io n ju st b e -
n e a t h t h e p o st e rio r fa ce t .
■ Th e p in is t h e n u se d a s a le ve rin g t o o l t o re st o re
t h e Bo h le r a n g le o f t h e fra ct u re d ca lca n e u s (TECH
FIG 1 B).
OPEN REDUCTION
■ If t h e Bo h le r a n g le is n o t re d u cib le o r if a st e p -o ff re -
m a in s in t h e p o st e rio r fa ce t , a n o p e n re d u ct io n is p e r-
fo rm e d .
■ I p re fe r a sm a ll sin u s t a rsi in cisio n a p p ro a ch t o a id in
t h e re d u ct io n .
■ A 4- t o 6-cm sin u s t a rsu s in cisio n is m a d e t o
e xp o se t h e p o st e rio r fa ce t , t h e a n t e ro la t e ra l fra g -
m e n t , a n d a p o rt io n o f t h e la t e ra l ca lca n e a l w a ll
(TECH FIG 2 ).
■ Th e p o st e rio r fa ce t is re d u ce d u n d e r d ire ct visio n , a n d
t h e re d u ct io n is co n firm e d w it h flu o ro sco p y. An a rt h ro -
sco p e is h e lp fu l a s w e ll.
■ A t ra ct io n p in in t h e t u b e ro sit y ca n h e lp re st o re ca lca n e a l
h e ig h t .
■ La t e ra l t o m e d ia lly d ire ct e d la g scre w s a re p la ce d a cro ss
t h e p o st e rio r fa ce t . A m in i-fra g m e n t p la t e is u se d t o
b rid g e t h e p o st e rio r fa ce t t o t h e a n t e ro la t e ra l fra g m e n t .
TECH FIG 2 • La t e ra l a p p ro a ch fo r t h e sm a ll in cisio n t e ch n iq u e .
SIMULTANEOUS MEDIAL AND LATERAL APPROACHES
■ In g e n e ra l, e xce p t fo r o p e n fra ct u re s, t im in g sh o u ld b e
g u id e d b y t h e p re se n ce o f t h e w rin kle sig n a n d h e a lin g
o f fra ct u re b list e rs.
■ This t e ch niqu e is ide a lly in dica te d fo r San d e rs II fractu res
w it h 2 to 10 mm o f disp la cem e n t of t h e p o st e rio r fa ce t,
a nd a la rg e sup e ro me d ia l fra gme n t. It ca n b e a pp lied t o
n early a n y fract u re p at te rn , b u t t h e lim it ed e xp o su re
m akes p o st erio r facet re d u ct io n mo re d ifficu lt fo r San d e rs
III a nd IV pat te rns.
■ A g e n e ro u s b u m p is p la ce d u n d e r t h e ip sila t e ra l h ip . Th e
h e e l is le ft slig h t ly o ff t h e e n d o f t h e b e d t o fa cilit a t e t h e
p la ce m e n t o f a xia lly d ire ct e d fixa t io n .
■ 0.25% Ma rca in e w it h e p in e p h rin e is in je ct e d in t o t h e
fra ct u re h e m a t o m a a n d so ft t issu e s. A p o p lit e a l b lo ck is
a lso p la ce d b y t h e a n e st h e sia t e a m .
■ Takin g a lateral view o f th e n o rmal h eel an d savin g it o n
the flu oro scope p ro vides a compariso n to ju d ge reduction.
■ On ce t h e fra ct u re is re d u ce d , o n e o r t w o ca n n u la t e d
scre w s a re in t ro d u ce d fro m t h e t u b e ro sit y in t o t h e a n -
t e rio r p ro ce ss o f t h e ca lca n e u s (TECH FIG 1 C,D).
■ Alt e rn a t ive o r a d ju n ct ive fixa t io n st ra t e g ie s in clu d e
p la cin g a 4.0-m m scre w fro m t h e p la n t a r t u b e ro sit y
in t o t h e d o rsa l ca lca n e u s su rfa ce . Th is re sist s p la n t a r
d isp la ce m e n t o f t h e t o n g u e fra g m e n t .
■ An o t h e r la g scre w p o ssib ilit y is o n e d ire ct e d fro m t h e
la t e ra l ca lca n e u s in t o t h e su p e ro m e d ia l fra g m e n t
(TECH FIG 1 E–G). Th is is m o re d ifficu lt in t h is p a t t e rn
b e ca u se b y d e fin it io n it h a s a sm a ll su p e ro m e d ia l
fra g m e n t .
■ Th e la t e ra l w a ll sh o u ld b e m a n u a lly co m p re sse d a t t h is
p o in t .
■ Consideration can be given to adding a calcium phosphate
cold h a rd e n in g com po site to provid e e xt ra su pp o rt.
■ La ye re d clo su re is p e rfo rm e d .
Incision site
■ Th e co m b in a t io n o f t h e se t w o b lo cks w ill a llo w fo r
o u t p a t ie n t su rg e ry m a n a g e m e n t o f t h is in ju ry.
In cisio n s a n d Disse ct io n
■ Th e m e d ia l a p p ro a ch is p o st e rio r a n d p a ra lle l t o t h e n e u -
ro va scu la r b u n d le (TECH FIG 3 A).
■ Th e m e d ia l ca lca n e a l se n so ry b ra n ch is id e n t ifie d
d e e p t o t h e fle xo r re t in a cu lu m a n d p re se rve d . Th is
d ire ct ly e xp o se s t h e su p e ro m e d ia l fra g m e n t
a n d ke e p s t h e n e u ro va scu la r b u n d le in t h e a n t e rio r
fla p .
■ Th e la t e ra l a p p ro a ch e xt e n d s a n t e rio rly 4 t o 6 cm fro m
t h e t ip o f t h e fib u la (se e Te ch Fig 2).
■ Th is w ill p ro vid e e xp o su re o f t h e p o st e rio r fa ce t a n d
a n t e ro la t e ra l fra g m e n t .
■ It is p e rfo rm e d a ft e r t h e m e d ia l a p p ro a ch .
 Ch a p t e r 5 3 SURGICAL TREATM ENT OF CALCANEAL FRACTURES 531

TECHNIQUES
TECH FIG 3 • A. Me d ia l a p -
p ro a ch fo r t h e sm a ll-in ci-
sio n t e ch n iq u e . B. A t e n -
sio n e d 1.6-m m sm o o t h
Kirsch n e r w ire is p la ce d in
t h e in fe rio r t u b e ro sit y a n d
is u se d t o a p p ly t ra ct io n t o
Incision site t h e ca lca n e u s. Th e h e e l is
slig h t ly o ff t h e e n d o f t h e
b e d t o fa cilit a t e p la ce m e n t
A B o f a xia l fixa t io n .

■ At t h is p o in t , a ll fra ct u re fra g m e n t s a re id e n t ifie d a n d t u b e ro sit y is o b t a in e d , p a rt icu la rly w it h re sp e ct t o

cle a n e d o f d e b ris.
■ Th e p o st e rio r fa ce t is p a rt ly re d u ce d t o a vo id o b st ru c-
t io n o f t h e su p e ro m e d ia l fra g m e n t a n d t u b e ro sit y re -
d u ct io n .
■ A 1.6-m m St e in m a n n p in is in t ro d u ce d in t o t h e t u b e ro s-
it y o f t h e ca lca n e u s in a m e d ia l-t o -la t e ra l d ire ct io n .
Te n sio n e d w it h a Kirsch n e r b o w , it a llo w s fo r co rre ct io n
o f sh o rt e n in g (TECH FIG 3 B).
■ Th e m e d ia l fra ct u re fra g m e n t s a re cle a n e d o f d e b ris, a n d
la n d m a rks fo r re d u ct io n a re id e n t ifie d .
Me d ia l Re d u ct io n a n d Fixa t io n
■ Re d u ct io n a n d fixa t io n ca n b e d o n e w it h o n e o f t w o
st ra t e g ie s.
■ Th e first is w it h a n a n t ig lid e 2.7-m m p la t e .
■ On e ca n p re d rill a h o le o n t h e t u b e ro sit y fra g m e n t
n e xt t o t h e fra ct u re sit e a n d t o t h e le n g t h m e a su re d .
■ Wit h u se o f d ist ra ct io n a n d m a n ip u la t io n , a n a p p ro x-
im a t e re d u ct io n o f t h e su p e ro m e d ia l fra g m e n t a n d
le n g t h .
■ A 2.7-m m five -h o le T p la t e is t h e n p la ce d o n t h e b o n e
a n d t h e p re m e a su re d scre w in se rt e d . As t h e p la t e
t ig h t e n s t o t h e b o n e , it w ill h e lp re d u ce a n y t u b e ro s-
it y t ra n sla t io n (TECH FIG 4 ).
■ Th e re d u ct io n is ch e cke d b y flu o ro sco p y in a ll p la n e s.
■ If sa t isfa ct o ry, a d d it io n a l scre w s ca n b e in se rt e d , t a k-
in g ca re t o a vo id t h e p o st e rio r fa ce t .
■ Th e se co n d m e t h o d is t o o b t a in a re d u ct io n b y t ra c-
t io n a n d t ra n sla t io n o f t h e t u b e ro sit y.
■ On e ca n t h e n in t ro d u ce a xia l ca n n u la t e d scre w s—o n e
u p t h e in sid e o f t h e m e d ia l w a ll a n d t h e o t h e r a s a la g
scre w fro m t h e in fe rio r la t e ra l t u b e ro sit y in t o t h e
su p e ro m e d ia l fra g m e n t .
■ Th is la t t e r la g scre w is a u se fu l a d ju n ct t o a m e d ia l
a n t ig lid e p la t e .
La t e ra l Re d u ct io n a n d Fixa t io n
■ On ce t h e m e d ia l sid e is re d u ce d , t h e la t e ra l sid e is
a d d re sse d .

A B

TECH FIG 4 • Axia l (A) a n d m e d ia l (B) vie w s o f fixa t io n w it h a m e d ia l p la t e

a n d la t e ra l scre w s.
 532 Se c t i o n VI FOOT AND ANKLE

■ Th e p o st e rio r fa ce t is m a n ip u la t e d a n d re d u ce d . Th e re -
TECHNIQUES

d u ct io n is ch e cke d w it h Bro d e n vie w s a n d t h e a rt h ro -

sco p e (TECH FIG 5 ).
■ It is co m m o n t o a p p ro xim a t e o n e p o rt io n o f t h e fa ce t ,
o n ly t o h a ve a n o t h e r p o rt io n m a lre d u ce d .
■ On ce a n a n a t o m ic re d u ct io n is o b t a in e d , p ro visio n a l fix-
a t io n w it h Kirsch n e r w ire s is p e rfo rm e d . Tw o la t e ra l-t o -
m e d ia l–d ire ct e d la g scre w s a re t h e n in se rt e d ju st
b e n e a t h t h e a rt icu la r su rfa ce o f t h e p o st e rio r fa ce t .
■ Th e a n t e ro la t e ra l fra g m e n t w ill n o w re d u ce a n a t o m i-
ca lly t o t h e p o st e rio r fa ce t . It ca n b e fixa t e d w it h e it h e r
a m in i-fra g m e n t p la t e t h a t b rid g e s fro m t h e p o st e rio r
fa ce t t o t h e a n t e ro la t e ra l fra g m e n t , o r a la g scre w
fro m t h e a n t e ro la t e ra l fra g m e n t t o t h e su p e ro m e d ia l
fra g m e n t .
■ Th e la t e ra l w a ll sh o u ld b e m a n u a lly co m p re sse d a t t h is
p o in t . TECH FIG 5 • Th e a rt h ro sco p e is in t ro d u ce d t h ro u g h t h e o p e n
■ Consid erat io n ca n be g ive n t o a d ding a ca lcium p h o s- la t e ra l w o u n d t o p ro vid e m a g n ifica t io n a n d visu a liza t io n o f
p hat e cold h a rde n in g co m p osite t o p ro vide e xtra su pp o rt. t h e su b t a la r su rfa ce .
■ La ye re d clo su re is p e rfo rm e d .

EXTENSILE LATERAL APPROACH

■ Tim in g sh o u ld b e g u id e d b y t h e p re se n ce o f t h e w rin kle
sig n a n d h e a lin g o f fra ct u re b list e rs. Th is ca n t a ke u p t o
3 w e e ks.
■ Th is t e ch n iq u e is in d ica t e d fo r a ll t yp e s o f ca lca n e a l fra c-
t u re s w it h in t ra -a rt icu la r d isp la ce m e n t . Op e n fra ct u re s
a re b e st a p p ro a ch e d in a st a g e d fa sh io n .
■ Th e la t e ra l d e cu b it u s p o sit io n is u se d , w it h t h e
in ju re d sid e u p . Th e C-a rm co m e s in o p p o sit e t h e
su rg e o n .
■ 0.25% b u p iva ca in e w it h e p in e p h rin e is in je ct e d in t o t h e
fra ct u re h e m a t o m a a n d so ft t issu e s. A p o p lit e a l b lo ck is
a lso p la ce d b y t h e a n e st h e sia t e a m . To u rn iq u e t co n t ro l
is re q u ire d .
■ An L-sh a p e d in cisio n is m a d e p a ra lle l t o t h e Ach ille s t e n -
d o n a n d cu rve s a n t e rio rly a lo n g t h e b o rd e r o f t h e p la n -
t a r skin o f t h e h e e l (TECH FIG 6 A).
■ Th e in cisio n is m a d e t o b o n e , w it h a su b p e rio st e a l a n d
p e rio st e a l fla p ra ise d a lo n g it s e n t ire e xt e n t . In t h e re -
g io n o f t h e p e ro n e a l t e n d o n sh e a t h a t t a ch m e n t , t h e t e n -
d o n s a re re t ra ct e d a n t e rio rly a n d t h e d isse ct io n is co n t in -
u e d o n t h e d e e p la ye r, a b o ve t h e a b d u ct o r fa scia .
■ On ce t h e e n t ire la t e ra l sid e o f t h e ca lca n e u s is e xp o se d ,
t w o Kirsch n e r w ire s ca n b e d rive n in t o t h e t a lu s t o p ro -
vid e re t ra ct io n o f t h e fla p (TECH FIG 6 B).
■ Th e la t e ra l w a ll is e n t e re d a n d t h e p o st e rio r fa ce t e le -
va t e d fro m it s d isp la ce d p o sit io n (TECH FIG 6 C).

A B

TECH FIG 6 • A. In cisio n fo r t h e e xt e n sile la t e ra l a p p ro a ch . B. Th e la t e ra l fla p h a s b e e n ra ise d . Th e Kirsch n e r

w ire s in t h e t a lu s se rve t o re t ra ct t h e so ft t issu e s a n d a ssist e xp o su re . (co n t in u e d )
 Ch a p t e r 5 3 SURGICAL TREATM ENT OF CALCANEAL FRACTURES 533

■ If t h e su p e ro m e d ia l fra g m e n t is su b lu xa t e d b y t h e a n t e - ■ Th e po st erio r facet can n o w be red uced and p ro visio n ally

rio r p ro ce ss, t h is is co rre ct e d b y le ve ra g e a n d a Kirsch n e r
w ire d rive n a cro ss t h e re d u ce d fra g m e n t s.
■ A Sch an z scre w is d rive n in t o t h e t u b e ro sit y t o facilit a t e
m an ip ula t io n o f t h e fra gm e n t s. Alt ern a t ive ly, a t en sio n e d
w ire ca n b e u se d .
■ At t e n t io n is t u rn e d t o t h e m e d ia l w a ll, w h e re t h e su p e r-
o m e d ia l fra g m e n t is id e n t ifie d .
■ Wit h t ra ct io n a n d m a n ip u la t io n o f t h e p ie ce s, t h e m e -
d ia l w a ll is re d u ce d a n d p in n e d w it h a xia l Kirsch n e r
w ire s t h a t t ra ve l ju st in sid e t h e m e d ia l w a ll o f t h e
ca lca n e u s.
TECHNIQUES
fixa t e d w it h Kirsch n e r w ire s, a n d la t e ra l-t o -m e d ia l–-
directed lag screws are placed. Broden views are essential
to e nsu re an ato mic reduction .
■ Th e a n t e ro la t e ra l fra g m e n t is re d u ce d t o t h e p o st e rio r
fa ce t a n d p in n e d in t o t h e su p e ro m e d ia l fra g m e n t .
■ A p e rim e t e r p la t e is n o w a p p lie d t o t h e la t e ra l su rfa ce o f
t h e ca lca n e u s (TECH FIG 6 D,E). Co n t o u rin g o f t h e p la t e
is n o t re co m m e n d e d , e xce p t in t h e a re a n e xt t o t h e
cu rve d p o st e rio r p o rt io n o f t h e p o st e rio r fa ce t if n e e d e d .
It fu n ct io n s in a se n se a s a g ia n t w a sh e r, se rvin g t o co m -
p re ss t h e ca lca n e u s fro m la t e ra l t o m e d ia l.

C D

TECH FIG 6 • (co n t in u e d ) C. Aft e r re m o va l o f t h e la t e ra l w a ll,

t h e d e p re sse d p o st e rio r fa ce t is cle a rly se e n . D. Kirsch n e r w ire s
p ro vid e p ro visio n a l fixa t io n , a n d a p la t e is co n t o u re d t o t h e
su p e rio r ca lca n e u s, b e h in d t h e p o st e rio r fa ce t . Th e re m a in d e r
o f t h e p la t e is le ft fla t t o p re ve n t va ru s d isp la ce m e n t o f t h e
t u b e ro sit y. E. In t ra o p e ra t ive la t e ra l ra d io g ra p h w it h t h e
Kirsch n e r w ire s a n d p la t e in p la ce . F. La t e ra l vie w o f p la t e
sh o w in g scre w p la ce m e n t . G. Fin a l p o st o p e ra t ive la t e ra l ra d i-
o g ra p h . Th e scre w s a re a im e d in t o t h e ju xt a -a rt icu la r re g io n s
G o f t h e ca lca n e u s.
 534 Se c t i o n VI FOOT AND ANKLE

■ Scre w s a re d ire ct e d in t o t h e t u b e ro sit y a n d t h e ju xt a - ■ Ca re fu l la ye re d clo su re is p e rfo rm e d o n t h e w o u n d .

TECHNIQUES

a rt icu la r a re a s o f t h e ca lca n e u s (TECH FIG 6 F,G). Th e ■ He m o st a sis is o b t a in e d b e fo re clo su re a n d co n sid e ra -

su p e ro m e d ia l fra g m e n t u su a lly o ffe rs t h e b e st b o n e
fo r scre w fixa t io n , a lo n g w it h t h e re g io n b e n e a t h t h e
p o st e rio r fa ce t .
■ Ca re is t a ke n t o a vo id p e n e t ra t in g t h e m e d ia l cu b o id
fa ce t (w h ich cu rve s t o w a rd t h e t u b e ro sit y) a n d t h e
m e d ia l p o st e rio r fa ce t (w h ich cu rve s t o w a rd t h e p la n -
t a r su rfa ce ).
t io n is g ive n t o p la cin g a d e e p d ra in o r w o u n d
va cu u m o ve r t h e su t u re lin e . Sim p le ru n n in g st it ch is
su fficie n t fo r m o st ca se s, a lt h o u g h so m e su rg e o n s
p re fe r Allg ö w e r-Do n a t i–t yp e m a t t re ss skin clo su re .
■ A w e ll-p a d d e d sh o rt -le g ca st is a p p lie d a n d sp lit t o a llo w
fo r sw e llin g .

PEARLS AND PITFALLS

In d ica t io n s
Fra ct u re re d u ct io n
Fra ct u re im p la n t s
Co m p lica t io n s
Po st o p e ra t ive ca re
■ Le ss in va sive a p p ro a ch e s re q u ire a n a ccu ra t e d e fin it io n o f t h e p a t h o a n a t o m y, t h e n m a t ch in g t h e
p a t h o a n a t o m y w it h a n o p e ra t ive p la n .
■ Ext e n sile a p p ro a ch e s sh o u ld b e u se d ca u t io u sly w it h o p e n fra ct u re s.
■ Wit h o p e n a p p ro a ch e s, t h e o rd e r o f re d u ct io n is t h e sa m e : su p e ro m e d ia l fra g m e n t t o a n t e rio r p ro ce ss,
su p e ro m e d ia l fra g m e n t t o t u b e ro sit y, p o st e rio r fa ce t t o su p e ro m e d ia l fra g m e n t , a n t e ro la t e ra l fra g m e n t
t o p o st e rio r fa ce t , la t e ra l w a ll.
■ Exa ct p o st e rio r fa ce t re d u ct io n is d ifficu lt t o a ch ie ve b u t re q u ire d t o a ch ie ve e xce lle n t re su lt s. Ad ju n ct s
o f flu o ro sco p y a n d a rt h ro sco p y h e lp visu a lize t h e h ig h ly co n g ru e n t su b t a la r jo in t .
■ In Sa n d e rs III fra ct u re s, t h e in t e rm e d ia t e p ie ce ca n b e fixa t e d t o t h e su p e ro m e d ia l fra g m e n t w it h
2.0-m m la g scre w s, t h u s co n ve rt in g it t o a Sa n d e rs II p a t t e rn .
■ Ext ra -lo n g m in i-fra g m e n t scre w s a re e sse n t ia l t o a llo w m a t ch in g o f scre w a n d fra g m e n t size , e sp e cia lly
in t h e p o st e rio r fa ce t .
■ Th e a p p lica t io n o f a st ra ig h t p la t e t o t h e la t e ra l ca lca n e a l su rfa ce w ill a vo id va ru s o f t h e h e e l.
■ St rict fo o t e le va t io n u n t il su t u re re m o va l is re co m m e n d e d t o a ssist in w o u n d h e a lin g .
■ Re lia b le p a t ie n t s w it h o u t d ia b e t e s ca n sa fe ly p e rfo rm t o u ch -d o w n ra n g e -o f-m o t io n e xe rcise s t o a ssist
in re co ve ry o f su b t a la r m o t io n .

POSTOPERATIVE CARE ■ Symptom improvement can take up to a year to plateau.

■ In a recent randomized study, visual analog pain scores be-
■ A well-padded short-leg cast is applied, split, and over-
tween nonoperative and operative groups were similar, but
wrapped with a loosely applied elastic wrap.
■ The patient is instructed to maintain strict elevation as much
nonoperative treatment resulted in a 5.5 times greater inci-
dence of late subtalar fusion.
as possible until the sutures are removed. ■ In that same study, females, non-workmen’s-compensation
■ The same cast is retained until the sutures are removed
cases, and nonmanual laborers had improved results with
2 weeks postoperatively.
■ In reliable nondiabetic patients, the cast can be discontinued
operative treatment.
■ Better results were also seen with an anatomic reduction
and range-of-motion exercises begun.
■ Touch-down weight bearing to promote ankle and subtalar
versus a nonanatomic one.
■ Soft tissue complications frequently lead to a poor result.
motion can be started at the same time. ■ Amputations have been reported with extensile lateral
■ Physical therapy is prescribed on an individualized basis.

■ At 6 weeks, a radiograph is obtained and weight bearing

progressed as pain allows. Full weight bearing is expected by
12 weeks postoperatively.
OUTCOMES
■ Despite appropriate care, most patients with a calcaneal
fracture will lose some degree of foot function and have per-
manent symptoms.
■ While nonoperative treatment yields the fewest iatrogenic
complications, it accepts malunion in nearly 100% and a
approaches.
■ O pen techniques should be used cautiously in diabetic pa-
tients, although injuries such as fracture-dislocation are best
treated with operative reduction and fixation.
COMPLICATION S
■ The complications of nonoperative treatment include malu-
nion, persistent foot pain, and a higher chance of later subta-
lar fusion.
■ Severe crush deformities affect not only the subtalar joint,

higher incidence of later subtalar fusion. but the midfoot and ankle as well. They can be difficult to
 Ch a p t e r 5 3 SURGICAL TREATM ENT OF CALCANEAL FRACTURES
reconstruct, so initial management to avoid such a malunion is
recommended.
■ Smoking, diabetes, and open fracture are the most signifi-
cant risk factors for soft tissue complications.
■ Infection occurs in about 2% of fractures treated operatively
with open incisions.
■ Flap necrosis can occur with any incision but is most likely
with the extensile lateral approach. Débridement and closure
by secondary intention is often successful for minor flap losses.
If a large portion of the flap is lost, consultation with a plastic
surgeon is recommended.
■ Deep infection is managed with débridement and intra-
venous antibiotics based on culture results.
■ Retention of hardware (if providing bone stability) until
bone healing is optimal.
■ Removal of the hardware to eradicate the infection once
the bone is healed is sometimes needed.
■ Posterior tibial nerve injury can result from the fracture and
commonly presents with severe pain nonresponsive to nar-
cotics in the postinjury period.
■ Administration of medications aimed at neuropathic pain
is recommended, and consultation with a pain specialist is
considered.
■ Cushioned shoe inserts are often comforting to individuals
with postfracture plantar heel pain. A rocker-bottom shoe can
also reduce discomfort.
■ Late implant-related symptoms are rare with percutaneous
or small-incision techniques. They are lessened by the use of
low-profile “ perimeter” plates with the extensile lateral
approach.
REFEREN CES
1. Abidi N , Dhawan S, Gruen G, et al. Wound-healing risk factors after
open reduction and internal fixation of calcaneal fractures. Foot
Ankle 1998;19:856–861.
2. Benirschke S, Sangeorzan B. Extensive intraarticular fractures of the
foot: surgical management of calcaneal fractures. Clin O rthop Relat
Res 1993;290:128–134.
3. Bézes H , M assart PL, Delvaux D, et al. The operative treatment of in-
traarticular calcaneal fractures: indications, technique and results in
257 cases. Clin O rthop Relat Res 1993;290:55–59.
4. Buckley R, Tough S, M cCormack R, et al. O perative compared with
nonoperative treatment of displaced intra-articular calcaneal frac-
tures: a prospective, randomized, controlled multicenter trial. J Bone
Joint Surg Am 2002;84A:1733–1744.
5. Burdeaux B. Fractures of the calcaneus: open reduction and internal
fixation from the medial side: a 21-year prospective study. Foot
Ankle 1997;18:685–692.
6. Burdeaux B. Reduction of calcaneal fractures by the M cReynolds me-
dial approach technique and its experimental basis. Clin O rthop
Relat Res 1983;177:87–103.
7. Carr JB. M echanism and pathoanatomy of the intraarticular cal-
caneal fracture. Clin O rthop Relat Res 1993;290:36–40.
8. Carr JB. Surgical treatment of intra-articular calcaneal fractures: a
review of small incision approaches. J Orthop Trauma 2005;19:
109–117.
9. Carr JB. Surgical treatment of intra-articular calcaneal fractures: a
review of small incision approaches. J O rthop Trauma 2005;19:
109–117.
10. Carr JB, H amilton J, Bear L. Experimental intra-articular calcaneal
fractures: anatomic basis for a new classification. Foot Ankle 1989;
10:81–87.
535
11. Carr JB, Scherl J. Small incision approach for intraarticular calcaneal
fractures. Presented at: O rthopaedic Trauma Association annual
meeting; 1998; Toronto, O ntario, Canada.
12. Carr JB, Tigges R, Wayne J, et al. Internal fixation of experimental
calcaneal fractures: a biomechanical analysis of two fixation meth-
ods. J O rthop Trauma 1997;11:425–429.
13. Ebraheim N , Elgafy H , Sabry F, et al. Sinus tarsi approach with
trans-articular fixation for displaced intra-articular fractures of the
calcaneus. Foot Ankle 2000;21:105–113.
14. Folk J, Starr A, Early J. Early wound complications of operative treat-
ment of calcaneus fractures: analysis of 190 fractures. J O rthop
Trauma 1999;13:369–372.
15. Fernandez D, Koella C. Combined percutaneous and “ minimal”
internal fixation for displaced articular fractures of the calcaneus.
Clin O rthop Relat Res 1993;290:108–116.
16. Gupta A, Ghalambor N , N ihal A, Trepman E. The modified Palmer
lateral approach for calcaneal fractures: wound healing and postop-
erative computed tomographic evaluation of fracture reduction. Foot
Ankle 2003;24:744–753.
17. Johnson E, Gebhardt J. Surgical management of calcaneal fractures
using bilateral incisions and minimal internal fixation. Clin O rthop
Relat Res 1993;290:117–124.
18. Koski A, Koukkanen H , Tukiainen E. Postoperative wound compli-
cations after internal fixation of closed calcaneal fractures: a retro-
spective analysis of 126 consecutive patients with 148 fractures.
Scand J Surg 2005;94:243–245.
19. Letrounel E. O pen treatment of acute calcaneal fractures. Clin
O rthop Relat Res 1993;290:60–67.
20. Levine D, H elfet D. An introduction of the minimally invasive os-
teosynthesis of intra-articular calcaneal fractures. Injury 2001;32:
S-A51–54.
21. Lindsay WR, Dewar FP. Fractures of the os calcis. Am J Surg
1958;95(4):555–576.
22. M cReynolds J. The surgical treatment of fractures of the os calcis.
O rthop Trans 1982;3:415.
23. Rammelt S, Amlang M , Barthel S, et al. M inimally-invasive treatment
of calcaneal fractures. Injury 2004;35:S-B55–63.
24. Rammelt S, Gavlik J, Barthel S, et al. The value of subtalar arthroscopy
in the management of intra-articular calcaneus fractures. Foot Ankle
2002;23:906–916.
25. Raymakers J, Dekkers G, Brink P. Results after operative treatment
of intra-articular calcaneal fractures with a minimum follow-up of 2
years. Injury 1998;29:593–599.
26. Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone
Joint Surg Am 2000;82A:225–250.
27. Sanders R, Fortin P, DiPasquale T, et al. O perative treatment in 120
displaced intraarticular calcaneal fractures: results using a prognostic
computed tomography scan classification. Clin O rthop Relat Res
1993;290:87–95.
28. Stephenson J. Surgical treatment of displaced intraarticular fractures of
the calcaneus: a combined lateral and medial approach. Clin O rthop
Relat Res 1993;290:68–75.
29. Thordarson D, Krieger L. O perative vs. nonoperative treatment of
intra-articular fractures of the calcaneus: a prospective randomized
trial. Foot Ankle 1996;17:2–9.
30. Thordarson D, Latteier M . O pen reduction and internal fixation of
calcaneal fractures with a low profile titanium calcaneal perimeter
plate. Foot Ankle 2003;24:217–221.
31. Tornetta P. O pen reduction and internal fixation of the calcaneus
using minifragment plates. J O rthop Trauma 1996;10:63–67.
32. Tornetta P. Percutaneus treatment of calcaneal fractures. Clin O rthop
Relat Res 2000;375:91–96.
33. Tornetta P III. The Essex-Lopresti reduction for calcaneal fractures
revisited. J O rthop Trauma 1998;12:469–473.
34. Z wipp H , Tscherne H , Therman H , et al. O steosynthesis of displaced
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 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 54 Fix a t io n o f Lis f r a n c In ju r ie s
M ich ae l P. Clare an d Ro y W . San d e rs
DEFIN ITION
■ A Lisfranc injury refers to bony or ligamentous compromise
of the tarsometatarsal and intercuneiform joint complex and
includes a spectrum of injuries ranging from a stable, partial
sprain to a grossly displaced and unstable fracture or fracture-
dislocation of the midfoot.
AN ATOMY
■ The bony elements of the medial three tarsometatarsal joints
(medial, middle, and lateral cuneiforms and first, second, and
third metatarsal bases) feature a unique trapezoidal shape in
cross-section, creating a concave arrangement plantarly resem-
bling a Roman arch (FIG 1 A).
■ The second metatarsal is recessed between the medial and
lateral cuneiforms in the axial plane and is positioned at the
apex of the Roman arch in the coronal plane. It thus functions
as the keystone of the entire midfoot complex (FIG 1 B).
■ The tarsometatarsal joints are stabilized by dorsal and plan-
tar tarsometatarsal ligaments.
■ Dorsal and plantar intermetatarsal ligaments provide fur-
ther stability between the second through fifth metatarsal
bases.
■ There are no intermetatarsal ligaments between the first and
second metatarsals, which may predispose the area to injury.
■ The Lisfranc ligament courses from the plantar portion of
the medial cuneiform to the base of the second metatarsal
(FIG 1 C).
■ The unique bony arrangement of the medial midfoot imparts
inherent bony stability to the medial and middle columns of the
foot, which in combination with the stout plantar ligaments pre-
vents plantar displacement of the metatarsal bases and facili-
tates the weight-bearing function of the first ray (FIG 2 ).
■ The medial three tarsometatarsal joints and the adjacent in-
tercuneiform and naviculocuneiform articulations (medial and
middle columns) have limited inherent motion, making these
joints nonessential to normal foot function and therefore rela-
tively expendable.
■ The medial column refers to the first tarsometatarsal and
navicular–medial cuneiform articulations; the middle col-
umn includes the second and third tarsometatarsal joints,
and articulations between the navicular and middle and lat-
eral cuneiforms, respectively.
■ The fourth and fifth tarsometatarsal (lateral column) joints
have distinctly more inherent motion and are critical in accom-
modation of the foot to uneven surfaces.
■ These joints are considered essential joints to normal foot
function and therefore nonexpendable.
PATHOGEN ESIS
■ Lisfranc injuries are generally the result of a high-energy in-
jury, such as a fall from a height or a high-speed motor vehicle
accident, but depending on the position of the foot, they may
536
also result from a lower-energy injury, such as a slip and
ground-level fall.
■ These injuries result from a combination of axial load, and
dorsiflexion, plantarflexion, abduction, or adduction (or vari-
able combinations thereof) of the midfoot.
■ The pathoanatomy is individually specific and highly vari-
able and may consist of a pure ligamentous injury, a pure bony
injury (fracture), or a combination.
■ While the injury classically includes the first, second, and
third tarsometatarsal joints, there may be involvement of all five
tarsometatarsal articulations, extension into the intercuneiform
joints, or even fracture lines into the navicular or cuboid proxi-
mally, or metatarsal shafts or necks distally.
■ In pure ligamentous patterns, the stability of the injury de-
pends on the status of the plantar tarsometatarsal ligaments.
Disruption of these stout structures makes the injury unstable.
■ Partial injuries (sprains) occur as a result of lower energy
and are more common with axial load and plantarflexion,
such as in competitive sports.
■ In this instance, by definition the plantar tarsometatarsal
ligaments remain intact, making the injury stable.
N ATURAL HISTORY
■ Stable injuries (partial sprains, extra-articular fractures) often
require prolonged recovery time. When accurately diagnosed,
however, patients with these injuries can generally expect
full recovery and return to activity with minimal long-term
implications.7
■ Unstable injuries that are misdiagnosed or inadequately
treated generally go on to a poor result with persistent pain,
activity limitations, and progressive posttraumatic arthritis in
the involved joints,2,3 necessitating arthrodesis as salvage.4,9
■ A high index of suspicion must therefore be maintained; his-
torically up to 20% of unstable Lisfranc injuries are misdiag-
nosed on plain radiographs.3
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ The physician should obtain a history of trauma and details
of the exact injury mechanism (position of foot, direction of
force, extent of energy involved).
■ The physician should observe any initial swelling and inabil-
ity to bear weight.
■ A thorough examination of the involved foot and ankle also
includes assessment of associated injuries and any other areas
of swelling or tenderness to palpation.
■ The physician should observe the skin and soft tissue enve-
lope. Diffuse swelling of the midfoot or plantar ecchymosis at
the midfoot suggests a Lisfranc injury.
■ The physician should palpate the midfoot joints; pain at the
midfoot with palpation suggests a Lisfranc injury (see Exam
Table for Pelvis and Lower Extremity Trauma, pages 1 and 2).

A ■ The medial border of the second metatarsal should
B C
FIG 1 • A. Axia l CT im a g e d e p ict in g t h e Ro m a n a rch co n fig u ra -
t io n o f t h e t a rso m e t a t a rsa l jo in t s. B. An a t o m ic sp e cim e n
d e m o n st ra t in g t h e ke yst o n e o f t h e Ro m a n a rch : t h e se co n d
m e t a t a rsa l b a se is re ce sse d b e t w e e n t h e m e d ia l a n d la t e ra l
cu n e ifo rm s (b lack arro w ). C. Lig a m e n t o u s co n n e ct io n s o f t h e
t a rso m e t a t a rsa l re g io n .
■ The physician should test midfoot stability with passive
flexion of the metatarsal heads and passive abduction and
adduction through the forefoot. Pain at the tarsometatarsal
joint region with passive forefoot range of motion suggests a
Lisfranc injury.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Initial radiographic evaluation consists of non-weight-bearing
anteroposterior (AP), oblique, and lateral views of the foot,
which, depending on the extent of intra-articular displacement,
may provide sufficient diagnostic information (FIG 3 A–C).
■ Fluoroscopic stress views may be helpful in more subtle in-
juries; however, these studies are painful and generally require
anesthesia.
■ We therefore prefer weight-bearing radiographs of the foot
for more subtle injuries (FIG 3 D–H); comparison weight-bear-
ing radiographs of the contralateral foot may also be obtained
where necessary.
FIG 2 • No rm a l w e ig h t -b e a rin g la t e ra l ra d io g ra p h d e m o n st ra t -
in g n o rm a l a lig n m e n t o f t h e m e d ia l co lu m n a n d t h e w e ig h t -
b e a rin g first ra y (w h it e lin e ).
Ch a p t e r 5 4 ORIF OF LISFRANC INJURIES 537
■ The weight-bearing AP view of the foot will demonstrate
intra-articular displacement through the first and second tar-
sometatarsal joints (so-called Lisfranc joint), intercuneiform
joint, and naviculocuneiform joint; fractures through the first
and second metatarsal bases, medial and middle cuneiforms,
and proximal extension into the navicular; and the extent of
columnar shortening or asymmetry.
align with the medial border of the middle cuneiform
(FIG 3 D).
■ The oblique view will reveal intra-articular displacement
through the third, fourth, and fifth tarsometatarsal joints,
and fractures of the third, fourth, and fifth metatarsal bases,
lateral cuneiform, and cuboid.
■ The medial borders of the third and fourth metatarsals
should align with the medial borders of the lateral
cuneiform and cuboid, respectively (FIG 3 E).
■ The lateral view may reveal dorsal–plantar displace-
ment of fractures or dislocations, as well as any flattening of
the medial longitudinal arch, thereby reflecting the status of
the weight-bearing medial column and first ray (FIG 3 F).
■ Computed tomography (CT) scanning may also be benefi-
cial in the instance of a subtle Lisfranc injury, particularly in a
polytrauma patient or a patient with multiple extremity in-
juries that preclude weight-bearing radiographs; and to delin-
eate proximal fracture line extension into the navicular,
cuboid, or cuneiforms (FIG 4 ).
DIFFEREN TIAL DIAGN OSIS
■ Partial Lisfranc injury (sprain)
■ Isolated metatarsal fracture
■ N avicular–cuneiform fracture
■ Anterior process of calcaneus fracture
■ Lateral ankle sprain
N ON OPERATIVE MAN AGEMEN T
■ N onoperative treatment is indicated for partial Lisfranc in-
juries (sprains), which by definition are stable and therefore
nondisplaced on weight-bearing radiographs.
■ N onoperative treatment is also indicated for nondisplaced
or minimally displaced extra-articular metatarsal base frac-
tures with no intra-articular involvement (displacement) on
weight-bearing radiographs.
■ Because of the often subtle nature of Lisfranc injuries and
the negative consequences of misdiagnosis, if the findings are
inconclusive, weight-bearing radiographs may be repeated 2 to
3 weeks after the injury.
■ N onoperative management consists of immobilization in
a venous compression stocking and prefabricated fracture boot.
■ The patient is allowed to bear weight to tolerance, and
early progression to range of motion is encouraged.
■ The patient continues in the fracture boot for 5 to 6
weeks, at which point maintenance of alignment or radi-
ographic union is confirmed on repeat weight-bearing
radiographs.
■ The patient is then allowed to wear regular shoes, and ac-
tivities are advanced as tolerated thereafter.
■ Full recovery and return to sports or other rigorous activity
may require up to 3 to 4 months.
538 Se c t i o n VI FOOT AND ANKLE

A B D

E F G H

FIG 3 • No n -w e ig h t -b e a rin g AP (A), o b liq u e (B), a n d la t e ra l (C) ra d io g ra p h s o f g ro ssly u n st a b le , p u re ly lig a m e n t o u s, Lisfra n c d islo ca -
t io n in vo lvin g a ll five t a rso m e t a t a rsa l a rt icu la t io n s. Ma rke d la t e ra l su b lu xa t io n t h ro u g h a ll five t a rso m e t a t a rsa l jo in t s is e vid e n t o n t h e
AP a n d o b liq u e vie w s, a n d sig n ifica n t d o rsa l d isp la ce m e n t is e vid e n t o n t h e la t e ra l vie w . We ig h t -b e a rin g la t e ra l (D), AP (E), a n d
o b liq u e (F), a n d n o n -w e ig h t -b e a rin g (G) a n d o b liq u e (H) ra d io g ra p h s o f m o re su b t le Lisfra n c in ju ry. La t e ra l a n d p la n t a r su b lu xa t io n
(b lack arro w s) is e vid e n t o n t h e w e ig h t -b e a rin g ra d io g ra p h s, a n d d isp la ce m e n t o f n o rm a l ra d io g ra p h ic la n d m a rks (b lack lin e s)
co n firm s in ju ry.
 Ch a p t e r 5 4 ORIF OF LISFRANC INJURIES 539

A B
FIG 4 • CT sca n sh o w in g d isp la ce m e n t t h ro u g h se co n d
t a rso m e t a t a rsa l a n d in t e rcu n e ifo rm a rt icu la t io n s (A) a n d in t ra -
a rt icu la r fra ct u re o f n a vicu la r (B, b lack arro w s) in a d iffe re n t
p a t ie n t .

SURGICAL MAN AGEMEN T

■ Surgical management is indicated for unstable (displaced)
injuries of the midfoot, including pure ligamentous, bony, or FIG 5 • Clo se d re d u ct io n o f Lisfra n c d islo ca t io n ; d isp la ce d fra g -
variable combinations. m e n t s w e re t e n t in g skin .
■ Recent studies suggest that pure ligamentous Lisfranc in-

juries are best managed with open reduction and primary

arthrodesis of the medial and middle columns.6
■ Any dislocation producing tension on the overlying skin and
soft tissue envelope should be immediately reduced and immo-
bilized (FIG 5 ).
■ Definitive surgery is generally delayed 10 to 14 days to
exposure to the fourth and fifth tarsometatarsal joints where
necessary.
■ A third, more proximal and lateral incision may be required
to stabilize the cuboid where necessary.
■ Because of the limited soft tissue envelope overlying the

allow adequate resolution of soft tissue swelling. midfoot, the importance of meticulous soft tissue handling
and maintaining full-thickness soft tissue flaps cannot be
Preoperative Planning overemphasized.
■ The injury and weight-bearing radiographs and CT images
are reviewed and the injury is classified,8 which allows plan-
ning for the anticipated pathoanatomy of the injury.
■ Pure ligamentous injuries require rigid screw fixation for the

medial and middle column joints and Kirschner wire fixation

for the lateral column joints; bony injury patterns, particularly
those with more comminution, may require minifragment
bridge plate fixation.1,5
Positioning
■ The patient is placed supine with a bolster beneath the ipsilat-
eral hip. Protective padding is placed around the contralateral
limb, primarily to protect the peroneal nerve, and the contralat-
eral limb is secured to the table.
■ A sterile bolster is placed beneath the operative limb at

the knee to facilitate access to the midfoot and intraoperative

fluoroscopy.
Approach
■ We prefer the dual-incision approach (FIG 6 ).
■ The medial incision courses directly over the extensor hal-

lucis longus (EH L) tendon and is centered over the first tar-
sometatarsal joint. It affords access to the first and second
tarsometatarsal joints.
■ The lateral incision is centered over the lateral border of

the third tarsometatarsal joint. If extended, it also provides FIG 6 • Pla n n e d in cisio n s fo r d u a l in cisio n a p p ro a ch .
 540 Se c t i o n VI FOOT AND ANKLE
TECHNIQUES

MEDIAL INCISION
■ Th e m e d ia l in cisio n is m a d e d ire ct ly o ve r t h e EHL t e n d o n
a n d is ce n t e re d o ve r t h e first t a rso m e t a t a rsa l jo in t .
■ Th e t e n d o n sh e a t h is in cise d d o rsa lly, a n d t h e EHL is
re t ra ct e d la t e ra lly (TECH FIG 1 A).
■ Th e flo o r o f t h e t e n d o n sh e a t h is t h e n in cise d a n d su b p e -
rio st e a l d isse ct io n co m m e n ce s m e d ia lly, e xt e n d in g t o t h e
m e d ia l m a rg in o f t h e first t a rso m e t a t a rsa l jo in t a n d p ro -
d u cin g a fu ll-t h ickn e ss fla p .
■ Su b p e rio st e a l d isse ct io n t h e n e xt e n d s la t e ra lly t o t h e la t -
e ra l m a rg in o f t h e se co n d t a rso m e t a t a rsa l jo in t , a g a in
p ro d u cin g a fu ll-t h ickn e ss fla p , w h ile p re se rvin g t h e
a d ja ce n t n e u ro va scu la r b u n d le w it h in t h e so ft t issu e fla p
(TECH FIG 1 B).
■ Th e st a t u s is n o t e d o f e a ch o f t h e t a rso m e t a t a rsa l a n d in -
t e rcu n e ifo rm jo in t ca p su le s d o rsa lly, a n d t h e re fo re t h e
e xt e n t o f in st a b ilit y o f e a ch jo in t (TECH FIG 1 C,D).
■ We p re fe r u sin g t h e m e d ia l (EHL) in cisio n fo r a cce ss t o
t h e se co n d t a rso m e t a t a rsa l a n d in t e rcu n e ifo rm jo in t s,
e ve n if t h e first t a rso m e t a t a rsa l jo in t is n o t in vo lve d , b e -
ca u se t h e n e u ro va scu la r b u n d le re m a in s p ro t e ct e d
w it h in t h e fu ll-t h ickn e ss fla p .

EHL

B C

TECH FIG 1 • A,B. Me d ia l in cisio n . A. De e p d isse ct ion co n t inu e s m e d ia l

t o e xt e n so r h a llu cis lo n g u s t e n d o n . B. Fu ll-t hickn e ss su b pe rio st e a l fla p s
p ro vid e a cce ss t o first a n d se co n d t a rso m e t a t a rsa l, a n d m e d ia l-m id d le
in t e rcu n e ifo rm jo in t s. C,D. Gro ss in st a b ilit y t h rou g h first t a rso m e t a t a rsa l
jo in t (C) a n d se co n d t a rso m e t a t a rsa l a n d in t e rcu ne ifo rm jo in t s (D) in a
D d iffe re n t p a t ie n t .

LATERAL INCISION
■ A Fre e r e le va t o r is p la ce d b e n e a t h t h e fu ll-t h ickn e ss
fla p t o t h e le ve l o f t h e t h ird t a rso m e t a t a rsa l jo in t ,
a n d t h e la t e ra l in cisio n is m a d e o ve rlyin g t h e la t e ra l
b o rd e r.
■ Disse ct io n e xt e n d s t h ro u g h t h e o ve rlyin g e xt e n so r re t i-
n a cu lu m , e xp o sin g t h e e xt e n so r d ig it o ru m co m m u n is
A
t e n d o n a n d m e d ia l m a rg in o f t h e e xt e n so r d ig it o ru m
b re vis m u scle , b o t h o f w h ich a re re t ra ct e d la t e ra lly
(TECH FIG 2 ).
■ Ca re is t a ke n n o t t o vio la t e t h e a d ja ce n t n e u ro va scu -
la r b u n d le , w h ich is m a in t a in e d w it h in it s so ft t issu e Base of the 3rd metatarsal
e n ve lo p e .
■ Th e u n d e rlyin g t h ird t a rso m e t a t a rsa l jo in t ca p su le is
id e n t ifie d a n d a fu ll-t h ickn e ss su b p e rio st e a l fla p is d e -
ve lo p e d e xt e n d in g m e d ia lly t o w a rd t h e la t e ra l p o rt io n
o f t h e se co n d t a rso m e t a t a rsa l jo in t , a n d la t e ra lly t o - B
w a rd t h e fo u rt h a n d fift h t a rso m e t a t a rsa l jo in t s w h e re
TECH FIG 2 • La t e ra l in cisio n . De e p d isse ct io n co n t in u e s m e -
n e ce ssa ry. d ia l t o e xt e n so r d ig it o ru m co m m u n is t e n d o n a n d e xt e n so r d ig -
■ Ag a in , t h e st a t u s is n o t e d o f e a ch o f t h e t a rso m e t a t a rsa l it o ru m b re vis m u scle (A) a n d e xp o se s t h e t h ird t a rso m e t a t a rsa l
a n d in t e rcu n e ifo rm jo in t ca p su le s d o rsa lly, a n d t h e re fo re a n d t h e la t e ra l p ort io n o f t h e se co n d t a rso m e t a t a rsa l (n o t
t h e e xt e n t o f in st a b ilit y o f e a ch jo in t . visu a lize d h e re ) jo in t s (B).

ARTICULAR SURFACE ASSESSMENT AND DECISION MAKING
■ Th e fra ct u re lin e s a n d a rt icu la r su rfa ce o f t h e in vo lve d
jo in t s a re t h e n d é b rid e d o f re sid u a l h e m a t o m a a n d a s-
se sse d fo r ch o n d ra l d a m a g e .
■ If m o re t h a n 50% o f t h e a rt icu la r su rfa ce o f t h e m e d ia l
a n d m id d le co lu m n jo in t s is in vo lve d , p rim a ry a rt h ro d e -
sis sh o u ld b e co n sid e re d , a lt h o u g h t h is is co n t ro ve rsia l.
■ Art h ro d e sis o f t h e fo u rt h a n d fift h t a rso m e t a t a rsa l jo in t s
sh o u ld b e a vo id e d if p o ssib le .
PROVISIONAL REDUCTION AND DEFINITIVE STABILIZATION
Fir s t Ta r s o m e t a t a r s a l Jo in t
■ Th e p ro visio n a l re d u ct io n b e g in s m e d ia lly a t t h e
first t a rso m e t a t a rsa l jo in t if in ju re d . Alt h o u g h t h e
e xa ct re d u ct io n m a n e u ve r m a y va ry d e p e n d in g o n
t h e in ju ry p a t t e rn , t h e first m e t a t a rsa l is t yp ica lly
su p in a t e d (e xt e rn a lly ro t a t e d ) re la t ive t o t h e m e d ia l
cu n e ifo rm .
■ Co rre ct io n o f t h is ro t a t io n a l d e fo rm it y is cru cia l in re st o r-
in g t h e m e d ia l co lu m n a n d t h e w e ig h t -b e a rin g fu n ct io n
o f t h e first ra y. Th e re d u ct io n o f t h e re m a in in g m id fo o t
jo in t s d e p e n d s o n a n a n a t o m ic re d u ct io n o f t h e first t a r-
so m e t a t a rsa l jo in t .
■ Th e p ro visio n a l re d u ct io n is h e ld w it h a 2.0-m m
Kirsch n e r w ire a n d co n firm e d u n d e r flu o ro sco p y (TECH
FIG 3 A).
A B
TECH FIG 3 • Re d u ct io n a n d st a b iliza t io n o f first t a rso m e t a t a rsa l jo in t .
A. Pro visio n a l re d u ct io n . B. Dist a l-t o -p ro xim a l scre w . C. Pro xim a l-
D t o -d ist a l scre w . D. Lo n g b ico rt ica l t ra je ct o ry o f scre w s fo r e n h a n ce d st a b ilit y.
Ch a p t e r 5 4 ORIF OF LISFRANC INJURIES 541
TECHNIQUES
■ If p rim a ry a rt h ro d e sis is e le ct e d , t h e in vo lve d jo in t s a re
m e t icu lo u sly d é b rid e d o f re sid u a l a rt icu la r ca rt ila g e , p re -
se rvin g t h e u n d e rlyin g su b ch o n d ra l p la t e .
■ Th e jo in t s a re irrig a t e d a n d t h e su b ch o n d ra l p la t e is
p e rfo ra t e d w it h a 2.0-m m d rill b it t o st im u la t e va scu -
la r in g ro w t h .
■ Su p p le m e n t a l a llo g ra ft m ixe d w it h h ig h ly co n ce n -
t ra t e d p la t e le t a sp ira t e is t h e n p la ce d w it h in t h e in -
vo lve d jo in t sp a ce s.
■ De fin it ive st a b iliza t io n is t h e n o b t a in e d a t t h e first t a r-
so m e t a t a rsa l jo in t w it h 3.5-m m so lid co rt ica l p o sit io n
scre w s (TECH FIG 3 B–D).
■ Th e first scre w is p la ce d fro m d ist a l t o p ro xim a l, st a rt -
in g a t t h e d o rsa l cre st a n d d ist a l t o t h e m e t a p h y-
se a l–d ia p h yse a l ju n ct io n , a n d is a n g le d t o w a rd t h e
p la n t a r–p ro xim a l co rt e x o f t h e m e d ia l cu n e ifo rm ; t h is
scre w is g e n e ra lly 45 t o 50 m m lo n g .
■ A se co n d scre w is p la ce d fro m p ro xim a l t o d ist a l st a rt -
in g a t t h e e d g e o f t h e n a vicu lo cu n e ifo rm jo in t , a n d
sim ila rly a n g le d t o e xit a t t h e p la n t a r co rt e x d ist a l t o
t h e m e t a p h yse a l–d ia p h yse a l ju n ct io n . Th is scre w t yp -
ica lly m e a su re s 40 t o 45 m m .
■ In a p rim a ry a rt h ro d e sis, t h e se scre w s a re p la ce d in
la g fa sh io n .
■ Fo r la rg e r p a t ie n t s, 4.0-m m co rt ica l scre w s m a y b e
u se d fo r fu rt h e r st a b ilit y.
C
 542 Se c t i o n VI FOOT AND ANKLE
TECHNIQUES

A B C
TECH FIG 4 • Re d u ct io n a n d st a b iliza t io n o f Lisfra n c jo in t . A. Po in t e d re d u ct io n fo rce p s. B. Su p p le m e n t a l
Kirsch n e r w ire . C. Scre w fixa t io n . Tra je ct o ry o f scre w m irro rs t h e n o rm a l p a t h o f lig a m e n t o u s st ru ct u re s.
In t e rcu n e ifo rm jo in t w a s p re vio u sly re d u ce d a n d st a b ilize d a s in it ia l st e p .

Lis f r a n c Jo in t t o w a rd t h e p ro xim a l m e t a p h ysis o f t h e se co n d

■ A p o in t e d re d u ct io n fo rce p s is t h e n p la ce d fro m
t h e m e d ia l cu n e ifo rm t o t h e la t e ra l b o rd e r o f t h e se co n d
m e t a t a rsa l t o a n a t o m ica lly re d u ce t h e so -ca lle d Lisfra n c
jo in t ; ca re is t a ke n t o e n su re a ccu ra t e d o rsa l–p la n t a r
a lig n m e n t o f t h e se co n d t a rso m e t a t a rsa l jo in t .
■ Th e re d u ct io n is co n firm e d u n d e r flu o ro sco p y, a n d a
2.0-m m Kirsch n e r w ire t h a t m irro rs t h e in t e n d e d p a t h
o f t h e scre w is p la ce d t o p ro vid e fu rt h e r ro t a t io n a l co n -
t ro l (TECH FIG 4 A,B).
■ Th e re is t yp ica lly a d ist in ct co rt ica l “ sh e lf” o n t h e m e d ia l
cu n e ifo rm t h a t p ro vid e s a n e xce lle n t b u t t re ss fo r scre w
p u rch a se .
■ A 3.5-m m co rt ica l scre w is p la ce d t h ro u g h a st a b in ci-
sio n o ve rlyin g t h is co rt ica l sh e lf m e d ia lly, a n g lin g
m e t a t a rsa l; fo r a p rim a ry a rt h ro d e sis, t h is scre w is
p la ce d in la g fa sh io n (TECH FIG 4 C).
Ot h e r Jo in t s
■ If t h e in t e rcu n e ifo rm jo in t is in vo lve d , it is first re d u ce d
a n d st a b ilize d b e fo re st a b ilizin g t h e Lisfra n c jo in t (TECH
FIG 5 A). Alt e rn a t ive ly, t h is jo in t m a y a lso b e re d u ce d a n d
st a b ilize d b e fo re st a b ilizin g t h e first t a rso m e t a t a rsa l
jo in t .
■ A 3.5-m m co rt ica l scre w is a g a in u se d , co u rsin g
p a ra lle l t o t h e p la n e o f t h e n a vicu lo cu n e ifo rm jo in t . It
is p la ce d in la g fa sh io n fo r a p rim a ry a rt h ro d e sis.
■ Ca re is t a ke n n o t t o vio la t e t h e a rt icu la t io n b e t w e e n
t h e m id d le a n d la t e ra l cu n e ifo rm .

A B C

TECH FIG 5 • A. Re d u ct io n a n d st a b iliza t io n o f in t e rcu n e ifo rm jo in t .

B. Re d u ct io n a n d st a b iliza t io n o f se co n d t a rso m e t a t a rsa l jo in t . C. Re d u ct io n
D a n d st a b iliza t io n o f t h ird t a rso m e t a t a rsa l jo in t .

A B
■ Th e se co n d t a rso m e t a t a rsa l jo in t is t h e n p ro visio n a lly
re d u ce d a n d p ro visio n a lly st a b ilize d w it h a 1.6-m m
Kirsch n e r w ire .
■ De fin it ive fixa t io n is o b t a in e d w it h a co u n t e rsu n k
2.7-m m co rt ica l scre w fro m d ist a l t o p ro xim a l; it is
p la ce d in la g fa sh io n fo r a p rim a ry a rt h ro d e sis (TECH
FIG 5 B).
■ Th e t h ird t a rso m e t a t a rsa l jo in t is re d u ce d a n d st a b ilize d
in id e n t ica l fa sh io n (TECH FIG 5 C).
■ Fo r a m e t a t a rsa l b a se fra ct u re o r fra ct u re -d islo ca t io n
p a t t e rn p re clu d in g t ra n sa rt icu la r fixa t io n , b rid g e p la t e
fixa t io n m a y b e re q u ire d .
■ We p re fe r a lo w -p ro file (2.0 o r 2.4 m m ) re co n st ru c-
t io n p la t e a n d 2.4-m m co rt ica l scre w s (TECH FIG 6 ).
■ The fourth and fifth tarsometatarsal joints are then re-
d u ce d a n d d e fin it ive ly st a b ilize d w it h 1.6-m m Kirsch n e r
wires.
■ Because the int e rmeta ta rsa l lig a me nts bet wee n t he
third, fourt h, an d fift h meta ta rsa ls a re oft e n pre served ,
t h e se jo in t s m a y a n a t o m ica lly re d u ce in d ire ct ly,
the re by allo wing percut an e ou s sta b ilization.
TECH FIG 7 • Kirsch n e r w ire fixa t io n o f fo u rt h a n d fift h t a r-
so m e t a t a rsa l jo in t s.
Ch a p t e r 5 4 ORIF OF LISFRANC INJURIES 543
TECHNIQUES
TECH FIG 6 • Brid g e p la t e fixa t io n o f se co n d
a n d t h ird m e t a t a rsa l b a se s (A) a n d se co n d a n d
t h ird t a rso m e t a t a rsa l jo in t s (B) in a d iffe re n t
p a t ie n t .
■ Th e Kirsch ne r w ires are co n t o u red a n d bu ried ben e at h
t h e skin la yer t h ro u g h sep ara te sta b in cisio n s, wh ich
fa cilit a t e s re mo va l a t 6 w e e ks p o st o p e ra t ive ly, e ith e r
in the o ffice unde r loca l an est he sia or in th e o perat ing
ro o m u n d e r se d a t io n (TECH FIG 7).
■ Fo r a cu b o id fra ct u re , t h e cu b o id is re d u ce d a n d
d e fin it ive ly st a b ilize d t o e n su re re st o ra t io n o f la t e ra l
co lu m n le n g t h b e fo re st a b ilizin g t h e fo u rt h a n d fift h
t a rso m e t a t a rsa l jo in t s; b y d e fin it io n , t h is is t h e n a n
o p e n re d u ct io n (TECH FIG 8 A).
■ Fin a l flu o ro sco p ic im a g e s a re o b t a in e d , co n firm in g
a rt icu la r re d u ct io n a n d im p la n t p la ce m e n t (TECH
FIG 8 B).
TECH FIG 8 • A. Re d u ct io n a n d st a b iliza t io n o f cu b o id
t h ro u g h se p a ra t e p ro xim a l–la t e ra l in cisio n . B. Flu o ro sco p ic
im a g e .
 544 Se c t i o n VI FOOT AND ANKLE
TECHNIQUES

CLOSURE
■ Th e w o u n d s a re irrig a t e d , a n d clo su re co m m e n ce s w it h
t h e m e d ia l in cisio n . Th e flo o r o f t h e EHL t e n d o n sh e a t h
(a n d su b p e rio st e a l fla p s) is clo se d w it h d e e p n o . 0 a b -
so rb a b le su t u re , t h e re b y se a lin g t h e in t ra -a rt icu la r su r-
fa ce s o f t h e first a n d se co n d t a rso m e t a t a rsa l jo in t s a n d
in t e rcu n e ifo rm jo in t s.
■ Th e EHL t e n d o n sh e a t h is clo se d in sim ila r fa sh io n ,
t h e re b y se a lin g t h e t e n d o n (TECH FIG 9 A).
■ Th e re m a in d e r o f t h e in cisio n is clo se d in la ye re d fa sh io n
w it h su b cu t a n e o u s 2-0 a b so rb a b le su t u re , a n d 3-0
m o n o fila m e n t su t u re fo r t h e skin la ye r u sin g t h e m o d i-
fie d Allg ö w e r-Do n a t i t e ch n iq u e (TECH FIG 9 B).
■ Th e t o u rn iq u e t is d e fla t e d a n d st e rile d re ssin g s a re A B
p la ce d , fo llo w e d b y a b u lky Jo n e s d re ssin g a n d We b e r
sp lin t . TECH FIG 9 • Wound closure. A. Dee p la yered clo su re se alin g
int ra-articular con te nts a nd e xt ensor hallucis long us te ndon.
B. Skin clo su re wit h m o d ifie d Allg ö w er-Do n at i te ch n iq u e.

PEARLS AND PITFALLS

Misd ia g n o sis o f p ro xim a l jo in t
in ju rie s (m e d ia l, m id d le , o r la t e ra l
cu n e ifo rm ; in t e rcu n e ifo rm jo in t ;
cu b o id fra ct u re )
Co rre ct in g p la n t a r d isp la ce m e n t o r
m a la lig n m e n t o f t h e first a n d
se co n d t a rso m e t a t a rsa l jo in t s
Co rre ct in g su p in a t io n m a lro t a t io n
o f first t a rso m e t a t a rsa l jo in t
De fin it ive fixa t io n o f first
t a rso m e t a t a rsa l jo in t
De fin it ive fixa t io n o f Lisfra n c jo in t
■ Be ca u se o f t h e h ig h ly va ria b le in ju ry p a t t e rn s, a h ig h in d e x o f su sp icio n m u st b e
m a in t a in e d . In ju ry ra d io g ra p h s m u st b e clo se ly scru t in ize d p re o p e ra t ive ly fo r p ro xim a l
jo in t in vo lve m e n t . If ra d io g ra p h s a re in co n clu sive , CT e va lu a t io n is w a rra n t e d . Du rin g
su rg e ry, t h e st a t u s is n o t e d o f e a ch o f t h e in t e rcu n e ifo rm jo in t ca p su le s d o rsa lly, a n d
t h e re fo re t h e e xt e n t o f in st a b ilit y o f e a ch jo in t .
■ St rict a t t e n t io n is p a id t o d o rsa l–p la n t a r a lig n m e n t o f t h e first a n d se co n d m e t a t a rsa ls
a n d t h e ir re sp e ct ive cu n e ifo rm s, b e ca u se p la n t a r d isp la ce m e n t o r m a la lig n m e n t
g re a t e r t h a n 2 m m m a y a ffe ct t h e w e ig h t -b e a rin g m e t a t a rsa l ca sca d e , p o t e n t ia lly
re su lt in g in a t ra n sfe r (m e t a t a rsa lg ia ) le sio n .
■ Th e re is t yp ica lly a d ist in ct d o rsa l cre st o n b o t h t h e first m e t a t a rsa l a n d m e d ia l
cu n e ifo rm . Th e y sh o u ld b e p re cise ly a lig n e d t o e n su re a n a ccu ra t e re d u ct io n .
■ Be ca u se o f t h e h a rd co rt ica l b o n e a t t h e d ia p h ysis o f t h e first m e t a t a rsa l, t h e
scre w h e a d o f t h e d ist a l-t o -p ro xim a l scre w is sp e cifica lly co u n t e rsu n k t o a vo id
co m p ro m ise o f t h e d o rsa l co rt e x a n d lo ss o f fixa t io n .
■ With fixatio n o f th e Lisfran c jo in t, th e screw mu st an g le slig h tly d o rsally (relative to t he
p la n tar foo t) to acco mm od ate th e n orma l “ Roma n arch” co n fig ura tio n in t he co ro n al pla ne .

POSTOPERATIVE CARE ■ We do not routinely remove hardware unless symptomatic

■ The patient is converted to a venous compression stocking
and prefabricated fracture boot, and early progression to mo-
tion is initiated.
■ The Kirschner wires traversing the lateral column joints
are removed 6 weeks postoperatively.
■ Weight bearing is not permitted until 10 to 12 weeks post-
operatively, at which point weight-bearing radiographs are ob-
tained to confirm maintenance of reduction.
■ The patient is gradually allowed to resume regular shoes,
and activity is advanced as tolerated thereafter.
or specifically requested by the patient, in which case the im-
plants may be removed at 1 year after surgery.
OUTCOMES
■ O utcomes after open reduction and internal fixation of
Lisfranc injuries are generally good overall, as patients have
relatively few activity limitations. An accurate diagnosis
and anatomic reduction are crucial to ensuring satisfactory
results. 5
■ O utcomes for pure ligamentous patterns are less predictable

■ In a primary arthrodesis, the limb is immobilized in serial
short-leg non-weight-bearing casts for 10 to 12 weeks after
surgery, at which point radiographic union is confirmed on
weight-bearing radiographs.
■ The patient is then converted to a venous compression
stocking and prefabricated fracture boot, and weight bear-
after open reduction and internal fixation; these patients tend
to have higher rates of posttraumatic arthritis.5 Primary
arthrodesis appears to be especially beneficial in this situation:
one recent study reported a greater than 90% return to prein-
jury level after primary arthrodesis.6
■ Late arthrodesis as salvage for posttraumatic arthritis pro-

ing is advanced as described previously. vides predictable pain relief and functional improvement.4,9

COMPLICATION S
■ Delayed wound healing, wound dehiscence, deep infection
■ M alunion or nonunion
■ Late displacement (premature implant removal)
■ N eurovascular compromise
■ Chronic pain
REFEREN CES
1. Arntz CT, Veith RG, H ansen ST. Fractures and fracture-dislocations of
the tarsometatarsal joint. J Bone Joint Surg Am 1988;70A:154–162.
2. Curtis M , M yerson M , Szura B. Tarsometatarsal injuries in the ath-
lete. Am J Sports M ed 1994;21:497–502.
3. Goossens M , DeStoop N . Lisfranc’s fracture-dislocations: etiology,
radiology, and results of treatment. Clin O rthop Relat Res 1983;176:
154–162.
Ch a p t e r 5 4 ORIF OF LISFRANC INJURIES 545
4. Komenda GA, M yerson M S, Biddinger KR. Results of arthrodesis of
the tarsometatarsal joints after traumatic injury. J Bone Joint Surg
Am 1996;78A:1665–1676.
5. Kuo RS, Tejwani N C, DiGiovanni CW, et al. O utcome after open re-
duction and internal fixation of Lisfranc joint injuries. J Bone Joint
Surg Am 2000;82:1609–1618.
6. Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint
injuries: primary arthrodesis compared with open reduction and in-
ternal fixation: a prospective, randomized study. J Bone Joint Surg
Am 2006;88A:514–520.
7. M eyer SA, Callaghan JJ, Albright JP, et al. M idfoot sprains in colle-
giate football players. Am J Sports M ed 1994;22:392–401.
8. M yerson M S, Fisher TR, Burgess RA, et al. Fracture-dislocations of
the tarsometatarsal joints: end results correlated with pathology and
treatment. Foot Ankle 1986;6:225–242.
9. Sangeorzan BJ, Veith RG, H ansen ST. Salvage of Lisfanc’s tar-
sometatarsal joints by arthrodesis. Foot Ankle Int 1990;4:193–200.
 Op e n Re d u ct io n a n d In t e r n a l
Ch a p t e r 55 Fix a t io n o f Jo n e s Fr a ct u re s
W illiam R. Cre e vy an d Se t h P. Le vit z
DEFIN ITION
■ A Jones fracture represents an acute injury at the
metaphyseal–diaphyseal junction of the fifth metatarsal. The
fracture should not have extension distal to the fourth–fifth
intermetatarsal articulation (FIG 1 ).
■ This fracture is often seen as a result of sporting or athletic
activities.
■ The fracture begins on the lateral aspect of the fifth
metatarsal and may propagate into the metatarsocuboid joint.
■ Three subsets of the fracture exist, as described by Torg
(FIG 2 ):
■ Type 1: Acute fracture where the fracture line has sharp
margins and no intramedullary sclerosis. O ften involves only
the lateral cortex.
■ Type 2: Delayed union where fracture line involves both
cortices with associated periosteal bone formation, widening
of the fracture line, and evidence of intramedullary sclerosis
■ Type 3: N onunion demonstrated by bone resorption with
radiolucency at the fracture line and obliteration of the
medullary canal by sclerotic bone14
AN ATOMY
■ There are two major motor insertions onto the fifth
metatarsal:
■ The peroneus brevis inserts onto the dorsal aspect of the
fifth metatarsal tubercle.
■ The peroneus tertius inserts onto the dorsal aspect of the
metatarsal at the metaphyseal–diaphyseal junction.
■ The plantar fascia has a strong insertion along the plantar
aspect of the fifth metatarsal.
■ The shaft is supplied by a single nutrient artery that enters
from the medial cortex at the junction of the proximal and
middle thirds of the diaphysis. The base and tuberosity are
supplied by secondary epiphyseal and metaphyseal arteries
(FIG 3 ).12,13
PATHOGEN ESIS
■ Acute Jones fractures are the result of plantarflexion at the
ankle and adduction of the forefoot.
■ Tensile forces along the lateral border of the metatarsal re-
sult in a transverse fracture.
■ They are typically the result of sporting or athletic events,
with many instances described in football and basketball
players.
■ This should not be confused with a diaphyseal stress frac-
ture, where the athlete describes prodromal symptoms that
have existed for weeks to months. Radiographic assessment of
this type will demonstrate signs of a stress reaction.2
N ATURAL HISTORY
■The Jones fracture was originally described in 1902 by Sir
Robert Jones, who described a transverse fracture at the
546
metaphyseal–diaphyseal junction in four individuals, includ-
ing himself. 5
■ The natural history and outcomes of nonoperative and op-
erative treatment are difficult to determine because many
published reports include a mixture of acute Jones fractures
and diaphyseal stress fractures.
■ Various studies have examined nonoperative versus opera-
tive treatment.
■ O perative treatments have included internal fixation with or
without bone grafting and bone grafting alone.
■ N onoperative treatment of the acute fracture is associated
with an increased risk of delayed or nonunion due to the wa-
tershed blood supply at the metaphyseal–diaphyseal junction
in the metatarsal.
PATIEN T HISTORY AN D PHYSICAL
FIN DIN GS
■ The patient may describe participation in an athletic event
where, after a particular maneuver, there is an acute onset of
pain over the lateral border of the foot.
■ The patient may have swelling and ecchymosis over the lat-
eral border of the foot.
■ Pain will be elicited with direct palpation over the base of
the fifth metatarsal.
■ Physical examination should include:
■ Direct palpation over the base of the fifth metatarsal: Pain
in this region increases suspicion of injury.
■ Direct palpation over the tarsometatarsal joint complex:
Pain indicates possible injury to the Lisfranc complex.
■ Passive dorsiflexion–plantarflexion of individual metatarsal
heads: Pain indicates possible injury to the Lisfranc
complex.
■ Attempted single-limb heel lift: Pain indicates possible
injury to the Lisfranc complex.
IMAGIN G AN D OTHER DIAGN OSTIC
STUDIES
■ Radiographs of the affected foot, including anteroposterior,
lateral, and oblique, are sufficient to diagnose an acute Jones
fracture.
■ Weight-bearing radiographs of the affected foot are ob-
tained to rule out a Lisfranc injury.
DIFFEREN TIAL DIAGN OSIS
■ Diaphyseal stress fracture
■ Avulsion fracture of the base of the fifth metatarsal
■ Lisfranc sprain or subluxation
■ Cuboid fracture
N ON OPERATIVE MAN AGEMEN T
■ N on-weight bearing in a short-leg cast for 6 weeks, fol-
lowed by weight bearing in a walker boot for an additional
6 weeks
 Ch a p t e r 5 5 ORIF OF JONES FRACTURES 547

FIG 1 • Acu t e Jo n e s fra ct u re . Th e fra ct u re lin e is a t t h e

junct ion of Zones 1 and 2; t he re is no cort ica l hyp ert rophy or
p e rio st e a l re a ct io n .

■ Torg’s series of 15 patients demonstrated a 93% union rate Preoperative Planning

at an average of 6.5 weeks.14 ■ If percutaneous screw fixation of the fifth metatarsal is
■ Clapper reported union in 72% of acute Jones frac- planned, preoperative measurement of the intramedullary canal
tures treated with a non-weight-bearing short-leg cast for will ensure that the proper hardware is available.
8 weeks followed by weight bearing in a cast or walker
boot. 1 Positioning
■ The patient should be placed in the supine position on a ra-
SURGICAL MAN AGEMEN T diolucent table.
■ The indications for surgical fixation of an acute Jones frac- ■ A bolster should be placed under the ipsilateral buttock to

tures have not been clearly defined. increase the exposure to the lateral aspect of the foot.
■ H igh-performance athletes or individuals desiring a quicker ■ A C-arm image intensifier is used to assist in the operative

return to activity may benefit from intramedullary screw fixa- procedure. It is helpful to have the entire limb draped free so
tion, as this provides a more predictable and shorter recovery that the knee may be flexed past 90 degrees. This will also
period. facilitate imaging of the foot (FIG 4 ).

FIG 2 • To rg t yp e II d ia p h yse a l st re ss fra ct u re . Wid e n in g o f t h e fra ct u re lin e a n d p e rio st e a l b o n e fo rm a t io n

a re sh o w n .
 548 Se c t i o n VI FOOT AND ANKLE

Intramedullary
nutrient
artery

Metaphyseal
II vessels

A III B

FIG 3 • A. Th e t h re e a n a t o m ic a n d clin ica l zo n e s fo r fra ct u re s FIG 4 • Flu o ro sco p ic co n t ro l; fle xio n o f t h e kn e e p a st 90 d e g re e s

o f t h e p ro xim a l fift h m e t a t a rsa l. B. Art e ria l b lo o d su p p ly o f t h e a llo w s AP im a g in g .
fift h m e t a t a rsa l.

■ A tourniquet is not required but may be chosen based on ■ A longitudinal incision is made over the base of the fifth
surgeon preference. metatarsal.
■ Skin flaps are developed.
Approach ■ The peroneus brevis tendon is identified as it inserts onto the
■ A dorsolateral approach to the base of the fifth metatarsal is base of the fifth metatarsal.
preferred.
TECHNIQUES

PERCUTANEOUS INTRAMEDULLARY SCREW FIXATION

In cisio n a n d Disse ct io n
■ A 2- t o 3-cm in cisio n is m a d e p a ra lle l t o t h e p la n t a r su r-
fa ce o f t h e fo o t .
■ Th e in cisio n sh o u ld b e g in 2 cm p ro xim a l t o t h e t ip o f t h e
fift h m e t a t a rsa l t u b e ro sit y. Th e lo ca t io n sh o u ld b e co n -
firm e d w it h a C-a rm im a g e (TECH FIG 1 ).
■ Blu n t d isse ct io n is u se d t o e xp o se t h e t u b e ro sit y.
Scre w Po rt a l Cre a t io n a n d Gu id e w ire
Pla ce m e n t
■ Wit h a d rill g u id e u se d t o p ro t e ct t h e so ft t issu e s, a 2.5-
m m d rill is u se d t o o p e n t h e e n t ry p o rt a l fo r t h e scre w .
■ Th e co rre ct e n t ry sit e is o n e t h a t is in lin e w it h t h e
m e d u lla ry ca n a l ju st m e d ia l t o t h e t ip o f t h e t u b e ro s-
it y (TECH FIG 2 A).
TECH FIG 1 • Skin in cisio n p ro xim a l t o t u b e ro sit y.
■ Th e co rre ct st a rt in g p o sit io n is co n firm e d w it h a
C-a rm im a g e (TECH FIG 2 B).
■ Th e su rg e o n a d va n ce s t h e d rill d o w n t h e m e d u lla ry
ca n a l, e n su rin g t h a t t h e d rill p a sse s t h e fra ct u re sit e . Th is
sh o u ld b e p e rfo rm e d u n d e r b ip la n a r C-a rm g u id a n ce t o
e n su re p ro p e r d e p t h .
■ Le a vin g t h e d rill g u id e in p la ce , t h e su rg e o n re m o ve s t h e
d rill a n d p la ce s a g u id e w ire d o w n t h e in t ra m e d u lla ry
ca n a l (TECH FIG 2 C).
■ Th e g u id e w ire is a d va n ce d b y h a n d t o e n su re t h e co r-
t e x is n o t vio la t e d .
■ Pro p e r p la ce m e n t o f t h e g u id e w ire is co n firm e d w it h
b ip la n a r C-a rm im a g e s (TECH FIG 2 D,E).
Scre w Pla ce m e n t
■ Th e su rg e o n re a m s t h e in t ra m e d u lla ry ca n a l w it h a 3.2-
m m ca n n u la t e d d rill, le a vin g t h e d rill sle e ve in p la ce t o
p ro t e ct so ft t issu e s (TECH FIG 3 A,B).
■ Th e d rill sh o u ld b e p a sse d d ist a l t o t h e fra ct u re sit e .
■ Th e p ro xim a l e n d is t h e n re a m e d w it h a 4.5-m m d rill. Th is
fa cilit a t e s co u n t e rsin kin g t h e scre w t o a vo id so ft t issu e ir-
rit a t io n .
■ Th e su rg e o n u se s t h e g u id e w ire t o m e a su re t h e p ro p e r
le n g t h o f t h e scre w re q u ire d (TECH FIG 3 C).
■ Th e su rg e o n p la ce s a n a p p ro p ria t e ly size d 4.5-m m , p a r-
t ia lly t h re a d e d AO scre w w it h a sm a ll p ro file h e a d in t o
t h e in t ra m e d u lla ry ca n a l (TECH FIG 3 D,E).
■ In la rg e r in d ivid u a ls, a 6.5-m m scre w m a y b e su b st it u t e d ,
u sin g t h e a p p ro p ria t e ly size d d rills t o cre a t e t h e st a rt in g
p o rt a l a n d t o o ve rre a m t h e p ro xim a l co rt e x.
 Ch a p t e r 5 5 ORIF OF JONES FRACTURES 549

TECHNIQUES
A B C

D E

TECH FIG 2 • A. Cre a t io n o f t h e st a rt in g p o rt a l w it h a 2.5-m m d rill b it a n d d rill g u id e . B. Flu o ro sco p ic co n firm a -

t io n o f e n t ry p la ce m e n t . C. In se rt io n o f a fle xib le g u id e w ire d o w n t h e in t ra m e d u lla ry ca n a l. D,E. Flu o ro sco p ic
co n firm a t io n o f g u id e w ire p la ce m e n t .

B
D E

TECH FIG 3 • A. Pre p a ra t io n o f t h e in t ra m e d u lla ry ca n a l w it h a 3.2-m m

ca n n u la t e d d rill a n d p ro t e ct ive d rill sle e ve s. B. Flu o ro sco p ic vie w .
C C. Me a su re m e n t o f t h e co rre ct scre w le n g t h . D,E. Fin a l ra d io g ra p h s.
 550 Se c t i o n VI FOOT AND ANKLE
TECHNIQUES
INLAY BONE GRAFTING WITHOUT INTERNAL FIXATION
■ Th e t e ch n iq u e is sim ila r t o t h e Ru sse t e ch n iq u e fo r
sca p h o id n o n u n io n .11,14
■ Th e b a se o f t h e fift h m e t a t a rsa l is a p p ro a ch e d t h ro u g h
a cu rvilin e a r d o rso la t e ra l in cisio n (TECH FIG 4 A).
■ Th e fra ct u re sit e is e xp o se d su b p e rio st e a lly a n d a re c-
t a n g u la r se ct io n o f b o n e m e a su rin g 0.7 2.0 cm ce n -
t e re d o ve r t h e fra ct u re is o u t lin e d b y fo u r d rill h o le s.
■ A sh a rp o st e o t o m e is u se d t o re m o ve t h e o u t lin e d se c-
t io n o f b o n e (TECH FIG 4 B).
■ Th e m e d u lla ry ca n a l is t h e n cu re t t e d , d rille d , o r b o t h
u n t il a ll o f t h e scle ro t ic b o n e h a s b e e n re m o ve d a n d t h e
ca n a l h a s b e e n re -e st a b lish e d .
■ An a u t o g e n o u s co rt ico ca n ce llo u s b o n e g ra ft w it h t h e
sa m e m e a su re m e n t s a s t h e re m o ve d fra g m e n t is t h e n
A B
Peroneus brevis m.
C Bone graft
PERCUTANEOUS INTRAM EDULLARY SCREW FIXATION WITH LOCAL
BONE GRAFT
■ Th e p ro ce d u re is p e rfo rm e d a s d e scrib e d fo r p e rcu t a -
n e o u s in t ra m e d u lla ry scre w fixa t io n . 8
■ On ce t h e m e d u lla ry ca n a l h a s b e e n o ve rd rille d o ve r t h e
g u id e w ire , t h e w ire is re m o ve d .
■ A sle n d e r cu re t t e is a d va n ce d t o t h e d e p t h o f t h e fra c-
t u re a n d m a n ip u la t e d t o a d d a m a ss o f ca n ce llo u s b o n e
t o t h e fra ct u re sit e .
re m o ve d fro m t h e a n t e ro m e d ia l a sp e ct o f t h e d ist a l
e n d o f t h e t ib ia .
■ Th e g ra ft sh o u ld b e co n t o u re d so t h a t t h e co rt ica l p o r-
t io n o f t h e g ra ft fit s a ccu ra t e ly in t o t h e re ct a n g u la r
d e fe ct a n d d o e s n o t o b st ru ct t h e m e d u lla ry ca n a l (TECH
FIG 4 C).
■ Th e p e rio st e u m , su b cu t a n e o u s t issu e , a n d skin a re t h e n
clo se d .
■ To a vo id a st re ss rise r, t h e b o n e re m o ve d fro m t h e fift h
m e t a t a rsa l is p la ce d in t o t h e t ib ia d e fe ct b e fo re w o u n d
clo su re .
■ Th e p a t ie n t is t h e n im m o b ilize d in a n o n -w e ig h t -b e a r-
in g ca st .
TECH FIG 4 • A. Cu rvilin e a r in cisio n o ve r d o rso la t e ra l a sp e ct
o f fo o t . B. Th e fra ct u re sit e is e xp o se d a n d a re ct a n g u la r
a re a is o u t lin e d in t h e b o n e u sin g d rill h o le s. C. Th e g ra ft is
sh a p e d a n d p la ce d in t o t h e d e fe ct cre a t e d .
■ Ca re sh o u ld b e t a ke n t o lim it p ro cu re m e n t o f b o n e t o
w it h in 7 m m o f t h e fra ct u re sit e .
■ On ce t h e lo ca l b o n e g ra ft in g h a s b e e n co m p le t e d , t h e
w ire is re in t ro d u ce d in t o t h e ca n a l.
■ Th e in t ra m e d u lla ry scre w is p la ce d a s d e scrib e d fo r p e r-
cu t a n e o u s in t ra m e d u lla ry scre w fixa t io n .

PEARLS AND PITFALLS
Fa ilu re o f h a rd w a re ■ A 4.5-m m scre w o r la rg e r is u se d w h e n p o ssib le .
Fa ilu re o f h a rd w a re ■ To u ch -d o w n w e ig h t b e a rin g in a w a lke r b o o t is u se d fo r 6 t o 8 w e e ks. We ig h t b e a rin g is a d va n ce d o n ly
w h e n ra d io g ra p h ic e vid e n ce o f fra ct u re h e a lin g is o b se rve d .
POSTOPERATIVE CARE
■ Immediately after surgery, the patient should be immobi-
lized in a walker boot and should be limited to touch-down
weight bearing for 6 to 8 weeks.
■ During this period, range of motion and gentle strengthen-
ing may be allowed.
■ After 6 to 8 weeks, weight bearing and boot removal are
allowed when radiographic evidence of healing is observed.
■ Return to full activity, especially competitive athletics,
is allowed only when complete healing is observed on
radiographs in three planes: anteroposterior, lateral, and
oblique.
■ Functional bracing or orthosis is recommended for individ-
uals returning to athletic activities.
OUTCOMES
■ Portland et al10 treated 15 patients with acute Jones fracture
or Torg type I fracture and achieved 100% union at an aver-
age of 6.25 weeks.
■ DeLee et al3 reported 100% success in acute Jones fractures
treated with percutaneous intramedullary screw fixation. N o
complications were reported.
■ M indrebo et al9 treated nine patients with acute Jones frac-
tures with outpatient intramedullary screw fixation and
had 100% union at an average of 6 weeks. O ne patient had
the screw removed because of theoretical concerns over
screw breakage.
COMPLICATION S
■ Refractures and nonunions may occur when small-diameter
screws are used. Screws less than 4.5 mm have been shown
biomechanically to be weaker than larger screws. Using the
largest-diameter screw where all of the screw threads cross the
fracture site has been demonstrated to provide the best biome-
chanical fixation.
■ Refractures and nonunions may occur when the patient
returns to early weight bearing and when the Jones fracture
Ch a p t e r 5 5 ORIF OF JONES FRACTURES 551
is fixed in elite-level competitive athletes who may push
themselves to return to activities before union has occurred.
REFEREN CES
1. Clapper M F, O ’Brien TJ, Lyons PM . Fractures of the fifth metatarsal:
analysis of a fracture registry. Clin O rthop Relat Res 1995;315:
238–241.
2. DeLee JC. Fractures and dislocations of the foot. In: M ann RA,
Coughlin M J, eds. Surgery of the Foot and Ankle, ed 6, vol 2. St.
Louis: M osby-Yearbook, 1993:1627–1640.
3. DeLee JC, Evans JP, Julian J. Stress fractures of the fifth metatarsal.
Am J Sports M ed 1984;11:349.
4. Glasgow M T, Naranja RJ, Glasfow SG, et al. Analysis of failed surgi-
cal management of fractures of the base of the fifth metatarsal distal to
the tuberosity: the Jones fracture. Foot Ankle Int 1996;17:449–457.
5. Jones R. Fractures about the base of the fifth metatarsal by indirect
violence. Ann Surg 1902;35:697–700.
6. Kelly IP, Glisson RR, Fink C, et al. Intramedullary screw fixation of
Jones fractures. Foot Ankle Int 2001;22:585–589.
7. Larson CM , Almekinders LC, Taft TN , et al. Intramedullary screw
fixation of Jones fractures: analysis of failure. Am J Sports M ed 2002;
30:55–60.
8. Lawrence SJ. Technique tip: local bone grafting technique for Jones
fracture management with intramedullary screw fixation. Foot Ankle
Int 2004;25:920–921.
9. M indrebo N , Shelbourne KD, Van M eter CD, et al. O utpatient per-
cutaneous screw fixation of the acute Jones fracture. Am J Sports
M ed 1993;21:720–723.
10. Portland G, Kelikian A, Kodros S. Acute surgical management of
Jones’ fractures. Foot Ankle Int 2003;24:829–833.
11. Russe O . Fracture of the carpal navicular: diagnosis, non-operative
treatment, and operative treatment. J Bone Joint Surg Am 1960;42A:
759–768.
12. Shereff M J, Yang Q M , Kummer FJ, et al. Vascular anatomy of the
fifth metatarsal. Foot Ankle Int 1991;11:350–353.
13. Smith JW, Arnoczky SP, H ersh A. The intraosseous blood supply of
the fifth metatarsal: implications for proximal fracture healing. Foot
Ankle Int 1992;13:143–152.
14. Torg JS, Balduini FC, Z elko RR, et al. Fractures of the base of the
fifth metatarsal distal to the tuberosity. J Bone Joint Surg Am 1984;
66A:209–214.
15. Wright RW, Fischer DA, Shively RA, et al. Refracture of proximal
fifth metatarsal fracture after intramedullary screw fixation in ath-
letes. Am J Sports M ed 2000;28:732–736.
 IN DEX
Page numbers followed by f and t indicated figures and tables, respectively.
A fibula and, posterior plating of, 506,
Acetabular posterior wall, O RIF of, 315–324
anatomy and, 315
complications of, 323–324
definition of, 315, 316f
diagnostic studies for, 317
differential diagnosis of, 317
fracture reduction and, 320–321
fracture site débridement/exposure and, 320
imaging of, 317
internal fixation and, 321–322, 321f
Kocher-Langenbeck approach to, 318–320,
318f, 319f
natural history of, 316
nonoperative management of, 317
outcomes of, 323
pathogenesis of, 315–316, 316f
patient history and, 316–317
pearls and pitfalls of, 323
physical findings for, 316–317
postoperative care for, 323
surgical management of, 317–318, 318f
wound closure and, 322, 322f
Acetabulum
anatomy
O RIF and, 315
Acromial process fracture, O RIF of, 208,
209f
Acute compartment syndrome. See also
Compartment syndrome
fasciotomy of leg for, 472–482
anatomy and, 472, 473f, 473t
closure for, 480, 481f
complications, 482
definition, 472
diagnostic studies and, 475–476
differential diagnosis of, 475–476
double-incision technique for, 477, 478f
imaging and, 475–476
muscle débridement, 480
natural history and, 474
nonoperative management and, 476
one-incision technique for, 479, 480f
outcomes and, 481–482
pathogenesis and, 472–474
patient history and, 474–475
pearls and pitfalls for, 481
physical findings and, 474–475, 475f
postoperative care and, 481
surgical management and, 477
Aftershock sheeting, pelvic, circumferential,
279, 279f
Agee reduction maneuver, 87, 87f
Angiography
O RIF, sacrum/SI joint, 303, 304f
O RIF of, 499–508
anatomy and, 499, 500f
complications of, 508, 508f
definition of, 499
diagnostic studies for, 500
differential diagnosis of, 501
fibula and, direct lateral approach to,
502–503, 502f, 503f
506f
imaging for, 500, 501f
medial malleolus, anteromedial approach
to, 503–504, 504f
nonoperative management of, 501
outcomes of, 507
pathogenesis and, 499, 501f
pearls and pitfall of, 507
physical findings and, 499–500
posterior malleolus and, fixation of, 505,
505f
postoperative care of, 507
surgical management of, 501–502
syndesmosis fixation and, 506, 506f
tibia and, posterolateral approach to,
504, 505f
Anterograde IM N
femoral, 381–392
anatomy and, 381
complications of, 392
definition of, 381
diagnostic studies for, 382–383
differential diagnosis of, 383
distal interlocking screw placement for,
390–391, 390f, 391f
fracture reduction and, 387–388, 388f
guidewire placement in, 387–388, 388f
imaging for, 382–383
measurement and, 389
nail placement for, 389
natural history and, 382
nonoperative management of, 383
outcomes of, 391–392
pathogenesis and, 381–382
patient history and, 382
percutaneous method of nailing for,
386–387, 386f, 387f
physical findings and, 382
piriformis fossa entry and, 385–386,
385f
postoperative care for, 391
proximal interlocking screw placement
for, 389
reaming and, 389
soft tissue dissection and, 385
surgical management of, 383–385,
384f
trochanteric entry and, 385–386, 385f,
387–388, 388f
of humeral shaft fractures, 200–203, 200f,
203f
AO classification, tibial plateau fractures,
lateral, 435, 435t
AO /O TA classification, distal femur fracture,
399, 399f, 399t
Arthroscopic classification of carpal
instability, 40, 41t
Arthroscopic reduction/fixation
distal radius styloid fracture, 40–49
complications for, 49
metaphyseal comminution for, 46–48,
46f, 47f
outcomes for, 49
pearls and pitfalls for, 48–49
postoperative care for, 49
techniques for, 44, 44f
three-part, 45–48, 45f, 46f, 47f
ulnar styloid fracture, 40–49
techniques for, 48, 48f
Arthroscopy-assisted reduction/fixation,
dorsal, 103–106, 104f, 105f
Arthrotomy
open DRUJ, 26–27, 26f, 27f
palmaris graft for, 27
Avulsion repair
TFCC, 23–26, 24f, 25f
B
Bicondylar plateau
anatomy, O RIF and, 425, 426f
O RIF, 425–433
anatomy and, 425, 426f
complications of, 432
definition of, 425, 426f
differential diagnosis of, 427
fixation and, 430–431, 430f, 431f
imaging for, 427, 427f
lateral exposure and, 429, 430f
natural history and, 425
nonoperative management of, 427
outcomes of, 432
pathogenesis and, 425
patient history and, 425–427
pearls and pitfalls of, 432
physical findings and, 425–427
posterior approach to, 431, 432f
posteromedial approach to, 428, 429f
postoperative care for, 432
surgical management of, 428, 428f
Bone grafting
inlay, O RIF for Jones fracture and, 550,
550f
O RIF, distal femur, 410, 410f
percutaneous intramedullary screw fixation
with, O RIF for Jones fracture and,
550
Boyd approach, O RIF, of radial head/neck
fractures, 237, 238f
Bridge plating, distal radius fracture, 86–91
anatomy and, 86
approach for, 88–89, 88f
articular fixation for, 89–90, 90f
closed reduction maneuver of Agee for, 87,
87f
complications of, 91
definition of, 86
DRUJ management for, 90
indications for, 86–87, 87t
outcomes of, 91
pearls and pitfalls of, 90
plate fixation for, 89–90, 90f
plate insertion for, 88–89, 88f
postoperative care of, 90–91
surgical management and, 86–87, 87f, 87t
I-1
I-2 INDEX

C distal interlocking technique for, 356, CM C fracture-dislocations, finger

Calcaneal fractures 356f adjunctive techniques for, 6
anatomy, 524 fracture reduction and, 350, 350f anatomy and, 1, 2f
complications, 534–535 fracture reduction and canal preparation complications of, 6–7, 7f
definition, 524 for, 353, 353f definition of, 1, 1f
diagnostic studies, 526–527, 527f imaging for, 346 definitive fixation for, 5, 5f
differential diagnosis, 527 integrated screw, 355, 355f, 356f diagnostic studies for, 2–3
imaging, 526–527 natural history and, 345 differential diagnosis of, 3
lateral approach to, 530–532, 531f, 532f nonoperative management of, 346–347 dorsal exposure and, 4, 4f
extensile, 532–534, 532f, 533f outcomes of, 357–358 fracture exposure and, 4
medial/lateral approaches to, simultaneous, pathogenesis for, 345 fracture reduction and, 4–5, 5f
530–532, 531f, 532f patient history and, 345–346 imaging of, 2–3, 3f
natural history, 526 pearls and pitfalls for, 357 natural history of, 1
nonoperative management, 527 physical findings and, 345–346 nonoperative management of, 3
open reduction, 530, 530f portal acquisition/protection and, operative treatment of, 1–7
outcomes, 534 351–352, 352f operative treatment of, techniques for, 4–6,
pathogenesis, 524–526, 525f, 526f positioning for, 349, 349f 4f, 5f
patient history, 526 postoperative care of, 357 outcomes of, 6
pearls and pitfalls, 534 precision portal placement/trajectory pathogenesis of, 1, 2f
physical finding, 526 control and, 351, 351f patient history for, 1–2
postoperative care, 534 preoperative planning of, 347–349, 347f, pearls and pitfalls for, 6
surgical management, 527–528 348f physical findings for, 1–2
surgical treatment of, 524–535 single-screw/single-device designs for, postoperative care of, 6
tongue, percutaneous reduction and 354, 354f surgical management of, 3–4, 4f
fixation of, 529–530, 529f surgical management of, 347–349, 347f, Compartment syndrome, 472
Capitellar fractures 348f, 349f Computed tomography (CT)
anatomy and, 227 two-screw construction, 354, 354f O RIF
definition, 227, 227f wound closure, 356 distal femur, 398, 398f
diagnostic studies, 228 Clavicle sacrum/SI joint, 303, 303f
differential diagnosis, 228 anatomy, 140 Condyle
imaging, 228, 228f fractures and, 144, 144f fixation, O RIF of distal femur and,
natural history, 227 Clavicle fractures 405–406
nonoperative management, 228 definition, 140 Coracoid process fracture, O RIF of, 209,
O RIF of, 227–232 diagnostic studies, 140 209f
complications for, 232 differential diagnosis, 140 Coronoid fracture, O RIF, 270–271, 271f
outcomes and, 232 fracture compression and, 150, 150f CT. See Computed tomography
pearls and pitfalls for, 231 fracture reduction and, 149, 149f Cystography, retrograde, O RIF, sacrum/SI
postoperative care for, 232 imaging, 140 joint, 303
techniques for, 229–230, 229f intramedullary fixation, 144–153
pathogenesis, 227 butterfly fragment management and,
patient history, 228 151, 151f D
physical findings, 228 clavicle preparation and, 148, 148f Débridement
surgical management, 228–229 complications of, 153 fracture site, O RIF, acetabular posterior
Capitellar-trochlear shear fractures dissection in, 147, 147f wall, 320
anatomy and, 227 fracture compression and, 150, 150f muscle, fasciotomy of leg and, 480
definition, 227, 227f fracture reduction and, 149, 149f Diaphyseal forearm fractures
diagnostic studies, 228 incision in, 147, 147f anatomy, 8–10, 8f, 9f
differential diagnosis, 228 outcomes of, 153 definition, 8
imaging, 228, 228f pearls and pitfalls of, 152 diagnostic studies, 11, 12f
natural history, 227 pin insertion and, 149, 149f differential diagnosis, 11
nonoperative management, 228 pin positioning, final and, 150, 150f imaging, 11
O RIF of, 227–232 pin removal in, 152, 152f natural history, 10
complications for, 232 postoperative care of, 152, 152f nonoperative management, 12
outcomes and, 232 wound closure and, 151, 151f O RIF, 8–19
pearls and pitfalls for, 231 natural history, 140, 140f anterior approach to radius and, 13, 13f
postoperative care for, 232 nonoperative management, 140–141 anterior approach to ulna and, 16–17,
techniques for, 230–231, 230f, 231f pathogenesis, 140 16f
pathogenesis, 227 patient history, 140 complications of, 19
patient history, 228 physical findings, 140 fracture reduction/fixation and, 17, 17f
physical findings, 228 plate-and-screw fixation outcomes of, 19
surgical management, 228–229 anterior, 142 pearls and pitfalls of, 18
Capitellum, 227 superior, 141–142, 141f, 142 posterior approach to radius and, 15–16,
Carpal instability, arthroscopic classification plate fixation, 140–142 15f
of, 40, 41t complications of, 142 posterior approach to ulna and, 17
C-clamp, O RIF and, symphysis, 293, 293f outcomes of, 142 postoperative care of, 19
Cephalomedullary nailing pearls and pitfalls of, 142 pathogenesis, 10
fixation, O RIF and, 340–341, 340f, 341f postoperative care for, 142 patient history, 10–11
integrated screw, 355, 355f, 356f surgical management, 141, 141f physical findings, 10–11, 11t
proximal femur, 345–358 Closed fractures, Tscherne and Gotzen surgical management, 12–13
anatomy and, 345, 346f grading system, 486, 486t Distal femur
approach to, 349, 349f Closed reduction anatomy
complications of, 358, 358f distal radius fracture, 33 O RIF and, 394, 395f, 396f
definition of, 345 Closed reduction and percutaneous fixation O RIF, 394–415
diagnostic studies for, 346, 346f femoral neck fractures, 333–344 anatomy and, 394, 395f, 396f
differential diagnosis of, 346 technique for, 337–338, 337f approach to, 401–402, 402f

articular surface and, stabilizing, 412,
412f
bone grafting and, 410, 410f
complications of, 414–415, 415f
definition of, 394
diagnostic studies for, 395–398
differential diagnosis of, 399
distal segment reduction and, 413, 413f
fixation choices and, 400, 400f
imaging for, 395–398, 397f, 398f
lateral approach to, 411, 411f
locking plates for, 404–413, 404f–411f
locking plates for, plate placement and,
406–407, 407f, 413, 413f
locking plates for, wound closure for,
411, 411f, 413, 413f
natural history and, 394
nonoperative management of, 399
outcomes of, 414
pathogenesis and, 394
patient history and, 394–395
pearls and pitfalls of, 413–414
physical findings and, 394–395
positioning for, 401, 402f
postoperative care for, 414
preoperative planning for, 400–401, 401f
reduction of shaft to distal segment in, 406
screw placement and, 408–409, 408f,
409f
surgical management of, 399–402, 399f,
399t, 400f, 401f, 402f
temporary bridging external fixation for,
403, 403f, 404f
Distal femur fractures, AO /O TA
classification, 399, 399f, 399t
Distal radioulnar joint (DRUJ)
anatomy, 20
arthrotomy, open, 26–27, 26f, 27f
bridge plating of distal radius fractures and,
90
dislocations, 20
dissociation, surgical management, 94, 94f,
95f
Galeazzi fractures
complications for reduction/stabilization
of, 28–29
diagnostic studies for, 22–23
differential diagnosis of, 23
imaging of, 22–23, 22f
natural history of, 20–21
nonoperative management of, 23
outcomes for reduction/stabilization of,
28
pathogenesis of, 20
patient history of, 21–22
pearls and pitfalls for
reduction/stabilization of, 28
physical findings for, 21–22, 21f
postoperative care for
reduction/stabilization of, 28
reduction/stabilization following, 20–29
surgical management of, 23
TFCC avulsion repair and, foveal,
23–26, 24f, 25f
Shuck test, 21f, 22, 22t
Distal radius. See also Radius
anatomy, 30, 30f, 40, 63, 63f
Distal radius fractures
anatomy and, 30, 30f
bridge plating, 86–91
anatomy and, 86
approach for, 88–89, 88f
articular fixation for, 89–90, 90f
closed reduction maneuver of Agee for,
87, 87f
complications of, 91
definition of, 86
DRUJ management for, 90
indications for, 86–87, 87t
outcomes of, 91
pearls and pitfalls of, 90
plate fixation for, 89–90, 90f
plate insertion for, 88–89, 88f
postoperative care of, 90–91
surgical management and, 86–87, 87t
closed reduction of, 33, 33f
definition, 30
diagnostic studies, 31, 73–75, 64, 52–53, 86
differential diagnosis, 31, 65, 53
dorsal plate fixation, 63–70
anatomy and, 63, 63f
complications of, 70
definition, 63
dorsal intramedullary device for, 68, 68f
outcomes of, 70
pearls and pitfalls of, 69
postoperative care of, 70
radial intramedullary device for, 69
surgical management of, 65–66, 65f, 66f
techniques for, 66–68, 66f, 67f, 68f
external fixator application for, bridging,
35–36, 35f, 36f
external fixator application for,
nonbridging, 36–37, 37f
fragment-specific fixation, 71–85
anatomy and, 71–72, 72f
complications of, 85
dorsal approach to, 77, 77f
free articular fragment support with
buttress pin for, 83, 83f
outcomes of, 85
pearls and pitfalls for, 84
postoperative care of, 84–85
radial column fixation with radial pin
plate for, 78–79, 79f
surgical management of, 75–76
ulnar corner/dorsal wall fixation for,
80–81, 80f, 81f
volar approach to, extensile, 77, 77f
volar approach to, limited-incision, 76,
76f
volar rim fragment and, 81–82, 82f
volar-ulnar approach to, 78, 78f
imaging, 31, 31f, 73–75, 74f, 64, 64f,
52–53, 53f, 86
Kapandji technique for percutaneous
pinning of, 33–34, 33f
K-wire fixation of, with/without external
fixation, 30–38
complications for, 38
outcomes for, 38
pearls and pitfalls in, 37
postoperative care for, 37–38
natural history, 30–31, 63–64, 52, 86
nonoperative management, 31–32, 65, 53,
86
pathogenesis, 30, 72–73, 72f, 63, 52, 52f,
86
patient history, 31, 64, 52, 86
physical findings, 31, 64, 52, 86
surgical management, 32, 32f, 65–66, 65f,
66f, 53–54, 54f
volar plating, 51–61
anatomy and, 51–52, 51f
complications of, 61
definition of, 51
fixed-angle, 54–59, 55f, 56f, 57f, 58f,
59f
fixed-angle, using plate as reduction tool,
60, 60f
INDEX I-3
outcomes of, 61
pearls and pitfalls of, 60–61
postoperative care of, 61
Distal radius malunion
anatomy and, 130, 130f
definition, 130
diagnostic studies, 131
differential diagnosis, 131
imaging, 131, 131f
natural history, 130–131
nonoperative management, 131
osteotomy, corrective, 130–139
complications of, 139
dorsal extra-articular, 133–134, 133f,
134f, 135f
intra-articular, 137, 138f
outcomes of, 139
pearls and pitfalls of, 138
postoperative care of, 139
volar extra-articular, 135–136, 136f,
137f
pathogenesis, 130
patient history, 131
physical findings, 131
surgical management, 132, 132f
Distal radius styloid fractures
anatomy and, 40
arthroscopic reduction/fixation of, 40–49
complications for, 49
metaphyseal comminution for, 46–48,
46f, 47f
outcomes for, 49
pearls and pitfalls for, 48–49
postoperative care for, 49
techniques for, 44, 44f
definition, 40
diagnostic studies, 41–42
differential diagnosis, 42
four-part, arthroscopic reduction/fixation
of, 46–48, 46f, 47f
imaging, 41–42, 42f
natural history, 40–41
nonoperative management, 42
pathogenesis, 40
patient history, 41
physical findings, 41
surgical management, 42–43, 43f
three-part, arthroscopic reduction/fixation
of, 45–48, 45f, 46f, 47f
Distal tibia
fractures, 483–485, 484f
Dorsal plate fixation. See also Plate fixation
distal radius fracture, 63–70
anatomy and, 63, 63f
complications of, 70
definition, 63
dorsal intramedullary device for, 68, 68f
outcomes of, 70
pearls and pitfalls of, 69
postoperative care of, 70
radial intramedullary device for, 69
surgical management of, 65–66,
65f, 66f
techniques for, 66–68, 66f, 67f, 68f
Dorsal wall fixation, fragment-specific
fixation and, 80–81, 80f, 81f
Double plating. See also Plating
O RIF, symphysis, 296, 296f
RUJ. See Distal radioulnar joint
E
EDC. See Extensor digitorum communis
Elbow
anatomy, 267, 267f
I-4 INDEX
Elbow dislocation, simple
classification, 259
definition, 259
diagnostic studies, 260
etiology, 259
hinged external fixation, 265, 265f
imaging, 260
management, 259–266
complications of, 266
nonoperative, 260–261
outcomes of, 265–266
pearls and pitfalls of, 265
postoperative care for, 265
surgical, 261–262
pathoanatomy, 259, 260f
patient history, 259–260, 261f
physical findings, 259–260, 261f
ulnar collateral ligament reconstruction for,
lateral, 264, 264f
ulnar collateral ligament repair for, lateral,
262–263, 262f, 263f
Elbow fracture-dislocations
with complex instability
anatomy and, 267, 267f
definition of, 267
diagnostic studies for, 268
differential diagnosis of, 268
imaging of, 268, 268f
lateral exposure and, 270, 270f
natural history of, 268
nonoperative management of, 268, 269f
O RIF of, 267–274
O RIF of, complications and, 274
O RIF of, outcomes and, 274
O RIF of, pearls/pitfalls for, 273–274
O RIF of, postoperative care and, 274
pathogenesis of, 268, 268f
patient history and, 268
persistent instability and, 273
physical findings for, 268
surgical management of, 269–270, 269f,
269t, 270f
LCL repair and, 272–273, 272f
External fixation.
hinged, elbow dislocation, simple, 265,
265f
O RIF, talus and, 520–521, 521f
pelvis, 275–286
aftershock sheeting, circumferential
pelvic, 279, 279f
anterior iliac crest, open technique,
279–280, 280f
anterior iliac crest, percutaneous
technique, 282, 282f
complications of, 286
diagnostic studies for, 275–276
differential diagnosis of, 276–277
frame application/reduction and, 283, 284f
imaging for, 275–276, 276f, 277f
natural history of, 275
nonoperative management of, 277
outcomes of, 286
pathogenesis and, 275f
patient history and, 275
pearls and pitfalls of, 286
pelvic antishock clamp, 284, 284f, 285f
physical findings, 275
postoperative care for, 286
supra-acetabular technique, 282, 283f
surgical management of, 277–278, 277f,
278f
tibial, 441–453
anatomy and, 441, 443f
ankle-spanning fixator for tibial pilon
fracture and, 451, 451f
complications of, 453
definition of, 441, 442f
diagnostic studies for, 444
imaging for, 444, 445f
knee-spanning fixator for tibial plateau
fracture and, 450, 450f
monolateral four-pin frame application
for tibial shaft fracture and,
446–447, 447f, 448f
monotube four-pin frame application for
tibial shaft fracture and, 448–450,
449f
natural history and, 442–443
outcomes of, 453
pathogenesis and, 441–442, 443f
patient history and, 444
pearls and pitfalls of, 452
physical findings and, 444, 444f
pin insertion technique for, 446, 446f
postoperative care of, 452–453
surgical management of, 444–445,
445f
two-pin fixator for tibial fractures and,
451, 452f
F Femur.
Fasciotomy
closure, 480, 481f
leg, for acute compartment syndrome,
472–482
anatomy and, 472, 473f, 473t
closure and, 480, 481f
closure for, 480, 481f
complications, 482
definition, 472
diagnostic studies and, 475–476
differential diagnosis of, 475–476
double-incision technique for, 477,
478f
imaging and, 475–476
muscle débridement, 480
natural history and, 474
nonoperative management and, 476
one-incision technique for, 479, 480f
outcomes and, 481–482
pathogenesis and, 472–474
patient history and, 474–475
pearls and pitfalls for, 481
physical findings and, 474–475, 475f
postoperative care and, 481
surgical management and, 477
Femoral head
anatomy, O RIF and, 326, 326f
Femoral head fractures, O RIF, 326–332
anatomy and, 326, 326f
complications of, 332
definition of, 326
diagnostic studies for, 326–327
differential diagnosis of, 327, 327t
imaging for, 326–327, 327f
natural history and, 326
nonoperative management of, 327
outcomes of, 332
pathogenesis and, 326, 327f
patient history and, 326
pearls and pitfalls of, 332
physical findings of, 326
postoperative care for, 332
Smith-Peterson anterior approach to,
328–330, 329f, 330f
surgical management of, 327–328
Femoral neck
anatomy, O RIF for fractures and, 333,
334f
Femoral neck fractures
closed reduction and percutaneous fixation,
333–344
technique for, 337–338, 337f
O RIF, 333–344
anatomy and, 333, 334f
cephalomedullary nail fixation and,
340–341, 340f, 341f
complications of, 343–344
definition of, 333, 334f
diagnostic studies for, 334
differential diagnosis of, 335
fixation, minimally invasive with sliding
hip screw and, 342–343, 342f, 343f
imaging for, 334
natural history of, 333
nonoperative management of, 335
outcomes of, 343
pathogenesis for, 333
patient history for, 333–334
pearls and pitfalls of, 343
physical findings for, 333–334
postoperative care for, 343
surgical management of, 336–337, 336f
Watson-Jones approach to, 338–340,
339f
anatomy
anterograde IM N and, 381
retrograde IM N and, 370, 371f
anterograde IM N , 381–392
anatomy and, 381
complications of, 392
definition of, 381
diagnostic studies for, 382–383
differential diagnosis of, 383
distal interlocking screw placement for,
390–391, 390f, 391f
fracture reduction and, 387–388, 388f
guidewire placement in, 387–388, 388f
imaging for, 382–383
measurement and, 389
nail placement for, 389
natural history and, 382
nonoperative management of, 383
outcomes of, 391–392
pathogenesis and, 381–382
patient history and, 382
percutaneous method of nailing for,
386–387, 386f, 387f
physical findings and, 382
piriformis fossa entry and, 385–386,
385f
postoperative care for, 391
proximal interlocking screw placement
for, 389
reaming and, 389
soft tissue dissection and, 385
surgical management of, 383–385, 384f
trochanteric entry and, 385–386, 385f,
387–388, 388f
retrograde IM N of, 370–379
alternative techniques, 379t
anatomy and, 370, 371f
approach to, 374
classification of, 371–373, 371f, 371t,
372f, 373f
complications of, 379
contraindications for, 373
definition of, 370
diagnostic studies for, 370–371
fracture reduction and, 375
guardwire and, passing, 375
guardwire placement and, 375
imaging for, 370–371

nail placement and, 376, 377f
outcomes of, 379
pathogenesis and, 370
patient history and, 370
pearls and pitfalls of, 378
physical findings and, 370
positioning for, 374
postoperative care for, 378–379
preoperative planning for, 373–374, 374f
reaming and, 376, 376f
relative indications for, 371–373, 371f,
371t, 372f, 373f
screw fixation and, 377
starting hole and, creating/reaming, 375
surgical management of, 371–374, 371f,
371t, 372f, 373f, 374f
wound closure and, 378
Fibula
fixation, O RIF of pilon and, 492
O RIF of ankle and, 502–503, 502f, 503f,
506, 506f
plating of, posterior, 506, 506f
reduction, O RIF of pilon and, 492
Fingers
CM C fracture-dislocations
adjunctive techniques for, 6
anatomy and, 1, 2f
complications of, 6–7, 7f
definition of, 1, 1f
definitive fixation for, 5, 5f
diagnostic studies for, 2–3
differential diagnosis of, 3
dorsal exposure and, 4, 4f
fracture exposure and, 4
fracture reduction and, 4–5, 5f
imaging of, 2–3, 3f
natural history of, 1
nonoperative management of, 3
operative treatment of, 1–7
operative treatment of, techniques for,
4–6, 4f, 5f
outcomes of, 6
pathogenesis of, 1, 2f
patient history for, 1–2
pearls and pitfalls for, 6
physical findings for, 1–2
postoperative care of, 6
surgical management of, 3–4, 4f
Fixation. See also specific types
condyle, O RIF of distal femur and,
405–406
malleolus, posterior, 505, 505f
minimally invasive, with sliding hip screw,
O RIF and, 342–343, 342f, 343f
nail, cephalomedullary, O RIF and,
340–341, 340f, 341f
O RIF, bicondylar plateau, 430–431, 430f,
431f
pelvic, spinal, 305, 312, 312f
syndesmosis, 506, 506f
Forearm
anatomy, 8–10, 8f, 9f
fractures, diaphyseal, 8–19
ligaments, 9, 9f
muscles, 9, 9f
nerves, 10
Forearm shaft fracture, pediatric,
intramedullary fixation of
techniques for, 140–179f
Fracture compression, clavicle, 150, 150f
Fracture reduction
anterograde IM N , femoral, 387–388, 388f
canal preparation and, 353, 353f
cephalomedullary nailing and, proximal
femur, 350, 350f, 353, 353f
clavicle, 149
humeral shaft, 193, 193f
O RIF, peritrochanteric hip fracture, 362,
363f
peritrochanteric hip, 362, 363f
retrograde IM N , femoral, 375
Fragment-specific fixation
definition, 71
distal radius fracture, 71–85
anatomy and, 71–72, 72f
complications of, 85
dorsal approach to, 77, 77f
free articular fragment support with
buttress pin for, 83, 83f
outcomes of, 85
pearls and pitfalls for, 84
postoperative care of, 84–85
radial column fixation with radial pin
plate for, 78–79, 79f
surgical management of, 75–76
ulnar corner/dorsal wall fixation for,
80–81, 80f, 81f
volar approach to, extensile, 77, 77f
volar approach to, limited-incision, 76,
76f
volar rim fragment and, 81–82, 82f
volar-ulnar approach to, 78, 78f
G complications of, 205
Galeazzi fractures
definition, 20
DRUJ
complications for reduction/stabilization
of, 28–29
diagnostic studies for, 22–23
differential diagnosis of, 23
imaging of, 22–23, 22f
natural history of, 20–21
nonoperative management of, 23
outcomes for reduction/stabilization of,
28
pathogenesis of, 20
patient history of, 21–22
pearls and pitfalls for
reduction/stabilization of, 28
physical findings for, 21–22, 21f
postoperative care for
reduction/stabilization of, 28
reduction/stabilization following, 20–29
surgical management of, 23
TFCC avulsion repair and, foveal,
23–26, 24f, 25f
Geissler classification, 40, 41t
Glenoid
neck
O RIF of, posterior approach to,
207–208, 208f
O RIF of, superior approach to, 208,
208f
Glenoid cavity
O RIF and anterior approach to, 215, 216f
O RIF and posterior approach to, 214, 215f
O RIF and superior approach to, 215, 215f
Glide pin positioning, hip screw, sliding,
363–364, 364f
Gustilo and Anderson grading system, open
fractures, 486, 486t
H outcomes of, 224, 225t
H emiarthroplasty
for proximal humerus fractures, 180–187
complications of, 187
deltopectoral approach for, 182, 182f
INDEX I-5
final implant placement for, 185–186,
186f
humeral retroversion and, determination
of, 184, 184f
humeral shaft preparation and, 184, 184f
outcomes of, 187
pearls and pitfalls of, 187
postoperative care of, 187
prosthetic height and, determination of,
184, 185f
surgical wound closure for, 186
trial reduction for, 185, 185f
tuberosity mobilization for, 182–183,
183f
H inged external fixation, elbow dislocation,
simple, 265, 265f
H ip screw, sliding, glide pin positioning for,
363–364, 364f
H umeral shaft, anatomy, 189, 197
H umeral shaft fractures
anatomy and, 189, 197
definition, 189, 197
diagnostic studies, 190, 198
differential diagnosis, 190, 198
imaging, 190, 198, 198f
IM N
antegrade, 200–203, 200f, 203f
retrograde, 203–204
intramedullary fixation, 197–205
outcomes of, 205
pearls and pitfalls of, 204
postoperative care of, 204–205
natural history, 189, 197
nonoperative management, 190, 198
pathogenesis, 189, 197
patient history, 189–190, 197–198
physical findings, 189–190, 197–198
plate fixation, 189–196
anterolateral approach to, 191–192, 191f
complications of, 196
fracture nonunion and, exposure of, 193
fracture reduction and, 193, 193f
medial approach to, 194, 194f
outcomes of, 196
pearls and pitfalls of, 195
plate application and, 194, 194f
posterior approach to, 192, 192f
postoperative care of, 195, 195f
reduction, 193, 193f
surgical management, 190–191, 191f,
198–200, 200f
positioning for, 199–200, 200f
I
Iliac crest, anterior
open technique, pelvic external fixation
and, 279–280, 280f
percutaneous technique, pelvic external
fixation and, 282, 282f
Iliosacral screws, 305
placement of, O RIF of sacrum/SI joint and,
310–311, 310f, 311f
Intercondylar fractures
diagnostic studies, 219
imaging, 219, 219f
O RIF, 219–225
complications of, 224
internal fixation and, 222–223, 222f, 223f
pearls and pitfalls of, 224
postoperative management of, 224
surgical approach to, 220–221, 221f
patient history, 219
I-6 INDEX
Intercondylar fractures (continued)
physical findings, 219
shortening and, 223, 224f
surgical management, 219–220, 220f
Internal fixation. See also O pen reduction and
internal fixation
O RIF, acetabular posterior wall, 321–322,
321f
Intramedullary fixation
antegrade, of humeral shaft fractures,
199–203, 200f, 202f
of clavicle fractures, 144–153
butterfly fragment management and,
151, 151f
clavicle preparation and, 148, 148f
complications of, 153
dissection in, 147, 147f
fracture compression and, 150, 150f
fracture reduction and, 149, 149f
incision in, 147, 147f
outcomes of, 153
pearls and pitfalls of, 152
pin insertion and, 149, 149f
pin positioning, final and, 150, 150f
pin removal in, 152, 152f
postoperative care of, 152, 152f
wound closure and, 151, 151f
forearm shaft fracture, pediatric
techniques for, 140f–179f
of humeral shaft fractures, 197–205
complications of, 205
outcomes of, 205
pearls and pitfalls of, 204
postoperative care of, 204–205
of proximal humerus fractures, 172–179
complications and, 179
entry site reaming and, 177
fragment reduction and, 176, 176f
guidewire placement and, 176–177
interlocking screw, 177–178, 178f
K-wire placement and, 175, 175f
nail insertion and, 177, 177f
pearls and pitfalls in, 178–179
postoperative care for, 179
tuberosity, 178
retrograde, of humeral shaft fractures,
199–200, 203–204
Intramedullary nailing (IMN ). See also specific
types of intramedullary nailing
definition, 454
tibial, 454–470
complications of, 470
distal metadiaphyseal, fractures, 468,
469f
outcomes of, 469
pearls and pitfalls of, 469
postoperative care of, 469
proximal metaphyseal, fractures,
465–468, 466f, 467f, 468f
surgical approach to, 459–465, 459f,
460f, 461f, 462f, 463f, 464f, 465f
J surgical management and, 477
Jones fracture
anatomy, O RIF and, 546, 548f
O RIF of, 546–551
anatomy and, 546, 548f
complications of, 551
definition of, 546, 547f
diagnostic studies for, 546
differential diagnosis of, 546
imaging for, 546
inlay bone grafting without internal
fixation for, 550, 550f
natural history and, 546
nonoperative management of, 546–547
outcomes of, 551
pathogenesis and, 546
patient history and, 546
pearls and pitfalls of, 551
percutaneous intramedullary screw
fixation for, 548, 548f, 549f
percutaneous intramedullary screw
fixation for, with bone graft, 550
physical findings and, 546
postoperative care of, 551
surgical management of, 547–548, 548f
Jungabluth clamp, O RIF and, symphysis,
294, 294f
K postoperative care of, 544
Kapandji technique, percutaneous pinning of
distal radius fracture, 33–34, 33f
Köcher approach
O RIF, of radial head/neck fractures, 238,
238f
radial head replacement, 240, 240f
Kocher-Langenbeck approach, O RIF,
acetabular posterior wall, 318–320,
318f, 319f
K-wires
distal radius fracture fixation, with/without
external fixation, 30–38
complications for, 38
outcomes for, 38
pearls and pitfalls in, 37
postoperative care for, 37–38
L fixation of, 505, 505f
Lateral collateral ligament (LCL)
repair, 272–273, 272f
LCL. See Lateral collateral ligament
Leg
anatomy, fasciotomy and, 472, 472f, 472t
fasciotomy of, for acute compartment
syndrome, 472–482
anatomy and, 472, 473f, 473t
closure and, 480, 481f
closure for, 480, 481f
complications, 482
definition, 472
diagnostic studies and, 475–476
differential diagnosis of, 475–476
double-incision technique for, 477, 478f
imaging and, 475–476
muscle débridement, 480
natural history and, 474
nonoperative management and, 476
one-incision technique for, 479, 480f
outcomes and, 481–482
pathogenesis and, 472–474
patient history and, 474–475
pearls and pitfalls for, 481
physical findings and, 474–475, 475f
postoperative care and, 481
Ligament
reconstruction, lateral ulnar collateral, 264,
264f
repair, lateral ulnar collateral, 262–263,
262f, 263f
Lisfranc injury
anatomy, O RIF and, 536, 537f
O RIF of, 536–545
anatomy and, 536, 537f
articular surface assessment, decision
making and, 541
closure for, 544, 544f
complications of, 544
definition of, 536
definitive stabilization of, 541–543, 541f,
542f, 543f
diagnostic studies for, 537, 538f, 539f
differential diagnosis of, 537
imaging for, 537, 538f, 539f
lateral incision for, 540, 540f
medial incision for, 540, 540f
natural history and, 536
nonoperative management of, 537
outcomes of, 544
pathogenesis and, 536
patient history and, 536–537
pearls and pitfalls of, 544
physical findings and, 536–537
provisional reduction for, 541–543, 541f,
542f, 543f
surgical management of, 539, 539f
Locking plates
O RIF
distal femur, 404–413, 404f–411f
distal femur, wound closure and, 411,
411f, 413, 413f
midline approach to, 404–405, 405f
plate placement, O RIF of distal femur,
406–407, 407f, 413, 413f
M
M alleolus
medial
O RIF of ankle and, 503–504, 504f
posterior
O RIF of ankle and, 505, 505f
M etaphyseal comminution, distal radius
styloid fracture arthroscopic
reduction/fixation and, 46–48,
46f, 48f
M onteggia fractures, adult, 275–281
complications, 281
definition, 275, 276t
diagnostic studies, 275
differential diagnosis, 275
imaging, 275, 277f
nonoperative management, 275
outcomes, 281
pathogenesis, 275
patient history, 275
pearls and pitfalls, 280, 280f
physical findings, 275
postoperative care, 281
radial head management and, 278, 278f
surgical approach, 278, 278f
surgical management, 275, 277f
ulna fracture fixation and, 279, 279f
wound closure, 280
N
N onarticular scapular fractures
anatomy and, 206, 206f
definition, 206
diagnostic studies, 206
differential diagnosis, 206
imaging, 206
natural history, 206
nonoperative management, 207
O RIF of, 206–210
acromial process fracture and, 208, 209f
complications for, 210
coracoid process fracture and, 209, 209f

outcomes for, 210 ankle, 499–508
pearls and pitfalls for, 210 anatomy and, 499, 500f
posterior approach to glenoid neck and, complications of, 508, 508f
207–208, 208f definition of, 499
postoperative care for, 210 diagnostic studies for, 500
superior approach to glenoid neck and, differential diagnosis of, 501
208, 208f fibula and, direct lateral approach to,
pathogenesis, 206 502–503, 502f, 503f
patient history, 206 fibula and, posterior plating of, 506,
physical findings, 206 506f
surgical management, 207, 207f imaging for, 500, 501f
medial malleolus, anteromedial approach
to, 503–504, 504f
O nonoperative management of, 501
O lecranon outcomes of, 507
anatomy, 252 pathogenesis and, 499, 501f
O lecranon fracture-dislocations, plate and pearls and pitfall of, 507
screw fixation for, 256–257, 256f, physical findings and, 499–500
257f posterior malleolus and, fixation of, 505,
O lecranon fractures 505f
definition, 252, 252f postoperative care of, 507
diagnostic studies, 253 surgical management of, 501–502
differential diagnosis, 253 syndesmosis fixation and, 506, 506f
imaging, 253 tibia and, posterolateral approach to,
natural history, 252 504, 505f
nonoperative management, 253 bicondylar plateau, 425–433
O RIF of, 252–258 anatomy and, 425, 426f
complications and, 258 complications of, 432
pearls and pitfalls for, 258 definition of, 425, 426f
plate and screw fixation for, 255–256, differential diagnosis of, 427
255f, 256f fixation and, 430–431, 430f, 431f
postoperative care for, 258 imaging for, 427, 427f
tension band wiring for, 253–254, 253f, lateral exposure and, 429, 430f
254f, 255f natural history and, 425
pathogenesis, 252 nonoperative management of, 427
patient history, 252 outcomes of, 432
physical findings, 252 pathogenesis and, 425
plate and screw fixation for, 255–257, patient history and, 425–427
255f, 256f, 257f pearls and pitfalls of, 432
surgical management, 253 physical findings and, 425–427
O pen fractures, Gustilo and Anderson posterior approach to, 431, 432f
grading system, 486, 486t posteromedial approach to, 428, 429f
O pen reduction postoperative care for, 432
calcaneal fractures, 530, 530f surgical management of, 428, 428f
sacrum, posterior approach to, 308–309, Boyd approach to, 237, 238f
308f of capitellar fractures, 227–232
SI joint, posterior approach to, 308–309, of capitellar-trochlear shear fractures,
308f 227–232
O pen reduction and internal fixation (O RIF) of coracoid process fracture, 209, 209f
acetabular posterior wall, 315–324 of coronoid fracture, 270–271, 271f
anatomy and, 315 of diaphyseal forearm fractures, 8–19
complications of, 323–324 anterior approach to radius and, 13, 13f
definition of, 315, 316f anterior approach to ulna and, 16–17,
diagnostic studies for, 317 16f
differential diagnosis of, 317 complications of, 19
fracture reduction and, 320–321 fracture reduction/fixation and, 17, 17f
fracture site débridement/exposure and, outcomes of, 19
320 pearls and pitfalls of, 18
imaging of, 317 posterior approach to radius and, 15–16,
internal fixation and, 321–322, 321f 15f
Kocher-Langenbeck approach to, posterior approach to ulna and, 17
318–320, 318f, 319f postoperative care of, 19
natural history of, 316 distal femur, 394–415
nonoperative management of, 317 anatomy and, 394, 395f, 396f
outcomes of, 323 approach to, 401–402, 402f
pathogenesis of, 315–316, 316f articular surface and, stabilizing, 412,
patient history and, 316–317 412f
pearls and pitfalls of, 323 bone grafting and, 410, 410f
physical findings for, 316–317 complications of, 414–415, 415f
postoperative care for, 323 definition of, 394
surgical management of, 317–318, 318f diagnostic studies for, 395–398
wound closure and, 322, 322f differential diagnosis of, 399
of acromial process fracture, 208, 209f distal segment reduction and, 413, 413f
anatomic plating for, proximal humerus fixation choices and, 400, 400f
fracture, 167–169, 167f, 168f, 169f imaging for, 395–398, 397f, 398f
INDEX I-7
lateral approach to, 411, 411f
locking plates for, 404–413, 404f–411f
locking plates for, plate placement and,
406–407, 407f, 413, 413f
locking plates for, wound closure for,
411, 411f, 413, 413f
natural history and, 394
nonoperative management of, 399
outcomes of, 414
pathogenesis and, 394
patient history and, 394–395
pearls and pitfalls of, 413–414
physical findings and, 394–395
positioning for, 401, 402f
postoperative care for, 414
preoperative planning for, 400–401, 401f
reduction of shaft to distal segment in,
406
screw placement and, 408–409, 408f,
409f
surgical management of, 399–402, 399f,
399t, 400f, 401f, 402f
temporary bridging external fixation for,
403, 403f, 404f
elbow fracture-dislocations with complex
instability, 267–274
complications and, 274
outcomes and, 274
pearls/pitfalls for, 273–274
postoperative care and, 274
femoral head fracture, 326–332
anatomy and, 326, 326f
complications of, 332
definition of, 326
diagnostic studies for, 326–327
differential diagnosis of, 327, 327t
imaging for, 326–327, 327f
natural history and, 326
nonoperative management of, 327
outcomes of, 332
pathogenesis and, 326, 327f
patient history and, 326
pearls and pitfalls of, 332
physical findings of, 326
postoperative care for, 332
Smith-Peterson anterior approach to,
328–330, 329f, 330f
surgical management of, 327–328
femoral neck fractures, 333–344
anatomy and, 333, 334f
cephalomedullary nail fixation and,
340–341, 340f, 341f
complications of, 343–344
definition of, 333, 334f
diagnostic studies for, 334
differential diagnosis of, 335
fixation, minimally invasive with sliding
hip screw and, 342–343, 342f, 343f
imaging for, 334
natural history of, 333
nonoperative management of, 335
outcomes of, 343
pathogenesis for, 333
patient history for, 333–334
pearls and pitfalls of, 343
physical findings for, 333–334
postoperative care for, 343
surgical management of, 336–337, 336f
Watson-Jones approach to, 338–340, 339f
glenoid cavity and, anterior approach to,
215, 216f
glenoid cavity and, posterior approach to,
214, 215f
glenoid cavity and, superior approach to,
215, 215f
I-8 INDEX
O pen reduction and internal fixation
(O RIF) (continued)
glenoid neck, posterior approach to,
207–208, 208f
glenoid neck, superior approach to, 208,
208f
of intercondylar fractures, 219–225,
219–226
complications of, 224
internal fixation and, 222–223, 222f,
223f
outcomes of, 224, 225t
pearls and pitfalls of, 224
postoperative management of, 224
surgical approach to, 220–221, 221f
Jones fracture, 546–551
anatomy and, 546, 548f
complications of, 551
definition of, 546, 547f
diagnostic studies for, 546
differential diagnosis of, 546
imaging for, 546
inlay bone grafting without internal
fixation for, 550, 550f
natural history and, 546
nonoperative management of, 546–547
outcomes of, 551
pathogenesis and, 546
patient history and, 546
pearls and pitfalls of, 551
percutaneous intramedullary screw
fixation for, 548, 548f, 549f
percutaneous intramedullary screw
fixation for, with bone graft, 550
physical findings and, 546
postoperative care of, 551
surgical management of, 547–548, 548f
Köcher approach to, 238, 238f
Lisfranc injury, 536–545
anatomy and, 536, 537f
articular surface assessment, decision
making and, 541
closure for, 544, 544f
complications of, 544
definition of, 536
definitive stabilization of, 541–543, 541f,
542f, 543f
diagnostic studies for, 537, 538f, 539f
differential diagnosis of, 537
imaging for, 537, 538f, 539f
lateral incision for, 540, 540f
medial incision for, 540, 540f
natural history and, 536
nonoperative management of, 537
outcomes of, 544
pathogenesis and, 536
patient history and, 536–537
pearls and pitfalls of, 544
physical findings and, 536–537
postoperative care of, 544
provisional reduction for, 541–543, 541f,
542f, 543f
surgical management of, 539, 539f
of nonarticular scapular fractures,
206–210
acromial process fracture and, 208, 209f
complications for, 210
coracoid process fracture and, 209, 209f
outcomes for, 210
pearls and pitfalls for, 210
posterior approach to glenoid neck and,
207–208, 208f
postoperative care for, 210
superior approach to glenoid neck and,
208, 208f
of olecranon fractures, 252–258
complications and, 258
pearls and pitfalls for, 258
plate and screw fixation for, 255–256,
255f, 256f
postoperative care for, 258
tension band wiring for, 253–254, 253f,
254f, 255f
patellar, 416–423
anatomy and, 416, 417f
approach to, 418
complications of, 423
definition of, 416
diagnostic studies for, 417, 418f
differential diagnosis of, 417
imaging for, 417, 418f
interfragmentary screws without tension
banding for, 421, 422f
natural history and, 416
nonoperative management of, 417
outcomes of, 423
partial phallectomy and, 422, 422f
pathogenesis and, 416
patient history and, 416–417
pearls and pitfalls of, 423
physical findings and, 416–417
positioning for, 418
postoperative care for, 423
preoperative planning for, 418
surgical management of, 417–418
tension band and, modified with
cannulated screws, 420, 421f
tension band wiring for, 419–420, 419f,
420f
peritrochanteric hip fracture, 359–369
anatomy and, 359
blade plate insertion for, 365–366, 366f
complications of, 368f, 369
definition of, 359
diagnostic studies for, 359
differential diagnosis of, 360
fracture preparation for, 363–364,
364f
fracture reduction for, 362, 363f
glide pin positioning for sliding hip screw
and, 363–364, 364f
imaging for, 359, 360f
implant insertion and, 364–365, 365f
incision for, 362
natural history and, 359
nonoperative management of, 360
outcomes of, 368
pathogenesis and, 359
patient history and, 359
pearls and pitfalls of, 366–367, 367f
physical findings and, 359
postoperative care for, 367–368, 368f
surgical management of, 360–361, 361f,
362f
wound closure for, 366
pilon, 483–498
anatomy and, 483
anterolateral approach to, 490, 491f
anteromedial approach to, 489–490,
489f, 490f
articular fixation and, 493–494, 493f
articular reduction and, 493–494, 493f
complications of, 497–498
definition of, 483
diagnostic studies for, 486, 487f
differential diagnosis of, 486
extra-articular fixation and, 494, 494f
extra-articular reduction and, 494, 494f
fibula and, reduction/fixation of, 492
imaging for, 486, 487f
natural history and, 485
nonoperative management of, 486
outcomes of, 496–497
pathogenesis and, 483–485, 484f, 485f
patient history and, 485–486
pearls and pitfalls of, 495–496
physical findings and, 485–486, 486t
posterolateral approach to, 492
posteromedial approach to, 492
postoperative care of, 496
surgical management of, 486–488, 487f,
488f, 489f
wound closure/care and, 495, 495f
of proximal humerus fractures, 163–170
anatomic plating for, 167–169, 167f,
168f, 169f
complications of, 170
outcomes of, 170
pearls and pitfalls of, 169
postoperative care for, 170
of radial head/neck fractures, 233–241,
271–272, 272f
Boyd approach to, 237, 238f
closure for, 240
complications and, 241, 241f
fixation and, 240, 240f
Köcher approach to, 238, 238f
pearls and pitfalls for, 240
postoperative care for, 240
results for, 240
of sacrum, 299–314
anatomy and, 299, 300f, 301f
anterior approach to, 309, 309f
complications for, 314
diagnostic studies for, 302–303, 303f,
304f
iliosacral screw placement and, 310–311,
310f, 311f
imaging for, 302–303, 302f, 303f
natural history of, 299–301
nonoperative management for, 303–304,
304f, 305f
outcomes and, 313
pathogenesis of, 299
patient history and, 301
pearls and pitfalls, 312–313
pelvic fixation, spinal, 312, 312f
physical findings for, 301, 301f
posterior approach to, 307–309, 307f,
308f
postoperative care and, 313
sacral nerve root decompression and,
312
surgical management for, 305–307, 305f,
306f
scaphoid fractures, acute, 109–115
anatomy and, 109
complications of, 115
open dorsal approach to, 111–114, 112f,
113f
open volar approach to, 114, 114f
outcomes of, 115
pearls and pitfalls of, 114–115
postoperative care of, 115, 115f
of scapular fractures, intra-articular,
212–218
anterior approach to glenoid cavity for,
215, 216f
complications and, 218
fixation techniques for, 216, 216f, 217f
outcomes for, 218
pearls and pitfalls for, 217
posterior approach to glenoid cavity for,
214, 215f
postoperative care for, 217–218

superior approach to glenoid cavity for,
215, 215f
of SI joint, 299–314
anatomy and, 299, 300f, 301f
anterior approach to, 309, 309f
complications for, 314
definition of, 299
diagnostic studies for, 302–303, 303f,
304f
iliosacral screw placement and, 310–311,
310f, 311f
imaging for, 302–303, 302f, 303f
natural history of, 299–301
nonoperative management for, 303–304,
304f, 305f
outcomes and, 313
pathogenesis of, 299
patient history and, 301
pearls and pitfalls, 312–313
pelvic fixation, spinal, 312, 312f
physical findings for, 301, 301f
posterior approach to, 307–309, 307f,
308f
postoperative care and, 313
sacral nerve root decompression and, 312
surgical management for, 305–307, 305f,
306f
of supracondylar fractures, 219–225,
219–226
complications of, 224
internal fixation and, 222–223, 222f, 223f
outcomes of, 224, 225t
pearls and pitfalls of, 224
postoperative management of, 224
surgical approach to, 220–221, 221f
of symphysis, 288–297
acute management of, 291
anatomy and, 288, 289f
C-clamp use and reduction in, 293, 293f
complications and, 297
definition of, 288
diagnostic studies for, 290
differential diagnosis of, 290
double plating technique and, 296, 296f
imaging of, 290, 291f
Jungabluth clamp reduction in, 294, 294f
natural history of, 288–289
nonoperative management of, 291
outcomes and, 297
pathogenesis of, 288, 290f
patient history and, 290
pearls and pitfalls in, 296
Pfannenstiel approach to, 292, 292f
physical findings for, 290, 290f
plate placement and, 295–296, 295f
postoperative care for, 297
surgical management of, 291–292
Weber clamp reduction and, 292, 293f
wound closure, 296
talus, 509–523
anatomy and, 509
approach to, 513–514, 514f, 515f, 516f
body of, 518, 518f, 519f
complications of, 523
definition of, 509
diagnostic studies for, 510–511, 511f
differential diagnosis of, 511
external fixation for, 520–521, 521f
imaging for, 510–511, 511f
lateral process of, 520, 520f
natural history and, 509–510, 510f
neck of, 516–518, 517f
nonoperative management of, 511–512
outcomes of, 522–523
pathogenesis and, 509
patient history and, 510
pearls and pitfalls of, 521
physical findings and, 510
positioning for, 513, 513f
posterior body of, 519, 519f
postoperative care of, 522
preoperative planning for, 512–513
surgical management of, 512–514, 513f,
514f, 515f, 516f
ulnar fracture, 92–100
complications of, 100
outcomes of, 100
postoperative care of, 100
techniques for, 97–100, 97f, 99f, 100f
Watson-Jones approach to, 338–340, 339f
O pen reduction and suture fixation, of
proximal humerus fractures, 167,
167f
O RIF. See O pen reduction and internal
fixation
O steosynthesis
tibial plateau fractures, lateral, 438, 439f
O steotomy
corrective
distal radius malunion, 130–139
radial diaphyseal malunion, 117–123,
120f, 121f
ulnar diaphyseal malunion, 117–123,
121f
dorsal extra-articular, distal radius
malunion, 133–134, 133f, 134f, 135f
intra-articular, distal radius malunion, 137,
138f
volar extra-articular, distal radius
malunion, 135–136, 136f, 137f
P Pilon
Parapatellar arthrotomy. See also Arthrotomy
lateral, O RIF of distal femur and, 404–405,
405
Patella.
anatomy, O RIF and, 416, 417f
O RIF of, 416–423
Pelvis
aftershock sheeting, circumferential, 279,
279f
O RIF of SI joint/sacrum and, 299, 300f,
301f
external fixation, 275–286
aftershock sheeting, circumferential
pelvic, 279, 279f
anterior iliac crest, open technique,
279–280, 280f
anterior iliac crest, percutaneous
technique, 282, 282f
complications of, 286
diagnostic studies for, 275–276
differential diagnosis of, 276–277
frame application/reduction and, 283,
284f
imaging for, 275–276, 276f, 277f
natural history of, 275
nonoperative management of, 277
outcomes of, 286
pathogenesis and, 275f
patient history and, 275
pearls and pitfalls of, 286
pelvic antishock clamp, 284, 284f, 285f
physical findings, 275
postoperative care for, 286
supra-acetabular technique, 282, 283f
surgical management of, 277–278, 277f,
278f
fixation of, spinal, 305, 312, 312f
INDEX I-9
Percutaneous fixation
closed reduction and
femoral neck fractures, 333–344
femoral neck fractures, technique for,
337–338, 528f
scaphoid fracture, acute, 102–107
complications in, 107
dorsal arthroscopy-assisted reduction
and, 103–106, 104f, 105f
outcomes for, 107
pearls and pitfalls for, 107
postoperative care for, 107
volar percutaneous approach to, 106,
106f
tongue fractures, 529–530, 529f
Percutaneous pinning
Kapandji technique for, distal radius
fracture, 33–34, 33f
for proximal humerus fractures, 154–162
complications of, 162
outcomes of, 161–162
pearls and pitfalls of, 161
postoperative care of, 161
surgical neck fractures, 158–159, 158f, 159f
tuberosity fractures, three-part greater,
159–160, 159f
valgus-impacted proximal humerus
fractures, 160–161, 160f
Percutaneous reduction
tongue fractures, 529–530, 529f
Peritrochanteric hip fractures.
fracture reduction, 362, 363f
O RIF, 359–369
Pfannenstiel approach, O RIF, symphysis, 292,
292f
Phallectomy, partial, O RIF, patellar and, 422,
422f
anatomy, O RIF and, 483
articular fixation of, O RIF and, 493–494,
493f
articular reduction of, O RIF and, 493–494,
493f
extra-articular fixation of, O RIF and, 494,
494f
extra-articular reduction of, O RIF and,
494, 494f
O RIF of, 483–498
anatomy and, 483
anterolateral approach to, 490, 491f
anteromedial approach to, 489–490,
489f, 490f
articular fixation and, 493–494, 493f
articular reduction and, 493–494, 493f
complications of, 497–498
definition of, 483
diagnostic studies for, 486, 487f
differential diagnosis of, 486
extra-articular fixation and, 494, 494f
extra-articular reduction and, 494, 494f
fibula and, reduction/fixation of, 492
imaging for, 486, 487f
natural history and, 485
nonoperative management of, 486
outcomes of, 496–497
pathogenesis and, 483–485, 484f, 485f
patient history and, 485–486
pearls and pitfalls of, 495–496
physical findings and, 485–486, 486t
posterolateral approach to, 492
posteromedial approach to, 492
postoperative care of, 496
surgical management of, 486–488, 487f,
488f, 489f
wound closure/care and, 495, 495f
I-1 0 INDEX
Pilon fractures, 483–485, 484f
Plafond, 483
fractures, 483–485, 484f
Plate and screw fixation
olecranon fracture-dislocations, 256–257,
256f, 257f
olecranon fractures, 255–257, 255f, 256f,
257f
Plate-and-screw fixation, anterior, clavicle
fracture, 142, 142f
Plate-and-screw fixation, superior, clavicle
fracture, 141–142, 141f, 142f
Plate fixation
bridge plating and, 89–90, 90f
of clavicle fractures, 140–142
complications of, 142
outcomes of, 142
pearls and pitfalls of, 142
postoperative care for, 142
of humeral shaft fractures, 189–196
anterolateral approach to, 191–192, 191f
complications of, 196
fracture nonunion and, exposure of, 193
fracture reduction and, 193, 193f
medial approach to, 194, 194f
outcomes of, 196
pearls and pitfalls of, 195
plate application and, 194, 194f
posterior approach to, 192, 192f
postoperative care of, 195, 195f
Plate placement, O RIF, symphysis, 295–296,
295f
Plating
fibula, 506, 506f
Provisional reduction
O RIF, Lisfranc injury, 541–543, 541f,
542f, 543f
Proximal femur
anatomy
cephalomedullary nailing and, 345, 346f
anatomy of pediatric, 1187, 1187f
cephalomedullary nailing, 345–358
anatomy and, 345, 346f
approach to, 349, 349f
complications of, 358, 358f
definition of, 345
diagnostic studies for, 346, 346f
differential diagnosis of, 346
distal interlocking technique for, 356, 356f
fracture reduction and, 350, 350f
fracture reduction and canal preparation
for, 353, 353f
imaging for, 346
integrated screw, 355, 355f, 356f
natural history and, 345
nonoperative management of, 346–347
outcomes of, 357–358
pathogenesis for, 345
patient history and, 345–346
pearls and pitfalls for, 357
physical findings and, 345–346
portal acquisition/protection and,
351–352, 352f
positioning for, 349, 349f
postoperative care of, 357
precision portal placement/trajectory
control and, 351, 351f
preoperative planning of, 347–349, 347f,
348f
single-screw/single-device designs for,
354, 354f
surgical management of, 347–349, 347f,
348f, 349f
two-screw construction, 354, 354f
wound closure, 356
Proximal humerus.
anatomy, 1786, 1787f, 1816, 154, 154f,
163–164, 180, 180f
innervation, 172–173
osteology, 172, 172f
vascular supply, 172
Proximal humerus fractures
anatomy and, 172–173, 172f, 180, 180f
definition, 154, 163, 163f, 172, 180
diagnostic studies, 155–156, 164, 173, 181
differential diagnosis, 156, 164, 181
four-part, valgus impacted, percutaneous
pinning for, 160–161, 160f
hemiarthroplasty, 180–187
complications of, 187
deltopectoral approach for, 182, 182f
final implant placement for, 185–186, 186f
humeral retroversion and, determination
of, 184, 184f
humeral shaft preparation and, 184, 184f
outcomes of, 187
pearls and pitfalls of, 187
postoperative care of, 187
prosthetic height and, determination of,
184, 185f
surgical wound closure for, 186
trial reduction for, 185, 185f
tuberosity mobilization for, 182–183, 183f
imaging, 155–156, 156f, 164, 173, 181, 181f
intramedullary fixation of, 172–179
complications and, 179
entry site reaming and, 177
fragment reduction and, 176, 176f
guidewire placement and, 176–177
interlocking screw, 177–178, 178f
K-wire placement and, 175, 175f
nail insertion and, 177, 177f
pearls and pitfalls in, 178–179
postoperative care for, 179
tuberosity, 178
natural history, 155, 155f, 173, 180
nonoperative management, 156, 164, 181
open reduction and suture fixation for,
167, 167f
O RIF, 163–170
anatomic plating for, 167–169, 167f,
168f, 169f
complications of, 170
outcomes of, 170
pearls and pitfalls of, 169
postoperative care for, 170
pathogenesis, 155, 164, 173, 173f, 180
patient history, 155, 164, 173, 180
percutaneous pinning for, 154–162
complications of, 162
outcomes of, 161–162
pearls and pitfalls of, 161
postoperative care of, 161
physical findings, 155, 164, 173, 180
surgical management, 156–158, 157f,
164–165, 165f, 173–174, 174f,
181–182, 182f
surgical neck fractures, percutaneous
pinning for, 158–159, 158f, 159f
tuberosity fractures and, isolated, fixation
of, 165, 166f
tuberosity fractures and, three-part greater,
percutaneous pinning for, 159–160,
159f
R fracture inspection/preparation and, 239,
Radial diaphyseal malunions
anatomy and, 117, 117f
definition, 117
diagnostic studies, 118–119
differential diagnosis, 119
imaging, 118–119, 118f
natural history, 118
nonoperative management, 119
osteotomy, corrective, 117–123
complications of, 123
dorsal approach to, 120, 121f
outcomes of, 123
pearls and pitfalls of, 122
postoperative care of, 123
reduction, plating, bone grafting in,
121–122, 121f
volar approach to, 120, 120f
pathogenesis, 117–118
patient history, 118
physical findings, 118
surgical management, 119, 119f
Radial diaphyseal nonunions
anatomy and, 124, 124f
definition, 124
diagnostic studies, 125
differential diagnosis, 125
imaging, 125, 125f
natural history, 124
nonoperative management, 125
operative treatment, 124–129
complications of, 129
outcomes of, 129
pearls and pitfalls of, 129
postoperative care of, 129
pathogenesis, 124
patient history, 124–125
physical findings, 124–125
plate fixation for treatment of, 126–128,
127f, 128f
compression, 128, 128f
surgical management, 125–126
Radial head
anatomy, 233, 234f, 242, 242f
M onteggia fractures and management of,
278, 278f
replacement, 242–251
common extensor split and, 245, 245f,
246f
completion of, 249
complications of, 251
definition of, 242
diagnostic studies for, 243
differential diagnosis of, 243
imaging and, 243
Köcher approach to, 240, 240f
lateral soft tissue closure and, 248, 248f
natural history of, 242
nonoperative management of, 243
outcomes of, 250–251
pathogenesis of, 242
patient history and, 242–243
pearls and pitfalls of, 250
physical findings and, 242–243
postoperative care of, 250
radial head/neck preparation and, 246,
246f, 247f
surgical approach to, 244, 245f
surgical management of, 243–244, 244f
techniques for, 247, 247f
Radial head/neck fractures
anatomy and, 233, 234f
definition, 233, 233f
diagnostic studies, 235–236
differential diagnosis, 236
239f
imaging, 235–236, 236f
natural history, 234–235, 235f

nonoperative management, 236–237, 236f
O RIF of, 233–241, 271–272, 272f
Boyd approach to, 237, 238f
closure for, 240
complications and, 241, 241f
fixation and, 240, 240f
Köcher approach to, 238, 238f
pearls and pitfalls for, 240
postoperative care for, 240
results for, 240
pathogenesis, 233–234, 234f
patient history, 235, 235f
physical findings, 235, 235f
reduction and provisional fixation for, 239,
239f
surgical management, 237, 237f
Radial neck, anatomy, 233, 234f
Radiography, plain
O RIF
distal femur, 394, 397f
sacrum/SI joint, 302–303, 302f, 303f
Radius
anatomy, 8–9, 8f
diaphyseal fracture O RIF and, 13–16, 13f,
15f
Reconstruction.
TFCC, palmaris graft for, 27
Retrograde IM N
femoral, 370–379
alternative techniques, 379t
anatomy and, 370, 371f
approach to, 374
classification of, 371–373, 371f, 371t,
372f, 373f
complications of, 379
contraindications for, 373
definition of, 370
diagnostic studies for, 370–371
fracture reduction and, 375
guardwire and, passing, 375
guardwire placement and, 375
imaging for, 370–371
nail placement and, 376, 377f
outcomes of, 379
pathogenesis and, 370
patient history and, 370
pearls and pitfalls of, 378
physical findings and, 370
positioning for, 374
postoperative care for, 378–379
preoperative planning for, 373–374, 374f
reaming and, 376, 376f
relative indications for, 371–373, 371f,
371t, 372f, 373f
screw fixation and, 377
starting hole and, creating/reaming, 375
surgical management of, 371–374, 371f,
371t, 372f, 373f, 374f
wound closure and, 378
of humeral shaft fractures, 203–204
Retroversion, humeral, 184, 184f
S open dorsal approach to, 111–114, 112f,
Sacroiliac (SI) joint
anatomy, O RIF and, 299, 300f, 301f
imaging, 1859
open reduction, posterior approach to,
308–309, 308f
O RIF of, 299–314
anatomy and, 299, 300f, 301f
anterior approach to, 309, 309f
complications for, 314
diagnostic studies for, 302–303, 303f,
304f
iliosacral screw placement and, 310–311,
310f, 311f
imaging for, 302–303, 302f, 303f
natural history of, 299–301
nonoperative management for, 303–304,
304f, 305f
outcomes and, 313
pathogenesis of, 299
patient history and, 301
pearls and pitfalls, 312–313
pelvic fixation, spinal, 312, 312f
physical findings for, 301, 301f
posterior approach to, 307–309, 307f,
308f
postoperative care and, 313
sacral nerve root decompression and, 312
surgical management for, 305–307, 305f,
306f
Sacrum
anatomy, O RIF and, 299, 300f, 301f
fractures, u-shaped, 305–306, 306f
nerve decompression, 305, 305f
O RIF of sacrum/SI joint and, 312
open reduction, posterior approach to,
308–309, 308f
O RIF of, 299–314
anatomy and, 299, 300f, 301f
anterior approach to, 309, 309f
complications for, 314
diagnostic studies for, 302–303, 303f,
304f
iliosacral screw placement and, 310–311,
310f, 311f
imaging for, 302–303, 302f, 303f
natural history of, 299–301
nonoperative management for, 303–304,
304f, 305f
outcomes and, 313
pathogenesis of, 299
patient history and, 301
pearls and pitfalls, 312–313
pelvic fixation, spinal, 312, 312f
physical findings for, 301, 301f
posterior approach to, 307–309, 307f,
308f
postoperative care and, 313
sacral nerve root decompression and,
312
surgical management for, 305–307, 305f,
306f
Scaphoid
anatomy, 102, 109
Scaphoid fractures, acute
anatomy and, 102
definition, 102, 109
diagnostic studies, 102–103, 110, 110f
differential diagnosis, 103, 110
imaging, 102–103, 110, 110f
natural history, 102, 109
nonoperative management, 103, 110–111
O RIF, 109–115
anatomy and, 109
complications of, 115
113f
open volar approach to, 114, 114f
outcomes of, 115
pearls and pitfalls of, 114–115
postoperative care of, 115, 115f
pathogenesis, 102, 109
patient history, 102, 109–110
percutaneous fixation of, 102–107
complications in, 107
dorsal arthroscopy-assisted reduction
and, 103–106, 104f, 105f
INDEX I-1 1
outcomes for, 107
pearls and pitfalls for, 107
postoperative care for, 107
volar percutaneous approach to, 106,
106f
physical findings, 102, 109–110
surgical management, 103, 111
Scapula
anatomy, 212, 213f
nonarticular, anatomy, 206, 206f
Scapular fractures, intra-articular
anatomy and, 212, 213f
definition, 212
diagnostic studies, 212
differential diagnosis, 212
imaging, 212, 213f
natural history, 212
nonoperative management, 212
O RIF of, 212–218
anterior approach to glenoid cavity for,
215, 216f
complications and, 218
fixation techniques for, 216, 216f, 217f
outcomes for, 218
pearls and pitfalls for, 217
posterior approach to glenoid cavity for,
214, 215f
postoperative care for, 217–218
superior approach to glenoid cavity for,
215, 215f
pathogenesis, 212
patient history, 212
physical findings, 212
surgical management, 212–214, 214f
Screw fixation. See also specific types of
screw fix ation
interlocking, proximal humerus fracture,
177–178, 178f
percutaneous intramedullary
bone graft with, 550
O RIF for Jones fracture and, 548, 548f,
549f, 550
retrograde IM N , femoral, 377
Smith-Peterson anterior approach
O RIF, femoral head fracture, 328–330,
329f, 330f
Supracondylar fractures
diagnostic studies, 219
imaging, 219, 219f
O RIF, 219–225
complications of, 224
internal fixation and, 222–223, 222f,
223f
outcomes of, 224, 225t
pearls and pitfalls of, 224
postoperative management of, 224
surgical approach to, 220–221, 221f
patient history, 219
physical findings, 219
shortening and, 223, 224f
surgical management, 219–220, 220f
Surgical management. See also specific types
of surgical m anagem ent
anterograde IM N , femoral, 383–385, 384f
calcaneal fractures, 527–528
cephalomedullary nailing, proximal femur,
347–349, 347f, 348f, 349f
external fixation
pelvic, 277–278, 277f, 278f
tibial, 444–445, 445f
fasciotomy, leg, for acute compartment
syndrome, 477
O RIF
acetabular posterior wall, 317–318, 318f
ankle, 501–502
I-1 2 INDEX
Surgical management (continued)
distal femur, 399–402, 399f, 399t, 400f,
401f, 402f
femoral head fracture, 327–328
femoral neck fracture, 336–337, 336f
Jones fracture, 547–548, 548f
Lisfranc injury, 539, 539f
patellar, 417–418
peritrochanteric hip fracture, 360–361,
361f, 362f
pilon, 486–488, 487f, 488f, 489f
sacral, 305–307, 305f, 306f
SI joint, 305–307, 305f, 306f
symphysis, 291–292
talus, 512–514, 513f, 514f, 515f, 516f
retrograde IM N , femoral, 371–374, 371f,
371t, 372f, 373f, 374f
tibial plateau fractures, lateral, 435–436,
435f, 435t, 436f, 436t
Surgical neck fractures, percutaneous pinning,
158–159, 158f, 159f
Symphysis
definition, 288
O RIF of, 288–297
acute management of, 291
anatomy and, 288, 289f
C-clamp use and reduction in, 293, 293f
complications and, 297
definition of, 288
diagnostic studies for, 290
differential diagnosis of, 290
double plating technique and, 296, 296f
imaging of, 290, 291f
Jungabluth clamp reduction in, 294, 294f
natural history of, 288–289
nonoperative management of, 291
outcomes and, 297
pathogenesis of, 288, 290f
patient history and, 290
pearls and pitfalls in, 296
Pfannenstiel approach to, 292, 292f
physical findings for, 290, 290f
plate placement and, 295–296, 295f
postoperative care for, 297
surgical management of, 291–292
Weber clamp reduction and, 292, 293f
wound closure, 296
Syndesmosis
fixation, 506, 506f
T outcomes of, 469
Talus.
anatomy
O RIF and, 509
body of, O RIF for, 518, 518f, 519f
dislocated talar body and, O RIF for,
517–518
lateral process of, O RIF for, 520, 520f
neck of
dislocated talar body ORIF and, 517–518
O RIF for, 516–518, 517f
O RIF of, 509–523
anatomy and, 509
approach to, 513–514, 514f, 515f, 516f
body of, 518, 518f, 519f
complications of, 523
definition of, 509
diagnostic studies for, 510–511, 511f
differential diagnosis of, 511
external fixation for, 520–521, 521f
imaging for, 510–511, 511f
lateral process of, 520, 520f
natural history and, 509–510, 510f
neck of, 516–518, 517f
nonoperative management of, 511–512
outcomes of, 522–523
pathogenesis and, 509
patient history and, 510
pearls and pitfalls of, 521
physical findings and, 510
positioning for, 513, 513f
posterior body of, 519, 519f
postoperative care of, 522
preoperative planning for, 512–513
surgical management of, 512–514, 513f,
514f, 515f, 516f
posterior body of, O RIF for, 519, 519f
Tarsometatarsal joint, first
O RIF of Lisfranc injury and, 541, 541f
Tension band wiring
modified, with cannulated screws, 420, 421f
O RIF, patellar, 419–420, 419f, 420f, 421f
TFCC. See Triangular fibrocartilage complex
Tibia.
anatomy, 435, 435f, 454, 455f
external fixation and, 441, 443f
external fixation, 441–453
anatomy and, 441, 443f
ankle-spanning fixator for tibial pilon
fracture and, 451, 451f
complications of, 453
definition of, 441, 442f
diagnostic studies for, 444
imaging for, 444, 445f
knee-spanning fixator for tibial plateau
fracture and, 450, 450f
monolateral four-pin frame application
for tibial shaft fracture and,
446–447, 447f, 448f
monotube four-pin frame application for
tibial shaft fracture and, 448–450,
449f
natural history and, 442–443
outcomes of, 453
pathogenesis and, 441–442, 443f
patient history and, 444
pearls and pitfalls of, 452
physical findings and, 444, 444f
pin insertion technique for, 446, 446f
postoperative care of, 452–453
surgical management of, 444–445, 445f
two-pin fixator for tibial fractures and,
451, 452f
IM N , 454–470
complications of, 470
pearls and pitfalls of, 469
postoperative care of, 469
surgical approach to, 459–465, 459f,
460f, 461f, 462f, 463f, 464f, 465f
injuries
diagnostic studies for, 454–455
imaging of, 454–455
natural history of, 454
nonoperative management of, 455–456,
456f
pathogenesis of, 454
patient history of, 454
physical findings of, 454
surgical management of, 456–459, 457t,
458f, 458t, 459f
O RIF of ankle and, 504, 505f
Tibial fractures
distal metadiaphyseal, 468, 469f
proximal metaphyseal, 465–468, 466f,
467f, 468f
Tibial plateau fractures, lateral, 434–440
anatomy, 434
anterolateral approach to, 436, 436f
complications, 440
definition, 434
diagnostic studies, 435
differential diagnosis, 435
imaging, 435
meniscal repair, 438
natural history, 434
nonoperative management, 435
osteosynthesis, 438, 439f
outcomes, 439–440
pathogenesis, 434
patient history, 434–435
pearls and pitfalls, 439
physical findings, 434–435
posterolateral approach to, 437, 437f
postoperative care, 439
reduction, 437, 437f
reduction of impacted segments, 437, 437f
surgical management, 435–436, 435f, 435t,
436f, 436t
Tongue fractures
percutaneous fixation, 529–530, 529f
percutaneous reduction, 529–530, 529f
Triangular fibrocartilage complex (TFCC), 22
foveal, avulsion, arthroscopically assisted
repair of, 23–26, 24f, 25f
reconstruction, palmaris graft for, 27
repair, 26–27, 26f, 27f
Tscherne and Gotzen grading system, closed
fractures, 486, 486t
Tuberosity fractures, isolated, fixation of,
165, 166f
Tuberosity fractures, three-part greater,
percutaneous pinning, 159–160,
159f
U
Ulna
anatomy, 8–9, 92, 93f
diaphyseal fracture O RIF and, 16–17, 16f
distal, 92, 92f
Ulna fracture fixation, M onteggia fractures
and, 279, 279f
Ulnar collateral ligament reconstruction,
lateral, elbow dislocation, simple,
264, 264f
Ulnar collateral ligament repair, lateral,
elbow dislocation, simple, 262–263,
262f, 263f
Ulnar corner fixation, fragment-specific
fixation and, 80–81, 80f, 81f
Ulnar diaphyseal malunions
anatomy and, 117, 117f
definition, 117
diagnostic studies, 118–119
differential diagnosis, 119
imaging, 118–119, 118f
natural history, 118
nonoperative management, 119
osteotomy, corrective, 117–123
approach to, 121, 121f
complications of, 123
outcomes of, 123
pearls and pitfalls of, 122
postoperative care of, 123
reduction, plating, bone grafting in,
121–122, 121f
pathogenesis, 117–118
patient history, 118
physical findings, 118
surgical management, 119, 119f
Ulnar diaphyseal nonunions
anatomy and, 124, 124f
definition, 124
 INDEX I-1 3

diagnostic studies, 125 O RIF, 92–100 patient history, 41

differential diagnosis, 125 incision/exposure in, 97–98, 97f physical findings, 41
imaging, 125, 125f techniques for, 99, 99f surgical management, 42–43, 43f, 94, 95f
natural history, 124 surgical management, 96 Ulnar styloid nonunion
nonoperative management, 125 Ulnar metadiaphyseal fractures O RIF, 99
operative treatment, 124–129 anatomy and, 92, 93f surgical management, 96, 96f
complications of, 129 O RIF, 92–100 Urethrography, retrograde, O RIF, sacrum/SI
outcomes of, 129 Ulnar neck fractures joint, 303
pearls and pitfalls of, 129 distal, O RIF for, 100, 100f
postoperative care of, 129 surgical management, 96–97, 96f
pathogenesis, 124 Ulnar shaft fractures V
patient history, 124–125 distal, O RIF for, 100, 100f Valgus-impacted proximal humerus fractures,
physical findings, 124–125 surgical management, 96–97, 96f 160–161, 160f
plate fixation for treatment of, 126–128, Ulnar styloid fractures Volar plating, distal radius fracture, 51–61
127f, 128f anatomy and, 40, 92, 93f anatomy and, 51–52, 51f
compression, 128, 128f arthroscopic reduction/fixation of, 40–49 complications of, 61
surgical management, 125–126 complications for, 49 definition of, 51
Ulnar fractures metaphyseal comminution for, 46–48, fixed-angle, 54–59, 55f, 56f, 57f, 58f, 59f
diagnostic studies, 93–94 46f, 47f fixed-angle, using plate as reduction tool,
distal, O RIF for comminuted outcomes for, 49 60, 60f
intra-articular, 100 pearls and pitfalls for, 48–49 outcomes of, 61
imaging, 93–94, 93f postoperative care for, 49 pearls and pitfalls of, 60–61
natural history, 92, 93f techniques, 44, 44f, 48, 48f postoperative care of, 61
O RIF definition, 40 Volar rim fragment, fragment-specific fixation
complications of, 100 diagnostic studies, 41–42 and, 81–82, 82f
outcomes of, 100 differential diagnosis, 42
postoperative care of, 100 imaging, 41–42, 42f
pathogenesis, 92 natural history, 40–41 W
surgical management, 94–97, 94f, nonoperative management, 42 Watson-Jones approach, O RIF, 338–340,
95f, 96f O RIF, 92–100 339f
Ulnar head fractures techniques for, 98, 99f Weber clamp reduction, O RIF, symphysis,
anatomy and, 92, 93f pathogenesis, 40 292, 293f
 Ex a m Ta b le f o r Pe lv is a n d
Lo w e r Ex t re m it y Tr a u m a
Ex a m in a t io n
Effusion, inspect ion for
(Chapt er 10, Ant erograde
Int ramedullary Nailing of
the Femur; Chapter 11,
Open Reduct ion and
Int ernal Fixat ion of t he
Dist al Femur)
Heel st rike (Chapt er 17,
Fasciot omy of t he Leg for
Acut e Compart ment
Syndrome)
Lower ext remit y rot at ion
(Chapt er 17, Fasciot omy
of t he Leg for Acut e
Compart ment Syndrome)
Midfoot joint palpat ion
(Chapt er 22, Open
Reduct ion and Int ernal
Fixat ion of t he Symphysis)
Midfoot st abilit y,
(Chapt er 22, Open
Reduct ion and Int ernal
Fixat ion of t he Symphysis)
Te ch n iq u e
The examiner palpates and per-
forms ballottement of the
patella. Smaller effusions can be
detected by compressing fluid
from the suprapatellar pouch.
Light blows of the fist or heel of
hand to the heel of the
injured leg
In a patient with a suspected
femoral neck fracture, gentle in-
ternal and external rotation at
the leg is all that is needed to
elicit pain.
Direct palpation of each of mid-
foot joints, particularly the me-
dial column of the foot
Gentle passive dorsiflexion and
plantarflexion of each of the
metatarsal heads; gentle passive
abduction and adduction
through the forefoot
Illu s t r a t io n Gr a d in g & Sig n if ica n ce
Trace, mild, moderate, or large. Presence
of an effusion is indirect evidence of
intra-articular injury. Most commonly
graded subjectively as mild, moderate, or
larger. New onset of effusion after injury
localizes injury to within the capsule of
the knee.
Groin pain that did not exist at rest im-
plies hip fracture.
Pain in the groin is concerning for
femoral neck fracture but may also be
caused by fractures of the anterior
pelvic ring.
Presence or absence of pain. The pres-
ence of pain at the midfoot with palpa-
tion suggests a Lisfranc injury.
Presence or absence of pain. The pres-
ence of pain at the tarsometatarsal joint
region with passive forefoot range of
motion suggests a Lisfranc injury.
(co n t in u e d )
1
2 EXAM TABLE
Ex a m in a t io n
Pat ellar palpat ion
(Chapt er 11, Open
Reduct ion and Int ernal
Fixat ion of t he Dist al
Femur)
Iliac wing compression
(Chapt er 2, Open
Reduct ion and Int ernal
Fixat ion of t he
Symphysis)
Pelvic inst abilit y: ext ernal
rot at ion (Chapt er 2, Open
Reduct ion and Int ernal
Fixat ion of t he Symphysis)
Pelvic inst abilit y: int ernal
rot at ion (Chapt er 2,
Open Reduct ion and
Int ernal Fixat ion of t he
Symphysis)
Pelvic inst abilit y: vert ical
inst abilit y (Chapt er 2,
Open Reduct ion and
Int ernal Fixat ion of t he
Symphysis)
Te ch n iq u e
The patella, quadriceps tendon,
and patellar tendon are palpated
for defects. The examiner notes
inferior or superior patellar dis-
placement in comparison to the
Quadriceps
unaffected side.
The examiner can test for stabil-
ity of the pelvic ring by placing
the palms of the hands on the
outside of the iliac wings and
pushing the two wings together.
Legs are positioned flexed, ab-
ducted, and externally rotated.
Hands are placed on the iliac
crests and an AP force is applied.
Legs are positioned extended
and internally rotated. Hands are
positioned lateral to iliac crests
and a lateral-to-medial compres-
sive force is applied.
Legs are positioned extended.
While one extremity is supported
at the heel, traction is applied to
the other.
Illu s t r a t io n Gr a d in g & Sig n if ica n ce
Patella
Patella baja is an inferiorly displaced
Patellar tendon
patella seen with quadriceps tendon rup-
ture; patella alta is a high-riding patella
associated with patellar tendon rupture.
The placement of the patella and palpa-
tendon tion of defects with the patella, quadri-
ceps tendon, or patellar tendon can help
differentiate between patellar fracture
and ligamentous extensor disruption.
This should be avoided if radiology
demonstrates displacement.
Palpable widening of the pelvis or in-
creased sacroiliac joint space or symphy-
seal widening is seen on simultaneous
fluoroscopic images with the C-arm.
Palpable instability of the pelvis or a
decrease in sacroiliac joint space or
symphyseal diastasis is seen on simulta-
neous C-arm images.
A visual change in leg-length discrep-
ancy can be seen in some cases.
Otherwise, simultaneous C-arm images
may disclose one acetabulum or iliac
crest at a different level than the other.